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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.

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metastar hospital payment monitoring program hpmp project kick off with hospital participants

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


Vice President eHealth Strategies

November 16, 2006

need for the project
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 15th 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
Wisconsin Ranks High in Specific DRGs
  • DRG 127 (Congestive Heart Failure) – 15th
  • DRG 143 (Chest Pain) – 12th
  • DRGs 182 & 183 (GI) – 19th
  • DRG 243 (Medical Backs) – 6th
  • DRGs 296 & 297 (Nutritional) – 14th
need for the project5
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
How Did MetaStar Identify ThisProject Topic?
  • Florida QIO completed a similar project in the 7th 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
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
Inappropriate Inpatient AdmissionsResulted 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
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
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
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
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
MetaStar Experience With PreviousOne-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
Wisconsin Experience With PreviousOne-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
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
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
Phase Two
  • Identified group of one-day stay high outlier PPS hospitals
  • Will require a quality improvement plan from the hospital
project indicators
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
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
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
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
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
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
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
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
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 (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

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

MetaStar Team
contact information

Contact Information:

MetaStar, Inc.

2909 Landmark Place

Madison, WI 53713

(608) 274-1940

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