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Programs mesh clinical, financial data
It's becoming clearer with each passing day that merely collecting outcomes data without the ready ability to analyze them, including integrating costs, falls woefully short of most outcomes managers' needs. Hence, many providers are beginning to invest in software programs, especially decision support software, that accommodates quick turnarounds of outcomes information.
Take Medical Center East in Birmingham, AL, for example. Clinically adjusted comparative data from HCIA Inc. in Baltimore is imported into Trendstar, a decision support system developed by HBOC in Atlanta, says Paul Graham, director reimbursement and decision support. With the new system, the six case managers in the outcomes management department receive quarterly benchmarking data on their personal computers. "It's like having the information on a Web site. Case managers can tap in and view charts and graphs, drilling down in a specific DRG to payer, physician, and patient level. They can also see how we vary from the local and national market," Graham explains.
Previously, the benchmarking data came in a huge notebook. "The information was great, but it wasn't in a user-friendly format, and it wasn't easily accessible by those who really needed it," says Mary Beth Briscoe, chief financial officer. "With the new decision support software, all that has changed."
MCE's director of case management Suzanne Holland agrees. "Before, the binders were over in finance, and we were in the hospital," she says. "We had to query for the information, and often we didn't even know what to ask for or how to ask for it."
There also wasn't a good opportunity to integrate clinical and financial data, notes Beth Hoffman, decision support manager.
Graham and Holland point out that the real advantage of the system lies not only with its ability to generate detailed instant reports, but also in the synergy it has created between the finance and case management departments. "We have taken responsibility for communicating the financial information, and case management has taken the responsibility for using that information for change," Graham says.
For example, Graham and other members of the decision support department, along with contract management and utilization review, meet weekly with the case managers to discuss reimbursement issues and challenges. (Representatives from social services, home health, and medical records also attend.)
"We've learned to speak each other's language," Graham says. By providing definitions and examples of the following concepts, clinicians quickly see how their decisions affect the hospital's bottom line:
· direct vs. indirect costs;
· fixed vs. variable costs;
· charges vs. costs;
· reimbursement vs. actual collections.
He also explains how capitated rates and fee schedules are figured, as well as payment under the new Medicare provisions. Rather than giving such information in a straight lecture format, he weaves it into a current case scenario, he says.
A representative who negotiates third-party contracts also attends the meetings. "Any time there is an update or new contract, we point it out so clinicians know this patient is on that insurance with a certain rate of reimbursement," he says. "The goal is to help clinicians understand the financial ramifications of care."
Graham also points out that close contact with clinicians has given him cost-effective insights his accounting background didn't provide. "For example, if a particular drug is the most advantageous, yet expensive, I know when I see it's name during a contract negotiation that I may need to carve it out and make provisions for a separate payment," he explains.
Armed with a good working knowledge about reimbursement and cost structures, case managers take that information to their interdisciplinary practice groups. The groups include clinicians from various disciplines who have expertise in the following areas:
· renal care;
· respiratory care;
· cardiovascular surgery;
· cardiovascular medicine;
· obstetrics/post-partum care;
· well-baby nursery;
· newborn intensive care unit;
· wound care.
The purpose of the practice groups is to develop clinical pathways, monitor outcomes, and recommend practice pattern or care delivery changes, Holland explains. Physicians are responding well to the new system, she notes.
"The data stands on its own," she says. "Instead of forcing [benchmarking and best practices] down their throats, we are telling them,'We are not the critical pathway police,' and they are coming to us for help," she says.
For example, when a cardiovascular physician asked to evaluate cost per case, the case manager ran a report that compared the costs of performing an outpatient catheterization in which the patient stayed post-procedure on the nursing unit or in the same-day services area. "We found it saved money using same-day service, and the patient still received the same level of care," she says.
This concept of the most appropriate utilization of service is inherent in any practice pattern change, Holland points out.
[For more information, contact:
· HCIA Inc., 300 E Lombard St., Baltimore, MD 21202. Telephone: (410) 576-9600 or (800) 568-3282.
· HBOC, 301 Perimeter Center North, Atlanta, GA 30346-2403. Telephone: (800) 981-8601.
· Suzanne Holland, Medical Center East, 50 Medical Park E Drive, Birmingham, AL 35235. Telephone: (205) 838-3104.]