Focus on publicly reported data enhances the case manager's role

Quality metrics will affect reimbursement, patient choice

As the Centers for Medicare & Medicaid Services and commercial payers move to base reimbursement on quality and consumers become more savvy about their choices of health care providers, complete and accurate documentation will become even more important.

"Hospitals are being required to do more public reporting, resulting in additional transparency in health care. This creates an increased level of focus and attention on hospital performance," says Carolyn Scott, RN, MEd, MHA, vice president of performance improvement and quality for Premier, a health care improvement alliance.

The increase in transparency is accelerating hospitals' focus on quality improvement to maximize reimbursement and boost their publicly reported statistics, points out Quint Studer, CEO of Studer Group, a health care consulting firm based in Gulf Breeze, FL.

"Case managers have always played an important role in process improvement. As the emphasis on publicly reported data increases, the case management role is likely to expand, and the hospital leadership is likely to give case managers the support they need to be successful, Studer says.

The purpose of public reporting is to create transparency and accountability, aid consumers in their choice of providers, and stimulate quality improvement activities, says Beverly Cunningham, RN, MS, vice president, clinical performance improvement, Medical City Dallas Hospital.

"Consumers are beginning to pay more attention to publicly reported data, and there is an increasing amount of publicity about the types of sites patients can access to find out how their physicians and hospitals are performing. The attention will only intensify over time as health care consumers assume more responsibility for their choices and make sure that they go to high-quality providers with documented, favorable outcomes," Scott adds.

The Centers for Medicare & Medicaid Services began publicizing its newly revamped Hospital Compare website in 2008, taking out advertisements in newspapers in major metropolitan areas to encourage consumers to use the information when they choose providers.

The website now averages 2.5 million page views a month, reports Deborah Hale, CCS, president of Administrative Consultant Services LLC, a health care consulting firm based in Shawnee, OK.

In addition to the Hospital Compare site, consumers can log onto a variety of national websites that publish data on hospitals' quality of care, patient safety, and patient satisfaction, with more likely to come. In addition, many states have their own hospital rating sites, and many hospitals are posting quality data on their own websites along with a comparison to state or national averages.

Consumers are beginning to pay more attention to publicly reported data when they make health care choices, but that's not the only reason hospitals should focus on quality improvement, Cunningham says.

Health care reform legislation mandates that by 2012, CMS establish a value-based purchasing program in Medicare for hospitals and develop plans for implementing similar programs for skilled nursing facilities, home health agencies, and ambulatory surgery centers, Hale says.

"CMS has been moving in the direction of pay for performance for several years. The agency intends to no longer be a passive payer but to be an active purchaser of high-quality care and to make health care data transparent to the public," she says.

For reimbursement under value-based purchasing, hospitals will have to do more than just report. They will have to demonstrate performance on a set of specific metrics. Those with the highest levels of performance will be the "winners" in the new system, Scott says.

CMS is requiring hospitals to report on 46 quality measures in 2011 and has an additional 69 measures under consideration for 2012, including emergency department throughput measures, cardiac surgery measures, and nursing-sensitive measures, Hale says.

Already, CMS is limiting reimbursement for certain hospital-acquired conditions and has announced that it will penalize hospitals when patients with heart failure, heart attack, and pneumonia have high readmission rates.

Commercial insurers also are beginning to look at quality and to consider pay-for-performance initiatives, Scott says.

Many commercial insurers already have programs in place to give hospitals incentives for setting up action plans to improve and report complications, such as urinary tract infections or MRSA, she point out.

"As CMS moves toward value-based purchasing and commercial insurers follow suit, these data are going to have an effect on our reimbursement as well," she adds.

The health care reform legislation gives the Department of Health and Human Resources a lot of latitude in determining the final details, Scott points out.

Case managers have a huge impact on publicly reported data, Cunningham points out.

"We don't know exactly how public reporting is going to be expanded as health care reform rolls out, but it's important that we make sure everything in the patient record is complete and documented correctly," she says.

One thing health care reform definitely will do is reduce reimbursement, Studer says.

"The only way hospitals can be successful when they get less money but more volume is to get rid of wasted steps and eliminate errors," he says.

One indication of what is in the future for hospitals is what CMS is doing with hospital-acquired conditions and never events, Studer adds.

"These are incidents can be prevented, and the fact that CMS is limiting reimbursement when these occur is a first step in basing reimbursement on quality," he says.

Case managers should make sure all documentation is complete so the data present an accurate picture of patient outcomes, Scott says.

For instance, mortality rates are sometimes inaccurate because the physician documentation doesn't include diagnostic technology that supports the severity of illness of their patients, Hale adds.

"Complete documentation is required for accurate coding of patients' acute and co-morbid conditions, which are used in risk adjustment of complications and mortality," she adds.

If documentation integrity is part of their role, case managers should make sure that physician documentation reflects how sick the patient is.

"When patients are sicker, complications and readmissions are more likely and they are placed in a higher-weighted DRG. Reimbursement is always important, but publicly reported data are equally important because they reflect the quality of care patients receive," she says.

The additional emphasis on documentation integrity and quality improvement has the potential for overloading already busy case managers, Hale says.

"All of the new documentation and data-gathering initiatives tend to become the responsibility of case managers, but if they still have the same high caseloads, it will be nearly impossible for them to address all the issues," Hale says.

If case managers are in charge of documentation integrity and core measures in addition to their other duties, it's important for case management directors to make sure they have adequate staffing, Cunningham says.

"Pressure to improve documentation of publicly reported data is going to be increasing in the future, and often, this job falls to case managers. Hospitals don't want to be in a position where case managers are so overloaded with responsibilities that they have to choose whether to perform care coordination, utilization management, or documentation. Case management departments must be adequately staffed," she says.

Case managers' jobs will become easier if the people who are responsible for certain things are held accountable when they don't happen, Studer says.

For instance, case managers typically are responsible for length of stay, but if patients fall or develop infections, the length of stay is likely to increase, through no fault of the case manager.

"The biggest issue in improving scores on publicly reported data is lack of accountability. Typically, the manager of a hospital unit isn't evaluated for reducing falls and infections. If the people on the frontline are held accountable for publicly reported data, the case manager's role will become easier and the hospital's scores will improve," he says.

Case management directors should make sure that hospital executives know what the case management job entails and that they hold people accountable for what they are supposed to do when it comes to the quality improvement metrics the case managers are working to achieve, he says.

"It's not that case managers don't know what to do or how to do it. The problem is the execution. If case managers are told to achieve certain outcomes but the manager of the unit isn't evaluated for the same outcomes, the process doesn't work," he says.

[For more information, contact: Deborah Hale, president, Administrative Consultant Services LLC, e-mail:; Beverly Cunningham, RN, MS, vice president, clinical performance improvement, Medical City Dallas Hospital, e-mail; Quint Studer, CEO, Studer Group, e-mail:; Carolyn Scott, RN, MEd, MHA, vice president of performance improvement and quality, Premier, e-mail:]