MetaStar Hospital Payment Monitoring Program (HPMP) Project Kick Off with Hospital Participants Reduction of Unnecessary One-Day Stays Through Use of a Case Management Protocol Bill French, MBA, RHIA, CPHQ,CPHIT Vice President eHealth Strategies November 16, 2006

Need for the Project 56% of admission denials are one-day stays 76% of admission denials are one- or two- day stays Wisconsin has the 15 th highest ratio of one- day stays to all stays in the nation One-day stays account for over 14% of all Wisconsin inpatient stays

Wisconsin Ranks High in Specific DRGs DRG 127 (Congestive Heart Failure) – 15 th DRG 143 (Chest Pain) – 12 th DRGs 182 & 183 (GI) – 19 th DRG 243 (Medical Backs) – 6 th DRGs 296 & 297 (Nutritional) – 14 th

Need for the Project Some Wisconsin Hospitals may be at risk for attention by regulatory agencies The project is appropriate regardless of PEPPER outlier status for the individual hospital

How Did MetaStar Identify This Project Topic? Florida QIO completed a similar project in the 7 th Statement of Work (SOW) Wisconsin Hospitals learned of the project and requested MetaStar to consider a case management protocol-based project MetaStar HPMP Advisory Group supported project

Objectives of the Florida (QIO) Project Decrease the number of inappropriate inpatient admissions Assist physicians in identifying the appropriate care setting Assist hospitals in decreasing Medicare admission denials

Inappropriate Inpatient Admissions Resulted From: Lack of documentation by physicians to support medical necessity for inpatient admission Physician lack of knowledge and understanding of the hospital admission criteria

Florida’s Case Management (CM) Protocol Based on the assumption that Case Managers and Utilization Management Personnel are proficient in the use of admission criteria Admissions based on case management protocol would provide more accurate assignment of inpatient admission status

Florida’s Case Management (CM) Protocol (cont.) Physician order to admit patient per Case Management Protocol when inpatient is not the obvious care setting Two to six hour hold status during which time CM assess the patient CM assigns patient to appropriate status Decision upheld by ordering physician

Design of Florida Project Identified intervention group of 20 hospitals to utilize the CM protocol Control group of similar hospitals not utilizing the CM model

Results of Florida Project The relative reduction in admission denial rate was three times greater for the protocol group as the control group Positive correlation between positive improvement and relative frequency of use of the protocol Protocol used in 30% of admissions

MetaStar Experience With Previous One-Day Stay Projects Focused on discussions with MetaStar’s Physician Consultant and Hospital Medical Staff Discussions were generally favorable but it was difficult to engage a large number of physicians

Wisconsin Experience With Previous One-Day Stay Projects Hospitals utilizing a case management model more accurately assigned the correct patient classification Involvement of the physician in the case management process resulted in more accurate assignment of patient classification

Two Phase Project Phase One: Volunteer group of hospitals (PPS and CAH) develop and pilot protocols Phase Two: High Outlier PPS hospitals not participating in Phase One Baseline and re-measurement will be accomplished in both phases

Phase One All hospitals regardless of outlier status will be invited to participate Develop and pilot case management protocols Employ case management protocols at the hospital level - if appropriate

Phase Two Identified group of one-day stay high outlier PPS hospitals Will require a quality improvement plan from the hospital

Project Indicators Percent of one-day stays to all stays Gross payment error rates Number of Wisconsin PPS hospitals utilizing a case management protocol at the beginning of the project compared to conclusion of the project

Expectation of Participants Attend Webinars, calls and other events Consider use of a case management protocol Include appropriate hospital and medical staff on the project Assist MetaStar in baseline and re- measurement

MetaStar’s Role Work with individual hospitals or groups of hospitals to develop a case management protocol appropriate for the hospital Communicate with the Fiscal Intermediary and other agencies Sponsor educational events Assist in overcoming barriers

Project Goals Relative reduction of one-day stays by 3% Reduction of 458 unnecessary one-day stays 50% of PPS hospitals adopt a case management protocol

Benefits of Participation Feedback/education on CM process from MetaStar and other participants Strengthen Compliance Program Assist in communication with physicians/medical staff

Benefits of Participation (cont.) Assistance with overcoming barriers Sharing of best practices Benefit from previous successful project conducted in other states Coordination with Fiscal Intermediary

Project Timeline Determine baseline data – December 2006 through January 2007 Develop and implement Case Management Protocol – January 2007 through March 2007 Implement and utilize protocols – April 2007 through August 2007 Determine re-measurement and sustain improvements – September 2007 through November 2007

Next Steps Participants sign/decline Confidentiality Agreements to work as part of a group Gather questions, barriers, concerns to be addressed by MetaStar Determine where hospitals are in the Case Management Protocol process

A Word About PEPPER Program for Evaluating Payment Patterns Electronic Report (PEPPER) Provide trended data on how hospitals compare to other hospitals in the state Provide trended data on how individual states compare to the nation Provided quarterly to hospitals via QNet

PEPPERs (cont.) PEPPERs available on QNet for a period of seven days Hospital has to request report if not uploaded in seven days 67% of hospitals open report in seven days

MetaStar Team Bill French, MBA, RHIA, CPHQ, CPHIT Vice President eHealth Strategies Kim Horton, RHIT, CCS, CPHQ Coding/UR Consultant Candi Davis, RHIA, CPHQ Coding/UR Consultant Eric Streicher, MD Medical Director Jennifer Parisi Administrative Assistant

Contact Information: MetaStar, Inc Landmark Place Madison, WI (608) This material was prepared by MetaStar under contract with the Centers for Medicare & Medicaid Services (CMS), an agency of the U.S. Department of Health and Human Services. The contents presented do not necessarily reflect CMS policy. 8SOW-WI-INP-06-53