The Bundle: We Did Better than We Thought!
To review the impact of the bundle through the first nine months of 2011, at our Users' Meeting, we assembled several expert panels that reviewed and discussed administrative strategies and revenue cycle management activities that were used during the year. In addition, the panels also discussed quality improvement, clinical operations, and expense control techniques.
An executive panel that included Dr. J. Bhat of Atlantic Dialysis Management Services (ADMS), Larry Jones of Innovative Dialysis Systems (IDS), Gary Barnes of Central Florida Kidney Center (CFKC), and Dan Orlinski of Renal Ventures Management (RVM) addressed the bundle and Quality Incentive Program (QIP), discussed the decision making process for determining whether to phase in or go all in to the bundle. The panel also reviewed the outcomes of this decision (i.e., did they successfully assess the economic impact?), the problems of capturing co-morbidities for revenue adjustments, whether there was any return on the outlier part of the bundling program, and other similar topics. The panel generally agreed that their performance was better than they had anticipated it would be a year ago.
After the optimistic outlook of the executive panel, seven revenue cycle managers discussed in detail what actions led to the results that the executive panel reported. The revenue cycle panel discussion was led by Jeff Lehman of Dialysis Consulting Group (DCG) and included Jessica Jones (IDS), Dan Nye (CFKC), Debbie Archibald (Satellite Healthcare –SHC), Charla Williams (US Renal Care - USRC), Alan Douglas (Liberty/Renal Advantage - RAI), and Dawn Williams (GHS). The revenue cycle panel agreed that hard work, preparation, attention to detail, and the support and expertise provided by QMS were all critical factors in their ability to succeed in the new revenue paradigm. The panel reported that getting accurate, on time lab information for claims was critical, requiring specific attention. Additionally, communicating with fiscal intermediaries, processing 2728 forms and timely receipt of “new on-set” patients were all problems that had to be addressed.
The third panel consisted of clinicians: Dr. Premila Bhat (ADMS), Melinda Martin-Lester (RVM), Dan Nye (CFKC), and Kathleen Radtke and Margit Doelle both of GHS. This group discussed treatment modifications to reduce or optimize the expenses associated with dialysis so as to work within the new revenue realities. Among these modifications were specific changes in anemia management, specifically the use of ESAs and IV iron, optimizing lab analyses, structuring of lab contracts, management of bone disease, and optimizing use of lytics. Kathleen Radtke discussed a program called LEAN that was implemented at GHS that increased efficiency and reduced waste in all aspects of their operation. Many of these initiatives were facilitated by the use of QCS, which all of the providers in the panel use as their EMR. We can demonstrate these specific functions at NRAA – Booth 212.
QIP: Background & What you Need to Know
The QIP program is a mechanism to reduce provider payments for failing to meet certain quality criteria – anemia and dialytic adequacy – as measured by hemoglobin levels (Hgb) and urea reduction ratio (URR), which will take place January 2012. As such, it is not a pay for performance program since there is no reward for meeting or exceeding target levels. To prepare your company for the 2012 QIP changes, an understanding of what constitutes the QIP and how it's applied over time is important for all dialysis providers.
The initial metrics, contained in the ESRD PPS final rule in August 2010, established three criteria – one for adequacy (URR >65% - 25% contribution to one's score) and two for anemia (Hgb >12 g/dl – 25% contribution; Hgb < 10 g/dl – 50% contribution). Providers have been aware of these metrics since last year, although the payment year year (the year whose values will be used to determine payment reductions) was calendar year 2010. The result is that two-thirds of the performance year had passed before a provider knew what criteria they would be held to.
The QIP proposed rules – released July 8, 2011 – suggest dropping the lower Hgb metric for payment in calendar year 2013 (performance data based on the current year – data for which presumably will be completed before the rule is finalized; note that in 2010 Hgb < 10 g/dl accounts for 50% of the payment reduction.)
For payment year (PY) 2014 the metrics have been expanded from three in PY2012 to 4 in PY2013 (dropping Hgb <10 g/dl and adding two vascular access criteria), to 8 metrics in PY2014.
There were a number of comments from the field – many from QMS clients.
• Dr. Derick Latos (Wheeling Dialysis – QMS) commented on eliminating the lower Hgb metric as both welcoming because of the difficulty in controlling Hgb in a 2 g/dl band, but also a concern with no lower limit to protect the patient. He also produced an analysis of co-morbid conditions (not included in the PPS payment structure- such as cardiovascular issues, cancers, treatment venue, etc. – conditions that have a direct effect on acuity and therefore the cost of care) that applied to 15% to 30% of the patient population.
• Dr. Anthony Besarab (GHS – QMS) also commented on eliminating the lower bound on Hgb as it would be expected to increase transfusions and frustrate renal transplantation.
• Dr. Alan Nissenson (DaVita – QMS) took CMS to task as violating a key provision of MIPPA in establishing payment reductions for performance periods that are in the past:
“MIPPA expressly provides that ‘the Secretary shall establish the performance standards … prior to the beginning of the performance period for the year involved.'”
Clearly the performance standards for 2012 were established in PY2010; those proposed for 2013 are being generated by providers before they know the final metrics for PY2011.
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Preparing for QIP: How QMS Focus Can Help
QMS began a project in early 2011 to help QMS clients evaluate the metrics in QIP and also to provide a means to integrate payment reductions in the QMS revenue management system – QMS Focus.
All of the QIP metrics included in 2012 and 2013 payment reductions have been incorporated on dialysis claims since July 2010. This is the source of QIP data for these two payment years. QMS has designed a feature in QMS Focus that allows our clients to mimic the CMS calculation of QIP metrics. Using all CMS rules, QMS Focus clients generate dialysis claims using this system and it therefore has all of the data that CMS uses for its calculation. Unfortunately, the period during which providers could contest the values for PY2012 ended this summer; this computation will be possible for QMS clients for PY2013 which will be based on performance in 2011.
The QMS Focus Accounts Receivable functions have been modified to allow clients to enter the payment reduction parameters from CMS to allow for accurate tracking of expected collection amounts. There are several aspects of these new features. We presented a summary of them at the meeting and encourage you to contact our support staff for more in depth instruction and a demonstration of capabilities. We would be happy to share these new capabilities with you at the NRAA – Booth 212.
QCS & QIP
Clinical initiatives using QCS were highlighted at our Users' Meeting. Melinda Martin-Lester of RVM presented specific projects to improve fluid management in RVM patients and described the use of several reporting capabilities, existing and new, to advance this project. She also described the RVM initiative to reduce catheter use in their patients. We have worked with RVM in designing the access report to assist in this project – an objective that CMS and the industry has been trying to address over several years (it is one of the objectives of the QIP criteria for PY2013). Ms. Martin-Lester has also been using QCS to evaluate and improve treatment compliance.
Kathleen Radtke and Margit Doelle from GHS along with Dr. Premila Bhat from ADMS shared how they use QCS to guide clinical operations – reducing waste and increasing efficiency, as well as managing anemia and bone disease in the post bundling environment. Finally, Victor Paras from ADMS reported on a joint QMS-ADMS project to evaluate the effectiveness of implementing an EMR (QCS) in a multiple clinic setting. This is a challenge with sophisticated software implemented over a large organization. The analysis was done in collaboration with our QCS staff to evaluate the population of data fields needed for effective use of this system. It has resulted in a dramatic and more uniform and comprehensive use of QCS within the wide spread ADMS clinical groups.
Still Have Questions?
Come see us at the NRAA in New Orleans, QMS will be exhibiting at Booth 212! Please stop by to share your thoughts, ideas, and concerns with us. We look forward to seeing you there. Or visit our website www.qms-us.com.
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