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The Evolving Role of the Compliance Officer in the Age of Accountable Care

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Much has been written about new competencies physicians must develop in the face of payment and delivery system reform. But providers are not the only ones seeing their roles change. Compliance …

Much has been written about new competencies physicians must develop in the face of payment and delivery system reform. But providers are not the only ones seeing their roles change. Compliance officers, who serve as organizations’ internal police officers, will have many new challenges. PYA Principal Martie Ross presented a national Health Care Compliance Association (HCCA) webinar entitled “The Evolving Role of the Compliance Officer In the Age of Accountable Care.”

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  • 1. The Evolving Role of the Compliance Officer In the Age of Accountable Care Health Care Compliance Association Web Conference February 27, 2014 Prepared for Health Care Compliance Association February 27, 2014 Page 0
  • 2. Fences Around Fee-For-Service • • • • • • • • Anti-Kickback Statute Stark Law Civil Monetary Penalties NCDs/LCDs CoPs False Claims Act Documentation standards Coding rules …and the list goes on… Prepared for Health Care Compliance Association February 27, 2014 Page 1
  • 3. Compliance-Related ACA Provisions • Mandatory compliance programs • Increased funding for enforcement • Physician Payment Sunshine Act • IRC 501(r) (non-profit hospitals) • Stark self-disclosure protocol • 60-day window for refunding overpayments • AKS violations = FCA liability • Government-subsidized insurance = FCA liability? Prepared for Health Care Compliance Association February 27, 2014 Page 2
  • 4. Evolution of Health Care Today Tomorrow IP Facilities CIN MultiSpecialty Groups ACO OP Facilities Patient Ancillary Services PCPs ACO Specialists Specialists Facilities Facilities Medical Home Medical Home Specialists Person Person Prepared for Health Care Compliance Association February 27, 2014 Page 3
  • 5. Evolution of Relationships Tomorrow • Hospitals as police officers • Physicians as cherrypicking competitors • Exception-based practice • Provider-entered care • Care coordination and provider collaboration • Evidence-based practice • Patient-centered care Prepared for Health Care Compliance Association February 27, 2014 Page 4
  • 6. Evolution of Reimbursement Fee for Service Shared Savings Visitor Bundled Partial Payments Capitation Patient Symptomatic Episode Acute Needs Most Common Conditions Services and Supplies Packaged Treatments Unit-Based Efficiency-Based No Financial Risk Partial Financial Risk Global Payment Person Overall Health Community Health Characteristics Manage Well-Being Outcome-Based Full Financial Risk Prepared for Health Care Compliance Association February 27, 2014 3/5/2014 Page 5 Page 5
  • 7. Foot in Two Canoes • If quality – not quantity – drives payment, what happens to compliance risk as we know it? • If new payment models encourage collaboration, but existing regulations discourage it, how do we deal with inconsistencies? • How do we avoid unintended consequences in designing incentives for quality and efficiency? Prepared for Health Care Compliance Association February 27, 2014 Page 7
  • 8. Two Strategies Payment Based on Quality Rewards for Clinical Integration Prepared for Health Care Compliance Association February 27, 2014 Page 8
  • 9. Payments Based on Quality Four Tactics 1. Hospital Readmission Reduction Program 2. Hospital Value-Based Purchasing DRG Modifier HAC/Never Event Penalty 3. Physician Quality Reporting System 4. Physician Value-Based Payment Modifier Prepared for Health Care Compliance Association February 27, 2014 Page 9
  • 10. Hospital Readmission Reduction Program • Penalty based on 3-year historical 30-day hospital readmission rates for AMI, heart failure, and pneumonia – Same or any other subsection (d) hospital – Reason for readmission irrelevant – List expands in 2015 to include hip/knee arthroplasty and COPD Prepared for Health Care Compliance Association February 27, 2014 Page 10
  • 11. Penalties Penalty attaches to all DRG payments: FY2013 1% Reduction 2,200 hospitals penalized $280 million FY 2014 2% Reduction FY 2015 and going forward 3% Reduction Even more costly • Negative perception in community • Commercial insurance/employers Prepared for Health Care Compliance Association February 27, 2014 Page 11
  • 12. Hospital Value-Based Purchasing • Medicare Modernization Act of 2003 – Hospital IQR Program • Report on quality measures to avoid 2% cut in payment updates • 90% participation • American Reinvestment and Recovery Act of 2009 – Meaningful use incentive payments (quality reporting) • Affordable Care Act of 2010 – DRG modifier – HAC/Never Event penalty Prepared for Health Care Compliance Association February 27, 2014 Page 12
  • 13. DRG Modifier • Adjustment to DRG payment based on clinical quality measures and patient satisfaction scores – Achievement and improvement – Budget neutral (winners and losers) – Percentage of DRG payments at risk (withhold and redistribute) • 1.25 percent for FY2014 Prepared for Health Care Compliance Association February 27, 2014 Page 13
  • 14. HAC/Never Event Penalty • Begins in FY2015 • Top quartile (lowest scores) = 1 percent payment reduction Prepared for Health Care Compliance Association February 27, 2014 Page 14
  • 15. Measures • Proposed “never events” – – – – – – Pressure ulcer rate Volume of foreign object left in the body Iatrogenic pneumothorax rate Post-operative physiologic and metabolic derangement rate Post-operative pulmonary embolism or DVT rate Accidental puncture and laceration rate • Proposed HACs – Central line-associated blood stream infection – Catheter-associated UTI Prepared for Health Care Compliance Association February 27, 2014 Page 15
  • 16. Rock and a Hard Spot • JAMA: Surgical Complications and Hospital Finances – Analyzed data from 10-hospital system in southern US – Surgical complications = higher hospital contribution margins (except for Medicaid and self-pay) – Substantial adverse near-term financial consequences of reducing overall complication rate Prepared for Health Care Compliance Association February 27, 2014 Page 16
  • 17. Physician Quality Reporting System • Submission of reports, not achievement of scores – Range of reporting options • Carrots followed by sticks – 0.5% bonus in 2013 and 2014 – 1.5% penalty in 2015 if ≠ report in 2013 – 2.0% penalty in 2016 ≠ report in 2014 (and thereafter) • Meaningful Use penalties – 1% penalty in 2015 if not MU in 2014; 2% in 2016; 3% in 2017; 4% in 2018 or 2019 – eRx Incentive Program Payment Adjustment – 2% penalty in 2014 Prepared for Health Care Compliance Association February 27, 2014 Page 17
  • 18. Physician Value-Based Payment Modifier • Phased in between 2015 and 2017 • 2013 performance determines 2015 modifier for providers in groups of 100+ • Budget neutral (winners and losers) • wRVU x conversion factor x VBPM – Positive number = paid more – Negative number = paid less • Far broader impact than Medicare payment Prepared for Health Care Compliance Association February 27, 2014 Page 18
  • 19. Physician Feedback Reports • Individual reports on resource use and quality of care as compared to peer group based on Medicare data • Used to calculate Medicare physician value-based payment modifier • Schedule – By April 2013, reports to physicians in groups of 25+ in nine states based on 2011 data (CA, IL, WI, MN, MI, MO, IA, KS, NE) – By February 2014, reports to physicians in groups of 25+ nationwide based on 2012 data – All physicians by 2016 Prepared for Health Care Compliance Association February 27, 2014 Page 19
  • 20. SGR Fix • Formula (never) used to calculate Medicare physician payment rates • CBO now estimates cost around $120 billion (a bargain!) • HR 4015, The SGR Repeal and Medicare Provider Payment Modernization Act of 2014 – Phase 1: Stabilize FFS payment rates – Phase 2: Merit-based Incentive Payment System – Phase 3: Alternative Payment Models Prepared for Health Care Compliance Association February 27, 2014 Page 20
  • 21. Compliance Priorities Payments Based on Quality • Physician incentives – Employed physicians – Gainsharing – Co-management agreements – Care management services • • • • Patient inducements Lemon dropping/cherry picking Accuracy of quality data reporting Medical record documentation (consistent with quality reports) Prepared for Health Care Compliance Association February 27, 2014 Page 21
  • 22. Clinically Integrated Care Pillar 1: Collaborative Leadership Pillar 2: Aligned Incentives Pillar 3: Clinical Programs Pillar 4: Technology Infrastructure Governance body Physician compensation Disease programs Health information exchange Clinical metrics Patient longitudinal record Payer strategy Program infrastructure Population health management Disease registry Culture change Physician support Compliant legal structure Care protocols Patient portal Prepared for Health Care Compliance Association February 27, 2014 Page 22
  • 23. Rewards for Clinical Integration Three Tactics 1. FFS Payment for Care Management 2. Accountable Care Organizations 3. Bundled Payments Prepared for Health Care Compliance Association February 27, 2014 Page 23
  • 24. FFS Payment for Care Management • New MPFS payment for post-discharge transitional care management • Key elements – Contact within 2 days of discharge – Face-to-face visit within 7 (or 14) days – Non-face-to-face care management services over 30-day period • Proposed chronic care management payments in CY2015 Prepared for Health Care Compliance Association February 27, 2014 Page 24
  • 25. Accountable Care Organization • Providers who voluntarily work together to improve quality/reduce costs • Patient attribution based on PCP • Opportunity for shared savings – Total FFS payments – benchmark – Held accountable for quality of care by performance standards Prepared for Health Care Compliance Association February 27, 2014 Page 25
  • 26. Medicare Shared Savings Program ACO Functions • Establish and maintain quality assurance and improvement program • Promote evidence-based medicine, patient engagement, care coordination, patient-centeredness • Compile and report participants’ quality measure scores • Distribute shared savings and assess shared losses Prepared for Health Care Compliance Association February 27, 2014 Page 26
  • 27. Calculating Shared Savings/Losses • Each ACO participant continues to bill fee-for-service independently • Eligibility for and level of shared savings based on performance score • Calculate actual total cost of care for assigned patients against pre-determined benchmark • Apply formula to determine share of savings (losses) Prepared for Health Care Compliance Association February 27, 2014 Page 27
  • 28. MSSP ACO Waivers • Stark Law, Anti-Kickback Statute, CMPs on gainsharing, beneficiary inducement • Governing body determines financial arrangement promotes MSSP purposes • Pre-participation waiver up to one year prior to application submission • Participation waiver remains in place so long as part of MSSP Prepared for Health Care Compliance Association February 27, 2014 Page 28
  • 29. Bundled Payments Medicare ACE Demonstration Project Single payment for defined group of services within specified episode of care Pricing based on discount of payer’s historic total cost of care Formula to distribute payment among providers; incentives for cost reductions Prepared for Health Care Compliance Association February 27, 2014 Page 29
  • 30. Commercial Payers • Blue Cross Blue Shield of TN – ortho bundle • Walmart bundled payments for spine and cardiac procedures – Exclusive to six “Centers of Excellence” – No-cost medical tourism for employees • Cleveland Clinic’s cardiac bundles with Boeing and Lowe’s • Carolina HealthCare cardiac bundles for private pay, local employers Prepared for Health Care Compliance Association February 27, 2014 Page 30
  • 31. Compliance Priorities Clinical Integration • Privacy and security of PHI shared among providers • Billing for care coordination/management services • Mergers and acquisitions – Due diligence – Post-transaction integration • Network alliances • Joint payer negotiations (antitrust) • Waivers of fraud and abuse laws Prepared for Health Care Compliance Association February 27, 2014 Page 31
  • 32. Clinical Integration = Risk Integration? • Brother’s keeper? • If undertake to monitor . . . – Undertake education? – Undertake remediation? – Undertake mitigation? Prepared for Health Care Compliance Association February 27, 2014 Page 32
  • 33. Integrating Compliance • What entity will you work for? • How may hats will you wear? – GQRC Prepared for Health Care Compliance Association February 27, 2014 Page 33
  • 34. Shifting Risk • Evidence-based clinical standard of care • Negligence relating to cost/efficiency • Clinical integration = risk integration? Prepared for Health Care Compliance Association February 27, 2014 Page 34
  • 35. Choosing Wisely • Initiative of the American Board of Internal Medicine Foundation started in 2011 • 46 specialty societies have published “Five Things Physicians and Patients Should Question” • 24 Consumer Reports patient education guides Prepared for Health Care Compliance Association February 27, 2014 Page 35
  • 36. Financial Harm • First, Do No (Financial) Harm (JAMA 08/14/13) – “Medical bills are now a leading cause of financial harm, and physicians decide what goes on the bill.” • Duty to counsel? Duty to avoid unnecessary costs? Prepared for Health Care Compliance Association February 27, 2014 Page 36
  • 37. Thank You! Martie Ross Pershing Yoakley & Associates, PC 9900 W. 109th Street, Suite 130 Overland Park, KS 66210 (913) 232- 5145 jellis@pyapc.com mross@pyapc.com This presentation is for general informational purposes only. Please consult with a qualified advisor with regard to the application in specific circumstances of the information discussed herein. Prepared for Health Care Compliance Association February 27, 2014 Page 37

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