Quality and Compliance HCCA Philadelphia Regional Conference · 2015. 5. 27. · 5/27/2015 1...
Transcript of Quality and Compliance HCCA Philadelphia Regional Conference · 2015. 5. 27. · 5/27/2015 1...
5/27/2015
1
Presented by
Quality and Compliance
HCCA
Philadelphia Regional Conference
Richard E. Moses, D.O., J.D.
D. Scott Jones, CHC
w w w . hpix-ins . c o m
Speakers’ Disclaimer
● Richard E. Moses, DO, JD and D. Scott Jones, CHC do not
have any financial conflicts to disclose.
● This presentation is not meant to offer medical, legal
accounting, regulatory compliance or reimbursement
advice and is not intended to establish a standard of care.
Please consult professionals in these areas if you have
related concerns.
● The speakers are not promoting any service or product.
2
5/27/2015
2
w w w . hpix-ins . c o m
Presentation Goals● Consider the growing importance of measurable quality
of care on compliance programs
● Review the impact of SGR Repeal and PPACA quality
reporting mandates, timeliness, and reimbursement
penalties
● Examine PPACA and Clinical Practice Guidelines (CPGs)
● Discuss the impact of SGR, PPACA and CPGs, and other
requirements, on quality of care and reporting
3
w w w . hpix-ins . c o m
PPACA and SGR Repeal:
Measurable Quality and
Compliance
4
5/27/2015
3
w w w . hpix-ins . c o m
From Fee Based to Quality Based
● Fee-for-service → Value-based/Quality-based
reimbursement system
• Reward doctors and hospitals for improving quality of care
• Reimbursement based decreased demand for inpatient hospital
services, higher demand for outpatient services
• Increasing numbers of insured patients
• Improving patient experience key to preserving reimbursement
• Public outcomes reports on the “Compare” websites = market
competition on outcomes and total value
• Clinically Integrated Networks and Population Health Initiatives
5Health Affairs October 11, 2012
w w w . hpix-ins . c o m
PPACA and Physician Payments● Patient Protection and Affordable Care Act (PPACA 2010) as
amended by the Health Care and Education Affordability
Reconciliation Act (HCERA 2012)
• Quality and Cost Payment (Title III, §§ 3002, 3003, 3007) – Adjusts
physician payments based on quality and cost through a value-
based modifier, beginning January 1, 2015
• PQRS – penalties for not reporting beginning in 2015 up to 2% of
the prevailing fee schedule
• Fee-for-service → value-based reimbursement (“quality”)
6
www.physiciansfoundation.org/uploads/default/Physicians_Foundation_2012_Biennial_Survey.pdf
www.ncsl.org/documents/health/ppaca-consolidated.pdf
5/27/2015
4
w w w . hpix-ins . c o m
Value Based Modifier (VBS)
● How quality data reported under PQRS equals modification to
payments under the FS
● VBS use began 2015; full implementation 2017
● Physician groups of 10 or more must report beginning 2016;
expect all physicians to report by 2017
● Quality tier system results in FS reductions of up to 2%
● QRUR (Quality and Resource Use Reports) will report how the
value based modifier will impact individual physician
reimbursement
7
w w w . hpix-ins . c o m
SGR Repeal and Medicare Provider Payment
Modernization Act of 2015 (HR 1470)
● Amends title XVIII (Medicare) of the Social Security Act to:
(1) remove sustainable growth rate (SGR) methodology from
the determination of annual conversion factors in the formula
for payment for physicians' services, and (2) revise the update
in rates for 2015 and subsequent years
● Directs the Secretary of Health and Human Services to
establish a Merit-based Incentive Payment (MIP) system
under which eligible professionals shall receive annual
payment increases or decreases based on their performance
8https://www.congress.gov/bill/114th-congress/house-bill/1470
5/27/2015
5
w w w . hpix-ins . c o m
SGR Repeal and Medicare Provider Payment
Modernization Act of 2015 (HR 1470)
● Requires specified incentive payments to eligible participants in an alternative
payment model
● Requires the Secretary to: (1) draft a plan for development of quality measures to
assess professionals, including non-patient-facing professionals; and (2) make
payments for chronic care management services
● Expands the kinds of uses of Medicare data available to qualified entities. Directs the
Secretary to provide Medicare data to qualified clinical data registries to facilitate
quality improvement or patient safety
● Declares it a national objective to achieve widespread exchange of health information
through interoperable certified electronic health records technology nationwide by
December 31, 2018
9https://www.congress.gov/bill/114th-congress/house-bill/1470
w w w . hpix-ins . c o m
MIPS Quality Performance
● PERFORMANCE CATEGORIES → Under the MIPS, the
Secretary shall use the following performance categories
in determining the composite performance score….
● “(i) Quality”
● “(ii) Resource use”
● “(iii) Clinical practice improvement activities”
● “(iv) Meaningful use of certified EHR technology”
10https://www.congress.gov/bill/114th-congress/house-bill/1470
5/27/2015
6
w w w . hpix-ins . c o m
MIPS Clinical Practice Improvement
● Expanded practice access, such as same day appointments for urgent needs
and after hours access to clinician advice
● Population management, such as monitoring health conditions of individuals to
provide timely health care interventions
● Care coordination, such as timely communication of test results, timely
exchange of clinical information to patients and other providers, and use of
remote monitoring or Telehealth
● Beneficiary engagement, such as the establishment of care plans for individuals
with complex care needs, beneficiary self-management assessment and
training, and using shared decision-making mechanisms
● Patient safety and practice assessment, such as through use of clinical or
surgical checklists and practice assessments related to maintaining certification
11https://www.congress.gov/bill/114th-congress/house-bill/1470
w w w . hpix-ins . c o m
PPACA Rule CMS-1600-P
Quality Reporting Measures● Physician Quality Reporting System (PQRS) 2014:
• 9 Measures be reported
• 3 from National Quality Strategy domains
• For 50% of the entire Medicare-eligible patient population
● Effect of not reporting PQRS occurs in 2016
● Failure to report a selection of the measures = up to 2% reduction
in prevailing Medicare FS
● Qualified Clinical Data Registries created for sub-specialists
dealing with specific diagnoses, conditions (§ 1848(m)(3)(E)(ii))
12
5/27/2015
7
w w w . hpix-ins . c o m
PPACA Section 10331(a)(2): CG-CAHPS
● Clinician and Group Consumer Assessment of Healthcare
Providers and Systems (CG-CAHPS)
• Patient surveys began 2014…individual physician surveys 2015
• Timely care, appointments, information
• How well doctors communicate
• Patient ratings of doctors
• Health promotion and education
• Shared decision making
• Health status/functional status as a result of care rendered
13
w w w . hpix-ins . c o m
Hospital Value-Based Purchasing
● PPACA Title III, Subtitle A: Transforming the Health Care
Delivery System
• Incentive Payments to Hospitals meeting performance standards in
� MI, Heart Failure, Pneumonia, Surgery, Infections, Pulmonary Embolism
and DVT Prophylaxis, Stroke
� ED, Readmissions, Children’s Asthma
• Performance Scores increase/decrease DRG payments
• Incentives up to 2% of the Medicare FS by 2017
• Data and Scores on Hospital Compare Internet Site
• GAO reports October 2015 and January 2016
14http://www.medicare.gov/hospitalcompare
5/27/2015
8
w w w . hpix-ins . c o m
Integrated Care Demonstration Project
● PPACA Section 2704
● Project continues through December 31, 2016
● Goal: Establish bundled payments for services and
providers involving an episode of care and hospitalization
● Severity of illness adjusted payment
● Data collection monitors outcome, cost, quality
● Report to Congress: December 31, 2017
15
w w w . hpix-ins . c o m
National Strategy for Quality Improvement
in Health Care
● PPACA Part S, Subpart I, Section 399HH(2)(B)(i-iii)
● Calls for CMS to establish priorities that will:
• Have the greatest potential for improving health outcomes,
efficiency, and patient-centeredness…
• Identify areas…that have the potential for rapid improvement in
the quality and efficiency of patient care…
• Address gaps in quality…
16
5/27/2015
9
w w w . hpix-ins . c o m
PPACA and Volume
• Increase from 260.2 Million Americans with health insurance to
292.6 Million under PPACA
• US Census Bureau 2012 Current Population Survey, Annual Social and
Economic Supplement
• 32-40 Million Americans acquire new health insurance benefits
with PPACA; proof of insurance required 2015
• U.S. physician workload expected to increase by 29% from 2005-
2025
• More than 50% of physicians are health system employees
17
w w w . hpix-ins . c o m
PPACA
and
Clinical Practice Guidelines
18
5/27/2015
10
w w w . hpix-ins . c o m
New Nomenclature
● Community Based Standard/Standard of Care
● Clinical Practice Guidelines = CPG
● Evidence Based Medicine = EBM
Williams, C. 61 Wash & Lee L. Rev. 179 (2004)
Leape, L. et al. 288 JAMA 501 (2002) 19
w w w . hpix-ins . c o m
Evidence Based Medicine
● Institute of Medicine (IOM)
● EBM Defined:
� “The conscientious, explicit, and judicious use of
current best evidence in making decisions about the
care of individual patients.”
Sacket, D. et al. 312 Brit. Med. J. 71 (1996)
Eddy, D. 26 J. Health Pol., Policy & L. 387 (2001) 20
5/27/2015
11
w w w . hpix-ins . c o m
Clinical Practice Guidelines
Institute of Medicine, TO ERR IS HUMAN: BUILDING A SAFER HEALTH CARE SYSTEM (1999)
Barry Furrow, et al., HEALTH LAW 267 (2nd ed. 2000)
Finder, J. Health Matrix: Journal of Law-Medicine 2000;10:67-115
● IOM
● CPGs Defined:
� “Systematically developed statements to assist the
practitioner with patient decisions about appropriate
health care for specific clinical circumstances.”
21
w w w . hpix-ins . c o m
Clinical Practice Guidelines
● Purpose of CPGs
• Improve effectiveness & efficiency of medical practice
• Standardize practice
• Improve healthcare outcomes
● CPGs produced by professional societies, healthcare
organizations, government, international
organizations
22
5/27/2015
12
w w w . hpix-ins . c o m
Clinical Practice Guidelines
● Published in 1970s & 1980s
● 1990s showed significant increase in CPGs
● NIH database → 6,793 English language CPGs
• 2011
● Variations in scientific validity, reliability, and usability
exist across the world
• “standardization of the standards” has been advocated
23http://qualitysafety.bmj.com/content/12/1/18.full.pdf+html
w w w . hpix-ins . c o m
Clinical Practice Guidelines
24
Number of English-Language References for “Clinical Practice
Guidelines” from 1974 – 2011 Per NIH Database, PubMed
Taylor C. Journal of Legal Medicine 2014;35:273-290.
5/27/2015
13
w w w . hpix-ins . c o m
CPGs: Quality & Reimbursement
• Measures collected under PQRS → “Quality Measures”
• Assessment of patient health outcomes & functional status of
patients
• Assessment of continuity & coordination of care & care
transitions
• Assessment of efficiency
• Assessment of patient experience & patient, caregiver, &
family engagement
• Assessment of safety, effectiveness, & timeliness of care
25
w w w . hpix-ins . c o m
CPGs v. Standard of Care
Conundrum
● Multiple treatment options are frequently available
● Questions in medicine frequently not answered by
scientific evidence
● Medical malpractice issue
● “Art” remains critical along with science
26
5/27/2015
14
w w w . hpix-ins . c o m
CPG v. Reality
• CRC Screening Recommendations
• Colon cancer prevention tests should be offered. The
preferred CRC prevention test is colonoscopy every 10
years, beginning at age 50.
• Screening should begin at age 45 in African
Americans
• REALITY CHECK → insurance coverage
• Despite PPACA
Rex DK, et al. Am J Gastroenterol 2009;104:739-750. 27
w w w . hpix-ins . c o m
Example: Quality Indicators for Colonoscopy
1. Appropriate indication
2. Informed consent is obtained, including specific discussion of risks associated with colonoscopy
3. Use of recommended post polypectomy and post cancer resection surveillance intervals
4. Use of recommended ulcerative colitis/Crohn’s disease surveillance intervals
5. Documentation in the procedure note of the quality of the preparation
6. Cecal intubation rates (visualization of the cecum by notation of landmarks and photo documentation of
landmarks should be present in every procedure)
7. Detection of adenomas in asymptomatic individuals (screening)
8.Withdrawal time: mean withdrawal time should be >6 minutes in colonoscopies with normal results performed in
patients with intact anatomy
9. Biopsy specimens obtained in patients with chronic diarrhea
10. Number and distribution of biopsy samples in ulcerative colitis and Crohn’s colitis surveillance.
11. Mucosal based pedunculated polyps and sessile polyps < 2 cm in size should be endoscopically resected or
documentation of unresectability obtained
12. Incidence of perforation by procedure type (all indications vs screening) is measured
13. Incidence of post polypectomy bleeding is measured
14. Post polypectomy bleeding managed non-operatively
Rex DK, et al. Am J Gastroenterol 2006;101:873–885.28
5/27/2015
15
w w w . hpix-ins . c o m
Colonoscopy Guidelines
real time…
29
w w w . hpix-ins . c o m
30
5/27/2015
16
w w w . hpix-ins . c o m
31
w w w . hpix-ins . c o m
CPGs Can Be Our Friends…
32Rex DK. Clin Gastroenterol Hepatol 2013;11:768-773.
5/27/2015
17
w w w . hpix-ins . c o m
Guidelines & QualityCompliance, Quality, Fraud & Malpractice
● Government Accountability Office (GAO)
• “…beneficiaries…who receive healthcare from providers who adhere to
PPACA…may receive higher quality of care…Conversely, those who receive
care from providers who fail to do so may receive lower quality of care.”
• “…it is possible that, if these (PPACA) standards and guidelines become
accepted medical practice, they could impact the standard of care against
which provider conduct is assessed in medical malpractice litigation.”
● Inadequate Quality can = Fraud and Malpractice
33
w w w . hpix-ins . c o m
Measurement is now the
new normal!
34
5/27/2015
18
w w w . hpix-ins . c o m
COMBINING COMPLIANCE, QUALITY OF
CARE, RISK MANAGEMENT, &
MEDICAL MALPRACTICE
Building the Compliance
Program of the Future
35
w w w . hpix-ins . c o m
INTERDISCIPLINARITY
● No one discipline can accomplish compliance
● Integration between compliance disciplines is
necessary
● Interdisciplinarity uses integration to produce a
cognitive advancement resulting in a positive and
productive outcome
36
Repko AF. Interdisciplinary Research: Process & Theory. 2nd ed. Sage Publications Inc. 2012
5/27/2015
19
w w w . hpix-ins . c o m
INTERDISCIPLINARITYPPACA
● PPACA INTERDISCIPLINARITY
• Electronic Medical and Health Records
• Quality of Care Reporting
• Risk Management
• Medical Error Reduction
• Medical Error Disclosure
• Self Disclosure of Overbilling
• Patient–Staff–Physician Communications and Portals
• Quality of Care Violations/Medical Malpractice
• Physician/Medical Practice Management
37
w w w . hpix-ins . c o m
Creating the Compliance Culture
for the Future
● Create a Just Culture
● Create a Culture of Responsibility
● Create a Reporting Culture
● Create a Systems Culture
● Create a Quality Culture
38
5/27/2015
20
w w w . hpix-ins . c o m
CONCLUSIONS &
SUMMARY
39
w w w . hpix-ins . c o m
D. Scott Jones, CHC ● Senior VP, Risk Management &
Healthcare Compliance – HPIX
● Compliance, Risk and Claims for 3600 providers
● Former medical practice & hospital administrator
● Board Certified Healthcare Compliance Officer (CHC)
● Author, on quality, practice management, compliance
● Frequent speaker to state, regional and national organizations
● Over 1000 compliance risk assessments for healthcare organizations
nationwide
● [email protected] (904) 294.5633
40
5/27/2015
21
w w w . hpix-ins . c o m
Richard E. Moses, D.O., J.D.
● Practicing Gastroenterologist for over 30 years
● Board Certified:
● Gastroenterology
● Internal Medicine
● Forensic Medicine
● Adjunct Assistant Clinical Professor, Temple University School of Medicine
● Adjunct Professor of Law, Temple University Beasley School of Law
● Physician Advisor Healthcare Providers Insurance Exchange
● National Speaker, Author and Consultant on Medical, Risk and Compliance
education
● [email protected] (215) 742-9900
41
w w w . hpix-ins . c o m
42
5/27/2015
22
Presented byHealth Care Compliance Association
Philadelphia Regional Conference
Double Tree by Hilton Philadelphia
Philadelphia, PA
June 5, 2015
Thank You