Author Archive for: Case Management Weekly
Drug industry agrees to fund portion of Medicare doughnut hole
July 2nd, 2009 
The Pharmaceutical Research and Manufacturers of America, following negotiations with lawmakers, announced an agreement that calls for the industry to spend $80 billion over the next decade to assist Medicare beneficiaries and defray medication costs. The agreement calls for pharmaceutical companies to pay as much as half the cost of brand name drugs for lower- and middle-income senior citizens in the so called Medicare “doughnut hole.”
The doughnut hole occurs when patients’ total drug spending has exceeded $2,400. They must pay full cost for their medications until they have spent more than $3,850. And in 2007, about 15% of the 3.4 million Medicare beneficiaries who hit the doughnut hole quit taking their medications.
The agreement with the pharmaceutical industry marked a small victory for Sen. Max Baucus (D-MT), chairman of the Senate Finance Committee, who has been negotiating with health industry groups as he was working on drafting health reform legislation with his committee.
Source: HealthLeaders Media
Virtual patient advocate could reduce readmissions
July 2nd, 2009
The spotlight’s shining on readmission rates. A Commonwealth Fund–supported study published in the April New England Journal of Medicine found that one-fifth of Medicare beneficiaries return to the hospital within 30 days of discharge and one-third return within 90 days. The study stated that unplanned readmissions cost Medicare $17.4 billion in 2004.
Developed by Timothy Bickmore, PhD, assistant professor of computer and information science at Northeastern University in Boston, the virtual patient advocate is on clinical trial at Boston Medical Center to increase patient understanding of postdischarge self-care regimens. Bickmore and his team of researchers hope the system can decrease patient readmissions within 30 days of hospital discharge.
“Nationally, it’s been shown that about 20% of patients get readmitted within 30 days,” says Bickmore, who adds that one-third of those readmissions are preventable. “There is a lot of information patients need to know before they go home. The typical discharge in the [United States] lasts about eight minutes and it’s like, ‘Here are your prescriptions and a pat on the back.’ ”
Check out the July 2009 issue of Case Management Monthly to read the full article.
Obama administration calls for more hospital payment cuts
June 24th, 2009
In an effort to reform healthcare and reduce costs, President Obama has called for $313 billion in healthcare spending cuts.
The proposed cuts include a $220 billion reduction in hospital payments over the next 10 years. The American Hospital Association (AHA) expressed deep disappointment and noted that hospitals already face a previously announced potential $38 billion cut and $41 billion in cuts under the proposed Medicare Inpatient Prospective Payment System rule.
AHA President and CEO, Rich Umbdenstock said, “Reform must improve care for patients without crippling hospitals’ ability to care for patients and communities.”
Source: AHA News Now
Tip: Analyze your registration process
June 24th, 2009
Patients typically arrive at the hospital as planned, urgent, or emergent admissions, and are registered in different ways. Errors made during the registration process can have a negative impact all the way to throughput and discharge planning. For this reason, the hospital may want to consider a performance improvement project to identify if there are registration errors, the types and frequency of these errors, and when they occur. For example, do errors occur more often on emergency admission on the night shift? What types of errors are they? Are they duplicate medical record numbers, errors in Social Security numbers, or the spelling of patient names? Any of these issues will have an impact on patient safety, discharge planning, and even billing or denials.
Editor’s note: This tip comes from HCPro’s newest training resource for hospital case managers—Core Skills for Hospital Case Managers: A Training Toolkit for Effective Outcomes by Beverly Cunningham, MS, RN, and Toni Cesta PhD, RN, FAAN, available now at HCMarketplace.com.
Manual changes related to condition code 44
June 18th, 2009
By Kimberly Anderwood Hoy, HCPro's director of Medicare and compliance
I’d like to turn my attention to the manual changes related to condition code 44, as promised. Overall, the changes were designed to incorporate discussion and FAQs that were previously published in MLN Matters Article SE0622. In this respect, the changes to the manual have very few surprises. Almost everything added came directly from SE0622 and nothing added was really anything new. With that said, however, I do think that hospital case managers and anyone involved in condition code 44 cases or billing for cases with changed status should review the changes carefully to be sure they follow all the guidance provided.
One of the disappointing things about the changes is that they did not address the issue of whether the period of time from the inpatient order up to the time the patient is changed to outpatient and the observation order is written can be billed as observation time. The language stating that the entire episode of care should be billed as outpatient remains unchanged and nothing was added to clarify it. However, if we carefully consider the other changes made to the observation sections, I think we can discern that CMS does not mean for these hours of care to be billed as observation.
Read the rest of this post, or share your thoughts on this topic.
Fee-for-service payments under scrutiny
June 11th, 2009
As President Obama and Congress consider healthcare reform, they examine ways to reduce costs yet retain quality care.
Discussions have increased around facilities such as the Mayo Clinic in Rochester, MN, according to HealthLeaders Media. The Mayo Clinic is able to provide high quality care for less than the cost of care in other parts of the country, where the quality may be lower.
Is this because of overutilization? Are physicians increasing costs by ordering too many tests? If this is the case, then experts say that it could be time to change the way physicians are reimbursed. However, the details of this change are still unclear.
Source: HealthLeaders Media
Discuss patient financial information early in the hospital stay
June 3rd, 2009
The Patient Friendly Billing Project, a collaborative effort spearheaded by the Healthcare Financial Management Association (HFMA), has developed guidelines for care providers to help inform patients of their financial liability as early as possible during a hospital stay.
The guidelines describe these discussions as an opportunity to help patients make informed decisions about their care. Such discussions also help patients learn about payment alternatives, such as Medicaid or charity care, and begin the application process as early as possible.
Early discussions of treatment and financial options, says the HFMA, increases the likelihood that providers will receive sufficient payment. This helps ensure they will be able to continue providing high quality care.
Source: Healthcare Financial Management Association
Q&A: Case management documentation
June 3rd, 2009
Q: I am a case manager on a cardiac step-down unit. Our case managers’ work focuses primarily on l specific disease management and patient contact/education and nurse mentoring/chart reviewing, patient rounding, etc. We are very clinically focused.
We don’t do utilization review (UR) or discharge planning. We face the issue of case manager documentation. Legally, what must we document?
A: In this model, not doing utilization review allows the case manager to really focus on clinical progressions, which should be the focus of his or her documentation. The case manager should document how sick the patient is, and how the patient is progressing clinically each day. There’s no legal requirement for the case manager in this position to document, but there is a professional requirement to document the clinical progression as well as what the case managers taught the patient prior to discharge and how the patient responded. Every time they see, touch, or talk to a patient, the case managers should document.
This question was answered by Karen Zander, RN, MS, CMAC, FAAN.
