The Centers for Medicare and Medicaid Services' (CMS') Hospital Readmissions Reduction Program recently came under fire as hospitals question its fairness.
Providers and industry groups argue that the program does not take into account patients' socioeconomic status when calculating penalties. As a result, safety net hospitals are
significantly more likely to see their Medicare payments cut. Two senators responded by
introducing a bill they hope will make the calculation more equitable.
This conversation raises a fundamental question: to what degree can hospitals meaningfully affect patient outcomes — the numerator in the all-important quality calculation? Do provider decisions and care coordination really make a difference? Can we ultimately influence the way our patients behave? And is this a reasonable goal for hospitals, which unlike primary care providers, are one step removed from their patients' home lives?
We believe the answer is yes. Although the hospital cannot control patient behavior or the outcomes of disease, there is little question that better quality care leads to better outcomes. However, research suggests that financial incentives, care transition management and
provider-patient relationships can all influence patients' health behaviors.
As healthcare continues to shift toward value-based reimbursement, it's imperative that hospitals mobilize every available resource to engage providers in maximizing quality. In this post, we'll look at the importance of communication, and how working collaboratively with a few key players can help to boost the value of care provided.
The Importance of an Inpatient Strategy
When Congress first passed the Affordable Care Act industry experts predicted that the bulk of patient care would shift outside the hospital. Many expected that innovative care delivery models, such as accountable care organizations (ACOs), would soon dominate the landscape.
Hospital administrators responded by focusing externally. Many worked to improve clinical integration, create strong partnerships with primary care providers and partner with outpatient centers like ambulatory surgery centers, urgent care centers and community clinics.
To date, CMS' most successful quality achievements are on the inpatient side. Meanwhile, programs aimed at reducing hospital readmissions and hospital-acquired infections have prompted large-scale change, while ACOs have struggled to achieve widespread cost savings and acceptance.
So for the foreseeable future, administrators need to be doing everything they can to get their inpatient physicians and staff on board to promote success under value-based purchasing. By 2018, upwards of 30 percent of CMS revenues could be tied to performance metrics, and it's likely that private payers will follow suit.
So in order to maximize value, hospital administrators monitor and influence inpatient provider and staff behavior. It's crucial that every professional working in the Acute Care Continuum — hospitalists, ED providers, intensivists, anesthesiologists and others — understand hospital quality metrics and their meaning so they can become a partner in creating value.
Whom Should Administrators Be Communicating With?
To maximize patient outcomes, hospitals need to not only measure quality, but they must also communicate the necessary data to the individuals responsible for organizational change. Ideally, this communication should happen across multiple levels of the organization.
Vituity uses its business intelligence capabilities to assist our clients in this process. Based on our experience, here are some of the communication pathways that can be most effective for improving quality:
Payers. This "lever" for influencing behavior is often overlooked, but it can have a huge impact on physician priorities and decisions as well as resource utilization by patients. Onerous contract provisions can make it very difficult for both administrators and providers to focus on quality improvement. For this reason, administrators must work closely with the contracting team to shape win-win provisions for all stakeholders.
Care coordinators. Chronic disease is now the leading cause of death and disability in our country and accounts for the majority of healthcare spending. Incorporating case managers into the quality strategy helps patients access resources that can help to prevent both readmissions and future admissions. Resources include education, clinical monitoring and care planning.
Research suggests that case management is a cost-effective solution for increasing treatment adherence and self-management in at-risk patients.
Quality improvement departments. QI should ideally provide direction, coaching, structure and feedback to support quality initiatives across the hospital. Administrators enhance these efforts by regularly meeting with the quality team to discuss goals, review progress and troubleshoot roadblocks. Administrators can also support the QI efforts by fostering a culture of accountability. Everyone in the organization should understand the need for change and
take ownership of the process.
Providers. Physicians, nurses, nurse practitioners and physician assistants are in the best position to influence patient behavior, control costs and improve overall quality. They're also perhaps the most difficult for administrators to communicate with consistently and effectively. Because of this, we've dedicated a section to administrator-providers communication strategies.
Keys to Reaching Physicians
In order to change their behavior and become partners in achieving the organization’s goals, providers need timely, actionable feedback on their performance. To this end, many organizations rush out to purchase practice management software, thinking it will provide a turnkey solution.
There are several problems with this. One, commercially developed software often has data integrity issues. Two, it's costly. And three, given the well-documented shortcomings of some of these systems, providers are sometimes suspicious of the data.
To ensure the integrity of the program, Vituity developed an in-house practice management dashboard that provides individual feedback to every one of our hospitalists on:
- Length of stay (overall and by diagnosis-related group, or DRG)
- Case mix index (which relates to documentation quality)
- Readmission rate (overall and by DRG)
- Providers per case (how many hospitalists cared for the patient during the stay—this metric measures care continuity throughout the hospitalization)
- Scores on all other CMS and Physician Quality Reporting System (PQRS) measures
Using this tool, our medical and regional directors can provide hospitalists with direct and timely performance feedback. And because the solution was developed in-house with the involvement of many of our own physicians, providers are far more likely to trust the results and act upon them.
The Power of a Partnership
Today's hospitals face many challenges in the transition to value-based reimbursement, and positive partnerships can help. An aligned physician group can be an enormous asset in this process by providing innovative solutions and leadership. Data transparency can tackle the very problems that ACOs and other internal and external cost containment and quality improvement strategies have failed to solve. Further, by monitoring physician behavior and providing data-driven feedback, the partner group relieves administrators of a considerable burden, freeing them to focus on the big picture of change.
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