Quality and Compliance HCCA Philadelphia Regional Conference · 2015. 5. 27. · 5/27/2015 1 Presented by Quality and Compliance HCCA Philadelphia Regional Conference Richard E. Moses,

5/27/2015

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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.

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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

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PPACA and SGR Repeal:

Measurable Quality and

Compliance

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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


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

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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

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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

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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



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”


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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



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))

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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

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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

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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

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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…

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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

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PPACA

and

Clinical Practice Guidelines

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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


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

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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.”

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● Purpose of CPGs

• Improve effectiveness & efficiency of medical practice

• Standardize practice

• Improve healthcare outcomes

● CPGs produced by professional societies, healthcare

organizations, government, international

organizations

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● 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



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.

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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

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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

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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


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

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Colonoscopy Guidelines

real time…

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CPGs Can Be Our Friends…

32Rex DK. Clin Gastroenterol Hepatol 2013;11:768-773.

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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

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Measurement is now the

new normal!

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COMBINING COMPLIANCE, QUALITY OF

CARE, RISK MANAGEMENT, &

MEDICAL MALPRACTICE

Building the Compliance

Program of the Future

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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

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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

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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

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CONCLUSIONS &

SUMMARY

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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

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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

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Presented byHealth Care Compliance Association

Philadelphia Regional Conference

Double Tree by Hilton Philadelphia

Philadelphia, PA

June 5, 2015

Thank You

Documents

Quality and Compliance HCCA Philadelphia Regional Conference · 2015. 5. 27. · 5/27/2015 1 Presented by Quality and Compliance HCCA Philadelphia Regional Conference Richard E. Moses,