Ethics Whisperer

Saturday, July 12, 2014

The Next Hot Word in Compliance

Hear yea! Hear yea! Hear yea! The next hot word in compliance will be UPQUALING. This, of course, is on the model of UPCODING. Healthcare reform is a gamble on the idea that incentives can be given to lower the cost of care while maintaining or improving its quality. This has been tried before with limited success under the rubrics "managed care," "HMO" or "Medicare Part C." The problem is that these strategies have not been wildly successful at saving money and they run into the fact that folks just don't trust that the quality of care is the same. So reform is taking a two pronged attack by rewarding providers who concurrently lower costs and maintain or improve quality. This is the main idea behind ACOs and the Medicare Shared Savings Program. The problem with this is that quality is in the eye of the beholder - and, in this case, CMS is the beholder. CMS has done the only possible thing, and done it well, which is to prescribe a set of areas that are important to healthcare while being measurable. In other words, money will now follow quality as measured against this prescribed set of measures. When money follows coding, we get upcoding, which is one of the reasons compliance exists in healthcare today. But where is compliance with respect to the equally tempting risk of upqualing - fudging the numbers so the quality of your outcomes appears better than it really is? This is the next frontier and it will go by the awkward word "upqualing" - or so I am betting.