Checks and balances manage MCO data needs
Keeping up with growing need for health data
Computerized patient records offer the dazzling promise of low-cost, high-quality health care and vast amounts of information at our fingertips.
But that increased efficiency comes at a price for health information managers. For managed care organizations to promise quality, cost-effective care, they have to be able to prove it, and they’re going to look to you to fill their voracious needs for data to make their case.
"The whole HIM department is a lot busier than it ever has been," says Harry Rhodes, MBA, RRA, health information management practice manager for the Chicago-based American Health Information Management Association. "You have to be able to measure the quality of the care provided. And to get this measurement, you need accurate, timely, and useful information."
During contract negotiations, managed care organizations typically ask hospitals for outcomes measurement data including mortality rates, complication rates, readmission rates, infection rates, cesarean rates, average length of stay, returns to surgery, and occupancy rates. And with the new 3.0 version of Health Plan Employer Data and Information Set (HEDIS), health plans are required for the first time to measure the functional status of their members in order to be accredited by the National Committee for Quality Assurance
HEDIS 3.0 asks for such information as childhood immunization status, availability of primary care providers, and eye exams for people with diabetes. Since many of the items, such as advising smokers to quit are not usually found on the medical record, HIM departments may need to set up a system that creates data fields to capture the information, Rhodes says.
An increasing need for health information
Add to those requirements the growing number of data requests from groups conducting national, regional, and local studies, and you’ve got the makings of an overburdened department. On the other hand, this growing need for health information offers an unprecedented opportunity to boost your hospital’s bargaining power and relationship with managed care organizations by demonstrating how crucial your data capturing system is for measuring outcomes and quality in a timely manner.
"The changes have allowed HIM departments to make a real contribution to the success of the facility and to positively affect the bottom line," Rhodes says. "Before automation of records, studies were few and far between, and it wasn’t unusual that there was very little use of the information.
Build in audit trails
Along with that opportunity comes a greater accountability, Rhodes says, so it’s more important than ever to perform audit trails, build checks and balances into your system, and follow coding guidelines. Other tips for providing accurate, helpful information to managed care organizations include the following:
- Analyze how you capture the information.
Pay attention to who’s capturing the information and whether they’re doing it correctly. For example, if you have nurses logging in cesareans and ending up with different rates than the HIM department, then maybe those nurses are too busy to perform that function properly, Rhodes says. Identify the best place to capture your data.
- Make sure staff understand the whys as well as the whats.
People who capture information need to know why it’s important. Tell them what the data will be used for, and let them know you can’t do it without them, Rhodes says.
He points to a situation at a former employer where 80% of cardiac catheterization patients were being categorized as urgent admissions. HIM staff checked and found that the admitters didn’t understand their choices and were categorizing almost everyone as urgent. The problem was fixed by providing inservice for the employees and embedding drop-down menus in the software program so that employees could go to help screens that offer a range of choices and appropriate definitions.
"Everyone who’s using the record needs to understand the medical vocabulary," Rhodes says. "You can design computer screens, forms, and data dictionaries to make sure information is not being distorted or misunderstood."
- Get involved upfront.
Don’t wait until the end of the year to find out what data the MCO will want, Rhodes says. In some cases, MCOs ask for information you don’t normally capture. If you find out at the beginning of negotiations, you can set up your system to capture that information as you go along. If you don’t, you’ll have to do labor-intensive searches through medical charts farther down the road.
- Make sure you understand what is requested.
Sometimes it’s hard to find clear definitions, for example, of what constitutes a complication rate vs. an expected outcome. Ask the MCO, and look to professional groups like the American College of Surgery for good definitions, Rhodes advises.
- Seek out similar requests.
Pay attention to questions that are asked by more than one MCO, and save the answers in subfiles so you don’t have to search through or sort the information again.
- Arm your administration with data.
Monitor the case mix of the patient population of individual health plans for clues to high resource utilization. If, for example, you see that 80% of the patients in a particular plan are smokers, your hospital might be seeing more emphysema, respiratory problems, or cancer cases as a result. Before contract negotiations, your administration should know if an MCO has a high percentage of people who are difficult and expensive to manage.
Such data can lead to wellness programs such as smoking cessation to improve quality of life and reduce health care costs.
- Profile your physicians.
Use your information system to compare physicians and help them become aware of their practice patterns. You could look at a group of orthopedic surgeons who do total hip replacements, for instance, and compare length of stay and resource utilization. If one physician uses more lab and pharmacy resources but has the same outcomes as others performing the same procedure, you can make that known. "You can make them aware of their practice patterns, but let them control and decide what’s best for the patient. This can be a positive and eye-opening experience to provide this data and get doctors to change their behavior."
- Educate your physicians.
Management and use of health information to improve quality and outcomes are cornerstones of managed care, but the need for such data can seem a low priority to busy physicians. Ginger Sullenger, MCHE, director of managed care for Elkhart (IN) General Hospital, says a good relationship with physicians goes a long way toward gaining their cooperation.
"Tell them what’s going on so they’re not fighting changes brought on by managed care," she says. "They’re usually interested because it hits their pockets immediately." Sullenger produces a newsletter, gives bimonthly seminars, sends staff members to physicians’ offices, and works closely with the physician independent practice association to keep physicians informed and ensure their cooperation.
- Do some internal analysis.
Many times it’s not as hard to provide the information an MCO requests as it is to analyze whether the deal is a good one for the hospital, Sullenger says. "It’s a real wake-up call when MCOs who have been in many big markets come to the second and third tier markets," she says. "Big city hospitals are used to figuring all this out, but [hospitals in] smaller markets aren’t."
Get advice from colleagues
Sullenger advises consulting with colleagues at other hospitals who have worked with an MCO to see how they handled information needs. Also, invest in staff to do periodic follow-up work to make sure you’re collecting the appropriate information.
- Comply with contract requirements.
Ron Nakamura, RRA, manager of coding and reimbursement at Loyola University Medical Center in Maywood, IL, advises paying close attention to coding requirements from different health plans.
Some MCOs only look at the first coding position and not at secondary diagnoses and procedures, he says, so you need to make sure you’re putting codes in the correct positions. Provide frequent inservice training for your staff to make them aware of managed care requirements, and help them understand reimbursement.
- Seek feedback.
Nakamura also advises close contact with the hospital’s business office and provider relations department about managed care issues. If they’re getting too many rejections, maybe the coding is off. "Keep everybody in the loop," he says.
Harry Rhodes, MBA, RRA, Health Information Management Practice Manager, American Health Information Management Association, 919 N. Michigan Ave., Suite 1400, Chicago, IL 60611-1683. Telephone: (312) 787-2672, Ext. 330.
Ginger Sullenger, MCHE, Director of Managed Care, Elkhart General Hospital, 600 East Blvd., Elkhart, IN 46514. Telephone: (219) 523-7914.
Ron Nakamura, RRA, Manager of Coding and Reimbursement, Loyola University Medical Center, 2160 S. First Ave., Maywood, IL 60152. Telephone: (708) 216-4011.
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