John Yeary, Freestone’s CEO, said that CIHQ’s educational assistance is greatly needed. “When you get into some of the patient areas of (Medicare’s conditions of participation) ... it’s open to interpretation,” he said. “We can read the standard, we think we know what it means ... and it may or may not meet the condition of participation according to the surveyor’s findings. The accreditation organization helps us understand what Medicare wants to accomplish. They’re not telling us how to do it, they are pointing us in the right direction.”
Freestone Medical isn’t alone in its reliance on accreditors to meet Medicare’s conditions of participation. Most providers overwhelmingly oppose the CMS placing any restrictions on the education and consulting services accrediting organizations offer, according to comments from a December 2018 request for information from the agency.
The CMS issued the RFI in response to concerns from the public that the Joint Commission has conflicts of interest by acting as both an enforcer of Medicare rules for provider participation while taking on the same providers as clients to help improve their performance.
The agency hasn’t proposed any rulemaking since the comment period closed in mid-February, and a CMS spokesman declined to comment on potential next steps. The agency already requires accreditors to disclose the policies and procedures it has in place to avoid conflicts, but through the RFI the agency inquired if it should be doing more.
Hospitals and accrediting organizations argue that while it may appear to the public there’s a conflict of interest in consulting arrangements, that’s not the case because accreditors have robust firewalls in place, such as rules that ban surveyors from talking with consultant colleagues about customers. Furthermore, hospitals claim they need the guidance from accreditors to ensure they clearly understand the standards of participation, which they contend are difficult to interpret.
Medicare’s standards were intentionally written in a vague manner so they can be broadly applied, according to experts. With more than 5,000 hospitals in the country that must comply with the standards, it makes sense the CMS leaves room for interpretation, said Nancy Foster, vice president for quality and patient-safety policy at the American Hospital Association.
Ten organizations are currently approved by the CMS to accredit healthcare providers for Medicare participation. Just the Joint Commission and CIHQ offer consultancy services as part of their business model. The other accreditors offer education services to customers, which they argue is different from consulting because it involves a hands-off approach with broadly applicable resources.
“Hospitals want to be in compliance 100% of the time. That’s hard to do if you don’t understand what is written in somewhat broad terms and how that’s applicable to your circumstances, so they use these consultants,” Foster said.
National Nurses United is convinced the tactic fosters conflicts of interest, no matter the safeguards in place. “It creates this system that is overly complicated where the CMS has to monitor the monitors,” said Carmen Comsti, regulatory policy specialist at the union, which represents roughly 155,000 registered nurses nationally. “They could create firewalls but who is going to make sure that is actually happening? It’s a burden on the federal government that the CMS has to monitor this. It’s much easier to say you can’t do it (offer consultancy services) at all.”
Whether hospitals using consulting services from the same organizations that accredit them results in conflicts of interest is difficult to gauge. Hospitals have myriad consultants to choose from and some likely opt to hire experts affiliated with the accrediting organization because they feel it’ll improve their chances of achieving accreditation, said Andrew Wachler, principal of consulting firm Wachler and Associates.
Consultancy divisions of accrediting institutions also face pressure to contribute to the bottom line, he added, which means providers must believe that working with them will enhance their chances of accreditation so they’ll remain customers.
“If every time you hire the consulting arm you fail the survey, the consulting arm wouldn’t be (successful),” he added.
The financial relationship between the Joint Commission and its separate, and lucrative, not-for-profit arm, Joint Commission Resources, is a sticking point for critics of the practice.
The financial relationship explains why the Joint Commission rarely pulls accreditation from its customers, argues Comsti with National Nurses United. “Having hospitals as clients puts into question the entire accreditation process,” she added.
Even with the financial connection between the two entities, the Joint Commission contends their firewall policy ensures there is no conflict of interest.
A firewall policy prohibits the consultants and surveyors from sharing information about customers. Consultants can’t help customers appeal survey findings, be in contact with a customer during a survey or be on-site when surveyors are present.