Dental Risk Management for Health Center Oral Health Programs

Presented by: Ronald Salyk, DDS and Juris Svarcbergs, DMD, MPHMorris Heights Health Center , CAMCare

Monday, March 21, 2005

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Risk Management for Health Center Oral Health Programs and the Federal Tort

Claims Act Review ProcessNational Primary Oral Health Care

ConferenceDecember 13, 2004

by Jay R. Anderson, DMD, MHSAChief Dental OfficerDivision of Clinical QualityBureau of Primary Health Care

Bureau of Primary Health Care

Division of Clinical Quality

Background• HRSA

– Mission: To improve and expand access to quality health care for all.

– Goal: Moving toward 100 percent access to health care and 0 health disparities for all Americans.

• BPHC– Mission: To increase access to comprehensive

primary and preventive care and to improve the health status of underserved and vulnerable populations.

– Goal: Developing and supporting systems of high quality, community-based, culturally competent health care.

HRSABureau of Primary Health Care

Structured for the Quality Improvement of Health Care

for Underserved Populations

Division of Clinical Quality

This image cannot currently be displayed.

This image cannot currently be displayed. Office of the

Director

Division ofHealth CenterDevelopment

Division of StateAnd Community

Assistance

Division of

Health CenterManagement

Office of Minorityand

Special Populations

BPHC Divisions and Offices

Interdependent & Complementary

IMPROVING

QUALITY HEALTH CARE

FOR VULNERABLE PEOPLE

Division of Clinical Quality

Supports and enhances the provision of high quality clinical care within the

national system of Federally funded health centers.

Division of Clinical QualityOFFICE OF THE DIVISION DIRECTOR

Suzanne Feetham, PhD, RN, FAAN Director

Amy M. Taylor, MD, MHS, FAAP Principal Program Manager

Clinical Quality Improvement Branch

Ahmed Calvo, MD, MPH, FAAFPBranch Chief

Clinical Quality Systems Branch

Felicia Collins, MD, MPH, FAAPBranch Chief

Clinical Quality Data Branch

Kay Felix-Aaron, MDBranch Chief

Clinical Quality Improvement Branch (CQIB)Roles and Activities

• Provides an infrastructure to assist health centers in responding to key health issues:– mental health– substance abuse– oral health– integration of science into prevention and the management of acute

and chronic health conditions

• Coordinates BPHC participation in Healthy People 2010 activities

• Coordinates workforce issues• Leads the Health Disparities Collaboratives activities

Clinical Quality Systems Branch (CQSB)Roles and Activities

• Develops risk management and quality assurance activities for health center implementation– Administers the Federal Tort Claims Act (FTCA) medical

malpractice insurance programs• Health centers• Free clinics

– Coordinates the external accreditation of health centers– Formulates and provides leadership for health center emergency and

disaster preparedness– Develops other activities:

• Patient safety• Patient centered evaluation

• Nearly 800 health centers deemed• Program has saved health centers an estimated $1

Billion since its inception in 1993• FTCA Program leadership within BPHC/DCG

– FTCA Program Manager• Aida Stark 301-594-4442

– Health Center FTCA Risk and Claim Management Coordinator• Susan Lewis 215-861-4364

Risk Management and Quality Assurance Health Center FTCA Program

General Updates

Number of Health Centers with FTCA* Medical Malpractice Coverage has Kept Pace with the

Annually Increasing Number of Health Centers FTCA Deemed** Health Centers, 1996-2003

439489 520 544

577 591 622695

890843

748730690694671686

0100200300400500600700800900

1000

1996 1997 1998 1999 2000 2001 2002 2003

Year

Num

ber

Deemed Centers Total Number of Health Centers

Source: Triton Group, Incorporated , Pompton Lake, NJCreated by: Amy Chanlongbutra, CQSB/DCQ/BPHC/HRSA, April 2004

†

*Federal Tort Claims Act**A deemed health center is a health center with

FTCA Medical Malpractice Coverage.†Estimated Number

Health Centers with FTCA Medical Malpractice Coverage have Realized Yearly Savings*Estimated Average Savings Per Health Center, 1993-2003

0

50,000

100,000

150,000

200,000

250,000

1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003

Year

Dol

lars

Source: Triton Group, Incorporated , Pompton Lake, NJCreated by: Amy Chanlongbutra, CQSB/DCQ/BPHC/HRSA, April 2004.

$234,517

*Health Center savings were calculated by The Triton Group based on the number of health centers deemed in each year and the malpractice premium structure for that year. Savings are a result of the Federally Supported Health Centers AssistanceAct of 1992 which significantly reduced the need of health centers to purchase private malpractice coverage.

Claim Status• Oct. 1994 thru March 2004 - 1375 Claims filed against the United

States– Closed Claims - approximately 55% of total– Paid Claims – approximately 30% of closed claims– Average cost per paid claim - $370,000– Average cost per closed claim - $114,000

Health Center Judgment Fund– FY 2004: sufficient funds available– Lack of funds have no effect on Health Center coverage.

Protection remains if fund is depleted. Plaintiffs have to wait to be paid.

Risk Management and Quality Assurance Health Center FTCA Program

Claims and Judgment Fund Updates

• Original Deeming – Health centers can submit applications at any time during

the year– BPHC notifies health centers of “deemed” status via an

original deeming letter– Original deeming valid for the remainder of the

calendar year (CY)– Health Center FTCA Original Deeming Coordinator

• Susan Lewis 215-861-4364

Risk Management and Quality Assurance Health Center FTCA Program

Original Deeming Reminders

• Redeeming – Application should be submitted concurrent with each

competitive and noncompetitive grant application Competitive grant cycle – Redeeming application reviewed by DCQ Noncompetitive grant cycle – Redeeming application reviewed by

Division of Health Center Management Project Officers– Redeeming letters – will be sent annually

CY 2005 letters – expected December 2004 – DCQ Redeeming Coordinators

• Original Deeming Coordinator - Susan Lewis 215-861-4364• Redeeming Coordinator- Barbara (Bobbie) Braden 301-594-1324• Deeming/Redeeming Letter Coordinator - Julie Pinkham Wright 301-594-

4139

Risk Management and Quality Assurance Health Center FTCA Program

Redeeming – Reminders & New Processes

Who is and isn't covered?

• FTCA covers ALL employees. • This also includes employees who work part-time or

those hired for short periods of time - such as locum tenens.

• As with any employee, there should be job descriptions and policies and procedures that clearly delineate roles, duties, responsibilities and tasks.

• These types of documents define the scope of employment, or those actions that employees can undertake on behalf of the community health center (CHC) and, therefore, will be protected under the FTCA malpractice claims immunity.

Who is and isn't covered?

• FTCA also covers ALL full-time contractors. • The Act will cover part-time contractors

(physicians, as well as non-physician providers) in family practice, pediatrics, OB/GYN, and general internal medicine.

• Any other specialty contractor (Dentists/Hygienists) must be full-time (over 32.5 hours/week) to be covered. For example, part-time contract dentists are not covered. Part-time employed dentists are covered.

Who is and isn't covered?• Furthermore, in order for the contractor to be covered,

the contract must be between the individual contractor and the entity as evidenced by a W-2 income tax form.

• FTCA does not cover contracts between the health center and any corporation. Contractors who work for an entity such as an agency, hospital, managed care organization or professional corporation will not be covered.

What activities are covered?

• All activities within the employee scope of employment and those that the health center has built into its approved scope of project are covered.

• Two situations that come up frequently: (1) all sites where health care services are performed are not listed in Exhibit B of the grant; and (2) changes to the scope of project are not requested prior to the change or are not requested at all.

• Sites not listed tend to be nursing homes, school-based programs and homeless shelters. Both of these situations may result in employees working without FTCA coverage.

Claims Management• A contract with KePro has recently been executed to

provide medical malpractice claim services such as recommendations on risk management, claims, and claim trend data for the Center for Risk Management.

• HCs that have received a notice of a claim against an employee will receive a letter from KePro that will indicate the names of individuals assigned to perform the investigation and proper procedures.

• It is important that HCs cooperate in order to develop a complete assessment of the possible liabilities.

References• "Clinician's Handbook on the Federal Claims Act“• PIN 97-6: Clarification of Certain Policies and

Procedures for Health Centers Deemed Covered under the FTCA for Medical and Dental Malpractice Liability

• PAL 99-15: Q & A on the FTCA Coverage; PIN 99-08: Health Centers and the FTCA

• PIN 00-04: Scope of Project Policy. • All of these documents can be downloaded from the

Bureau of Primary Health Care's (BPHC's) website at: www.bphc.hrsa.gov.

N o

Y e s

P r o c e s s e n d s .

C l a i m a n t f i l e s c l a i m ( S F - 9 5 ) w i t h P S C . 1 8 0 - d a y r e v i e w p e r i o d b e g i n s .

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P S C o b t a i n s i n f o r m a t i o n t o d e t e r m i n e t h e c l a i m ’ s F T C A e l i g i b i l i t y .

P S C f o r w a r d s t h e c l a i m t o H R S A f o r r e v i e w a n d n o t i f i e s t h e Q R P o f t h e c l a i m .

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T h e m e d i c a l r e v i e w e r o p i n e s i f t h e s t a n d a r d o f c a r e w a s m e t .

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P R P s e n d s t h e m e d i c a l r e v i e w a n d t h e s u m m a r y r e p o r t t o H R S A .

H R S A n o t i f i e s t h e Q R P t h a t t h e c l a i m i s r e a d y f o r r e v i e w .

Q R P r e q u e s t s t h e c l a i m a n d a l l r e l e v a n t d o c u m e n t s f r o m H R S A f o r r e v i e w .

Q R P r e v i e w s t h e c l a i m , i n c l u d i n g t h e m e d i c a l r e v i e w a n d t h e P R P s u m m a r y .

Q R P o p i n e s i f t h es t a n d a r d o f c a r e w a s m e t a n d n o t i f i e s P S C o f i t s d e c i s i o n .

P S C p r e p a r e s a s u m m a r y r e p o r t o f t h e c l a i m .

C l a i m o v e r $ 1 0 , 0 0 0 ?

C l a i m a n t f i l e s

s u i t ? O n l y a f t e r 1 8 0 - d a y s h a v e

p a s s e d . * *

A p p e n d i x A . A d m i n i s t r a t i v e R e v i e w P r o c e s s F o r M e d i c a l M a l p r a c t i c e C l a i m s A g a i n s t D e e m e d H e a l t h C e n t e r s F u n d e d B y H R S A

Y e s

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N oN o

A b b r e v i a t i o n s S F - 9 5 : S t a n d a r d f o r m f o r s u b m i t t i n g c l a i m s a g a i n s t t h e F e d e r a l G o v e r n m e n t . P S C : P r o g r a m S u p p o r t C e n t e r C l a i m s B r a n c h f o r t h e D e p a r t m e n t o f H e a l t h a n d H u m a n S e r v i c e s F T C A : F e d e r a l T o r t C l a i m s A c t P R P : P r i n c e t o n R i s k P r o t e c t i o n , I n c . H R S A : H e a l t h R e s o u r c e s a n d S e r v i c e s A d m i n i s t r a t i o n O G C : O f f i c e o f G e n e r a l C o u n s e l f o r t h e D e p a r t m e n t o f H e a l t h a n d H u m a n S e r v i c e s D O J : D e p a r t m e n t o f J u s t i c e

P S C f o r w a r d s c l a i m t o O G C .

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N o

O G C a l l o w s t h e c l a i m ? *

P S C a l l o w s t h e c l a i m ?

Y e s

O G C r e v i e w s t h e c l a i m a n d a l l r e l e v a n t d o c u m e n t a t i o n .

C l a i m a n t r e c e i v e s p a y m e n t a n d t h e p r o c e s s e n d s .

C l a i m a n t r e c e i v e s p a y m e n t a n d t h e p r o c e s s e n d s .

C l a i m a n t i s n o t i f i e d .

D O J w i t h a s s i s t a n c e f r o m O G C d e f e n d s t h e c a s e .

Neoplasms8%

Injury12%

Obstetrical Care28%

Disease of the Nervous System

30%

Circulatory Diseases

8%

Gastrointestinal Diseases

3%

Symptoms & Ill-Defined Conditions

5%

MusculoSkeletal Disorders

2%

Mental Health3% Dental

1%

y , , j % y

Note: Status as of April 30, 2004Diagnosis for Injury Alleged by ClaimantSource: Triton Group, Incorporated , Pompton Lake, NJCreated by: BA Bartman,, CQSB/DCQ/BPHC/HRSA, June 2004

Neoplasms11%

Injury17%

Obstetrical Care18%

Symptoms & Ill-Defined Conditions

12%

Circulatory Diseases

10%

Disease of the Nervous System

8%

Gastrointestinal Diseases

5%

MusculoSkeletal Disorders

4%

Dental3%

Mental Health2% Other

10%

Note: Status as of April 30, 2004Diagnosis for Injury Alleged by ClaimantSource: Triton Group, Incorporated , Pompton Lake, NJCreated by: BA Bartman,, CQSB/DCQ/BPHC/HRSA, June 2004

Distribution of ICD-9 Diagnoses

Health Center Malpractice Cases, N=913OB Care, Injuries and Neoplasms Most Common Cases

Risk Management and Quality Assurance Health Center FTCA ProgramTechnical Assistance Reminders

• FTCA HELP LINE– Technical Assistance on Health Center

FTCA Program– Proof of coverage requests– Call 866-FTCA-HELP (866-382-2435)

• Is a benchmark of quality• Increases competitiveness in marketplace• Enhances staff recruitment and retention• Improves staff morale and cohesion• Provides systemic performance improvement

Risk Management and Quality Assurance HRSA Accreditation Program

Benefits of Accreditation

DCQ’s Clinical Quality ChargeTriple 100%

DCQ will support and enhance health centers’ ability to move towards:– 100% participating in a Health Disparities

Collaborative– 100% obtaining external accreditation of

ambulatory care services– 100% participating in structured risk

management continuing education activities

BPHC’s CHALLENGE AND GOAL:

BE THE MODEL FOR PRIMARY HEALTH CARE IN

THE UNITED STATES

Contact Information• Jay Anderson, DMD , MHSA• Chief Dental Officer, Division of

Clinical Quality, Bureau of Primary Health Care, HRSAjanderson@hrsa.gov301-594-4295