May, 2012

BROUGHT TO YOU BY PHOENIX: THE HOSPITAL CASE MANAGEMENT COMPANY

Elective Joint Replacement
We first heard about it here in Florida. Then clients in West Virginia, Texas, Ohio and Pennsylvania started reporting that the RACs and the MACs are denying elective joint replacement cases because there is no documented evidence that conservative medical treatment was attempted first. And this time around, both hospitals and physicians are feeling the pain. We recently sent out a press release about this situation to 320 case management leaders and we got 48 requests for information on how to better document....many from physician advisors and CMOs. We also got an email from a case manager in California who reports that the CMO and the program Director developed a process as part of their centralized Patient Access Center. Their hospital has taken the position that to schedule an elective joint replacement, physician documentation confirming SIM criteria must be reviewed by the PAC case manager. We asked if the surgeons balked at this requirement and she reported that the community's only ortho group took it upon themselves to develop a form (paper and electronic) used by community referring physicians to list all the medical treatments that were attempted and the patient's response, prior to the surgical consult. Now that the physicians have a vested interest in good documentation, they can be quite innovative.

ACMA Conference
We just returned from the national ACMA conference in Denver and can report that the hospital case management constituency is thriving. The conference had many interesting speakers from veterans like Frank Bellamy to delightful newbies like Julie Graham. There were sessions that we would characterize as having very basic content perhaps best targeted at newly minted case managers. There were also programs that were more advanced though we sensed from the side bar conversations in the back of the room, that the material being presented may have been at a higher level than expected. When the first question asked in one of those sessions was "what's an ROI?" we suspect that the content had to be a bit overwhelming to that audience member. The conference was very well managed and carefully orchestrated to keep 1200 attendees on track. The staff did a great job and the convention center venue was very pleasant. All in all, the conference was worth the trip and it was great connecting with colleagues, clients and friends. The only suggestion I would make for the future, is to consider having an 'advanced' or 'leadership' track to help members identify the most appropriate session to attend.

First Time Quality
We make it a point never to endorse a particular product though we will relate our clients' experiences with products if asked. And one of the questions we're being asked frequently has to do with CDI programs. About half of the CDI programs we encounter report to the case management protgram while the other half are evenly split between HIM and/or finance. We recently heard the term 'first time quality' from a CFO who reported that his expectation of a new case management model at his hospital is to "get it right the first time, every time." Music to our ears but it takes a large dose of executive commitment to make it happen. Confirming medical necessity at the time of pre-admission is the hallmark that many CFOs hold as their gold standard. They intuitively recognize that once an unqualified patient gets a bed, it takes many resources to make it right. As a result, along with a highly proficient UR specialist, CDI and/or concurrent coding initiatives in the ED are rapidly taking hold. And that's where ChartWise shines. We recently discovered this web based product and were amazed at its ease of use to help physicians document accurately. It's a fraction of the cost of the more popular programs now on the market and was developed by a physician for hospitalists to use 'real time.' I spoke to several ChartWise clients and feel quite comfortable suggesting that our clients explore its value. So should you.

CoxHealth
We're off to Springfield, Missouri to spend time with the case management teams at the three CoxHealth hospitals. We are excited about working with their executive team, department heads and case management teams to help them design a third generation outcome model that will meet the demands of the new marketplace. Join us in extending a welcome to the newest member of the Phoenix Client Community!

Regionalize Hospitalist Patients

There is an article in the March issue of Today's Hospitalist that supports our long-held position that hospitalist efficiency, team building, and interdisciplinary care coordination can be optimized if patients being medically managed by a hospitalist team were regionalized geographically. With the permission of Editor and Publisher, Edward Doyle, below are his editorial comments concerning the article which can be found at todayshospitalist.com/index.php

You might have noticed that this month’s cover story focuses on a topic we’ve covered before: unit-based staffing, also known as geographic rounding or localization.

We’re revisiting the story again for a couple of reasons. For one, hospitalist groups that have embraced unit-based staffing have had some success in working out the kinks.

Hospitalists have found that geographic rounding gives an essential boost to teamwork, making multidisciplinary rounds both more possible and more efficient. That sense of teamwork can give hospitalists a sense of collegiality and ownership, two factors that go a long way toward improving professional satisfaction.

Another reason this story remains important is that hospitalists aren’t the only ones embracing unit-based staffing. Increasingly, hospital administrators are pushing hospitalist groups to move to geographic localization. They hope that by clustering hospitalists’ patients more tightly, they’ll lower length of stay and reduce readmissions.

But rolling out—and maintaining—unit-based staffing isn’t easy. Hospitalists find that they may have to fight to put patients in specific units, particularly when the hospital is trying to move patients out of the ED as quickly as possible.

However, hospitalists are learning how to overcome these obstacles, and some are seeing their success replicated in other parts of the hospital. One hospitalist reported that his group had so much success with unit-based staffing that several other specialties moved to “regionalize” their patients in the hospital as well.

Another hospitalist reported that within 15 months of her program implementing unit-based staffing and multidisciplinary rounds, such rounds had become the norm throughout every hospital unit and across every specialty.

This isn’t the first time that an initiative spearheaded by hospitalists has caught on with the rest of the hospital. But it is an excellent example of the growing influence of the specialty.

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"The Myth of Length of Stay"

For years, Phoenix associates have been promulgating the idea that the organization's slavish focus on length of stay as the primary indicator for case management or financial success is, like the definition of insanity, doing the same thing over and over again expecting different results. We've argued that cost per case is the more logical metric since it reflects resource utilization at the physician and patient level and it, more than LOS, impacts the bottom line. Our position was broadcast in an article published in 2008 in HealthLeadersMedia www.healthleadersmedia.com/content/FIN-215087/The-Myth-of-Length-of-Stay.html

So now comes the April 24 announcement by CMS proposing new measures for its value based purchasing program. Among the proposals, which include prescribing a statin at discharge for AMI patients and measuring central line associated bloodstream infections, is a new entry which marks the introduction of an efficiency measure. Wanna take a guess what it is?? You got it....Medicare spending per beneficiary!

For years we've said that length of stay, while significant if you have consistent through-put challenges, does little for the hospital's bottom line and it seems, that the US government agrees. Positive margins result when the expenses are less than the reimbursement despite the patient's length of stay...that's just simple math. And with VBP and the expected revenue shortfalls, the pool of resources utilized in the care of the inpatients, is the last remaining source of spending cuts that make sense. Why does a patient need 16 CBCs when the first 5 were within normal limits? If case managers are going to serve as advocates for patients and the community, then those practice decisions (which have nothing to do with medical judgment) must be questioned and steps taken to demonstrate that they do not contribute to the quality of the patient outcome - in fact, we know that there is an inverse relationship between cost and quality - the higher the cost, the lower the quality.

So now we have CMS which is saying what years of reseacrch by the Rand Corp and the Dartmouth Atlas have found ----- Wide variations in spending among similar populations add unnecessary costs to care.

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Observation and SNF

You've probably heard that Representative Joe Courtney (D-CT) has introduced a bill to amend the Medicare rules so that an individual receiving outpatient observation services in a hospital can still satisfy the three-day inpatient hospital requirement in order to entitle the individual to Medicare coverage in a SNF.  This is the second time he's tried to get this piece of legislation passed. In 2010, his bill went nowhere.

Given some of the recent media attention to the issue of patients finding out after the fact that their SNF stay is not covered under Medicare if their inpatient status was outpatient/observation, we think it stands a better chance of passing this time around. In fact, Courtney has 17 members of Congress as co-sponsors.

We're not so sure this is a good idea for several reasons. To begin with, physicians still don't understand how inpatient or observation status is determined and since they are the arbiters of who gets a hospital bed, no amount of coaching can prevent inappropriate hospital level services.  Despite the physician's decision, whether supported by documentation or not, CMS via the RACs and the MACs will second guess the situation and may deny the admission. Then the hospital has to devote resources to play the appeal game. In the meantime, lacking any 'skin in the game,' the physician will still get paid.

Secondly, there are many hospitals that do not have CDUs and are placing outpatients in inpatient beds. Sick patients needing that bed have to stay in the ED or get transferred to a facility with bed availability.   And thirdly, we see it as a green light for more patient dumping. Let's be very real about this....every one of us can relate stories about families dropping off their frail and elderly relatives in the ED because they cannot or will not care for them - or because they want a respite in DisneyWorld (true story!). The savvy EDCM will try to get these patients into a nursing home right from the ED though its not always possible.....even when the hospital offers to pick up the tab for a few days. So they are placed in observation in an inpatient bed where their iatrogenic risk factors skyrocket and they receive medical interventions to justify 'observation' status even though they just require custodial care.

This bill may not be in the patients' best interest and it certainly doesn't solve the root cause of the problem - a healthcare system mired in legacy 'cure' strategies rather than 'care.'

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