David Way, MAIS, CHC

1. The Crossroads of Quality and Compliance David Way, MAIS, CHC

2. Agenda Defining the Terms 1 Compliance as a by product 2 ✓ The driving force for Quality 3 4 Initiatives and Incentives 5 Healthcare Reform 6 Corporate Compliance: An Overview 7 Quality of Care: The OIG weighs in

3. Agenda The Crossroads 8 Legal Risks 9 ✓ Action Steps to Mitigate Risks 10 11 Discussion

4. 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. David Way MAIS, CHC

5. A Paradigm Shift Compliance Quality 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. The corporate compliance objective is to create quality in the goods of services it produces. tQuality in reducing the expenses and costs associated with non compliance Quality in reducing poor public perception Quality in the goods or services produced Quality 1 2 David Way, MAIS, CHC

6. Compliance is a By-Product Editable diagram - Pyramid 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. David Way MAIS, CHC

7. 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 David Way MAIS, CHC

8. 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 David Way MAIS, CHC

9. Incentives Pay for Reporting Pay for Performance Payment Disincentives 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 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. 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. 3 2 1 David Way MAIS, CHC

10. Demonstration Projects 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. 3 Hospital Quality Incentive Demonstration (HQID) 1 The Physician Group Practice (PGP) Demonstration 2 The Medicare Management Performance (MCMP) Demonstration David Way, MAIS, CHC

11. Health Reform Patient Protection and Affordable Care Act Quality Affordable HC for all Americans 1 Improving the quality and efficiency of health care 2 Prevention of Chronic Disease & Improving Public Health 3 Transparency and Program Integrity 4 Revenue Provisions 5 Strengthening Quality, Affordable health care for All Americans 6 Boards of Directors are look upon 7 David Way, MAIS, CHC

12. The Driving Forces for Compliance 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. 3 Integrity 1 Quality 2 Fiscal David Way, MAIS, CHC

13. Compliance Program Seven ‘Voluntary’ Steps ✓ Designate a Compliance Officer 1 ✓ Written Policies and Procedures 2 ✓ Conduct Effective Training and Education 3 ✓ Develop effective lines of communication 4 ✓ Enforcing Standards through well publicized Guidelines 5 ✓ Auditing and Monitoring 6 ✓ Responding to Detected Offenses and create Action Plan 7 David Way MAIS, CHC

14. 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. David Way MAIS, CHC

15. 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. David Way MAIS, CHC

16. 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. David Way MAIS, CHC

17. 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 "quality-of-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

18. Important Considerations 2 Reimbursement is moving toward a “quality based” system. Non compliance with measures may not be reimbursed or may generate an external audit reimbursement Quality Management is typically an operations function. QM practices are driven by standards. Sometimes QM departments may function as a silo. QM. 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. Compliance David Way MAIS, CHC

19. The Crossroad An inetgral convergence • Compliance 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. David Way MAIS, CHC

20. 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. David Way MAIS, CHC

21. 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. David Way MAIS, CHC

22. 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 David Way MAIS, CHC

23. 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 David Way MAIS, CHC

24. 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 David Way MAIS, CHC

25. 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 David Way MAIS, CHC

26. 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 • Executives • Board Members • Physicians • Direct care David Way MAIS, CHC

27. Action Steps to Mitigate Quality of Care Risks • Accountability • 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 David Way MAIS, CHC

28. 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

29. The Continuum Your own footer

30. THANK YOU!