EXECUTIVE SUMMARY

Despite all of the changes in Washington, DC, the Centers for Medicare & Medicaid Services (CMS) remains committed to providing high-quality, efficient, and cost-effective care.

  • CMS announced quality programs for providers throughout the continuum and left intact all rules about medical necessity and utilization review in the Inpatient Prospective Payment System (IPPS) final rule for 2018.
  • Case managers should stay informed about CMS changes and continue to prepare for value-based care, bundled payments, and other quality programs.
  • It’s more important than ever for case managers to be a part of the multidisciplinary team, work closely with the documentation staff, physicians, and nursing, and communicate with their counterparts across the continuum, especially when patients transition.

There’s a new administration in Washington, DC, and new leaders at the helm of the Department of Health and Human Services (HHS) and the Centers for Medicare & Medicaid Services (CMS). But at CMS, emphasis on quality remains.

Despite the changes in Washington, the focus of case managers has not changed, says Cheri Bankston, RN, MSN, senior director of clinical advisory services for naviHealth, a Cardinal Health company. “We know that CMS is still working toward value-based care and that patient outcomes are going to drive the future. There may be some changes, such as shifting bundled payments from being mandatory to being voluntary, but the emphasis in healthcare will continue moving from volume to value,” she says.

CMS indicated that it still has a strong commitment to improving quality and patient satisfaction, primarily through value-based care, adds John Wagner, associate director at Berkeley Research Group.

For instance, CMS has introduced programs that emphasize quality for every major component of the continuum of care, Wagner points out. “This indicates that CMS is going to continue driving toward value-based reimbursement,” he says.

Quality-based programs also are very popular among commercial payers and government organizations. In fact, some commercial payers are requiring large provider groups and systems to participate in quality programs in order to obtain multi-year contracts, Wagner says.

“Clearly, the commercial payers believe that there is also a lot of benefit to base contracts with networks on quality programs,” Wagner says.

The Inpatient Prospective Payment System (IPPS) final rule left all the basic rules about medical necessity and the utilization review process unchanged, says Kurt Hopfensperger, MD, JD, vice president of compliance and education at Optum Executive Health Resources in Philadelphia. The final rule, issued in August, made technical changes, such as how readmission penalties are calculated, and minor changes to the hospital-acquired conditions and value-based purchasing program. Not many of those affect case management, Hopfensperger says.

With the continuing emphasis on Medicare spending-per-beneficiary and other quality-based programs, the case management role will continue to grow in importance, he adds.

However, some of the biggest changes initiated by CMS are independent of the IPPS, says Edward Hu, MD, CHCQM-PHYADV, president of the American College of Physician Advisors.

For instance, CMS announced that the Medicare Administrative Contractors (MACs) will be conducting Targeted Probe and Educate audits. “This is a significant change because the MACs no longer are auditing everyone, but analyzing claims and focusing on hospitals with the biggest percentage of errors,” Hu says. (For details on the MACs and other audit programs, see related article in this issue.)

Another example is CMS’s recent announcement that it intends to develop voluntary bundled payment initiatives rather than require hospitals to participate. The news came as the agency announced changes to the Comprehensive Care for Joint Replacement initiative that significantly reduced the number of hospitals required to participate and proposed canceling the Episode Payment Models and the Cardiac Rehabilitation Incentive Payment model that was scheduled to begin Jan. 1, 2018. (For details on the bundled payments changes and their effect on case managers, see related article in this issue.)

“The new administration is looking at new, innovative ways to reduce the total cost of care while maintaining quality, and will continue to make changes,” Hu says.

But many hospitals are not prepared for constant and rapid change, says Elizabeth Lamkin, MHA, chief executive officer and partner in PACE Healthcare Consulting, based in Bluffton, SC.

“In this fluid environment, case managers should stay informed about what changes impact their day-to-day activities. Case management leadership and physician advisors should be working closely with the compliance and policy departments to help ensure they are getting the information they need to make sure the hospital complies with new regulations,” Lamkin says.

For instance, in the IPPS final rule, CMS announced the addition of the 30-day episode of care for pneumonia to value-based purchasing in fiscal 2022, reports Susan Wallace, MEd, RHIA, CCS, CDIP, CCDS, FAHIMA, vice president of inpatient services for Administrative Consultant Services, a Shawnee, OK, healthcare consulting firm.

It’s tempting to think about how long it is until 2022 and plan on dealing with it later, Wallace says. She points out, however, that the baseline period for the measure has already ended and that the performance period starts Aug. 1, 2018.

“All of the initiatives instituted by CMS make it extremely important for hospitals to treat patients as efficiently and effectively as possible,” Wallace says.

That’s why it’s important for case managers to familiarize themselves with payer rules and regulations, she says. Pay particular attention to the measures in the hospital inpatient quality reporting program and focus your process improvement projects on those measures, she says.

The problem is that case managers still have one foot in the fee-for-service world and the other in value-based care, Bankston says. “Both have the same goal, which is doing what is best for the patient,” she says.

Today’s healthcare environment offers case managers a great opportunity to be real agents of change, Bankston adds. She advises case managers to be proactive and continue to prepare for value-based care. “This is where we shine and where we can really lead the charge toward focusing on outcomes and what is best for the patient,” she adds.

If every provider focused solely on quality and outcomes, all facets of patient care would be significantly improved, especially the bottom line, Wagner says. “Case managers should be extremely focused on quality and identifying risks for readmissions and putting interventions in place to prevent them,” he adds.

As payers continue to emphasize high-quality, cost-effective care in hospital and post-acute settings, case managers should be shepherding patients through the entire episode of care and should review every case, every day for medical necessity, Hopfensperger says. A major focus of case managers should be length of stay, he adds.

“Any time case managers can do anything to prevent a patient waiting another day for a test, that contributes to the length of stay, and ultimately affects the cost of treatment,” Wallace says.

For hospitals to succeed in value-based purchasing, case managers must properly identify patients at risk for readmission early in the stay and take steps to help patients avoid coming back, says Teresa Marshall, RN, MS, CCM, senior managing consultant for Berkeley Research Group.

“Case managers can help prevent readmissions if they understand each patient’s barriers to following the discharge plan, collaborate with the rest of the team to overcome the barriers, and make sure everyone is on the same page when the patient moves to another level of care,” she says.

Case managers must move more of their work to the front end of the patient stay, rather than waiting 24 hours or longer to review a chart, Lamkin says. Every entry point should be covered by a case manager who is knowledgeable about the risk areas, she says.

Case management must be proactive in identifying issues at the time of admission that can result in a loss of reimbursement, she adds. This means working with other departments, such as patient financial services and clinical documentation improvement teams, to ensure that all required documentation and authorizations are in place to prevent a denial downstream, she says.

“A good check-and-balance is to track denials for root cause and create a feedback loop to the front-end case managers so they can lead the clinical team to correct deficiencies that result in denials,” Lamkin suggests. For instance, if a physician requests a bed for a patient after surgery, there must be a mechanism for case management to review the case and ensure that the patient meets inpatient criteria, or the criteria for an outpatient with observation services, she says.

“Hospitals can’t just depend on physicians to choose the correct bed status,” she says.

Some hospitals aren’t big enough to have a case manager on site 24/7, Lamkin points out. In these cases, she suggests staggering the hours of the staff, with some coming in early and other staying late.

Hospitals have to do more than just become compliant. They have to be as efficient as they can with community resources, Wallace says. “Case managers should make sure that patients have exactly what they need — not more or less. They should focus on the overall efficiency of services delivered and work to ensure a successful discharge,” she says.

Work closely with physicians on documentation to the extent that the case management role in your hospital includes documentation improvement, Wallace says.

Almost all CMS quality measures are risk-adjusted, Wallace points out. This means that all of a patient’s significant chronic conditions should be documented in the medical record.

“In the past, hospitals focused only on including documentation to indicate a Complication or Comorbidity or Major Complication or Comorbidity that would change the DRG [diagnosis-related group]. But there are hundreds of diagnoses that affect risk adjustment but do not affect the DRG,” Wallace says.

“Patients could have five or more complications or comorbidities, and the DRG would be the same as if they had only one. But five complications or comorbidities would have a big impact when the hospital’s data is risk-adjusted,” she adds.

For instance, when a diabetic patient has hyperglycemia, it doesn’t change the DRG but it does affect risk adjustment, she adds.

“Case managers should continue to focus on what we are good at, which is driving outcomes,” Bankston says.

Bankston suggests that case managers change their perspectives and instead of concentrating on a patient’s acute care needs, analyze what he or she will need during the entire episode of care.

“The challenge is to look outside the four walls of the hospital and assess the entire 90-day episode of care. Historically, we waved goodbye from the hospital door. Now we have to manage the complex episode after discharge,” she says. The biggest challenge in the future may be to determine which providers will be the most effective in a particular episode, Bankston says.

“We need to look at the quality of care provided at each step of the patient’s journey and determine which has the biggest impact on proven outcomes,” she says.

Effective discharge planning is important and requires a balancing act, Wallace points out. Where the patient goes after discharge contributes to the cost of the episode of care and, if the discharge fails and the patient comes back, it affects the hospital’s performance on the readmission reduction program, Wallace adds.