As the U.S. healthcare system moves inevitably further into value-based care delivery and payment, patient care organizations face increasing challenges with regard to any gaps in clinical documentation. Any such gaps or problems can negatively impact case mix index (CMI), and decrease reimbursement. Some hospitals, medical groups, and health systems are beginning to make progress in this area, among them Florida Hospital, the eight-facility, 2,500-bed Orlando-based integrated health system.
Beginning the clinical documentation solution from the Burlington, Mass.-based Nuance Corporation in the summer of 2014 and completing that implementation across nine hospitals by May 2015, senior Florida Hospital executives were able to make a range of improvements. Among them, use of the solution led to such an improved level of documentation that it allowed the organization to reduce observed-to-expected inpatient mortality rates by 48 percent in less than one year; physicians broadly improved their document and their engagement; and resulting improvements in case mix index have led to a $72.5 million increase in appropriate reimbursement since go-live.
An April 27 press release from Nuance quoted Jeff Hurst, senior vice president and senior finance officer of Florida Hospital as saying that, “Both financially and clinically, implementing Nuance’s CDI program has been a tremendous success. Since deploying, we’ve seen a 29 basis point increase in CMI that equates to a $72.5 million increase in appropriate revenue over two years. Physician participation is also a strong success measurement and we’ve seen up to 92 percent response rates and strong engagement from physicians in our CDI program.”
Hurst spoke recently with HCI Editor-in-Chief Mark Hagland regarding the broad activity in this area. Below are excerpts from that interview.
Tell us about the origins of this initiative.
Certainly. Probably late 2013, we made a decision, for a variety of reasons, given all the changes in the healthcare industry—the focus on reducing costs, improving documentation, and improving publicly reported quality measures, we made the decision to implement a formal clinical documentation improvement program, leveraging the Nuance CDI platform. We launched our first facility in June 2014, and over the next 13 months from June 2014, through May 2015, we brought up each of those eight facilities one by one. By the third quarter of 2015, we were fully implemented from a facility standpoint.
And since then, we’ve been leveraging our performance, with regard to physician engagement. And if you compare our performance prior to and after, we’ve seen significant measurable improvements, in terms of both our financial performance and clinical outcomes, in particular, with regard to our mortality measures. We’ve seen a 29-basis-point improvement in our Medicare PPS case mix index, and for our organization, we see about 40,000 Medicare inpatients a year. And so every one basis point change in case mix index is worth about $2.5 million in additional net revenue reimbursement. So 29 basis points times $2.5 million per basis point, that translates to $72.5 million, as referenced by Nuance. Case mix index in simple terms is a measure of the acuity level of the patient you’re treating. So for lack of a better way of saying it, the sicker your patients, the higher your case mix index.
So improvement means that you’ve lowered their acuity?
No, the way the Medicare payment program works is that there’s something called a blended rate, which is basically the DRG rate they pay you for a case mix index of 1. And as you’re treating more acute patients, that rate is measured higher. And the way Medicare ultimately pays you is that they take the blended rate times the case mix rate for that patient, so you get a payment. So the more acute the patient you’re treating, the more cost you’re incurring for that patient, so the more Medicare will pay you. So Medicare is trying to align your payment rate with the acuity of your patients. So your case mix index ultimately hinges on three things: it hinges on the care you’re providing the patient; on how accurately you document the care you’ve provided to the patient; and, that documentation through our coding team is ultimately translated into specific codes—procedure, diagnosis codes, that get translated into a DRG. So your coding is dependent on the accuracy of your documentation.
So improving your basis points means improving your documentation?
Yes, that’s right. So you are being underpaid if you’re not coding accurately. And secondly, when Medicare and other organizations look at you from a quality standpoint, your quality measures are being understated. So you have every motivation to make sure your documentation is as accurate and thorough as possible, both because of the reimbursement you receive, and because of the quality scores you have that are reported publicly; so documentation is ultimately the key to everything.
So, how did you accomplish this improvement?
We did really three things. First and foremost, we leveraged the Nuance CDI technology solution. Nuance has been a great partner with us through this entire journey, and we take every opportunity to leverage that technology. The CDI platform allowed us to leverage technology. And we added staff—highly skilled, highly trained staff, all of whom are registered nurses; and third, we very much partnered with our physician group, our medical staff. Because ultimately, you’re relying on the documentation from your physicians. So there has to be a very high level of engagement and partnership with your physicians, to be sure that they’re fully engaged in the program and are really taking ownership of the documentation—both the content and timeliness of the documentation.
Stated more simply, it’s really a triad: the internal staff whom we added to the team, the partnership we have in place with Nuance, and the partnership we have in place with our medical staff, from a physician standpoint.
Did that involve extensive training and consultation between the HIM [health information management] staff and physicians?
As we brought each campus live, there were upfront education and training sessions with our staff. Our staff becomes our representatives and liaison partners with our medical staff. And then there were discussions with the hospital administration and the medical staff leadership team—more so from an awareness standpoint, less so from an education standpoint.
We explained what we were doing, explained the reasons why it was important for doctors to be highly engaged in the program. And ultimately, the RNs are up rounding on the units. And when they use the solution to identify a documentation opportunity, often, they’ll have a face-to-face interaction with the physicians, explaining how to use the solution. And a lot of this in the early stages was really face-to-face conversations between our CDI staff and physicians. As the program ramped up and everyone gained a better understanding of the situation, it didn’t require as much human or manual interaction as it did in the early stages.
What does the $72.5 million mean in terms of scale?
That was effectively almost a 20-percent increase in our inpatient reimbursement. That’s for our Medicare PPS inpatient volume in our region. The other benefit of the Nuance CDI platform is that you can expand it to all DRG payers. For example, in the state of Florida, Medicaid pays on an APR DRG basis—it’s a case rate similar to a Medicare DRG, just slightly different model. All-patient refined DRG—the aggregate population is used, as opposed to the Medicare DRG being paid based purely on the Medicare population.
What would you say the biggest lessons learned have been so far, in all of this?
I would probably cite three things. Number one, as I said earlier, you have to have a great technology partner. Your ability to leverage technology is only as good as the technology. Itself. Second, you’ve got to have highly skilled, highly trained staff on your team. Our team is composed of RNs, in most cases, with 10, 15, 20 years of experience. You really want your best and brightest, because first, they’re most familiar with patient conditions; and second, they’re most experienced in collaboration and partnering with physicians. And third, you really have to have a highly engaged medical staff. A CDI improvement program really depends on the physicians, because it’s their documentation you’re relying on, because you really need a highly engaged medical staff.
What would your advice be for CIOs and CMIOs, related to the data and IT elements involved?
Probably my first point on biggest lessons learned: healthcare is becoming more and more complex and complicated, and the pace and magnitude of change are unlike anything I’ve ever seen. And obviously, the value of technology, of a sophisticated partner in the technology space, is becoming increasing important. I think going forward in really all aspects of healthcare, we’re going to rely more and more and more on sophisticated technology, on our ability to leverage data and analytics, to drive performance improvement. Stated more simply, I believe the future of healthcare really, really is the future of technology. Technology will be foundational to what we’re able to accomplish in healthcare.