Impact of Healthcare Payment Reform on Health Information Management Professionals

Transcription

1 Impact of Healthcare Payment Reform on Health Information Management Professionals Sponsored by 1915 N. Fine Ave #104 Fresno CA Phone: (559) Fax: (559) Program Handouts Tuesday, June 9, 2015 Track Two 2:10 pm 3:10 pm 2015 State Convention and Exhibit Speaker Ann Chenoweth, MBA, RHIA, MBB, FAHIMA Copyright California Health Information Association, AHIMA Affiliate

2 California Health Information Association California Health Information Association Impact of Healthcare Payment Reform on Health Information Management Professionals Ann Chenoweth, MBA, RHIA, MBB, FAHIMA Senior Director of IndustryRelations 3M Health Information Systems CHIA 2015 Annual Meeting Objectives Review payment reform initiatives impacting healthcare providers today Explore research results on the impact of payment reform on the HIM professional Share opportunities for HIM professionals Copyright California Health Information Association, AHIMA affiliate 1

3 PAYMENT TRANSFORMATION Our system is becoming more complex as it moves from rewarding volume to delivering value VOLUME BASED SYSTEM VALUE BASED SYSTEM SYSTEM Employers Exchanges Payer 1 Payer 2 Payer 3 CLINICIAN ACO Payer 1 Payer 2 Medical Home Payer 3 ACO PCP PCP Specialist PCP Specialist PCP PCP PCP PCP Specialist Specialist PATIENT PATIENT PATIENT PATIENT Providing Services Managing Health Copyright California Health Information Association, AHIMA affiliate 2

4 Value Equation Value = * Quality ** Cost * A composite of patient outcomes, safety, and experiences **The cost to all purchasers of purchasing care Population Health Management Defined The disciplined management of clinical and financial risk for a defined group or population. To accomplish this, health care providers and payers must stabilize the chronically ill, keep the healthy fit, standardize the quality of care provided [and measure value delivered through cost and quality outcomes]. Copyright California Health Information Association, AHIMA affiliate 3

5 Shift to Accountability Continuum of Payment Models Episodic Cost Total Cost Fee-for-Service Pay-for- Performance Episodic Bundling Partial Risk / Shared Savings Full Risk/ % of Premium HM0 Provider Accountability Patient Centered Medical Home Accountable Care Organization Proprietary and Confidential Treo Solutions, LLC 2013 Copyright California Health Information Association, AHIMA affiliate 4

6 Overarching Trends 1. Higher percentage of revenue coming from riskbased contracts 2. Organizational commitment to population health 3. Investment in infrastructure, particularly in analytics, for managing risk Growth in Risk Based Revenues REVENUE AT RISK 0% 100% Source: The Academy Huron Institute Population Health Collaborative. Dec Copyright California Health Information Association, AHIMA affiliate 5

7 Increase Commitment to Population Health SPENDING FOR POPULATION HEALTH SMALL INVESTMENT LARGE Source: The Academy Huron Institute Population Health Collaborative. Dec New Questions, New Tools Switching from managing individual services for individual patients to managing population health poses new questions and requires new tools. Which patients? How is data shared? What services? What data is shared? Which providers? With whom is data shared? Copyright California Health Information Association, AHIMA affiliate 6

8 RESEARCH RESULTS Voice of Market Research HIM Vice Presidents/Corporate Directors Accountable Care Organization Population Health Management Initiatives Risk Based Contracts Common Theme: Information Governance Copyright California Health Information Association, AHIMA affiliate 7

9 Information Governance (AHIMA) The specification of decision rights and an accountability framework to ensure appropriate behavior in the valuation, creation, storage, use, archiving and deletion of information. It includes the processes, roles and policies, standards and metrics that ensure the effective and efficient use ofinformation in enabling an organization to achieve its goals. Information Governance is a Continual Process HIM Utilization Legal/Risk HR Care Coordination Patient Experience People Executive Team Finance Business Intelligence Clinical Safety Consumers ACO EHR Clinical Systems Mobile Devices NLP ACO PHR EMPI Reporting Decision Support Business Objects Technology Process IG Framework Methodology Redesign KPIs BI Metrics Dashboards Critical Success Factors Privacy and Security Copyright California Health Information Association, AHIMA affiliate 8

10 Clinical Documentation and Coding Now People Care Physicians recognizing link between clinical documentation codes VBP Public reporting of hospital and physician performance Preparing for Population Health Management Aligning incentives and determining shared saving Increasingly accepting financial risk Negotiating pay for performance contracts Measuring performance excellence and total cost of care Total Cost of Care Variable Across the Network 30% 20% 10% 0% Network Provider 1 Provider 2 Provider 3 Provider 4 Provider 5 Provider 6 10% 20% 30% 40% Data for Illustration Only 50% Unit Diff Util Diff PMPM Diff Quality Copyright California Health Information Association, AHIMA affiliate 9

11 Clinical Documentation and Coding Focus on Quality accelerating Common Quotes: Telling the patient s t story Coders need to be more clinical today Working closely with Clinical/Quality leadership Sitting on Quality/Patient Safety Committees Evaluating HIM reporting CQO CDI Quality HIM Clinical Documentation and Coding The work you are doing (in HIM) has increased the accuracy of our patient's story and our organizational performance Quote from CMO to HIM Leader in Midwest Copyright California Health Information Association, AHIMA affiliate 10

12 Enterprise Clinical Documentation Integrity Program Clinical Documentation and Coding HIMS leadership in data integrity expanding across the care continuum Increasing responsibility bl for pro fee and home health coding Integrating enterprise wide coding and CDI into existing HIM organization Diagnosing root causes for coding inconsistencies across the enterprise then leading effort to fix Examining and redesigning physician office data capture and coding processes Copyright California Health Information Association, AHIMA affiliate 11

13 Clinical Documentation and Coding Moving to OP CDI Few have implemented OP CDI but actively discussing expect to expand CDI into OP Modifying EHR templates in OP settings to improve accurate documentation Drivers: Data integrity across the care continuum ICD 10 E&M coding compliance Two midnight rule Hierarchical Condition Category (HCC) HCC Overview CMS risk adjusted payment model used for Medicare Advantage Plans Bi Being applied to dt determine payments for ACOs and Value Based Purchasing Assigned using diagnosis from: hospital IP, hospital OP, physician, and clinically trained non physician Must supportpresencepresence of condition and indicate provider s assessment and plan for management Must occur at least annually for CMS to recognize patient continues to have condition Government audits of HCCs increasing Copyright California Health Information Association, AHIMA affiliate 12

14 HCCs Driving CDI Expansion Expanding CDI program to include HCCs Extending the current CDI workflow to support a centralized model ofconcurrent HCC review Adding HCC specialists to current CDI team Forming Outpatient CDI program specifically targeting HCCs Building tools within EHR to help physicians Providing ongoing education and assessment to physicians, CDI specialists and coders One HIM Leader s Journey GA EHR Review Hospital coding summaries compare to office provider notes MD, NP, etc. Enter new ICD 9 codes based on documentation & codes not previously submitted on claims Helped the Health Plan & Epic team to develop reports of cases with potential for change Root cause analysis revealed truncated claims Epic PB & HB resolutions Audit team 15 HIM professionals redeployed for two months to review medical records for 5,000 patients to extract diagnoses which were documented & not coded to support the supplemental data submission Implemented an outpatient CDI program to query MDs prior to office visits Expanded to the ACO population Data extraction & NLP project HIM Financial Contribution $2.2M MA Plan Collects Hospital & Physician Data MA Plan Verifies Data Source is Acceptable MA Plan Submits Risk Adjustment Data to CMS in Risk Adjustment Processing Format Front End Risk Adjustment System Conducts Initial Edit Checks Risk Adjustment Processing System Conducts Detailed Edit Checks Risk Adjustment Processing System Database Stores Diagnosis Clusters Risk Adjustment Processing System Database Extracts Diagnostic Data from RAPS Database & Calculates Risk Score & Plan Payments Copyright California Health Information Association, AHIMA affiliate 13

15 Commonly Missed Diagnoses Diabetic complications (specificity is extremely important) CKD (level defined by GFR) COPD Atherosclerosis of the aorta Identified oncxror or CTscan Neuropathy, ideopathic Alcohol dependence Alcohol abuse with sequelae (intoxication, delirium, insomnia, etc) Narcotic dependence, episodic use Insulin long term use Hemiparesis Old MI Old CVA with monoplegia Hepatitis, chronic Complications (bleeding) related to anticoagulants CHF variants (hypertensive LVH with failure) Ulcers (many types) Amputations (incl fingers/toes; specificity is important) Ostomy Major depression 296 (vs depression 311 which is adjustment or griefrelated) Morbid obesity Pancreatic disorders Malnutrition Spinal compression fracture Spinal cord injuries and sequelae Complications of chemotherapy or radiation Complications of surgery, procedures, etc Providers get familiar with patients over time and neglect documentation of chronic stable conditions One HIM Leader s Journey LA Initially built an NLP and ran clinic notes through it found HCCs physicians documented but did not code Specially trained coders reviewed findings, determined accuracy and rebilled Built tools in Epic to help physicians Added health risk assessment visits with nurse practitioners Formed an outpatient CDI program specifically targeting HCCs Copyright California Health Information Association, AHIMA affiliate 14

16 EHR Data Integrity Extending shared EHR to independent physician practices Leading efforts on reducing poor data integrity in EHR so data can be trusted EHR Templates Cut/Paste (cloning) Problem lists Creating new positions focused on improving EHR data integrity Increasing focus on front end speech Technology Efficiencies Computer assisted coding/cdi Generate facility and pro fee coding from a single coding session Data mining to identify documentation gaps Identify cloned documentation Capture/extract quality indicators Data analytics and reporting Computer assisted physician documentation Provide documentation prompts to MDs at point of care Audit real time front end speech documentation Copyright California Health Information Association, AHIMA affiliate 15

17 Population Health Management Big Data Challenges Lack of Common Definitions Multiple Versions of Truth Data Sharing and Reusability Capturing Clinical Data Converting Data to Information Population Health Information Management HIM Taking Lead Addressing data/interoperability challenges Enhancing EHR design and information capture Creating data standards and definitions Positioning themselves as leaders: Understanding sources of clinical data Promoting information and data governance Serving as data stewards Co chairing patient safety/quality committees Leading patient identity management initiatives Championing policies/procedures (access, security, privacy, data integrity, etc.) Copyright California Health Information Association, AHIMA affiliate 16

18 Patient Identity Management Expanding HIM leadership: Assuring data integrity when new entities are merged Developing structure, policies, andprocesses across the enterprise Increasing collaboration with patient access and revenue teams Chairing key committees (Registration Quality Committee, Patient Safety MPI Committee) Leveraging multiple tools: HIE, ACO, EHR Creating data integrity team focused on identity management across the ACO Information Governance (IG) Majority of HIM leaders state organization have IG initiatives in place HIM professionals leading IG Conducted IG audit and identified gaps/risk areas Created a vision to drive change, defined value, connected to strategy Developed IG business plan Created foundation/framework Started small, defined success, created momentum When HIM not leading IG, viewed by C suite as major stakeholder Copyright California Health Information Association, AHIMA affiliate 17

19 Research Summary 1. Expanding and integrating HIM Practices across the care continuum. This includes data integrity and enterprise information management. 2. Capitalizingon new opportunitiesin in areassuchsuch ashcc/raf payment models, patient engagement strategies, quality and analytics. 3. Addressing increased pressure to assure organizations are receiving optimal payment per patient. This includes process redesign in areas such as appropriate status of patients, clinical documentation expansion and proactive denials management. 4. Expanding into Information Governance. This includes developing an accountability framework, standards, and policies that ensure information is both trustworthy and actionable. 5. Responding to demand for greater efficiency and accountability in achieving industry best practice. HIM LEADER ADVISE AND RECOMMENDATIONS Copyright California Health Information Association, AHIMA affiliate 18

20 Recommendations Look for opportunities to demonstrate value of HIM knowledge and expertise Go the extra mile Never say not my job Offer to take on special projects Secure champions and align on key issues Partner and collaborate closely with clinical and quality leadership and teams Educate yourself (and teams) on value based payment initiatives impacting organization Recommendations Expand responsibility beyond traditional HIM department create business case Learn how physicians i are being bi incented d( (quality metrics, etc.) Strengthen clinical skills needed to tell patients story Copyright California Health Information Association, AHIMA affiliate 19

21 QUESTIONS AND DISCUSSION Presenter Ann Chenoweth, MBA, RHIA, MBB, FAHIMA Senior Director of Industry Relations at 3M Past member, AHIMA Board of Directors Treasurer, Finance Committee Chair Audit Committee Chair Governance Committee member Current chair: AHIMA Grace Committee Current member: HIMSS ICD 10 Task Force Contact Information: Copyright California Health Information Association, AHIMA affiliate 20

22 Appendix: Common Definitions Fee for Service (Volume Based Healthcare): Payment dependent on quantity of services rendered. Pay For Performance (P4P, Value Based Purchasing): Providers are rewarded for meeting performance measures for quality and efficiency and penalized for poor outcomes, medical errors or increased costs. Bundled Payment: A single payment to providers for given condition or treatment. Patient Centered Medical Home: Team based care where patient care is coordinated through primary care physician. The goal is to enhance coordination. Accountable Care Organization (ACO): Group of healthcare providers who agree to be accountable for the quality, cost and overall care of the population. Full or partial risk with sharing of savings across care participants. Shared Savings: The difference between target and actual costs represents the shared savings which you would share with your physician community. Often includes quality metrics. Shared Risk: Refers to arrangements in which providers accept some financial liability for not meeting specified financial i or quality targets. t Capitation: Healthcare provider gets a fixed amount for each enrolled person per period of time, whether that person seeks. Population Health: Defined as the health outcomes of a group of individuals, including the distribution of such outcomes within the group. It is an approach to health that aims to improve the health of the entire population it serves. Copyright California Health Information Association, AHIMA affiliate 21