For the first time, the Department of Health and Human Services has set specific goals for basing Medicare fee-for-service payments on quality or value by the end of 2018.
• Commercial payers are expected to follow suit and develop their own programs for basing payment on quality or value.
• Since much of the data used in the Centers for Medicare & Medicaid Services quality-based programs is risk-adjusted, complete and detailed documentation that represents all of the patients’ conditions and services received is vital.
• The emphasis on care throughout the continuum means that case managers are going to have to communicate regularly with their counterparts in post-acute providers and make sure patients do well in the post-discharge setting.
The U.S. Department of Health and Human Services’ (HHS) announcement of goals to tie Medicare fee-for-service payments to quality or value is a game-changer that will impact every case manager across the nation and make the case management role critically important throughout the continuum of care, according to Andy Ziskind, MD, managing director at Huron Consulting, a Chicago-based healthcare consulting firm.
“CMS has been introducing payments based on metrics and quality scores. Now, they will dominate the Medicare payment system. At a high level, this is going to accelerate all the changes that hospitals and health systems need to make to deliver care to patients efficiently throughout the continuum. The focus on quality and value-based payments raises the importance of the care manager,” he adds.
In January, Health and Human Services Secretary Sylvia M. Burwell announced a goal of tying 85% of all Medicare fee-for-service payments to quality or value by the end of 2016 and 90% by the end of 2018 through initiatives such as the Value-based Purchasing Program and the Hospital Readmission Reduction Program. She also announced a goal of making 30% of fee-for-service Medicare payments through alternative payment models such as bundled payment arrangements and accountable care organizations by the end of 2016 and making 50% of payments through these models by the end of 2018.
CMS is already basing a portion of reimbursement on quality in the Value-based Purchasing Program, the Hospital Readmission Reduction Program, and the Hospital-Acquired Condition (HAC) Reduction Program, Ziskind points out. Alternative payment models currently account for about 20% of Medicare payments, but this is the first time there have been specific goals to aggressively increase tying Medicare payments to performance, he adds.
Ziskind anticipates that commercial payers will follow Medicare’s lead and expand their own programs to base payments on quality measures.
“The emphasis on quality means that hospitals have to find ways to make sure they are delivering the services that patients want and that CMS expects,” says Elizabeth Lamkin, MHA, chief executive officer and partner in PACE Healthcare Consulting, LLC, based in Beaufort County, SC.
Rounds are the best way to understand what is going on in the hospital and what is going on with patients, Lamkin says. “Leadership rounds are essential so hospital leaders will understand what is working, what is not, and what changes need to be made so patients can get what they need. This is good for quality measures, Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) scores, and patient satisfaction,” she says. Nursing rounds and nurse manager rounds also are crucial, she says.
“Multidisciplinary rounds are important for value-based purchasing scores and for patient throughput,” she adds.
The biggest thing case managers can do is make sure the plan of care and discharge information is clearly articulated, Lamkin says.
With the increasing emphasis on value-based purchasing and other quality-based initiatives, complete and detailed documentation takes on new importance, says Deborah K. Hale, CCS, CCDS, president of Administrative Consultant Services, a Shawnee, OK, healthcare consulting firm.
The outcomes scores for value-based purchasing are based on risk-adjusted data, and documentation needs to reflect the patient’s diagnosis in very specific terms based upon clinically supported data in the medical record, she points out.
“The Complications and Comorbidities (CCs) and Major Complications and Comorbidities (MCCs) are important for reimbursement, but even if they are well documented, a hospital still may be in a bad position when it comes to risk adjustment if there are other conditions that are not documented,” she says.
CMS uses the hierarchical condition classification (HCC) system for risk adjustment in the value-based purchasing program, Hale says. “Hospitals are not likely to fare well when it comes to mortality rates, readmissions, patient safety indicators, and cost-per-beneficiary ratios if they don’t understand the hierarchical condition classification system and ensure that every condition the patient has is documented and reported according to Official Coding Guidelines,” she says.
CMS developed the HCC model as a risk-adjustment model to determine payments for the Medicare Advantage program, Hale says. The model identifies individuals with serious or chronic illnesses, using ICD-9 codes, and assigns a risk category based on the individual’s conditions and demographic factors.
“This system helps CMS give hospitals and physicians credit for severity of illness. CMS expects the sickest patients to have more frequent readmissions, incur greater costs, and expire more frequently. However, documentation must support the condition and the physician’s assessment and treatment plan,” Hale says.
“It all folds into clinical documentation improvement and an awareness on the part of the clinical documentation improvement staff, the coding staff, and physicians. CMS has allowed hospitals to report up to 25 diagnoses, but the documentation has to match up,” Hale says.
Clinical documentation improvement programs should be about more than just coding and finding better ways to identify comorbidities, Lamkin advises. “Clinical documentation staff should help physicians navigate the electronic medical record,” she says. For instance, if there is a physical therapy note or a lab value that the physician needs, make sure he or she saw it and reacted.
Lamkin suggests that hospitals consider moving clinical documentation improvement to care management or the quality department. “Clinical documentation improvement goes hand in glove with utilization and making sure that everyone follows the regulations and documentation rules,” she says.
CMS is starting to align the incentives for the health system to invest in post-acute care management, Ziskind says. Value-based purchasing and significant payment penalties from the readmission reduction program give hospitals a financial interest in investing in initiatives to make sure patients do well in their post-discharge setting, he says.
“The bundled payment initiative puts the healthcare organization at risk from the time patients enter the system through an episode of care. Since the payment model spans more than inpatient care, there is a growing need for coordination between the inpatient and outpatient providers,” he says.
In the future, care management models will have to be much more patient-centered than facility-centered and will have to extend beyond the four walls of the hospital and across the post-acute continuum, he adds.
Hospital case managers will need to communicate with their counterparts in patient-centered medical homes and other post-acute settings and share best practices across those sites of care, he says.
Coordination between venues of care and standardization of care is already happening within many hospital systems, but it needs to spread throughout the healthcare system, Ziskind says.
“We know that reducing variation in care reduces both complications and costs. Standardizing processes makes it clear so that everybody knows what to expect every step of the way,” he says. Some health systems still have a different model of case management at every facility within the system. “These organizations need to develop a standardized process which will improve care coordination and communication as patients move between sites of care,” he says.
Make sure the entire clinical staff, including nurses, understand the Medicare regulations and the consequences of not following them, suggests Sherry Daugherty, RN, nurse analyst for Pershing, Yoakley & Associates in Atlanta, who recently joined the firm after 15 years as an emergency department nurse.
“In all my years working in hospitals, nobody ever told me why some of the things we had to do were important. Every time there was a new requirement added, it just seemed burdensome because we didn’t know why we were doing it,” she says.
Educate the staff on whatever admission guidelines your hospital uses, Daugherty advises. “In the emergency department, we use clinical judgment to determine if someone should be admitted. There was never any feeling that we had to make sure the patient met medical admission criteria,” she adds.
Daugherty suggests educating the staff on the ramifications of an audit, how much staff time it takes, and how much it costs to appeal denials. “None of the nurses or physicians I worked with had any idea of the cost of the audit and what going through one entails,” she says.