What's up for quality in 2014's IPPS proposal?
Providers will need more education on changes
Financial Disclosure:
Editor Lisa Hubbell, Executive Editor Russ Underwood, Associate Managing Editor Jill Drachenberg, and nurse planner Paula Swain report no consultant, stockholder, speaker's bureau, research, or other financial relationships with companies having ties to this field of study. Consulting Editor Patrice Spath discloses she is principal of Brown-Spath & Associates.
No one expects everyone to read through the 1,000-plus pages of the Centers for Medicare & Medicaid Services (CMS) Inpatient Prospective Payment System (IPPS) proposals for 2014. But there are parts of the proposal that impact quality departments, and they demand some study.
Among the changes of consequence to hospital quality managers are new quality measures and penalties for new categories of readmitted patients, and the much-talked-about "two midnight rule," which defines an inpatient as one who has stayed in the hospital over two midnights. Other components of the proposal include changes to the hospital readmissions criteria to make more allowance for planned readmissions within the 30-day window, and adding exacerbation of COPD and elective total knee and total hip replacements to the 2015 readmission reduction program. Currently, it includes heart attack, pneumonia, and heart failure.
Experts say you can start preparing now for the final rules, which should be released in the early fall. Here are five tips.
1. Teach providers to document better.
"With the continued emphasis on value-based purchasing, there is a lot that is dependent on appropriate documentation," says Lisa Roat, RHIT, CCS, CCDS, manager of HIM product development and compliance at Tampa-based J.A. Thomas & Associates, Nuance Communications. "There are so many things that factor into the equations for value-based purchasing surrounding hospital readmissions. If you don't document and code comorbidities, the hospital could end up losing money due to a readmission that might not have anything to do with the original hospital stay. Think of a surgeon who writes that there was a post-operative complication, she says, meaning that it happened in the post-operative time period, not that it happened because of the surgery. "You have to be careful the way things are worded."
Getting providers to understand the proper way to document can be difficult, she says. Many were trained using just a DRG code. Now there is pressure to document everything carefully and fully in a way vastly different from what they learned. "You may have to create a documentation improvement program or hire outside consultants to do some training of providers," says Roat.
2. Look closely at data.
It's possible that your data could show a spike in a negative data point, like hospital-acquired conditions or another patient safety indicator. But it might not be a problem in need of a quality improvement project. Roat says to investigate anomalies that don't make sense with an eye to documentation. You may find you just need to educate a provider or two on better documenting the care they provide.
3. Understand the "two midnight" rule.
Roat says that the presumption is always going to be that a patient who does not stay in the hospital over two midnights was inappropriately admitted. "It's a red flag to auditors," she says. But approval is as easy as the right documentation and support from the medical record. "I can't emphasize enough how significant this is. RAC auditors are really pushing on this."
As a corollary to the two midnight rule, providers need to understand, too, that if a patient is deemed to have been inappropriately labeled inpatient and would have been better documented as an observation patient, there are financial repercussions not just for the hospital, but for the patient, Roat notes. The portion of the bill the patient is responsible for is greater for observation status than for an admitted inpatient, she says. Patients will complain if they are billed more money when they feel they shouldn't be. This can affect patient experience scores.
4. Educate leaders about the finance/quality intersect.
While a lot of quality departments feel the righteousness of their job — providing quality is always the right thing to do — for many hospital executives, the quality department has long been viewed as a cost center that doesn't do anything to help the revenue stream. But Scott Hodson, MBA, a principle at Miami-based Maverick Healthcare Consulting, says that with value-based purchasing and the readmission reduction program, there is now a way to demonstrate the financial benefit of investing in quality programs.
"This is a vehicle for you to say 'We are important,'" he says. "I have a client that made $10 million more than it would have because of investments they put into the quality department. This included more people and technology that made data gathering easier." That $10 million was a powerful incentive for the hospital leadership to continue to invest in a department that has long been considered a financial burden. "Use this as the start to a meaningful conversation at the nexus of quality and finance. You really can show value beyond just doing the right thing, that more quality is better than less."
5. Preach the gospel of communication.
It's no longer a hypothesis that better communication across the continuum of care is better for patients, says Hodson. "It clearly works. In Maryland, one client has seen a 25% reduction in readmissions because they are working better together across the various levels of care," he says. "The reward is getting more money even though admissions are going down. Who would do anything to reduce admissions if this was still a fee-for-service system?"
The complete proposal is available at http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/AcuteInpatientPPS/FY-2014-IPPS-Proposed-Rule-Home-Page.html.
For more information on this story contact:
• Lisa Roat, RHIT, CCS, CCDS, Manager HIM Product Development & Compliance AHIMA-Approved ICD-10-CM/PCS Trainer, J.A. Thomas & Associates, Nuance Co., Tampa, FL. Telephone: (888) 359-0599 ext. 8561.
• Scott Hodson, MBA, Principle, Maverick Healthcare Consulting, Miami, FL. Telephone: (305) 502-5945.
