Case managers can take the lead in pay-for-performance initiatives
Proliferation of programs on the horizon
At some point in the not-too-distant future, your hospital’s reimbursement is likely to hinge on its performance on quality measures, at least for some diagnoses.
"We’re seeing that pay for performance works. We’re seeing increased quality of care for patients, which will mean fewer costly complications — exactly what we should be paying for in Medicare," said Mark B. McClellan, MD, PhD, administrator of the Centers for Medicare & Medicaid Services (CMS), upon release of data from the CMS/Premier pay-for-performance Medicare demonstration project.
In that project, CMS has awarded $8.5 million to 123 hospitals that showed measurable improvements in care during the first year of the program. This is the first time that Medicare has awarded monetary bonuses to health care providers in a pay-for-performance demonstration. The results of the first year’s performance were released late in 2005.
Under new rules that went into effect Oct. 1, 2005, CMS is taking an additional step toward implementing its pay-for-performance initiatives by giving the full 3.7% market basket (inflation-based) reimbursement increase only to hospitals that submit previously voluntary quality data, and only if the quality data meet accuracy standards for two consecutive quarters.
"One of the problems is that CMS has been getting inaccurate data. Once they begin receiving correct data for the core measures, they will add more performance measures to the list and ultimately move toward pay for performance for hospitals that meet quality targets," predicts Teresa Fugate, RN, BBA, CPHQ, CCM, a case manager with Crescent PPO in Asheville, NC.
"Pay for performance is a win-win situation for Medicare. If hospitals improve the quality of care for their patients, they’re naturally going to decrease their costs," Fugate points out.
In addition, the Leapfrog Group, a Washington, DC-based organization focused on quality and safety initiatives, has rolled out its Hospital Rewards Program, which ranks hospitals in four tiers based on quality measures and resource use, allowing commercial insurers and employer groups to use the data for pay-for-performance initiatives.
"The idea behind pay for performance is mounting evidence that the quality and efficiency of health care varies tremendously from one institution to the next and even from one service line to the next within the same institutions. It doesn’t make sense to pay all providers the same. The pay-for-performance concept is something that is going to last," says Suzanne Delbanco, CEO of the Leapfrog Group.
The trend toward pay for performance represents opportunities for case managers to take the lead in making sure that patients receive the recommended care and that performance measures are documented in the patient’s medical record, Fugate says.
"Pay for performance is going to be a really big deal to the executive team, because reimbursement will be tied to how a hospital performs," says Jan McNeilly, RN, CPHQ, CPHE, principal for clinical advisor services at Premier. "If case managers don’t get involved in their hospital’s initiatives on the core measures and other performance improvement measures, they’re losing out on a great opportunity for professional growth and development. They have an opportunity to be on the forefront, helping get the hospital geared up and ready to go."
Case managers are critical to a hospital’s pay-for-performance initiatives because they are working with patient charts every day and conducting concurrent review based on standards of care. They are in a position to provide oversight to ensure that the core measures and other performance indicators are being met, Fugate adds.
Hospitals have systems in place for physicians to document that they followed the care recommendations, but physicians aren’t accustomed to having to justify why they didn’t satisfy a CMS requirement when the core measures aren’t met, McNeilly points out.
"Until we have something in place, somebody needs to facilitate the process. In many hospitals, the case management department is expanding beyond discharge planning and utilization management to make sure that specific patient populations get the recommended care and flow correctly through the hospital," she adds.
In today’s fast-paced hospital environment, it’s hard for physicians and nurses to keep up with all of the key indicators that need to be provided for a particular patient. This puts case managers on the front line when it comes to ensuring that the hospital is doing well on the performance measures, Fugate adds.
"Case managers are in the charts every day, reviewing what is going on with the patients. They are responsible for coordinating the care of the patient. Quality indicators should be part of this process," Fugate says.
Case managers should be careful to make sure that the services mandated in the quality indicators are not only provided but also are correctly documented in the patient record, she adds.
"The bottom line is to merge the clinical and financial and understand how improvement in quality of care can impact reimbursement," she says.
Know the key indicators and make sure they are being followed. Assist in prompting and issuing reminders to make sure that clinicians at your hospital are following the indicators. Make sure your hospital is monitoring the performance measurements concurrently, when deficits can be corrected, instead of retrospectively, after the patient has left the hospital. "If you collect data only retrospectively, you have lost the ability to intervene and affect the outcomes," she says. When you review the charts, make sure you have a sheet with a list of the indicators appropriate to that patient so you can check off which ones are being followed.
When your hospital’s data are compiled, study them and come up with ways to improve compliance. "When there are deficits in compliance, the hospital should be doing something on the front end to improve. It’s simple to educate the nurses, physicians, and other people who are responsible for making sure the performance indicators are carried out," Fugate says.
At INTEGRIS Rural Healthcare, an 11-hospital system based in Oklahoma City, case managers drive efforts to comply with the core measures, says Denise Caram, MS, CPUM, CPUR, director of support services.
The hospital system uses the data submitted quarterly to CMS and creates a color-coded dashboard showing each hospital’s performance on each of the core measures.
"If we’re not doing so well on one of the core measures, the case managers drill down, find the reason, and come up with ways to improve. When they review the charts for patients with pneumonia, congestive heart failure, or MI, they have a sheet that lists the appropriate care; and if it isn’t being done, they check with the physician to find out why," she says.
The case managers can’t be totally responsible for a hospital’s performance, Fugate says.
"All the disciplines in the hospital — including physicians, nursing staff, and ancillary services — need to be educated about how the things they do every day can impact the hospital’s reimbursement. Case managers are in key positions to help remind the clinicians of what they should be doing as they go through the process," she says.
If everyone in the hospital concentrates on meeting the quality initiatives, patient care will improve, and the hospital’s reimbursement will go up, Fugate says.
In the meantime, the pay-for-performance initiatives are in the start-up phase, and many people in the hospital may not understand their importance, she says.
"It’s a situation similar to what happened when CMS started its prospective payment system, and case managers had to help the physicians understand why they needed to meet the target length of stay for each DRG. Case managers are in a primary position to help remind the other disciplines of the importance of complying with the core measures and educating them about the quality-of-care indicators," she says.
Pay-for-performance scores improving
More than 250 hospitals are participating in the CMS/Premier pay-for-performance project, which began in October 2003. The three-year project concludes on September 30, 2006.
The initiative focuses on five clinical areas — acute myocardial infarction, pneumonia, coronary artery bypass graft, hip replacement, and knee replacement — and has a total of 30 quality measures. The hospitals performing in the top 10% for a given condition receive a 2% bonus in addition to their regular Medicare payments for that condition. Hospitals in the second 10% receive a 1% bonus.
Preliminary information from the second year of the program shows that scores are continuing to improve, with the poorest-performing hospitals improving the most, according to CMS.
The Leapfrog Group’s Hospital Rewards Program, launched last summer, measures performance for quality and efficiency in five clinical areas: coronary artery bypass graft, percutaneous coronary intervention, acute myocardial infarction, community-acquired pneumonia, and deliveries/newborn care.
These five clinical areas represent 33% of commercial hospital admissions and 20% of the money spent by commercial payers, Delbanco says.
"This is the first national pay-for-performance program that rewards efficiency and effectiveness through the use of national accepted and standard measures of performance. It was designed specifically to make use of the data the hospitals are already reporting, whenever possible," Delbanco says.
The Leapfrog Hospital Rewards project includes measures of quality endorsed by the National Quality Forum and that are being collected either through the Leapfrog Hospital Quality and Safety Survey or through the ORYX initiatives of the Joint Commission on Accreditation of Healthcare Organizations.
The data will be available on The Leapfrog Group’s web site.
At some point in the not-too-distant future, your hospitals reimbursement is likely to hinge on its performance on quality measures, at least for some diagnoses.You have reached your article limit for the month. Subscribe now to access this article plus other member-only content.
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