Healthcare Revenue Cycle Management, ICD-10, Claims Reimbursement, Medicare, Medicaid

Reimbursement News

Why Focusing on Hospital Readmission Causes Is Essential

By Jacqueline DiChiara

- The ongoing payment transition from volume to value is bringing the concept of forced alignment into the spotlight. Hospitals, unsure what new outpatient services are best to implement, are now focused on making effective choices. Are such choices focused on the wrong areas?

hospitals healthcare systems challenges

To offer greater insight regarding notable trends in hospital admissions, key healthcare provider challenges and opportunities, and where physicians need to focus their energies as the final quarter of 2015 kicks into gear, RevCycleIntelligence.com spoke with Bryan Cote, Managing Director at Berkeley Research Group.

Questions of acquisition and available resources remain prominent, he says, as hospitals expand their focuses onto wellness, prevention, chronic management, mental health, and wound care. The standalone question remains: how can growth be effectively executed? Additional challenges, says Cote, involve how money will be shared among risk-based entities and health systems.

An even greater challenge for healthcare systems, says Cote, is revenue cycle and performance improvement. Of primary concern is how to merge clinical and financial information. Making sure payer contracts are maximized while managing a great deal of information simultaneously is key.  Hospitals face a great challenge comparing physicians and clinicians on such measures, says Cote.

“You’re getting paid, say as an Accountable Care Contract with a Blue Cross Blue Shield plan. Are you getting the appropriate reimbursement level based on what you're doing for the patients? Have you been documenting fully?” asks Cote. “Is your readmission rate for a certain population of patients – let's say smoking patients – better than everybody in the network? How is that factored into your contract so your reimbursement's appropriate?”

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A physician faces different challenges and concerns than a hospital, says Cote. “Do I just try to integrate with another physician group, or do I owe it to the hospital? You may not have either of those options as a physician," he says. "Perhaps the hospital's already got the specialists it needs, and doesn't need you. How do you compete in this environment, and have a quality of life as a doctor, given all the hoops you have to jump through to justify what you're doing to your health plan?”

Another challenge within the current turbulent period of shifting payment, says Cote, is providing access for physicians to manage care and diagnostics. A focus on maintaining physicians’ high quality of life needs to become an imperative focus, says Cote. 

All physicians, he says, are struggling on some level. “We're still losing doctors,” he says. “What do they do? Do they retire? Get into consulting?”

Cote referred to his co-authored 2009 publication with 900 physicians and nursing homes that studied early readmissions causes and available solutions. Offering deeper insight on the publication within the interview, Cote says it was based on the fact that patients were essentially bouncing back and forth from home, to hospital, to nursing home, to doctor, and around again.

“There's no communication, and no one's really incented to help the patient and do the right thing,” he says, in reference to the publication. “There's no collaboration and no accountability. Guess what sort of started to form out of that? Accountability.”

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Cote says since the study was conducted, there has been “a ton of improvement” with payers addressing the issue. “Hospitals, doctors, nursing homes are trying to collaborate to better transition patients, communicate what's going on, so the next physician or caregiver has everything they need to reduce the likelihood of a re-hospitalization.”

Skilled nursing facilities (SNFs) are a particularly strong healthcare trend, he says, because they face substantial reimbursement pressures based on readmissions. SNFs are now being held accountable similarly to hospitals, he says.

“If you go in for one thing, and then with a week later, it's the same thing, you’re not going to get paid,” he explains. “They often don't get a full picture when the patient gets to the SNF of why the patient was there and what went on in the hospital. That's a problem.”

Too much focus is being placed upon on the isolated cause of readmissions, Cote maintains. Addressing mental status changes involving depression, mood, bipolar, and anxiety and the management of such conditions is key, says Cote. A focus on a patient’s reason for admission is imperative.

“Are they really there for the hip fall, which they are there for, because they did fall and broke their hip or shoulder, or what's really driving it? Is it anxiety, dementia, or depression?” he asks. If such questions are not addressed, the patient will likely just experience another fall, says Cote.

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In terms of greater end-of-year considerations, Cote says business arrangement is a number one priority. Tangible growth is to be expected within multispecialty practices, says Cote, such as the concept of primary care merged with a behavioral health element or an orthopedic group now associated with sports medicine.

With more patients entering the health system via the Affordable Care Act and Medicaid expansion, understanding how to capitalize on such growth from a physician or physician group standpoint is vital, he says. The payer community, he says, is very receptive to achieving top outcomes.

“You can do the right thing for the patient and have a protocol that you're sure to follow. Then the payer doesn't have to manage you as aggressively, because you're consistent. They know your utilization's based on doing the right thing. They can pay your more efficiently and more appropriately, and therefore there's less concern on this fight about revenue all the time,” Cote says. Physicians will in turn be focused on operating their businesses and best positioning themselves with payers, he adds.

Cote says another key healthcare focus this year involves the migration of refugees into the United States and how policies will evolve heading into the next presidential election. Social services will soon dominate the healthcare industry as an area of opportunity for health systems to innovatively reduce cost, says Cote.

“There's very likely to be some migration and some increase in certain communities and states,” he says. “It's likely to be certain cities take on more. It is important to understand that that's a population likely to be largely in Medicaid. So you're talking about even further pressure on the Medicaid system.”

Health systems and hospitals need to focus not only on assessing how to bring patients into the system but on social service investment, new models of care delivery, and the Medicaid population at large, he says.

“The old strategy of going to see your doctor for a half-hour visit and then come back if you get sick just doesn't work anymore – particularly with a refugee population or certain Medicaid populations,” he says.

“Hospitals are so focused on their own silos, surgeries, and revenue streams, and that's important. But they're starting to think in far more unique ways in terms of the outpatient growth. They need to think farther beyond just their health network and healthcare services,” says Cote. 

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