The Dilemma of Healthcare: More Quality with Less

1
The Dilemma of Healthcare More Quality with
Less?!

• HFMA State Meeting
• June 2008
• Joy King, RHIA, CCS

2
Wrong E-mail Address

• My Dearest Wife,
• Just got checked in. A lot of turbulence during
  the trip! Looking forward to your arrival
  tomorrow.
• Signed,
• Your loving husband
• P.S. It sure is hot down here!
  

3
Top 10 Compliance Challenges

• RACs
• MS-DRGs
• Quality
• POA
• Data Mining
• Special Certification Supplemental Payments,
  e.g. GME, Outliers, etc.
• Medicaid Compliance
• Stark Self-Referral Ban
• Clinical Trial Billing
• Board Involvement

4
RACs Demonstration Project

• IP OP Incorrectly coded 131 m
• Excisional Debridement
• Respiratory Failure
• Wrong units billed
• Claims w/ single secondary dx (CC)
• DRG 72 hour payment window
• Medically unnecessary services 120 m
• 1-Day stays, especially through ED
• IRF
• No/Insufficient Documentation 30 m
• Other Reasons 50 m

5
RACs Potential New Areas

• MS-DRGs
• POA Indicators
• Readmissions
• LTCH Admissions

6
RACs Provider Implications

• Timely interdepartmental communication critical
• Detailed records of RAC requests, MR release,
  reimbursement activity, time frames
• Appeal processvery labor intensive, expensive
  and lengthycan take up to 2 yearsshould be
  based on cases involved to justify expense
• Review of operations
• Root cause analysis of valid takebacks
• Additional FTEs to handle volume of requests
• Involvement of clinical, financial legal
  expertise

7

• REIMBURSEMENT CHALLENGES

8
Final Rule FY 2008 MS-DRGs

• 2-year transition to coincide w/ transition to
  cost-based relative weights
• 1st year, r.w. a blend of 50 current DRG and 50
  MS-DRG r.w.
• 2/3 cost-based/ 1/3 charge-based r.w.
• FY 2009, 100 cost-based, 100 MS-DRG relative
  weights

9
Pneumonia MS-DRGsFY 09

• Simple Pneumonia (DRG 89, r.w. 1.0376)
• 193 w/ MCC 1.2505 1.4303 7,867
• 194 w/ CC 1.0235 1.0041 5,523
• 192 w/o CC 0.8398 0.7301 4,016
• Complex Pneumonia (DRG 79, r.w. 1.6268)
• 177 w/ MCC 1.8444 2.0391 11,215
• 178 w/ CC 1.5636 1.4979 8,238
• 179 w/o CC 1.2754 1.0409 5,725

10
Post-Acute Transfer PolicyProposed FY 2009

• FY 2007, 190 DRGs subject to policy
• FY 2008, 273 of 745 DRGs subject to policy (see
  Table 5 of Final Rule)
• If one DRG meets criteria, all severity levels of
  that DRG are subject to policy
• Change to transfer to HH policy extend the 3-day
  window to 7 days. If HH not related to IP
  admission, condition code 42, if related, use
  condition code 43 along w/ d/c status code 06

11
Impact on CMI

• Off-setting adjustment to allow for increases in
  Case Mix that are due to improved documentation
  coding, rather than real case mix changes
• 1st year, -1.2--reduced to 0.6
• 2nd year, -1.8--reduced to 0.9
• Cumulative0.6 0.9 -1.5
• Adjustment for 2010 of -1.8 will be adjusted
  based on data

12
Case Mix IndexWhy Should MDs Care?

• Low CMI low severity
• Low CMI impression of low quality
• Low quality high cost contract loss patient
  loss
• High CMI high expected cost LOS
• Being used in credentialing/re-credentialing
  process
• P4Pwhich MDs bring Quality (core measures)
  and/or Value (Quality/Cost) to your patients
  your healthcare system?

13
Impact on Severity/Reimbursement

• Patient admitted w/ dysphagia slurred speech.
  HP noted patient also has renal insufficiency
• PDx CVA
• Secondary Dx Renal Insufficiency
• MS DRG 66 CVA w/o CC/MCC r.w. 0.8426 4,634
• If MD documents Stage 4 CKD
• MS DRG 65 CVA w/ CC r.w. 1.1748 6,461
• 1,827 additional reimbursement

14
Impact on Severity/Reimbursement

• Adm for COPD exacerbation w/ acute bronchitis.
  Stools occult EGD confirmed gastritis.
• PDX COPD exacerbation
• Secondary Dx Gastritis
• MS DRG 192 COPD w/o CC/MCC r.w. 0.7239 3981
• Secondary Dx Gastritis, GI bleed
• MS DRG 191 COPD w/ CC r.w. 0.9734 5354 (1,373)
• Secondary Dx GI bleed due to gastritis
• MS DRG 190 COPD w/ MCC r.w. 1.3004 7152 (3,171)

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Analyze Financial Impact

• Need for concurrent documentation personnel
• Potential need for additional coders
• Increased software service costs
• Training costs
• Less markup for ancillary charges
• Decreased productivity
• Impact on DNFB, AR days
• Potential decreased reimbursement w/o effective
  CDIP program

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Quality of Care

• Consumers demand information quality
• Move toward positive outcomes and evidence-based
  medicine
• Scorecards used by consumers to make choices
  about providers

17
Quality of Care

• Dominant Theme in Payment Compliance
• There is a quality chasm between healthcare
  entities which operate as silos and the needs of
  patients w/ chronic conditions. Factors
  contributing to patient-focused shift include
  consumerism and P4P. Quality Measures utilize
  evidence-based medicine approach to help level
  the playing field among providers give
  consumers consistently measures results. (IOM,
  2001)

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Quality of Care

• gt 90 million Americans suffer from chronic
  illnesses
• gt75 of the 1.4 trillion per year medical costs
  according to the CDC
• Studies show 60 of diabetic patients did not
  take their ACE inhibitors or ARBs as prescribed
• 48 of CAD patients did not comply w/ their
  statin meds.

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Patient Safety

• One of the most important initiatives in the last
  50 years
• Everyone involved w/ patient care shares
  responsibility
• A new way to look at quality

20
Safety Quality

• Thomson Healthcare Study names top 100 hospitals
  on Patient Safety
• Measured 8 patient safety measures for 2001
  2005 Medicare patients
• Measures on risk-adjusted mortality
  complications, core measure scores,
  severity-adjusted LOS, expense per adjusted d/c,
  profit, and cash-to-debt ratio
• If all hospitals performed at level of the top
  100, it would have saved 253 million and 7,914
  lives during that time period

21
Safety Quality

• HealthGrades 4th Annual Patient Safety Report
• Safety incidents increased to 3 from 2003 2005
• gt40 million Medicare hospital records showed 1.16
  m preventable incidents at an excess cost of 8.6
  billion.
• Highest-performing hospitals had 40 lower rate
  of medical errors
• 2,200 hospital deaths would be avoided each year
  if lowest-performing hospitals would catch up w/
  top performers on quality measures

22
Quality of Care

• VBP to link hospital payments to performance on
  quality measures
• Premier Hospital Quality Incentive Demonstration
  Project
• Reporting Hospital Quality Data for Annual
  Payment Update (RHQDAPU)
• Leapfrog Groups 3 Leapsstructural measures

23
Quality Measures Examples--IP

• Heart Failure
• Assessment of heart function done?
• ACE inhibitor given?
• Pneumonia
• Initial antibiotic timing? Revised from within 4
  hrs to 6 hours of arrival (proposed rule)
• Pneumococcal vaccine given?

24
Quality Measures

• IPPS Final Rule for FY 2008
• 6 additional measures (27 total)
• HCAHPS Survey (patient satisfaction data)
• VTE prophylaxis ordered for surgery patients
• VTE prophylaxis w/in 24 hrs pre/post surgery
• Prophylactic abx for surgical patients
• AMI 30-day mortality (based on claims data)
• Heart Failure 30-day mortality (based on claims)
• 4 measures for FY 2009 already approved
• 7 measures approved for OP reimbursemt

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Quality Measures for FY 2009

• 30-day mortality Pneumonia (claims data)
• Cardiac surgery patients w/ controlled 6 am
  postop serum glucose
• Surgery patients w/ appropriate hair removal
• Data for these start w/ 1st Qtr CY 2008
  discharges
• Total measures for FY 2009 would be 30

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Surgical Care Improvement Project

• Elevated BS decreases WBC functionparalyzes
  cells so they cant fight infection
• WBC may be OK, but cells dont function properly
• BS gt 126 can increase risk, regardless of whether
  patient is diabetic
• Postop glucose gt 220 in General Surgery increased
  infection rate by 6 times

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Proposed Quality Measures for FY 2010

• SCIP measure CVS patients on beta blocker prior
  to arrival who received one during perioperative
  period
• 4 nursing measures 1) failure to rescue, 2)
  pressure ulcer prevalence incidence by
  severity, 3) patient falls prevention, 4) patient
  falls w/ injury
• 3 readmission measures 30-day readmission for
  AMI, heart failure, pneumonia (claims data)

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Proposed Quality Measures for FY 2010

• 6 VTE measures
• 5 Stroke measures
• 9 AHRQ Patient Safety (PSI) Inpatient Quality
  Indicators (IQI) measures claims-based outcome
  measures proposing submission of all-payer
  claims data
• 15 Cardiac Surgery measures proposing to accept
  data from Cardiac Surgery Clinical Data
  Registry43 additional measures

29
Proposed Quality Measures

• FY 2009 30 measures
• FY 2010 72 measures, retire 1 measure
• FY 2011 table of 59 measures and 4 measure sets
  from which to select future quality measures for
  RHQDAPU program
• Include increased outcome, efficiency
  experience of care measures
• Expand scope of services to which applied
• Seek alternative sources of data

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Public Reporting of Infections

• 20 states w/ laws requiring public reporting
• 2 states require public reporting of infection
  info, but not rates (CA, RI)
• 2 states require confidential reporting of
  infection rates (NE, NV)
• 1 state has voluntary law requiring public
  reporting infection rates (AR)
• All other states except WY, AZ, MT, ND have
  considered laws, but have not yet passed
  legislation

31

• Jim Bullock had surgery to repair and place
  internal hardware on his heel broken while doing
  roof repair on his house. The surgical site and
  hardware placed in his heel were infected with
  hospital-acquired infections that ended up almost
  costing him the foot. According to Jim, "I picked
  up 6 different infections (Super-bug Staph
  Strep, E-Coli, yeast and a couple others) between
  the hospital and doctor office visits during the
  course of 5 surgeries." His treatments to fight
  the infections included being placed on a VAC
  (Vacuum Assisted Closure) machine, 120 day IV
  treatment with a PICC line IV treatment. It took
  multiple surgeries to finally clear up the
  infection, and today he still walks with a limp.
• Read more _at_ Share your Hospital Infection Story.
• Have you or your loved one contracted a hospital
  infection when you went in for surgery or other
  illness? Over 1000 people have shared their
  hospital infection experiences. We would like to
  hear your story. Read their stories

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Value-Based Purchasing (P4P)

• Reimbursement based on Quality of Care (Quality
  Measures Hospital-Acquired Conditions)
• Proposed Rule indicates potential application to
  OP Depts, SNFs, ESRD facilities MD practices
• Proposed modification of Medicare secondary payer
  policy provider that failed to prevent a HAC
  would pay for all or part of necessary followup
  care in a second setting
• Payers starting to refuse payment for NQFs
  never events

33
Hospital-Acquired Conditions

• 98,000 Americans die each year due to medical
  errorscosts are 17 - 29 billion
• In 2000, CDC estimated hospital-acquired
  infections added nearly 5 b to US healthcare
  costs
• A 2007 study indicated that 1.7 m hospital
  acquired infections occurred in 2002 resulting
  in 99,000 deaths
• 2007 Leapfrog Group survey of 1,256 hospitals
  found 87 do not follow prevention guidelines to
  prevent most common infections

34
Value-Based Purchasing (P4P)

• Approved hospital-acquired conditions
• Catheter-associated UTI (44,043/stay)
• Pressure (decubitus) ulcers (Stage 3 or 4)
  (43,180/stay)
• (Object left in during surgery (63,631/stay)
• Air embolism (71,636/stay)
• Blood incompatibility (50,455/stay)
• Vascular catheter-associated infections
  (103,027/stay)
• Mediastinitis following CABG (299,237/stay)
• Falls, fractures, intracranial injuries, crushing
  injury, burns (33,894/stay)

35
Value-Based Purchasing (P4P)

• In Proposed Rule for FY 2009
• Staph aureus septicemia (84,976/stay)
• Vent-associated pneumonia (new code 997.31)
  (135,795/stay)
• DVT and PE (50,937/stay)
• C. difficile associated diseases (CDAD)
  (59,153)
• Surgical Site Infection for Total Knee, Lap
  Gastric Bypass Gastroenterostomy,
  Ligation/Stripping Varicose Veins (63,000
  180,000//stay)
• Legionnaires Disease (86,014/stay)
• Diabetic Ketoacidosis, Nonketotic Hyperosmolar
  Coma, Diabetic coma, Hypoglycemic Coma (35,000
  - 45,000/stay)
• Iatrogenic Pneumothorax (75,089/stay)
• Delirium (23,290/stay)
• If approved, effective 10/1/08, along with the
  original 8 conditions

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Evidence-Based Guidelines

• Surgical Site Infections prophylactic abx, using
  clippers rather than razors, tight control of
  postop glucose
• Delirium reducing certain meds, reorienting
  patient, assuring sensory input sleep, avoid
  malnutrition dehydration
• VAP educating staff, hand washing, gowns
  gloves, proper patient positioning, elevating
  head of bed, changing vent tubing, sterilizing
  reusable equipment, monitor sedation daily, etc

37
Hospital-Acquired Conditions

• 2007 Leapfrog Group survey of 1,256 hospitals
  found 87 do not follow prevention guidelines to
  prevent most common infections
• Can hospitals afford NOT to follow the prevention
  guidelines??

38
Impact on ReimbursementFY 09

• Patient admitted w/ Pneumonia due to Candidiasis
• Secondary Dx Decubitus ulcer Stage III (MCC),
  COPD, CHF, A fib, Anemia
• MS DRG 177 Resp Inf w/ MCC r.w. 2.0391
  11,215
• Decubitus not POA, case regrouped to
• MS DRG 179 Resp inf w/o MCC/CC r.w. 1.0409
• 5,725
• 5,490 difference average cost to tx decubitus
  of 43,180

39
Liability Implications

• Were prevention guidelines followed?
• Public reporting of infections, hospital-acquired
  conditions (HACs)
• MD-specific data on HACs
• Increase in lawsuits against hospitals/MDs
• Some hospital-acquired conditions or infections
  are expected
• How can hospitals/MDs defend against
  hospital-acquired conditions?

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• EVALUATING QUALITY

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Uses of POA Indicator

• Analysis of Factors to prevent HACs
• Calculate incidence of HACs by hospital
• Monitoring Complication Rates
• Quality Reporting

42
Data Quality

• Data integrity of POA indicators is VERY
  important
• Impact on public report cards--once the data is
  out there for public review, it cant be taken
  back
• Impact on reimbursementValue-Based Purchasing
  Program

43
Using POA Indicator to Monitor Complications

• In-hospital complications may indicate problems
  w/ quality of care
• Complications are inevitable
• Hospitals w/ higher complication rates are more
  likely to have quality problems
• Complications are more likely in sicker patients
• POA identifies possible complications (from dx
  that occur after admission)
• POA helps assess severity of illness on admission
  (based on only dx POA)

44
Post-Admission Patient Complications (PPCs)

• 12,988 ICD-9-CM dx code were reviewed 1,534
  identified as PPC dx
• Each PPC dx assigned to 1 of 64 PPC Groups
• Dx assigned to a group were similar in clinical
  presentation and clinical impact
• Risk adjustment is essentialbased on reason for
  adm, SOI, comorbid conditions
• PPCs developed by 3M

45
PPC Reports Examples

• Rates of pneumonia among GI surgery groups
• Overall rates of major PPCs
• Major PPCs by service lines
• Major PPCs by General Surgery service lines

46
Use of PPCs

• Assist hospitals in identifying possible quality
  problems
• Allow health systems, govt agencies, etc. to
  monitor hospital performance
• A possible basis for adjusting hospital
  reimbursement under P4P

47
Use of POA for Quality Reporting

• Venous Thromboembolism (VTE) included in new
  quality measures for FY 2009
• Venous thrombosis is formation of a clot in the
  veinsan embolism occurs when the clot travels to
  a different site of the body through the blood
  vessels
• The clot can travel to the lungs block a
  pulmonary artery, resulting in a pulmonary
  embolism (PE)

48
Use of POA for Quality Reporting

• PE resulting from DVT is the most common cause of
  preventable hospital deaths
• Over 200,000 new cases of VTE occur annually
• 30 die within 3 days
• 20 suffer sudden death due to PE
• 30 develop recurrent VTE within 10 years
• Average charges per stay 50,937

49
Use of POA for Quality Reporting

• Solucient developed complication methodology w/
  following criteria
• VTE must be secondary dx
• VTE, embolism, thrombophlebitis cannot be PDx
• Interruption of vena cava not performed
• Record review of hospital data to identify
  cases POA
• Clinical analysis of non-POA VTE cases

50
Use of POA for Quality Reporting

• Risks communicated to MDs
• Appropriate prophylaxis standards developed
• Re-review of non-POA VTE cases using root cause
  analysis
• Coding guideline created for VTE to differentiate
  current VTE (453.40-453.42) vs. hx of VTE
  (V12.51)
• Coding Clinic review Coder education

51
Use of POA for Quality Reporting

• Estimates vary about the impact of POA indicators
  in assessing quality
• One Canadian study on CABG patients estimates
  that 13-35 of identified complications were POA
• POA has high impact on public measures,
  including
• AHRQ PS Indicators HAC measures
• VBP program SCIP measures

52
Some Quality Concerns

• ED triage, ED wait times
• Bed assignment/utilization
• LOS
• Medication administration
• Site marking for surgical other procedures
• Patient falls
• Patient restraints

53
Quality Analysis

• Postop Days for Open Heart Surgery
• Diagram of entire process
• Increased LOS due to A fib, lack of consistent
  ambulation
• Correct the problems w/ better tx A fib
  consistent ambulation
• Reduction of 53 to 22 that fell outside LOS
  benchmark for the procedure--400,000 savings
• Reduction of blood borne infections--450,000
  savings
• Supplies, Meds, gt ICU beds available, decreased
  LOS, labor

54
Quality Management Systems
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Anything Less Not Acceptable

• Even with 99.977 accuracy (Five Sigma)
• 70,000 patients/year w/ surgery performed on
  wrong part of the body
• 5000 adverse surgical cases per week
• 4,000 families would leave w/ the wrong baby per
  year
• Six Sigma 99.999 accuracy or 3.4 errors/million

56
Process Issues

• Integration of Case Management, Quality
  Management, UR, Coding/Reimbursement
• Medical Staff Infrastructure
• Using TQM, Six Sigma, Rapid Cycle Improvement
  Process activities to improve clinical
  processes/quality
• Documentation--Revised Forms

57

• EFFECTIVE MANAGEMENT OF RESOURCES

58
Resource Management

• Most costly resource to manage
• An MD w/ a pen in his hand

59
Resource Management

• Move from educating clinicians and staff about
  DRGs to facilitation of changes in patient care
  practices
• Multi-disciplinary approach
• Look at patterns to improve clinical outcomes,
  patient satisfaction, and cost of providing care

60
Data Mining

• This process is data driven
• MDs are key to modifying clinical processes--they
  respond to data
• Medical record information is pivotal in patient
  care, accreditation surveys, hospital stats and
  finances
• Crucial to collect, store, and process health
  info and apply evidence-based knowledge in real
  time

61
Data Mining

• Look for patterns of care resource use from
  highest to lowest charges/case
• One hospital looking at top 6 DRGs
• CMI was tracking upward overall about 4.7 4.8
• However, analyzing data on paid claims showed
  hospital is - 193,743 since 10/1/07

62
Data Mining
63
Data Mining
64
Data Mining

• Data on Simple Pneumonia MS-DRGsLoss of 38,540
  so far
• Several patients who presented w/ AMS and had CTs
  ordered in ED
• 2 patients had heart cath performed during
  Pneumonia stay
• 2 patients in lowest severity level had ICU days
  billed
• 1300-1800 billed per case on Lab Chem

65

• DEVELOP SOLUTIONS

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Strategic Plan

• Multidisciplinary Team
• Educational Efforts
• Clinical Documentation Improvement Program
• Process Issues (monitoring/feedback)
• Financial Impact
• Administrative Support critical
• Medical Staff buy-in critical

67
CDI Program Addresses Quality Reimbursement
Issues

• Potential adverse effects of incomplete data
• Public perception of your hospital
• Medicare Quality Indicators
• P4P Implications
• Performance on Report Cards

68
Documentation Improvement Strategies

• Streamline forms
• Revise standing orders/Cath Lab, GI Lab forms,
  ED, Nursing Admission Assessment, Wound Care
  forms to include documentation specificity needed
  for both severity POA
• Perform documentation audits w/ scorecards
• Develop minimum documentation standards necessary
  to maintain medical staff privileges
• Incorporate poor documentation ratings into
  credentialing process

69
Education on Documentation

• Start w/ Major Players
• Cardiology, CV Surgery
• ED physicians
• Hospitalists
• Orthopedic Surgeons
• MD extenders (NPs, PAs, etc)
• NOTE Board of Trustees also needs to be well
  aware of financial/liability implications

70
MD Education

• If you consumed a resource to manage a
  Complication/Comorbidity (CC), DOCUMENT it
• CCs impact Severity/Complexity Scorecards
  support E/M codes billed
• CCs impact P4P
• CCs provide data for true severity of
  illnessimproves severity-adjusted quality
  outcomes, mortality rates, costs, LOS, etc.
• CCs provide medical necessity for
  tests/admissions
• CCs impact hospitals blended rate for DRGs

71
Crew Resource Management (CRM) Training

• Aviation Healthcare
• Healthcare is a decade or more behind other
  high-risk industries in its attention to ensure
  basic safety.
• establish team training programs for personnel
  in critical care areas (e.g. ED, ICU, OR) using
  proven methods such as Crew Resource Management
  training techniques employed in aviation. (IOM
  2000)

72
Crew Resource Management (CRM) Training

• United Flight 173led to institution of CRM
  training in 1980used throughout the world
• also known as Cockpit Resource Management
• Eastern Flight 401

73
Crew Resource Management (CRM) Training

• Based on NASA research into causes of transport
  accidents
• Human error failures in communication,
  decision-making, leadership
• Reduce pilot error through better use of human
  resources on the flight deck (crew)
• Team training approach being applied to patient
  safety in healthcare areas such as ICU, OR, LD

74
Crew Resource Management (CRM) Training

• 3 Elements of Human Effectiveness
• Safety
• Efficiency
• Morale

75
Crew Resource Management (CRM) Training

• Situational Awareness
• (88 of Human Error Accidents)
• Perception of elements in environment
• Comprehension of their meaning
• Projection of the near future
• Should lead to a decision performance of actions

76

• BEWARE ATTACK PHYSICIAN

77
Crew Resource Management (CRM) Training

• Studies on Practitioner Intimidation in the
  Workplace
• Intimidation pervasive in the workplacemore
  frequently, but not limited to, MDs
• Impact on Safety
• 49 said intimidation altered their handling of
  order clarifications
• 75 used avoidance techniques to clarify orders
• 31 allowed MD to give med despite concerns
• 49 felt pressure to accept, dispense, or
  administer a medication despite concerns

78
Crew Resource Management (CRM) Training

• Normalization of errorstrategies to manage error
• Cognitive errors slips
• Deleterious effects of stressors
• Non-punitive approach
• Team-Building Training
• Educates people on cognitive errors and how
  stressors like fatigue, work overload, etc.
  contribute to errors

79
Crew Resource Management (CRM)
80
CRM Success Story 2008

• Nebraska Medical Center
• Implemented sustained CRM
• OR, ER, LD, Cardiac Cath Lab
• Housewide (all units)
• CMO-CEO-CNO-Key Leaders-Board
• Training/Dealing w/ non-compliance
• AHRQ Patient Safety Culture Survey

81

• 80 of medical error is system derived
• Every system is perfectly designed to achieve
  the results it gets.
• Donald Berwick
• Institute for Healthcare Improvement
• Identify the human factors
• Fix the system

82
Questions?

• Contact Information
• Joy King Consulting, LLC
• jkinginc_at_charter.net
• [phone]