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Presented by

PPACA & Non‐Physician Clinicians: New Roles, New Risks

D. Scott Jones, CHC

Richard E. Moses, D.O., J.D.

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Presentation Goals

● Understand the changing healthcare system under PPACA

● Review the expanding role and risks faced with non‐physicians clinicians (NPCs) under PPACA

● Discuss the evolving compliance and quality risks associated with Clinical Practice Guidelines (CPGs)

● Review the quality demands and reporting requirements of PPACA

● Discuss the current changes to date as they relate to patients

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INTRODUCTION

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INTRODUCTION

● Background

● Identify the current demands on the Healthcare System

● Current state of physician workforce

● Non‐physician Clinicians (“Midlevel Providers”)

● Guidelines: Risks & Reimbursement

● Quality Reporting Measures Under PPACA

● Summary & Conclusions

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BACKGROUND

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Health Care Reform

President Obama Signs PPACAMarch 23, 2010

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Health Care Reform

● Health Care Reform Goals

Improve access

Universal coverage

Increase quality reporting to include outcomes

Increase integration of care through partnerships of physician networks and hospitals

Cost control and cost reduction

7Physician Compliance Network

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Health Care Reform● PPACA 2010 was amended by the Health Care and 

Education Affordability Reconciliation Act (HCERA 2012)

Quality and Cost Payment (Title III, § 3002, 3003, 3007) – Adjusts physician payments based on quality and cost through a value‐based modifier, beginning January 1, 2015

PQRS – possible penalties for not reporting beginning in 2015 up to 2% of the prevailing fee schedule

Fee‐for‐service → value‐based reimbursement (“quality”) 

8www.physiciansfoundation.org/uploads/default/Physicians_Foundation_2012_Biennial_Survey.pdfwww.ncsl.org/documents/health/ppaca-consolidated.pdf

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Health Care Reform● Fee‐for‐service → Value‐based/Quality‐based reimbursement 

system Goal: Reward doctors & hospitals for improving quality of care

● Subsequent trends: Outcome‐based payments

Lower demand for hospitals

Increased number of insured patients

Improving patient experience

Hospital competition on outcomes and total value

Increased physician employment by health systems 

9Health Affairs October 11, 2012

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DEMANDS:THE CHANGING 

HEALTH CARE SYSTEM

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Demands on the System

● Increase from 260.2 Million Americans with health insurance to  296.6 Million under PPACA U.S. Census Bureau 2012 Current Population Survey, Annual Social & 

Economic Supplement

● 32 Million Americans may acquire new health insurance with PPACA

● U.S. physician workload expected to increase by 29% from 2005‐2025

● Over 60% physicians are health system employees

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Demands on the System

● Association of American Medical Colleges (AAMC) Center for Workforce Study on Physician Shortage:

2015 → 63,000 physicians

2020 → 91,500 physicians

2025 → 130,600 physicians

● Primary care faces greatest physician shortage

12www.aamc.org/newsroom/newsreleases/2010/150570/100930.html

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PHYSICIAN WORKFORCE

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The Physicians Foundation

● National not‐for‐profit grant making organization dedicated to advancing the work of practicing physicians and to improving the quality of healthcare for all Americans

● Founded in 2003 through settlement of a class action law suit brought by physicians and state medical associations against third‐party payers

● Board of Directors: physicians and medical society leaders across the United States

14www.physiciansfoundation.org

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The Physicians Foundation

● 2014 Biennial Survey

Every other year a national survey of physicians is conducted

Provide a “state of the union of the medical profession”

Survey sent to over 650,000 physicians 80% of all physicians currently involved in patient care

20,000+ physicians responded in all 50 states

15http://www.physiciansfoundation.org/uploads/default/2014_Physicians_Foundation_Biennial_Physician_Survey_Report.pdf

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The Physicians Foundation

● 2014 Biennial Survey

Data derived from responses to > 35 questions

● Many questions multi‐response

Over 13,000 written comments by physicians on current state of medical profession & healthcare system

Data compared to 2012 and 2008 surveys

16http://www.physiciansfoundation.org/uploads/default/2014_Physicians_Foundation_Biennial_Physician_Survey_Report.pdf

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Physician Opinion: Retirement 2014

I will accelerate my retirement plans 38.7%

I will defer my retirement plans 18.6%

I will not change my retirement plans 42.7%

Medicine and healthcare are changing in such a way that:

17http://www.physiciansfoundation.org/uploads/default/2014_Physicians_Foundation_Biennial_Physician_Survey_Report.pdf

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Physician Opinion: PPACA

● The Physicians Foundation 2014 Biennial Report

46% Physicians give PPACA grade of D or F 

25% Physicians give PPACA grade A or B

39% Physicians are accelerating retirement plans due to PPACA

18http://www.physiciansfoundation.org/uploads/default/2014_Physicians_Foundation_Biennial_Physician_Survey_Report.pdf

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Physician Opinion: Key Findings

● 81% physicians  overextended or at full capacity

Up from 75% in 2012 & 76% in 2008

19%  have time to see more patients 

● 44% physicians  plan to reduce patient access to services

Cut back visits, work part‐time, retire, close practice to new patients, seek non‐clinical jobs

● 35% physicians  independent practice owners

Down from 49% in 2012 & 62% in 2008

19http://www.physiciansfoundation.org/uploads/default/2014_Physicians_Foundation_Biennial_Physician_Survey_Report.pdf

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Physician Opinion: Key Findings

● 17% physicians are in solo practice Down from 25% in 2012

● 69% physicians believe their clinical autonomy has been limited & their decisions compromised

● 24% physicians do not see Medicare patients or limit the number seen

● 26% physicians participate in an ACO 13% of this group believe ACOs will enhance quality & decrease costs

20http://www.physiciansfoundation.org/uploads/default/2014_Physicians_Foundation_Biennial_Physician_Survey_Report.pdf

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Physician Opinion: Key Findings

● Physicians spend 20%  of their time on non‐clinical paperwork

● Concierge/Direct pay medicine

7% physicians now practice this way in some form

13% indicate they are planning to transition in whole or in part

17% physicians 45 yo or younger indicate they will transition to this form of practice

21http://www.physiciansfoundation.org/uploads/default/2014_Physicians_Foundation_Biennial_Physician_Survey_Report.pdf

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NON‐PHYSICIAN CLINICIANS

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Nomenclature

● Non‐physician Clinician = Physician Extender = Midlevel Provider

● Number & Use of NPCs → increasing

Nurse Practitioner (CRNP)

Physician Assistant (PA)

Others CRNA → Cer fied Registered Nurse Anesthe st

CRNM → Nurse Midwives

23Gore C. J Legal Med 2000;21:125-142.

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Arguments to Expand NPC Duties

● Competent to diagnose and treat at a physician level

● Delegation of routine tasks allows physician to deliver higher quality of care

● Physician may attend to more serious patient health care concerns

● NPCs deliver less expensive treatment

● NPCs improve access in underserved areas

● Solution to physician shortage

24Walsh JH. Gastroenterology 2000;188:459-60.

Druss BG, et al. New Engl J Med 2003;348:130-7.

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NPCs: Current Trend

● Skirmishes across the nation re: roles NPCs should play in medical care NB: Physician shortage & increased insured population

● NPCs taking on duties once solely performed by physicians Mini Clinics (Pharmacies +/‐ Urgent Care Centers)

Clinical practice and hospital Emergency Departments 

VHA proposal to allow NPs to practice throughout the system without physician supervision

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NPCs: Current Trend

● State Scope‐of‐Practice Rules differ widely on autonomy

● CRNAs battling for autonomy

● PAs have greater role in hospital, Emergency Department, and office care  

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Nurse Practitioner Supervision Environment

Updated 5/13/14

27http://www.aanp.org/images/documents/state-leg-reg/stateregulatorymap.pdf

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NPC Health Care FraudNurse Practitioner Cases

● NP indicted for allegedly billing $2.2M for allergy testing and treatments not performed (Atlanta/Stone Mountain, GA) http://www.wsbtv.com/news/news/local/nurse‐practitioner‐facing‐federal‐fraud‐

charges/nkFXr

● NP and physician partner indicted allegedly falsely billing Tricare, private insurers, and Medicare for services never rendered and false statements in patients’ records involving x‐rays services and office visits (St Louis, MO) http://www.justice.gov/usao/moe/news/2013/july/lucas_mel.html

● NP convicted of upcoding and recoding scheme receiving $1M in fraudulent reimbursements from insurance companies for laser skin care (Mobile, AL) http://www.wkrg.com/story/27175655/local‐nurse‐practitioner‐convicted‐of‐federal‐

crimes

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NPC Health Care Fraud Physician Assistants

● PA convicted of defrauding Medicare by signing and selling fraudulent prescriptions for DME who then submitted the fraudulent claims in Medicare resulting in $3M of false payments (Los Angeles, CA) 

http://www.justice.gov/opa/pr/los‐angeles‐physician‐assistant‐pleads‐guilty‐two‐medicare‐fraud‐cases

● PA convicted for participating in Medicare fraud scheme involving ~$200M in fraudulent billings by a mental health company (Miami, FL)

http://www.justice.gov/opa/pr/miami‐area‐physician‐assistant‐sentenced‐15‐years‐prison‐200‐million‐medicare‐fraud‐scheme

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NPC Health Care FraudPhysician Assistants

● PA (unlicensed) and physician partner convicted of defrauding Medicare $2.1M in 2 months for fraudulently billing rectal sensation tests and electromyogram (EMG) studies of the anal and urethral sphincter that were never performed (Austin, TX) http://www.fbi.gov/houston/press‐releases/2014/jury‐convicts‐austin‐

doctor‐and‐unlicensed‐physicians‐assistant‐of‐health‐care‐fraud

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Physician Liability for NPCs

Physician Liability (Vicarious)

● Lack of adequate supervision

● Untimely referral to consultant

● Failure to properly diagnose

● Inadequate examination

● Negligent misrepresentation

● Violation of health care fraud laws

Legal Theories

● Vicarious liability

● Negligent supervision

● Negligent hiring/negligent selection

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Moses RE, Feld AD. Am J Gastroenterol 2007;102:6-9.Moses RE, Jones DS. JHCC 2011;12:51-56,75. (March-April)

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Avoid Liability

● Check all credentials

● Check all references 

● Hire qualified NPC

● Know state rules

● Properly train NPC

● Properly supervise

● Follow state supervision requirements

● Review work regularly

● Encourage interaction

● Proper NPC introductions

● Set high standards of care

● Make sure procedures are followed

● Stress documentation

● Compliance monitoring

32Moses RE, Jones DS. JHCC 2011;12:51-56,75. (March-April)

Moses RE, Feld AD. Am J Gastroenterol 2007;102:6-9.

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GUIDELINES:QUALITY 

&REIMBURSEMENT

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Clinical Practice Guidelines

● Institute of Medicine (IOM)

● CPGs defined: “Systemically developed statements to assist

the practitioner with patient decisions about appropriate health care for clinical circumstances.”

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Institute of Medicine, TO ERR IS HUMAN: BUILDING A SAFER HEALTH CARE SYSTEM (1999)Barry Furrow, et al., HEALTH LAW 267 (2nd ed. 2000)

Finder J. Health Matrix: Journal of Law-Medicine 2000;10:67-115.

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INTERSECTION:Compliance, Quality, Fraud, & Malpractice 

● OIG Work Plan 2014

● PPACA & Quality

● Government Accountability Office (GAO) “…beneficiaries…who receive health care from providers who adhere to 

PPACA…may receive higher quality of care…Conversely, those who receive care from providers who fail to do so may receive lower quality of care.”

“…it is possible that, if these (PPACA) standards and guidelines become accepted medical practice, they could impact the standard of care against which provider conduct is assessed in medical practice litigation.”

35www.gao.gov/assests/590/589657.pdf

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CPG: Quality & Reimbursement

● Measures collected under Physician Quality Reporting System (“PQRS”) → “Quality Measures”

● Assessment of patient health outcomes & functional status of patients

● Assessment of continuity & coordination of care & care transitions

● Assessment of efficiency

● Assessment of patient experience & patient, caregiver, & family engagement

● Assessment of safety, effectiveness, & timeliness of care

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CURRENT STATUS

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The Real World

● Increased insured population

● Increased insurance premiums

● Health insurance company control increased: Higher insurance premiums ‐> less benefits

Higher deductibles

Higher co‐pays

Limited formularies

Denial of treatment of expensive conditions

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The Real World

● Population Health

● Employers changing plans and offerings  limited access

● Physician employment shift

● Increased role and employment of Non‐physician Clinicians

● Increased taxes (direct & indirect)

● Increased U.S. debt

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The Real World

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SUMMARY & 

CONCLUSIONS

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D. Scott Jones, CHC ● Senior VP Claims, Risk Management &  Compliance ‐ HPIX

● Leads a team managing over 700 malpractice claims 

● Compliance, Risk and Claims for 3600 providers

● Former medical practice & hospital administrator

● Board Certified Healthcare Compliance Officer (CHC)

● Author, 12 nationally published books and over 50 articles on quality, practice management, and regulatory compliance

● Frequent speaker to state, regional and national organizations 

● Over 1000 risk assessment service visits to healthcare organizations nationwide

● sjones@hpix‐ins.com (904) 294‐5633

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Richard E. Moses, D.O., J.D.● Practicing Gastroenterologist for over 30 years

● Board Certified:   Gastroenterology

Internal Medicine

Forensic Medicine

● Adjunct Assistant Clinical Professor, Temple University School of Medicine

● Adjunct Professor of Law, Temple University Beasley School of Law

● Physician Advisor Healthcare Providers Insurance Exchange

● National Speaker, Author and Consultant on Medical, Risk and Compliance issues 

● remoses@mosesmedlaw.com (215) 742‐9900

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Presented byHealth Care Compliance Association19th ANNUAL COMPLIANCE INSTITUTE

Disney Swan & Dolphin Resort 

Lake Buena Vista, Florida

April 19‐22, 2015

Thank You

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The End

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