MetaStar Hospital Payment Monitoring Program (HPMP) Project Kick Off with Hospital Participants Reduction of Unnecessary One-Day Stays Through Use of.

MetaStar Hospital Payment MetaStar Hospital Payment Monitoring Program (HPMP) Monitoring Program (HPMP) Project Kick Off with Hospital Project Kick Off with Hospital ParticipantsParticipantsReduction of Unnecessary One-Day Stays Reduction of Unnecessary One-Day Stays Through Use of a Case Management Through Use of a Case Management ProtocolProtocol

Bill French, MBA, RHIA, CPHQ,CPHITBill French, MBA, RHIA, CPHQ,CPHITVice President eHealth StrategiesVice President eHealth Strategies

November 16, 2006November 16, 2006

Need for the ProjectNeed for the Project

56% of admission denials are one-day stays56% of admission denials are one-day stays

76% of admission denials are one- or two-76% of admission denials are one- or two-day staysday stays

Wisconsin has the 15Wisconsin has the 15thth highest ratio of one- highest ratio of one-day stays to all stays in the nation day stays to all stays in the nation

One-day stays account for over 14% of all One-day stays account for over 14% of all Wisconsin inpatient staysWisconsin inpatient stays

Wisconsin Ranks High in Specific DRGsWisconsin Ranks High in Specific DRGs

DRG 127 (Congestive Heart Failure) – 15DRG 127 (Congestive Heart Failure) – 15 thth

DRG 143 (Chest Pain) – 12DRG 143 (Chest Pain) – 12thth

DRGs 182 & 183 (GI) – 19DRGs 182 & 183 (GI) – 19th th

DRG 243 (Medical Backs) – 6DRG 243 (Medical Backs) – 6 thth

DRGs 296 & 297 (Nutritional) – 14DRGs 296 & 297 (Nutritional) – 14 thth

Need for the ProjectNeed for the Project

Some Wisconsin Hospitals may be at risk Some Wisconsin Hospitals may be at risk for attention by regulatory agenciesfor attention by regulatory agencies

The project is appropriate regardless of The project is appropriate regardless of PEPPER outlier status for the individual PEPPER outlier status for the individual hospitalhospital

How Did MetaStar Identify ThisHow Did MetaStar Identify ThisProject Topic?Project Topic?

Florida QIO completed a similar project in the 7Florida QIO completed a similar project in the 7 thth Statement of Work (SOW)Statement of Work (SOW)

Wisconsin Hospitals learned of the project and Wisconsin Hospitals learned of the project and requested MetaStar to consider a case requested MetaStar to consider a case management protocol-based projectmanagement protocol-based project

MetaStar HPMP Advisory Group supported MetaStar HPMP Advisory Group supported projectproject

Objectives of the Objectives of the Florida (QIO) ProjectFlorida (QIO) Project

Decrease the number of inappropriate Decrease the number of inappropriate inpatient admissionsinpatient admissions

Assist physicians in identifying the Assist physicians in identifying the appropriate care settingappropriate care setting

Assist hospitals in decreasing Medicare Assist hospitals in decreasing Medicare admission denialsadmission denials

Inappropriate Inpatient AdmissionsInappropriate Inpatient AdmissionsResulted From:Resulted From:

Lack of documentation by physicians to Lack of documentation by physicians to support medical necessity for inpatient support medical necessity for inpatient admissionadmission

Physician lack of knowledge and Physician lack of knowledge and understanding of the hospital admission understanding of the hospital admission criteriacriteria

Florida’s Case Management (CM) ProtocolFlorida’s Case Management (CM) Protocol

Based on the assumption that Case Based on the assumption that Case Managers and Utilization Management Managers and Utilization Management Personnel are proficient in the use of Personnel are proficient in the use of admission criteriaadmission criteria

Admissions based on case management Admissions based on case management protocol would provide more accurate protocol would provide more accurate assignment of inpatient admission statusassignment of inpatient admission status

Florida’s Case Management (CM) Protocol Florida’s Case Management (CM) Protocol (cont.)(cont.)

Physician order to admit patient per Case Physician order to admit patient per Case Management Protocol when inpatient is not the Management Protocol when inpatient is not the obvious care settingobvious care setting

Two to six hour hold status during which time CM Two to six hour hold status during which time CM assess the patientassess the patient

CM assigns patient to appropriate statusCM assigns patient to appropriate status

Decision upheld by ordering physicianDecision upheld by ordering physician

Design of Florida ProjectDesign of Florida Project

Identified intervention group of 20 hospitals Identified intervention group of 20 hospitals to utilize the CM protocolto utilize the CM protocol

Control group of similar hospitals not Control group of similar hospitals not utilizing the CM modelutilizing the CM model

Results of Florida ProjectResults of Florida Project

The relative reduction in admission denial rate The relative reduction in admission denial rate was three times greater for the protocol group as was three times greater for the protocol group as the control groupthe control group

Positive correlation between positive improvement Positive correlation between positive improvement and relative frequency of use of the protocoland relative frequency of use of the protocol

Protocol used in 30% of admissionsProtocol used in 30% of admissions

MetaStar Experience With PreviousMetaStar Experience With PreviousOne-Day Stay ProjectsOne-Day Stay Projects

Focused on discussions with MetaStar’s Focused on discussions with MetaStar’s Physician Consultant and Hospital Medical Physician Consultant and Hospital Medical StaffStaff

Discussions were generally favorable but it Discussions were generally favorable but it was difficult to engage a large number of was difficult to engage a large number of physicians physicians

Wisconsin Experience With PreviousWisconsin Experience With PreviousOne-Day Stay Projects One-Day Stay Projects

Hospitals utilizing a case management Hospitals utilizing a case management model more accurately assigned the correct model more accurately assigned the correct patient classificationpatient classification

Involvement of the physician in the case Involvement of the physician in the case management process resulted in more management process resulted in more accurate assignment of patient classificationaccurate assignment of patient classification

Two Phase ProjectTwo Phase Project

Phase One: Volunteer group of hospitals Phase One: Volunteer group of hospitals (PPS and CAH) develop and pilot protocols(PPS and CAH) develop and pilot protocols

Phase Two: High Outlier PPS hospitals not Phase Two: High Outlier PPS hospitals not participating in Phase Oneparticipating in Phase One

Baseline and re-measurement will be Baseline and re-measurement will be accomplished in both phasesaccomplished in both phases

Phase OnePhase One

All hospitals regardless of outlier status will All hospitals regardless of outlier status will be invited to participatebe invited to participate

Develop and pilot case management Develop and pilot case management protocolsprotocols

Employ case management protocols at the Employ case management protocols at the hospital level - if appropriatehospital level - if appropriate

Phase TwoPhase Two

Identified group of one-day stay high Identified group of one-day stay high outlier PPS hospitalsoutlier PPS hospitals

Will require a quality improvement plan Will require a quality improvement plan from the hospitalfrom the hospital

Project IndicatorsProject Indicators

Percent of one-day stays to all staysPercent of one-day stays to all stays

Gross payment error ratesGross payment error rates

Number of Wisconsin PPS hospitals Number of Wisconsin PPS hospitals utilizing a case management protocol at the utilizing a case management protocol at the beginning of the project compared to beginning of the project compared to conclusion of the projectconclusion of the project

Expectation of ParticipantsExpectation of Participants

Attend Webinars, calls and other eventsAttend Webinars, calls and other events

Consider use of a case management Consider use of a case management protocolprotocol

Include appropriate hospital and medical Include appropriate hospital and medical staff on the project staff on the project

Assist MetaStar in baseline and re-Assist MetaStar in baseline and re-measurementmeasurement

MetaStar’s RoleMetaStar’s Role

Work with individual hospitals or groups of Work with individual hospitals or groups of hospitals to develop a case management hospitals to develop a case management protocol appropriate for the hospitalprotocol appropriate for the hospital

Communicate with the Fiscal Intermediary Communicate with the Fiscal Intermediary and other agenciesand other agencies

Sponsor educational eventsSponsor educational events

Assist in overcoming barriersAssist in overcoming barriers

Project GoalsProject Goals

Relative reduction of one-day stays by 3%Relative reduction of one-day stays by 3%

Reduction of 458 unnecessary one-day Reduction of 458 unnecessary one-day staysstays

50% of PPS hospitals adopt a case 50% of PPS hospitals adopt a case management protocolmanagement protocol

Benefits of ParticipationBenefits of Participation

Feedback/education on CM process from Feedback/education on CM process from MetaStar and other participants MetaStar and other participants

Strengthen Compliance ProgramStrengthen Compliance Program

Assist in communication with Assist in communication with physicians/medical staff physicians/medical staff

Benefits of Participation Benefits of Participation (cont.)(cont.)

Assistance with overcoming barriersAssistance with overcoming barriers

Sharing of best practicesSharing of best practices

Benefit from previous successful project Benefit from previous successful project conducted in other statesconducted in other states

Coordination with Fiscal Intermediary Coordination with Fiscal Intermediary

Project TimelineProject Timeline

Determine baseline data – December 2006 through January Determine baseline data – December 2006 through January 20072007

Develop and implement Case Management Protocol – Develop and implement Case Management Protocol – January 2007 through March 2007January 2007 through March 2007

Implement and utilize protocols – April 2007 through Implement and utilize protocols – April 2007 through August 2007August 2007

Determine re-measurement and sustain improvements – Determine re-measurement and sustain improvements – September 2007 through November 2007September 2007 through November 2007

Next StepsNext Steps

Participants sign/decline Confidentiality Participants sign/decline Confidentiality Agreements to work as part of a groupAgreements to work as part of a group

Gather questions, barriers, concerns to be Gather questions, barriers, concerns to be addressed by MetaStaraddressed by MetaStar

Determine where hospitals are in the Case Determine where hospitals are in the Case Management Protocol processManagement Protocol process

A Word About PEPPERA Word About PEPPER

PProgram for rogram for EEvaluating valuating PPayment ayment PPatterns atterns EElectronic lectronic RReport (PEPPER)eport (PEPPER)

Provide trended data on how hospitals Provide trended data on how hospitals compare to other hospitals in the statecompare to other hospitals in the state

Provide trended data on how individual Provide trended data on how individual states compare to the nationstates compare to the nation

Provided quarterly to hospitals via QNetProvided quarterly to hospitals via QNet

PEPPERs PEPPERs (cont.)(cont.)

PEPPERs available on QNet for a period of PEPPERs available on QNet for a period of seven daysseven days

Hospital has to request report if not Hospital has to request report if not uploaded in seven daysuploaded in seven days

67% of hospitals open report in seven days67% of hospitals open report in seven days

MetaStar TeamMetaStar Team

Bill French, MBA, RHIA, Bill French, MBA, RHIA, CPHQ, CPHITCPHQ, CPHIT

Vice President eHealth Vice President eHealth [email protected]@metastar.com

Kim Horton, RHIT, CCS, Kim Horton, RHIT, CCS, CPHQCPHQ

Coding/UR ConsultantCoding/UR [email protected]@metastar.com

Candi Davis, RHIA, Candi Davis, RHIA, CPHQCPHQ

Coding/UR ConsultantCoding/UR [email protected]@metastar.com

Eric Streicher, MDEric Streicher, MDMedical DirectorMedical [email protected]@metastar.com

Jennifer ParisiJennifer ParisiAdministrative AssistantAdministrative [email protected]@metastar.com

Contact Information:Contact Information:

MetaStar, Inc.MetaStar, Inc.2909 Landmark Place2909 Landmark PlaceMadison, WI 53713Madison, WI 53713

(608) 274-1940(608) 274-1940

www.metastar.comwww.metastar.comThis material was prepared by MetaStar under contract with the Centers for Medicare & Medicaid Services (CMS), an agency of the 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 U.S. Department of Health and Human Services. The contents presented do not necessarily reflect CMS policy.  8SOW-WI-INP-06-53