Evidence-based practices benefit entire communities at a low cost.
While healthcare organizations have offered integrative health services such as massage therapy, acupuncture, and neurofeedback for the last two decades, most patients do not benefit from them due to sporadic offerings and high out-of-pocket costs. Ruthann Russo, PhD, and her employer Berkeley Research Group (BRG) aim to change this through a unique integrative population health (IPH) program. “Research shows that as many as 67% of hospitals offer integrative services to their patients that are managed as a revenue center and generally not covered by insurance. We want to do better,” says Russo.
IPH programs provide integrative healthcare services that help patients manage chronic conditions efficiently and at a low cost. Integrative health involves using natural and/or traditional interventions along with conventional medicine treatments, notes Russo, managing director at BRG in New York City. “IPH is a data-driven, evidence-based, customized, and person-focused methodology that helps healthcare organizations, hospitals, and employers expand their influence in the communities they serve, and it can be used in conjunction with a population health program,” says Russo, who develops programs for healthcare organizations and Fortune 500 companies.
How IPH works
IPH includes evidence-based therapies provided by a licensed and/or certified practitioner. It also uses integrative practices, which are first taught by a practitioner and later practiced independently by patients. Such practices include meditation, yoga, guided imagery, self-hypnosis, biofeedback, and acupressure.
Integrative therapies and practices can be used to treat the symptoms of almost any chronic condition, including diabetes, tobacco abuse, hypertension, obesity, and anxiety and depression, says Russo. She notes that while both integrative therapies and integrative practices are essential in helping patients manage chronic conditions, the latter are more effective in IPH, as they can be taught in a group setting to larger numbers of patients at a lower cost. For example, meditation is particularly effective in helping people with diabetes maintain stable blood sugar levels.
“We focus primarily on helping hospitals implement programs centered around teaching integrative practices to groups of patients,” says Russo. “Research shows that when you train people in a group setting, they not only learn the modality, but also are able to practice it, and this changes the patient’s behavior.”
Critical juncture: Why it’s the right time for IPH
Using IPH to help manage chronic conditions is cost-effective and creates a “significant and interesting competitive advantage,” says Russo. “These interventions provide a relationship-building opportunity with patients who are looking for help to improve their health, well-being, and lifestyle.” Research also tells a compelling story on the benefits of integrative health interventions, she adds. BRG research shows that in the state of Maryland, which operates the Maryland All-Payer Model, 83% of inpatients ages 5 and older can benefit from integrative health interventions.
IPH and traditional chronic disease management programs have key differences. Most traditional programs use case managers who provide one-on-one interventions with patients. IPH, however, focuses on group and community interventions and emphasizes health coaching. “To improve sustainability, we use evidence-based health coaching, as opposed to instruction,” says Russo. This involves guiding people through the stages of change and engaging them in specific communication techniques that help them learn from their peers.
Getting started
“Follow the data” to determine if IPH is right for your organization, recommends Russo. Data analytics clearly show the benefits of IPH from clinical, financial, and patient experience perspectives. “In our program, we analyze the research on every integrative practice and the clinical evidence supporting its efficacy in managing the symptoms of certain chronic conditions,” says Russo. The program matches ICD-10 codes to a specific hospital’s claim database to determine the percentage of patients who could benefit by participating in an IPH program. “Also, we can provide data analysis before and after an intervention and show its impact on medication use, length of stay, and overall patient satisfaction,” says Russo.
The medical literature builds a compelling case for using integrative practices, she adds. For example, one study shows that Beth Israel Deaconess Medical Center in Boston saved an estimated $367.50 per patient by providing hypnosis to reduce patients’ anxiety during interventional radiology procedures, producing estimated savings of $1.6 to $2.4 million annually.
It’s important to start with a strong team, says Russo: “Our teams employ doctoral-level-prepared professionals.” For organizations that are interested but not ready to fully commit, she suggests attempting an employee pilot program. “We have had a lot of interest from self-insured hospitals that want to try out the program with staff and even physicians and senior leaders. This gives you an opportunity to see if it is right for your organization and to build support, which is so critical with new programs.”
Hospitals are creating strategic programs to improve physician documentation practices
As patient care continues to move from inpatient to outpatient settings, hospitals are mobilizing for change. The March 2016 Medicare Payment Advisory Commission Report to the Congress: Medicare Payment Policy shows hospital inpatient discharges declined nearly 20% between 2006 and 2014, while outpatient services experienced a cumulative increase of approximately 44%. Hospitals are employing higher numbers of physicians and unveiling new strategies focused on outpatient growth. The number of hospital-employed physicians jumped 50% from 2010 to 2015, says Bonnie Peters, a managing director at Berkeley Research Group. “Coupled with the fact that value-based reimbursement continues to grow, this is incentivizing hospitals to launch outpatient clinical documentation improvement (CDI) programs,” says Peters.
Inpatient vs. outpatient CDI
While hospital leaders may be familiar with inpatient CDI, there are key differences with outpatient CDI, notes Peters. For example, an inpatient CDI program’s focus revolves around chart reviews during the patient’s stay. Hospitals also concentrate on an accurate case-mix index and identifying comorbid and major comorbid conditions. “Outpatient CDI reviews occur at a much faster pace, and there are different billing forms and coding rules/regulations,” explains Peters; also, physicians do not have the same resources to dedicate to outpatient CDI. However, it is becoming more critical to accurately capture ICD-10-CM diagnosis codes in the outpatient environment, as physicians’ reimbursement is predicated on quality over volume.
Inpatient and outpatient settings also differ in how they approach revenue, says Peters. “In the inpatient arena, a strong CDI program ensures providers are accurately capturing the severity of illness (SOI) and acuity of the patient to include any comorbid conditions. This drives appropriate reimbursement, which impacts the return on investment. Whereas in the outpatient arena, the organization may focus more on revenue protection and preventing denials.”
Why outpatient CDI is critical today
Outpatient CDI is also receiving buzz due to Medicare payment changes impacting physician practices, including the MACRA Quality Payment Program and its two tracks: the Merit-based Incentive Payment system (MIPS) and the advanced Alternative Payment Models. For the first year of MACRA, more than 70% of physicians will participate in the MIPS track, says Peters. “Under MIPS, physicians’ documentation this year will affect their 2019 reimbursement.”
Having a strong outpatient CDI program is important. “The resources that physician practices need are growing at an exponential pace,” says Peters. “They need to provide quality care and manage costs simultaneously in the outpatient setting, just as they do in the inpatient setting. The only way they can achieve this is if their documentation is accurate and complete.” Also, with Medicare Advantage growth, providers are under even more pressure to document accurately. By the 2020s, it is projected that as many as 40% of Medicare beneficiaries will be in a Medicare Advantage plan that uses Hierarchical Condition Categories for payment, says Peters. Documentation is especially critical with Medicare Advantage because the diagnoses that physicians document also predict future expenditures, she explains.
“It is important to capture additional specificity, accurately document the SOI, and link those conditions as appropriate, like we do with the inpatient CDI. If physicians do not capture the true SOI and risk of mortality for patients, they will not be reimbursed appropriately for the level of care they are providing under a risk-adjusted model,” Peters notes. This is where an outpatient CDI program is essential. For example, an outpatient CDI specialist can help Medicare Advantage–participating physicians document all conditions to the greatest specificity each year so the physicians receive the appropriate reimbursement for the care provided.
Getting started
When creating an outpatient CDI program, key areas to consider include Medicare risk adjustment in hospital-owned practices and the emergency department, especially if the facility has a high volume of medical necessity denials, says Peters. “Sometimes we see gaps or conflicting provider documentation in the ED.” It is important to have the correct documentation when a patient is placed into observation or is admitted to inpatient status.
Start with data analysis and review outpatient charges and denials related to coding for the previous 12 months, suggests Peters. Also, perform documentation and operational assessments, reviewing workflow and charge capture entry on encounter forms. It is also important to interview the coding and accounts receivable staff to learn about denial activity. Finally, perform a charge capture audit to determine which charges are being billed inappropriately; provide physician training, including a corrective action plan; and establish best practices. Ultimately, says Peters, “developing a detailed outpatient CDI strategy isn’t just about improving the bottom line, but also about capturing accurate documentation that supports the high quality of care provided.”
CMS partnership changes hospital financial incentives, resulting in more than $400 million in savings over three years.
"As we transition to value-based care, including ACOs and other models, the techniques being piloted in Maryland have more and more appeal." — Patrick Redmon, PhD, director at Berkeley Research Group
In 2014, Maryland and CMS’ Center for Medicare & Medicaid Innovation took a significant step toward value-based care by beginning to partner in a demonstration model that updated the state’s unique all-payer hospital payment system and its 36-year Medicare Waiver.
The result was the Maryland All-Payer Model, a five-year initiative designed to cut Medicare costs and boost care quality. The demonstration model requires hospitals to rein in spending and reduce hospital-acquired conditions (HAC) and unnecessary hospitalizations through tighter collaboration and rigorous quality programs. To date, hospitals have saved hundreds of thousands of dollars and are meeting other key goals. The All-Payer Model also has implications for hospitals in other states.
Creating a new model of care
Maryland was a strong target for the All-Payer Model because of its existing payment system. Under the state’s original Medicare Waiver and all-payer system, hospitals were paid the same rate from commercial and government payers, with the stipulation that Medicare costs could not grow faster than the national average. This posed a problem when the Affordable Care Act (ACA) was passed, says Patrick Redmon, PhD, director at Berkeley Research Group. As hospitals reduced readmissions and short stays, they were left with sicker patients and higher charges per case, he explains.
"The All-Payer Model seeks to change this by conforming to the ACA and the IHI’s Triple Aim," says Redmon. "Instead of focusing on DRGs and charge per case, the demonstration model is trying to improve care coordination and contain hospital costs as well as the total cost of care." Under the demonstration, hospitals are paid through a global or a fixed budget. "Providers are strongly incentivized to move away from volume-based care and keep patients healthy and out of the hospital," Redmon says.
All-payer key provisions
The demonstration, which applies to hospital care for Maryland residents only, has five provisions. The first is a requirement that 80% of the state’s hospital revenue fall under a population-based reimbursement method by year five of the model. Second, hospital spending cannot grow faster than the state’s economy. The demonstration caps hospital gross patient revenue at 3.58% per capita annually, which matches Maryland’s 10-year per capita growth of its gross state product, says Redmon. "Prior to this, Maryland’s hospital per capita revenue was growing at double the rate of the state’s economy."
Provisions three and four call for Maryland hospitals to reduce Medicare readmissions to the national average and reduce HACs by 30% over the course of the demonstration model. Regarding the latter, hospitals must meet the requirements of the Maryland Hospital Acquired Conditions program, which includes 65 potentially preventable complications. The final provision requires hospitals to save $330 million over the entire demonstration.
Hospitals move the needle
Maryland hospitals are rising to the challenge and changing care delivery, says Redmon. "They’ve had to reconfigure their thinking and work more closely with physicians and post-acute care providers to take care of patients with a fixed budget." The state is helping through grant money for infrastructure that improves care coordination, especially for patients who are frequently readmitted. Hospitals are using the funds to implement case management programs, station nurse practitioners in nursing homes, and establish more mental health resources.
Mid-demonstration results are positive. The state regulatory agency has limited hospital revenue growth to less than 3.58% in the first three years, says Redmon. The state also estimates it has saved Medicare more than $400 million. Maryland hospitals have met their goal for reducing HACs and are on track to lower Medicare readmissions to the national average. Moreover, approximately 95% of state hospital revenue is now under a global budget, which meets the definition of a population-based model.
Still, challenges have emerged with the transition to a global budget, says Redmon. Global budgets were developed based on historic volumes, but some hospitals have experienced a rise in volumes due to shifting populations, changing physician affiliations, and normal changes in use rates that occur over time. "Hospitals that are acquiring volume are getting hurt financially," says Redmon.
"To compensate for this, state regulators have developed a methodology that allows dollars to follow patients when they shift across facilities," Redmon says. But he adds that only 25 cents on the dollar is changing from one hospital to another. The state must also figure out how to pay for hospital innovations, such as new technology systems, under a fixed budget. "Both are longer-term policy discussions," says Redmon.
CMS considers next moves
"As we transition to value-based care, including ACOs and other models, the techniques being piloted in Maryland have more and more appeal," says Redmon. CMS has indicated an interest in using global budgets outside of Maryland, he adds. In the meantime, Maryland hospitals are preparing for phase two of the demonstration, which seeks to control total state Medicare spending over a five-year period. "In addition to containing hospital costs, it will also target physician and post-acute care spending, which together comprise about three quarters of the total spend for Maryland Medicare patients," says Redmon.
