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.”

1. The Evolving Role of the
Compliance Officer
In the Age of Accountable Care
Health Care Compliance Association
Web Conference
February 27, 2014
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February 27, 2014
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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…
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February 27, 2014
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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?
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February 27, 2014
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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
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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
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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
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8. 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?
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February 27, 2014
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9. Two Strategies
Payment
Based on
Quality
Rewards
for Clinical
Integration
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10. 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
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11. 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
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February 27, 2014
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12. 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
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February 27, 2014
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13. 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
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14. 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
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February 27, 2014
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15. HAC/Never Event Penalty
• Begins in FY2015
• Top quartile (lowest scores) = 1 percent payment
reduction
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February 27, 2014
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16. Measures
• Proposed “never events”
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–
–
–
–
–
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
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February 27, 2014
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17. 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
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February 27, 2014
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18. 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
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19. 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
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February 27, 2014
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20. 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
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February 27, 2014
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21. 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
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22. 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)
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February 27, 2014
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23. 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
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24. Rewards for Clinical Integration
Three Tactics
1. FFS Payment for Care Management
2. Accountable Care Organizations
3. Bundled Payments
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25. 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
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26. 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
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27. 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
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28. 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)
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29. 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
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30. 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
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February 27, 2014
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31. 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
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32. 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
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33. Clinical Integration = Risk Integration?
• Brother’s keeper?
• If undertake to monitor . . .
– Undertake education?
– Undertake remediation?
– Undertake mitigation?
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34. Integrating Compliance
• What entity will you work for?
• How may hats will you wear?
– GQRC
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35. Shifting Risk
• Evidence-based clinical standard of care
• Negligence relating to cost/efficiency
• Clinical integration = risk integration?
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36. 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
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37. 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?
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38. 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.
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