Who Will Win at Population Health Management?

Healthcare by transaction is dead. This economic model cannot be sustained. The new frontier involves aligning care providers across the continuum so they can think differently – and act differently. Successful population health management involves the strategic use of data to deliver the right care to the right population at the right time. Instead of managing the health of an individual episodically, providers will be challenged to manage the health of a group of individuals over time. The shift from volume to value requires providers to take on accountability for the total cost of care, the quality of care and the outcomes of care – rather than simply provide services when people are sick. Continue reading

Integrating Sociodemographic Factors into Risk Adjustment: Important Considerations for NQF’s “Robust Trial Period”

Why is it necessary that risk adjustment incorporate sociodemographic factors for my diabetic schizophrenic patients who have unstable housing?

Healthcare is fundamentally about people. That’s why, at the end of the day, it is the differences and disparities among individuals that are at the heart of the challenge facing the National Quality Forum (NQF) as it debates incorporating sociodemographic factors into risk adjustment.

Here’s a real-life example of the importance of SES factors to risk adjustment: Robert is a diabetic patient of mine who is schizophrenic with episodes of psychosis. He has difficulty with his meds in part because his housing situation is not stable. From time to time he is homeless. If there is any possibility of stabilizing his diabetes, he will need additional case management time over and above a diabetic schizophrenic who does not have the added SES burden. The case manager would not just deal with “medical” issues like making sure that Robert is taking his meds every day but also working with Robert to address conflict with neighbors that in turn are making him extremely anxious. In this case, the neighbors were extremely rowdy with loud music. The case manager was able to defuse the situation – when the neighbors were told by the housing authority to move. The same challenge applies to my asthmatic patients who live in substandard housing and are exposed to different allergens than those impacting middle-class asthmatics. In this situation, the case manager might help with making sure that insects exacerbating the asthma attacks are eliminated from the apartment. Continue reading

Alert Fatigue: The Implications for Reducing Preventable Hospital-Acquired Conditions

Blog post by Krysten Brooks, RN, BSN, MBA

Hospitals across the country have launched a wide-range of initiatives to reduce hospital-acquired conditions (HACs), but despite their efforts, a quarter of the nation’s hospitals face reimbursement penalties according to a preliminary analysis released in June by CMS that scored hospitals based on rates of acquired conditions and patient complications. While Medicare’s HAC Reduction Program plans to release final scores later this year, the healthcare organizations facing penalties can expect to lose approximately one percent of each Medicare payment from October 1, 2014 through September 30, 2015, translating into billions of dollars in lost reimbursement.

The Medicare penalties will undoubtedly hit some organizations hard, and these hospitals are moving quickly to analyze avoidable complications and intervene to improve quality. Facilities are also auditing clinical documentation for completeness and accuracy and examining documentation workflow to analyze process breakdowns and problems. Continue reading

New Partnerships and New Metrics for Better Population Health

“How do we achieve better population health?”

This is the question on the minds of health care leaders across the country today.

At a recent 3M health care executive conference in Saint Paul, Minnesota, representatives from health plans, hospitals, Medicaid and several non-profit organizations gathered to discuss patient-centered models of care as a way to achieve better population health outcomes.

But attendees didn’t walk away with a clear-cut answer to the question “how do we achieve better population health?” There is no such thing. Instead, they left with affirmation that better population health is going to require (1) new collaborative partnerships and (2) thoughtful consideration of the right metrics for measuring population health. Continue reading

E&M Coding: The Final Level of Care

In keeping with the theme of previous blog posts–the professional realm of E&M coding–I’d like to discuss medical necessity as it relates to the final level of care. CMS has stated that medical necessity is the over-arching criterion for payment of E&M services, which, in pure CMS fashion, gives us a goal, but not guidelines as to how to get there. We have no medical necessity policies for the differing E&M codes.

I think we all understand the intent of that statement, which I interpret as “don’t game the system”. But how do I, as a coder, teach a provider how to do that? And, how does the provider document a record to reflect the medical necessity clearly? So, let’s put a pin in that and talk about the calculation of the E&M codes, then circle back. Continue reading

AHIMACon vs. Comic-Con: We All Have a Role to Play

Last week I checked in on Facebook from the AHIMA convention in San Diego. My brother, who attends San Diego Comic-Con religiously every year, decided to weigh in:

Brother: My San Diego convention is superior to your San Diego convention.

Me: My convention is more conventional than your convention.

Brother: I expect you’ll have better Cosplay, though.

Me: Lots of Clark Kent and Lois Lane types.

It turns out this exchange fit perfectly with the vibe at #AHIMACon14 over the following three days. I arrived at the Monday general session in time to see and hear several inspirational messages about how innovation and, as AHIMA CEO Lynne Thomas Gordon put it, “embracing reinvention,” are the keys to success in health information management. Continue reading

CMS: CDI Take Note – Physician Claims Related to Hospital Denials Will Soon Be Scrutinized

On September 4, 2014 CMS replaced Transmittal 534 with Transmittal 540, Change Request 8802 to “adhere to CMS Inpatient recoding policy standards, which was accomplished by removing the recoding language in section 3.2.3 in the Manual Instructions.” They went on to specify “The purpose of this CR is to allow the MACs and ZPICs the discretion to deny claims that are ‘related’ and provide approved examples of such situations.”

Effective September 8, 2014 CR 8802 allows MACs and ZPICs to deny “related” professional claims submitted before or after the facility claim being questioned. CMS determines that “documentation associated with one claim can be used to validate another claim, (then) those claims may be considered ‘related.’” Continue reading

From the OSEHRA Summit

Senthil Nachimuthu Blog post by Senthil Nachimuthu

I had the opportunity to talk about 3M’s open source HDD Access at the 2014 OSEHRA Open Source Summit in the Washington D.C. area (Bethesda, to be precise) earlier this month. This was my first time attending OSEHRA; I enjoyed the conference and I hope to be back to learn and contribute more. The title of my talk was “Enabling Interoperability between Standard and Local Terminologies using HDD Access.” The two other speakers in the session talked about the difficulties encountered when trying to achieve interoperability. This turned out to be a good introduction to my talk, which focused on how HDD Access can help to achieve interoperability. Continue reading

The Future Is Now: Transformation to Value-Based Care Is Underway

Barbara DeBuono and Richard KellerBlog post by Barbara DeBuono and Rich Keller

Over 85 attendees at 3M’s healthcare conference in New York City heard from the payer, government and provider speakers on how the ground is shifting from underneath us all. Value-based care is no longer the new frontier; it is right where we are standing. Linking payment to performance is here to stay. Financial incentives that reward high volume are going away; they are part of a model that is on its way to becoming the exception rather than the rule. Consider that:

  • 45% of hospitals are already part of an ACO;
  • Payers expect fee-for-service payment to represent less than 1/3 of all payments in 5 years;
  • 40% of all commercial in-network payments are value-oriented; and
  • 50 percent of delivery systems say they will be in the insurance business in the coming years.

Continue reading

The Ethics of Quality…Should Hospitals Be Incentivized to Improve Quality?

I believe most human beings have some sort of a moral compass, especially in the healthcare arena. I might be naïve in my view but I believe most healthcare professionals choose to work in health care to care for others. As part of that drive, I also believe that we informally and formally have always assessed the care we give and look for opportunities to improve — often acting as a Monday morning arm chair quarterback review. As part of that review, many root cause analyses and written protocols for care and/or critical pathways have been developed to ensure patients received the best quality and most efficient health care. Continue reading