Healthcare Reform Spawns Daunting Regulations

Cheryl Clark, for HealthLeaders Media , January 13, 2011
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"By how much it overstates it will vary by hospital, but it will likely result in more hospitals than appropriate being cut by the maximum penalty."

The AHA is working to correct that language, he says.

For Jeff Rose, MD, vice president of clinical excellence, informatics, for Ascension Health, a St. Louis-based system with 67 hospitals in 20 states, a top concern is that the regulations require standardization of what and how hospitals must report and to whom. And that's especially true with readmissions, which he says many hospitals now record diagnostically in a variety of ways.

"If we are going to be reimbursed based upon that data, we have to make sure that data is clean, comparable, and standardized," he says. "We need to be sure we're comparing apples to apples."

"You've got the AHRQ, HCAHPS, NHQM, and the RHQDAPU, in addition to anything you may be doing internally," Rose says. "And there's The Joint Commission, and meaningful use. So now what we have is a whole lot of data confusion about what's going to need to be reported, and how, and when. Getting that data together, consistent and valid as well as timely, is a very big deal."

And that's the job of the government or its regulators to make that happen, he says. They should "specify precisely the terminology or codes to be used, and the definitions or conditions of those codes, to provide the necessary clarity. And it is then the hospital's responsibility to ensure that their reporting is mapped precisely to the definitions, codes, or terms."

M. Michael Shabot, MD, system chief medical officer for Memorial Hermann Healthcare System in Houston, sees another major flaw in the readmission legislation: There's no allowance if the patient fails to follow discharge instructions. "There is no provision we see for patient accountability," he says.

But Memorial Hermann isn't sitting around complaining. Several years ago, it launched an aggressive readmission program for congestive heart failure patients in which hospital teams send patients home with their first supply of medications and make their first postdischarge appointments with their doctors. So far, says Pat Metzger, system executive for care management, the program has lowered 30-day returns by 50% among its 700 participants. 

"We were seeing a lot of our CHF patients coming back, and realized that they just needed someone to talk to and to remind them of the things they needed to be doing," Metzger says. The Memorial Hermann community case managers call the patients to make sure they're following other instructions.
Many hospital executives express concern that the regulations---when they emerge---must be precise about how the penalties will be imposed. "I also don't think it's totally clear how hospitals will be selected to be in the penalty group," Shabot says.

Which readmissions will be counted, and will the severity adjustment for patients with multiple comorbidities be fair? Will planned readmissions be excluded? And will readmissions that are obviously unavoidable, for a patient who fell or had a new and unrelated acute diagnosis, be counted, too?

Hospital Value-Based Purchasing Program

For discharges after Oct. 1, 2012, this PPACA provision will drop DRG reimbursement for all prospective payment system hospitals by 1% in FY 2013, 1.25% in FY 2014, 1.5% in FY 2015, 1.75% in FY 2016, and 2% in FY 2017 and thereafter.

But hospitals will have a chance to earn that back starting in FY 2013. Before then, the HHS secretary will establish a methodology for evaluating quality of care provided for heart attack, heart failure, and pneumonia patients; those undergoing certain surgeries; and those who were treated for healthcare-associated infections as posted here.

The measures will also assess efficiency in how much the hospital spends per beneficiary. And the scoring equation will include HCAHPS scores of what patients thought of their care.

The elements included in this score could number more than 10, says John Byrnes, MD, senior vice president of system quality for Spectrum Health, a seven-hospital nonprofit health system based in Grand Rapids, MI. "We know every way in which we currently operate is going to change. Particularly, we'll need to significantly decrease our costs of care, at the same time we improve our clinical outcomes," he says.

For Bruce Solomon, COO of Stony Brook University Medical Center, a 571-licensed- and -staffed-bed hospital on Long Island, NY, cutting costs has meant a project to decrease its FTE per adjusted occupied bed expenditures by redeploying administrators to other jobs and practicing more cost-effective medicine. "Instead of ordering an x-ray, CBC, or blood culture every day, tests are based on current clinical criteria and need and, as a result, have decreased substantially," he says.

For some hospitals, then, there's a race to eliminate waste where doing so also improves patient satisfaction and speeds up care. 

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