Australia’s healthcare provider for asylum seekers in detention accepted that fraud would occur within its own ranks and expected to fail a series of healthcare benchmarks set by the immigration department, leaked internal documents have revealed.
One presentation suggests ways the firm, International Health and Medical Services, can “grab from ‘the excuse bag’” when it misses government targets.
An investigation by Guardian Australia into IHMS has exposed serious concerns about the medical organisation and its relationship with the Department of Immigration and Border Protection in caring for asylum seekers held in detention in Australia, Papua New Guinea and Nauru.
Leaked internal presentations show the tension at the heart of the company as it grappled with meeting professional standards of clinical care, balanced against its commercial interest in maintaining its contract with successive Australian governments and avoiding financial penalties.
A spokeswoman for IHMS said the company did not compromise clinical care against its contractual requirements. A spokesman for the immigration minister Peter Dutton said the immigration department was investigating the concerns raised by IHMS in consultation with the minister.
In one September 2013 presentation titled “briefing – contractual performance management” a senior business analyst outlines the state of play for the organisation six months after a scheme imposing financial penalties on it for poor performance at Christmas Island began.
The scheme – known as the “abatements regime” – relies on a series of benchmarks around adequate clinical care, such as meeting GP appointments, completeness of staff records, writing incident reports and handling complaints.
It focuses mostly on a range of different deadlines, and requiring IHMS to meet certain time limits for different medical duties, with high thresholds for meeting these deadlines.
According to the internal briefing, the heavy focus on deadlines combined with high performance thresholds means there is a “conflict between clinical and contractual objectives” and a “requirement for national office to help determine priorities so staff can resolve such conflicts”.
The slide concludes with the remark that, in the context of meeting these goals, “fraud is inevitable”.
In a later slide the business analyst outlines serious concerns with the contract that governs IHMS, the immigration department’s overall management, and weaknesses within IHMS itself.
It says the contract with the immigration department is “poorly drafted” and there is an “inconsistency between contract and day-to-day activity”. It says that a “major challenge” is converting a contractual obligation which is “often vague” into staff procedures.
It describes the immigration department stance as “confused”, and notes that within IHMS there is a focus on “here and now”, and not long-term planning, and an “inability to implement basic procedures”.
Other documents reveal a pattern of comments in internal briefings that highlight concerns meeting the terms of the contract, the immigration department’s rigid views of performance, and how this could conflict with clinical care.
A spokeswoman for IHMS said: “IHMS does not compromise clinical care against its contractual requirements. The performance management framework is aligned to the provision of quality health outcomes.
“At no stage has IHMS’s contractual requirements impacted the quality of care it provides to detainees. IHMS enjoys an open and transparent relationship with the department and we recently agreed upon a new set of performance measures closely aligned to clinical outcomes.”
‘The excuse bag’
In 2012 the performance management scheme IHMS was subject to for its care of asylum seekers was introduced. The scheme was being phased in, so while IHMS was monitored, it was not being financially penalised for breaches.
In one internal July 2012 presentation titled “Abatements – progress review” the current performance measures were being considered.
The slide is titled: “Inevitability: fail to meet a KPI – grab from ‘the excuse bag’.”
Items to choose from the “excuse bag” are events such as infrastructure failings, personnel shortfalls, and the immigration department’s failure to provide information.
It said “many of the metrics are poorly designed”, and notes that “inevitably, any discussion about performance will resolve around what’s been pulled from the excuse bag, not on performance itself”.
The slide strongly suggests that the care of asylum seekers was not being measured effectively by the scheme that governs IHMS.
A spokeswoman for IHMS said in response: “There are provisions in our contract with the department to accommodate inability to deliver services due to reasons beyond IHMS’ control. Our contract with the department at the time (2012) allowed for excusable performance failure to be considered as part of the monthly reporting framework and the department typically considered external elements that affected IHMS’ ability to provide the service.”
Littered through the presentations are various references to this conflict. When the department and IHMS were negotiating new benchmarks, IHMS noted in a May 2012 briefing: “many of the metrics focus more on efficiency. Only one metric (‘mental health screenings’) focuses on continuity of care.”
Another July 2012 presentation highlights the “potential for confusion” of “providing quality healthcare” and “minimising abatements/maximising incentives”.
It continues: “policy: healthcare outcomes are first priority. However we … cannot hide behind ‘healthcare’ as an excuse for failing to perform … must record circumstances where decisions have been made to place healthcare needs above the need to avoid abatements (where these objectives conflict).”
‘Looking at what the potential excuses could be’
The challenges of meeting both clinical and commercial goals led to tension within the organisation. In August 2013 a conference of health service managers (HSMs) within the organisation was held to discuss how they could respond to a range of different issues.
In a feedback document about the conference , the notes say: “HSMs are concerned about ‘the rules’. These rules are very significant policy decisions with significant ramifications in terms of clinical outcomes, management of workload on site, relationship with DIAC [Department of Immigration and Citizenship] etc. These rules should not be formulated by the performance reporting team in isolation.”
It notes the managers are worried and “quite certain they will not be able to comply with all metrics”. As a result of this, they “are already looking at what the potential excuses for performance failures could be.”
Movement of asylum seekers and how that affected deadlines was seen as one of the key issues, including the way that affected sites like Manus Island, Christmas Island and Nauru.
“Best example is large volumes of clients coming off CI [Christmas Island] who have not had screenings done and then receiving site is left holding the bag,” the notes said.
The feedback notes also contain comments from an IHMS business analyst. As a final note to the document he wrote: “If we want we can get very tricky and tactical about this, attributing performance in a way that will minimise the financial impact. ie try to attribute bad performance to smaller sites with a smaller at risk fee. If one site is guaranteed to fail anyway you can stack on more bad performance.
“If one site is almost certain to pass then you can give them some bad performance and they will have a sufficient buffer to still pass. All of this however is driven by client movements and we do not control that.”
In response to the comments outlined in the feedback notes an IHMS spokeswoman said: “In August 2013 there were no financial penalties under the performance management framework. The performance management framework assessed performance at each individual facility and clinical care at each facility has always been prioritised.”
‘It’s your regime and we’ve followed the contract’
At various points through its management of the detention centres, IHMS attempted to seek changes to the contract to bring it more in line with clinical care objectives. Other documents highlight how it pushed for changes to the contract or resisted measures and faced a backlash from the department.
In one instance, IHMS had a “significant performance failure” in its monthly report for May 2012. The response from an immigration officer in the slide is: “I’m very pissed off and have told Paul Windsor about this. IHMS has simply tried to justify why its performance shouldn’t be measured for the month”.
The IHMS official said its response was: “It’s your regime and we’ve followed the contract. Given the design of the metrics, the outcome was guaranteed.”
The slide goes on to say that the department made the point that it “needs to be able to front a parliamentary committee and demonstrate that it is holding IHMS to account”. It adds that the department told them: “We just need to show progress.
The IHMS officer responded and said: “IHMS has done all the work. DIAC has never provided guidance.” It adds that “DIAC’s data is poor”. One slide refers to a “Mickey Mouse” metric.
Changes were then considered to the scheme by IHMS, where it considered a range of potential changes to the current regime. In the event that “bad metrics” were retained, the slide notes: “Unrealistic thresholds (fraud guaranteed)”.
An earlier October 2011 slide reveals similar concerns about the early rollout of the abatement scheme to Christmas Island. In a slide titled “potential traps”, the author of the slide notes “dirty, ‘work around’ solutions are inevitable”.
‘A real prospect of severe and increasing financial penalties’
Separate documents also reveal that the company expected it would fail key performance benchmarks in its care of asylum seekers. In August 2013 the new abatement scheme was only just going live in detention centres around the country.
It notes that the company was “unprepared” for the abatements regime and said that there was “a real prospect of severe and increasing financial penalties”.
It assessed that at the time there was an extreme risk of failure to meet obligations surrounding asylum seeker healthcare records and health inductions assessments.
High risks were also identified for mental health screenings, health discharge assessments, incident reports, vaccinations, diabetes and complaint management.
The same presentation also notes that providing compelling excuses for failing and meeting performance standards will initially be “equally important”.
The slide also reiterates other concerns within the immigration department.
The immigration department’s measurements of performance for detention services has had some official scrutiny. In a 2012-13 report the Australian National Audit Office noted that the abatement metrics at the time “could be better balanced to increase the focus on the quality of services provided to detainees”.
The immigration department accepted the recommendations, and began implementing a joint services delivery assurance framework (JSDAF) to re-examine the effectiveness of the current measurements.
An internal audit report released under freedom of information laws dated to April 2014 recommended that the health contract also be included in this framework to ensure that “performance is aligned with and incentivised toward achieving the desired outcomes”.
The immigration department advised in its response that the health provider would be governed by such a scheme.
But it remains unclear to what extent the metrics have changed, and whether the conflict between clinical and commercial objectives has been resolved.
A spokesman for the immigration minister Peter Dutton said: “The claims being made relate to a period several years ago mainly under the previous Labor government and it was a period of great dysfunction.
“Contracts for the provision of health services were re-negotiated late last year under the coalition and the performance measures in the new contracts were made more rigorous.”
“The Coalition government expects contract conditions to be met by any service provider.”
Documents
Contractual performance management Sep 13
Contractual performance management Oct 11
Abatements progress review Jul 12
HSM conference performance management
Contractual performance management May 12