>What a Difference a Day Makes

From the June 2002 Issue

What a Difference a Day Makes

A Houston health plan customizes its care management technology to eliminate unnecessary inpatient days.

By Connie Commander, R.N., C.C.M., A.B.D.A., C.P.U.R, executive director of medical management at MethodistCare. Contact her at ccommander@methodistcare.com.

When patients stay in a hospital longer than they need to, they unnecessarily increase the risk of infection, and precious healthcare resources are wasted. Making sure someone is hospitalized for just the right amount of time, no more and no less, can mean significant savings for a health plan and improved outcomes for patients.

The Challenge

MethodistCare of Houston was still a relative newcomer to the managed care business in the beginning of 2000, when I arrived to head up the medical management department. The plan, which today has close to 100,000 members throughout southwest Texas, was created as a subsidiary of Methodist Health Care System, a hospital-based network. Our patients’ average length of stay was between 3.8 and 4 days, with each day costing MethodistCare about $800 per patient. With MethodistCare members passing through the doors of about 20 hospitals each year, the ability to save a small amount of this average could yield significant savings.

Together with the medical director and case management staff, we set a goal to create a “possibly avoidable days” (PAD) program. The program would identify any days spent in the hospital that could have been avoided, determine the reason for the delay in leaving the hospital, assign responsibility, and then educate our physicians and facilities about possible actions they could take to avoid these days in the future.

The first order of business was to staff our department with the right type of people: case managers with strong backgrounds in both utilization and case management. I see the two activities as complementary, requiring the skills that would help us identify overstays and come up with creative treatment options. Since our program would be built on unassailable data, I needed employees who would be meticulous about entering chart information into the system.

Tech Strategy

We also needed the right technology to take center stage in the program, technology that made my staff feel comfortable and that would keep tabs on how our patients move through the hospital system—who stays too long and why, and who is responsible for overstays.

We were already using McKesson’s CareEnhance™ Care Manager. The software, a component of the CareEnhance Clinical Management software product suite, tracks members for utilization and case management purposes and serves as a repository of a wide range of information. First, users can input extensive notes into the software, invaluable for someone who needs to become familiar with the nuances of a case quickly, such as claims staff. Second, McKesson’s InterQual® Criteria for acute care and home care is readily accessible within the software by a quick tab command.

CareEnhance Care Manager provided the sound technology foundation we were looking for and also was relatively easy for us to customize. We designed a drop-down table that identifies the person or group responsible for the avoidable day: physicians, the facility (e.g., central supply, lab, OR), members or “other.” With help from our medical informatics department, we then created lists of possible reasons for the avoidable days, categorized by the party responsible.

For example, under “facility responsible,” the reasons range from “acute bed not available” to “delay in treatment: radiology” to “case manager or discharge planner did not assess.” Under “physician responsible,” the reasons range from “drug/test not ordered timely” to “late physician rounds” to “surgery not next day—MD convenience.” Members might be responsible if they postpone discharge because they lack a caretaker at home, among other reasons.

We made this addition to the software without calling in consultants, saving ourselves time and money. Having the drop-down table as part of the application my staff was already using was important, too.

Now, case managers enter chart data for each patient into the system every day, with an eye toward identifying PADs. When an inpatient day looks avoidable, they discuss it with a physician reviewer or the medical director. If that physician agrees that the day could have been avoided, this information is entered into the software and activity moves to the next level. If not, the matter is dropped.

The Results

The data we are generating is accurate and timely, and we can create easy-to-read reports that “slice and dice” the data in a number of ways. We can track which physicians and facilities have the worst (and best) records for PADs, and we can delineate the most common reasons for overstays. The top three for our first year of the program were: 1) Care could have been managed at a less intense level; 2) lack of documentation to support the level of care received or the length of the hospital stay (InterQual Criteria sets supply standards for this); 3) consult was not requested in timely fashion.

We also use the software to identify the type of bed that is unnecessarily occupied and what the costs are. For example, if we pay on average between $800 and $1,000 for a medical/surgical bed per diem and rehabilitation beds cost us between $500 and $700, a patient moved to a rehabilitation unit a day later than he should have been means we unnecessarily spent an extra $300. Let’s say we have 10 of these days per month in one of our facilities. That’s $36,000 per year in savings, for just one facility.

The PAD program is a learning tool and has been effective in demonstrating exactly what it costs us when a physician fails to move a patient to a rehabilitation setting in a timely fashion, or, conversely, how much we save when we motivate that physician to use levels of care more appropriately. If the doctor is accustomed to scheduling only one test or procedure each day, the patient’s hospital stay may be unnecessarily extended. If we make the doctor aware of this tendency and its impact, he or she may schedule the tests closer together. The patient gets home earlier, and we save money.

For the first year of the program, our focus was giving feedback to all parties involved. We did not want to financially penalize physicians or facilities by denying payment for unnecessary days, but rather change their behavior.

Although we have begun to deny payments in the program’s second year, our goal is to do this as a last resort. There has been some resistance—mostly from the hospitals—but having a physician reviewer sign off on each PAD has avoided controversy and has enlightened case managers, physicians and facilities. For the most part, physicians and facilities have been very cooperative, especially because we can show their performance in relation to their peers. We also have an appeals process, which is used only about 10 percent of the time.

In 2001, the first year of the program, we identified 278 days that were avoidable. Utilizing $800 a day, that’s $222,400 of possible savings for the health plan had we been denying payment. In terms of effecting organizational change, we reduced the average length of stay by about 10 percent. Since we started the program, we have also seen an increase in patient satisfaction with the case management department. The bottom line is—we have introduced a new level of accountability to our healthcare system, which in the end benefits everyone.