All Entries Tagged With: "data collection"
Conduct a cost benefit analysis to improve care
Hospitals are under immense scrutiny to keep costs at an all-time low. Most case managers and social workers understand the various payment methods, especially case rate or DRG-based payments. Unfortunately, directors often don’t help their case management teams understand the difference between charges and costs; we also don’t explain how to use this information to change the situation on the floor.
A case management team that knows the costs of a room and basic services can determine whether a patient who doesn’t meet inpatient criteria should move to a more appropriate level of care for the duration of the hospital stay anticipated by the physician. This would improve care from both a medical necessity and economic perspective.
The following information is necessary to conduct a cost benefit analysis:
- The average cost of room and board at your facility
- The cost of any associated major treatments or equipment (e.g., ventilator)
- The number of days the patient is expected to stay in the hospital
- The cost of care at the proposed alternative level of care
- The number of days the organization plans to pay for care at the alternative level
First, multiply the room and board rate by the number of days the patient is expected to remain in the hospital. Be sure to include any associated major costs in the room and board rate.
Next, multiply the cost of care at the alternative level of care (e.g., SNF) and the number of days the organization plans to pay for care at that level
Finally compare the two amounts to determine which choice is more cost-effective.
Cost shouldn’t be the sole reason for placement at a lower level of care. List all non-financial reasons why the alternative setting will benefit the patient and hospital (e.g., avoiding hospital acquired conditions, family requests, etc.)
Transferring a patient from acute care to an onsite SNF or rehabilitation unit, when these options exist, may be appropriate and cost effective. If turf wars begin, a cost benefit analysis can resolve the conflict. It will demonstrate to the CFO that the cost of inpatient care is significantly higher than the cost of a lower level of care. This knowledge can promote proper intervention for the patient.
Other solutions exist for patients who are ready for discharge, but have nowhere to go. My facility had an Italian-speaking patient who was dying. We used a significant amount of resources to employ a telephonic interpretation service to communicate with him. The interpreter told us the patient simply wanted to die at home, in Italy.
Using a cost benefit analysis along with some creativity and influence, we were able to fly him home at minimal cost. The airline donated his ticket and a durable medical equipment company worked with us to minimize the cost of an oxygen tank. The airline returned the tank to the company on the return flight. We worked diligently with our risk management office to obtain all necessary signatures on various forms to eliminate any liability for the hospital and airline.
The patient’s family arranged for oxygen upon his arrival. The patient died four days later but he was able to spend his last few days with his family.
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.
Meeting meaningful use criteria
On December 30, 2009, Congress announced the long-awaited proposed goals for health information technology. Congress, with support from the Office of the National Coordinator (ONC) outlined several goals for meaningful use. This is an essential concept because to qualify for monetary incentives, eligible professionals (physicians, nonphysician providers, podiatrists, etc) and hospitals must adopt certified EHR technology and demonstrate meaningful use of that technology.
Congress further requires that eligible professionals verify that EHR or EHR modules meet government certification criteria. While standardization ensures hospitals can finally communicate with each other, let’s look more closely at what this means to hospitals and healthcare providers who have some form of technology now.
If you are lucky enough to work in a setting that uses case management software and/or EHRs your institution must determine if it is going to attempt to meet the meaningful use criteria. If your software was purchased from a vendor (Allscripts, Cerner, Epic, etc.) it is a bit easier because you can depend on the vendor to make any necessary upgrade. If you aren’t sure if your vendor plans to upgrade, you could switch to a vendor that has announced their intent to comply with standards. Check with your vendor to determine when they plan to have their products certified.
The problem is more acute for providers that use ‘home-grown’ systems.
Before bringing a home-grown system up to standard it will be necessary to determine the cost and effort to do so. Will the expense be worth the extra reimbursement CMS provides to comply initially? If it appears that the reimbursement will not cover the cost, some intuitions may choose not to upgrade.
However, there is a downside to that decision. How will the facility communicate with others when the nation’s EHRs are standardized? How will the lack of compliant technology impact its market share? Stay tuned. We will explore market share options in future posts, as providers debate issues in the proposed rule.
Meaningful use proposed criteria
Congress and the ONC determined that meaningful use will be achieved in three stages. The proposed Stage 1 meaningful use criteria, which goes into effect in 2011:
“…focuses on electronically capturing health information in a coded format; using that information to track key clinical conditions and communicating that information for care coordination purposes (whether that information is structured or unstructured, but in structured format whenever feasible); consistent with other provisions of Medicare and Medicaid law, implementing clinical decision support tools to facilitate disease and medication management; and reporting clinical quality measures and public health information.” – Health Information Technology: Initial Set of Standards, Implementation Specifications and Certification Criteria for Electronic Health Record Technology, 45CFR Part 170
Sound confusing? I will talk more about what Stage 1 means and how it will affect case managers in my next post. I will also examine each of the other stages.
If anyone wants to see the 169-page document in its entirety, the proposed criteria was posted in the January 13, Federal Register. Lawmakers and industry leaders are preparing comments to the proposed criteria as I write.
Are you paying attention to your case mix index?
What is Case Mix Index (CMI) and why, as a case manager, do I care what that is? According to the Financial management for nurse managers and executives (3rd ed.), CMI is the measurement of the average severity of illness of patients treated by a healthcare institution. Basically, CMI helps determine the dollar amount assigned to a diagnosis related group (DRG) for the Medicare population. Medicare assigns a dollar amount for every facility, which is partially determined by the CMI.
Hospitals use the CMI to determine the budget, and if the actual CMI is lower than the budgeted CMI, the incoming money for those DRGs will be less. This causes an imbalance in the hospital revenue. If the money isn’t coming in as planned, a financial fiasco can occur. Think of CMI as the yellow light that warns the hospital of any impending decrease in hospital income. The financial wizards and senior management monitor the CMI on a monthly basis.
Appropriate DRG assignment for each inpatient case impacts the CMI. This is another reason why complete and accurate documentation is important. Coders need thorough documentation to assign the appropriate DRG. Appropriate coding determines the DRG, and the average DRG weight determines the CMI. Case management and clinical documentation improvement specialists can help the coding team by ensuring documentation supports the appropriate diagnoses, which will lead to appropriate assignment of a DRG.
CMI is complex, but essential to the revenue survival of hospitals. CMI is used to adjust the hospital’s average cost per patient. CMS uses the annual CMI to determine the DRG amounts for the next year. CMI is a very complicated concept to grasp, but it is important to remember that CMI is a tool that is used to predict income, outlines patient types, and helps explain the cost of treating a hospital’s population. In the end it goes back to complete, accurate and timely documentation and appropriate coding practices.
Do you know what your institution’s budgeted CMI is and what your actual CMI is?
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.
Readmissions data now reported by CMS
CMS released a statement on Thursday, July 9, saying that its Hospital Compare Web site will now contain data reporting how frequently patients return to a hospital after being discharged, “a possible indicator of how well the facility did the first time around,” says the statement.
The statement goes on to say that, on average, one in five Medicare beneficiaries discharged from a hospital is readmitted within a month. President Obama and Congress are focusing on reducing readmissions as a way to improve quality and achieve cost savings, according to the statement.
Hospital Compare data show that 19.9% of patients admitted to a hospital for heart attack treatment will return to the hospital within 30 days, 24.5% of patients admitted for heart failure will return to the hospital within 30 days, and 18.2% of patients admitted for pneumonia will return to the hospital within 30 days.
“Research has shown that hospital readmissions are reducing the quality of healthcare while increasing hospital costs,” the statement reports.
