I think the the conversation needs to be pivoted from why is it so complicated coming from them? To why aren't physicians not making health care more personable to their patients? And I think when when we begin to focus on the people involved, that we turn, quality of care to not only being a measurable outcome of somebody's health, but also a measurable outcome of somebody's knowledge of their health care.
Welcome to Now or Never Long-Term Care Strategy making. themselves. with Kosta Yepifantsev a podcast for all those seeking answers and solutions in the long term care space. This podcast is designed to create resources, start conversations and bring awareness to the industry that will inevitably impact all Americans. Here's your host Kosta Yepifantsev.
Hey, y'all, this is Kosta. And today, I'm here with my guest, Hassan Abdallah, CEO of ATLA Healthcare Group. Today, we're talking about how to assess quality care from a compliance expert. Thank you for joining us, Hassan, would you start by sharing a bit about your career in health care, compliance and regulatory affairs? But also, what does this mean to the everyday person?
Well, cuz the first foremost, thank you so much for having me on. Absolutely excited to be here. longtime listener, first time caller, I've been wanting to say that for a while. So I hid out in healthcare, just a little over a decade ago, I actually started off as a claims auditor for one of the big four, specifically in the healthcare space. And so you'll hear me a little bit talk about that I've been on each side of the transaction. So my journey began in as an auditor, so not very
welcomed. And then I actually transitioned into a space that was probably less welcomed, which was as an SIU fraud investigator, oh, nice space, really got a ton of experience in the managed care space around fraud, waste, and abuse, False Claims Act, doing joint investigations, with other health plans, and payers, really living within the swamp of the CMS regulations. And then I moved into leadership positions
within compliance. I kind of got on the to the transactional side a little bit, I worked for a private entity where I overseen the compliance but from a contracts and acquisition perspective. They were one of the few groups that got into private equity in the healthcare
space early, very early on. And then I became the Chief Compliance Officer of Health Alliance plan, which is one of the largest plans here in the state of Michigan, it was a very interesting time, because I was the youngest C suite executive in the company at the time, which was challenging, because compliance is already a tough sell to the board and to, you know, when you're talking about things in terms of strategy, and then I spent about a year and a half, at a startup in New York,
where we were the first ever we were building from the ground floor, as a compliance officer. And so what it means to the everyday individual, it's a niche space, where our job is, we're not lawyering, we're not ending or litigating. Our job is to make sure that compliance is a living organism, throughout the culture and processes of a
company. And what that really means is, are their checks and balances through the job duties and, and the job responsibilities of every individual throughout the company that ultimately uphold regulatory laws and rules.
Fascinating. And I say that with literally all the endearment because I work with compliance all of the time. And we have this debate, essentially, you know, are we a company that focuses on compliance for our payers? Or are we a company that focuses on quality of care for our patients? But, you know, I believe, Hassan that these two metrics are intertwined. And so from a regulatory and compliance perspective, how would you define quality of care? So from,
I think it's important to bring up what it means clinically, right, clinical quality of care is the degree to which services healthcare services for individuals and populations lead to better health care outcomes. Right. Well, compliance perspective, what I believe it means is, to which degree the rules and policies that are being put in place, help sustain those positive health care outcomes. And so to me, it comes into three buckets. One is accountability to the provider.
The second is a payer system that one continues to make health care accessible and affordable, which is a constant challenge within the US. And the third bucket to me is ongoing enforcement and justification of, you know, whether it's audits or other ones. So that to me is the regulatory perspective of quality of care.
In your opinion, what are the key indicators we should be looking for when assessing the quality of care in a healthcare facility? Be it a long term care, facility, assisted living, or even home care?
Well, you know, that last piece, a little caveat, because home care is so much on the rise right now mobile, so much on the rise right now, when we look at traditional health care facilities, obviously, one of the ones that you're going to look at is morbidity rates, right? You know, what are they looking at each one of these facilities? What is the return rate of patients for the same type of incident or illness in situations where there are not
chronic illnesses at a hand. And what I mean by that is, you know, if individuals are consistently coming back for the same level of care for the same level of service, for something that likely should have been treated at the onset, without the necessity to have prolonged post acute care, trend trajectories, those are the metrics you really want to look
at. And I think what's really important is, from an assisted living perspective, it's a very difficult space to to assess from a regulatory perspective.
And that's kind of not to interject, but I was going to ask, like, how do you regulate an assisted living facility? Because there's no government funds that because the way the language first off, you're speaking my language, and I didn't mean to interrupt that question, but I just had to tell you, I totally like resonate with everything that you're saying. And I follow it, and I understand it. But assisted living lives outside of the traditional long term care space, even though it is
considered long term care. So I am fascinated with what with how you would regulate that type of entity.
And there's so many factors, right, there's a political factor, you know, the administration that's currently in place is always going to play a factor into that the way the House and the Senate are moving legislatively is going to play a factor into that, which is another conversation because the politics of health care within the US is another you in another
mountain to climb. But I think in this living, it's so difficult, because unfortunately, the amount of people who need health care services in a traditional or non traditional setting far outweighs the number of resources that the government and payers have to oversee the we are we are in a even in 2023, even with the advancement of technology that we have, we are still very much in a pay and chase system, meaning we are paying on claims and hoping that we have enough data metrics or
AI or smart data in place to tell us, hey, these six months of claims for this provider 18 months ago, probably shouldn't have been paid. And by now that guy is probably in Barbados or or world, you're chasing him. And so it's going to continue, I think to be difficult to that in this post COVID enforcement world as a whole whole nother space that's really going to, I think change the trajectory.
Ultimately, I think it leads to specifically when it comes to home care and assisted living that state agencies are going to have an increased responsibility. And unless that comes with an increase in federal funding to support those agencies continue to have this struggle and physicians who are in it for the wrong reasons, or private equity that's coming into the space where armies will continue to benefit from the lack of enforcement
as a regulatory and government compliance professional, what are the most important regulations our listeners should be aware of when evaluating Long Term Care Options?
It's a great question. I think, first and foremost, we have to recognize some of the more recent legislative changes, which is like the no surprises billing act, right. So we need to look there and understand that now. healthcare entities are required to show you what healthcare is going to cost you. And that should be one of the most, you know, the first and foremost thing you should be seeing when
choosing a provider. The other laws that need to be understood by provider or by patience is when it comes to the transparency and billing requirements, whether it's the False Claims Act, or otherwise, is that when you get an EOB an explanation of benefits, you should be looking at those. Most people don't I'll be honest with you, I know I've gotten them and usually they end up in the trash or most people don't understand
them. And your explanation of benefits is what tells you as a patient, hey, this is who you seen. This is the service that was built and so If you see something there that you believe you didn't receive, call your health plan, you should be talking to them. And then, you know, that's the flip side of this conversation is that our health plans equipped to be able to provide that level of service
and knowledge. And so I think those two things are really probably at the precipice of what consumers or patients should be aware of when you know, entering into any healthcare relationship.
Why does it have to be so complicated? Why does the EOB have to literally be like, you know, a Latin written text?
Man, it's a million dollar question. Ya know, it's interesting. At the top, I mentioned that I recently, you know, did some work a little over a year with a startup. And it was completely focused on being a patient first, technology based, you know, company, and we're seeing this trend, right? It's, we want to make it fast, want to make it
easy on people to see it. The difficulty is, your average person doesn't understand CPT codes, you know, they see this IX of numerology in numbers and, and then the medical language that's in there, it's like e&m visit for the you know, and then they're, they went in there, and they're like, do it, I had a cold, and I just wanted to go in to get a checkup. Um, you know, I think it's a mix. One is payer requirements, force physicians, to be very copious in their notes and documentation to which
they provided service. So I think that's the one piece the other piece of it is, in order for government payers to pay on these claims, they then need to see an equivalent sufficient line of documentation coming, but by the time it reaches the patient, they're so far out of the loop or don't understand the communication. And so I think the the conversation needs to be pivoted from, why is it so complicated coming from them to? Why aren't physicians not making healthcare more personable to
their patients? And I think when we begin to focus on the people involved, then we turn quality of care to not only being a measurable outcome of somebody's health, but also a measurable outcome of somebody's knowledge of their health care.
That's impressive. And it ties in to the next question when we're talking about kind of the compliance metrics taking away from the quality of care. So I want to talk about Medicare and Medicaid regulations. Because obviously, majority of people in the United States received their long term care from Medicaid. And as we become more of an aging population, more individuals are participating in Medicare, which has another set
of regulations. So arguably, they're some of the most complicated and far reaching in the care industry. At the end of the day, do you believe that these regulations truly protect patients and ensure they actually receive high quality care?
I think they're very much intended to do that doesn't It doesn't always lead to it. And it's going to be very interesting to see what happens between now and 2030. Because by 2030, CMS is planning to phase out itself from the payer system. And I think in order to do that, there are a couple things that need to happen. First, CMS needs to very clearly articulate a vision and landscape for value based care so that we can move away from a fee for service type schedule.
The second piece is that CMS has to accelerate the incentives for providers who are providing value based care. Unfortunately, what has happened in the Medicare space, specifically, is there are more providers who are willing to move towards a capitation payment system than a fee for service system? Because ultimately, they're still making the same amount of money. Right, and they're not holding any
higher standard. Exactly. And I think the last thing is that health equity has to be a central feature to the value based system. And what I mean by that is, CMS has to play a critical role in the legislative build up of how commercial payers are more accessible, unfortunately, that the higher on ones to people with more money. That's the reality of it. I mean, you even see it when you get a new job, and you're
offered a health plan. You see that some of the employers who use more than one payer, you see there's a package a that $70 a month for a family and a package C which is you know, usually your Blue Cross Blue shield's that gives you all the bells and whistles, but it's $2,700 a month for a family And until that gap closes, health, quality of care health care outcomes will continue to be as disparaged as the gap of health equity and excesses,
I'm gonna go down the rabbit hole and stop me if it gets too complicated or too technical, I don't think you're gonna have a problem with it. But I am curious. You can quantify compliance. Like, you know, you get suffered, I work with managed care. So I understand how health plans and how they integrate with the
overall Medicaid system. So I know when they say we want to see X, Y, and Z, you do XY and Z. value based care, though, is a, it's somewhat subjective, because I don't know how you can quantify with specific outcomes and metrics, the overall health of a human being. And that is, and I'm fascinated to hear what you think about that, like, how do you actually quantify is it? Is it hospital visits? Is it the amount of medications that one person's take that one person
takes? Is it the amount of falls that one person may sustain within a period of time? How would you quantify value based care?
So right now, value based care is looking at essentially, two, essentially two factors, or they are I would think so is that efficiency and effectiveness? Right? Yes. Now, when you look at efficiency, physicians look at this is how quickly can I see someone? Right? In and out? Yes, we're going to have the same 15 minute Spiel with every single patient. But then that leads to things like in the billing world, what they call impossible days, because then they're seeing 70 patients in a eight hour
timeframe. Yeah. And then effectiveness, the measurement of it is what is it? The amount of encounters that are being built? Is it the linkage to a specific prescription? So for me, value based care has to be metric around the ability for physicians and health care entities to provide care, that leads to less consequential health care services after that initial visit. And again, this is all going to be dependent on the type of service that the
person is being visited. Sure, but I think one of the, the difficulties you have in any of these health care models is we are still looking for a healthcare model that incentivizes whom? The physician, right, and that's, and that, to me is the challenge is, I'll give you a brief example not to sidetrack too much. No, please. I recently had a physician client in a consultation or an intake, who during COVID made an egregious
amount of money. And he said the one thing that every physician, Clive, almost half of those are almost always said, which is everybody's doing it this way. And then I thought about that statement after 10 years in healthcare, and I said, is everybody doing it this way? Because everyone's greedy, or everyone's just naturally fraudulent? Or is it doing it this way? Because the system incentivizes it to be correct,
correct? When it does, yes, I'm not saying there aren't bad players in the physician game there are we know that there are in the legal field in every field, but many of them, many of them start out following the model that was provided to the right. And it is hard to ascertain, you know, or to differentiate whether or not from a fraud perspective if they truly had intent and knowledge
to deceit, the payer system. And so when we relate this to quality of care, we really need to be thinking about who are we truly incentivizing from value based models? Is our following value based models incentivizing healthcare entities or following value based models, ultimately, incentivizing people that who need these services? Because we know this as well, unfortunately, America has ranked 11 in quality of care in all first world countries. However, we're ranked number two
in the cost of health care. But what's that? Who's number one? Yeah, that's a good question. I would have to go back and check.
Okay. Anyway, sorry. Those disparities are saying. It says that
that disparity tells you a lot is that if the cost of healthcare to the person continues to be on the rise, but health equity, meaning the access to quality health care continues to drop, the gap continues. Are Are we really creating payer systems that incentivize better quality of care? Are we creating by the healthcare systems that simply incentivize physicians and health care entities
We have this discussion to nausea within our organization. And, like, for me, maybe call me call me a rogue player or call me somebody that's unorthodox. But I've just never really put a lot of credence on documentation. I know, that's like the cardinal sin of all health care. But in terms of like, my capacity for billing and claims and things like that, yes, there's a long list of processes and checks and balances, to make sure that
we're properly billing. But in terms of like daily documentation, in terms of what I want my staff to be doing, our staff to be doing. Documentation is not at the top of the list. But But the reason that I say that is because there are a lot of companies, that documentation is the number one thing on their list. So people provide care second, but they document first.
So it's such a so so just interesting story I could share recently, we are retained to represent the physician in a fair hearing, where he was going to have his clinical privileges terminated after a decade at this entity, because his discharge summary documentation was under par for a certain period of time. Right. Now, let me let me equate this
for you. The guy was there for over a decade, he had served in leadership capacity, he had led certain initiatives within the hospital to help promote better health care outcomes, patient access, right. When we got in there, and I first read this initial complaint, my first thought was we're show me where the patient harm is because my thought was right, no discharge summary leads to the seceding physician to not have adequate
notes to provide care. Right, there was not a single instance of when any record of his discharge summary with bind you what they were hitting him on his he had to get it done within 48 hours, there were some days he got it done in three, you're sure that's different, just makes sense. But there was not a single iota of evidence brought forward that this led to patient harm, or anything else. So what does that tell you? I'll tell
you what it told me. What it told me is that this healthcare entity is likely incentivized, right? By this division of the hospital is likely incentivized by their ability to meet this compliance metric of X percentage of discharge summary is being done within a certain period of time. But where does that get driven from? It gets driven from the fact that the payer system is so focused on the minutiae of documentation in areas where it is not related to patient care, but it's getting
done. So therefore, you got to pay on it. And therefore, we got to make sure we're doing it. And there's so much resources and time putting into that, that the patient themselves is the one dealing with the consequences.
And Hassan to take it once even one step further. I would say that they probably need that discharge summary, almost acting as an authorization to bill for any type of remaining service guaranteed. And then and you know, under there's a financial incentive.
Absolutely. And you think about to like the consequences, then physicians have to deal with like, yeah, I that the first half of our conversation may make me sound like I'm not empathetic to them, but I am because it's stressful. I mean, my wife is a PA, right? And they're coming home from
shifts during COVID. And she was more stressed about what she did, or didn't write down, then dealing with the she's an ICU PA, dealing with the people who are dying in front of right or, or more worried about that than bringing home COVID to me and my daughters. It really does make you think is like, you know, physicians are put under an enormous amount of stress.
Because even if they wanted to focus to your point on providing care first, their business aspect, the economics of their practice, may take a hit.
It puts their job at risk. Yeah, yeah. Our whole career
about a guy who was there for a decade you know, it's totally up Yeah. And now, potentially losing his license, potentially being out of work for a year. It's it's crazy to me,
as someone that works in compliance, do you have any advice for how to advocate for our loved ones receiving care? And what rights do we have? And how can we ensure that these rights are upheld?
Yeah, so advocating for our loved ones for care, I think the most important thing is, you know, and I'm gonna take this from perspective of coming from a minority community. So I live in the city of Dearborn, Michigan, Dearborn, Michigan is home to a majority of an Arab American population, many of whom are first generation, like myself, who had parents who came here long, long ago, never spoke the language. My dad came here in 51. You know, he worked on the assembly line of Chrysler and,
and that was our upbringing. And so I think the first thing is, is we truly have to understand that health care, their healthcare relationship is a two way street. And what I mean by that is, unfortunately, it is not built right now, to where they are thinking about things like communication with the
patient first. And so you have to really build relationships with your physician and healthcare community, the rules and laws that are available to you is like one, you should be able to always access any type of request or need you have on medical records. There should be
no impediments to that. The other piece is understanding that, who to go to if you have issues, if it's not someone at your local state agency, understanding who to call like here, it would be the Michigan Department of Health and Human Services, understanding, you know, those avenues. But more importantly is your payer is having understanding who to contact at your payer system, whether it's for an appeal or grievance if this situation may
arise. And I do want to tailor this to those in the minority communities is that for those of you listening, who may be in the minority community that are English, speaking first, like myself, be the advocate of change and hope for those who are not you, it really does take a very intentional effort by those of us who are relied on within those communities, so that we can provide additional services, whether it's simply translating something for somebody, or being the reason
why people you know, have more knowledge and resources, that's something we do as a consulting group, quite a bit of as we try to offer as many free resources to people in our community, people, we have no expectation of ever being clients simply because we all play a role in better health care outcomes within this country, whether we're providers or not. And as compliance professionals, that means continuously finding ways to make information accessible and easy to understand.
You and I have a very, I have a feeling that we live a very similar life, at least professionally, in terms of PII trying to help people that don't understand the health care system. Because you know, you and I can talk about this all day long to understand what each what each other are saying we understand all the abbreviations, we understand, you know, all the different
terms that come up. But there's a lot of people that look at an explanation of benefits, like we were saying earlier, and like, what is this? And I think it's naturally complicated, because there are, the system doesn't just say, okay, you know, this is John, John 65 years old, John suffers from these types of medical illnesses, or over the course of his history. And it's probably going to cost us $75,000, to make sure that John has his basic needs met, every year for the next 15 years. They
don't budget like that. They say, Okay, here's John, and you bill for every service that you provide to John, and we'll pay you and then we'll do and then make sure your documentation is in line or will recoup your money will charge you back. And so these benefits, these explanations have so many billing codes and terminology that's foreign to most people.
And so the fact that you spend the time helping your community and just helping people in general, being able to navigate this, I think that that's one of the driving forces to change. I think that the you tell you tell 10 people the next time, you know they have a friend that reaches out to them, they at least have some general understanding of what you told them. And I think as more people understand that this system doesn't have to be this complicated.
Yeah, you know, I'll tell you like a very normal occurrence for me on any given day any given First, it starts with my mom. My mom is English was their second language. Still, as she has been here 45 years, primarily speaks the Arabic language. It wasn't until maybe just over a decade ago, that language access requirement laws started requiring these entities to actually translate these documents into a language where 5% or more of their population speaks. I mean, that's, that's crazy. You know,
and, wow. And so, then this really means is like they're getting a paper, they have no idea where it's coming from what it means. But here's, here's, I think the residual impact of this right? Is it causes nervousness. It causes this kind of low grade fear that single time I go to see a doctor, something is coming to me that I don't understand. I don't know what it means. It has numbers on there. I don't I didn't expect it. I don't know if I have to
pay it. I didn't expect it. I thought I was Medicaid eligible. I thought this was covered. So now what does this mean? So what does that lead to is then people become hesitant to go get care. And I'll tell you, my mom is a traditional Southern Lebanese woman, she's as old school as they come, she still believes that Vernors and soup are the best remedy to any illness, which she has a good argument
for. But point being is that in minority communities, this is what it has led to is that they you know, when you talk about the discussion of quality care, you also have to think about what does that mean to different people in different populations? Good point, because quality of care to an affluent, or to mid income level, people who do speak the language means okay, am I in good health? Are they providing the service that leads to better health? To other people? That may mean as simple
as something is? Can I make an appointment? Yeah. Oh, having to call a family member to come provide translation services for me?
Yeah, no, that's a that's a fantastic analogy. And like we were talking about in terms of health equity, I think it's very important. So let's move on, what do you believe is the future of healthcare compliance and regulations? And how will this impact the quality of care, especially for the senior care sector?
That's an excellent question, especially in specifying that sector. So future of government health care compliance, I think you have to look at trends, healthcare compliance consistently has been evolving. And I talked about us continuing to be in a pain Chase system. But I do think that AI is going to play a considerable role in the data mining of
living claims. And the ability for AI and other data centric platforms or software's to identify claims on the pre pay side, is going to play a significant role in healthcare being less costly, because if you can stop claims from leaving the door before you pay them, and then make sure that there are certain compliance requirements being met, it drives down the cost for the payer, it drives down the cost for the government, which naturally drives on cost of
health care. Overall, from an auditing perspective, I think that CMS pushing back from its role between now and 2030 is going to lead to a very specific state by state agenda that is going to be specifically tailored for that state's populations, which then leads to the implications of political elections, because we all know that health care is a really sexy sell during campaign season. And because of that, you know, a lot of legislative advocacy or promises and
otherwise are made. And so that as it pertains specifically to the senior care centers, is one most most I would say, I statistically can reference this but from what I've seen is more and more seniors are leaning towards specialty care facilities or home care, include, I'll tell you, my mother included for their type
of care. And so depending on how the government reacts to the governance of homecare related services, is going to be a really telling a metric if it's anything like has happened in the past, meaning when new health care services have come up, whether it's mobile care, wound care, laboratory care, it usually leads to a new agency
being created. The agency having a derivative authority from the Department of Justice or the OIG some cyber relation in there, and then combining that relationship with delegating authority to health plans. and state agencies to maintain compliance.
Fascinating. I mean, I'm just fascinating. I could sit here and talk literally hours about this. But I know that it's going to this is going to serve a wide range
of people. And I think it's really giving people an opening, kind of opening the door, to better understand how our industry works, how our system works, even though on somewhat of a technical level, but it's a necessary technical level, because I think you and I have both established in this episode that it's because of the complicated nature and because it kind of happens behind the scenes, somewhat in the shadows, even in terms of you know, billing departments, being in
the basement, punching in claims all day long, you know, on, on up to four forms. It's because of the nature of the business that most consumers are like, Yeah, I'm not, I don't know anything about it. I don't know how it works. I don't know how much I'm gonna pay. I just like I walk in, I get sick, I get question marks. And honestly, they're probably more anxious and suffer even worse health outcomes, because of the
anxiety. And not to mention, obviously, the equity part of it where people from different social, economic socio economic groups probably suffer even higher levels. So we always like to end the show with a call to action, what are some actionable steps we can take today, to ensure we're choosing the best long term care options for ourselves or apparent,
I highlighted this a little bit briefly before but you shouldn't have a relationship with with your primary care physician. What I mean by that is choosing a physician who is accessible. If you have a language restriction, a physician whose office can support you, by Him, him or herself or their staff, to with those language access requirements, I think that's such a key piece with the growing diverse communities that we are building here across the
United States. And I think more than, than all of that is understand what your health care plan provides you. And this is you you know, as much as we want to try to challenge the system, we also have to understand the system. What I mean by that is you brought it up is that some people before they get care, they think, man if I get if I take an ambulance ride right now that's 800 bucks that I don't want yeah. So let me let me
think twice about that. So understanding the system is very important too, because and reaching out to individuals like yourself, like our group and and I think even you know, the true call to action here, Costa is to people like you and me as people that are in the positions of knowledge, our knowledge is power. And so when you have the knowledge you have to use that knowledge to benefit those that we know otherwise wouldn't be able to at least that's what I feel as a part of our obligation
in this profession. And so I think continue to find ways to serve those communities and you know continue fighting the good fight we got to take little little chips at it you know, much like how probably was with you in the in the in the hockey rink, because, you know, when that fight comes, dropping, loves to take it head on and you know, sooner or later hopefully, we'll continue to create better health systems.
Thank you for joining us on this episode of Now or Never Long-Term Care Strategy with Kosta Yepifantsev.If you enjoyed listening and you wanna hear more make sure you subscribe on Apple podcast Spotify or wherever you find your Podcasts,leave us a review or better yet share this episode with a friend. Now or Never Long-Term Care Strategy is a Kosta Yepifantsev production.Today’s episode was written and produced by Morgan Franklin.Want to find out more
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