Health system designs tool for DRG-specific report
Keep an eye on the big picture
Case managers often are so busy with the immediate demands they face that they can lose sight of what types of information they may be receiving from a population standpoint about high-risk, high-volume, and high-cost services, warns Lisa Zerull, MS, RN, program director at Valley Health System in Winchester, VA.
Zerull says that when she talks to case managers around the country, she finds that many of them are so focused on individual patients during a shift that they miss the big picture. Hospitals are selling themselves short when they fail to have case managers look at patient populations along with ways to improve quality of life, quality of care, or cost reductions, she says.
"My sense is that most acute-care hospitals focus on the day-to-day activities for individual patients and do not take the time to request necessary information in a useful tool to help them in modifying practices and pathways," Zerull says.
To remedy that problem at Valley Health, she worked with the process-design and finance departments to develop a one-page report referred to as a dashboard that includes items such as average length of stay, primary ICD-9 codes, and primary demographics.
In addition, Zerull’s facility developed a list of questions in areas such as length of stay. "It may have been one patient who stayed the whole month, a change in medical procedure, or something else," she says. The three-page question set for case managers helps encourage the case manager for a given population to think critically about what is taking place with that population from one month to the next. (To see sample dashboard with hypothetical data, click here.)
In addition to patient demographics, report cards also are useful for analyzing resource utilization and cost for specific case types, says Toni Cesta, PhD, RN, director of case management at Saint Vincents-Manhattan Hospital in New York City. "The report card outlines the expected cost of a typical patient with that diagnosis and the projected cost as indicated on the clinical guideline or pathway. The organization can then monitor the actual cost against these projected costs."
According to Cesta, when cost is outside the expected (usually by at least two standard deviations), then the data warrant further analysis. The team might identify where the additional dollars are being spent and whether this excess cost is appropriate, she says. If it is found to be appropriate, the benchmark costs may need to be adjusted up, she says. Conversely, if the excess costs are not found to be clinically justified, specific patterns of overuse need to be identified. These may be by product line, by practitioner, or by category such as radiology, pharmacy, or laboratory. Other indicators may be bed days such as critical-care bed usage.
Cesta says report cards also may identify underutilization, or areas in which a particular patient type is not being managed consistent with the organization’s guidelines.
The same process outlined earlier would be used to investigate and correct the problem. In addition, actual reimbursement can be compared to expected reimbursement, factoring in the rate of third-party denials, she says.
Finally, report cards can be a useful tool during managed care contract negotiations. "This information can give the organization significant leverage when negotiating rates," Cesta says. "If the organization has a good sense of its true cost for a case type, then it can negotiate appropriate rates which reflect actual cost, not charges."
[For more information, contact:
- Lisa Zerull, Program Director, Valley Health System, Winchester, VA. Telephone: (540) 536-5344. E-mail: [email protected].
- Toni Cesta, Director of Case Management, Saint Vincent’s-Manhattan, New York City. E-mail: [email protected].]
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