Successfully reported this slideshow.
We use your LinkedIn profile and activity data to personalize ads and to show you more relevant ads. You can change your ad preferences anytime.
Engaging Boards in Improving  Quality, Performance, and           Integrity           Adelman, Sheff & Smith, LLC
Goals of the Presentation• Address the fiduciary obligations of officers and directors with  respect to quality of care ma...
The Board’s Core Fiduciary Duties• The Duty of Care   –   Acting in “good faith”   –   Prudent person standard   –   Reaso...
The Board’s Fiduciary Duty of Care• Director obligations with respect to:   – Supervising medical staff credentialing deci...
The Board’s Fiduciary Duty of CareNote various board committees with quality of careresponsibilities, e.g.,:   •   Quality...
Informational Support to             Governor Board• Right to rely on management, committees, and advisors• Use of “perfor...
Informational Support to         Governor Board (cont’d)• Focus on system-level improvement through data  reflecting:   – ...
Duty of Care and Quality• Emerging quality of care issues  – Collaboration among providers of care  – Monitoring and repor...
Quality Improvement              and Measurement• Quality must receive same attention as financial  viability.• Boards mus...
Quality Data and Transparency• Data access and transparency key components of new  payment models• Data for informed consu...
Government Enforcement & Quality• Enforcement priority   – DOJ, OIG, and State Attorneys     Generals   – Training and col...
Enforcement and Quality of Care• Linkage of payment to quality of care creates new  criminal, civil, and administrative ex...
Enforcement Sources• Whistleblowers, Ombudsman, Licensure Boards• Mining of quality/reimbursement data                    ...
Enforcement Tools• False Claims Act   – Implied false certification   – Failure of care/worthless services• Civil Money Pe...
More Enforcement Tools• Corporate Integrity Agreements  – Independent reviews and quality monitors  – Board certifications...
CIA Provisions Addressing Quality• Unique CIA Provisions focused on oversight of  medical staff  – Appointment of a Medica...
Focus on Officer, Director               AccountabilityGeneral Perspective:   – Enhanced governmental interest in “followi...
Responsible Corporate            Officer Doctrine• Supreme Court-based theory increasingly used by FDA  and DOJ and other ...
OIG Permissive Exclusion Authority• Entity sanction precondition• Provides two different bases for exclusions   – Individu...
OIG Permissive Exclusion           Authority (cont’d)• Four factors OIG will consider in deciding whether to  exclude an o...
“Willful Blindness”• An aggressive doctrine of liability, applied in both civil  and criminal cases• Seductive theory beca...
What’s A Board to Do?• Key Concept: How do these issues relate to Quality?• Possible Action Items:   – Educating Boards on...
What’s A Board to Do? (cont’d)– Adopting compliance protocols to guide  officers, executives, and management on appropriat...
Duty of Care and Quality• The “bottom line”:   – Quality is an essential component of the mission of the     health care p...
Lessons Learned from                Past Enforcement• Redding Medical  ̶ Allegations: Billing for medically unnecessary ca...
Lessons Learned from Past         Enforcement (cont’d)• Our Lady of Lourdes (2006)  ̶ Allegations: Billing for medically u...
Lessons Learned from Past          Enforcement (cont’d)• Saint Joseph‟s Medical Center (2010)  – Allegations:   o   Billin...
Lessons Learned from Past           Enforcement (cont’d)• Peninsula Regional Medical Center (2011) - Allegations: Billing ...
Lessons Learned from Past                  Enforcement (cont’d)• Satilla Regional Medical Center/ Dr. Azmat (2011)      ̶ ...
Lessons To Be Learned• Don‟t ignore the conduct of your top billers• No physician is “too big” to challenge/review• Have a...
More Lessons To Be learned• Draft and follow appropriate policies and  procedures• Enforce accountability across all emplo...
Suggested Questions for Directors• Quality goals and institutional leadership?   – Understanding structures & processes   ...
Suggested Questions for Directors• Coordination with compliance program?  – Integration of regulatory compliance  – Qualit...
Suggested Questions for Directors• Adequate resources?   – Staffing levels   – Acquisition of new technologies and service...
Tips for Boards for             Overseeing Quality• Create a comprehensive policy establishing a quality  improvement prog...
More Tips for Boards• Use dashboards and benchmarks to measure progress  to improve outcomes and patient satisfaction  – “...
More Tips to Promote Oversight• Recruit sufficient clinical expertise to advise the Board  on quality review functions• Pe...
Board Tips to Ensure an Effective      Compliance Program• Develop lists of questions for management that assess  the comp...
My Patient vs. Our PatientMoving from a model that focuses on individual performance to systems-based performance         ...
Taking One for the Team                           Physician                                                      OP Rehab ...
The New Medical Staff on the Block          Current                                                                       ...
Clinical Co-Management 1.0                     Hospital                                  Physicians                       ...
Clinical Co-Management 2.0                           Clinical Integration                 Management Services             ...
Quality Counts…                                          But Can You Prove It?1.    AMI-2 Aspirin Prescribed at Discharge2...
One Matters  Adelman, Sheff & Smith, LLC
The Rubber Hitting the Road1.61.4                                                                  1.499                  ...
Beyond the Four Walls• CMS Nursing Home Quality Initiative  – Nursing Home Compare website: past performance of    every M...
Medicare ASC Quality     Reporting Program                                                                             Pay...
Beyond the Four Walls                      Quality/                HealthProductivity                     Efficiency      ...
Aligning Quality Measures             PQRS: 194 measures in 2012       • Better care for individuals       • Better health...
Quality 2.0• Core Measures No Longer Enough• At Risk vs. In Addition To• Consider Degree of Difficulty   - Threshold Metri...
CMS is Not AloneWhat information should be shared and who is sharing it?   • Hospital Compare   • Physician Compare      ̶...
It’s Not Easy Being Green         Adelman, Sheff & Smith, LLC
Key Reference Material• The Health Care Director‟s Compliance Duties: A  Continued Focus of Attention and Enforcement.• Gu...
Case Study  Adelman, Sheff & Smith, LLC
Case StudySt. Elsewhere Hospital was overjoyed when Dr. Bones joined its staff in 2005 afterleaving his post as head of sp...
Case Study Cont’dAt the beginning of his practice in St. Elsewhere‟s community, Dr. Bones sawpatients of all ages and trea...
Case Study Cont’dNursing staff were trained by outside nursing consultants to ensure that they wereskilled in caring for o...
Case Study Cont’dIn direct contrast to the trend seen at St. Elsewhere, Dr. Bones‟ practice remainedbooming. While his ove...
Case Study Cont’dOne of St. Elsewhere‟s long-time Ortho nurses, Cherry Ames, has complained to hermanager that seemingly h...
Upcoming SlideShare
Loading in …5
×

Engaging Boards in Improving Quality, Performance, and Integrity

686 views

Published on

Published in: Health & Medicine, Business
  • Be the first to comment

  • Be the first to like this

Engaging Boards in Improving Quality, Performance, and Integrity

  1. 1. Engaging Boards in Improving Quality, Performance, and Integrity Adelman, Sheff & Smith, LLC
  2. 2. Goals of the Presentation• Address the fiduciary obligations of officers and directors with respect to quality of care matters• Identify leading trends attributing liability to officers and directors for organizational misconduct• Review enforcement activity related to quality of care-related violations of Medicare/Medicaid laws• Examine the OIG‟s permission exclusion authority guidelines• Suggest a course of action for health care boards to consider with respect to quality and compliance plan enhancements Adelman, Sheff & Smith, LLC
  3. 3. The Board’s Core Fiduciary Duties• The Duty of Care – Acting in “good faith” – Prudent person standard – Reasonably acting in the best interest of the entity – Application o The decision-making functions o The oversight functions• The Duty of Loyalty/Obedience to MissionIn addition to the traditional duty of hospital board members tobe responsible for granting, restricting, and revoking privilegesof membership in the organized medical staff. Adelman, Sheff & Smith, LLC
  4. 4. The Board’s Fiduciary Duty of Care• Director obligations with respect to: – Supervising medical staff credentialing decisions arise within the context of the Decision Marking Function – Supervising overall institutional quality of care arise in the context of the Oversight Function: an ongoing task; directors are expected to “keep their finger on the pulse” of matters relating to quality of care and patient safety – Monitoring the corporate compliance implications of quality of care arise in the context of the Oversight Function, in the same manner as does more traditional compliance issues Adelman, Sheff & Smith, LLC
  5. 5. The Board’s Fiduciary Duty of CareNote various board committees with quality of careresponsibilities, e.g.,: • Quality of Care/Patient Safety • Medical Staff • Finance/Audit • Compliance • Information Technology • Strategic PlanningKey: Coordination of information amongst committees Adelman, Sheff & Smith, LLC
  6. 6. Informational Support to Governor Board• Right to rely on management, committees, and advisors• Use of “performance scorecards” or “dashboards” as a means for promoting and monitoring institutional quality of care ̶ “High level” dashboard for full board ̶ Topic-specific dashboards at committee levels Adelman, Sheff & Smith, LLC
  7. 7. Informational Support to Governor Board (cont’d)• Focus on system-level improvement through data reflecting: – Performance measures – Targets for reducing patient safety risks – Protocols for quality improvement• Caution: appropriate balance of deference to medical staff representatives on governing board with the experience and background of “lay” directors Adelman, Sheff & Smith, LLC
  8. 8. Duty of Care and Quality• Emerging quality of care issues – Collaboration among providers of care – Monitoring and reporting requirements o Data is central to the Quality Movement – Payment policies• Significant opportunities and risks – Quality linked to reimbursement – Transparency – Public/private collaboration – Government enforcement Adelman, Sheff & Smith, LLC
  9. 9. Quality Improvement and Measurement• Quality must receive same attention as financial viability.• Boards must: ̶ Be sensitive to emerging quality of care issues. ̶ Be attentive to quality of care measurement and reporting requirements. ̶ Request periodic updates on quality of care initiatives. ̶ Respond diligently when quality concerns are raised. Adelman, Sheff & Smith, LLC
  10. 10. Quality Data and Transparency• Data access and transparency key components of new payment models• Data for informed consumers• Data essential tool for whistleblowers and consumers• Boards must: – Have tools, data from which to oversee quality; – Monitor relationship between public reporting of quality measures and hospital reputation. Adelman, Sheff & Smith, LLC
  11. 11. Government Enforcement & Quality• Enforcement priority – DOJ, OIG, and State Attorneys Generals – Training and collaboration – Federal and state “Whistleblower” statutes Adelman, Sheff & Smith, LLC
  12. 12. Enforcement and Quality of Care• Linkage of payment to quality of care creates new criminal, civil, and administrative exposure (“Failure of Care” constitutes FCA violation).• Data transparency creates a new degree of provider accountability.• New authorities create additional exposure: – FCA overpayment reporting and return requirement. – Expansion of Recovery Audit Contractors authority.• New government resources and new use of old authorities. Adelman, Sheff & Smith, LLC
  13. 13. Enforcement Sources• Whistleblowers, Ombudsman, Licensure Boards• Mining of quality/reimbursement data Adelman, Sheff & Smith, LLC
  14. 14. Enforcement Tools• False Claims Act – Implied false certification – Failure of care/worthless services• Civil Money Penalties – Misrepresentation of certification – Pattern of medically unnecessary service• Program Exclusion – CMP violation – Services in excess of need Adelman, Sheff & Smith, LLC
  15. 15. More Enforcement Tools• Corporate Integrity Agreements – Independent reviews and quality monitors – Board certifications (e.g., Tenet Healthcare Corp.) – Stipulated penalties Adelman, Sheff & Smith, LLC
  16. 16. CIA Provisions Addressing Quality• Unique CIA Provisions focused on oversight of medical staff – Appointment of a Medical Director for the Cardiac Catheterization Lab and/or appointment of a Physician Executive – Detailed policies and procedures regarding medical staff peer review/credentialing, and management of a cardiac cath lab – Engagement of a Peer Review Consultant to conduct a Systems Review – Cardiac Catheterization Procedures Review by IRO (in place of Claims Review) Adelman, Sheff & Smith, LLC
  17. 17. Focus on Officer, Director AccountabilityGeneral Perspective: – Enhanced governmental interest in “following the conduct” to identify individuals who can be held accountable for corporate wrongdoing – whether they are “in the field”, executive suite, or the board room.Recent Examples: – IRS (withholding tax liability) – SEC (executive compensation clawbacks) – DOJ (application of the FCPA) – SEC (focus on negligence, rather than scanter, based offenses) – DOJ and FDA‟s use of FDCA Adelman, Sheff & Smith, LLC
  18. 18. Responsible Corporate Officer Doctrine• Supreme Court-based theory increasingly used by FDA and DOJ and other federal agencies to attribute responsibility to corporate officers for public welfare criminal misdemeanors, without any evidence that they may have been aware of, or participated in, the underlying problematic conduct.• Recently used by DOJ in several high profile prosecutions involving officers of medical device and pharmaceutical companies; “Too Big to Fire” application. Adelman, Sheff & Smith, LLC
  19. 19. OIG Permissive Exclusion Authority• Entity sanction precondition• Provides two different bases for exclusions – Individuals with an ownership or control interest who knew or should have known of the prohibited conduct – Officers and managing employees, even in the absence of evidence that they knew or should have known of the prohibited conduct (this is the strict liability/”RCOD” concept)• Definition of “managing employee” excludes corporate director Adelman, Sheff & Smith, LLC
  20. 20. OIG Permissive Exclusion Authority (cont’d)• Four factors OIG will consider in deciding whether to exclude an officer or managing employee in the absence of evidence that the person knew or should have known the misconduct: 1. Circumstances of misconduct; seriousness of offense 2. Individual‟s role within sanctioned entity 3. Individual‟s action in response to the misconduct 4. Certain information about the sanctioned entity Adelman, Sheff & Smith, LLC
  21. 21. “Willful Blindness”• An aggressive doctrine of liability, applied in both civil and criminal cases• Seductive theory because it is subject to a highly subjective analysis, particularly when facts look bad and harm has occurred• Core Concept: Willful blindness occurs when a person purposely turns away from learning something because he/she knows the chances were high that he/she would learn something bad that would make improper or illegal what they were doing. Adelman, Sheff & Smith, LLC
  22. 22. What’s A Board to Do?• Key Concept: How do these issues relate to Quality?• Possible Action Items: – Educating Boards on connection between quality and compliance; making sure they are provided with examples of oversight questions they should ask and continuous flow of information; see, e.g., “Dashboards” to interpret mounds of data; quality resources. – Advising management team regarding 1128(b)(15) exposure and how it may be implicated by quality of care issues. Adelman, Sheff & Smith, LLC
  23. 23. What’s A Board to Do? (cont’d)– Adopting compliance protocols to guide officers, executives, and management on appropriate response to take when they become aware of alleged quality of care concerns/misconduct– Enhancing existing compliance plan provisions and requirements to reflect good faith “extraordinary care” by officers and executives– Assuring the presence of the general counsel in all meetings of the board and of key committees to help support discussion regarding legal issues associated with quality of care matters Adelman, Sheff & Smith, LLC
  24. 24. Duty of Care and Quality• The “bottom line”: – Quality is an essential component of the mission of the health care providers – Quality must receive the same level of Board attention as the corporation‟s financial viability – Quality and cost efficiency are complementary, not contradictory, elements of an effective health care system – Unique opportunity for leadership and positive change Adelman, Sheff & Smith, LLC
  25. 25. Lessons Learned from Past Enforcement• Redding Medical ̶ Allegations: Billing for medically unnecessary cardiac procedures by two physicians ̶ Red flags: o The CEO told concerned staff “to mind own business”  The two physicians were two of the top billers in the hospital o No conflict of interest protocol  Review of procedure volume showed a very high rate of cardiac procedures ̶ Outcome: Tenet - $54 million; o Hospital sold o Physicians  Suspended practice; no malpractice insurance  License revoked (stayed) and three years probation Adelman, Sheff & Smith, LLC
  26. 26. Lessons Learned from Past Enforcement (cont’d)• Our Lady of Lourdes (2006) ̶ Allegations: Billing for medically unnecessary cardiac procedures between 1999 and 2003 ̶ Red flags: o Scrub techs and nurses complained to management of the unnecessary nature of surgeries  Failure to review or monitor practices  A top revenue generator for the hospital o Hospital stepped in only after two cardiologists complained ̶ Resolution: Hospital paid $3,800,000 o Hospital entered a 5-year CIA o Doctor prosecuted and sentenced to 10 years Adelman, Sheff & Smith, LLC
  27. 27. Lessons Learned from Past Enforcement (cont’d)• Saint Joseph‟s Medical Center (2010) – Allegations: o Billing for medically unnecessary carotid artery stent procedures o Kickbacks to cardiologists in exchange for the referral of cardiac procedures – Red Flag: gross overutilization of health care services, standards of care violations, and the failure to keep adequate medical records. – Outcome: Saint Joseph‟s paid $22,000,000 and 5-year CIA o Doctor‟s license revoked.  Unprofessional conduct, false reports,  Board found that he unnecessarily inserted cardiac stents because of "pressure to produce” Adelman, Sheff & Smith, LLC
  28. 28. Lessons Learned from Past Enforcement (cont’d)• Peninsula Regional Medical Center (2011) - Allegations: Billing for medically unnecessary heart stent procedures - Red flags: o Prevalent sarcastic joking amongst catheterization lab employees about the nature and percentage of surgeon‟s stents o Responsibility to monitor the medical necessity of Cardiac Catheterization Lab procedures assigned but never carried out o Hospital did not assess or compare utilization rates of its interventional cardiologists during the relevant time period - Settlement: Peninsula paid $2,767,924; 5-year CIA o Surgeon convicted on one count of health care fraud and five counts of making false statements relating to health care matters; eight years in federal prison Adelman, Sheff & Smith, LLC
  29. 29. Lessons Learned from Past Enforcement (cont’d)• Satilla Regional Medical Center/ Dr. Azmat (2011) ̶ Allegations: Billing for medically unnecessary and worthless endovascular procedures preformed by surgeon ̶ Red flags: o Executives ignored complaints from employees that doctor was a danger to patients  One patient died o Hospital knew or should have known through its credentialing and peer review procedures that doctor was not competent to perform endovascular procedures by:  Not adequately considering information of prior limitations placed on privileges at a different facility  Allowing doctor to perform endovascular procedures when:  He had never been granted privileges to perform such procedures at any prior facility  He had not demonstrated competency to perform the procedures ̶ Outcome: Satilla paid $840,000 to settle False Claims Act; Center purchased, resulting in a new Board of Directors, new administration, and new compliance program o Azmat excluded Adelman, Sheff & Smith, LLC
  30. 30. Lessons To Be Learned• Don‟t ignore the conduct of your top billers• No physician is “too big” to challenge/review• Have a conflict of interest protocol and follow it• Review your data and understand what it means• Listen to the concerns of all employees, not just other physicians or administrators Adelman, Sheff & Smith, LLC
  31. 31. More Lessons To Be learned• Draft and follow appropriate policies and procedures• Enforce accountability across all employment levels• Sometimes joking needs to be taken seriously• Board needs to hold leadership accountable for fulfilling their job requirements• Appropriately review and evaluate the skills and abilities of physicians Adelman, Sheff & Smith, LLC
  32. 32. Suggested Questions for Directors• Quality goals and institutional leadership? – Understanding structures & processes – Linkage between quality, peer review, and compliance• Board orientation and expertise? – Dashboards and benchmarks – Recruiting expertise Adelman, Sheff & Smith, LLC
  33. 33. Suggested Questions for Directors• Coordination with compliance program? – Integration of regulatory compliance – Quality and risk assessment/corrective actions• Internal reporting and communications? – “Whistleblower” protections – Culture of candor Adelman, Sheff & Smith, LLC
  34. 34. Suggested Questions for Directors• Adequate resources? – Staffing levels – Acquisition of new technologies and services• Addressing specific quality concerns and adverse events? – Quality and the peer review process – Responding to incidents of deficient care Adelman, Sheff & Smith, LLC
  35. 35. Tips for Boards for Overseeing Quality• Create a comprehensive policy establishing a quality improvement program – Ensure stakeholders share a common definition of quality – Incorporate its objectives into employee performance and incentive compensation Adelman, Sheff & Smith, LLC
  36. 36. More Tips for Boards• Use dashboards and benchmarks to measure progress to improve outcomes and patient satisfaction – “What gets measured gets done” – Use PEPPER and other metrics to compare with peers Adelman, Sheff & Smith, LLC
  37. 37. More Tips to Promote Oversight• Recruit sufficient clinical expertise to advise the Board on quality review functions• Perform self-assessments of the board and its committees – Review boards response to systemic failures• Implement conflict of interest policies to identify and manage financial conflict that may affect clinical judgment Adelman, Sheff & Smith, LLC
  38. 38. Board Tips to Ensure an Effective Compliance Program• Develop lists of questions for management that assess the compliance program – See OIG website for suggestions• Protect the independence of the compliance officer – Separate the role from the legal department• Understand how the compliance systems work and how information flows to the Board Adelman, Sheff & Smith, LLC
  39. 39. My Patient vs. Our PatientMoving from a model that focuses on individual performance to systems-based performance Requires a shift in thought MY PATIENTS OUR PATIENTS INDIVIDUAL EVIDENCE-BASED PERFORMANCE OUTCOMES Adelman, Sheff & Smith, LLC
  40. 40. Taking One for the Team Physician OP Rehab HOSPITAL Home HealthPatient • Acute Care • PAC services Skilled • Emergency • IP Surgery Nursing • Diagnostic • IP Rehab Adelman, Sheff & Smith, LLC
  41. 41. The New Medical Staff on the Block Current Future The medical staff is a self- New healthcare era requires a governing entity that is structure in which all responsible for the quality of stakeholders are responsiblecare rendered at the hospital. for quality of care and efficient use of financial resources. This autonomy in decision- Creation of a quality making creates an oversight committee environment that makes facilitates communication systems-based change and coordination of care. difficult. “The Joint Commission‟s American Model of medical staff “self-governance” provides an infrastructure which allows for, and perhaps fosters, the accentuation of material conflicts among and between medical staff members, physician leadership and physician committees, and the governing body relative to the definition, adoption, implementation and enforcement of requisite Quality/Safety standards.”11Peters, Brian M. and Nagele, Robin Locke. Promoting Quality Care and Patient Safety: The Case for Abandoning The Joint Commission‟s “Self-Governing”Medical Staff Paradigm. MSU Journal of Medicine and Law. 2010. No. 313, p. 313-373. Adelman, Sheff & Smith, LLC
  42. 42. Clinical Co-Management 1.0 Hospital Physicians Management Service ContractHospital • Base management fees • Incentive Compensation Company/ to Manage Hospital‟s Pays for: (limited) Including: - Quality - Operational $ LLC/Committee Service Line at Risk for Quality and Operational Efficiency Goals Hospital Physicians Adelman, Sheff & Smith, LLC
  43. 43. Clinical Co-Management 2.0 Clinical Integration Management Services Council Agreement Integration Contract PMA’s Other PMA’s Other Medical(Orthopedic, Cardiac, (Service or Specialty Areas) Services Urology) • PMA Quality • PMA Quality • Other Medical Quality • PMA Operations • PMA Operations • Other Medical Operations Adelman, Sheff & Smith, LLC
  44. 44. Quality Counts… But Can You Prove It?1. AMI-2 Aspirin Prescribed at Discharge2. AMI-7 a Fibrinolytic Therapy Received Within 30 Minutes of Hospital Arrival3. AMI-8a Primary PCI Received Within 90 Minutes of Hospital Arrival4. HF-1 Discharge Instructions5. HF-2 Evaluation of LVS Function6. HF-3 ACEI or ARB for LVSD7. PN-2 Pneumococcal Vaccination8. PN-3b Blood Cultures Performed in the Emergency Department Prior to Initial Antibiotic Received in Hospital Clinical9. PN-6 Initial Antibiotic Selection for CAP in Immunocompetent Patient Process of HCAHPS10. PN-7 Influenza Vaccination11. SCIP-Inf-1 Prophylactic Antibiotic Received Within One Care 30% Hour Prior to Surgical Incision12. SCIP-Inf-2 Prophylactic Antibiotic Selection for Surgical Measures Patients13. SCIP-Inf-3 Prophylactic Antibiotics Discontinued Within 70% 24 Hours After Surgery End Time14. SCIP-Inf-4 Cardiac Surgery Patients with Controlled 6AM Postoperative Serum Glucose15. SCIP-Card-2 Surgery Patients on a Beta Blocker Prior to Arrival That Received a Beta Blocker During the Perioperative Period16. SCIP-VTE-2 Surgery Patients with Recommended Venous Thromboembolism Prophylaxis Ordered17. SCIP-VTE-2 Surgery Patients Who Received Appropriate Venous Thromboembolism Prophylaxis Within 24 Hours Prior to Surgery to 24 Hrs After Surgery Source: CMS Special Open Door Forum: VBP 2/10/2011 Adelman, Sheff & Smith, LLC
  45. 45. One Matters Adelman, Sheff & Smith, LLC
  46. 46. The Rubber Hitting the Road1.61.4 1.499 1.4201.2 1.2551.0 1.041 1.0390.8 0.8220.6 0.661 0.5510.40.20.05th %tile 10th 25th 50th Mean 75th 90th 95th %tile %tile %tile %tile %tile %tile Adelman, Sheff & Smith, LLC
  47. 47. Beyond the Four Walls• CMS Nursing Home Quality Initiative – Nursing Home Compare website: past performance of every Medicare and Medicaid certified nursing home in the country – Includes aspects of residents health, physical functioning, mental status, and general well being• LTACH Outcome Benchmark Project – Working to develop meaningful metrics – Crude mortality, ventilator weaning, pressure ulcers, catheter-related infections, readmissions, unplanned transfers Adelman, Sheff & Smith, LLC
  48. 48. Medicare ASC Quality Reporting Program Payments Measure Reporting Period Affected Beginning1. Patient Burn Begins October 1, 2012 20142. Patient Fall Begins October 1, 2012 20143. Wrong Site, Side, Patient, Begins October 1, 2012 2014 Procedure, Implant4. Hospital Admission/Transfer Begins October 1, 2012 20145. Prophylactic IV Antibiotic Timing Begins October 1, 2012 20146. Safe Surgery Checklist Use in July 1 thru August 15, 2013 2015 2012 (measures use 1/1/12-12/31/12)7. 2012 Volume of Certain July 1 thru August 15, 2013 2015 Procedures (measures use 1/1/12-12/31/12)8. Influenza Vaccination Coverage October 1, 2014 thru March 31, 2015 2016 Among Health Care Personnel Adelman, Sheff & Smith, LLC
  49. 49. Beyond the Four Walls Quality/ HealthProductivity Efficiency Status Total “The Secretary shall establish a payment modifier that provides for differential payment to a physician or a group of physicians under the fee schedule established under subsection (b) based upon the quality of care furnished compared to cost …” Adelman, Sheff & Smith, LLC
  50. 50. Aligning Quality Measures PQRS: 194 measures in 2012 • Better care for individuals • Better health for populations • No HCAHPS Meaningful Use: 49 measures ACO: 33 measures in 2012 for Stage 2 in 2014 • Partial overlap with PQRS• Partial overlap with VBP • HCAHPS• Partial overlap with PQRS VBP: 13 measures in 2012 • Subset of Hospital Inpatient Quality Reporting Program • HCAHPS Adelman, Sheff & Smith, LLC
  51. 51. Quality 2.0• Core Measures No Longer Enough• At Risk vs. In Addition To• Consider Degree of Difficulty - Threshold Metrics - Change Management• Composite Metrics on the Horizon• Quality Replacing Productivity Measures Entirely• Process to Outcomes to Systems Adelman, Sheff & Smith, LLC
  52. 52. CMS is Not AloneWhat information should be shared and who is sharing it? • Hospital Compare • Physician Compare ̶ Not there yet! ̶ Challenges with reporting exist • The Public Domain ̶ Angie‟s List ̶ HealthGrades ̶ US News ̶ Thompson Reuters ̶ Your local community Adelman, Sheff & Smith, LLC
  53. 53. It’s Not Easy Being Green Adelman, Sheff & Smith, LLC
  54. 54. Key Reference Material• The Health Care Director‟s Compliance Duties: A Continued Focus of Attention and Enforcement.• Guidance for Implementing Permissive Exclusion Authority (Oct. 19, 2010).• Peregrine and Buchman, “A „Responsible Corporate Officer‟ Defense Plan” (AHLA Connections, March 2011).• “Driving for Quality in Acute Care: A Board of Directors Dashboard”. Adelman, Sheff & Smith, LLC
  55. 55. Case Study Adelman, Sheff & Smith, LLC
  56. 56. Case StudySt. Elsewhere Hospital was overjoyed when Dr. Bones joined its staff in 2005 afterleaving his post as head of sports medicine and orthopedics at Bigcity MedicalCenter. Located in a small town that sprung up around a paper clip manufacturingplant, St. Elsewhere has historically enjoyed a lucrative payor mix of plantemployees and local retiree Medicare beneficiaries. Adding Dr. Bones to themedical staff as an independent physician was seen as a major win for St.Elsewhere, as the hospital desired to expand its orthopedics program into a “Centerof Excellence”. Physicians of Dr. Bones‟ reputation were rare to find in a small town– and the Board of Directors knew it. Bill Blowhard, a member of the Board, wasinstrumental in bringing Dr. Bones to town, using a combination of his strongopinions and negotiating skills and a stronger arm with his fellow Board membersand hospital CEO, Maurice Meeks. Adelman, Sheff & Smith, LLC
  57. 57. Case Study Cont’dAt the beginning of his practice in St. Elsewhere‟s community, Dr. Bones sawpatients of all ages and treated a variety of orthopedic injuries; however, hisacknowledged specialty was orthopedic problems of the hip and knee. Over the firstfew years of his booming practice, Dr. Bones saw hundreds of patients andprescribed various treatment modalities to address their orthopedic concerns. Thosetreatments included surgical repair and replacement of joints in those patients withdegenerative disease. From 2005 to 2008, Dr. Bones performed 150 hip and kneereplacements at St. Elsewhere, with some patients coming from miles away toreceive treatment from the “big city” doctor.Anticipating the need to care for an increased patient volume, St. Elsewhere took outa significant line of credit to fund the build of an “Orthopedic Center ofExcellence”, housed in the Blowhard Pavilion, so named for its main benefactor, theBlowhard family. The St. Elsewhere Board enthusiastically supported the project asnecessary to support the financial stability and prestige of the institution. Mr.Blowhard and CEO Meeks described the proposal as a “slam dunk”, and it wasapproved with little analysis. Adelman, Sheff & Smith, LLC
  58. 58. Case Study Cont’dNursing staff were trained by outside nursing consultants to ensure that they wereskilled in caring for orthopedic patients – and in handling Dr. Bones, whose talentwas only outweighed by his ego and abrasive manner. Dr. Bones is made theMedical Director of the soon- to- be- built Center, received a very generous stipendfor assuming that role, and was given responsibility for overseeing the recruitmentand credentialing of the team of surgeons who would practice at the Center.By all accounts, St. Elsewhere and Dr. Bones were both doing well. Then, at thebeginning of the recession in 2009, the paper clip plant closed (staples were justmore economical), tossing 2,000 people out of work. St. Elsewhere saw a dramaticincrease in its self-pay and charity care qualifying patients. The Orthopedic Centerof Excellence and all other capital improvements were put on hold as St. Elsewheresaw its patient and procedure volumes decrease precipitously…but for Dr. Bones. Adelman, Sheff & Smith, LLC
  59. 59. Case Study Cont’dIn direct contrast to the trend seen at St. Elsewhere, Dr. Bones‟ practice remainedbooming. While his overall patient volume decreased, those he sawwere, apparently, in more advanced states of degenerative disease. The totalnumber of hip and knee replacements performed by Dr. Jones in 2009 and 2010topped 150, and in 2011 he completed 100 joint replacement procedures. At thesame time, Dr. Bones‟ referrals for physical therapy or other care modalitiesdecreased.The Board was cheered by the rebound in Dr. Bones‟ practice and the financialreturns it was generating for the institution. Upon Mr. Meeks‟ recommendation, theBoard began to reconsider the Center for Excellence project. Adelman, Sheff & Smith, LLC
  60. 60. Case Study Cont’dOne of St. Elsewhere‟s long-time Ortho nurses, Cherry Ames, has complained to hermanager that seemingly healthy young people are undergoing hip and kneereplacements for minor sports injuries. Although she raises her concerns to hersupervisor several times the other nursing staff are tight-lipped about the situationand nothing changes. After an angry confrontation with Ms. Ames in St. Elsewhere‟sadministrative offices, during which Cherry accused Dr. Bones in front of CEOMeeks of replacing what were probably perfectly healthy joints for profit, Dr. Bonessuggested to Bill Blowhard that he could use some help getting “the nosy nurses offmy back.” Mr. Blowhard, of course, agreed, and demanded that Mr. Meeks fire Ms.Ames for insubordination. Mr. Meeks complied.To cover his back, Mr. Meeks referred Nurse Ames‟ concerns to St. Elsewhere‟s peerreview panel. After meeting with Dr. Bones, the panel concluded that he has greaterexpertise than the members of the panel, he can articulate a reasonable justificationfor the surgeries and it closes the matter without taking any action. The panel doesnot review any of Dr. Bones‟ records. Adelman, Sheff & Smith, LLC

×