What do the CMS rules mean to you?
Focus on readmissions, practice implementation now
April and May were busy months for the Centers for Medicare & Medicaid Services (CMS), which issued several proposed and final rules that will affect hospitals and other healthcare organizations for years to come. Two are of specific concern to acute care settings. One will affect how hospitals are paid under the Inpatient Prospective Payment System (IPPS), strengthen the value-based purchasing program (VBP), and add new measures related to central-line infections. The second proposed rule would standardize the identifiers healthcare organizations use with third-party payers and also delay implementation of the new set of codes, ICD-10, for a year.
The first rule, available to view at http://www.ofr.gov/inspection.aspx?AspxAutoDetectCookieSupport=1, provides a 2.3% increase in payments to hospitals and puts more focus on the VBP program by emphasizing certain performance metrics. One of the new ones in the proposed rule is spending per beneficiary from three days prior to hospitalization to 30 days post-discharge. They will also focus on central-line-associated bloodstream infections (CLABSI), perinatal care, hip and knee replacement surgery, and the use of checklists in the operating room. A new survey measure for the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) aims to assess care transitions. Hospitals that have excess readmissions for heart failure, heart attack, and pneumonia face financial punishment starting in the next fiscal year, which begins Oct. 1, 2012. The proposed rule provides the algorithm for determining how much money those hospitals will lose.
Cancer hospitals that are currently exempt from PPS will also come under a quality measure reporting program, and ambulatory surgery centers will have additional requirements added to their program.
"I think one thing it does is add another dimensionality to what quality professionals do," says Kunal Pandya, a senior analyst for healthcare, insurance and payments at Aite Group in Chicago. "The proposed rules add another layer to providing better quality care. It will take more time to manage all the rules. But it will be beneficial to patient care. The rules will ensure that certain areas aren't overlooked because you aren't gathering information on them."
Pandya says smart hospitals will start piloting these rules quickly so that they can work out any kinks before the requirements are mandatory. "I think that larger hospitals are already pretty prepared. But I'm not sure how smaller facilities will fare. They have lagged behind in some of these issues."
Certainly not every hospital is going to win at the new rules. A recent survey of 79 hospitals done by Zynx Health of Los Angeles found that there are great gaps even now in how hospitals use clinical decision support (CDS) in the electronic health record (EHR) to address conditions of interest to CMS, such as heart failure and pneumonia, says David C. Rhew, MD, vice president and chief medical officer at the company. The voluntary audit indicates that there is on average a 30-40% "quality" gap in the CDS (e.g., order sets, plans of care, rules, structured documentation, dashboards, policies and procedures) that is being implemented in hospital EHRs across the country, and this gap translates to significant opportunities to improve patient care and reduce costs.
There are some 20 metrics related to heart failure that could be included in a facility's electronic health record, but in just about every case, the gap of 30-40% was the same, whether it was a large hospital or a small, rural or academic medical center. No one used all of the processes proven to improve outcomes.
"It's not obvious to some that pay for performance is set up so that you have money pulled out up front and have to earn it back, and even if you do relatively well, you may not earn it all back," he says. According to Rhew, 40% of hospitals will get less money than they did before. And the scores a hospital needs to break even — 41 next fiscal year — are set to go up, reaching 85 by 2017.
"You have to do exceptionally well on the metrics," he says. "You will have to do better than a large number of hospitals on process of care measures to do well financially. And next fiscal year, they will add additional metrics, which will continue to expand." If hospitals aren't hitting their clinical process metrics now, how likely is it that they will hit all the metrics they need to in a year or two to make the same amount of money they are now?
Rhew says that given how competitive the system is designed to be, with hospitals essentially competing against each other for a closed pool of dollars, they need to start right now to do everything they can to maximize performance. "You want the best outcomes, the lowest mortality, the highest level for process measures, the lowest readmissions," he says. "Identify the broader set of things beyond core measures that you need to look at and standardize care to the highest degree."
The change to the daily lives of quality professionals won't be as massive as some fear, says Jon Elion, MD, FACC, CEO, ChartWise Medical Systems, Wakefield, RI, who also practices cardiac medicine at an area academic medical center and is an associate professor at Brown University. "All the things you've been doing will now translate to dollars and cents," Elion says. "That's cool. And it's also now getting attention at the c-suite level that it didn't get before there was money involved." What might have been viewed at one time as nice aspirations but something of a luxury is now going to be required to maintain a facility's financial health.
What he hopes people will recognize is that despite the 30% emphasis on patient experience and new questions on the HCAHPS survey, paying too much attention to that aspect will get you nowhere fast. "If you go to a fast food restaurant and it's clean and you get your meal fast, you're happy," he says. "If you go to an expensive restaurant and you think it took too long, you might rate it lower than the fast food joint. But where would you rather eat?" he asks. "If you have two patients in the same room, with the same nurse, the same care, both waiting for results of a lung biopsy and one gets good news and the other bad, which one will rate the patient experience better? When the cancer patient comes in for chemo and you ask him about his patient experience, he's hardly going to say fabulous. A lot of things have to go right for a patient to be satisfied."
Similarly if you spend a lot of money and attention on a lovely facility, a room with amenities, restaurant-quality food and sweet nurses, you might get good patient satisfaction scores. But who cares if the patient dies of untreated pneumonia? "If you get a lot of grumpy scores, of course you should look at it. And if they are high, you're doing something right. But the other measures should take more of your attention," Elion says.
The best advice he has is to work on standardization. "If you do the right thing at the right time for the right reason all the time, you'll have good outcomes far more often than not." But that's not the end of the matter. Elion also says that people often forget to continually monitor progress. If a quality improvement program is based on the Plan, Do, Check, Act model, he says, people often stop after the plan and do parts. Checking results and acting on any that seem out of sync with expectations is imperative to having the kind of improvement these rules require for hospitals to do well financially.
Elion also suggests focusing on a new set of goal words. Length of stay is often an issue with administrators. But you shouldn't blindly try to make stays as short as possible. "If you have a patient with open heart surgery, there is a move to get them home sooner and reduce length of stay. But reducing is the wrong thing to focus on. You should be optimizing it." If you release the patient too early, you may end up with a bounce back. Part of the problem is that even under the new rules, there is no cost-per-day calculation. If there was, the goal would be not to shorten the last part of the stay but the first, since most care is done in the first couple of days of a hospitalization. The last two or three days are relatively cheap, so getting them out too early saves you far less than you think, he says. And if a patient bounces back, it will certainly cost you more than you saved.
Because there is some leeway in the new rules for readmissions related to some conditions, you want to be sure you track and code them properly, too, Elion notes. "Heart failure patients are typically readmitted for their comorbidities. I treat them for heart failure and a week later they come back in for a hot gall bladder. I shouldn't be dinged for that. Make sure the primary diagnosis is correct."
Look for patients who are at high risk for readmissions, he says, as well as the attending and referring physicians associated with 30-day readmits. You might find some actionable data there.
With the future of health reform up in the air right now, many quality professionals might be unsure of how to proceed, says Wayne J. Miller, Esq., partner at the Compliance Law Group in Los Angeles. But even if there is a negative decision by the Supreme Court in June, the theme of reducing costs and improving quality will continue in whatever comes next.
If the VBP and hospital readmission reduction programs are implemented, QI professionals may focus on those potential heart attack and pneumonia readmissions, says Miller. "This will mean scrutiny of cases for potential heart or respiratory complications resulting in possible longer initial stays to rule out these complications." On the other end, staff may be asked to highlight potential readmits that may fall into these categories. But there is a downside, he continues: "The focus on avoiding readmissions may detract from other quality initiatives and efforts that you will need to make to avoid patient readmit dumping' on other facilities and negative payment consequences."
For now, review case histories to evaluate the historical short readmission experience at a facility and its potential impact on payments based on the rule, Miller advises. Review the types of cases that may trigger readmissions as well as the procedures in place to address heart and respiratory issues in a single admission rather than multiple ones.
Rhew says he doesn't think there will be as much pushback with the VBP rules as there was with the ICD-10 code changes — uproar that ultimately led to another one-year delay. "That required organizations to do some very labor-intensive things that were outside their core mission," he says. "These things are all about patient care. It's about outcomes, mortality, readmissions — although that's based on cost metrics." But this stuff matters for patients and providers alike.
Not that everyone is happy. "The new rules change the width of the goalposts and the number of time-outs per half, but they do not change the game," says J. Deane Waldman, MD, MBA, a professor of pediatrics, pathology and decision science at the University of New Mexico. "Thus, the players will still be gaming the system so that they win, but their winning or losing does not connect with whether the patients win or lose."
Putting it more plainly, Waldman says that the quality the new rules ask for isn't the quality that really matters: good patient outcomes. "They still use rule-following as a surrogate for the desired results, and the surrogate doesn't work. Until the system starts directly measuring and tracking positive patient outcomes, and then linking incentives to those, the quality we want from the system will not be enhanced."
For more information on this topic, contact:
- Kunal Pandya, Senior Analyst, Healthcare Insurance and Payments, Aite Group, Chicago. Email: [email protected].
- J. Deane Waldman, MD, MBA, Professor of Pediatrics, Pathology & Decision Science, University of New Mexico. Email: [email protected].
- David Rhew, MD, Senior Vice President and Chief Medical Officer, Zynx Health, Los Angeles. Email: [email protected].
- Jon Elion, MD, FACC, CEO, ChartWise Medical Systems, Wakefield, RI. Telephone: (401) 473-2020.
- Wayne J. Miller, Esq., partner, Compliance Law Group, Los Angeles. Email: [email protected].
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