With public reporting on the rise, documentation becomes more important
With public reporting on the rise, documentation becomes more important
Data affect compliance, reimbursement, and patient decisions
In an unprecedented move to publicize the newly revamped Hospital Compare web site, the Centers for Medicare & Medicaid Services (CMS) took out ads in 58 newspapers in major metropolitan areas on May 21, outlining some of the publicly reported hospital data that could be found on the web site.
The newspaper ads, aimed at reaching areas covered by about 1,000 hospitals, suggested that readers "Compare the Quality of Your Local Hospitals." They included specific data from a sampling of hospitals in the area on two of the 26 quality measures for which hospitals must submit data. Hospital scores were included on the percentage of patients given antibiotics one hour prior to surgery and the percentage of patients who always received help when they requested it, as reported by patients on the Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey.
"These ads — and Hospital Compare — are intended to give consumers more information for making choices about their health care," says Mike Leavitt, secretary of the Department of Health and Human Services.
"Patients and their family members can use this information to see how well their hospitals are providing care, and hospitals can use the data to focus on areas where there are opportunities to improve the quality of care," adds CMS acting director Kerry Weems.
A few months earlier, when CMS released the first results of its HCAHPS survey, the story, including specific data on local hospitals, made the front page of The New York Times and other newspapers all over the country.
"Medicare beneficiaries tell us that just like the information they receive about other products and services they consume, they want to know what their neighbors are saying about the care they received while in the hospital; they want to know how much it costs and they want to know about the quality of that care," Weems says.
That's just the tip of the iceberg. In addition to the Hospital Compare site, consumers can log on to a variety of national web sites that publish data on hospitals' quality of care, patient safety, and patient satisfaction with more likely to come. In addition, many states have their own hospital rating sites.
"Hospitals' scores on a variety of measures are going to be in front of our consumers much more frequently in the future. Public reporting and mandated reporting are continuing to grow and hospitals need to develop strategies to meet the requirements," says Beverly Cunningham, RN, MS, vice president, clinical performance improvement, Medical City Dallas Hospital.
The purpose of public reporting is to create transparency and accountability, aid consumers in their choice of providers, and stimulate quality improvement activities, she says.
This trend makes it even more imperative that documentation in the medical record be accurate because it not only affects compliance and reimbursement, the data reported can influence consumers about whether they will choose your hospital for health care.
"One challenge is that consumers don't understand the publicly reported data. Case managers have an opportunity to help them understand it, but in order to do so, they must understand what data their colleagues are collecting and how it is used," Cunningham says.
Patients as consumers
Publicly reported data are important because they are the only information the general public has to make a decision about where they will receive health care, adds Liz Youngblood, RN, MBA, vice president, patient care support services at Baylor Health Care System in Dallas.
"Consumers have the right and need to be more informed in order to make appropriate decisions about where to seek health care. They are becoming more savvy and more active in making decisions about their health care. They no longer rely solely on their physicians when it comes to choosing a hospital. They are looking on the Internet and asking a lot of questions," Youngblood says.
In addition to CMS, commercial insurers are focusing more and more on quality of care, taking comparative data into account, and beginning to base reimbursement on performance, says Carolyn C. Scott, RN, MEd, MHA, director, KPMG LLP's Healthcare Advisory Services practice, points out.
"It's not just the government but the private sector is also beginning to look at quality of care and to consider pay-for-performance initiatives. Payers and big employee groups are paying a lot of attention to what the Leapfrog Group and other quality organizations have to say about hospital safety and quality," she says.
The Leapfrog Group's Hospital Rewards Program, which ranks hospitals in four tiers, based on quality measures and resource use, allows commercial insurance and employer groups to use the information for pay-for-performance initiatives.
The nonprofit organization also publishes data on its web site, which is available to consumers. (For more information on this and other web sites that feature hospital report cards, see box.)
The CMS/Premier Hospital Quality Incentive Demonstration, the first national pay-for-performance initiative, concluded that patients in the more than 250 hospitals participating in the project lived longer and received the recommended treatments more often than their counterparts in nonparticipating hospitals.
Now in its fourth year, the project awards the top-performing hospitals on 18 publicly reported quality measures for acute myocardial infarction, heart failure, community-acquired pneumonia, coronary artery bypass graft, and hip and knee surgery.
CMS has announced its intention to move toward value-based purchasing, which includes making hospital payments contingent on actual performance on quality measures, rather than merely requiring hospitals to report the data, Scott says. Plans call for pay for performance to be phased in, beginning in 2009.
CMS outlined the key components of its value-based purchasing plan in its report to Congress last November.
"In announcing its value-based purchasing initiative, CMS says that it has been a passive payer and would reimburse providers just for providing care. The quality of care provided was not a factor in the payment equation. CMS is now saying that it is going to be an active purchaser of quality health care services," Scott points out.
Reducing MS-DRG reimbursement?
"Right now, CMS is looking at reducing MS-DRG reimbursement and giving hospitals the opportunity to earn the full reimbursement based on quality. They have said that they want to reward at two levels: top performers and those who continue to improve," she says.
As part of CMS' move toward value based purchasing, the agency has announced its intention to enhance the site to show performance results for all the quality measures, Scott says.
Insurance companies also are instituting pay-for-performance initiatives based on clinical measures and sometimes patient satisfaction measures, Scott points out.
"Where CMS goes, others will follow. Once CMS rolls out its value-based purchasing plan, commercial insurers will come up with plans of their own," she says.
Case managers should be aware of all the quality mandates that will affect the hospital; they should know what quality information is being reported to which sources as well as what is potentially coming in the future, Scott says.
Data that are being publicly reported come from documentation in the patient record and are dependent on physician documentation being complete, comprehensive, and accurate, Cunningham adds.
CM role in documentation integrity
"While involvement in documentation integrity programs is not a core competency for case managers, some hospitals require their case management staff to be involved in these programs. If case managers are involved in such initiatives, they should make sure that they collaborate with physicians so their documentation is as accurate as possible," she says.
It's important case managers understand their hospital's documentation integrity program even if they are not responsible for it, Cunningham adds.
"Case managers should be aware of what kinds of data are being collected by their colleagues and how the publicly reported data will affect their hospital. If they are involved in data collection or analysis, they need to make sure it's done accurately," she says.
Comparative information that is used for hospital report cards is driven by administrative data, Youngblood points out.
"Most comparisons are risk-adjusted, which makes it imperative that the medical record accurately reflects the condition of the patient. Case managers can be the link between the clinical and administrative side of data reporting by ensuring that the full clinical picture is documented by the physician. The coders can then code correctly so that the risk-adjusted data accurately reflect severity of illness and risk of mortality," she says.
It is important for case managers to understand the MS-DRG system, Youngblood says.
"They don't have to be coders but they need to understand how codes are generated and what drives the code assignment," Youngblood adds.
Make sure your case management staff understand the basic concepts of the new coding system and have a general knowledge of coding rules and how physician documentation affects the final code, Youngblood suggests.
"Continuing education is a critical piece. It's not enough to learn the MS-DRG system when it's new; it will be updated every year and case managers should keep up with changes," she says.
Physician documentation is a critical part of the process, Youngblood points out. Case managers should make sure the documentation contains the specific words and sentences a coder needs to accurately code.
Physicians should understand that making sure documentation accurately reflects how sick their patients are is important when they are compared to their peers.
Make sure there is a good query process in place. If case managers or coders have questions about documentation, they should ask them both concurrently and retrospectively.
"If there is a question about what the doctor meant when he or she documented, it's important that the doctor respond to the question. Case managers should work with the medical staff to make sure they understand the importance of accurate documentation and response to the questions," Youngblood says.
Be able to explain the results and why they are important to physicians. By monitoring and reporting outcomes and trends, you can develop strategies to improve your hospital's performance, she adds.
When you query doctors, keep in mind that physicians are being approached by a multitude of people about a multitude of issues, Cunningham says.
"Case managers may be talking to a doctor about utilization management and care coordination. A documentation integrity nurse may be querying him or her about documentation, and a core measures nurse may be discussing core measures results," she adds.
Look for areas on the public report cards that case managers have influence and work to improve those, Scott suggests, such as 30-day mortality results and readmission rates.
In an unprecedented move to publicize the newly revamped Hospital Compare web site, the Centers for Medicare & Medicaid Services (CMS) took out ads in 58 newspapers in major metropolitan areas on May 21, outlining some of the publicly reported hospital data that could be found on the web site.Subscribe Now for Access
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