Aligning Quality Outcomes Data with Financial Performance Driving Case Mix and Revenue Improvement Susan E. Belley, M.Ed., RHIA Cleveland Clinic Garri L. Garrison, RN, CPC, CMC, CPUR 3M Health Information Systems Cleveland Clinic Not-for-profit, multi-specialty academic medical center Integrates clinical and hospital care with research and education Consistently ranked as one of the nation s top hospitals by US News & World Report heart and heart surgery program ranked No. 1 in the nation since 1995 9 regional hospitals in Northeast Ohio, Cleveland Clinic Florida, the Lou Ruvo Center for Brain Health in Las Vegas and Cleveland Clinic Canada 2,000 full-time, salaried physicians and researchers 35,000 employees 1
In the News Obama Praises Cleveland Clinic For top-notch quality and lower costs One of America s Best Hospital Recognized by US U.S. News &W World ldreport for the 15th consecutive year HealthGrades Recognized by Hillcrest, Marymount and South Pointe Recognized for clinical excellence in 2010 Ohio Consumers Names Cleveland Clinic #1 National Research Corporation names Cleveland Clinic #1 in quality healthcare Magnet Recognition One of the highest honors bestowed upon a health care organization Other Recognitions Newsweek, The Hospital That Could Cure Health Care, CNN, Cleveland Clinic May Be Hospital of the Future, Healthcare Issues and Trends Financial pressures Healthcare consumerism Change to severity-based payment Reduction in payments due to MS-DRGs and RAC initiatives Pending change to ICD-10 2
Industry Issues that Impact Quality Data and Financial Performance Incomplete documentation Incorrect or incomplete coding Sequencing of coded data Understating complexity (both severity and risk of mortality) Documentation Impact on Quality Data Physician Documentation Principal Diagnosis Secondary Diagnosis Principal Procedures Secondary Procedures ICD-9-CM Codes DRG Assignment Severity-Level Profiles Risk-Adjusted Profiles Reimbursement Quality Measurements (Physicians/Hospitals) 3
The Challenge Physician Documentation is recorded in CLINICAL terms Breakdown between the two dialects Documentation for coding, profiling & compliance must contain specific DIAGNOSTIC terms This will be a bigger challenge when moving to ICD-10! Improved documentation bridges the communication gap Common Documentation Issues Unable to Code Acceptable to Code LUL Infiltrate LUL Pneumonia Hgb 5.2; Transfused Acute or Chronic Blood Loss Anemia Emaciated; Total Protein/Albumin Low; Nutrition Supplements Started Severe Protein Calorie Malnutrition ABG 7.22/68/44; Will Treat Accordingly Acute Respiratory Failure, Acidosis, etc. Will Rehydrate Patient Dehydration BP 70/40 on Dopamine for Support Shock Cardiac Enzymes Elevated; EKG Positive Acute MI No Overt CHF; Will Continue Meds Chronic systolic CHF Unable to Void; Cathed for 600 cc Urinary Retention Sputum Culture positive for Klebsiella, will Start antibiotics Klebsiella Pneumonia 4
Summary of 3M APR DRGs APR DRG Subdivide each APR DRG into subclasses 316 APR DRGs Four Severity of Illness Subclasses 1. Minor 2. Moderate 3. Major 4. Extreme Four Risk of Mortality Subclasses 1. Minor 2. Moderate 3. Major 4. Extreme 1,258 Subclass Cells 1,258 Subclass Cells Challenges with ICD-10 implementation Overcoming perception that transitioning to ICD-10 is only a Coding issue and HIM will handle the implementation - ICD-10 is a business issue that touches your revenue cycle, medical staff, and systems. It will require widespread education/ awareness/process change within your organization. Lack of Documentation Specificity to code to the highest degree within ICD-10 - Documentation requirements are greater under ICD-10 than they are today in ICD-9-CM Need to translate lists of codes used in departments - Pre-authorization ation lists, contracts, medical necessity, etc - Superbills, charge tickets, etc. Vendor Readiness - Testing 5
Specificity looks like this ICD-9-CM 821.01 Fracture of femur, shaft, closed S72301A Unspecified fracture of shaft of right femur, initial encounter for closed fracture S72301G Unspecified fracture of shaft of right femur, subsequent encounter for closed fracture with delayed healing S72302A Unspecified fracture of shaft of left femur, initial encounter for closed fracture S72302G Unspecified fracture of shaft of left femur, subsequent encounter for closed fracture with delayed healing S72309A Unspecified fracture of shaft of unspecified femur, initial encounter for closed fracture S72309G Unspecified fracture of shaft of unspecified femur, subsequent encounter for closed fracture with delayed healing S72321A Displaced transverse fracture of shaft of right femur, initial encounter for closed fracture S72321G Displaced transverse fracture of shaft of right femur, subsequent encounter for closed fracture with delayed healing ICD-10-CM S72322A Displaced transverse fracture S72326A Nondisplaced transverse of shaft of left femur, initial encounter for fracture of shaft of unspecified femur, closed fracture initial encounter for closed fracture S72322G Displaced transverse fracture S72326G Nondisplaced transverse of shaft of left femur, subsequent fracture of shaft of unspecified femur, encounter for closed fracture with subsequent encounter for closed fracture delayed healing with delayed healing S72323A Displaced transverse fracture of shaft of unspecified femur, initial encounter for closed fracture S72323G Displaced transverse fracture of shaft of unspecified femur, subsequent encounter for closed fracture with delayed healing S72324A Nondisplaced transverse fracture of shaft of right femur, initial encounter for closed fracture S72324G Nondisplaced transverse fracture of shaft of right femur, subsequent encounter for closed fracture with delayed healing S72325A Nondisplaced transverse fracture of shaft of left femur, initial encounter for closed fracture S72325G Nondisplaced transverse fracture of shaft of left femur, subsequent encounter for closed fracture with delayed healing S72331A Displaced oblique fracture of shaft of right femur, initial encounter for closed fracture S72331G Displaced oblique fracture of shaft of right femur, subsequent encounter for closed fracture with delayed healing S72332A Displaced oblique fracture of shaft of left femur, initial encounter for closed fracture S72332G Displaced oblique fracture of shaft of left femur, subsequent encounter for closed fracture with delayed healing S72333A Displaced oblique fracture of shaft of unspecified femur, initial encounter for closed fracture S72333G Displaced oblique fracture of shaft of unspecified femur, subsequent encounter for closed fracture with delayed healing Many possible codes 11 Baseline Parameters Specialty Respiratory Disorders Rheumatology Endocrinology Orthopedics Gynecology Ophthalmology Cancer Heart & Heart Surgery Digestive Disorders Urology Neurology & Neurosurgery U.S. News & World Report Ranking at Baseline 2005-2006* 10th 4th 8th 5th 9th 14th 14th 1st 2nd 2nd 6th 6
Baseline Parameters Other Parameters Baseline - MEDPAR 2005 Case Mix Index Overall 2.0665 Case Mix Index Medical 1.0784 Case Mix Index Surgical 2.9865 Severity of Illness 1.9431 Risk of Mortality 8.0% (lower than expected as compared to the peer group) Cleveland Clinic Objectives: To improve severity of illness and risk of mortality data To sustain Case Mix Index and prevent erosion due to regulatory changes To support internal quality initiatives To influence external quality measurements (US News & World Report Top 100 Hospitals) Begin preparation for ICD-10 implementation 7
Identified Areas to Manage Lack of awareness existed related to methodology and drivers within severity-adjusted system - Process/tools to see working APR DRG concurrently - Process to audit APR DRGs with deaths occurring in lower subclass levels Needed to proactively manage the change from CMS DRGs to MS-DRGs - Physician education - CDI Team and Coder education - Tools to support process and improve productivity Identified Areas to Manage Needed to manage new regulatory initiatives - Present on Admission status - Hospital Acquired Conditions - RAC activity Needed to improve capacity/productivity for CDI and Coding staff - Growing organization - Need to increase the number of concurrent reviews - Manage the volume of information in EMR, POA application and the potential impacts to Coding Quality and Productivity 8
Project Activities Implemented by Cleveland Clinic 1. Random audits to identify opportunities and focus areas 2. Educated staff on MS-DRGs and APR DRGs - Coding and CDI Teams - Physicians by specialty - Executive management 3. Established baseline information 4. Established oversight team - Manager of Coding and CDI - Supervisors from Coding and CDI - Physician sponsor from medical staff Project Activities Implemented by Cleveland Clinic 5. Utilized APR DRGs to identify target areas - Focused CDI Team and Coding staff on focus areas 6. Performed focus audits by Specialty group to review documentation, coding and determine patterns of missing information 7. Implemented pre-bill audit of cases that expired with a Mortality Subclass below 4 9
Project Activities Implemented by Cleveland Clinic 8. Implemented software to support existing CDI/coding team - Use of concurrent working APR DRG, MS-DRGs - Flag HACs and high risk RAC cases - Identify POA issues - Use of edits to identify what information is frequently missing from the medical staff - Use of ICD-10 educational edits 9. Built documentation edits into EMR 10. Implemented documentation rounds with specialties 11. Performed detailed data analyses by specialty identifying vulnerabilities Project Activities Implemented by Cleveland Clinic 12. Performed documentation audits on hospital and physician technical billing 13. Built improvement plans that address both hospital and technical billing 14. CDI/Coding staff participate in national CDI/coding roundtables and networking activities to continue search for best practice 15. Integrated CDI information into abstraction system to 5 teg ated C o at o to abst act o syste to facilitate improved communication between departments to influence outcome data 10
Next Steps for Cleveland Clinic Integrate tools to concurrently identify potentially preventable complications and readmissions - Allow us to proactively identify cases with potentially preventable complications and manage those cases to prevent additional complications/costs - Allow us to identify cases with potentially preventable readmissions or to manage those cases more aggressively Determine how we can integrate current tools and activities with computer-assisted coding tools - Determine how to continually utilize software to concurrently drive quality initiatives and improve productivity/quality of coding; move more toward editing functions Overall Case Mix - Cleveland Clinic 587% 5.87 Source: 3M TM APR DRG Classification System, Baseline is MEDPAR 2005 and Hospital Provided Data 2009 11
Understanding Your Case Mix Average Case Weights Medical Cases 1.00-125 1.25 Surgical Cases 2.00-3.50 In analyzing the change in your CMI from one year to another, the proportion of medical cases to surgical cases is of vital importance Medicine Case Mix - Cleveland Clinic 10.2 % Source: 3M TM APR DRG Classification System, Baseline is MEDPAR 2005 and Hospital Provided Data 2009 12
Surgical Case Mix - Cleveland Clinic 854% 8.54 Source: 3M TM APR DRG Classification System, Baseline is MEDPAR 2005 and Hospital Provided Data 2009 Case Mix Index By Service Lines 1.0558 1.1355.8059 1.9196 1.6803 1.0783 1.2096 1.0318 2.9403 5.1177 Pulmonary (2009) Pulmonary y( (Baseline) Renal (2009) Renal (Baseline) Cardiology (2009) Cardiology (Baseline) Medicine (2009) Medicine (Baseline) Neurology (2009) Neurology (Baseline) ) Source: 3M TM APR DRG Classification System, Baseline is MEDPAR 2005 and Hospital Provided Data 2009 13
Case Mix Index By Service Lines 2.6927 2.2286 2.1340 2.1055 5.8768 5.5370 CT Surgery (2009) CT Surgery (Baseline) Neuro Surgery (2009) Neuro Surgery(Baseline) Orthopedics (2009) Orthopedics (Baseline) Surgery (2009) Surgery (Baseline) 2.6970 2.3811 Source: 3M TM APR DRG Classification System, Baseline is MEDPAR 2005 and Hospital Provided Data 2009 Overall SOI Case Mix - Cleveland Clinic Source: 3M TM APR DRG Classification System, Baseline is MEDPAR 2005 and Hospital Provided Data 2009 14
SOI Case Mix By Service Lines 4.9634 5.4399 CT Surgery (2009) CT Surgery (Baseline) 2.6229 2.1811 1.8635 1.6531 Neuro Surgery (2009) Neuro Surgery(Baseline) Orthopedics (2009) Orthopedics (Baseline) Surgery (2009) Surgery (Baseline) 2.6728 2.1010 Source: 3M TM APR DRG Classification System, Baseline is MEDPAR 2005 and Hospital Provided Data 2009 Overall ROM Variance - Cleveland Clinic Lower Than Expected (Favorable) Average Higher Than Expected (Unfavorable) Source: Risk Adjustment by the 3M TM APR DRG Classification System and Hospital Data; Expected deaths are based on the State of Ohio s average death rate, risk adjusted by the 3M APR DRG Classification System. Data based on all cases using selection criteria. No inference is made or conclusion can be drawn about the significance of actual to expected mortality variance without further study. 15
Medicare Risk-Adjusted Mortality Analysis -65.5 % -32.7 % CT Surgery (2009) CT Surgery (Baseline) -25 % -21.3 % 2.3 % 20.8 % Neuro Surgery (2009) Neuro Surgery(Baseline) Orthopedics (2009) Orthopedics (Baseline) Surgery (2009) Surgery (Baseline) 2.1010 Lower Than Expected (Unfavorable) Average Higher Than Expected (Favorable) Source: 3M TM APR DRG Classification System, Baseline is MEDPAR 2005 and Hospital Provided Data 2009 3M APR DRG 137 Major Respiratory Infections and Inflammations Severity of Illness Baseline Cleveland Clinic Hospital Current Cleveland Clinic Hospital APR DRG Subclass Level Variance from baseline Actual Cases Distribution Total Weight Actual Cases Distribution Total Weight 1 3 3.7% 2.0445 1 1.1% 0.6815 2 16 19.5% 14.7008 12 13.3% 11.0256 3 47 57.3% 63.2338 42 46.7% 56.5068 4 16 19.5% 35.9504 35 38.9% 78.6415 Total 82 100% 115.9295 90 100% 146.8554 4.6% SOI Weight 1.4138 SOI Weight 1.6317 Moved distribution in Subclass 3 and 4 from 76.8% to 85.6% Data based on all cases using selection criteria. No inference is made or conclusion can be drawn about the significance of actual to expected mortality variance without further study. 16
3M APR DRG 221 Major Small and Large Bowel Procedures Severity of Illness Baseline Cleveland Clinic Hospital Current Cleveland Clinic Hospital APR DRG Subclass Level Actual Cases Distribution Total Weight Actual Cases Distribution Total Weight 1 93 23.4% 119.3097 65 17.2% 83.3885 2 159 40.1% 278.9178 132 34.8% 231.5544 3 106 26.7% 318.7632 96 25.3% 288.6912 4 39 9.8% 244.6470 86 22.7% 539.4780 Variance from baseline Total 397 100% 961.6377 379 100% 1143.1121 1.4% SOI Weight 2.4223 SOI Weight 3.0161 Moved distribution in Subclass 3 and 4 from 36.5% to 48% Data based on all cases using selection criteria. No inference is made or conclusion can be drawn about the significance of actual to expected mortality variance without further study. 3M APR DRG 162 Cardiac Value Procedures with Cardiac Cath - Risk of Mortality Baseline Cleveland Clinic Hospital Current Cleveland Clinic Hospital APR DRG Subclass Level Actual Cases Expected Deaths Actual Deaths Actual Mortality Rate Mortality Rate % Variance Actual Cases Expected Deaths Actual Deaths Actual Mortality Rate Mortality Rate % Variance 1 15 0.5 0 0.0% -100% 1 0.0 0 0.0% 0% 2 151 1.4 1 0.7% -29% 47 0.6 0 0.0% -100% 3 96 6.6 5 5.2% -24% 78 2.6 0 0.0% -100% 4 43 11.5 7 16.3% -39% 71 12.0 9 12.7% -25% Total 305 20.00 13 4.3% -35% 197 15.2 9 4.6% -41% All deaths now classified to Subclass 4 Data based on all cases using selection criteria. No inference is made or conclusion can be drawn about the significance of actual to expected mortality variance without further study. 17
Baseline Parameters vs. Current Performance Specialty U. S. News & World Report Ranking at Baseline* Respiratory Disorders 10th 4th Rheumatology 4th 2nd Endocrinology 8th 6th Orthopedics 5th 4th Gynecology 9th 6th Ophthalmology 14th 11th Cancer 14th 12th Heart & Heart Surgery 1st 1st Digestive Disorders 2nd 2nd Urology 2nd 2nd Neurology & Neurosurgery 6th 6th Current U.S. News & World Report Ranking * U.S. News & World Report, July 2009 Baseline Parameters Other Parameters Baseline - MEDPAR Current Ranking 2005 Case Mix Index 2.0665 2.1879 Overall Case Mix Index 1.0784 1.1884 Medical Case Mix Index 2.9865 3.2415 Surgical Severity of Illness 1.9431 2.3508 Risk of Mortality 8.0% (lower than -10.9% (better than expected as compared to peer group) expected as compared to peer group) 18
Questions To Ask Does my publicly available data accurately demonstrate the quality of care my hospital provides? Does my hospital s quality allow me to build a solid brand awareness, compete with my competitors and grow market share? Am I losing revenue under ICD-9 today? Am I prepared p for ICD-10? Is my coding, documentation and medical necessity strong enough to pass a RAC audit? Ten Steps to Blending Quality and Financial Performance 1. Identify key physician leaders and executives to participate/lead the process 2. Establish a committee to be accountable for results Physician Leader HIM/Coding Manager Quality Manager Concurrent Review Manager (if you don t have a concurrent review program based on quality, you should implement one) Executive Leaders (COO, CMO, VP Quality, CFO) 3. Establish your baseline performance in each area 4. Mutually agree on the data elements you plan to address based on baseline performance (CMI, Severity of Illness, Risk of Mortality, etc.) 5. Provide detailed education on addressing severity of illness and risk of mortality, documentation and quality issues 19
Ten Steps to Blending Quality and Financial Performance 6. Provide training to medical staff on correct documentation and reporting of complications 7. Utilize a severity-adjusted system for analyzing data otherwise credibility becomes an issue 8. Implement pre-bill mortality review for subclass less than 4 on cases that expire 9. Establish both quality and financial goals and track results against goals 10. Continually assess focus areas; adjust focus areas as sustainment occurs Susan E. Belley Cleveland Clinic belleys@ccf.org Garri L. Garrison 3M Health Information Systems glgarrison@mmm.com 20