CMS keeps raising the stakes on quality improvement
IPPS continues the focus on performance
If there ever was any doubt that the Centers for Medicare & Medicaid Services (CMS) is serious about improving quality, the 2015 Inpatient Prospective Payment System final rule should dispel that notion. A significant portion of the lengthy final rule is devoted to quality improvement initiatives.
Executive Summary
- Case managers must be involved with patients from the minute they come in the door, through the hospital stay, and after discharge, experts say.
- Reimbursement is affected by risk-adjustment, which means case managers must make sure the documentation is as complete and specific as possible to show the full picture of the patient's severity of illness as well as any conditions that were present on admission.
- As the readmission reduction program expands to add new diagnoses and the penalties for poor performance increase, case managers must change their focus from discharge planning to transition planning that takes into account what resources patients need after discharge, experts say.
In fiscal 2015, beginning October 1, hospitals have the potential to lose as much as 5.5% of their Medicare base payment if they perform poorly on all the quality initiatives. This includes 1.5% in the Hospital Value-based Purchasing Program, 3% in the Hospital Readmission Reduction Program, and 1% in the Hospital-Acquired Condition Reduction Program.
"There’s a lot at stake for hospitals. If they aren’t providing good quality in all of these areas, they could have big problems," says Linda Sallee, RN, MS, CMAC, ACM, IQCI, director for Huron Healthcare, with headquarters in Chicago.
In the final rule, CMS added chronic obstructive pulmonary disease and total knee and hip arthroplasty to the Hospital Readmission Reduction Program and proposed adding readmissions for coronary artery bypass graft to the program in fiscal 2017. Readmissions for myocardial infarction, heart failure, and pneumonia have been in the program since it began in 2012. Beginning Oct. 1, 2014, hospitals can lose up to 3% of reimbursement for every Medicare admission.
In fiscal 2014, hospital payments will automatically be reduced by 1.5% to fund the CMS Value-based Purchasing Program. CMS estimates that $1.4 billion will be dispersed to hospitals based on how well they perform on the value-based purchasing metrics.
In the first year of CMS’s hospital-acquired conditions payment reduction program, the 25% of hospitals that perform most poorly will lose 1% of their Medicare base payment.
All hospitals are already losing a portion of reimbursement on individual cases when patients acquire targeted conditions during the hospital stay, says Susan Wallace, MEd, RHIA, CCS, CDIP, CCDS, director of inpatient compliance for Administrative Consultant Services, a Shawnee, OK-based healthcare consulting firm. Now, the poorest-performing hospitals will also lose 1% of reimbursement on all Medicare discharges, she adds.
In 2015, 35% of a hospital’s score will be based on the Patient Safety Indicator 90, a composite of eight measures. The remaining 65% will be based on two healthcare-associated infection measures: central line-associated bloodstream infections and catheter-associated urinary tract infections. CMS proposed adding surgical-site infections to the program in 2016.
Quality rather than quantity
"CMS is moving steadily toward reimbursing hospitals for quality rather than quantity. Case managers have the potential to impact their hospital’s bottom line by ensuring that patients have an effective discharge plan, and collaborating with other providers across the continuum of care," says Deborah K. Hale, CCS, CCDS, president of Administrative Consultant Services.
"With its quality initiatives, CMS is not rewarding good quality as much as it is punishing poor quality. The quality programs are punitive rather than incentivizing hospitals to improve. Hospitals have to focus on quality to avoid penalties," says Thomas McCarter, MD, FACP, chief clinical officer at Executive Health Resources, a Newtown Square, PA, healthcare consulting firm.
CMS’s emphasis on quality means that case managers need to be involved from the time patients are admitted and throughout the entire stay, making sure that everything is documented, he adds. "The more you can document, the more correct the claim will be and the better the record will support it," McCarter says.
Medicare requires that all conditions be documented on every admission and that complications and comorbidities or major complications and comorbidities be considered for risk-adjustment purposes, he says. For instance, if a patient has diabetes, it should be noted in the documentation even if the patient is hospitalized for an entirely different reason.
"A hospital’s overall reimbursement can be incredibly impacted by risk adjustment. It’s imperative that all the patient’s conditions and services received are documented and that the documentation is as complete and specific as possible to show the full picture of the patient’s severity of illness as well as any conditions that were present on admission," Hale says.
It’s going to take a team approach for hospitals to do well on quality measures, Sallee says. "Case management is not just utilization review and discharge planning but it is coordination of care, and this is more important as CMS moves toward value-based purchasing. Coordination and collaboration between disciplines is going to be key," she says.
Case managers are the common denominator while patients are in the hospital, Sallee says. "Doctors write the orders, but they aren’t there to see that they are carried out in a timely fashion. Patients may have a different nurse every day, but the same case manager covers that unit," she says.
Case managers need to change their focus from discharge planning to transition planning that takes into account what resources the patients need when they go back to the community, Sallee says. They need to spend time with patients to find out their support system at home and assess them for risk of readmissions.
"A lot of readmissions occur due to social issues because patients didn’t have access to what they needed after discharge. Case managers and social workers have a huge responsibility to develop appropriate transition plans that include helping patients tap into whatever community resources they need," Sallee says.
In value-based purchasing, the measurement period is well in advance of the payment period. For instance, performance periods for some measures that will be included in the program in fiscal 2019 and 2020 are starting soon, Wallace says.
This means hospitals can’t wait until CMS adds measures to value-based purchasing to improve quality and impact their scores, she adds.
Instead, she advises case managers to look at the measures in the Hospital Inpatient Quality Reporting Program for clues as to what is likely to be included in value-based purchasing in the future since nothing can be included in value-based purchasing until it is part of the quality reporting measures.
