Articles on Compliance Strategies

Featured Health Business Daily Story February 12, 2008

Hospitalists Can Help Reduce Rate of Medically Unnecessary Admissions

Reprinted from REPORT ON MEDICARE COMPLIANCE, the nation's leading source of news and strategic information on false claims, overpayments, compliance programs, billing errors and other Medicare compliance issues.

The fact that hospitalists make a lot of admission decisions played a role in helping reduce the rate of medically unnecessary admissions in Michigan. Hospitalists are popular in Michigan hospitals, where the error rate for one-day stays has been reduced through a project sponsored by the Hospital Payment Monitoring Project (HPMP), CMS's vehicle to reduce inpatient payment errors.

At Borgess Medical Center in Kalamazoo, for example, hospitalists are responsible for 80% of Medicare patient admissions, says Marilyn Barnum, utilization management coordinator. So when she formed a team to address medically unnecessary Medicare one-day stays as part of the HPMP project that was run by the Medicare quality improvement organization (QIO) in Michigan, Barnum recruited both the chief clinical officer and a hospitalist.

"We decided to focus our energy for change on hospitalists since they make so many of the patient admissions," she says. "We figured we would have better success [with hospitalists] than with 200 other [private-practice] physicians around the hospital" with no particular loyalty — and who account collectively for only 20% of the Medicare admissions.

The team concentrated on reducing inappropriate one-day stays for cardiac-related problems since these are a frequent cause of unnecessary admissions. Chest pain (DRG 143), for example, is one of the 14 risk areas highlighted in Program for Evaluating Payment Patterns Electronic Report (PEPPER) submissions, which are hospital-specific data that QIOs provide to all hospitals nationally. The reports show where hospitals are above or below certain percentiles compared with all other hospitals in the state in each of the 14 risk areas so they can use their audit resources to further investigate the reason for the outlier billing.

In addition to the hospitalist, chief medical officer and Barnum, the team included the director of care management, an emergency department (ED) care manager, a care manager from the cardiac care center, an RN from patient placement area who does admission review and one staff/charge nurse from the cardiac area since the hospital was focusing on cardiac-related problems.

Physician Orders Are Part of Care Pathways

At first, the team met weekly and then biweekly through the spring, summer and fall of 2007. The team devised and implemented ideas for reducing inappropriate one-day stays that have been quite effective, she says. The goal is to make it absolutely clear whether the physician wants the patient to be admitted to an inpatient bed or placed in observation status. Because this isn't always a meaningful distinction to the doctor — beds are beds, treatment is treatment, and only the hospital cares because the reimbursement is vastly different for inpatient versus observation — this has long proved an uphill battle. But if the patient's admission is not considered medically necessary according to Medicare (as indicated by admission screening criteria like InterQual), the hospital's out of luck. So the team brainstormed a way to ensure physicians were explicitly indicating where the patient should be placed, and that it would be medically necessary.

The most innovative idea: incorporating the physician order into clinical pathway protocols, also known as care pathways, Barnum says. These are the sets of descriptions of the patients' symptoms and treatment plans according to pre-set plans.

Until 426-bed Borgess came up with this idea, status orders (e.g., inpatient versus observation) signed by the physician would not have been on pathways, she says. There was a separate order sheet, and physicians were expected to indicate what the patient's status should be on the otherwise-blank order sheet. "But often they did not check a box, so the order status was not clear," Barnum says.

Now "we have the order on the pathways [documentation]," she says. "If physicians sign the admitting order, that's just part of it."

For example, if the patient comes in for chest pain, there are two paths to go down. Observation is usually an appropriate placement for patients following ED treatment for the chest when the patient's cardiac enzymes and EKG are negative, and chest pain has resolved (either by itself or through the administration of nitroglycerin). If that's not the case, however, inpatient admission might be warranted. If the EKG and cardiac enzymes are positive, then the patient probably should be admitted as an inpatient. But the physician has to sign the proper order.

With the pathways method, "the order is right there from the beginning," she says. For instance, the statement that the patient needs to be admitted as an inpatient is smack dab in the middle of the "clinical pathway protocol for percutaneous transluminal coronary angioplasty/atherectomy/stent with or standby - pre-procedure." Now that the admission/observation order is integrated, the opportunity for error is much lower, according to Barnum. When the physician signs the clinical pathways, he or she is implicitly signing the admission or observation order, she says.

Borgess implemented other interventions to bring down the rate of one-day stays. Barnum cites the following:

Hospital administration approved extending the hours of case managers (Borgess calls them care managers) in the ED. "We went from a position of one person to where we have [the ED] covered seven days a week from 10 a.m. to 11 p.m.," she says. "Most admissions happen between 2:30 and 11 p.m."

Case managers help ensure admissions are medically necessary according to formal admission screening criteria. When admissions don't meet the criteria, case managers ask physicians to reconsider.

To help get the extra case manager time approved in the ED, "we had data, and we had ED physicians' support. We had all sorts of articles to support this, plus the chief medical officer's support," Barnum says. "This is seen as positive by the hospitalists' group. Case managers can consult with the doctor — hospitalist or resident — or physician assistant making admission decisions and ordering as the point person for us as we review the chart."

Borgess started physician training with staff physicians, including hospitalists. "We got on the agenda of different staff meetings for physicians, such as cardiologists," Barnum says. The chief medical officer did a short presentation, and she introduced the role of the case manager in the ED. Then, over the next three months, "dialogues with other staff physicians became easier," she says, which means it wasn't as personally challenging for case managers to ask physicians to reconsider an inpatient order, for example, that may be more appropriate as an observation placement.

The case managers look for "teachable moments" to encourage physicians to date and time their orders, says Barnum. "Some asked for InterQual criteria to brush up."

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