Author Archive for Glenn Krauss

Promoting efficient use of resources and appropriate hospitalization length of stay to physicians, a different approach

Physicians sometimes acquiesce to family wishes and desires and admit a patient for “social” reasons. On the other hand, a physician may keep a patient in the hospital an extra day because the patient expresses a desire to stay just “one more day.” These unnecessary, avoidable hospital days have a material effect on potential revenue loss for the hospital through denied days or denied hospital stays by third party payers.

A major challenge in motivating physicians to move the patient along the continuum is the disconnect between prudent hospital fiscal management and the practice patterns of physicians. The physician generally receives payment for his evaluation and management services regardless of whether the hospital is paid or denied for the patient care.

However, change is on the horizon. Medicare is currently considering provisions that will promote efficiency in the practice of medicine. Medicare and other third party payers are also committed to transitioning from physician payment based strictly on volume to payment based upon the relationship between quality, costs, and outcome. The efficiency and effectiveness of a physician’s practice of medicine will determine the physician’s financial welfare and business success.

Evidence of this impending change in reimbursement can be found in the General Accountability Office’s (GAO) report entitled “Per Capita Method Can Be Used to Profile Physicians and Provide Feedback on Resource Use.”  This report is a must read. In essence the report concluded that it is feasible to use Medicare claims data to profile physicians on resource use, taking into account patient acuity through risk adjustment methodologies.

The report examined the following:

• The extent to which physicians in selected specialties show stable practice patterns and how beneficiary utilization of services varies by physician resource use level
• The factors to consider in developing feedback reports on physicians’ performance, including per capita resource use
• The extent to which feedback reports may influence physician behavior

The GAO focused on four medical specialties (cardiology, diagnostic radiology, internal medicine, and orthopedic surgery) and chose four metropolitan areas (Miami, Phoenix, Pittsburgh, and Sacramento).

Take this oppurtunity to educate physicians about the possible changes in the reimbursement model

The message is out!

Now is the time for case managers to become familiar with these eventual changes to the healthcare reimbursement model from a physician and a hospital perspective. This reimbursement model transition will not only drive out waste in the practice of medicine. It will also drive and promote a collaborative approach to healthcare delivery by using financial incentives.

Case managers should educate physicians on the need to collaborate with case management to move the patient along the continuum efficiently because physicians will receive reduced reimbursement for excessive resources.

Let the education begin.

Understanding the insurance company case manager’s goals can help hospital case managers

While discussing a hospital admission with a case manager employed by a well-recognized national third-party payer, I learned of an interesting revelation that case managers may wish to take note of.

Each insurer-employed case manager is charged with meeting a monthly average length of stay goal set by the individual hospital as well as the aggregate hospital. The insurance case manager receives a weekly report of cases that achieved average length of stay compared to individually-assigned average length of stay goals and objectives. To this end, the case manager knows at any given time where he or she stands in regards to meeting the assigned goals for hospital length of stay.

This insurance company case manager informed me that he is reminded on a regular basis of the ramifications of not meeting the established monthly length of stay goals. In extreme situations, insurance companies will terminate case managers that do not meet objectives.

Depending on the time of month and how the insurance company’s case manager is faring, hospital case managers can expect different volumes of cases designated for medical director review and potential medical necessity denial. There exists a certain realism that insurer case managers and medical directors may err on the side of conservatism when using Interqual or Millman care guidelines and clinical judgment to determine denial of inpatient stays. The bottom line is hospital case managers will need to take inventory of their communication skills and core competencies, including drafting of effective, succinct denial appeal letters—if the hospital charges him or her with doing so as one of their duties.

In this context, hospital case managers should track and trend denials communicated by insurer case managers and understand these case managers need to achieve pre-established average monthly length of stay goals. Hospital case managers must prepare for increased inpatient stay denials given the current economic climate of private health insurers, decreased member covered lives, and resulting decrease in health insurance premium income. Increased medical loss ratios and the number of uninsured and underinsured patients seeking care through the emergency room with subsequent need for inpatient admission can also add to the number of denials.

I am certainly not advocating for case managers assuming additional work. At many hospitals, the administration assigns new tasks and assignments to case managers with the rationale being case managers already “review the record” and thus have the time to take on new responsibilities. Unfortunately, the case management function has become so convoluted that case managers find themselves regularly performing duties that questionably contribute to the role of case management. However, I am advocating for their development and reinforcement of core competencies and skill sets in the art of “forceful” communication and negotiation.

The FY 2010 IPPS changes impacting case managers

On July 31, the Centers for Medicare and Medicaid Services (CMS) released the FY 2010 Inpatient Prospective Payment System (IPPS) Final Rule. Hospital payment rates will increase by an average of 2.1%, as opposed to the 0.2% proposed earlier in the year. CMS elected not to implement a 1.9% reduction, referred to as the coding and documentation adjustment. This coding and documentation adjustment accounts for changes in clinical documentation and coding patterns—not real changes in patient acuity.

Implications for case managers

The start of the Medicare Fiscal Year IPPS, which begins each October 1, brings a host of new coding, payment, and other regulatory changes including updated relative weights for the 745 MS-DRGs. Some MS-DRG relative weights increase—others decrease. Relative weights are a proxy for patient acuity. Higher relative weights signify higher acuity, providing for a higher level of reimbursement, while lower relative weights translate into lower acuity with less reimbursement.

In reviewing the Healthcare Financial Management Association’s (HFMA) recent overview of the Final 2010 IPPS Rule, an interesting point was made that certainly impacts hospitals and case managers. [more]

Critical care tutorials

I came across this excellent reference for critical care that case managers may wish to use in their review of cases as part of the admission to Intensive Care Units. While screening criteria provides guidance from an intensity of service and severity of illness standpoint as to clinical conditions warranted admission and continued stay in the ICU, there are instances where patients do not meet the ICU criteria as published, yet from a clinical perspective the patient appears to be “sick” enough to appropriately be admitted and managed within the confines of the ICU.

In an earlier post, I discussed the merits and importance of physician clinical documentation to support his/her clinical impression and reflection of medical decision-making and clinical judgment. With this in mind, one may find the critical care tutorials helpful in expanding one’s knowledgebase and clinical understanding of critical care from a physician’s perspective. The tutorial includes definitions of critical care including a discussion on the different clinical entities constituting critical care. A quick review of these tutorials will help in gaining a better appreciation for critical care, thereby assisting the case manager in recognizing possible physician clinical documentation deficiencies contributing to inaccurate reflection and reporting of patient acuity, patient acuity required to clinically substantiate admission to the ICU. To this end, the case manager can address the identified  documentation deficiencies with a clinical discussion with the physician.

The critical care tutorials can be found here.

Enjoy

Medical necessity beyond screening criteria

An underlying foundation for case management is the practical and consistent use of commercially available screening criteria as guidance for initial admission patient status designation as well as continued stay determinations. I call your attention to the term “guidance” from the perspective of Medicare and the Recovery Audit Contractors (RAC).

In a RAC Special Open Door Forum held by Medicare on April 9th, several comments by Medicare representatives and RAC representatives, including the medical director for Health Data Insights, make it very clear that the screening criteria will not be used in and of itself to determine medical necessity or lack thereof for inpatient hospitalization. Consider the HDI medical director comment regarding his organization’s application of screening criteria in the medical necessity determination process:

“We follow CMS guidelines which are that these different products are guidelines. They’re not conclusive for a decision to or for a finding or not a finding.  We have contracts with both Milliman and Interqual and intend to use those along with clinical review judgment and of course, first and foremost the CMS guidelines.”

The implications for the case manager

Unequivocally, screening criteria should be applied and followed as part of the patient status
designation determination process. Just the same, the physician’s clinical judgment, medical-
decision making and clinical impression can and must be incorporated in this decision-making
guidance process.

The real challenge faced by case managers is the physician’s medical record documentation of the same. Commonly, the documentation available to the case manager upon initial and continued stay chart review fails to accurately and completely capture and represent the patient’s true clinical acuity, risk of morbidity and mortality, and other physician clinical concerns that ultimately led the physician decision to admit the patient to the hospital. This lack of focus in clinical documentation further challenges the case manger in providing objective guidance in the complex, arbitrary patient designation status process. [more]