Janis Anfossi brings broad and varied experience in nursing and law to her post as Associate Compliance Officer and Director of Corporate Compliance, Privacy and Security Offices at Rush University Medical Center in Chicago. Following her graduation with a bachelor of arts degree from the University of California, San Diego, Ms Anfossi received the RN degree from Grossmont College in El Cajon, Calif. She then served as a staff nurse at the University of California Medical Center in San Diego. As Assistant Administrator of the Hospital of Scripps Clinic and Research Foundation in La Jolla, Calif, from 1986 to 1990, she supervised the departments of quality improvement, risk management, utilization management, medical records, social services and discharge planning, patient education, safety, and housekeeping.
In 1990, Ms Anfossi received her master of public health degree from San Diego State University and moved to the Order of Saint Francis Health System's St. Francis Regional Medical Center in Peoria, Ill. There, she served as Director of Quality Resource Management, responsible for programs of quality management, accreditation, utilization management, and clinical risk management, at a 750-bed regional academic medical center. From 1992 until 1998, Ms Anfossi served as Vice President for Quality Resource Management of the Carondelet Health System, St. Louis, Mo. The Carondelet Health System operates 14 acute care hospitals, 5 long-term care facilities 2 rehabilitation hospitals, and 2 psychiatric care facilities in 9 states.
In 1998, Ms Anfossi became Corporate Vice President, Risk Services, of the SSM Health Care System, headquartered in St. Louis. The SSM Health Care System operates 18 acute care hospitals, a managed care organization, a rehabilitation institute, and multiple physicians' offices and clinics. Here, she was responsible for the management of all aspects of the risk-quality interface, including the planning and operation of risk financing, risk management, and malpractice claims administration. She managed the SSMHC Insurance Company and the Self-Insured Professional Liability Trust. Ms Anfossi served on the systemwide Baldrige Applications Task Forces.
During these years, Ms Anfossi's long-term interest in law continued to grow. She enrolled in St. Louis University's School of Law, receiving her doctor of jurisprudence degree in 2000. At the St. Louis firm of Larson, Allen, Welshair & Company, LLP, during 2001, her responsibilities included a variety of issues related to health care quality management, risk management, and corporate compliance.
In December 2001, Ms Anfossi became Associate Compliance Officer at Rush University Medical Center in Chicago. The broad and complex Rush umbrella organization includes a medical college, a graduate college of nursing, a geriatric and posthospital rehabilitation center, numerous research centers, a large acute care hospital, owned physician practices, clinics, and a graduate department of health care systems management.
At Rush, Ms Anfossi's responsibilities cover all aspects of federal, state, and local regulatory compliance as well as the development, monitoring, and implementation of Rush's policies. She serves as a faculty member in the Health Systems Management department, teaching the course in Integrity Management. In her presentations and publications she has addressed the role and strategies of complex health care organizations in interpreting and complying with current regulatory requirements.
QMHC: What is the principal focus of your work at this time?
JA: We're always involved in ensuring compliance with federal regulations concerning billing and the provision of Medicare and Medicaid services. This means ensuring accurate coding and billing, and reviewing the care of Medicare and Medicaid patients against Centers for Medicare and Medicaid Services (CMS) standards.
We have to be sure that coding and documentation of care of all patients support the billing. The act of formulating the bill is similar to the end of a conveyor belt-it summarizes everything that was done for the patient. For Medicare and Medicaid patients, we must ensure that there are no violations of the False Claims Act.
Interestingly, because of the development of extensive patient and hospital databases, the CMS now is in a position to double-check our data. They have more information about us than we do!!
QMHC: How do you do that?
JA: Among the resources at the government's disposal, and ours, to help in its evaluations are the published reports of the Program for Evaluating Payment Patterns (PEPPERS). These reports were developed as part of a comparison and evaluation program commissioned by the CMS. A PEPPER is an electronic data report containing hospital-specific billing data for thirteen targeted diagnosis related groups (DRGs) and discharges that have been identified as being at high risk for payment errors. They (the government agencies) can look at us and compare our lengths of stay, clinical interventions, and so forth to compare our hospital's performance with national performance levels or norms.
QMHC: Fine, but that's billing. What does that have to do with the quality of care?
JA: Using a PEPPER points the CMS and the hospital reviewer toward certain quality issues. Inadequate clinical care or complications can result in extended stays or early readmissions for the same clinical diagnosis. These things become conspicuous when they affect the figures in a PEPPER. The presence of outliers calls the reviewer's attention to the possibility of inadequate or inappropriate patient care.
QMHC: What kinds of DRGs is the CMS looking at?
JA: One-day stays sound an alert. They look at several DRGs that reflect different types of one-day stays. The CMS wants to know whether the care and services provided during that one-day admission could have been appropriately provided on an ambulatory basis. On the other hand, after reviewing the chart, you might ask if this patient was discharged too early. That's a quality issue. Another type of admission that is reported and should be evaluated is the three-day admission that qualifies the patient for admission to a skilled nursing facility. Did it meet the CMS criteria? Admissions for five other diagnosis groups that have shown a high risk of inaccurate coding are reported. Complication-comorbidity pairs are reported. Another type of reported admission is readmission for the same diagnosis within seven days of discharge, which may point to a quality problem during the original admission or an ensuing complication.
QMHC: What if the patient who experiences a complication or recurrence goes to a different hospital? Isn't he lost to the reporting system? How could you follow up on him?
JA: No, with the development of the PEPPER and of the Medicare Administrative Contractor (MAC) system, he won't be lost. In those countries that have national health care systems, they have the advantage of a single comprehensive database that includes all of the individual's care, both inpatient and ambulatory. Beginning in 2007, the CMS is going to combine its two billings databases (Part A and Part B) under the management of new entities to be called MACs. Each MAC will be responsible for one of the ten different Medicare regions.
The MACs will be established over a five-year period beginning in 2007, with the last one brought on board by about 2011.
The databases set up by MACs will include both physician and hospital billing information, which of course identifies the type of diagnostic or therapeutic approaches taken. As the MACs become operational, the PEPPERs and other reports will include a readmission to the same hospital or elsewhere. This will be possible because Medicare data will include data on readmissions of individual patients drawn from the insurance carriers' (Medicare, Medicaid) databases. Suppose an individual who has Medicare coverage has an operation at downtown university Hospital A, goes home to the suburb where he or she lives, and a few days later develops an infection. He or she goes to his or her primary care physician's office and then is admitted to a suburban hospital B because his or her doctor diagnoses the infection as being associated with the surgery, and begins treatment.
His or her MAC will be able to trace the whole chain of events because it has access to both the hospitals and the physician's billing. It gets the hospitals' billing information through Medicare Part A hospital billings databases, and physician office or ancillary services' billing information through Medicare Part B billings databases. So, no matter where the Medicare beneficiary goes for medical care, his or her course can be tracked. Instead of falling through the cracks, all of the billings concerning the individual patient become part of one comprehensive data source. The MAC will be able to evaluate such things as readmission, recurrent treatment, and complications because of having this source of data. These evaluations are bound to have an effect on quality and risk management.
[QMHC note: Incidentally, the regulations stipulate that each MAC establish a corporate compliance program designed to measure and support the quality level of its own operations.]
The Joint Commission's use of tracing in evaluating patient care is a positive influence on quality and safety. Pay for Performance (P4P) is another. Managed care organizations are way ahead of Medicare in analyzing provider performance. The government is just catching up.
I strongly support efforts to quantify and measure the elements of good quality. I often think that the payers know more about us than we do. We providers should do more to learn about ourselves. We need to be able to defend ourselves. We are being evaluated by others, and we have little control over the indicators that they use. Using statistical process control is a step in the right direction.
As a nurse, before I went to law school, I was responsible for the risk management program at my hospital. One of the problems we dealt with was slow response by physicians to calls from nurses. It wasn't constant or universal; it varied, and we needed to find out what was responsible for it. We analyzed all of the circumstances surrounding doctors' response times, including the short times and the long ones, and the ways in which the nurses contacted them. We found that there was wide variation in the way in which the nurses communicated-that is, the tone of voice, the choice of words, and so forth. After a lengthy and detailed study, including objective measurement of the variables and the use of statistical process control analysis that looks at normal and abnormal variation in a system, we found that the response time was strongly influenced by the physician's perception of the severity of the patient's condition as conveyed by the nurse's voice and manner in a telephone conversation. The doctors picked up on these subtle indicators and responded accordingly. We developed a severity-score scale, and found that high perceived severity scores were positively associated with short response times. We observed that there were big differences in the ways in which different nurses would have reported the same incident or situation.
In an effort to bring about at least a measure of standardization in this kind of reporting, we taught the nurses to employ certain standardized language elements, to help all parties to understand the actual level of severity involved. You could say that we developed a communication algorithm. The idea was to reduce variation. The variation we had observed was interfering with something that influenced quality-namely the promptness with which physicians responded to their calls. The study and its findings illustrate the use of quantifiable approaches in supporting risk management and improving the quality of care.
QMHC: What policy issues are you currently dealing with?
JA: The question of who introduces the subject of an advance directive to the patient, and obtains the signed document, is an issue to me. It used to be that this sometimes disturbing subject was discussed with the patient by his doctor. Now, the admitting clerk is often the person who routinely makes sure that the patient has an advance directive. Thus, the clinicians lose the opportunity for a dialogue with the patient and the chance to explore his or her wishes. The whole transaction can become an impersonal clerical affair. That's unfortunate.
I am passionately interested in studying how the law functions in health care, and the problems involved in trying to handle bad quality through the tort system. The government takes the position that billing them, the CMS, for providing bad quality health care services can constitute fraud. The False Claims Act provides the Medicare and Medicaid systems with a remedy where bad quality of care can be demonstrated.
QMHC: The False Claims Act?
JA: Yes-it is being used to an increasing extent in combating fraud in the provision of federally funded health care services, Medicare and Medicaid. The act has an interesting history. Its objective is to prevent and punish fraudulent billing of the federal government. It was drafted and enacted in 1863 to combat fraud on the part of vendors who were selling horses and supplies to the Union Army. The act contained a qui tam clause, or what we now call the "whistle blower" provision, providing a reward to someone who files a suit on behalf of the government against the perpetrator of a fraud against the government. In 1943, Congress enacted revisions in the law, watering down the qui tam provisions to such an extent that the law was emasculated and fell into disuse.
Twenty years ago, following public outcry over procurement abuses and fraud, Congress enacted the 1986 amendments to the False Claims Act, once again strengthening the effectiveness of the qui tam provision. As a result, the number of whistle blower lawsuits, in health care and other fields, has greatly increased.
QMHC: How do you get away from the pressures of your work? Do you have some hobbies?
JA: I relax by reading and playing golf. You could say I'm a pretty enthusiastic golfer. My husband and I often play together.