Transcript Slide 1

The Crossroads of Quality and Compliance
David Way, MAIS, CHC
Agenda
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Defining the Terms
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Compliance as a by product
3
The driving force for Quality
4
Initiatives and Incentives
5
Healthcare Reform
6
Corporate Compliance: An Overview
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Quality of Care: The OIG weighs in
Agenda
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The Crossroads
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Legal Risks
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Action Steps to Mitigate Risks
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Discussion
Compliance & Quality
What is in a word?
•Compliance
The act or process of complying to a desire,
demand, proposal, or regimen or to coercion.
-Negativity is a common feeling toward
compliance’
•Quality
A ’degree of excellence’, superiority in kind, a
distinguishing attribute, an acuired skill.
-Excellence...Superiority, this certainly should
conjour up good feelings or pride.
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A Paradigm Shift
Compliance
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An ‘effective’ compliance program does
not coerce care providers into doing the
right thing. The worst circumstance or
system requirement is to have to make a
demand or coerce human behavior.
Quality
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tQuality in reducing the expenses and
costs associated with non compliance
Quality in reducing poor public perception
Quality in the goods or services produced
The corporate compliance objective is to
create quality in the goods of services it
produces.
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Quality
Compliance is a By-Product
Editable diagram - Pyramid
1.
Integrity
Compliance
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Quality
For years organizations have used
the ‘stick’ approach…if you do [this]
you will pay. Thinking of
compliance as a natural
progression forces us to consider
individual’s ethical principles. If my
standards of conduct are high I
likely am committed to the pursuit
of excellence [Quality] and
therefore will turn to the governing
rules/laws and standards to ensure
I am doing things legally.
The Driving Forces for Quality
Isn’t quality in medicine a no brainer?
•A Perfect Storm
 IOM’s To ”Err is Human and ”Crossing the Qualith
Chasm
Voluntary reporting programs
Dramatic advancements in IT
Depeletion of Medicare Trust Fund/Increasing
costs to Medicare program
Physician Compensation Models
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Health Care Quality Initiatives
Federal Government weighs in
•Federal and State initiatives to promote high quality,
efficient care:
 Payment Incentives (P4R and P4P)
Withholding/decreasing payments for HAC and
NCDs
Transparency though public reporting
•Health Reform
•Physician Compensation Models
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Incentives
Pay for Reporting
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Started as voluntary initiative
in 2003 with 10 quality
measures
Now mandatory and involves
more measures
Reductions in Medicare
payment for failure to report
Data is on the web at
hospitalcompare.hhs.gov
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Pay for Performance
2
Under the Hospital Quality
Incentive Demonstration, a
joint effort between CMS
and Premier Inc., quality
indicators for 260
participating hospitals rose
by 11.8 percent over two
years. The hospitals are
scored on their adherence
to 30 nationally
standardized measures in
five clinical areas: acute
myocardial infarction
(AMI/heart attack),
congestive heart failure,
coronary artery bypass graft
(CABG), pneumonia, and
hip and knee replacement.
Payment Disincentives
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tCMS is looking beyond
hospitals
Urging state Medicaid
programs to consider
similar programs
Since 2007 hospitals
required to report specified
HACs; and
Since 2008 Hospitals are
not paid the higher rate for
the reportable condition
unless it was POA.
Only inpatient…for now.
Demonstration Projects
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Hospital Quality Incentive
Demonstration (HQID)
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The Physician Group Practice
(PGP) Demonstration
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The Medicare Management
Performance (MCMP)
Demonstration
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CMS has released results from three
demonstration projects. These projects
offered participants incentives to improve
patient care with the belief that quality of
care would be increased and cost decreased.
As the link between payment and outcomes
grow stronger, hospitals and physicians
should ensure there is oversight to protect
the integrity of the data they submit to the
government in return for their rewards.
Health Reform
Patient Protection and Affordable Care Act
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Quality Affordable HC for all Americans
Improving the quality and efficiency of health care
Prevention of Chronic Disease & Improving Public Health
Transparency and Program Integrity
Revenue Provisions
Strengthening Quality, Affordable health care for All Americans
Boards of Directors are look upon
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The Driving Forces for Compliance
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Integrity
Quality
Fiscal
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With the passage of the Patient Protection
and Affordable Care Act of 2010, as
amended by the Health Care Education
Reconciliation Act of 2010 (the Healthcare
Reform Law), Congress for the first time has
mandated that a broad range of providers,
suppliers, and physicians adopt a
compliance and ethics program. Smaller
providers and suppliers may feel the impact
of these new compliance program
obligations most acutely given that many, if
not most, larger healthcare providers
already have some form of compliance
program.
Compliance Program
Seven ‘Voluntary’ Steps
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Designate a Compliance Officer
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Written Policies and Procedures
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Conduct Effective Training and Education
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Develop effective lines of communication
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Enforcing Standards through well publicized Guidelines
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Auditing and Monitoring
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Responding to Detected Offenses and create Action Plan
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OIG Focus on Quality of Care
Increasing Oversight
•Quality of Care CIAs – Key Focus Area
 28 Quality of Care CIAs as of 1/4/2011
 Additional Internal Requirements
 Quality of Care Review Program
 Board of Directors Dashboard – Communication
 Competency based training requirements
Quality of Care is a top enforcement priority. Prosecutors have used civil and criminal
statures to punish substandard car, and Medicare watchdogs have increasingly deployed
auditors to examine quality related issues.
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OIG Focus on Quality of Care
Increasing Oversight
•Government and private payers shift attention
 Medical necessity and quality of care is focal point
 The lines between coverage determinations and the
government’s expectation of clinical practice seem
blurred.
 Current investigations appear to be focused on
physicians medical judgment rather than types of
documentation and coding cases we have seen in the
past.
The HHS Office of Inspector General’s annual work plan targets quality, and in 2011 had an
item on “Hospitals’ controls for ensuring the accuracy of data released to quality of care,
which they submit to CMS for Medicare reimbursement.
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OIG Focus on Quality of Care
Increasing Oversight
•Government and private payers shift attention
 Increasing trend to hold hospitals accountable for
the physicians’ decisions within the four walls of the
hospital.
 Due to the changing invironment, it is becoming
critical for compliance officers to work with clinical
and quality departments to evaluate processes and
limit exposure from not only an outcomes perspective
but also a compliance perspective.
Quality must be a core measure of all we do.
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Quality of Care Corporate Integrity Agreements
•CIA
When a False Claims Act settlement resolves allegations of fraud
that impact the quality of patient care, OIG may enter into a "qualityof-care" Corporate Integrity Agreement (CIA) with the settling
provider. Under this type of CIA, OIG requires that the provider retain
an independent quality monitor. The quality monitor not only will
address the specific issues underlying the allegations, but also will
look at the entity's delivery of care and evaluate the provider's ability
to prevent, detect, and respond to patient care problems.
Quality must be a core measure of all we do.
David Way MAIS, CHC
Important Considerations
reimbursement
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Reimbursement
is moving toward a “quality
based” system. Non compliance with measures
may not be reimbursed or may generate an
external audit
QM.
Quality Management is typically an operations
function. QM practices are driven by standards.
Sometimes QM departments may function as a
silo.
Compliance
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Compliance is typically a staff person
responsibility. These individuals conduct
trainings, they monitor and audit internal
systems for compliance. They must collaborate
for success through systems, shared reports and
committee membership.
The Crossroad
An inetgral convergence
1.
Quality Management
Professional
Standards
Compliance
Credentialing/Screening
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Auditing
Monitoring
Compliance is the act of
conforming with stated
requirements. Organizationally, it is
achieved through management
processes which identify the
applicable requirements, assess
the state of compliance, assess the
risk and potential costs of non
compliance against the projected
expenses to achieve compliance,
and hence prioritize, fund and
initiate any corrective actions
deemed necessary.
Managing the Intersection
• Involve all units and all risk management
departments (legal, compliance, HR,
Quality etc.)
• Discuss priorities, overlap and
coordination
• Create annual work plans
• Integrate committees, if possible.
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Legal Risks
Learning from others.
•Management...Lack thereof
Hospitals have been penalized for conduct such as
chronic understaffing, reckless imposition of
budgetary constraints that impaired patient care,
and reckless submission of claims.
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Legal Risks
Learning from others.
•False Claim Act Liability
Three primary theories of liability, predominantly
triggered under the FCA by claims reimbursement
•Provision of medically unnecessary services
•Provision of care so deficient that it amounts to no
care at all, such that the claims are essentially
for services not rendered.
•Implied or false certification
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Legal Risks
Learning from others.
•Potential Provider Fraud Related to Federal Health Care
Quality Initiatives
•Billing for services not provided
•Upcoding – billing for a higher level of service than was
provided, or billing for services that did not meet the
P4P or P4R incentive payment conditions
•Failure to provide appropriate care
•Unnecssary and incorrectly performed procedures
•Poor Quality – intentional low quality care to save
money
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Action Steps to Mitigate Quality of Care Risks
• Improve Quality Compliance Oversight
– Quality must be on same par with financial and
regulatory
– Must identify relevant quality/safety issues and
establish a system for performance goals and
monitoring elements to ensure compliance.
– Solicit subject matter experts in compliance activities
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Action Steps to Mitigate Quality of Care Risks
• Engage Leadership
– Must promote the reporting of quality concerns and medical
errors and protect those reporting
– Ensure sufficient resources to support patient quality and safety
– Must measure resource changes in the context of quality and
safety outcomes/measures
– Competency assessment and training, credentialing, and peer
review must recognize necessary clinical and safety issues
– Must identify and report ‘adverse patient events’ so they are
analyzed and incorporated into the QI activities
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Action Steps to Mitigate Quality of Care Risks
• Employ Education Strategies
– Standardize and evaluate education efforts
– Keep records of quality-of-care education and attendance
– Provide profession/risk specific training
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Executives
Board Members
Physicians
Direct care
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Action Steps to Mitigate Quality of Care Risks
• Accountability
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Transparency and accountability are here to stay
Make accountability part of the fabric of your organization
Move from avoiding risk to maximizing excellence
Be patient…it takes time
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In our DNA
Quality and Compliance
The pursuit of quality and the commitment to
comply must be imbedded in the DNA of the
organization. Employees must ‘want’ to do
the right thing and feel safe and empowered to
report deviations from best practices, policies,
procedures etc.
David Way MAIS, CHC
The Continuum
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THANK YOU!