From Tom's Desk

Bose, the world class sound equipment manufacturer, was sued this past week in Federal Court, accused of collecting information on the listening content individual users and selling it as metadata. Though some have responded with outrage and calls for boycott and new regulation, the public has most commonly responded with a shrug and a what-do-you-expect?  Overall, it seems that we, as a society, are getting used to the fact that our zone of privacy is shrinking rapidly.
 
I wonder what the reaction will be if a healthcare delivery organization (HDOs) is found selling PHI-free metadata from their electronic health record?
 
Exposing your secret Barry Manilow obsession is one thing, exposing your STD history is another. Even if you can be assured it’s not identifiable, you’re gonna be pissed.
 
I have absolutely no knowledge that such metadata sales by HDOs are going on, only that they are definitely a grey area within the impenetrable scrivenings that are HIPPA law . And I also know that, in an era when the actual delivery of healthcare services carries decreasing margins, organizations are looking for every possible revenue stream to help support their cashflow. In our current environment, based on no specific information whatever, I would be stunned if such information exchanges are not occurring—and you know you would be to.
 
If found liable, I suspect Bose was exposed by a disgruntled employee. Even though the reaction has been blasé thus far, the company’s secrecy and denials are certainly not going to enhance it’s corporate reputation.
 
It’s frightening to think what might happen to the first HDO caught with its hand in the cookie jar.
 
After all, as clinicians and HDOs, the actual product we sell is trust.

You Should Know...

Hospital owners, their administrators and consultants have been tearing through CMS’ annual Prospective Payment System Rates report released in the past week. The communication is chock full of adjustments to compensation and quality programs for FY 2018. As a former hospital owner myself, the report has always been a useful indication of healthcare trends and the deep thoughts of CMS.
This year’s was especially interesting.
 
Hidden deep in the hundreds of pages, was a call for public comment about revising regulations regarding physician ownership of hospitals.
 
The ACA dramatically restricted the ownership and expansion of physician-owned inpatient facilities—a restriction that the only physician-author of the act publicly admitted in the Wall Street Journal the biggest mistake the drafters made.. It’s unclear how much regulatory relief CMS can actually provide given that the restrictions are formerly written into law—there was certainly no real relief in the recent attempt in Congress to “repeal” the act. But the call for comments on this issue is the first I have ever seen since the ACA—and it suggests a sea change in CMS’ thinking.
 
In my travels, I have networked with several of folks at CMS who call for and review these comments. At night, in the hotel bar, after a long day of meetings and all the cynicism is shed—they will admit that indeed these comments have an impact on policymaking. And the more grass-roots, the better.
 
So whether you’re of the opinion that, even in the healthcare sector, competition reduces prices and improves services or that physicians and patients need regulatory protection from the self-dealing and cherry-picking opportunities that physician-owned health systems can allow, this is your chance to make you comment heard. It’s also surprisingly  easy to do so using the Federal Government’s comment portal. If you’re interested, give it a try. 

High-Value Insight

Unspecified Pneumonia (ICD-10 J18.9) should be submitted with your outpatient claim if the clinician diagnoses pneumonia without specific evidence of the causative organism in the form of a positive culture result. Unfortunately, J18.9 is not associated with any increase in the patient’s risk score. The justification is that these unspecified pneumonias are often not pneumonias at all, and if they are, they carry a lower cost-burden on the resource pool—because the patients were not sick enough to justify a culture.
 
There is, of course, no mention of the high false negative rate associated with sputum cultures in the first place.
 
Inpatient rules for submitting risk-associated pneumonia codes are different and more generous than outpatient rules. But you don’t have to admit your patient just to get the increased RAF score associated with their illness—nor should you!
 
Just get a sputum culture.
 
There are no agreed upon guidelines for when a culture is indicated for lung infections.
 
Chest, NEJM, Archives of Internal Medicine—they all have their own opinions, but there is certainly no consensus.
 
And you should absolutely not get a culture simply to get a risk code.
 
But if you feel a culture is clinically indicated—severity of illness, co-morbidities, immunosuppression, whatever—simply record your justification in your medical record. If  comes back with a true positive, submit an addendum to the original visit with the organism specific IC-10 code—those are the codes that WILL map to increased risk scores. And the increases can be very significant.
 
I recommend reviewing the sputum culture guidelines in the journals above. I bet you’ll find you’re not doing doing them often enough.

Q&A with Dr. Tom

Are there any risk associated diagnostic code that are associated with financial loss even if coded appropriately?

Yes

The risk scores for full thickness pressure ulcers significantly understate the true direct and indirect costs of caring for these horrific injuries, even if the patient’s co-morbidities such as malnutrition and obesity are taken into account.

Though it’s important to capture these codes accurately, there is no way to “get ahead of the cost curve” for these particular conditions. The only way to do so is to keep them from happening at all.

It used to be the entire spectrum of pressure-related skin injury was associated with increased risk scores and therefore increased revenue to offset costs. But over-coding and outright fraud led the actuaries and trustees to limit the risk model to paying for only the worst ones.

Pressure ulcers are not like chronic diseases that you can catch early and submit for revenue year after year, even as you are keeping their costs down by keeping them under control.  Nor are they acute illness, where if you systematically catch and code each one, your overall revenue for that diagnosis will end up being greater than your average cost of care.  No, pressures ulcers are just plain losers—for the patients personally, the nurses professionally and the insurers financially.

And so many are preventable.

Prevention of pressure ulcers is an enormous subject. However, there is a simple intervention, which has fallen by the wayside due to fragmentation of care. 

Don’t allow any splints to be placed on your inpatients without a hospitalist’s order. 

Don’t allow the hospitalist to place the oder without a hard stop confirming they examined the patient.

I know this goes against everything I say about making care simpler and removing obstacles to letting clinicians provide care. But n the current, fragmented system, this is one exception which is both necessary and creates an enormous payoff for everyone involved.

Patients come in to the hospital with a history of wearing supportive splints for neurologic injuries. The nurses or therapist read the histories and place the splints, often without asking the patient or family member if the patient is compliant at home. The result is hard splint placement of unchallenged integument—and rapid development of pressure injuries in an already infirm patient. 

Alternatively, a patient with a new neurologic deficit has a new splint placed, with little or no eduction. The nursing staff often doesn’t even know that the splint is new and a new pressure injury results

In the old days, when the patient’s personal clinician was overseeing care, this was much less of a problem.

Today, with compartmentalized shift work and a cumbersome electronic health record, this is not an uncommon occurrence at all, and it can happen with startling rapidity and frequency. And even worse, since they generally show up in post-acute care environments, they are very difficult to measure.

Get your hospitalist to develop a plan for any splint, old or new, that’s going to be applied on your patient. Relive them of some of the other useless donkey work to make room, but by all means make this one mandatory.

If your pool is underperforming despite capturing a fair share of risk codes, do a deep dive on your pressure ulcers. I’ll bet their care costs are a significant source of your losses.

Prevent them and even if your RAF score goes down, your financial performance is certain to improve.

And your patients healthier.

 

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