The Role of Case Management in an Era of Healthcare Reform – Part 2
By Toni Cesta, PhD, RN, FAAN
Senior Vice President
Lutheran Medical Center
Brooklyn, NY
As we discussed last month, healthcare reform has changed the landscape of healthcare and of case management. Emerging trends and changes related to reimbursement, readmissions, pay for performance, outcomes and newly contracted reviewer agencies such as the Recovery Audit Contractors (RACs), have changed familiar payment methods and audits to new and different ones in a short amount of time.
The definition of quality of care is now tied to reimbursement so that hospitals that do not perform as well as their peers on a variety of indicators will not get full payments and may even have to return money to CMS (the Centers for Medicare & Medicaid Services).
This month, we will continue to review the healthcare reform changes most pertinent to case managers, both now as well as over the next several years.
Current Payment Splits
Currently, CMS has divided the weighting of the value based purchasing scores for FY 2013 as follows:
• 70% applied to processes of care (core measures)
• 30% applied to patient satisfaction
The combination of these provides the total performance score. Hospitals can earn back part of the withheld payments based on their performance in these areas.
Processes of Care (Core Measures)
There are a variety of "process of care" measures. They are discussed below with their performance measures.
Hospital Process of Care Measure Set
The process of care measures are also known as the core measures. Hospitals are required to follow these measures 100% of the time.
Case Managers and Core Measures
While most case managers are not directly responsible for managing core measures, case managers can still play an important role in watching for compliance gaps in their day to day work. Additionally, some hospitals include some concurrent core measure review into the role of identified members of the interdisciplinary care team. For example, concurrent core measure review may be a responsibility of the clinical documentation improvement specialist (CDI). This combination of roles makes sense when you think of it in terms of the diagnoses targeted for CDI and those that have core measures associated with them.
Hospital Acquired Conditions (HAC) – Also Known as "Present on Admission"
For discharges occurring on or after Oct. 1, 2008, hospitals will not receive additional payment for cases in which one of the selected conditions was not present on admission. That is, the case would be paid as though the secondary diagnosis were not present. An example of how the HAC provision may affect an MS-DRG payment, beginning Oct. 1, 2008, is presented below.
CMS also required hospitals to report present on admission information for both primary and secondary diagnoses when submitting claims for discharges on or after Oct. 1, 2007.
As can be seen by the examples above, these hospital-acquired conditions can have a large impact on the final reimbursement for these specific MS-DRGs. Clinical documentation specialists and case managers can play a role in identifying gaps in documentation associated with issues that were present on admission but not adequately documented. This process should be considered as one of the components of the role of the emergency department case manager, who is likely to be the first case manager to see the patient upon arrival to the hospital.
Meaningful Use
The Medicare and Medicaid Electronic Health Record (EHR) Incentive Programs provide incentive payments to eligible professionals, eligible hospitals and critical access hospitals (CAHs) as they adopt, implement, upgrade or demonstrate meaningful use of certified EHR technology.
Sometimes people use the terms "electronic medical record" or "EMR" when talking about electronic health record (EHR) technology. Very often an electronic medical record or EMR is just another way to describe an electronic health record or EHR, and both providers and vendors sometimes use the terms interchangeably. For the purposes of the Medicare and Medicaid Incentive Programs, eligible professionals, eligible hospitals and critical access hospitals (CAHs) must use certified EHR technology. Certified EHR technology gives assurance to purchasers and other users that an EHR system or module offers the necessary technological capability, functionality, and security to help them meet the meaningful use criteria. Certification also helps providers and patients be confident that the electronic health information technology products and systems they use are secure, can maintain data confidentially, and can work with other systems to share information.
Eligible hospitals may receive incentive payments for up to four years, beginning with fiscal year beginning 2011 (Oct. 1, 2010 – Sept. 30, 2011), provided they successfully demonstrate meaningful use of certified EHR technology.
Eligible hospitals may qualify to receive payments from both the Medicare and Medicaid EHR Incentive Programs.
A qualifying hospital is an eligible hospital that successfully demonstrates meaningful use of certified EHR technology for the EHR reporting period during a payment year. A Payment Year is a Federal Fiscal Year (FFY).
For the first year an eligible hospital demonstrates meaningful use of certified EHR technology, the EHR Reporting Period equals any 90 continuous days beginning and ending within the year. For every year thereafter, the EHR reporting period is the entire year.
Eligible hospitals may qualify to receive incentive payments for up to four years beginning in FY 2011. The last year for which an eligible hospital can begin receiving incentive payments for this program is 2015.
The incentive payment for each eligible hospital will be calculated based on:
1. An initial amount which is the sum of a $2 million base amount and the product of a per discharge amount (of $200) and the number of discharges (for discharges between 1150 and 23,000 discharges);
2. The Medicare share which has as its numerator Medicare fee-for-service and managed care acute-care inpatient bed-days and as its denominator the product of total acute care inpatient days and the percentage of hospital's total charges that are not attributed to charity care; and
3. A transition factor which phases down the incentive payments over the four-year period.
As a case management professional, you may not have any direct responsibilities related to meaningful use. The information provided here will allow you to understand why and how your employer is engaged in meaningful use activities through the implementation of an electronic health record at your organization.
At the same time, case management departments should be sure to be included in any discussions concerning the use and integration of an EHR as it relates to where and how they document, as well as how an existing or future case management software application might related to the electronic health record. If these discussions don't take place, there is the potential for the case managers and social workers to have to document in two places, in the electronic health record and in their own case management software application. This would obviously not be the most efficient use of either software application or of the time of the case management staff.
Next month's issue will continue with a review of additional indicators associated with value-based purchasing and healthcare reform. Included will be:
• HCAHPS Scores
• Mortality Scores
• The new efficiency of care measure!
As we discussed last month, healthcare reform has changed the landscape of healthcare and of case management. Emerging trends and changes related to reimbursement, readmissions, pay for performance, outcomes and newly contracted reviewer agencies such as the Recovery Audit Contractors (RACs), have changed familiar payment methods and audits to new and different ones in a short amount of time.You have reached your article limit for the month. Subscribe now to access this article plus other member-only content.
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