Study Validates the Value and Utility of Risk-Adjustment for Stratifying Complex Patients

Introduction by Norbert Goldfield, MD, and Richard Fuller

Increasing value, or more precisely, improving outcomes from health care spending, a recurring theme of the C&ER blog, is intrinsically linked with risk-adjustment. If we can’t accurately compare patients, then we can’t determine if we are paying too much for their care. We cannot be certain if their health outcomes deviate from what we should expect. As governmental and private payers increasingly employ both managed care and prospective payment programs with more complex patient populations, the need for accurate risk-adjustment grows exponentially since cost variation across patients is greater. This variation is often greatest in pediatric populations, which range from healthy kids to some of the sickest individuals insured by government programs. Continue reading

Palliative Care: Payers and Providers Collaborate to Improve Quality of Life, Care and Experience

A study published by the Institute of Medicine (IOM) this fall, Dying in America: Improving Quality and Honoring Individual Preferences Near the End of Life, concluded that improving the quality and availability of medical and social services for patients and their families could not only enhance quality of life through the end of life, but may also contribute to a more sustainable care system. Among the calls to action from the IOM committee are strengthening palliative care and the reorientation of policies and payment systems to support high-quality, end-of-life care.

What is palliative care? Continue reading

Tinted Moisturizer and Medical Necessity Data

I know what you are thinking – the woman has finally lost her mind. Or, this is the most ridiculous post I have ever seen – and I’m not going to waste my time reading it. Wait! I promise it will make sense.

Everyone has a favorite something – right? It’s a common enough story; in addition to holiday shopping this past weekend, I spent over an hour searching for a new tinted moisturizer to no avail. If you are a woman, you know what it’s like to have a favorite fragrance or lip gloss or nail color. Then, for some unknown and misguided reason, the manufacturer changes the formulation and it loses the je ne sais quoi that made it so special. Well, this just happened to my favorite aforementioned tinted moisturizer with sun screen! I want it back at any price – it has irreplaceable value to me. It was lightweight and matched my skin tone. Not too shiny or oily and just the SPF I need. I’ve searched but I can’t find a replacement I like. I trusted the product; it provided the ROI I was seeking. Continue reading

Taking a Closer Look at the November ICD-10 Coding Challenge

CONTEST QUESTION:

A 49-year old female arrived in the trauma ED via helicopter in cardiac arrest after sustaining a stab wound to her upper torso. The patient was attacked by an unknown assailant with a knife (found at the scene) as she was walking to her car in a parking lot. The patient was unable to be resuscitated and expired. The Emergency Department physician documented the following diagnoses:

1. Penetrating laceration of anterior left thorax with near complete laceration of thoracic aorta
2. Hemopneumothorax

Assign diagnosis codes for this Emergency Department encounter. Continue reading

U.S. Healthcare Costs: Steps to Reduce Payment Variation and Increase Value

In 2003, health policy experts Gerard Anderson and Uwe Reinhardt, along with two Johns Hopkins doctoral candidates, published an article in Health Affairs provocatively titled “It’s The Prices, Stupid: Why The United States Is So Different From Other Countries.” The article reports data from 2000 published by the Organization of Economic Cooperation and Development (OECD) that showed U.S. per capita health spending to be 134 percent higher than the OECD median and 44 percent higher than the country with the next highest per capita expenditure. This occurred despite the fact that most utilization measures in the U.S., such as physician visits per capita and hospital bed days per capita, were below the OECD median.

Not much has changed since then, except that prices keep going up. Continue reading

Cut through to the “Gut” of Accidental Lacerations

One of the most controversial complications is an accidental laceration. It is a potentially preventable complication (PPC), a complication in all surgical cohorts for Healthgrades and is a patient safety indicator (PSI 15). Additionally, PSI 15 is included in the PSI 90 composite score and is the highest weighted component (29.83%). Hence, the importance of “getting it right” cannot be underestimated.

So when should an accidental laceration be documented, coded or clarified? Continue reading

The Oops Factor Part 2: Noncritical Errors

Back in September, I wrote a blog about documentation errors and listed various types of critical errors that could potentially impact patient safety, care, or treatment. Clearly, errors that can cause harm are the first and most important to detect and resolve. Some errors don’t carry such severe potential consequences, but they still impact documentation quality.

Why should we be concerned about noncritical errors if their presence does not hurt the patient? First, these errors can affect perception about the author and/or organization if they are not addressed and corrected, especially if frequent or habitual. No physician or administrator wants to be questioned in court concerning incomplete, inaccurate, or just plain sloppy documentation because it introduces doubt regarding the attention to detail and professionalism of the organization and individuals providing care to the patient. Continue reading

Who’s After Your Healthcare Data?

It has been impossible to ignore the number of data breaches in the news lately. Whether you have been directly affected or not, one thing is certain: data security should be a top priority, especially in the healthcare industry. This eye-opening article talks about the new focus of hackers: targeting healthcare data. Healthcare data is extremely valuable when compared to the current value of Social Security numbers or credit card numbers on the black market. John Halamka, CIO at Beth Israel Deaconess Medical Center in Boston, sums it up:

While a stolen Social Security number might sell for 25 cents in the underground market, and a credit card number might fetch $1, “A comprehensive medical record for me to get free surgery might be $1,000,” Halamka says. “It is a commodity that is hot on the black Internet [market].” Continue reading

The IHI Triple Aim and Informatics

Recently I attended the American Medical Informatics Association (AMIA) annual symposium in Washington, D.C. I focused mainly on sessions related to nursing, interoperability, or both. The keynote speaker for the nursing preconference session was Dr. Deborah Troutman, CEO of the American Association of Colleges of Nursing (AACN). Dr. Troutman spoke about the Institute for Healthcare Improvement’s (IHI) Triple Aim. This blog gives an overview of the Triple Aim, discusses how it pertains to informaticians, and ends with a discussion about where we need to focus in the future.

The Triple Aim is a framework for developing new designs to optimize health system performance and to capture social needs in healthcare. The three aims are experience of care, health of populations, and costs of health. Experience of care means that if a person gets sick, the perception of their care, including quality, effectiveness, timeliness, etc., should be high. Population health is focused on causes of illness, such as obesity, substance abuse, and heart disease. The final aim is to lower cost, not by decreasing what people receive in their care, but through process improvement and illness prevention. The desired state is person-centered and is not focusing on illness care but moving towards wellness. Continue reading

HIMagine That! Inter-Rater Reliability

Donna: Sue, have you heard people using the buzz word inter-rater reliability in the context of ICD-10?

Sue: Isn’t that a statistical formula used to determine agreement or consensus between two raters or judges?

Donna: Yes, but HIM professionals are using the term, not the formula, to compare the agreement rate between two or more coders coding a case in ICD-10. Continue reading