Case Management Insider

The Role of Case Management in an Era of Healthcare Reform — Part 3

By Toni Cesta, PhD, RN, FAAN
Senior Vice President
Lutheran Medical Center
Brooklyn, NY

In the last two issues, we discussed some of the topics related to health care reform that are of greatest interest to case management professionals. This month's Case Management Insider continues this discussion with a look at patient satisfaction, mortality measures, and the new efficiency of care measure.

The HCAHPS (Hospital Consumer Assessment of Healthcare Providers and Systems) Survey

HCAHPS is classified as an "outcome" measure for purposes of measurement under value-based purchasing. Since July 2007, hospitals subject to the Inpatient Prospective Payment System (IPPS) annual payment update provisions must collect and submit HCAHPS data in order to receive their full IPPS annual payment update. IPPS hospitals that fail to publicly report the required quality measures, which include the HCAHPS survey, may receive an annual payment update that is reduced by 2.0 percentage points. The Patient Protection and Affordable Care Act of 2010 includes HCAHPS among the measures to be used to calculate value-based incentive payments in the Hospital Value-based Purchasing Program, beginning with discharges in October 2012.

HCAHPS is important because it is the first national, standardized, publicly reported survey of patients' perspectives of hospital care. It is a survey instrument and data collection methodology for measuring patients' perceptions of their hospital experience. While many hospitals have collected information on patient satisfaction for their own internal use, until HCAHPS there was no national standard for collecting and publicly reporting information about patient experience of care that allowed valid comparisons to be made across hospitals locally, regionally and nationally.

HCAHPS Content and Administration

The HCAHPS survey asks discharged patients 27 questions about their recent hospital stay. The survey contains 18 core questions about critical aspects of patients' hospital experiences (communication with nurses and doctors, the responsiveness of hospital staff, the cleanliness and quietness of the hospital environment, pain management, communication about medicines, discharge information, overall rating of hospital, and would they recommend the hospital). The survey also includes four items to direct patients to relevant questions, three items to adjust for the mix of patients across hospitals, and two items that support congressionally mandated reports.

The HCAHPS survey is administered to a random sample of adult patients across medical conditions between 48 hours and six weeks after discharge; the survey is not restricted to Medicare beneficiaries. Hospitals may either use an approved survey vendor or collect their own HCAHPS data (if approved by CMS to do so). HCAHPS can be implemented in four different survey modes: mail, telephone, mail with telephone follow-up, or active interactive voice recognition (IVR).

HCAHPS and Case Managers

Hospitals can use the HCAHPS survey alone, or include additional questions after the core HCAHPS items. Hospitals must survey patients throughout each month of the year. Case management departments should take a look at the questions that their hospitals are using and be sure that they reflect the roles and functions of their case managers and social workers. Some hospitals may choose to add additional questions that more greatly reflect the roles of the social workers and case managers but do so with the understanding that there will be no national database comparison of the questions. It is important that case management professionals are not held accountable for questions that are not directly related to their work.

Mortality Measures

Mortality measures are another example of the CMS "outcome" measures. The three mortality models estimate hospital-specific, risk-standardized, all-cause 30-day mortality rates for patients hospitalized with a principal diagnosis of heart attack, heart failure, and pneumonia. These are the only diagnoses identified by CMS for this measure at this time. All-cause mortality is defined as death from any cause within 30 days of the "index admission" date, regardless of whether the patient dies while still in the hospital or after discharge. An index admission is the admission with a principal diagnosis of a specified condition that meets the inclusion and exclusion criteria for the measure.

For each condition, the risk-standardized ("adjusted" or "risk-adjusted") hospital mortality rate can be used to compare performance across hospitals. The mortality measures for heart attack, heart failure, and pneumonia have been endorsed by the National Quality Forum (NQF), the non-profit public-private partnership organization that endorses national healthcare performance measures.

The CMS mortality measures assess all-cause mortality; that is, they consider deaths for all reasons, not just due to the underlying principal diagnosis. There are several reasons for this choice of outcome. First, from the patient perspective, death from any cause is the key outcome. Attributing mortality to a cause other than heart disease may provide little solace to patients and their families. Second, it is often hard to exclude quality issues and accountability based on the documented cause of death. For example, a patient with heart failure who develops a hospital-acquired infection may ultimately die of sepsis and multi-organ failure. It would be inappropriate to consider the death as unrelated to the care the patient received for heart failure. Another patient might have a complication leading to renal failure, resulting in death that is related to that event and yet quality of care could have reduced the risk of the complication. It is true that this approach will include some patients whose event is truly unrelated to their care. A patient, for example, could be involved in a motor vehicle accident after hospital discharge and the institution could reasonably claim to have had no role in the event. Nevertheless, events completely unrelated to the admission are expected to be uncommon and should not be clustered unevenly among hospitals.

Inclusion and Exclusion Criteria for Acute MI and Heart Failure

The CMS 30-day Mortality Measures for AMI and HF include fee-for-service Medicare enrollees with a principal discharge diagnosis of AMI (for AMI calculations) or HF (for HF calculations) at least 65 years of age at the time of their admission who were enrolled in fee-for-service Medicare during their admission and for at least one year prior to their admission.

Exclusion from this measure is based on the following criteria:

  • less than 65 years old;
  • cases with a length of stay of ≤ 1 day discharged alive (and not discharged against medical advice or transfer);
  • AMI or HF; Cases with a total length of stay exceeding one year;
  • patients admitted to your hospital who were transferred in;
  • AMI admissions for patients who had been previously admitted to your hospital or another hospital and died within.

Case Managers and Mortality Measures

The mortality outcome measure is another example of a measure that may not be directly related to the work of case management professionals but is important to understand. Under value-based purchasing, in federal fiscal year 2014, mortality measures will be used as one of the indicators for payment incentives to hospitals. Case managers and social workers can play a part in assisting patients and families at end of life so that they may select the most appropriate plan of care that meets their needs and capabilities. This may include end-of-life care at home with home hospice, sub-acute or long-term care settings with hospice programs. The destination selected must meet the wishes and capabilities of both the patient and the family and should be clearly articulated and explained to them so that the right decisions can be made.

The New Efficiency of Care Measure — Also Known as Spending per Beneficiary

Of all the measures we have discussed, the efficiency of care measure may have the greatest significance to case managers and social workers. The goal of this measure is to encourage hospitals to be more cost-efficient — looking for a lower number than a higher number in this case. CMS also describes this measure as the resource use measure and describes how this measure will be translated in practice by describing the following elements:

Resource use when combined with quality metrics will help Medicare to:

  • encourage the highest outcomes for the lowest cost;
  • identify the most efficient providers, systems of care, and regions;
  • prevent overuse and inappropriate use of health services;
  • improve the value of Medicare for beneficiaries and taxpayers.

By improving efficiency, the potential exists to reduce the rate of growth of health care costs while improving the value of that care at the same time.

Efficiency Defined

Efficiency is defined as the interaction between the resources used to deliver care and the quality of the care that is delivered. To accomplish the goal of delivering high-quality, lower-cost care requires quality and resource metrics. The baseline period for this measure was between 5/15/10 and 2/14/11. During the baseline period CMS assessed Part A and Part B beneficiary spending during a "per beneficiary" episode.

The most important change is that the "beneficiary episode" will now span from three days prior to a hospital admission through 30 days after discharge. Included in this 30-day period are transfers, readmissions and additional admissions. The measure is adjusted for age and severity of illness.

Because case managers play such an important role in resource management, it is important to understand how CMS will be defining resources. CMS is mainly focused on metrics associated with episodes of care. They define episodes of care as a series of separate but clinically related services delivered over a defined time period. Resources used in episodes of care are defined as the program costs as opposed to the costs that providers incur to deliver the services. They include both the Medicare program and the beneficiary payment.

The Spending per Hospital Patient with Medicare measure shows whether Medicare spends more, less, or about the same per Medicare patient treated in a specific hospital, compared to how much Medicare spends per patient nationally. This measure includes any Medicare Part A and Part B payments made for services provided to a patient during the three days prior to the hospital stay, during the stay, and during the 30 days after discharge from the hospital.

This result is a ratio calculated by dividing the amount Medicare spends per patient for an episode of care initiated at the hospital by the median (or middle) amount Medicare spent per patient nationally.

A result of 1 means that Medicare spends ABOUT THE SAME amount per patient for an episode of care initiated at this hospital as it does per hospital patient nationally.

A result that is more than 1 means that Medicare spends MORE per patient for an episode of care initiated at this hospital than it does per hospital patient nationally.

A result that is less than 1 means that Medicare spends LESS per patient for an episode of care initiated at this hospital than it does per hospital patient nationally.

For this measure lower numbers are better.

CMS "Dry Run" of Imaging Efficiency Measures

The Centers for Medicare & Medicaid Services (CMS) conducted a national "dry run" of reporting data for four Outpatient Imaging Efficiency (OIE) measures included in the Hospital Outpatient Quality Data Reporting Program (HOP QDRP). Throughout the 30-day dry run, which ended on March 18, 2012, hospitals were able to submit questions or comments regarding the Hospital Specific Report.

The four outpatient imaging tests being evaluated include:

  • MRI Lumbar Spine for Low Back Pain
  • Mammography Follow-Up Rates
  • Abdomen CT Use of Contrast Material
  • Thorax CT Use of Contrast Material

Implications for Case Management

Conceptually, this measure has broad implications for case managers and other health care professionals engaged in managing care processes and resource utilization. Consider the scenario of a patient seen in her physician's office two days prior to admission. The physician orders several diagnostic tests for the patient to have done, including a chest X-ray to rule out pneumonia. The patient has the tests and the physician determines that she does have pneumonia. He contacts the patient, who reports that her shortness of breath has worsened and that she has a temperature of 101° F. He directs the patient to go to the hospital's emergency room for evaluation and possible admission.

The patient goes to the emergency room where, in today's health care delivery system, the chest X-ray would probably be repeated. Additional tests already completed prior to arrival to the emergency room would also probably be repeated. After the tests are repeated, the patient is admitted to the hospital, where the pneumonia is treated with intravenous antibiotics. The patient is then discharged home with home care and infusion therapy. The home care agency will then follow the patient for several weeks as she completes her course of IV antibiotics.

In a bundled payment methodology scheme such as CMS is proposing under the new efficiency measure, the tests that the physician ordered from his office, the tests done in the emergency room, the treatment in the hospital, and the home care treatment would all be "bundled" into one payment.

Communication Is Essential

Under a bundled payment system, it will be essential that all interdisciplinary care team members are in communication as the patient transitions throughout the continuum of care. Case managers will play a key role in ensuring that pre-admission tests and results are communicated so that costs can be optimized and test results can be used regardless of the patient's location. Case managers will need to be embedded in the community as well as in the emergency department to make this as seamless as possible. Through electronic data exchange systems, case managers will be able to receive alerts when patients arrive in various locations along the continuum of care. A community-based case manager can alert the ED case manager of a patient and the diagnostic testing and/or treatments initiated in the community can be reviewed so that they are not replicated.

Reducing replication of services serves multiple purposes. It clearly reduces cost. In addition, it reduces patients' exposure to unnecessary radiology testing and other tests that may have long-term negative effects on patients. In addition, reducing testing and other procedures should increase throughput. If the physician obtains testing done out-patient in the prior 24 hours, then diagnosis and treatment can be initiated more quickly,


It is CMS's contention that this efficiency measure will positively impact on both cost and length of stay. It will do this by accomplishing all the goals listed above. Length of stay should be decreased as patients are treated more rapidly. Faster treatment means improved quality of care and less opportunity for adverse events to occur such as falls, medication errors or infections. In addition, if pre-admission and post-discharge costs and interventions are taken into consideration as part of a "package of services," compartmentalization of services is less likely to occur and patients will be less likely to be exposed to unnecessary tests, treatments and procedures. This shift in reimbursement, like other shifts before it, will hopefully result in a system that considers patient events regardless of where they happen across the health care continuum.