All Entries in the "Patient Flow/Throughput" Category
ER docs: We’re caught in the middle
Emergency room doctors see themselves in a health reform vise, squeezed on one side by administrators and payers who think they should work faster and better, and on the other by new penalty and billing rules they are only starting to understand.
That’s what many said during the annual meeting of the American College of Emergency Physicians being held in San Francisco being held this week, which drew a record attendance of more than 6,000. Their concerns are prompting them to “redesign” what they do and how they work to improve both their value and their image.
Emergency room doctors need to “consider stepping out of our perceived comfort zone and perception of only providing acute care,” said ACEP’s new president David Seaberg, MD, professor and dean of the University of College of Medicine in Chattanooga, during his opening remarks.
With this redesign, he said, emergency room doctors should drive “an additional team of health providers, physicians, mid-levels, nurses, techs, case managers, and social workers” who would provide preventive care, immunizations, healthcare screenings, promote wellness through education on diet, exercise and other lifestyle choices.
“We can use our access to patients as a vehicle to enhance emergency medicine’s value by serving as a conduit to integrated medical care, saving cost to the system and promoting quality care that keeps patients well,” Seaberg said.
Emergency department doctors also should “enhance our observation units to further reduce readmissions and potentially avoid admissions, and develop better disease management and palliative care protocols,” Seaberg said.
Hans House, MD, associate professor of the Department of Emergency Medicine at the University of Iowa Hospitals & Clinics, said that his emergency department, as opposed to the hospital, has already started to hire nurse managers and other care coordinators to visit patients and make calls to assure they and their families are getting appropriate care.
“We’re pleased, because it’s very well-received,” he said.
One keynote speaker, Richard Wolfe MD, chief of emergency medicine at Beth Israel Deaconess Medical Center in Boston, said emergency room physicians can do more to be effective gatekeepers to keep patients out of the hospital if they don’t need to be there.
“What is the most expensive thing we do?” He asked “It’s that we admit patients to the hospital.”
“If we can be effective gatekeepers, we can play an absolutely critical role (in reducing costs), but we need to start thinking about how we find other safe places to deliver care,” he said. “And I would argue that if we build home care networks… (and make sure there are) checks with primary care physicians the next day, a much better social infrastructure, and use of nursing facilities for those patients we admit a little bit for medical problems but a lot because we don’t think they’re safe at home, we can have a very huge impact at that point.”
“The next three years of healthcare reform will likely affect the next 30 years of our practice. It will touch all aspects of what we do: how we work, how we are paid, and how we interact with our patients. In short, it will redefine the specialty of emergency medicine.”
8 reasons why hospitals should reduce bed volume
By Cheryl Clark, for HealthLeaders Media
There are nearly one million hospital beds in the United States. But I’ve been wondering, what are we going to do with all the empty ones if the healthcare industry successfully achieves the goals of reform?
Should hospitals start thinking about closing them down? That’s anathema to the premise under which the industry has functioned for decades, which holds that the number of services, buildings and patients must grow to stay in play and maintain respect in the community.
Before you ask what I’ve been smoking, (nothing!) hear me out:
1. One in five or six patients is now readmitted within 30 days, but penalties and incentive programs can dramatically prevent those readmissions. A one-third reduction is not an unreasonable achievement, Elliott Fisher, MD, director of the Dartmouth Institute’s Center for Population Health, told me last week.
Fisher lamented how hospitals that have successfully reduced readmissions have turned around and launched questionable service lines that don’t improve care, such as spine surgeries. Hospitals are expanding volumes for procedures that, given correct and balanced information about their effectiveness and their alternatives, he says, patients would choose not to have.
“With hospitals that are dependent on fees for maintaining hospital margins, reducing unnecessary readmissions and avoidable admissions causes revenue losses, which will lead them to admit other patients to the hospital” for these elective procedures, he said.
That’s not consistent with the “systematic reform in healthcare that we at Dartmouth have been calling for, (which) is about keeping people healthy so they don’t need to be in the hospital,” he continued.
“It’s about making sure patients make informed choices about major surgical procedures or elective procedures, and then right-sizing the healthcare system, which may very well lead to many, many fewer hospital beds and hospitals in this country. And that’s how you would get lower costs.”
2. More patients will be encouraged – perhaps through premium incentives – to sign advance directives. We know from research that treatment-limiting advance directives have the potential to prevent aggressive, expensive, but futile care at the end of life, especially in regions of the country where imminent death is more expensively and often painfully prolonged.
3. Doctors and nurses will get better at constraining healthcare-associated infections, thus reducing longer stays. They will get better at preventing falls, surgical mishaps, and other avoidable adverse events, in part because those will now be publicly reported and because that extra care those errors require will not be federally reimbursed.
4. More patients will be treated in outpatient settings, because accountable care organizations and coordinated outpatient services will make sure patients stay out of the hospital if they don’t need to be there. Patients who do need hospital care will be discharged earlier because bundled payments will hasten that process.
Just this week for example, we see a report that many elective percutaneous coronary revascularization patients can be safely discharged six hours after their procedure, rather than kept in a hospital bed overnight. This could free at least 35,000 or more hospital beds days each year.
Even bariatric surgery, which just a few years ago required a hospital stay of a week or more, is now being done laparoscopically. Adjustable gastric band procedures, approved by the U.S. Food and Drug Administration in February, can sometimes be done on an outpatient basis.
5. Emergency departments will become even more creative in managing patients who don’t need admission, using urgent care clinics and observation alternatives.
6. In some states the number of hospital beds, even with hospital closures, is on the increase. In California, for example, the number of hospital beds has had a net growth of 5% between 2005 and 2010, according to the Office of Statewide Health Planning and Development. And, many hospitals that are rebuilding to meet the state’s strict safety requirements are adding licensed beds, not reducing them, as they upgrade from double-bed rooms to single-bed rooms, and expand in an effort to dominate a market.
Now, I know what you’re thinking: “What about all the normal growth in population and all the aging baby boomers who will soon need care? What about the 32 million uninsured Americans who will soon have coverage?”
7. Yes, aging baby boomers will need acute care. But how much? This generation isn’t the type to be content lying around in hospital beds at the rates of prior generations. They will do more research about their conditions and question medical authority more. And they will be better managed outside hospitals.
Last week, a survey in the Archives of Internal Medicine, found that 42%of primary care doctors “believe that patients in their own practice are receiving too much care,” that is, too many referrals and too many tests, and only 6% said patients are receiving too little. About 28% said they are practicing more aggressively than they would like.
8. As for those 32 million people who lack health coverage. Remember, most of them are barely accessing the healthcare system now. And if they are, it’s an inefficient and more expensive service, they’re getting at best. And in theory, much of it will be avoided with earlier, more preventive care.
Besides, I don’t believe that healthcare reform will prompt them to charge into hospitals to make up for lost time. Coverage should help them stay healthier.
You might argue that hospitals should keep those beds and even expand capacity to be ready in the event of an epidemic or disaster. Good point.
But remember that in the wake of the 9/11 attacks and the threat of H1N1, pandemic planners have been busy preparing to adapt schools, theaters, and even cruise ships to handle casualties outside of hospitals. During a crisis, a hospital may not even be the safest place to go.
These decisions are certain to further drive down rates of reimbursement for hospitals, physicians and other providers. And who knows how they will choose to compensate for that, whether by reducing services, salaries and staff, merging forces, postponing construction projects and by just being logarithmically more efficient than they are today.
Or by contriving ways to market more services with hefty margins, whether justified or not.
As Fisher said, the problem is not just readmissions, “it’s avoidable admissions overall.”
Cheryl Clark is a senior editor and California correspondent for HealthLeaders Media Online. She can be reached at cclark@healthleadersmedia.com. Follow Cheryl Clark on Twitter.
Provider-friendly change to tracking observation hours
Editor’s note: The following article is adapted from a blog by Kimberly Anderwood Hoy, JD, CPC, director of Medicare and compliance at HCPro, Inc., that appeared on Medicare Mentor.
In the July OPPS update, CMS made a very provider-friendly manual change to the section on counting observation hours. CMS amended Medicare Claims Processing Manual, Chapter 4 – Part B Hospital (Including Inpatient Hospital Part B and OPPS), §290.2.2 Reporting Hours of Observation, to allow providers to use average times when determining the amount of time to subtract from observation time for other procedures.
Providers have struggled with this issue since CMS added a clarification to the manual in 2008 that requires providers to subtract time for procedures that require active monitoring and interrupt observation care. Providers struggled with determining which procedures required active monitoring and how much time to subtract for these procedures.
In early 2010, CMS published FAQ 9974, addressing the issue regarding which procedures require sufficient active monitoring to necessitate subtraction from overall observation time. The specific question related to drug administration services. CMS said hospitals must determine service-by-service whether a particular drug administration service required active monitoring because services with the same HCPCS code may or may not need active monitoring. It provided examples of an antibiotic infusion as something that doesn’t require active monitoring and a complex drug infusion titration as something that does.
But this left the issue of how much time to subtract once a hospital determined that a service did indeed require active monitoring. The manual indicated that the beginning and end times of observation, or more likely the procedures, would require documentation to calculate total observation time. However, this was problematic for many of these bedside procedures…For instance for a procedure such as a PICC line placement, providers normally document all pertinent details about the procedure, but don’t necessarily document when they entered or left the room.
The most recent change to the manual will be a welcome change for providers who have struggled with this. CMS now allows providers to use an average time for these procedures that interrupt observation. The new manual section give providers the option of documenting start and stop times or using an average time when subtracting these procedures.
Providers who wish to use this new option, should consider putting in place policies indicating which procedures will be deducted and the average time to be deducted for those procedures. This may be as simple as updating an existing policy on observation billing, with an addendum with the procedures and their times.
In developing their listing of procedures and average times, the provider should look for the procedures they provided in conjunction with observation by looking at reports for past billing for observation cases. When determining the average times for those procedures, the provider may need to use several sources including the CPT book, staff interviews and hospital protocols. Though it doesn’t appear required, it will be useful for future updating to note what resource was used to establish the average time for each particular procedure.
One last note about the July OPPS update; CMS manualized a topic I discussed a couple of months ago about inpatient only procedures on an outpatient basis within the three day payment window. At that time, the guidance I was reporting was from the Medical Director of a specific MAC, but CMS has now added this to the Claims Processing Manual, making this a national policy. For more information see my previous post.
The Lean Six Sigma process applied to case management
I recently spoke with a hospital customer who was trying to improve processes in the case management and utilization review (UR) departments at a large teaching hospital. The facility recently instituted 24/7 case management in the ED and was looking to create process improvement in a culture reluctant to change.
One of my favorite quotes is attributed to Albert Einstein who said, “Insanity is doing the same thing over and over again and expecting different results.” I fear hospitals, providers, and payers are applying business-as-usual methods to a vastly changing industry. Hospitals and physicians who are willing to explore process change and embrace what other industries have used successfully will prosper.
The Lean process
According to the Lean Enterprise Institute, “The core idea in Lean Six Sigma is to maximize customer value while minimizing waste.”
Sigma is a term used to represent levels of excellence or quality. Six Sigma seeks to achieve a ratio of 3.4 defects per one million opportunities. The process began in manufacturing as a defect-reduction effort and has spread to other industries, most notably air transportation. Airlines strive to achieve perfection because lives are at stake when an error is made.
The six process elements also known as DMAIC(T) include:
- D-define opportunity
- M-measure performance
- A-analyze opportunity
- I-improve performance
- C-control performance and optionally
- T-transfer best practice (to spread learning to other areas of an organization
A company or facility that follows the Lean principles focuses its core processes on continuously increasing customer value while producing no waste. These efforts result in processes that require less input (e.g., human, space, time, or financial) which equates to fewer defects and reduced cost.
Lean makes an organization more nimble, which allows it to react to changes in the market and customer preference. A Lean organization can create products and services with more variety, higher quality, and lower cost. It can also manage information and data used to generate services more efficiently because the information is simpler and more accurate.
Key concepts
Two key concepts in the Lean method are customers and waste. To make process change you must be able to identify and quantify these concepts. I can immediately think of examples of waste in hospital processes.
Hospital errors typically occur due to the vast number of processes required to complete a task. Simple things like when a patient uses an expired insurance ID can result in case managers sending clinical information to a payer who no longer covers the individual. The time lost while sorting out the mistake can cost the hospital a day’s reimbursement.
Then I thought about the medical record. The process of several different individuals and departments documenting in the patient record is open to significant error. I can recall the frustration experienced when the chart itself disappeared.
The customer
It was a challenge to identify and quantify the case management customer.
My initial thought was clear–the patient is the customer. Then I spoke with colleagues who said the physician is a potential customer. Without physicians and other providers who admit patients and refer them to outpatient services, there would be no patient to serve. Then it occurred to me that perhaps the customer is the insurance company or third-party payer because they pay for the services consumed.
It is easy to see how many customers case managers serve. A case manager who makes arrangements for post discharge care at a SNF may say the rehabilitation facility with an available bed is the customer. The ambulance available to transport the patient to the post discharge facility is also a potential customer.
Clearly, case managers serve multiple entities. To begin successful process improvement in case management, how do we identify the customer? What are your thoughts?
Helping noncompliant patients cheat more effectively
Teaching noncompliant patients how to cheat seems counterproductive, but this strategy saved the lives of some members of one medical center’s renal patient population.
A large teaching hospital surveyed its renal patients and found that most didn’t adhere to their very restricted diet. Salt was the main culprit. Potassium rich foods came in a close second, and, unfortunately, street drugs were the third problem.
The case manager assigned to the renal patients worked closely with the nursing director and unit staff to create realistic diet goals.
They tackled the salt problem first. The team created five reduced-salt spice recipes and conducted a taste test. Each patient rated the spice concoctions from best to worst. Staff and physicians contributed money to buy the highest rated spices and gave them to the patients along with the recipes.
The team then took on potassium rich foods. First, the case manager ordered a dietary consultation to ensure that educational deficit wasn’t the problem. She then met with each patient who admitted to eating more potassium rich foods than allowed. They reached a compromise that allowed patients to have two of these foods weekly as long as it was two to four hours before dialysis and their physicians approved. The case manager knew that dialysis would help eliminate excess potassium and that cheating only twice weekly was far better than indulging daily.
The most telling conversations were with patients who had used illegal drugs. The issue was when they used them. Many patients had used them just prior to their dialysis treatments. This often caused the patients to go into full cardiac arrest during the procedure.
With the physicians’ consent, she spoke with these patients confidentially. She explained that using drugs prior to treatment was causing them to arrest while on the machine, and one day they might not be resuscitated back to life. She also told them the drugs were likely being dialyzed out, and that they were simply wasting their money.
She offered rehab as the first option, but the patients had refused rehab many times in the past. So she then engaged them in a reality discussion. She told the patients the worst times for them to use drugs. She couldn’t tell them the best time to get high—there is no good time—but identifying the worst times prevented future cardiac arrests for three patients. Reducing length of stay was a side benefit.
Case managers need be aware of what patients’ lives are like outside the four walls of the hospital. When the patient understands we are simply trying to help find a solution that will work, they will be more open to following a regime they can truly live by, hopefully for a long time.
Assess case management department FTEs: Demonstrate your impact on the revenue cycle
Case management departments need appropriate staff in order to meet goals and improve outcomes. Money talks. Departments that can demonstrate their influence on the hospital’s revenue cycle will be able to make a strong case for staffing needs.
Now is the time to assess how your case management department interfaces with the organization’s revenue cycle. Are your department’s goals clear, measurable and aligned with your organization’s goals? Do your case managers have more cases than they can handle? Are their caseloads preventing positive outcomes?
HCPro’s audio conference Assess Case Management Department FTEs: Demonstrate Your Impact on the Revenue Cycle will help case managers demonstrate their worth and justify staff.
Listen to the audio clip below to hear more about the program’s benefits from one of the speakers, Tina Davis, RN, MS, CMAC a consulting associate for The Center for Case Management in Wellesley, MA.
Sample transfer agreement
The January issue of Case Management Monthly includes an article about the importance of reciprocal transfer agreements.
Sherri Sochaski RN, BAS, director of case management at JFK Medical Center (JFKMC) in Edison, NJ was kind enough to provide a sample transfer agreement form from her facility. It is good parctice for facilities like (JFKMC), who accept patients for a more advanced level of care, to have a reciprocal transfer agreement policy. Reciprocal transfer agreements ensure the accepting facility can return a patient after specialized care is no longer necessary.
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.
Identifying emergency department regulars can improve throughput
It would be safe to say that every emergency department (ED) sees a fair share of “frequent fliers” or those patients who seem to use the ED as an alternative to other healthcare resources in the community. Knowing “the players” or the clientele of the ED can help an ED case manager address issues that affect throughput.
In the past year, we at University Hospital, Upstate Medical Center in Syracuse, NY have put together a pilot program, patterned after programs we have seen in other hospitals. The hospital generated a list of frequent fliers in the ED during the previous six month period. We identified a group of patients who not only frequent the ED but also have primary care providers within the same hospital system. We used a team approach involving case managers and social workers in the outpatient setting, to address any barriers in the patients’ lives that may cause him to use the emergency department rather than the primary care office.
The expectation was that a social worker or case manager would see the patient each time one of theses patients presented to the ED or the outpatient setting. The social worker would document the reasons for the visit as well as any interventions in a shared file in the computer. We were all able to access that information daily, and keep tabs on the progress of each patient.
The goal is not to keep patients from emergency care. Sometimes those patients presented to the ED with legitimate emergencies, but often times a different setting would have been more appropriate. In the first six months we were able to decrease the number of ED visits in all the identified patients, and we saw an increase in the number of attended visits with their primary care providers. When the hospital generated list of frequent fliers in the next six month period, over half of the original patients were no longer on the list.
I believe that the ED case manager is a crucial part of the throughput process, and knowing the clientele can only enhance the productivity and efficiency in the ED.
