1	Compliance and quality of care Rory Jaffe, MD MBA Chief Compliance Officer UC Davis Health System
2	Quality is job one Health care’s primary goal is health care Billing is a necessary evil Health care problems much more serious than billing problems
3	Consequences of failure Billing Temporary harm Fix by paying it back Temporary bad publicity Little public interest Quality May cause permanent harm or death May not be fixable Undermines public trust in the institution
4	People are more worried about their care than the accuracy of the bill Are you spending more time worrying about billing than about care?
5	A tale of two cities Sacramento Billing scandal Redding Quality scandal
6	The two cities
7	Sacramento: CHW Two payments by local hospital chain to settle fraud allegations by whistle-blowers $10.25M and $8.5M False cost reports Charged for preventive care, consults instead of referrals
8	Defense Simply errors Poor billing quality How would that defense work in a quality of care issue? A few newspaper articles Little interest Lying to insurers is socially accepted
9	The toll $18.75M CIA
10	Survey of potential jurors In response to restriction of health care, a physician should accept restriction, appeal restriction, or misrepresent a patient’s condition to obtain the desired service.
11	Redding Medical Center The following deals with allegations, nothing yet proven October 30, 2002: 40 FBI agents, many of them armed, descend upon Redding Medical Center Unnecessary procedures About 50% of all procedures
12	The toll Tenet market value plunged $4.8B 167 patients died, many unnecessarily Not from poor technique Inherent risks of unnecessary procedures Moon and Realyvasquez not practicing Cardiac program shut down 12.5% of hospital’s work force laid off
13	The lawyers’ response http://www.reddingmedicalcenter-lawsuit.com/ http://www.heartlaw.info/ 850 plaintiffs by March, more than 1800 requests for medical records
14	Should they have known? Warnings to hospital for 5 years Dismissed as jealous competitors’ complaints Reluctance to endanger a cash cow? Top billers in the state, even though in a small town with another hospital Bypasses per capita 7X state average
15	Is the hospital at risk? Tenet spokesman: “The decision to perform any medical procedure at a hospital is the decision of the attending physician. Our hospitals, like all hospitals, must rely upon the professionalism of the physicians who practice there in making these kinds of evaluations.”
16	Is the hospital at risk? Lawyer representing 600 patients: “It is our belief that the corruption within Redding Medical Center is not limited to Drs. Moon and Realyvasquez, but reaches all levels of the hospital up to Tenet Healthcare, its owner.”
17	Yes, the hospital is at risk Settled August, 2003, Medicare, Medicaid, and Tricare $54 million Unnecessary heart procedures 1997-2002 Largest in history of medical necessity fraud Lawsuits still pending
18	Getting involved in quality issues OK, so now what?
19	What should a compliance officer do? Don’t do other people’s jobs If a serious gap exists, make sure it gets filled Find a champion Particularly if you are not a clinician
20	Don’t do other people’s jobs
21	Don’t do other people’s jobs Many organizations already have a quality of care review process Intervention by compliance officer may be seen as ill-informed interference If you do it, others won’t Refer findings with potential quality issues
22	Refer findings with potential quality issues Incorrect documentation Insufficient Invented Incorrect utilization/medical necessity Underutilization Overutilization EMTALA
23	If a serious gap exists, make sure it gets filled
24	Fill the gaps! First step is to find them Learn what quality control activities occur Find out what should occur Evaluate adequacy of the activities
25	Adequacy of quality control activities Group think Conflicts of interest Domination by problem person No frank discussions No statistics Nothing happens
26	Keep a finger on the pulse Sit on quality oversight committee Meet periodically with person(s) responsible for quality of care monitoring
27	Find a champion
28	Find a champion Clinicians don’t think a bean counter knows beans about health care and won’t obey Why can’t you be effective by yourself?
29	Power and influence “Power is … the potential ability to influence behavior, to change the course of events, to overcome resistance, and to get people to do things that they would not otherwise do. Politics and influence are the processes, the actions, the behaviors through which this potential power is utilized and realized.”
30	Power sources Hierarchical: organizational position Reward: ability to give out rewards Coercive: ability to mete out punishment Expert: superior skills and knowledge Referent: others’ respect and admiration
31	Hierarchical Ban on corporate practice of medicine Clinicians typically in separate hierarchy Medical staff Compliance officer typically has no hierarchical power
32	Reward Typically not in the purview of compliance officers Might get “compliance bonuses” built into compensation structure
33	Coercive Can you directly punish a physician? Can you affect her income? Can you fire a physician? State laws may have special protections for physicians, e.g., hearing rights Faculty have special protections
34	Expert Physicians view themselves, not you, as having superior skills and knowledge What you know doesn’t count: it’s how much they value your knowledge that does
35	Referent Do physicians view you as a role model? Do you have charisma?
36	Champion traits Seek a provider who has the power Most clinicians are passionately committed to good health care Cultivate allies Understand the power structure Respected, knowledgeable Active in medical staff organization Has the “hammer”
37	Worst case scenario
38	Nuclear war When you have good reason to believe that serious quality issues are ignored Cannot win by yourself Must confirm suspicions Outside the area of expertise for most compliance officers Avoid MAD (Mutually Assured Destruction)
39	Get outside opinion Try to identify outside expert acceptable to both parties Agreement to abide by results Sources: State medical societies Universities Well-respected practitioners from outside the region
40	Benefits Obtain buy-in of involved doctors Validate your findings Avoid being sole target of anger Defensible conclusions Similar to obtaining outside legal counsel
41	Icing on the cake
42	Clinical quality initiatives Systems changes CPOE Clinical pathways JCAHO, Leapfrog, etc.
43	Conclusions Quality of care is a primary compliance concern The compliance officer must monitor, but cannot control, the process Reach out for help
44	Contact information http://compliance.ucdmc.ucdavis.edu/ rsjaffe@ucdavis.edu 916-734-8804