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The Centers for Medicare & Medicaid Services issued its final rule in August to update the Medicare payment policies for hospitals under the Inpatient Prospective Payment System and the Long-Term Care Hospital Prospective Payment System for fiscal year 2020. Changes were made to the rural hospital wage index, all-cause readmissions, and interoperability.
Antimicrobial resistance represents a serious risk for Medicare beneficiaries and for the public overall. CMS is finalizing an alternative new technology add-on payment pathway for antimicrobial products designated by the FDA as Qualified Infectious Disease Products (QIDPs). Under this policy, a QIDP will be considered new and will not need to demonstrate that it meets the substantial clinical improvement criterion; it will only need to meet the cost criterion. CMS also is increasing the new technology add-on payment to 75% for an antimicrobial designated as a QIDP.
To provide patients with better value and results, CMS has issued a final rule regarding the inpatient-only list of surgical procedures. This list includes procedures that typically are only provided in the inpatient setting and not paid under the Outpatient Prospective Payment System. Criteria for removing procedure from the inpatient-only list includes determining that the procedure is performed in numerous hospitals on an outpatient basis. For example, total knee arthroplasty moved from the list starting in 2018. Total hip arthroplasty is expected to be removed from the list in 2020.
As hospitals grapple with ever-changing utilization review (UR) guidelines from CMS and consolidate with other facilities, many are centralizing their UR operations. Under a centralized model, an offsite UR nurse or case manager is alerted when a new patient is admitted and sees all the documentation necessary to determine whether the medical record supports the patient’s status. Centralized UR establishes a standardized common process across facilities, which is a key benefit for multihospital health systems.
Hospitals and other healthcare organizations can improve patient navigation, quality, and efficiency by creating goals and a plan through data collection and a dashboard. Health systems are successfully using analytics to engage with electronic medical records and in creating roadmaps for patients. Electronic data collection helps health systems predict roadblocks more accurately. It also helps facilitate faster transitions.
Case managers in the ED can perform more than utilization reviews. In a newer model for their role, case managers can help put ED patients in touch with resources, helping them avoid readmissions and improve outcomes. Cleveland Clinic realized that with the changing landscape of healthcare, there is a way care management can put patients in touch with the community services they need to stay out of the hospital and ED. Case managers based in the ED can help patients with whatever they will need when they are well enough to leave.
No matter what size a hospital and case management department are, there are difficulties in finding the right level of staffing. There is no one-size-fits-all approach because each hospital has its own expectations and sensitive situations in which case management might be needed. The goal should be to have case managers work to the full capacity of their skills and abilities.
Financial Disclosure: Author Melinda Young, Author Jeanie Davis, Editor Jill Drachenberg, Editor Jonathan Springston, Editorial Group Manager Leslie Coplin, and Nurse Planner Toni Cesta, PhD, RN, FAAN, report no consultant, stockholder, speaker’s bureau, research, or other financial relationships with companies having ties to this field of study.
