The U.S. Attorney’s Office has declined to intervene in a case alleging that OneCare Vermont has committed fraud.
Robert Hoffman, a former manager of the analytics team for OneCare, asserted that the accountable care organization and the University of Vermont Medical Center had misled the state and federal agencies about the reliability of its data, which is central to the state’s health care reform efforts.
Hoffman claimed the government, specifically the federal Center for Medicaid and Medicare Services, had been defrauded and that he was fired from his job at OneCare because of the concerns he raised.
U.S. Attorney Christina Nolan declined to intervene in the case and made the court documents public on Wednesday. Nolan didn’t say why she made the decision, and she did not immediately respond to requests for comment.
Hoffman filed the complaint with the U.S. Attorney’s office in August 2018. He accused OneCare of violating the False Claims Act, which allows a whistleblower to come forward if they see a company commit fraud and if they believe it is costing the government money.
The law allows an individual to stand in the shoes of the federal government in court and includes stringent criteria to prove that the government was defrauded. The U.S. Attorney can intervene, decline or dismiss a case. If the DOJ declines to intervene, the whistleblower can come forward in the shoes of the government and sue. The U.S. Attorney’s office retains the right to step in and move forward with prosecuting the case at any time.
If true, Hoffman’s allegations raise significant questions about the value of OneCare’s data, which forms the basis for its efforts to reform Vermont’s health care system. Its data platforms have also cost the state and federal government millions of dollars.
Both OneCare and UVM Medical Center defended their data and said they were vindicated by the U.S. Attorney’s decision.
“When Mr. Hoffman first made these allegations over a year ago, OneCare and the UVM Medical Center conducted a robust internal and external investigation and found the claims to be unsupported,” UVM Medical Center said in a released statement. “Today, the state and federal governments both declined to intervene.”
OneCare also sent a written statement: “Mr. Hoffman worked for OneCare for less than two months in 2018,” the statement read. “Upon his departure he raised concerns that were investigated and determined to have no merit.”
Norm Watts, Hoffman’s attorney, says that even though the U.S. Attorney has declined to join the case, the issue may not be settled for good. Watts has filed a motion to dismiss the case without prejudice; he may prosecute the case himself, he said, or he may pursue a case arguing that Hoffman had been fired in retaliation. He and Hoffman will make a decision in the coming weeks, Watts said.
OneCare has been charged with enacting the state’s all-payer health care model which was created in 2016. OneCare collects money from Medicaid, Medicare, and private insurance companies. It then distributes the cash to doctors and hospitals as a way to coordinate care between doctors and save money. The University of Vermont Medical Center, a defendant in the case, partially owns and runs the accountable care organization.
A key part of OneCare’s mission is collecting and tracking data. The organization collects and tracks patient data to figure out if its efforts are keeping Vermonters healthy, and whether it is saving the system money. The company uses multiple systems to store and track that data, including the state-run Vermont Information Technology Leaders and their own system, called Health Catalyst, according to court filings. The state and the feds help to fund those platforms.
Hoffman was hired in January 2018 to manage the data analytics for OneCare.
The data systems in place were “flawed” and “virtually useless,” according to Hoffman’s complaint. There were gaps and inaccuracies in the data, he said. Hoffman confronted the leadership of OneCare about the issues he saw with the information, but they denied that there were problems, according to the complaint.
The faulty data and systems were also used to establish the standards, ultimately unrealistic and unfair ones, that doctors were supposed to meet, according to the filings. Medicare and Medicaid were also using the information under the impression that it was reliable, Watts wrote. The issues raised fundamental questions about whether OneCare was able to fulfill its mission, according to the complaint. “Thus, the basic purpose of an [accountable care organization] was deeply questionable and undependable,” Watts wrote.
Hoffman alleged he was “stonewalled” by his bosses after raising questions.
He was fired in May 2018, just two months after he started the job. OneCare said he was let go because of “poor performance,” according to the complaint.
Hoffman said in the complaint that he was fired because of his critiques. OneCare continued to assure the government that the data was reliable, according to the lawsuit. In doing so, they breached their contract with Medicare and Medicaid, Watts wrote.
According to the complaint, the feds have invested millions of dollars in the system. OneCare also paid millions of dollars for “worthless work,” Watts wrote.
The stakes could be high for OneCare if the case causes regulators to question the company’s data.
The accountable care organization is seeking approval of a $1.43 billion budget. Medicaid and Medicare are contributing $824 million of that total, which will be redistributed to hospitals and doctors for care. As part of that budget, OneCare is also asking for $3.5 million in state and federal money for health information technology investments.
The Green Mountain Care Board, which regulates health care in Vermont, will decide on the budget next month. Board chair Kevin Mullin declined to comment on the case.
Now, the ball is in Hoffman’s court.
He has the option to proceed with the same case with a private attorney against the company, Watts explained. In that scenario, he would prosecute the case instead of the U.S. Attorney on behalf of the federal government. Hoffman also can pursue a civil case against OneCare that alleges that his firing was retaliatory.
Watts said his client is not opposed to the all-payer health care system. Hoffman was formerly affiliated with the Wake Forest Baptist accountable care organization and trained under the chief architect of the ACO model, Elliott Fisher, at Dartmouth Institute.
“It’s not so much a matter of not liking the formula, the structure, or how it’s being managed,” Watts said. “He’s not opposed to the concept.”
And he added, Hoffman hasn’t given up in court. “He wants a remedy for those claims,” Watts said.
