The Virginia Mason Production System, Integrity, and Leadership
Inland Empire AAHAM 2019 Conference
November 8, 2019
© 2014 Virginia Mason Medical Center
Objectives
• High level introduction to the Virginia Mason Production System and leadership
• Shifts in reimbursement landscape and impact to Integrity Programs
• A leadership reflection
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© 2014 Virginia Mason Medical Center
The Virginia Mason Production SystemWe adopted the Toyota Production System philosophies and practices and applied them to health care because the industry lacked an effective management approach that would produce:
• Customer first orientation
• Highest quality
• Obsession with safety
• Highest staff engagement
• A successful economic enterprise
© 2019 Virginia Mason Institute
Learning from Other Industries
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Efficiency ≠ Faster
Value is determined by the customer
© 2014 Virginia Mason Medical Center
VMMC Strategic Plan
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Focus on the customer
Be the quality leader
VMPS is foundation for change
Reduce burden on the team
Remove waste
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VMM Strategic Plan
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Our Quality Equation
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Q:
A:
O:
S:
W:
Quality
Appropriateness
Outcomes
Service
Waste
© 2014 Virginia Mason Medical Center
Taisha Ohio's Seven Wastes
© 2014 Virginia Mason Medical Center
Sensei Sato’s Eight Wastes of Information
Information Waste
Invisibility
Hidden or incomplete information
Complication
Complicated information being sent or received
Waiting
Information must wait to be delivered,
approved, verified or completed
Redundancy
Duplicate work or same information kept in more than
one area
Process Variation
Everyone sets their own pace and does the
work they chooseTypos
Human error
Paperwork
Producing any unnecessary
documentation and forms
Re-work
Having to do it over or repeating
prior work
© 2014 Virginia Mason Medical Center
Concepts and Tools
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Value Stream
Mapping
Daily Management -Visibility and
Accountability
A3s – Strategic
Goal Development and
Deployment
Root Cause Analysis
Innovation –PDSA Cycles
Product Quantity
(PQ) AnalysisRPIW 3P
The Revenue “Cycle”
BILLING
CDMP
SCHEDULING
REGISTRATION
INSURANCEVERIFICATION
FINANCIALCOUNSELING
CASE MGMT/QUR
CDM/CHARGECAPTUREMEDICAL
RECORDS
CUSTOMER SERVICE
THIRD PARTYFOLLOW- UP
SELF PAYCOLLECTIONS
PROGRAMADMINISTRATION
CASH POSTING
POSTPAYMENT REVIEW
POINT OF SERVICE
COLLECTIONS
DENIALS
MANAGEMENT
FINANCIAL
CLEARANCE
Patient
Access
Documentation
Of
Services
BillingReceivables
Management
Customer
ServiceHospital
Scheduling
Registration
Pre-
Registration
Eligibility &
Verification
Financial
Counseling
Care
Delivery
Patient
Discharge
Transcription
Charge
Master
Coding/
CDMP
Charge
Capture
Payment
Posting
Claims
Editor
Customer
Inquiries
Bill
Reconciliation
Contractual
Adjustments
Legal
Collections
Issue
Resolution
Secondary
Billing
Bad Debt/
Write OffsPatient
Statements
Process Flow by Department
Late
Charges
Utilization
Management
Discharge
Planning
Case
Management
Claims
SubmissionFollow-Up
Appeals/
Denial Mgmt.
Feedback
© 2014 Virginia Mason Medical Center
The Importance of Leadership
The World-Class Management System is a leadership system that provides focus, direction,
alignment, and a method of management for daily work
This Or This
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© 2014 Virginia Mason Medical Center
VMMC Leadership CompactOrganization’s Responsibilities
Foster Excellence
• Recruit and retain the best people
• Acknowledge and reward contributions to patient care and the organization
• Provide opportunities for growth of leaders
• Continuously strive to be the quality leader in health care
• Create an environment of innovation and learning
Lead and Align
• Create alignment with clear and focused goals and strategies
• Continuously measure and improve our patient care, service and efficiency
• Manage and lead organization with integrity and accountability
• Resolve conflict with openness and empathy
• Ensure safe and healthy environment and systems for patients and staff
Listen and Communicate
• Share information regarding strategic intent, organizational priorities, business decisions and business outcomes
• Clarify expectations to each individual
• Offer opportunities for constructive open dialogue
• Ensure regular feedback and written evaluations are provided
• Encourage balance between work life and life outside of work
Educate
• Support and facilitate leadership training
• Provide information and tools necessary to improve individual and staff performance
Recognize and Reward
• Provide clear and equitable compensation aligned with organizational goals and performance
• Create an environment that recognizes teams and individuals
Leader’s Responsibilities
Focus on Patients
• Promote a culture where the patient comes first in everything we do
• Continuously improve quality, safety and compliance
Promote Team Medicine
• Develop exceptional working-together relationships that achieve results
• Demonstrate the highest levels of ethical and professional conduct
• Promote trust and accountability within the team
Listen and Communicate
• Communicate Virginia Mason values
• Courageously give and receive feedback
• Actively request information and resources to support strategic intent, organizational priorities, business decisions and business outcomes
Take Ownership
• Implement and monitor Virginia Mason approved standard work
• Foster understanding of individual/team impact on Virginia Mason economics
• Continuously develop one’s ability to lead and implement the Virginia Mason Production System
• Participate in and actively support organization/group decisions
• Maintain an organizational perspective when making decisions
• Continually develop oneself as a Virginia Mason leader
Foster Change and Develop Others
• Promote innovation and continuous improvement
• Coach individuals and teams to effectively manage transitions
• Demonstrate flexibility in accepting assignments and opportunities
• Evaluate, develop and reward performance daily
• Accept mistakes as part of learning
• Be enthusiastic and energize others
© 2014 Virginia Mason Medical Center
1. Know your business
2. RUN your business
3. IMPROVE your business
Daily management
is HOW you
accomplish
this…
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Leadership Expectations
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VMMC: Connecting the Dots
Our Strategic
Plan
Organizational
Goals
Department
Priorities
Cascading Goals
Department
Kaizen PlanDaily
Management
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© 2014 Virginia Mason Medical Center
Change…
Disequilibrium
Heifetz, Ronald A. and Marty Linsky. Leadership on the Line, Harvard Business School Press,
2002, p 108.
© 2019 Virginia Mason Institute
Pause forQuestions or Comments
before we move into Integrity
© 2014 Virginia Mason Medical Center
Happy Compliance & Ethics Week!
• Standards, Policies, Procedures
• Program Administration
• Scanning and Evaluation of Employees, Physicians, Vendors and other Agents
• Communication, Education and Training on Compliance Issues
• Monitoring, Auditing and Internal Reporting Systems
• Discipline for Non-Compliance
• Investigations and Remedial Measures
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© 2014 Virginia Mason Medical Center
Not an Integrity Officer, obviously
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© 2014 Virginia Mason Medical Center
OIG FY 2018 year in review
764 criminal actions
813 civil actions
$2.91B anticipated recovery
2712 excluded individuals/entities
CMS will continue to fund efforts to “detect” and efforts to “prevent”
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© 2014 Virginia Mason Medical Center
Big Dollars
Of the $2.8 billion actually recovered by the government from 2018 fraud cases, $2.5 billion involved healthcare.
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Employee Engagement
Of the $2.5 billion recovered from healthcare in 2018, $2.1 billion began with a whistleblower.
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© 2014 Virginia Mason Medical Center
CMS Savings
• Medicare “saved” an estimated $15.5 billion in Fiscal Year (FY) 2017, for an annual return on investment of $10.8 to $1
• The 2018 Medicare fee-for-service (FFS) improper payment rate was 8.12%, the lowest since 2010.
• This translates to about $4.5 billion less in estimated improper payments from 2017.
• For Medicaid, in FY 2018 CMS recovered $10.5 billion in FFS improper payments
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© 2014 Virginia Mason Medical Center
Professional Service Reimbursement
• Primarily still fee-for-service. Procedural reimbursement (time based, fee schedules, conversion factors)
• 2019 E/M documentation requirements
• Making way for heightened CMS focus on growing risk adjustment/quality reimbursement
• Integrity: Shifting our internal monitoring practices to expand our diagnostic coding education, analysis, and reviews
© 2014 Virginia Mason Medical Center
Growing CMS FFS Recognition for Non-Traditional Services
• Past few years: Reimbursement of “non-traditional” services
• Transitional Care Management
• Chronic Care Management
• Indirect Care (via portal or phone)
• With every payment opportunity CMS allows for these population health services, there are an array of exceptions and requirements
• We should expect to see these heavily audited in the near future; Integrity monitoring and auditing “opportunities”
© 2014 Virginia Mason Medical Center
Continuing challenges for Pro
• E/M Coding Payment, Coding and Documentation challenges, continued
• Expansion of telehealth services and advancement of virtual care…maybe
• Payment shifts and greater emphasis on site of service shifts (outpatient hospital to office, Ambulatory Surgical Centers vs Hospitals)
• And Integrity needs to adjust
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© 2014 Virginia Mason Medical Center
Facility Reimbursement
• Unstoppable rise of retrospective audits (Federal, State, and Commercial Plans)
• Challenging not only the codes but also the actual diagnosis documented by the provider
• Medical necessity of patient’s hospital status
• Medical necessity of services being provided
• The specificity of ICD-10 being used by payment community to micro-manage clinical decision making
© 2014 Virginia Mason Medical Center
Facility Reimbursement
• Seeking DRG downgrades and/or outright denials (“not medically necessary”)
• Outsourcing to vendors who do these retrospective audits on a contingency basis
• Volumes of pre-authorization, payment delays/medical review, chart requests, and denials on the rise
© 2014 Virginia Mason Medical Center
Regulatory Landscape for Integrity
CMS MAC data sharing—Parts A and B using RACs and ZPICs to target, then under DHHS:
State: MICs and MFCUs
Federal: HRSA, OCR, FBI, OIG, DOJ
DOJ
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© 2014 Virginia Mason Medical Center
Additional Integrity “Worries”
• Paying for value, price transparency, and “regulatory flexibility” are key topics in healthcare integrity
• Significant changes are either expected or already in progress
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CMS Shift to Quality
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© 2014 Virginia Mason Medical Center 45https://www.acc.org/membership/sections-and-councils/cardiovascular-management-section/section-updates/2018/01/18/12/07/the-transition-to-value-mostly-a-ripple-will-it-become-a-wave
© 2014 Virginia Mason Medical Center
Quality of Care and Compliance
• Quality of Care cases brought pursuant to FCA that seek to hold providers liable for substandard care.
• Submission of false claims when knowing failure to meet standards of care/evidence based practice…but wait for more….
• “Data competence”—EHR, quality data, patient data, revenue/payers, cost to deliver care, coding/billing 46
© 2014 Virginia Mason Medical Center
Provider Quality and Integrity Partnership• Quality and compliance build on each
other’s strengths
• Value-based care requires collaboration
• Conduct an assessment of where quality and compliance now intersect in your organization, and leverage this overlap.
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Jesep, Paul and Pelerin, Kristine; Quality and Compliance Defined;
Compliance Today, September 2019
© 2014 Virginia Mason Medical Center
Provider Quality and Integrity Partnership, continued
• Value based care and reimbursement
• Social determinates of health
• Risk stratification/Population health
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Jesep, Paul and Pelerin, Kristine; Quality and Compliance Defined;
Compliance Today, October 2019
© 2019 Virginia Mason Institute
Pause forQuestions or Comments
before we move into Resources
© 2014 Virginia Mason Medical Center
CMS Provider Compliance Tips
https://go.cms.gov/2IpUkgi
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CMS Provider Compliance
https://go.cms.gov/2L2MECq
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OIG Workplan
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Open Payments
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Open Payments, continued
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© 2014 Virginia Mason Medical Center
MPFSDB, IPPS, OPPS, ASC….
Physician Fee Schedule…final rule supposed to address “reducing burden, recognizing clinicians for the time they spend taking care of patients, removing unnecessary measures, and making it easier for clinicians to be on the path towards value-based care.”
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© 2014 Virginia Mason Medical Center
A word from our friends
• CMS bulletins
• Noridian A and B
• Many, many listservs and publications
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© 2019 Virginia Mason Institute
Pause forQuestions or Comments Before
we move into Hot Topics
© 2014 Virginia Mason Medical Center
New CMS Radiology Requirements
• Effective January 2021, CMS will not pay for advanced imaging orders (CT, MRI, PET, and Nuclear Medicine) unless providers consult a qualified Clinical Decision Support Mechanism
• CY 2020 is a education and testing year
• Impacted areas include Ambulatory, ED, and Observation settings
• Future rule making expected to refine requirements
• Integrity resources in all aspects of this topic!
© 2014 Virginia Mason Medical Center
Opioid Connection to Integrity• The largest ever federal takedown included opioid related charges against 600 individuals; defendants included 76 physicians charged for their roles in prescribing and distributing opioids.
• Between July 2017 and June 2018, OIG issued exclusion notices to 587 individuals based on their conduct related to opioid diversion and abuse
• OIG analyzed Medicare Part D data to identify opioid prescribing patterns, highlighting 15,000 beneficiaries appeared to be “doctor shopping.”
• In Ohio, OIG completed the first state-specific Medicaid review focused on curbing the opioid epidemic and found more than 700 beneficiaries in Ohio at risk of prescription opioid misuse; nearly 50 prescribers stood out by ordering opioids for more of these beneficiaries than other prescribers
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Source: https://oig.hhs.gov/reports-and-publications/archives/semiannual/2018/2018-fall-sar.pdf
© 2014 Virginia Mason Medical Center
Telehealth
• The CMS Medicare Learning Network, “Telehealth Services,” ICN 901705 dated January 2019
• Information on Medicare Telehealthreleased by the Centers for Medicare & Medicaid Services on November 15, 2018, further explored the future of telehealth services and current barriers that might prevent the expansion of telehealth services
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© 2014 Virginia Mason Medical Center
Hospital-Physician Payments
Stark (Physician Self Referral Law) Law—the physician must act on behalf of the patient
• Physician Compensation Arrangements May Result in Significant Liability (DOJ Fraud Alert, June 9, 2015)
• September 15, 2015, the Yates Memo—no protection of individuals involved
• May 13, 2019, a unanimous United States Supreme Court ruled in Cochise Consultancy, Inc., et. al. v. U.S. ex rel. Hunt, increasing the amount of time that whistleblowers have to come forward
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© 2014 Virginia Mason Medical Center
Patient Complaint Monitoring
Yes, and have a process to identify those complaints that relate to compliance concerns
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What is Covered?
• LCDs getting stripped of CPT/ICD
• MACs moving codes to Local Coverage Articles—removed from clinical criteria
• Supposedly by January 2020
• No notice or comment period—so can add or delete codes without input from healthcare
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© 2014 Virginia Mason Medical Center
FCA & Medical Judgment
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The court in U.S. v. AseraCare Inc., et al, No. 16-13004 (11th Cir. September 9, 2019) held that Medicare claims are not capable of being “false” under the False Claims Act if the claim of “falsify” amounts to a disagreement over medical judgement.
© 2014 Virginia Mason Medical Center
ICD-11….what?????
Timeline, legislation, funding, bugeting based on upcoming research of what is missing from ICD-10
The WHO fully electronic 1th edition of the ICD contains _________ codes, compared to the 14,400 in ICD-10.
31 countries are field testing.
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© 2014 Virginia Mason Medical Center
New Enforcement Authorities
• Program Integrity Enhancements to the Provider Enrollment Process (CMS-6058-FC)—effective 11/4/2019
• A new “affiliations” authority allows CMS to identify individuals and organizations that pose an undue risk of fraud, waste or abuse based on their relationships with other previously sanctioned entities
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© 2014 Virginia Mason Medical Center
DOJ Issues Guidance May 2019
https://www.justice.gov/opa/pr/department-justice-issues-guidance-false-claims-act-matters-and-updates-justice-manual
• Key: voluntary disclosure of misconduct & cooperation may lead to more favorable “resolution”
• Need to demonstrate certain provider-led compliance program elements 67
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Patient Discharge Status Codes
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Pause forQuestions or Comments
before we wrap up
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© 2014 Virginia Mason Medical Center 71
© 2014 Virginia Mason Medical Center
Be sure you
put your feet in
the right place,
then stand firm.
– Abraham Lincoln
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Be sure you
put your feet in
the right place,
then stand firm.
– Abraham Lincoln
Fry Family Vacation 2018
© 2014 Virginia Mason Medical Center
Integrity: Flexible and Innovative
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• Change how we assess risk, monitor and audit
• Look for enhancements in our electronic health record system and data reporting
• Understand data integrity monitoring/management programs
• Partner with providers across the care continuum
© 2014 Virginia Mason Medical Center
Board Focus: Integrity Behaviors
“Prior View”: Focus on metrics, trainings, calls/hotline, data, tools
“Future View”: Focus on behaviors, ethical decision-making, organizational justice, and freedom of expression
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© 2014 Virginia Mason Medical Center 75
Getty Images
© 2014 Virginia Mason Medical Center
Leadership Lessons from Apollo 11
1. Visions can come true
2. Teamwork matters
3. Be confident in your mission
4. Commit to getting the job done
5. Encourage ideas
6. It takes a village
7. Learn from mistakes
8. Be fascinated and motivated
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https://www.forbes.com/sites/michaelperegrine/2019/07/16/apollo-11s-
transcendent-leadership-lessons/#5e2543b5b6a7
© 2014 Virginia Mason Medical Center
Contact Information
Thank you.
Julie Fry
(206) 223-6397
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