All Entries Tagged With: "physicians"
A change in perspective may help build better physician relationships
Editor’s Note: Linda Renee Brown, a clinical documentation specialist at Banner Good Samaritan Medical Center in Phoenix, AZ, wrote the following post for the Association for Clinical Documentation Improvement Specialists (ACDIS) Blog. Some case managers may be able to relate to her experience of transitioning from bedside nurse to a new role.
I’m an old (and I do mean OLD) ICU nurse. As a working nurse, my relationships with physicians usually centered on getting them to listen to my assessments: Yes, you need to get out of bed and come see this patient who has stopped breathing! And getting them to do what they should to care for the needs of their patients: Yes, I could really use a new central line for the 17 vasoactive infusions you’ve ordered!
I respect their level of education and their place on the food chain, but each physician operates on an individual plane of competency and personality for which I sometimes had to make adaptations in my approach.
When I worked in ICU, there isn’t much I wouldn’t do for a nice, polite doctor who showed respect to me and the patients. I knew how hard it is to become a doctor, and how really hard it is to become a good doctor, so I used to try to help the physicians by writing out a verbal order and having it ready for his or her signature. I would try to have all the necessary supplies ready ahead of time and if something additional was needed, I’d be the first to run to get whatever else was needed. Nice physicians got to sit in my space to write their progress notes. I even shared my Twizzlers.
Conversely, if you were a mean, crotchety doctor who didn’t show respect to nurses or patients, I wouldn’t be necessarily unkind but I certainly wouldn’t go out of my way to make your day better. I probably wouldn’t have your orders written and ready for your signature, I would show you where the supply closet was rather than get your materials ready for you, and I’d most likely not let you use my spot at the nurses’ station to write your notes. And no, no Twizzlers for you. Ever. Because you have to be a nice person, first and foremost.
In 2008 I left ICU and became a CDI specialist. Nobody knew what that meant, least of all the doctors. They just knew that I left on Friday wearing a white uniform and stethoscope and came to work on Monday in street clothes, pushing a computer on wheels.
When I was no longer running cardiac outputs or sending off specimens for C.difficile, they could no longer comprehend my new role against their earlier vision of who a nurse is and the role nurses play in patient care. I had to create a new identity and that meant redeveloping my existing relationships.
My biggest surprise came from a doctor I’ll call Raquel (since that’s her name). Raquel is a wonderful, hard-working physician who always seems to get the most difficult cases. She works too many hours. She eats standing up to save time. When I was an ICU nurse, I was always happy to have Raquel taking care of my patient, and she seemed just as happy to have me as her patient’s nurse. We got along very well. So I was unprepared for the way our relationship changed when I changed roles. [more]
Offer physicians insight not just ‘education’
Editor’s Note: The following blog post originally appeared on the Association of Clinical Documentation Improvement Specialists (ACDIS) blog site.
I recently received a fortune cookie from a colleague. After reading the fortune several times, I realized the hidden message certainly has direct relevance to clinical documentation improvement (CDI) efforts toward affecting overall change in patterns of physician documentation. It read:
“Anyone can memorize things, but the important thing is to understand it.”
Most people remember reading college textbooks, listening to professorial lectures, taking notes, and regurgitating the information we supposedly “learned” on tests and final exams, as part of our endeavors of higher learning. We always seemed to ask ourselves why we were “learning” the majority of that rote information anyway. It was difficult to appreciate and understand its practicality and usefulness.
Now, let’s look at CDI training and education. The majority of training, education, and execution of CDI programs center around:
- understanding the MS-DRG system
- learning what a MCC/CC is
- gaining a practical sense and understanding of coding rules and policies governing principal and secondary condition selection/assignment
- learning how to review the record
- learning how to identify opportunities to improve clinical documentation and financial reimbursement
Finally we learn how to enter the data into the tracking software for reporting purposes. If we’re lucky we learn to track
- how many queries were left
- how many were responded to
- how many contained a positive response
- how often records were reviewed
- how much of a financial impact CDI has on hospital’s bottom line
The entire process is similar to the college experience in the sense we “memorize” the steps of CDI, apply its principles consistently, and ensure we review the standard number of records each day in the name of that learning. While I am not fundamentally against established “quotas” for record review, I do advocate for quality of chart reviews which work in tandem with CDI efforts to educate of physicians, particularly to the extent that we are not repeatedly leaving the same queries day in and day out for the likes of acute blood loss anemia or the type of congestive heart failure. [more]
Improve communication between physicians and case managers to prepare for reform
No one is really sure what is going to happen with healthcare reform, but we can be pretty sure today’s reimbursement model and treatment plans will be different tomorrow.
Currently, payers use a fee-for-service model. In the Medicare population, providers receive payment for inpatient stays according to a DRG. Commercial payers pay hospitals based on either a DRG system or a percentage of billed charges.
Healthcare reform will eliminate the fee-for-service model and create a world where payers bundle hospital and physician payments. That payment model will then evolve into an “episodic” payment plan where facilities and providers are paid one fee for a episode of care provided within a 60-90 day window. There is a fixed dollar amount for that episode, no matter what treatment is provided or whether the patient is readmitted during that time frame. From there, payment will move to a capitated model where providers received a flat fee for each patient, with percentage increases for top quality scores and other metrics. While all these changes are going on, accountable care organizations (ACO) will be forming.
An ACO is composed of one or more hospitals and physician groups that work together using evidence-based care to improve the quality of care, while controlling costs. The Medicare Payment Advisory Commission (MedPAC) an entity that reports to Congress, is continually researching and monitoring the ACO concept.
Case management’s role
Over the years, communication between physicians and nurses has greatly improved. For example, the physician used to simply tell the case manager and/or social worker to set up a SNF placement. Now, the case manager or social worker creates a discharge plan upon admission and discusses the appropriateness of the plan with the physician.
However, there is still room for improvement. Physicians and nursing staff have communicated at each other, but not necessarily with each other in determining the plan of care. One example of the opportunity for improved communication is when a physician writes an order for a test. It is essential for case managers to discuss with physicians whether it is necessary to keep the patient in the hospital for the test or whether the test can be completed as an outpatient.
Under healthcare reform, the communication and relationships between physicians and nurses will need to be integrated. It will be imperative for case managers and physicians to work as a team to maintain collaboration and quality care of the patients. They will need to work together to provide proactive discharge planning and patient education. They will need to team up to provide necessary tests and treatments, while making sure they use resources appropriately.
The healthcare organization I work for is very proactive in its healthcare reform planning. The organization provides education to physicians and involves them in the planning process for the future of healthcare. Our senior case management team is already creating processes and education that will provide opportunities to begin physician and case management integration, starting with our ED physicians. The minute the patient enters our healthcare organization, case managers and physicians begin to collaborate.
What is your organization doing to prepare for healthcare reform? If you do not know, find out. Now is the time to get involved in preparing your organization and healthcare team for what is ahead.
A holistic approach to ED case management
The emergency department (ED) operates 24 hours a day 365 days a year. Providing unscheduled episodic care requires close monitoring to ensure economic viability because of the volume of uninsured/underinsured patients and third party payers’ penchant to deny payment for services they believe lack medical necessity.
The ED is a major source of inpatient admissions and serves as the fundamental base for establishing medical necessity. An ED case management model promotes complete and accurate clinician documentation in the health record and establishes a foundation for promoting proper inpatient admissions.
The decision to admit a patient to the hospital is complex. The right decision requires that hospitals embrace physician clinical judgment, clinical acumen, and medical decision-making far beyond admission screening criteria. Consider the following excerpt from Chapter 1 section 10 of the Medicare Benefit Policy Manual:
The physician or other practitioner responsible for a patient’s care at the hospital is also responsible for deciding whether the patient should be admitted as an inpatient. The decision to admit a patient is a complex medical judgment which can be made only after the physician has considered a number of factors, including the patient’s medical history and current medical needs, the types of facilities available to inpatients and to outpatients, the hospital’s by-laws and admissions policies, and the relative appropriateness of treatment in each setting.
Factors to be considered when making the decision to admit include such things as:
- The severity of the signs and symptoms exhibited by the patient;
- The medical predictability of something adverse happening to the patient;
- The need for diagnostic studies that appropriately are outpatient services (i.e., their performance does not ordinarily require the patient to remain at the hospital for 24 hours or more) to assist in assessing whether the patient should be admitted; and
- The availability of diagnostic procedures at the time when and at the location where the patient presents.
Practical incorporation of documentation principles
In a previous blog, I discussed the merits of specific, accurate, and detailed clinical documentation that reflects patients’ severity, acuity, risk of morbidity and mortality, as well as physicians’ clinical judgment, clinical acumen, the amount of work performed, and clinical medical decision-making.
Taking one step back, let’s approach clinical documentation in the mind of the physician. The patient receives an appropriate EMTALA screening and subsequent care begins. [more]
Proactive discharge planning and collaboration with community resources leads to discharge without readmission
With so much going on in healthcare today, it is difficult to sift through the complexity and know what to do and when. Healthcare professionals keep hearing about proactive discharge planning, collaboration of care, transition to home, and preventing readmissions, but do we know how to put all these ideas together in the right sequence to improve quality of care?
Improved patient care starts with relationships. Hospital case managers and social workers must work with community home healthcare agencies, nursing and skilled nursing facilities, and the insurance company utilization management resources. Let’s see how strong relationships help MaryJo (MJ) as she makes her way through an inpatient hospital stay.
Educating MJ
MJ is a 59-year-old female who works as an administrative secretary. She is married and has two grown children. MJ has insurance through her employer and has been in the hospital three times in the past seven months for recurrent exacerbation of her COPD. During this admission, MJ ’s case manager immediately begins to discuss discharge planning with MJ and at interdisciplinary rounds.
At the interdisciplinary rounds meeting, staff notes that MJ has never participated in pulmonary rehab. The case manager also speaks with MJ’s insurance company and discovers she does have benefits for pulmonary rehab and home healthcare services. The social worker works with the area home healthcare agencies and finds one with a well established COPD disease management program. MJ is tired of being in the hospital and agrees to participate in the program.
The primary nurse speaks with MJ and discovers that no one has explained how MJ’s prescribed treatment will help her. MJ admits that others have taught her the anatomy and physiology of her disease, but no one has told her why she must follow through with her treatments and what she can do to control her COPD.
Medical necessity—It’s a physician thing
Medical necessity for inpatient hospitalizations—or lack thereof—is a contentious topic that case managers face on a daily basis. The patient’s clinical presentation to the ED, severity of illness, physician assessment, or proposed plan of care does not always establish medical necessity.
When the patient meets the parameters of medical necessity at admission, he or she often reaches medical stabilization, thus meeting criteria for safe discharge. However, physician resistance can sometimes stand in the way of an appropriate discharge. Physicians may wish to watch the patient an additional day or may acquiesce to a patient’s desire to stay one more day.
Competing forces
While case managers and physicians have long battled over adherence to reasonable standards of medical necessity, several factors have made promoting efficient use of hospital resources through physician education all the more important:
- Dwindling third party-payer reimbursement
- More aggressive insurance company nurse reviewers
- Increasing numbers of uninsured or underinsured patients presenting to the hospital
However, competing financial incentives make it challenging for case managers to instruct physicians to adhere to medical necessity standards and use resources efficiently.
Physicians receive payment for their evaluation and management (E/M) services, while placing providers at financial risk through the admission and continued stay process, regardless of medical necessity. Physicians account for up to 20% of the healthcare dollar expenditures through face-to-face patient encounters. They also account for up to 90% of dollar expenditures through orders for services such as home health, physical therapy, and radiology and laboratory tests. [more]
Understanding CERT helps address clinical documentation deficiencies
Persuading physicians to document thoroughly and effectively is often a lesson in futility. Physicians have a natural instinct to believe they are either doing a proficient job of documenting or assert that they are too busy to document more than what is currently in the record. The physician typically does not recognize that this viewpoint can significantly impact his or her finances.
There appears to be a misconception in physicians’ minds that clinical documentation is for the benefit of the hospital in MS-DRG assignment. However, nothing can be farther from the truth. Physicians are subject to increasing numbers of pre- and post-payment audits in an effort to circumvent the “pay and chase” payment process that currently exists for paying physician service claims.
A Medicare initiative that immediately comes to mind is the Comprehensive Error and Review Testing (CERT) Program. Under the CERT program, CMS selects a random sample of claims from each Medicare contractor and requests medical records from the providers who submitted those claims. These records are then reviewed to determine if the claim was submitted and paid appropriately.
CMS utilizes two contractors for the request and review of medical records: the CERT Documentation Contractor (CDC) and the CERT Review Contractor (CRC). The CDC is responsible for requesting and obtaining the medical records. The CRC reviews the supporting documentation for compliance with Medicare coverage, medical necessity, coding regulations, and billing rules.
ACE demonstration project could change how CMS pays hospitals and physicians
Before CMS institutes a new national regulation, it often tests it on a smaller group. These demonstration projects identify weaknesses in the new rules and allow CMS to make necessary tweaks and changes. Demonstration projects also allow other facilities that are not involved in the project to learn from their peers. A recent example of this is the Recovery Audit Contractors (RAC) demonstration period.
One of the current demonstration projects that could have a large effect on case management and coordination of care is the Medicare Acute Care Episode (ACE) Demonstration project.
Essentially ACE changes how Medicare pays for healthcare services. Instead of paying the hospital and physicians separately, CMS bundles both payments into a lump sum. The payment system operates much like the DRG system where the one payment will cover the patient’s entire stay, rather than each individual service.
Extending the DRG concept to pay for physician services would encourage physicians to work with hospitals to control costs and improve quality, stated the June 2008 Medicare Payment Advisory Commission’s Report to Congress: Reforming the Delivery System.
I spoke with a source who was excited about the idea of bundling payments. The source said physicians are currently paid for every day they see a patient so they really don’t have any incentive to keep LOS down. But the ACE program would make it so physicians have the same motivation hospitals have to effectively use resources and provide proper care in a timely manner.
Some physicians are skeptical of the idea. Some fear that the lump sum allows the hospital to control physician rates and possibly encourage hospitals to withhold certain services to keep costs down, according to a recent article published by the AMA.
CMS is conducting the ACE demonstration project is in Medicare Administrative Contractor (MAC) Jurisdiction 4 (Texas, Oklahoma, New Mexico, and Colorado).
Anyone who is at a participating facility and would like to discuss the program, please contact me (bamirault@hcpro.com). I am also interested to hear how folks that aren’t participating think this program could affect case management.
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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.
