Th 0215pm Linking Compliance Quality and RiskMgmt Murray.ppt · Becker’s Hospital Review 6...

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Community HospitalCommunity HospitalCommunity HospitalCommunity Hospital

Linking Compliance, Quality and Risk Linking Compliance, Quality and Risk Linking Compliance, Quality and Risk Linking Compliance, Quality and Risk Management for Better Patient OutcomesManagement for Better Patient OutcomesManagement for Better Patient OutcomesManagement for Better Patient Outcomes

Becker’s Hospital Review 6Becker’s Hospital Review 6Becker’s Hospital Review 6Becker’s Hospital Review 6 thththth Annual Meeting Annual Meeting Annual Meeting Annual Meeting –––– 7 May 20157 May 20157 May 20157 May 2015Presented by: David J. Murray, MS, BS, CCEP, CHPCPresented by: David J. Murray, MS, BS, CCEP, CHPCPresented by: David J. Murray, MS, BS, CCEP, CHPCPresented by: David J. Murray, MS, BS, CCEP, CHPC

Agenda for Today’s Rousing Session!

1) Board Fiduciary Responsibility

2) Past and Current Government Activity Linking Quality and Risk

3) Model for Linking Compliance, Risk and Quality

4) Case Reviews

Who are We Accountable Who are We Accountable Who are We Accountable Who are We Accountable to on Regulatory Side?to on Regulatory Side?to on Regulatory Side?to on Regulatory Side?

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Fundamental Oversight Duties of Trustees

• Management

• Strategic Planning

• Financial

• Compliance

• Quality

Responsibilities & Accountabilities of the Board

& Senior Management

Involvement and Commitment of the Board:

� “shall be knowledgeable”

� “shall exercise reasonable oversight”

� Annual board training

� Regular reports

� Sufficient information to accept key corporate choices

� Enhancing corporate culture

Responsibilities & Accountabilities of the Board &

Senior Management

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Headlines

U.S. spends more than twice as much as other developed

countries on healthcare . . .Yet lags well behind in key

measures of quality

4 in 10 Americans reported experiencing inefficient,

poorly coordinated or unsafe care. Commonwealth Fund

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Scorecard on U.S. health care

systems – Commonwealth Fund

For 37 key indicators for five health care system

dimensions (quality, access, equity, outcomes and

efficiencies), the overall U.S. score was 66 out of a

possible 100

Efficiency was the single worst score among the five

dimensions.

The U.S. is the worldwide leader in costs

The U.S. scored 15th out of 19 countries in mortality

attributable to health care services

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Scorecard on U.S. health care

systems – Commonwealth Fund

For 37 key indicators for five health care system

dimensions (quality, access, equity, outcomes and

efficiencies), the overall U.S. score was 66 out of a

possible 100

Efficiency was the single worst score among the five

dimensions.

The U.S. is the worldwide leader in costs

The U.S. scored 15th out of 19 countries in mortality

attributable to health care services

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Corporate Responsibility and

Health Care Quality

• Healthcare organization boards have distinct

fiduciary responsibility in quality

• Quality is also an enforcement priority for

health care regulators

E.g., poor or no quality is one definition of a

false claim

• Quality is considered a duty of care

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• Embedded within the duty of care is the

concept of reasonable inquiry – directors are

expected to make inquiries to management to

obtain the information to satisfy their duty of

care.

Corporate Responsibility and

Health Care Quality

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& Senior Management

Fiduciary Duties

• Duty of Care

• In re Caremark:

• Ensuring a corporate information and reporting system exists;

• Ensuring that the system is sufficient to assure appropriate information

regarding the organization’s compliance will come to the board’s

attention in a timely manner

• In re Citigroup:

• Held board members can be held personally liable for failure to oversee

corporate compliance activities . . .

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Focus on Areas of Concern to Enforcement

Community

• Submission of accurate claims and information

• Referral Statutes

• Payments to reduce or limit services

• EMTALA

• Substandard care

• Relationships with Federal health care beneficiaries

• HIPAA


& Senior Management

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Defining Quality – Institute of Medicine – Health care

should be:

1. Safe

2. Effective

3. Patient-Centered

4. Timely

5. Efficient

6. Equitable


& Senior Management

Compliance, Quality Compliance, Quality Compliance, Quality Compliance, Quality & Risk Convergence& Risk Convergence& Risk Convergence& Risk Convergence

Compliance:

�No/Poor Quality creates false claims

�Negligent Credentialing

�Non-retaliation for reporting


Quality

� Underutilization

� Overutilization

� Error – “To Err is Human” and “Crossing Quality Chasm”

� Outcomes

� Process Improvement

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Risk:

�Patient safety

�Incident reporting

�Push for Enterprise Risk Management


Government Enforcement:

�OIG Model Compliance

�Quality oversight

�Medically necessary services

�Over/Under utilization

�Guidance for Model Compliance Guides – Quality initiatives/links in each



�Work Plans – quality reviews – FY2015

�Hospitals – Quality of Care and Safety

�Participation in projects with QIO’s

�Oversight of pharmaceutical compounding

�Oversight of hospital privileging

� Inpatient Rehab – Adverse Events

�LTC Hospitals – Adverse events

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�Corporate Integrity Agreements-Quality

�St Joseph London

�Allegiance Health

�Dallas County Hospital District d/b/a Parkland Health and Hospital System

�All require integration of quality into system compliance programs with quality oversight (e.g. Chief Quality Officers etc.)



�Value Based Reimbursement

�Accountable Care Organizations

�Patient Centered Medical Homes

Our Organization and Case StudiesOur Organization and Case StudiesOur Organization and Case StudiesOur Organization and Case Studies

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Organization

Key Advantages

� No silos

� Communication

� Coordination

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Case StudyCase StudyCase StudyCase Study

Readmissions – Focus of all Payors:

� Do you know what your rates are?

� Implications for Reimbursement

� Focus of CMS

� A Case Study!!

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Case Study: - Readmissions

Period of Assessment: 14 months

Findings:

• 25% of readmissions had no

primary care provider

• Groups 4, 14, and 16 were

identified with cases by

volume

Intervention:• No primary care – high priority

for telephone follow up

• Target Groups: Partnerships for

transitions of care communication

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Results:

� Significant decrease in readmission rate

� Significant decrease in costs (i.e. consolidation of

admissions into one stay)

� Improved patient and provider satisfaction

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Avoidable Admissions/ED Visits/UC Visits:

� Assessment of Hierarchical Condition Categories (HCC)

presenting in any of these settings

� Identification of chronic conditions in acute exacerbation

within these groups


Avoidable Care –

Emergency Department at Community Hospital (CH)

• FY2014 YTD ED Visits: 27, at a cost to the health care system of approximately $40k (charges) (Average $1,470 per visit)

• FY2013 ED Visits: 66, at a cost to the health care system of approximately $105k (charges) (Average $1,590 per visit)

Observation and Inpatient Care at Community Hospital

• FY2014 YTD Inpatient/Observations: 16 cases at a cost to the health care system of approximately $473k (charges) (Average $29,562 per stay)

• FY 2013 Inpatient/Observations: 34 at a cost to the health care system of approximately $590k (charges) (Average $17,353 per stay)


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What We Found:

� In FY2013, 8 GVPC patients presented to CH ED across 11 visits

� In FY 2014 YTD, 3 GVPC patients presented to CH ED with diabetes out of control

� In FY2013, 7 GVPC patients were admitted (1 of which was admitted 3 times). [NOTE: Cost - $61k in care more than we were reimbursed]

� In FY2014 YTD, 5 GVPC patients were admitted [NOTE: Cost - $54k in care more than we were reimbursed]

� We had gaps in care – we needed to improve transitions


So we did some more data mining…

“empanelled patient population” – those

we had direct stewardship over in our

practices.


What We Found:

� 972 Patients empanelled at Grand Valley Primary Care (GVPC) are diabetic

� 81 have not been seen within the past year

� 62 are School District 51, 2 of which have not been seen within past year

� 111 GVPC patients visited Grand Valley Urgent Care (GVUC) in past year, totaling 353 visits

� At one point, 367 diabetics had their last HbA1C = 9 or higher


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Continued Evolution – Assess the Population we Manage – and Outcomes

Where we headed:

� Causality – Financial Barrier to Care� Employer Clinic for Self Funded Groups� Global Primary Care Fee (Doc + Lab + Pharm) – outside of deductible� EPO Arrangement� $$ to bottom line of the system

� Transitions� Longitudinal chronic care management with outcomes tracking� Aggressive inpatient management� Diabetic Education - Partnership Linkages� Provider Education – Feedback Loop on Patients

� Non-employed Physicians� Employed physicians

� No more avoidable visits for this for empanelled patients


Illustrative Example: Major Joint Replacements with Major

Co-Morbid Conditions – and average Operating Room Charges

Community Hospital Challenges . . .

Variance in Cost of Treatment

Major Joint Replacement (Hips & Knees)

with Major Co-Morbid ConditionAverage Operating Room Charges - FY 2009

Physician DRG 469 VAR AVERAGE VAR MEDIAN

10 $ 11,993 $ 3,674 $ 3,244

15 $ 9,184 $ 865 $ 435

5 $ 8,914 $ 595 $ 165

4 $ 8,749 $ 430 $ -

16 $ 7,264 $ (1,055) $ (1,485)

13 $ 5,932 $ (2,387) $ (2,817)

12 $ 5,349 $ (2,970) $ (3,400)

Average $ 8,319

Median $ 8,749


Illustrative Example: Major Joint Replacements without Major

Co-Morbid Conditions – and average Operating Room Charges



Major Joint Replacement (Hips & Knees)

without Major Co-Morbid ConditionAverage Operating Room Charges - FY 2009

Physician DRG 470 VAR AVERAGE VAR MEDIAN

9 $ 10,739 $ 2,893 $ 3,077

7 $ 10,161 $ 2,315 $ 2,499

3 $ 10,056 $ 2,211 $ 2,394

6 $ 8,652 $ 806 $ 990

12 $ 7,855 $ 9 $ 193

8 $ 7,469 $ (377) $ (193)

14 $ 6,435 $ (1,411) $ (1,227)

1 $ 6,058 $ (1,788) $ (1,604)

2 $ 6,052 $ (1,794) $ (1,610)

11 $ 4,979 $ (2,867) $ (2,683)

Average $ 7,846

Median $ 7,662


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Illustrative Example: Average Laboratory and Pharmacy Charges - Hips



Hip Replacement with No Major Co-

Morbid Conditions - FY 2010

Top Variance Cases by Gross Charges -

Laboratory

LABORATORY

CHARGES

VARIANCE

FROM MEAN

VARIANCE

FROM

MEDIAN

$ 2,455 $ 2,078 $ 2,270

$ 1,892 $ 1,515 $ 1,707

$ 1,739 $ 1,362 $ 1,554

$ 1,604 $ 1,228 $ 1,420

$ 1,523 $ 1,146 $ 1,338

$ 1,409 $ 1,032 $ 1,224

$ 1,353 $ 977 $ 1,169

$ 1,317 $ 940 $ 1,132

$ 1,154 $ 777 $ 969

$ 1,152 $ 776 $ 968

$ 1,129 $ 753 $ 945

$ 1,128 $ 751 $ 943

$ 1,068 $ 691 $ 883

$ 1,060 $ 684 $ 876

$ 1,059 $ 682 $ 874

$ 377 Mean

$ 185 Median

Hip Replacement with No Major Co-

Morbid Conditions - FY 2010

Top Variance Cases by Gross Charges

- Pharmacy

PHARMACY

CHARGES

VARIANCE

FROM

MEAN

VARIANCE

FROM

MEDIAN

$ 5,664 $ 3,410 $ 3,502

$ 5,479 $ 3,225 $ 3,317

$ 4,638 $ 2,384 $ 2,476

$ 4,204 $ 1,950 $ 2,042

$ 4,124 $ 1,870 $ 1,962

$ 3,661 $ 1,408 $ 1,500

$ 3,634 $ 1,381 $ 1,473

$ 3,605 $ 1,351 $ 1,443

$ 3,598 $ 1,344 $ 1,436

$ 3,252 $ 998 $ 1,090

$ 3,242 $ 988 $ 1,080

$ 3,225 $ 971 $ 1,063

$ 3,196 $ 942 $ 1,034

$ 3,157 $ 903 $ 995

$ 3,152 $ 898 $ 990

$ 2,254 Mean

$ 2,162 Median


Findings/Action

Waste:

� Significant waste in OR

� Lack of Control – Vendors and Orthos – What’s coming in our back door?

Potential Legal Issues

� Financial Arrangements – Suppliers and Orthos� Sunshine Act Results – a former surgeon was being paid

Compliance Oversight� Supply chain – standardization of supplies (e.g. “formulary”)

� Committee Process for Supply Selection


Illustrative Example – Simple Pneumonia: Average Laboratory and Pharmacy Charges



Simple Pneumonia - Adjusted for No Major Co-Morbid or

Co-Morbid Conditions

Physician ID

Average Charges

Laboratory

Variance

from Mean

Variance

from Median

47 $ 1,814 $ 889 $ 1,081

38 $ 1,715 $ 790 $ 982

30 $ 1,519 $ 593 $ 786

48 $ 1,303 $ 377 $ 570

50 $ 1,165 $ 240 $ 432

36 $ 879 $ (47) $ 146

31 $ 841 $ (84) $ 108

44 $ 777 $ (148) $ 44

33 $ 717 $ (209) $ (16)

42 $ 644 $ (282) $ (90)

35 $ 630 $ (296) $ (103)

39 $ 623 $ (302) $ (110)

41 $ 588 $ (337) $ (145)

46 $ 518 $ (407) $ (215)

45 $ 498 $ (427) $ (235)

34 $ 488 $ (438) $ (245)

49 $ 475 $ (451) $ (258)

43 $ 462 $ (464) $ (271)

32 $ 311 $ (614) $ (422)

40 $ 248 $ (678) $ (485)

37 $ 124 $ (802) $ (609)

Mean $ 925

Median $ 733

Simple Pneumonia - Adjusted for No Major Co-Morbid or Co-Morbid Conditions

Physician IDAverage Charges

PharmacyVariance

from Mean

Variance from

Median

47 $ 7,383 $ 5,336 $ 6,179

38 $ 4,512 $ 2,466 $ 3,308

31 $ 4,448 $ 2,401 $ 3,244

30 $ 3,149 $ 1,102 $ 1,945

48 $ 2,387 $ 340 $ 1,183

36 $ 2,222 $ 176 $ 1,018

32 $ 2,129 $ 82 $ 925

46 $ 1,578 $ (469) $ 374

35 $ 1,165 $ (882) $ (39)

34 $ 1,095 $ (952) $ (109)

50 $ 1,089 $ (958) $ (115)

33 $ 1,085 $ (961) $ (119)

45 $ 912 $ (1,134) $ (292)

41 $ 709 $ (1,337) $ (495)

43 $ 657 $ (1,390) $ (547)

42 $ 656 $ (1,390) $ (548)

39 $ 618 $ (1,429) $ (586)

49 $ 415 $ (1,631) $ (789)

44 $ 339 $ (1,708) $ (865)

37 $ 327 $ (1,720) $ (877)

40 $ 269 $ (1,777) $ (935)

Mean $ 2,047

Median $ 1,204


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Illustrative Example – Simple Pneumonia: “Profit” and Loss



Profit and Loss - Simple Pneumonia

Physician ID Net Payment P & L Patterns

20 $ (43,008)

23 $ (10,748)

36 $ (9,628)

21 $ (6,399)

28 $ (4,800)

37 $ (4,212)

22 $ (3,623)

25 $ (3,312)

26 $ (3,276)

24 $ (2,512)

30 $ (2,323)

34 $ (1,536)

31 $ (965)

29 $ (489)

38 $ (4) $ (96,836)

27 $ 57

33 $ 254

39 $ 1,098

32 $ 1,104

35 $ 2,412 $ 4,925

Grand Total $ (91,911)


Illustrative Example – Simple Pneumonia: Average Laboratory and Pharmacy Charges



Simple Pneumonia - Adjusted for No Major Co-

Morbid or Co-Morbid Conditions

Physician ID

Average

Charges Laboratory

Variance

from Mean

Variance

from Median

47 $ 1,814 $ 889 $ 1,081

38 $ 1,715 $ 790 $ 982

30 $ 1,519 $ 593 $ 786

48 $ 1,303 $ 377 $ 570

50 $ 1,165 $ 240 $ 432

36 $ 879 $ (47) $ 146

31 $ 841 $ (84) $ 108

44 $ 777 $ (148) $ 44

33 $ 717 $ (209) $ (16)

42 $ 644 $ (282) $ (90)

35 $ 630 $ (296) $ (103)

39 $ 623 $ (302) $ (110)

41 $ 588 $ (337) $ (145)

46 $ 518 $ (407) $ (215)

45 $ 498 $ (427) $ (235)

34 $ 488 $ (438) $ (245)

49 $ 475 $ (451) $ (258)

43 $ 462 $ (464) $ (271)

32 $ 311 $ (614) $ (422)

40 $ 248 $ (678) $ (485)

37 $ 124 $ (802) $ (609)

Mean $ 925

Median $ 733

Simple Pneumonia - Adjusted for No Major Co-Morbid or Co-Morbid Conditions

Physician IDAverage Charges

PharmacyVariance

from Mean

Variance from

Median

47 $ 7,383 $ 5,336 $ 6,179

38 $ 4,512 $ 2,466 $ 3,308

31 $ 4,448 $ 2,401 $ 3,244

30 $ 3,149 $ 1,102 $ 1,945

48 $ 2,387 $ 340 $ 1,183

36 $ 2,222 $ 176 $ 1,018

32 $ 2,129 $ 82 $ 925

46 $ 1,578 $ (469) $ 374

35 $ 1,165 $ (882) $ (39)

34 $ 1,095 $ (952) $ (109)

50 $ 1,089 $ (958) $ (115)

33 $ 1,085 $ (961) $ (119)

45 $ 912 $ (1,134) $ (292)

41 $ 709 $ (1,337) $ (495)

43 $ 657 $ (1,390) $ (547)

42 $ 656 $ (1,390) $ (548)

39 $ 618 $ (1,429) $ (586)

49 $ 415 $ (1,631) $ (789)

44 $ 339 $ (1,708) $ (865)

37 $ 327 $ (1,720) $ (877)

40 $ 269 $ (1,777) $ (935)

Mean $ 2,047

Median $ 1,204


Findings/Action

Waste/Over Utilization:

� Clinical benefit of resources used

� Quality/Risk oversight of resources used

Potential Legal Issues

� Deviation from standards of care

Compliance/Quality/Risk Oversight

� Credentialing Reporting – sufficient reporting?

� Ongoing monitoring/tracking

� Provider Education


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Health GradesHealth GradesHealth GradesHealth Grades

• Truven – Top 10% In Country for Quality Outcomes

• Community Hospital Receives 5-Star Ratings for Orthopedic Program

• Number 3 in Colorado!!!

• American Hospital Quality Outcomes 2013: Health Grades Report to the Nation– evaluates the performance of a 4,500 hospitals

nationwide – 30 of the most common conditions and

procedures

• Financial Improvement

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Fin

Questions?

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