Monday, August 5, 2013

Changes in hospital readmission rates by clinical severity

Medicare now penalizes hospitals for high readmission rates for acute myocardial infarction (AMI), congestive heart failure (CHF), and pneumonia. Anticipating the penalties,readmission rates have come down, though this does not prove a causal relationship.
medicare readmit trend
The chart illustrates a highly aggregated metric. Certainly readmission rates and changes in them vary by type of patient (in any number of dimensions). For example, recent work by Matthew Press et al. suggests that changes in readmission rates vary by condition severity.
In an analysis of Medicare fee-for-service beneficiaries nationwide, we found that those with the highest clinical severity had readmission rates in 1997 that were approximately 6.0 percentage points higher than those in the lowest severity quartile, with this gap increasing to 8.1 percentage points by 2007 for AMI. The difference in readmission rates for the highest versus lowest severity quartiles for CHF was 5.7 percentage points in 1997 and 6.4 percentage points in 2007. This relatively increasing risk of readmission for the highest severity patients occurred despite the fact that average severity scores decreased within each severity quartile over the 10-year period. Length of stay and in-hospital mortality also declined for all patients; however, postdischarge mortality increased for the highest severity patients, whereas it decreased for the lowest severity patients.
The authors offer two possible explanations for these findings. First, condition severity may have worsened more than observed for high severity patients and not accounted for in the risk adjustment approach applied in the analysis. That is, the highest quartile of condition severity in 2007 may have represented sicker patients than the highest quartile in 1997 in ways that were not controlled for. Sicker patients are expected to be readmitted more. Another is that actual care delivered (e.g., quality of care transitions) worsened for higher severity patients relative to lower severity patients. This might also lead to relatively more readmissions for sicker patients.
Unfortunately, their analysis ends in 2007, well before the readmission rate reduction exhibited in aggregate since 2011 in the figure. An open question is how this downturn might have varied by condition severity.

Dallas heart surgeon uses medicine as ministry

DALLAS (AP) — At 83, Carl Smith found himself facing quadruple-bypass surgery and the real possibility that he might not survive.
Within hours on this spring morning, Dr. Mark Pool would temporarily bring Smith's heart to a stop in an attempt to circumvent its blocked passages.
And to help his patient confront the uncertainty, Pool did something unusual in his profession: He prayed with him.
The power of healing: Medicine and religion have both had their day, and they haven't always been able to coexist. But as today's medical treatment becomes more holistic, doctors are increasingly taking spirituality into account.
The Dallas Morning News ( reports that studies show a majority of patients want their spirituality recognized, and most med schools now have classes related to the topic. In general, the new thinking asks doctors to note their patients' spiritual leanings and open doors to expression, especially when life is at risk.
Pool, a highly regarded heart and lung surgeon at Texas Health Presbyterian Hospital Dallas, is fervent about his Baptist faith. For about a year, he's routinely asked patients if they'd like him to pray with them pre-surgery — a gesture he says is always appreciated but one that exceeds advocates' suggested bounds.
"A physician should be open to a patient's spirituality but shouldn't push religion on patients," says Nathan Carlin, assistant professor at the University of Texas Health Science Center at Houston. "That's confusing personal and professional roles."
An inherent power differential divides doctors and patients, says Christina Puchalski, director of George Washington University's Institute for Spirituality and Health and co-editor of the recently published Oxford Textbook of Spirituality in Healthcare.
"They're coming to us for something other than prayer," Puchalski says. "If I, as a patient, perceive (a surgeon) as having my life in his hands, and he asks me to pray and I say no, he may not treat me well. And that's putting undue pressure on the patient."
As the saying goes, there are no atheists in foxholes: The idea that your fate is out of your hands offers fertile ground for re-examination.
"The moment somebody tells you that you have cancer," says Methodist Dallas Medical Center's Rohan Jeyarajah, a gastrointestinal surgeon who prays with patients, "you're going to believe in something."
But the situation, he says, requires caution: "We have to be careful about being in a position of perceived authority and not overstepping that bound. This is like a teacher-student relationship. There's a chance you could be inappropriate."
Pool pushes forward, eager to share the belief that drives him without making people feel awkward or flouting that power imbalance.
"I don't want to exploit their situation," he says. "At the same time, I want to give them the opportunity to explore the faith that I know."
You could say Pool comes from a religious background. His father, his grandfather, his father-in-law, his brother-in-law: all ministers. The family joke was that he started going to church nine months before he was born.
By age 6, he was well versed in Bible basics, but then something odd happened. One day at a prayer meeting, Pool says, he was touched by — well, not quite a vision, but an awareness.
"I had already understood that Jesus came to save the world," he says. "That was nice. But then I understood: Jesus came to save me. And that changed everything."
He's pursued a path of faith ever since. Medicine seemed like a good way to help people. Even so, as a med student, Pool pondered ditching the whole thing to go to seminary instead.
As a member of First Baptist Church of Dallas, he and wife Jessica lead relationship classes on Sundays for dozens of young married couples. Even in his crisp, black-patterned suit, Pool is impossibly youthful — lean and rosy-cheeked, posture straight as a fence post.
And as a cardiothoracic surgeon, another realization has set in: "I have a ministry. I don't need to be standing in a pulpit. I have found a ministry I did not expect. I am able to minister to people in times of need."
Since Texas Health is a faith-based hospital system, he felt at ease taking that step.
"The vast majority of people believe in God," he says, "and yet when people come to the hospital, that's completely ignored by doctors. If anything, they call the chaplain. It's unfortunate that more doctors don't try to engage that part of a patient's life."
That's starting to change. Two decades ago, barely a few med schools offered classes on spirituality. Now, three-fourths of them do.
"Medicine has figured out that we ignore the more human sides of health care at our own peril," says Craig Borchardt, interim chair of humanities and medicine at Texas A&M University.
Studies show 60 to 80 percent of patients want their beliefs noted, he says — not as affirmation but as a sign that the doctor actually cares. But fewer than 20 percent of doctors bring it up.
The push has met with some backlash — from busy doctors reluctant to take time away from other concerns or others who don't like talking about it.
"Some staff are more comfortable with it than others," says Mark Grace, vice president of mission and ministry for Baylor Health Care System.
He doesn't reject the idea of doctors offering to pray, but "if you don't listen to the answer, that's where you get into problems. . The doctor needs to be prepared if the patient says no."
George Washington University's Puchalski says the bottom line is doing what's best for the patient.
"Physicians are generally not trained to lead prayer," she says.
To illustrate the power differential she says exists, she recalls a patient who was also a fellow parishioner. One day, she noticed the woman hadn't been to church for a while, then realized the woman hadn't come into her office either.
When the patient finally resurfaced, Puchalski pressed the matter: "She told me, 'I thought you'd be upset that I switched churches.' That gives you an idea of the power we have over patients. So I would really caution against (taking advantage of) that."
Pool gleans his patients' spiritual beliefs at their initial meeting. Then, on the morning of surgery, he says: "This is a time when a lot of people turn to faith. Would you mind if I prayed with you?"
No one, he says, has ever declined, not even those who believe differently or not at all.
It's 6 a.m., and Pool, shiny black boots poking from beneath blue scrubs, briefs Smith on his surgery. At 83, Smith is fit, mowing the yard occasionally, an active driver.
But coronary artery disease caught up with the retired Farmers Branch pharmacist, slowing his blood flow and causing chest pain. Over time, it could lead to a heart attack.
Madge Smith, his wife of 63 years, and Leah Wilson, his youngest daughter, are near. Scott Smith, his son, would join later.
Pool explains his plan: He'll make an incision down Smith's breastbone, then take arteries from his left and right side, and a vein from his leg, to form new channels for blood to flow through his heart.
"So," he tells Smith, "you told me you're a Sunday school leader. . Would you mind if I said a prayer for you?"
Smith is touched. Pool places his hand on Smith's shoulder and begins:
"God, thank you for Mr. Smith. We ask that you would guard his life, keep him safe and bring him through this operation. Replace any anxiety that he may have. Give him a great assurance of your love and your power.
"I ask you to watch over our team, that you give us all clarity of thought, that you guide my hands as they move. We pray these things in Christ's name. Amen."
"Amen," Smith says.
Later, as Smith's family awaits the outcome, his wife says: "I have never had a doctor do that. It just meant so much to us. We just thought it was sent from God."
At 6:45 a.m., Pool starts in, using a tiny electric saw to patiently work through Smith's chest and breastbone.
The arteries he wants dangle inside like strings of soaked cooking twine above Smith's quivering lungs. He snips one end of each, then applies small plastic clamps to stop the thin spurt of blood.
"See that?" he says. "That's the blood flow that will be going into the heart."
A shot of potassium literally stops Smith's heart cold, temporarily abdicating its work to a heart and lung machine. To the heart, Pool will divert the snipped arteries, and repurpose a vein taken from Smith's leg, to offset the blockages within.
But first he has to open the heart's protective sac, unveiling the still-beating organ as it heaves inside. Pool eases it to one side, to reach a portion underneath — and in that moment, Smith's heart, the force pumping blood and oxygen throughout his body, rests in Pool's cradling grip.
Out in the family waiting area, Smith's son Scott says: "God has his hand on everything. He's in control. We're not. It's in God's hands."
Pool initially wondered if his praying might give patients pause, whether they'd worry he wasn't confident enough in his own skills to get through the surgery.
"It's been the opposite," he says. "They value the humility."
Last year, Shea Bowen of Kaufman had just delivered a son at Texas Health Presbyterian Hospital Rockwall four weeks early. Suddenly, she became short of breath. Tests revealed a tumor in her heart.
She was rushed to the network's Dallas hospital, where Pool met with her and her husband. She was shaking then, a complete wreck.
"It was terrifying for me," Bowen says. "I had to leave my few-hours-old baby. We knew there was a chance that . Not everyone comes out of surgery.
"Dr. Pool could tell. His words were 'I don't know if you guys believe in God, but I do,' and as soon as he said that, we both burst into tears. He said, 'I can cut and I can sew, but God is going to heal you, and I'm going to do everything in my power to make sure that happens.'
"There's a lot that's a blur, but I remember the comfort of knowing the person who was literally going to stop my heart and cut me open was going to do that for me under God."
Not long ago, Pool contacted a local evangelistic organization. "So I could up my game," he says. He wants to learn how to share his faith without being a "turn or burn" proselytizer.
"I wouldn't want for somebody to make a decision in a moment of crisis that they wouldn't make otherwise," he says. "I don't want to say, 'It's your last chance: Smarten up or else.'
"It doesn't mean I can't share my faith just because it might upset somebody in the world. This nation was founded on Christian ideals."
Pool pauses when asked if he'd pray with followers of Islam, a faith he considers antagonistic and unforgiving.
"I don't think they would get the same meaning" from it, he says. "Not that they would feel offended, but . not comforted."
He tries to avoid a holier-than-thou air and — with patients, anyway — doesn't claim only certain believers get into heaven.
"It's not my job to get somebody to make certain decisions," Pool says. "All I can do is live a life that makes it appealing to somebody and then share it with them. If I share and they say, 'I'm not interested,' I say no problem and move on. But seeds can be sown that you never see the fruit of."
Smith's operation was a success. Six weeks later, Pool meets with him one last time.
"You're doing extremely well," Pool says. "I'm going to fade away now. You don't have to come back and see me."
"I'd be 6 feet under if it wasn't for you," Smith says.
Pool dismisses the thought. "I'd like to say a prayer with you," he says.
Smith bows his head and closes his eyes.
"Lord," Pool begins, "thank you for getting Mr. Smith out of the hospital and getting him home. We ask that you continue that process of healing and give him a spring in his step once again. In Jesus' name we pray."
Smith is upbeat. He believes the gesture will help him get better. And in the end, that might be the most important thing of all.
Information from: The Dallas Morning News,

ICD-10 Transition: Maybe it's time to panic a little

We are about 14 months away from the ICD-10 implementation deadline. Surveys report that healthcare providers are in various states of readiness.

QualiTest Group surveyed more than 300 professionals about their ICD-10 testing plans. The two major findings are:
  • Most respondents have either completed ICD-10 assessments or are in the process of assessments.
  • 75 percent of respondents have not yet begun ICD-10 testing.
While starting sooner than later is important, this survey doesn't raise too many alarm bells. It does report a great deal of planning and progress in the ICD-10 transition. Other surveys released in the past few months have found less preparation.

Perhaps a more troubling indicator is the amount of newly released literature that suggests there is an audience that hasn't heard of ICD-10 implementation. If the healthcare industry is on its way to a smooth ICD-10 transition, we wouldn't need so many guides to planning ICD-10 implementation.
Seriously. That's so 2012.

The latest example I found is the white paper ICD-10: The Top 10 Things You Need To Do NOW from the medical billing firm MediGain. They advise:
  1. "Set up a team and appoint a leader."
  2. "Evaluate current software systems and office procedures in which you use ICD-10."
  3. "Pinpoint possible changes to your workflow and office processes."
  4. "Communicate with your payers about any modifications that need to  be made  to your contracts due to ICD-10."
  5. "Think about training efforts and costs."
  6. "Converse with your trading partners."
  7. "Test with your trading partners."
  8. "Survey your current PM vendor."
  9. "Assess your internal office systems and functions."
  10. "Revise and account for any plan adjustments."
Healthcare providers should have completed half those steps by now.

If not, then they should download the MediGain white paper. It's actually a pretty good document to start. The more detailed ICD10 Watch Implementation Timeline will help explain what needs to be done.

MGMA anticipates problems, disruptions with ICD-10: Q&A

  • Robert M. Tennant, MA, Senior Policy Advisor at the Medical Group Management Association (MGMA), can't figure out why CMS won't conduct end-to-end testing.
  • Before the HIPAA 5010 transition, National Days of Testing were very helpful.
  • Healthcare payers need to test more than if they can accept ICD-10 codes. They need to see how their payment policies will be affected.
  • Clearinghouses report 20 percent of their clients are still using HIPAA 4010 — which cannot handle ICD-10 codes.
  • Tennant worries that state Medicaid agences won't be ready for ICD-10 implementation so healthcare providers will need to use dual coding practices to get reimbursed.
  • Healthcare providers need to start practicing assigning ICD-10 codes to medical claims.

Cash on hand: You'll need it for ICD-10

  • Expect delays in reimbursements after Oct. 1, 2014.
  • Hoard enough cash to cover three to six months of operational expenses.
  • Talk to banks now when you don't need it.
  • Ask healthcare payers about contingency plans.

Increasing Revenue and Planning for ICD-10: How Clinical Documentation Improvement Accomplishes Both

Mel Tully, senior vice president of clinical service and education at technology firm Nuance, has three tips:
  1. Improve documentation now for ICD-9 coding.
  2. Analyze the DRGs and procedure codes that account for most of your revenue.
  3. Medical coders should start clarifications and queries now for information that supports ICD-10 coding.

Dual-Coding: An ICD-10 Strategy You Can Take to the Bank

Bonnie Cassidy writes about why healthcare providers need to consider dual coding:
  • It will require time and effort but should be worth it.
  • There are risks by not dual coding:
    • Not assigning the right ICD-10 codes.
    • Losing revenue.
    • Increasing claim denial and audits.
  • Medical coders will gain practice.
  • ICD-10 transition team can assess its education and training programs.

Three questions to ask your payers about ICD-10

  1. Will you conduct external testing?
  2. Will you be dual processing, and if so, when will you start?
  3. What will happen if something goes wrong?

Getting to the Good Stuff: An Active User’s Opinion of ICD-10

Barbara Aubry sings the praises of specificity. (3M Health Information Systems)

Diagnosis and Procedure Codes: Abbreviated and Full Code Titles

CMS has released the final update for the ICD-9-CM code set. It goes in effect Oct. 1. (Centers for Medicare & Medicaid Services)