June Gibbs Brown Reflects on Her Legacy as Health and Human Services Inspector General

Account of the Interview

Broadening the Mission of the Inspector General

Traditionally, the Inspector General (IG) role is one that is most strongly identified with enforcement. The conception that June Gibbs Brown brought to the Department of Health and Human Services (HHS) when she became the IG was unusual. She conceived of the role as going beyond enforcement and auditing. Under her oversight, the HHS Office of Inspector General (OIG) effectively enforced compliance-related regulations, as well as playing a critical part in preventing problems. This helped ensure beneficiaries of federal health care programs continued to receive quality care, and that providers appropriately delivered that care.

The health care industry was invited to the table to actively participate in dialogues about compliance guidelines for their own industry. The expectations of the OIG were clearly articulated, and there was little excuse for not voluntarily taking up the challenge of systematically identifying problematic areas before business and patient care integrity were compromised. Some may conceive of this broader mission for the OIG as overstepping the bounds of this role. However, the invitation to be part of a more preventive and collaborative approach offered many incentives and benefits. Ms. Brown's legacy is evident in the OIG's health care specific compliance program guidelines, roundtable discussions with industry representatives and professional associations, voluntary disclosure program, and fraud alerts, to name but a few of the direct benefits to the healthcare community.

Ms. Brown is unduly quiet about the significance of her achievements during her time as IG. When asked about the origin of her approach, she says that the underlying philosophy was not new. It was developed over many years, and was a continuation of beliefs and commitments formed during earlier terms as IG for other departments. Ms. Brown acknowledges that her time as IG for the Department of Defense laid the foundation for later initiatives in HHS. Ms. Brown came to the position in the Department of Defense at a time when compliance programs were rare and the industry was facing bad publicity associated with many allegations of fraud and corrupt practices. There was intense pressure to reform the industry and ensure that tax dollars were being spent appropriately. This was an overwhelming undertaking in the face of a huge, competitive, multi-national industry, which was accustomed to the security of government contracts and chummy relationships with contracting entities.

Ms. Brown said that her initial focus at Defense was to improve the Office's investigative capacities and successful prosecutions. However, over time she realized that this "was a drop in the bucket compared to the number of things going on out there." Her belief was that most companies were well intentioned but so large and complex that they needed systems to detect and prevent problems before they jeopardized the entire company. She also thought that companies allowed to continue their business after being prosecuted, should be required to monitor their activities so problems would be identified and rectified earlier. Ms. Brown said "I came up with the idea that we were looking for certain controls to be present in the company that were not necessarily in the contract. Once we had a company with wrong doing in it, if they weren't debarred or taken out of business, we wanted some rules that they had to live by, so we started to develop these compliance plans to let them know the things they had to put in place so they could continue doing business and to reach a settlement on whatever issue we were working on." Hence, her ongoing commitment to compliance programs and self-policing was born. The emphasis is on checks and balances and effective internal controls - an approach she says that was significantly influenced by her training in internal control systems as a CPA.

Over time, Ms. Brown said that the Office was producing many of these plans, detailing controls that a contractor was required to put in place as part of a settlement. These plans tended to focus on specific processes or activities within an organization, such as inventory control or personnel accounting. This tailored approach was feasible in an industry where there is a lot of commonality among the structures of different companies. Ms. Brown said that these internal control plans essentially articulated the OIG's expectations of reasonable practice for a specific part of the company's operations. Although these internal controls were initially intended for defense contractors who had been prosecuted, many of the systems became voluntarily adopted by other companies in the industry. Voluntary adherence to these compliance standards was advantageous for both the industry and the OIG. The standards gave companies a clear idea of the OIG's expectations, and offered them an opportunity to provide feedback to the OIG on the practicality and effectiveness of the control guidelines. This type of feedback allowed the OIG to improve its guidelines. As Ms. Brown said, "Where they could show us that a certain thing wouldn't work or was not reasonable, then we were able to understand their business better and do a better job."

The US Defense industry today has significantly reformed its business practices, and many of its compliance programs have become models for subsequent initiatives in financial services, telecommunications and health care. The industry has also taken important steps towards more ethical practices including the establishment of consortiums of companies dedicated to ethical business practices and relationships, such as the Defense Industry Initiative. The reforms in Defense are in part testimony to Ms. Brown's ability to bring disparate parties to the table, and foster collaborations that promote the interests of both providers of services and the beneficiaries of those services.

When Ms. Brown came to HHS in late 1993, she encountered many of the same types of problems she had seen in the defense industry. She said, "There had been very little enforcement in the past," and there was again need for significant reform and reduction of waste, fraud and abuse. Given that there were a number of significant cases of deliberate fraud and deception, such as where no care was given, patient records were fabricated, and networks of ghost providers created fictious claims - there was no doubt or question in Ms. Brown's mind as to what action should be taken here. The challenge was to help the legitimate providers that intended to do the right thing. However, health care posed some unique challenges. Ms. Brown found that most health care organizations were dominated by clinicians and scientists who were not used to the types of compliance-related internal control and regulatory systems that were now commonplace in industries such as defense. Further, health care was characterized by divergent organizational types and sizes that made it difficult to target specific processes for common compliance systems.

Similar to her days in Defense, Ms. Brown carried with her a belief that most health care organizations intended to do the right thing, but lacked the ability to establish the necessary systems to detect and prevent problems: "I had great sympathy for the industries we were going into because I feel many of the people were honestly trying to do a good job, but they did not know that there may have been individuals in the organization who were deliberately doing wrong and the organization itself would suffer greatly." Even though Ms. Brown was sympathetic toward well intentioned organizations that encountered difficulties, she recognized the dire consequences illegal and unethical practices could have on patients. The vulnerability of patients, and the fundamental importance of health care, made protecting the beneficiaries a critical priority for Ms. Brown. She said that she "would not make a monetary settlement without knowing that we had protection for the beneficiaries." Ms. Brown added that her key focus was "how do we change things so this won't happen somewhere else and how can we improve the ability of the industry to provide goods and services in an honest way at a fair return." In practice, this meant that most health care organizations allowed to continue operating after prosecution were required to comply with a Corporate Integrity Agreement. Ms. Brown elevated this requirement to an internal mandate, saying that "the rule I put out to my staff was in virtually all cases we would have an integrity agreement."

The compliance guidelines developed as part of these Corporate Integrity Agreements (CIAs) were generally developed to suit particular offenses and organizational contexts in health care, such as hospitals, laboratories, and long term care facilities. Although most CIAs were tailored to suit the particular organization and offense, Ms. Brown said that commonalities among these different compliance plans started to emerge as more agreements were enacted. Consequently, a decision was made to develop compliance program guidelines for health care industry segments more generally. This decision was predominantly driven by Ms. Brown's ongoing commitment to share the OIG's expectations with industry and to encourage self-policing through voluntary implementation of compliance programs. As she said, "My job wasn't just to catch people and stop a particular group – but to help the industry to work better and to put in their own controls so there won't be the kinds of problems we had identified in the past." The decision to develop program guidelines was also fueled by Ms. Brown's concern that some health care organizations were paying unscrupulous groups of consultants inordinate amounts of money to learn about the OIG's supposed expectations. In short, Ms. Brown pushed the development of publicly accessible program guidelines to demystify key aspects of the OIG's activities, and to encourage providers to adopt a more preventative focus.

The voluntary compliance program guidelines formulated under Ms. Brown's oversight were developed according to organizational type. Universal compliance guidelines were not developed for health care organizations, because this was not a practical approach for an industry characterized by diverse organizational types. Ms. Brown said that when the guidelines were first released there was a backlash from parts of the health care industry because the guidelines were perceived as yet more cumbersome regulation. Ms. Brown said that this was not her intention, as the guidelines were voluntary and organizations could implement alternatives as long as they were effective. "There was a great fear that the government was imposing a lot more regulations and a lot more requirements, and I was trying to get across, this is not the point. I want to share the information we have. I want you to know what we are looking for, so you have the option of setting up things that way or setting up an alternative that works. It would give a great deal of clarification I thought. That was the intent any way."

By the time of her retirement in December 2000, Ms. Brown had broadened the mission of the HHS OIG and left an indelible mark on the way the IG operated. When asked what she would like her legacy to be, she expressed the hope that there is now enough trust between health care organizations and the government that they can work together toward a mutual goal - to continue providing quality care. "I hope there is enough trust between the organizations that we can work together to improve the industry and to benefit the beneficiaries."

Inverview continued in the Issue of The Pastin Report on Healthcare Compliance. For a complete copy, please fill out our on-line request form.

The interview was conducted by Caitlin O'Brien. This extract from her notes was prepared by Ms. O'Brien and Mark Pastin. The Council of Ethical Organizations and the Health Ethics Trust thanks Ms. Brown for agreeing to be interviewed for this article. Questions about this article should be directed to Caitlin O'Brien at the Council at (703) 683-7916 or cobrien@corporateethics.com.

The material in this area is proprietary and protected by copyright registration to the Council of Ethical Organizations. Reproduction or dissemination-by any means-including photocopying and transmittal by FAX-is a violation of federal copyright law (17 USC 101 et seq) punishable by fines of up to $100,000 per violation. Violators will be prosecuted. Do not copy, quote, duplicate electronically or by any means disseminate without specific written permission.

The material in this area is proprietary and protected by copyright registration to the Council of Ethical Organizations. Reproduction or dissemination-by any means-including photocopying and transmittal by FAX-is a violation of federal copyright law (17 USC 101 et seq) punishable by fines of up to $100,000 per violation. Violators will be prosecuted. Do not copy, quote, duplicate electronically or by any means disseminate without specific written permission.