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Emphasis on quality means a new way of doing things
With the implementation of healthcare reform’s far-reaching initiatives, healthcare in this country is changing at dizzying speeds, and the role and mindset of case managers will have to change as well if they are to adapt to the new world, experts say.
"Healthcare delivery and reimbursement are changing drastically and creating new challenges and models for case management services. Mandates for quality now have financial implications, and the care coordination skills of nurses, social workers, and others will be the solution for much of the alignment necessary. Success for every segment of the continuum is going to take dramatically different ways of thinking about case management," says Karen Zander, RN, MS, CMAC, FAAN, president and co-owner of the Center for Case Management in Wellesley, MA.
In just the last few years, the Centers for Medicare & Medicaid Services (CMS) has moved from reimbursing hospitals for quantity toward basing payment on the quality of care hospitals provide and has stated its intentions to continue moving in that direction.
After the Patient Protection and Affordable Care Act was passed by Congress in 2010, CMS announced its Value-based Purchasing Program to reward hospitals for providing quality care, beginning in fiscal 2013. Initially, scores were based on processes of care and the patient experience. In the fiscal year beginning Oct. 1, 2014, 50% of hospitals’ scores are based on outcomes and efficiency, 30% on the patient experience, and only 20% on processes of care.
This year, CMS added a new domain to value-based purchasing. Hospital efficiency of care, also known as Medicare spending per beneficiary, bases hospital scores on spending during an entire episode of care starting three days before admission through 30 days after discharge. In fiscal 2015, the measure will make up 20% of a hospital’s value-based purchasing score. The figure will rise to 25% in 2016.
Penalties in the Hospital Readmission Reduction Program rose to 3% in fiscal 2015, and CMS added chronic obstructive pulmonary disease and total knee and hip arthroplasty to the program and proposes adding readmissions for coronary artery bypass graft in fiscal 2017.
In addition to those changes, the CMS Innovation Center, which was created by the Affordable Care Act, is piloting the Bundled Payments for Care Improvement Initiative, which pays a fixed price or lump sum for health services by multiple providers over a specified period of time or episode of care.
The latest initiatives by CMS are big game-changers for healthcare and for case managers, says Toni Cesta, RN, PhD, FAAN, partner and consultant in Dallas-based Case Management Concepts.
"Medicare spending by beneficiary and bundled payments involve length of stay and the cost of the case, and both are owned by case management. This is where case managers can have the biggest impact," she says.
Medicare’s new focus on quality and efficiency means that case managers must change their focus from concentrating on getting patients out the door as quickly and safely as possible to planning the transition and looking beyond hospital walls, says Catherine M. Mullahy, RN, BSN, CCRN, CCM, president and founder of Mullahy and Associates, a Huntington, NY-based case management consulting firm.
"A lot of hospitals still view case management as a utilization management function with the responsibility to move people in and out of the hospital as quickly as possible. They are going to have problems until they recognize that they have to do things differently," she says.
Hospitals have been focusing on cutting length of stay but now they are challenged to look at costs for post-acute care, Cesta points out.
"We’ve always tried to pick the least expensive option for the next level of care, but that needs to change," she says. Case managers need to take the quality of the post-acute providers into account as well as the costs, she adds. For instance, if a patient is likely to be able to manage at home with outpatient rehabilitation, that should be the option the case manager suggests, even if the patient’s insurance will pay for a subacute stay.
"It behooves hospitals to know which provider groups deliver the best value in post-acute care. Cheaper is not necessarily better," Zander says. For instance, case managers and discharge planners need to know which post-acute provider does the best work with orthopedic patients versus oncology patients, and which home care agency has organized specific readmission reduction programs.
The new healthcare arena continues to demand that individual decisions and subsequent plans have to be made with each patient and family/caregiver. In order to continue to provide customization within standardization, hospitals have to have a larger staff of care managers and social workers who have the ability to provide in-depth assessments and form relationships quickly, Zander says.
"They may be in a model that expects them to partner with each other across 30, 60, or 90 days of recovery. Length of time will not matter as much as cost per case across time and place," Zander says.
Case managers have only so much time, and with the focus on length of stay, either discharging patients or utilization review has gotten short shrift when case managers are expected to do both functions, Zander says. "Depending on the payer mix and contracts of specific hospitals, utilization review has become intense. However, utilization of resources will eventually include the relative price of providers at different levels of care. Criteria may become less important than internal systemwide agreements between levels of care," she says.
Zander predicts that people who do utilization review will become more like brokers and cost analysts who determine what the cost is likely to be for 30, 60, and 90 days for a particular patient.
Hospitals should create separate roles and job descriptions for nurses who do utilization review and those who do case management, Mullahy says.
"Years ago, hospitals decided that nurses can do both utilization review and case management. These are very different roles, and I don’t think the same nurse can do both effectively. Hospitals need to identify those professionals on the staff who are good at utilization review and those who will make good case managers," she says.
Case managers are going to have to understand what the right resource consumption is for each individual patient and work with physicians to keep the costs in line, Cesta says.
"Practice guidelines can dictate the resource usage for the average patient, but there has to be a way to balance and understand what happened when the case goes over in resource consumption," she says.
Since physicians make the final decision and order post-acute care, she suggests a hospitalwide drive to make physicians aware of the implications of what level of care they order. Analyze the cost per case by physician and point out when a lower level of care might have been just as effective, she suggests. "Physicians respond to data, and this is how to get their attention," she says.
Case management departments are going to need a commitment from their physician leader to take charge of implementing the changes. "Because the doctors are writing the orders, this has to be a physician-led initiative with support from the case managers," she says.