Driving healthy growth: proactive compliance
The value of a proactive stance to compliance
Organizations throughout the health care ecosystem are struggling to keep their footing in a rapidly changing regulatory and competitive environment.
In this complex landscape, regulators have heightened their scrutiny and are more frequently deploying the enhanced enforcement tools at their disposal.
Regulators and patients increasingly expect organizations to demonstrate an effective, proactive approach to managing risk and compliance that can prevent or promptly mitigate costly exposures such as security and privacy breaches. In response, organizations are increasingly being audited for compliance against standards and implementation specifications, such as those created by the HIPAA privacy and security requirements and the HITECH Act.
Mere compliance is no longer sufficient, and an uncoordinated approach is no longer sustainable.
To thrive, organizations need to develop mature, robust compliance processes that enable effective partnerships with health care entities that traditionally have stood alone. Organizations must embrace the idea of change, and effective change management is a basic requirement.
1. What’s the issue?
The Affordable Care Act's (ACA) focus on patient access and outcomes is driving fundamental change in the business models of both payers and providers, as well as their relationships with business associates. As part of that transformation, health care organizations are exposed to increased risk as they strive to create new opportunities in an environment where regulatory oversight and expectations have markedly increased.
The care networks needed to fundamentally affect health outcomes and bend the cost curve will require the formation of new partnerships, where each collaborating entity has a strong culture of compliance that can be effectively coordinated with the others. Demonstrating successful compliance at this level will enable organizations to extend their capabilities to partners.
2. Why now?
Health care reform, including the establishment of health care exchanges and the development of accountable care organizations, has resulted in an unprecedented amount of change while the pressures on the system are reaching their peak. The baby boomer generation is reaching Medicare age, and the ACA is expanding the safety net.
A growing portfolio of any health care organization’s business will be derived from Medicare and Medicaid. Federal and state governments will become the biggest “customer.”
This means thinner margins and more standardized transactions across the health care ecosystem.
3. How does this affect you?
An organization that is seen as taking undue risks or failing to manage risk appropriately will lose the confidence of its members, patients and partners.
A mature, proactive compliance model allows organizations to reduce compliance costs, enabling them to allocate scarce resources most efficiently. A compliance framework is an important quality measure for improving “customer” satisfaction that will enable growth and protect value, positioning the organization for success in the short term and the long term.
4. What’s the fix?
To cross the quality chasm, organizations must transform their compliance capabilities and create a competitive advantage.
The compliance transformation journey has three stages:
These enhanced capabilities provide a return on investment by protecting existing value — and by meeting the increased expectations of key customers, particularly the government.
5. What’s the bottom line?
Robust, integrated compliance capabilities help build confidence among shareholders, members and regulators, which empowers management to take the risks that create the opportunity for growth as health care organizations move into uncharted territory.
Confidence in your oversight functions’ coordinated efforts to achieve quality throughout the organization, with compliance leading the charge, will drive the focus on outcomes. By moving beyond “react and respond” to a proactive stance, robust compliance planning does more than simply protect the organization’s assets and reputation; it enables sustainable growth.