Value Based Healthcare and Case Management

Every hospital in the country is grappling with the transition from “volume” to “quality”. Major paradigm shifts like this occur rarely in any industry and can be a major challenge to the strongest organizations. Part of the challenge in this case is comprehension all of the changes that coming quickly and potentially effecting the bottom line.

While every department of the hospital needs to know the ins and outs of healthcare reform and Value-Based-Purchasing (VBP), the Case Management Department may well be positioned to have more impact than any other.

There are actually several programs that will affect hospital’s reimbursement rolling out. The major initiatives that will affect virtually every hospital are the penalties for 30 re-admissions, penalties for hospital acquired conditions (HAC), incentives for “meaningful use”, and the Value-Based Purchasing initiative. Meaningful use will provide some incentive payments to hospitals that develop a robust information technology infrastructure. Of course, that only comes after a significant amount of expense dedicated to reaching meaningful use. The re-admission penalties will increasingly cost hospitals one to three percent of their base Medicare reimbursement. Hospital acquired conditions will result in an adjustment of up to one percent. The “value” of Value-Based Purchasing will be increasing from one percent to two percent over the next several years. In total, that puts up to six percent of a hospital’s revenue at risk at the same time that money will be required for IT investments to reach meaningful use.

Value-Based Purchasing (VBP) requires a bit more explanation. Conceptually, VBP represents the shift from volume to quality. The ideas is that the product (the delivery of care) will be purchased based on its value. By way of analogy, you would return food to the kitchen of your favorite restaurant if it was not cooked the way that you requested. The government no longer wants to pay for care that does not meet certain “quality” standards.

Quality is difficult to define and is often in the eye of the beholder. For some, it may mean access to the latest technology and world class physicians, wherever that may occur. For others quality care means being cared for by physician who has good communication and compassion near enough that family and friends can easily visit. Because of the elusive definition of quality, surrogates are used to measure “quality.”

Case Managers Work at Containing Cost

These surrogates include the Core Measures and Patient Safety Indicators that hospital’s are already required to measure and report. That accounts for seventy percent of the VBP factor. The remaining thirty percent is based on the patient surveys or Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) scores. So in this case, value means that the patient should receive care, measurable care metrics must be met and reported and the patient must have satisfactory experience and report it as such on the HCAHPS survey.
Case Managers have long been tasked with containing costs and utilization management for patients. While that has not and will not change, there are new opportunities. The Meaningful Use projects are likely beyond the reach of most case management departments, but the other areas may mesh well.

Case Managers are in the Best Position to Monitor Core Measures

Case Managers are the only hospital employees who really see the entire course of the patient stay. Therefore, they may be in the best position to monitor the core measures. These include the appropriate and timely use of antibiotics for pneumonia diagnoses or peri-operatively. They can monitor catheter removals, central-line care, ejection fraction documentation and other Core Measures. While there are generally other departments in the hospital who have primary responsibility for these tasks, Case Management may be the best option in smaller hospitals.
Maintaining HCAHPS scores is a role of everyone within a hospital. However, if Case Managers are truly managing a case, they will be focused on assuring that the patient’s needs are met. This will include communication with the physicians, staff, pharmacy, environmental services and food and nutrition services. All of these are opportunities for an improved patient experience and better surveys.

Readmissions are clearly in the Case Management arena. Myriad programs for reducing “unnecessary” or “inappropriate” readmissions have evolved. All of them focus on Case Management interventions. Increased communication regarding the disease process, better discharge instructions, appropriate post-acute services and follow-up with the necessary physicians in a timely manner are the staple of Case Management interventions. Post-discharge phone calls have been shown to be effective as well. Asking the right questions and tracking the responses can often be very helpful in determining actionable issues to reduce readmissions.

In summary, hospital facing razor thin margins now also face the reality that six percent of their revenue will be at risk based on these metrics. The Case Management Department stock has increased in the light of these challenges. Opportunities abound for Case Managers to learn about these metrics and step in to help their organization thrive. Wise Case Managers will seize the opportunity.