MetaStar Hospital Payment Monitoring Program (HPMP) Project Kick Off with Hospital Participants

2. 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

3. 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

4. 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

5. 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

6. 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

7. 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

8. 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

9. 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

10. 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

11. 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

12. 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

13. 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

14. 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

15. 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

16. 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

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

18. 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

19. 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

20. 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

21. 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

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

23. 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

24. 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

25. 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

26. 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

27. 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

28. Bill French, MBA, RHIA, CPHQ, CPHIT Vice President eHealth Strategies bfrench@metastar.com Kim Horton, RHIT, CCS, CPHQ Coding/UR Consultant khorton@metastar.com Candi Davis, RHIA, CPHQ Coding/UR Consultant cdavis@metastar.com Eric Streicher, MD Medical Director estreich@metastar.com Jennifer Parisi Administrative Assistant jparisi@metastar.com MetaStar Team

29. Contact Information: MetaStar, Inc. 2909 Landmark Place Madison, WI 53713 (608) 274-1940 www.metastar.com 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