Pressures: How Hospitals and Doctors Can Work Together For Cost-Effective Care

Written by on August 31, 2012 in Features - No comments
“Why are non-physicians trying to tell me how to write a progress note?”
“The hospital’s length of stay initiative…”
“In other news, the readmission rates for local hospitals are under review.”

With third-party payers tightening their standards and scrutinizing inpatient records, both physicians and hospitals are finding that practicing cost-effective care is more important than ever—both for getting paid for our work and for keeping the hospital financially healthy. The process needs to start on the day of admission, and it requires cooperation between office caregivers, hospitals and hospital-based doctors.

“It’s just a diabetic with a kidney infection. Why does she have to sit around the ER instead of  going directly to the floor?”

While the primary care provider wants to keep well-insured patients happy, there are both clinical and financial reasons to make sure we have all the facts of a patient’s condition before assigning her a room. The sooner lab tests, imaging and treatment are started, the faster the patient will get better. And the ER staff will collect information and write orders that help hospital administrative personnel decide what level of care—observation, med-surg bed, telemetry, or ICU—is both appropriate and likely to meet standards for payment. Many ERs now have case managers, usually RNs, review all admissions, and they can often help with suggestions like higher IV fluid rates that are recognized as appropriate for acute admissions. A doctor who rejects their input is likely to spend more time than he likes arguing about unpaid bills.

Coding Made Easier

Office-based doctors already deal with ICD-9 and CPT codes and study how to get paid for the work they do. A similar system is followed for hospital visits, and documenting the work done will decrease the odds of “downcoding”, in which third party payers decide that a doctor must not have done much work if he only wrote a two-line note.

Hospital care adds another level of complexity: the diagnosis, and how doctors word their notes, can make a huge difference in what the hospital is paid. Since the 1980’s Medicare has paid by diagnosis codes and severity of illness, with big-ticket illnesses like heart failure subdivided into left and right ventricular, systolic and diastolic, etc. And more payment is received if there are complicating conditions like pulmonary edema.

Hospital coding specialists, usually registered nurses, keep up with changes in the diagnosis codes and ask doctors, usually with notes on patients’ charts, to clarify the situation. “Ventilator-dependent” may sound self-explanatory to a physician, but adding “respiratory failure” to the problem list helps assure payment for the $5000 a day that it costs the hospital to keep the patient alive. The coding specialist can use a form with alternative diagnoses (“acute blood loss anemia” vs. “anemia of chronic disease”) lets doctors check a box, scrawl a signature and move on to other matters—and a hospital’s bill listing expensive problems first improves the odds that the doctor will get paid for his work.

It Starts on the Day of Admission

The incentive to reduce hospital days began with diagnosis-related billing, meaning that any days spent getting inpatient treatment that could be given less expensively elsewhere will not be paid for. Unnecessary days are not just a financial problem, but can cause new problems like hospital-acquired infections and blood clots. Starting discharge planning early, particularly when a patient needs to change living situations, is both financially sound and helps patients and families adjust to change and avoid surprises.

Hospital case managers are doctors’ and hospitals’ biggest asset for planning where a patient goes after discharge and in making the arrangements for home IV antibiotics, skilled nursing facilities (SNF) or acute rehabilitation. They are especially helpful with elderly patients: a doctor who works with case managers instead of dodging their phone calls can not only improve average length of stay but spend less time on the phone explaining why SNF is a good idea and which one is best for the patient.

Hospitals also are under increasing pressure to reduce readmission rates—something everybody involved wants to avoid. Doctors can take advantage of hospitals’ nurse educators and medication reconciliation programs to be sure that patients and families understand how to monitor their conditions and can afford the needed medications; nurses can even check to be sure that all followup appointments have been made and written out before the patient leaves the building. Uninsured patients admitted via the ER may be eligible for county or state outpatient programs, and they can begin the application process from their hospital beds; my hospital’s case managers regularly fax paperwork and help patients arrange interviews from the nursing station.

Doctors, for their part, need to be sure that they have either notified their office that a patient is being discharged or made contact with the primary care provider to update him or her on what happened at the hospital. A smooth handoff between hospital and outpatient care is one of the most effective ways to ensure that the patient does not return to the ER with the same problem that caused the present admission.

Don’t Shoot the Messenger

It’s common to hear complaints from doctors about “hospital meddling”. But keeping length-of-stay records and letting staff physicians know how they rate compared to colleagues with similar practices makes it clear that cost-effective care is possible without impairing quality of care. The case manager who suggests a palliative care consult is not trying to take over medical decisions but rather to point out an option the doctor may not have considered. And reviewing patients’ test results to fill out those coding requests may improve both documentation and quality of care.

Hospitals can ease doctors’ adjustments to the changing rules in a number of ways: continuing education classes taught by physicians, mentoring by hospitalists or others more familiar with the current regulatory situation, and tactful reminders posted next to dictation phones.

In the end, underpayment is everybody’s problem. Good communication and communication are survival traits not only for hospitals but for the doctors whose patients depend on them.

By Stella Fitzgibbons, MD, FACP

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