QUALITY AND COMPLIANCE

Transcription

1 2015 HCCA SOUTHEAST CONFERENCE JANUARY 23, 2015 QUALITY AND COMPLIANCE Katie Fink Donna Lewis Susan Walberg Presenters Katie Fink Senior Counsel Office of Counsel to the Inspector General U.S. Department of Health and Human Services (404) Donna L. Lewis Vice President, Chief Compliance and Privacy Officer Broward Health (954) Susan Walberg Vice President, National Director of Compliance Kohler HealthCare Consulting, Inc. (301) The Intersection of Compliance and Quality of Care 1

2 Roadmap Background and Overview Enforcement Landscape Reimbursement Considerations Provider Challenges and Strategies Questions 4 COMPLIANCE AND QUALITY BACKGROUND AND OVERVIEW Background of Compliance Programs 1991: Federal Sentencing Guidelines : Voluntary OIG Compliance Program Guidance 2010: Mandatory Compliance Programs 6 2

3 Mandatory Compliance Programs The Affordable Care Act mandates effective compliance programs for certain providers as a condition of enrollment in Medicare, Medicaid or CHIP CMS will select the types of providers required to have such programs CMS shall establish core elements of the programs and determine the timeline for implementation CMS addressed compliance program requirements for nursing homes separately 7 Board Involvement Corporate Responsibility in Health Care Quality With a new era of focus on quality and patient safety rapidly emerging, oversight of quality is becoming more clearly recognized as a core fiduciary responsibility of health care organization directors. Boards have distinct compliance-related responsibilities in this area because quality of care is perceived as an enforcement priority for health care regulators. Corporate Responsibility and Health Care Quality: A Resource for Health Care Boards of Directors (Joint OIG/AHLA 2007 publication) 8 Examples of Quality Reporting Requirements Physician Quality Reporting System (PQRS) Eligible professionals who do not satisfactorily report data on quality measures are subject to a 1.5% payment penalty beginning in 2015 Medicare and Medicaid EHR Incentive Programs Requires providers to submit Clinical Quality Measures (CQMs) from certified EHR technology in order to receive incentive payments Inpatient Quality Reporting (IQR) Program Requires hospitals to report data on select quality measures to receive the full update to IPPS payment rates 9 3

4 Examples of Quality Reporting Requirements Home health quality reporting Home Health Agencies (HHAs) are required to submit Outcomes and Assessment Information Set (OASIS) data to receive the full market basket update. HHAs that do not meet the reporting requirements are subject to a two (2%) percentage point reduction to the HH market basket increase. Hospice quality reporting The Hospice Quality Reporting Program was mandated by Healthcare Reform. For fiscal year 2014, and each subsequent year, failure to submit required quality data shall result in a 2 percentage point reduction to the market basket percentage increase for that fiscal year. 10 ENFORCEMENT LANDSCAPE OIG s Increasing Focus on Care Quality Examples of quality of care initiatives in OIG s Work Plan for FY 2015 include: Hospitals Determine the extent and nature of hospitals participation in projects with Quality Improvement Organizations Determine how hospitals assess medical staff candidates before granting initial privileges Measure and analyze incidence of adverse and temporary harm events for Medicare beneficiaries receiving post-acute care in inpatient rehabilitation facilities and long-term care hospitals Nursing Homes Determine the extent to which Medicare beneficiaries in nursing homes are hospitalized as a result of conditions thought to be manageable or preventable in the nursing home setting 12 4

5 Recent Quality of Care Corporate Integrity Agreements King s Daughters Medical Center (amended Dec. 2014) St. Joseph Health System (2014) Parkland Health and Hospital System (2013) 13 Quality of Care CIA Provisions Independent Quality Monitor 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 Reportable Events Related to Quality Issues Excerpt from Saint Joseph Medical Center CIA, November Quality of Care CIA Provisions Clinical Quality Systems Review Excerpt from Parkland Health and Hospital System CIA, May

6 Quality of Care CIA Provisions Medical Necessity Claims Review Excerpt from St. Joseph Health System CIA, January REIMBURSEMENT CONSIDERATIONS Reimbursement the ACA A major, overarching theme in the Affordable Care Act is one of measurement, transparency, and altering payment to reinforce, not simply volume of services, but the quality of the effects of those services. Instead of payment that asks How much did you do? the Affordable Care Act clearly moves us toward payment that asks, How well did you do? and more importantly, How well did the patient do? That idea is at the heart of value-based purchasing. It is not just a CMS idea; it is one increasingly pervading the agenda of all payers. Excerpt from St. Joseph Health System CIA, January

7 Reimbursement Government View With respect to promoting value in Medicare, the Department should continue to prioritize the effective transition to value-based payment mechanisms and the development and refinement of quality, outcomes, and performance metrics. Data systems supporting programs that link payment to quality and value must be scrutinized for timeliness, accuracy, and completeness. FY 2014 Top Management and Performance Challenges Identified By OIG 19 Evolving Reimbursement Models Linked to Quality Reimbursement is changing from a volume/ fee for service model to a value-based model predicated on outcomes and population health management Pay-for-performance Accountable Care Organization quality metrics Increased bundling and tying to quality issues 20 Quality-Driven Reimbursement Hospital Value-Based Purchasing Program Pays hospitals based upon how well they perform on specific quality measures Hospital Readmissions Reduction Program Reduces IPPS payments for acute care hospitals with excess readmissions Hospital-Acquired Condition (HAC) Reduction Program Hospitals in the highest quartile for certain HACs (i.e., the poorest performing hospitals) will receive a 1% IPPS payment reduction 21 7

8 PROVIDER CHALLENGES Provider Challenges Complying with increasing regulatory requirements Engaging multiple stakeholders Facilitating correction of identified deficiencies Ongoing education for employees and others Documentation of resolution of quality of care issues Ongoing monitoring and follow up 23 Strategies Integrate compliance into operations by: Including Chief Medical Officer and Director of Quality on your compliance committee Participating in board level quality meetings Holding bi-weekly or monthly meetings with quality staff and legal department Include quality in collaboration workflow for hotline calls, issues, audits, etc. Review PEPPER reports for trends Include quality in your annual compliance section and dedicate a component of your work plan to medical necessity and quality 24 8

9 QUESTIONS? 9