MetaStar Hospital Payment Monitoring Program (HPMP) Project Kick Off with Hospital Participants

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(No Transcript)
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MetaStar Hospital Payment Monitoring Program
(HPMP) Project Kick Off with Hospital
Participants

• Reduction of Unnecessary One-Day Stays Through
  Use of a Case Management Protocol
• Bill French, MBA, RHIA, CPHQ,CPHIT
• Vice President eHealth Strategies
• November 16, 2006

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Need for the Project

• 56 of admission denials are one-day stays
• 76 of admission denials are one- or two-day
  stays
• Wisconsin has the 15th highest ratio of one-day
  stays to all stays in the nation
• One-day stays account for over 14 of all
  Wisconsin inpatient stays

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Wisconsin Ranks High in Specific DRGs

• DRG 127 (Congestive Heart Failure) 15th
• DRG 143 (Chest Pain) 12th
• DRGs 182 183 (GI) 19th
• DRG 243 (Medical Backs) 6th
• DRGs 296 297 (Nutritional) 14th

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Need for the Project

• Some Wisconsin Hospitals may be at risk for
  attention by regulatory agencies
• The project is appropriate regardless of PEPPER
  outlier status for the individual hospital

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How Did MetaStar Identify ThisProject Topic?

• Florida QIO completed a similar project in the
  7th Statement of Work (SOW)
• Wisconsin Hospitals learned of the project and
  requested MetaStar to consider a case management
  protocol-based project
• MetaStar HPMP Advisory Group supported project

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Objectives of the Florida (QIO) Project

• Decrease the number of inappropriate inpatient
  admissions
• Assist physicians in identifying the appropriate
  care setting
• Assist hospitals in decreasing Medicare admission
  denials

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Inappropriate Inpatient AdmissionsResulted From

• Lack of documentation by physicians to support
  medical necessity for inpatient admission
• Physician lack of knowledge and understanding of
  the hospital admission criteria

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Floridas Case Management (CM) Protocol

• Based on the assumption that Case Managers and
  Utilization Management Personnel are proficient
  in the use of admission criteria
• Admissions based on case management protocol
  would provide more accurate assignment of
  inpatient admission status

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Floridas Case Management (CM) Protocol (cont.)

• Physician order to admit patient per Case
  Management Protocol when inpatient is not the
  obvious care setting
• Two to six hour hold status during which time CM
  assess the patient
• CM assigns patient to appropriate status
• Decision upheld by ordering physician

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Design of Florida Project

• Identified intervention group of 20 hospitals to
  utilize the CM protocol
• Control group of similar hospitals not utilizing
  the CM model

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Results of Florida Project

• The relative reduction in admission denial rate
  was three times greater for the protocol group as
  the control group
• Positive correlation between positive improvement
  and relative frequency of use of the protocol
• Protocol used in 30 of admissions

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MetaStar Experience With PreviousOne-Day Stay
Projects

• Focused on discussions with MetaStars Physician
  Consultant and Hospital Medical Staff
• Discussions were generally favorable but it was
  difficult to engage a large number of physicians

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Wisconsin Experience With PreviousOne-Day Stay
Projects

• Hospitals utilizing a case management model more
  accurately assigned the correct patient
  classification
• Involvement of the physician in the case
  management process resulted in more accurate
  assignment of patient classification

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Two Phase Project

• Phase One Volunteer group of hospitals (PPS and
  CAH) develop and pilot protocols
• Phase Two High Outlier PPS hospitals not
  participating in Phase One
• Baseline and re-measurement will be accomplished
  in both phases

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Phase One

• All hospitals regardless of outlier status will
  be invited to participate
• Develop and pilot case management protocols
• Employ case management protocols at the hospital
  level - if appropriate

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Phase Two

• Identified group of one-day stay high outlier PPS
  hospitals
• Will require a quality improvement plan from the
  hospital

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Project Indicators

• Percent of one-day stays to all stays
• Gross payment error rates
• Number of Wisconsin PPS hospitals utilizing a
  case management protocol at the beginning of the
  project compared to conclusion of the project

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Expectation of Participants

• Attend Webinars, calls and other events
• Consider use of a case management protocol
• Include appropriate hospital and medical staff on
  the project
• Assist MetaStar in baseline and re-measurement

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MetaStars Role

• Work with individual hospitals or groups of
  hospitals to develop a case management protocol
  appropriate for the hospital
• Communicate with the Fiscal Intermediary and
  other agencies
• Sponsor educational events
• Assist in overcoming barriers

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Project Goals

• Relative reduction of one-day stays by 3
• Reduction of 458 unnecessary one-day stays
• 50 of PPS hospitals adopt a case management
  protocol

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Benefits of Participation

• Feedback/education on CM process from MetaStar
  and other participants
• Strengthen Compliance Program
• Assist in communication with physicians/medical
  staff

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Benefits of Participation (cont.)

• Assistance with overcoming barriers
• Sharing of best practices
• Benefit from previous successful project
  conducted in other states
• Coordination with Fiscal Intermediary

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Project Timeline

• Determine baseline data December 2006 through
  January 2007
• Develop and implement Case Management Protocol
  January 2007 through March 2007
• Implement and utilize protocols April 2007
  through August 2007
• Determine re-measurement and sustain improvements
  September 2007 through November 2007

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Next Steps

• Participants sign/decline Confidentiality
  Agreements to work as part of a group
• Gather questions, barriers, concerns to be
  addressed by MetaStar
• Determine where hospitals are in the Case
  Management Protocol process

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A Word About PEPPER

• Program for Evaluating Payment Patterns
  Electronic Report (PEPPER)
• Provide trended data on how hospitals compare to
  other hospitals in the state
• Provide trended data on how individual states
  compare to the nation
• Provided quarterly to hospitals via QNet

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PEPPERs (cont.)

• PEPPERs available on QNet for a period of seven
  days
• Hospital has to request report if not uploaded in
  seven days
• 67 of hospitals open report in seven days

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MetaStar Team

• Bill French, MBA, RHIA, CPHQ, CPHIT
• Vice President eHealth Strategies
• bfrench_at_metastar.com
• Kim Horton, RHIT, CCS, CPHQ
• Coding/UR Consultant
• khorton_at_metastar.com
• Candi Davis, RHIA, CPHQ
• Coding/UR Consultant
• cdavis_at_metastar.com

• Eric Streicher, MD
• Medical Director
• estreich_at_metastar.com
• Jennifer Parisi
• Administrative Assistant
• jparisi_at_metastar.com

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Contact Information

• MetaStar, Inc.
• 2909 Landmark Place
• Madison, WI 53713
• [phone]
• www.metastar.com
• This material was prepared by MetaStar under
  contract with the Centers for Medicare Medicaid
  Services (CMS), an agency of the U.S. Department
  of Health and Human Services. The contents
  presented do not necessarily reflect CMS policy. 
  8SOW-WI-INP-06-53