The Affordable Care Act, while not perfect and in need of improvement, has been a great success in many ways. It has resulted in the lowest number of uninsured Americans in history. It has brought access to health care to millions of hard working Americans through age and income-based subsidies on the federal and state exchanges, and, through Medicaid expansion, to millions of people who are employed but whose income is too high to qualify for Medicaid but too low to qualify for subsidies. These are the people who previously depended on hospital emergency rooms for crisis care and faced bankruptcy if unfortunate enough to develop a serious illness or have a damaging accident. 

I was pleased when President Trump promised health care reform that provided high quality universal coverage with lower premiums and lower deductibles – a plan with “heart.” Unfortunately, the Senate bill and House bills do none of this and will make the problems in health care worse.

In FY 2015, the Centers for Medicare and Medicaid Services (CMS) processed 1.2 billion claims. The Administrative Contractors denied 10% of these claims, amounting to 123 million denials. According to CMS, 3% of denied claims were appealed, resulting in 3.7 million appeals. (This CMS data does not distinguish between Part A and Part B claims, nor does it distinguish complex reviews of medical records from computer-generated automated denials of simple outpatient claims.)

Health care costs in this nation are much higher than any other developed nation. We are faced with this dilemma: How can we provide health care for more people and still pay less for it? On a microeconomic level, how do we provide beneficiaries with benefits that the current system does not entitle them to, but still achieve our overall macroeconomic goal of universal access to health care? The usual solution, unfortunately is to pay providers less. The less politically popular solution is to actually do something about healthcare bureaucracy, which consumes resources only modestly less than those used to actually pay hospitals and providers of care.

A big source of healthcare bureaucracy is the inpatient versus outpatient (including observation) level of care decision. Teams of hospital staff are employed to get it right. Teams of auditors are employed by the Centers for Medicare and Medicaid Services (CMS) to check their work and recoup overpayments. The One-Midnight Rule, proposed by ACPA Director Steven Meyerson MD, would relieve us of the need for a big chunk of that bureaucracy. What would providers need to know about the proposed One-Midnight Rule? JTCOP – Just Take Care Of Patients. If a beneficiary needs further care in the hospital after an ED visit, write an inpatient admission order. That’s all providers need to remember. It would be that simple.

“It removes the suffering of the sick, lessens the violence of their diseases, and it does not attempt to cure those who are mastered by their diseases, realizing that in such cases medicine is powerless.”

Does this sound familiar to your ears? Perhaps something you recently read or heard about the role of palliative care in managing chronic disease?

On December 15, Michael Salvatore, MD, FACP, CHCQM posted this comment on the popular RAC-Relief message board:

“Today we have 166 patients in beds [at our hospital] and 25 of them have either a human or electronic sitter – this is 15% of our inpatients whose minds are not working. They are all minds ravaged by mental illness, Lewy bodies, alcohol, amyloid, narcotics, trauma, and other things that most of us cannot imagine. Some are permanently lost, others just for the moment. Almost everyone is very old and either living alone or with a spouse who may have more or less mind left than they have. 

The current epidemic of copy/paste in documenting patient encounters in the hospital results not only in vacuous and voluminous notes but also another underappreciated consequence: accusations of fraud. 

All insurers, including Medicare, pay for content, not volume in documentation: they pay for the physician’s clinical judgment, not their computer skills. Including copy/pasted material in the medical record that is not identified as such is called cloning. Billing for services based on cloned records is a type of fraud.

Hospitals often track their outpatient to inpatient conversion rate, but this metric cannot be looked at in isolation. 

The devil, as they say, is in the details – and there is no benchmark to follow.

As our readers know, under the two-midnight rule physicians are supposed to admit patients they anticipate will require medically necessary hospital care for two midnights or more and use observation for those who need care in the hospital, but for a shorter period of time. When additional clinical information becomes available on observation patients that changes the treatment plan so that two midnights or more of hospital care are then anticipated, or the patient’s condition does not improve sufficiently for discharge prior to the second midnight, inpatient admission (conversion) is appropriate. At least that’s the way it’s supposed to work.

"When you need the answer to a medical question, ask the physician; when you need to know, what’s going on with your patient, ask a case manager!"

I sent this quote from an unknown source to my beloved case management team last week in recognition of National Case Management week. My role as a full time physician advisor is blessed by the fact that I get to interact in a supportive role with some of the most dedicated professionals in the healthcare world. Often a thankless, tiring, frustrating, and emotionally draining career, case managers across the country should be recognized as true caring and devoted professionals in every sense of the meaning.

Questions often arise about the use of screening criteria in utilization review (UR).

InterQual and MCG are nationally recognized commercial products consisting of specific clinical criteria used to assist in determining whether a patient qualifies for release from the hospital or Emergency Department, admission to the hospital, or placement in an outpatient bed with observation services. The proper use of screening criteria requires knowledge of which set a payer uses and an understanding of their limitations.

The deep gulf between part A and part B billing has been creating confusion in the minds of hospitalized Medicare beneficiaries when they believed they had been admitted as inpatient (paid by part A) but were actually in observation, an outpatient status paid by part B. Their financial liability for inpatient care is limited to the Part A deductible of $1,288, which covers up to 60 days of inpatient care, but as observation patients their out of pocket costs have included the annual part B deductible (currently $166), a 20% copayment for each part B service, and the billed charge for "self administered drugs"(those that the patient could take at home). Since January 1, the new comprehensive APC for observation services (C-APC 8011) has bundled all part B services associated with observation into a single bundled payment, limiting beneficiary copayment to 20% of the $2,275 hospital reimbursement plus the cost of the medications. The Office of Inspector General (OIG) has granted hospitals the option of discounting or giving away the self-administered drugs.

But most importantly for the many beneficiaries who may someday need skilled nursing facility (SNF) care, qualifying for the Medicare SNF benefit requires three nights of inpatient care but a night in observation doesn’t count toward that requirement.

Let's take a look at the operations of a typical clinical documentation improvement (CDI) program and examine how these programs may paradoxically and unexpectedly contribute to increased medical necessity and clinical validation denials.

Clinical documentation improvement programs strive to ensure that all relevant diagnoses that reflect patient acuity and severity of illness are documented in the chart. This process involves clinical documentation improvement specialists (CDISs) regularly reviewing charts and identifying potential opportunities for increased clinical specificity or for documenting additional diagnoses that are being managed, evaluated, and/or treated but are not documented. The CDIS sends a written non-leading query to the physician with a focus on the clarification of specificity or the documentation of additional diagnoses. If the physician agrees with inclusion of the diagnosis through his/her documentation, the results are tracked for outcome reporting for the CDI program.

A study from Johns Hopkins published in the British Medical Journal on May 3 (BMJ,2016;353:i2139) claimed that medical errors have caused some 250,000 deaths per year and are the third leading cause of death in the United States. According to an article in USA Today, this follows a 2010 study by the Office of Inspector General of the Department of Health and Human Services reporting 180,000 deaths per year from medical errors. And in 2013 a study by a NASA toxicologist who believes his son died in a hospital as a result of medical errors estimated this number at 210,000 to 400,000. 

This information should shock the public and healthcare professionals alike. But why are there so many errors?  

Community doctors have traditionally done three things in the hospital for their patients and for those they acquired when on-call: admissions, daily care, and discharges. Admitting and caring have been seamlessly taken over by hospitalists but discharging patients back to their primary care doctor remains problematic. Primary care doctors complain that they get insufficient follow up information and hospitalists complain there is insufficient access to practitioner’s offices for timely follow up visits. 

While hospitalists have freed up the community practitioner from hospital duties, there has been no reciprocal freeing up of openings in the community practice’s busy office schedule to see hospital discharges. I think this is due to several developments: 

Back in the day when I was in clinical practice – in the days of the paper chart (yes, charts were once on paper, like news was once in newspapers) during what we of a certain age now (egotistically) call "The Days of the Giants", I used a pen and paper to record daily progress notes in the hospital chart. After checking lab and X-ray reports, having a quick discussion with the patient’s nurse, and talking to and examining my patient, I sat down with a blank page in the chart, wrote the date (no one recorded the time back then) and after reviewing the notes and orders my consultants had written since the previous visit, started my SOAP note.

The SOAP note was the brilliant creation of Dr. Larry Weed, the guru of medical documentation, who in a now famous 1971 video (Don’t try to adjust your computer monitor; it’s black and white.) held up a massive paper chart and showed how it failed to provide a coherent record of the care or communicate critical clinical information. In emphasizing how the quality of the medical record reflected the quality of the care, Dr. Reed said, "the medical record is the care".

All of us realize that the field we work in, utilization management (UM) is driven by numbers - dashboards, length of stay (LOS), case mix index (CMI), observed over expected ratio (O/E), and many kinds of other numerical derivations.  But where do these numbers come from? Are they accurate? Are they current? Do they make sense or are we suffering from data overload?

To address this challenge, my hospital has decided to create a position of  “UM-dedicated Finance Analyst”. This idea was to create a new position for a data analyst who would have a finance background and report to the finance director, but would have at least 50 per cent of their duties centered in the UM Department.