Now, I would like to introduce our speaker to kick off our series today. Dr. Toni Sesta is a founding partner of Case Management Concepts, LLC, which is a consulting company that assists institutions in designing, implementing, and evaluating case management departments and models, educational programs, and on-site support for leadership and staff. Dr. Sesta has been active in the research and development of case management for more than 25 years. Her research has included two funded studies measuring the effects of a case management model on congestive heart failure and fractured hip patient populations, with measures of patient satisfaction, quality of life, and short- and long-term clinical perceptions and outcomes. We are so thankful that you're here to kick off this series for us. This morning, Dr. Sesta, we invite you to go ahead and get us started. Thank you so much, Lindsay. It's so great to be back with the Georgia Hospital Association and those of you dialing in today from other states. It's my pleasure to be bringing you this five-part boot camp. We're going to go through a lot of information over the next five weeks, and we're going to start today with what I call some of the foundational information that we all need to have to perform our jobs in case management. We'll talk about some of the payment methodologies, some of the new stuff that's come out from CMS that you may or may not be familiar with in the bundle payment arena. At the end today, I'm just going to spend a little bit of time exposing you to some of the stuff that's happening on the community side of case management. Of course, this is an acute care boot camp. However, I think as hospital-based case managers, we also need to have a sense of what's happening in the community relative to case management and how we can link up with those working on that side of the fence, as we might say. We're finding, certainly with the ACOs, accountable care organizations, as well as CMS's new payment methods like those bundled payments, that we have to think more across the continuum, perhaps, than we have in the past. You can add to that the efficiency measure. You can add to that the payment reductions for readmissions. All of these elements that CMS has put in place are geared toward having case management and hospitals in general think more across the continuum, rather than just siloing us in the hospital. With that in mind, let's get started. Lots of content, as I said. Let me get myself together here. I did update these numbers recently, probably a month or so ago. Hospitals should be pretty current. This gives us the frame of reference in terms of what's happening in the healthcare industry. We are an industry. We do provide a service. People don't like to say we are a business. They consider that a dirty word, but in fact, hospitals and healthcare systems are businesses. We have to at least take in as many dollars as we spend in order to be viable. We have to understand how all of that fits together. Pretty consistent over many, many years now, that a third of the dollars that are spent in healthcare are spent on hospital care. I don't think that's a surprise to any of us. However, did you know that our per capita spending on healthcare is the highest in the world? We spend $12,555. The next highest spending country is Switzerland, and they're only spending $8,000. We'll talk a bit today about why we may have that higher cost per person. 17.3%, this actually dropped, which I was shocked by, 17.3% of the gross domestic product is spent on healthcare. That actually went down a little bit. Just to put that into general terms, what that means is that 17% of every dollar earned is being spent in some way to healthcare, whether that's copay, deductible, and out-of-pocket, whatever it might be, and that's, again, pretty high. Uncompensated care, which we lump together as bad debt, meaning somebody was going to pay and they didn't, plus charity care is about 6% of revenue, and that has gone up 1%. So hospitals are giving away free care 6% of the time. We are consistently, as per the World Health Organization, couldn't get anything more recent than 2018, 45th in life expectancy and 45th in infant mortality, and it'll be interesting, and I'm not political at all, but with what's been happening with some of the changes related to abortion care, we'll see what happens with that. U.S. rates higher in prevalence of chronic diseases, and we fall behind other developed countries in the following quality domains, effective care, safe care, coordinated care, and patient-centered care. And if you think about what I just mentioned about CMS's focus on looking at exactly these things, you can see why. So although we spend a lot of money, we have to ask ourselves, you know, why can't we improve on some of these quality measures? And then this study that demonstrated that close to a third of the trillions of dollars we spend on health care goes to care that is duplicative, fails to improve patient health, and may actually make it worse. And this notion of duplicative care is, again, a focus for us in hospital case management as we look at managing resources for our patients and our hospitals. So this was an interesting little bit of information that I found from a group called, and I have to read it to you because I can't remember, it's OECD, and the Organization for Economic Cooperation and Development. So this is another look at how we fare compared to a global perspective and that higher spending and worse outcomes question that I've talked about actually for a long time. So we spend more on health care as a share of the economy. And so this OECD actually has 38 member nations today. These are all democratic countries, I want to say hospitals all the time. And so they have to agree that they are democratic and they are contributing to the market economy. So we're spending twice as much as the average, yet we have the lowest life expectancy and highest suicide rate. So that was a new one that we didn't see before. We have the highest chronic disease burden, as we just said, and an obesity rate that is two times higher than their average. Americans had fewer physician visits than their peers in most of these countries. And they're attributing that perhaps to a low supply of physicians in the United States. So we do have a lot of physicians use some expensive technologies, and we do, don't we? MRIs, specialized procedures, hip replacements more often than our peers. I'm not sure that that's a bad thing necessarily. The U.S. outperforms its peers in terms of preventive measures. That's good. We have one of the highest rates of breast cancer screening among women, ages 50 to 69. And the second highest rate of flu vaccines among people age 65 and older. So those are good things. And compared to the peer nations in this group, the U.S. has among the highest number of hospitalizations from preventable causes and the highest rate of avoidable deaths. And some of that I think has to do with discrepancies in insurance coverage, people seeking out primary care, people using emergency departments as their route of entry to the health system. We could talk probably an hour just on that point alone. So just, again, some interesting statistics that place case management, in my opinion, in a very important place. Now, 2020 was the last on this particular graph. Medicare average cost per beneficiary, $15,000. My guess is it's probably continued to go up from that $15,309 there. But again, we continue to spend, spend, spend. And we're going to talk in a minute or two about the DRGs, diagnosis-related groups. And the intention of those DRGs back in the day was to manage costs. And yet we still see that we are a high-spending country. So, of course, we know that the prospective payment system didn't quite get where we were as a country expecting it to go. So we still work in very complex environments, and we have a rising bed demand. And part of that, you know, I'm sure some of you may remember when we were downsizing hospitals, I don't know, probably 15 years ago now, we were downsizing hospitals. We thought we would need less beds. And to some extent, we do need less surgical beds in our hospitals, because so much of surgery has moved to the ambulatory setting, but we are still seeing an aging patient population with possibly multiple comorbidities. In fact, if you are at least 65 years old, you're likely to have at least one comorbidity. I think the average is three, believe it or not. So these are folks that are accessing the healthcare system and, of course, the hospital. Emergency departments, I really thought that over the years we would see a reduction in overcrowdedness in emergency departments, and it surely depends on where you are nationally, of course, where you're located, but we still have pockets where emergency departments remain crowded, and again, people using them as their routes of entry to the hospital as opposed to going to a primary care provider. Hospital gridlock continues on weekends, particularly, and what you get into is the seesaw pattern of busyness on Monday, and then by Friday, there's tons of discharges, and the folks that are in the hospital can't get certain services because of the lack of resources available over the weekend, and if you're in a critical access hospital and you're getting paid per diem perhaps, not for Medicare, but for some of your commercial payers, or you're in a hospital with a per diem contract, you're going to get those days carved out when you're not providing an acute level of care, so we'll talk more about that today as well. So let's just take a look at some of the case management definitions. I wanted you all to see some of the organizations. You do have professional organizations available to you, and it's always a good idea to join one of them or more than one if you're inclined to do that because it keeps you current as far as what's going on in the field. Webinars like this are another good way for you to remain current in the field, but, you know, net-net, you want to be linked to your peer group, and your peer group is case management, so this one is the Case Management Society of America. Now, that's CMSA that you've probably heard of. They were the first to organize in this way and the first to have a certification in case management, so that's another thing professionally that you can work toward if you're not already certified, so this is their definition. Case management is a collaborative process of assessment, planning, facilitation, and advocacy for options and services to meet an individual's health needs through communication and available resources to promote quality, cost-effective outcomes. That's a long sentence. It's long to read, and it's got a lot in there, so what they've got in there is your process, right? Always start with an assessment. We'll be talking about that, and, of course, facilitating care is part of care coordination. That we'll talk about, too, and advocating for our patients, but also our hospitals and that balance that we have to achieve between advocating on behalf of our patients and on behalf of the organization that we work for. Ultimately, our goals are to promote quality care and with cost-effectiveness as that other balance that we try to achieve. For the social workers, the National Association of Social Workers has this definition, and you can see the link there on the screen. Now, this is wordier, perhaps, and there wasn't a simple one-paragraph definition for you, so I included these different things. Let's just look at the top bullet quickly. Method of providing services whereby a professional social worker assesses needs of the client and the client's family when appropriate and arranges, coordinates, monitors, evaluates, and advocates for a package of multiple services to meet the specific client's complex needs. Now, we will, particularly in our fifth webinar in this series, talk about how we can optimize the skill sets of both the social worker and the nurse case manager so that both disciplines can work at the top of their license. I do consulting for case management departments. I'm working with one right now that has the social workers and the nurses all doing the same thing. You may be working in a hospital that is like that as well, so what happens then is we really don't optimize those skill sets, so I give you that as a prelude to what we will be talking about in a couple of weeks because I think we have a missed opportunity when we don't optimize those skill sets. So the other organization that I want to bring to your attention is the American Case Management Association, ACMA. Now, ACMA followed CMSA in terms of existence, but they also provide you with certification and case management. The difference, the main difference between the two organizations is that CMSA looks at case managers across the continuum of care, regardless of your setting, as long as you meet their criteria, you can be certified, whereas ACMA is principally based and focused on hospitals and healthcare systems, so some folks feel that ACMA is a better fit for a hospital case manager. That's really for you all to decide, but those are the demarcations between the two groups, and so their definition is a collaborative practice model, including patients, nurses, social workers, physicians, and other practitioners, caregivers, and the community, and I like that they included that. The case management process encompasses communication and facilitates care along a continuum through effective resource coordination. The goals of case management include the achievement of optimal health, access to care, and appropriate utilization of resources balanced with the patient's right to self-determination. Again, pretty long paragraph, but it does hit on all the main points that really give us the framework that we all work in. There are models, we'll be talking about those models today, and not today, but I mean there are contemporary models that give us, again, a foundation and framework for the work that we do. Okay, so let's talk a little bit about federal healthcare reimbursement. Let's start with that. So some people had healthcare back before 1965. It was an out-of-pocket kind of a thing, or if they were lucky enough, they might have gotten health insurance through their employer. That was really started only after World War II when a lot of people were returning to the workforce, and in order to be competitive, employers began to offer healthcare benefits as part of employment. Before that, that did not exist before World War II, and so we had these quote indemnity plans going up until around 1965 when the Medicare and Medicaid programs were initiated, and the payment on the Medicare and Medicaid programs was based on costs incurred. So there weren't a lot of checks and balances at that point in time, so hospitals could bill one of those programs and be reimbursed pretty much unquestioned, and what that, of course, did was drive up costs again, and so in the early 1980s, the federal government said, you know, we can't continue to pay these high costs for healthcare. Let's see if we can come up with a different payment methodology that would help to control costs, so by 1983, they had developed the prospective payment system, PPS, and so today we work with IPPS, the inpatient prospective payment system, but you probably also work with the outpatient prospective payment system, which covers your emergency department and your observation patients, but we'll come back to that. What they did was, believe it or not, they looked at, they had actuarials look at about a million medical records, and over that analysis, they came up with the DRG's diagnosis, the DRG's, which condensed diagnosis and procedure codes into this classification system, so this was how they decided to control costs, and we'll talk about how that works in a moment. In 1997, as doctors continued to complain about the fact that the DRG's did not allow for differences in patient acuity, Medicare put in place the MS DRG's, the Medicare Severity Diagnosis Related Groups, and that's what we still use today, and we'll take a look at that in a couple of minutes. So Medicare, as you know, is a federal health care system, so it's run by CMS, the Centers for Medicare and Medicaid Services, so it is a government program for people 65 and older, you can sign up for Medicare three months before you turn 65. If you have certain chronic conditions and or disabilities, and they do consider some of these chronic conditions like end-stage renal disease as a disability, then you can possibly be eligible for Medicare before you turn 65. So Medicare has four parts, right, and we hear this on TV a lot these days. Part A covers your hospital inpatient, but the patient has to be formally admitted for that to be considered, skilled nursing, and then that means the patient was formally admitted to the hospital for three days, and that's the dreaded three-midnight rule that we'll be talking about, and I hear this a lot as I go around the country. Well, you know, we needed to put the patient in a nursing home, and they needed to have a three-day stay, and that patient may or may not necessarily meet acute care criteria, but CMS clearly says you cannot admit them for those three days for custodial care. Those are not my words. Those are their words. So that's a real catch-22, isn't it? And also under Part A would be hospice services. Part B is outpatient. And we'll talk about Part B billing in a couple of webinars because we get into that a bit with our observation patients. So some provider services while inpatient at the hospital are covered under Part B. Outpatient hospital charges, even if the physician's office is physically in the hospital, that's still a Part B. And professionally administered prescription drugs. So if you have an intravenous Lasix administration outpatient, for example. Part C, of course, is your managed Medicare or your Medicare Advantage. We're seeing a lot of problems in the past year or so with your Medicare Advantage plans. And I can tell you from what we're reading online in my company, I think there's going to be some more crackdowns on Medicare Advantage because they're really kind of a little bit out of control. I'm sure some of you are probably shaking your heads that you've had that experience as well. But when patients sign up for Part C or Medicare Advantage, they are allowed to choose health plans that have at least Parts A and Part B. And also offers the benefits of a Part D or drug program. And always an annual out-of-pocket expense limit, which is very different from the traditional Parts A and B. So you'll see your seniors sign up for Part C because the initial monthly payments are lower. They don't have to worry about drug plans. They don't have to worry about supplemental plans. But like any managed care plan, there are limits to what you're going to get and the choices that you have. Part D covers mostly self-administered prescription drugs. So what happens is if you're staying with a traditional Medicare plan, you're going to have Part A, you're going to have Part B. And if you want Part D, you're going to have to pay extra for that. And then the other option you have, if you stay with traditional Medicare, as you can see on the very bottom, is that you can opt into a supplemental plan. And what those supplemental plans do, and there's tiers on those too, but if you sign up with one of those, then that means that some of your out-of-pocket of the traditional Medicare would be paid for. So you've got cost, you've got your Medicare payment, it's not free. You've got your supplemental payment, you've got your Part D payment. So a lot of cost if a patient chooses to stay in traditional Medicare. But the fact of the matter is, Medicare very seldom questions anything. You don't have to get pre-certified, and so there are benefits. And then of course, our Medicaid programs. And I just want to emphasize that these are very variable, depending on the state that you are located in. Some states have expanded their Medicaid program, and that was allowed. Some have not, or did not. And so we do see a tremendous amount of variability in our Medicaid programs. Medicaid is paid by the federal government as well as your state, so it's a combination of payments. And then of course, it's for people with limited income and resources. And again, that depends on your state, whether or not you will qualify to be in Medicaid. It also covers benefits that might not normally be covered under Medicare, which would include nursing home care and personal care services. So those are differences between the two programs. But fundamentally, one is for low-income folks, and one is for the elderly. There's also dual plans, and I'm sure some of you have patients that have both Medicare and Medicaid. So it does provide the largest source of funding for people with low income for medical and health-related services. And look at that, providing free health insurance to 74 million people, 23 percent of Americans, as well as paying for half of U.S. births. So that's huge. Medicaid is a huge program. Let's see, what else should I highlight here? So again, they're not required to participate, your states, but they all participate in some way. So along with your Medicare, your TRICARE, CHAMPVA, and Medicaid, you've got four very large federally and state-funded healthcare programs covering a lot of patients. When we look at the evolution of case management, we see some parallels to these changes in reimbursement starting back in 1985, but even before that in 1920. So I like to say we have now passed our 100th anniversary in terms of case management's existence. And in the 20s, we were in psychiatry and social work, but in the outpatient settings. So certainly during the depression, then we saw a ramp up in the 30s of public health, nursing, and other similar programs to help people who were suffering during the depression. In the 1950s, we began to see case management used for behavioral health across the continuum. And that was helpful, of course, until we started moving behavioral health patients back into the community. But that's a different conversation. In 1985, acute care moved, I'm sorry, case management moved into acute care following the advent of the DRG's prospective payment that we just talked about. And so a couple of hospitals, Carondelet St. Mary's in Tucson, Arizona, and New England Medical Center in Boston found that they were the first two to really say, what are we going to do to address this change in reimbursement? We're going to have to have some kind of better checks and balances for ourselves if we're going to get paid a flat rate. And we'll talk about that in a minute. But the bottom line was by the end of the 80s, everybody was trying to scramble around and figure out what they needed to do to address this new reimbursement scheme that had been put in place. And today, the models that we'll be talking about don't look very much like those early case management models. So we have evolved quite a bit over the last many years. In the 90s, Medicare put forward, CMS put forward similar prospective payment models for nursing homes, rehab, home care, outpatient, including the emergency department. And so I certainly lived through a period of time where all those levels of care were also using some kind of case management methodology. And we still see some of that today. And then by 90, 91, managed care was really starting to progress as a way for folks purchasing insurance to have a lower cost for themselves. So employers were looking at managed care organizations that provided lower cost for coverage for their employees. And so today, of course, it's just common to see managed care organizations everywhere. But that was not common only 30 years ago. And then in the 2000s, primary care started to look at case management for the reasons that I mentioned earlier, but we'll talk more about that. So case management today is pretty much across the continuum in one form or another. And I think that's a good thing, because when we talk about discharge planning in a couple of weeks, and we talk about transitions in care, we always want to think about to whom am I going to pass my baton, my patient, in those levels of care to continue providing seamless care for my patients. So that's the notion. So let's talk about how we actually get paid under the diagnosis-related groups. So they are really a case-mixed complexity system. And again, they're used to categorize patients with similar clinical diagnoses into these groupings, these DRGs, to better control hospital costs and to determine how much your reimbursement rates will be. And I'm going to show you the methodology. So for example, and why we got concerned when this happened was Medicare will pay out a set amount based on that patient's DRG as opposed to reimbursing the hospital for its total costs. So when that happened, it's like putting the hospital on a budget saying, here's X amount, this is what you're going to get for this type of patient. If you spend less than X amount, then you get to keep the difference. And if you exceed that amount, you have to eat the cost, as they say. So it's all a law of averages. CMS believing that at the end of the day, everything will kind of even out. That was the logic anyway. So every year CMS puts out a table of the DRGs and they do change every year. So you can't assume that what the average length of stay was this year is the same as last year, because they do update those based on performance for Medicare patients for the prior year. Each DRG is also weighted. What does weighted mean? Well, it has a weight applied to it. And I'll explain in one second. So when the system was first put together, they used heart failure as the center of the DRG program. What does that mean? Heart failure was the number one admitted diagnosis back then. And so they gave DRG an arbitrary weight of 1.0. Today, if you see a DRG with a weight below 1.0, you can assume that's a higher resource consuming, longer length of stay DRG. And when you see them above 1.0, then you assume that that's a higher length of stay, higher resource consuming group of patients. So those weights drive this base rate, which is adjusted for certain things. So I give you an example here. So if you're a hospital in New York City and you have higher wages, higher insurance, higher whatever, than a hospital B in rural Oklahoma, then the DRG base payment rate for the same DRG will be higher for hospital A than it will be for hospital B when everything else remains the same. So essentially what they're doing is they're adjusting the payment for areas of the country that have a higher overhead to run the hospital. Similarly, adjustments are made for hospitals that have a lot of uninsured patients. Some of these are safety net hospitals, high Medicaid population hospitals, and for teaching hospitals. So hospitals with graduate medical education also get paid a little bit more for that expense that they outline. So that assigned DRG weight is intended to reflect that resource consumption. As I said, and the higher the relative weight, the greater the payment to the hospital. Now what had happened was CMS was seeing that a lot of hospitals were admitting patients with those lower weighted DRGs. And a lot of those patients that back in the day would have been in the hospital with those low weighted DRGs are now your ambulatory surgery patients and other types of patients who are being treated on the ambulatory side. So they have been to some extent taken out of the conversation because they're now on the ambulatory side. Some other definitions that play into your DRGs or CC you may see, I've seen this, complications and or comorbidities. So one or the other or both will bump up the weight of a particular DRG. And complication isn't always what we think of as a complication. For their purposes, it's a condition that arises during the hospital stay, but it has to prolong the length of stay to get that bump up. So if the patient has a complication, but the length of stay remains the same, you're not going to get credit so to speak for that complication. Comorbidity, it's a preexisting condition that the patient comes to the hospital with that affects the treatment received and or prolongs again the length of stay. So in both instances, there has to be an impact of the complication of comorbidity in order for you to receive additional payment. The other one that I think is super important for case management is the principal diagnosis. Now, typically when you see a new admission, you're getting that quote admission diagnosis. And that's what's put in in the admitting office, unless it's a surgical procedure. Let's talk medical right now. What will happen is over the course of the stay, the diagnosis may change. That admitting diagnosis is really only a guesstimate, but it's the principal diagnosis that affects how the DRG will be assigned. So by definition, the principal diagnosis is the condition that the physician determined to be the chief reason why the patient was admitted to the hospital, not the admitting diagnosis. So for example, a patient might be admitted with pneumonia, but after study, the physician determines that it's heart failure. So the admitting diagnosis was pneumonia. The principal diagnosis is heart failure. So that patient will get assigned the heart failure DRG, not the pneumonia. So this is from the most recent table. And when I went back to update this, I got to tell you, some of the weights went up, some of them went down. It's kind of all over the place. So when CMS comes out with this, they're going to base it on last year, prior years performance, as I said earlier. And then the weights change accordingly. So these are just some samples. There's about 600 DRGs, I believe today. I would like us to turn our attention to the left-hand column. And let's see, second line down is DRG 54. And the one under that is DRG 55. So they give us numbers. And then all the DRGs are put into, if you follow along with me to the next column, they're put into the major diagnostic categories, which are different body systems. So, excuse me, major diagnostic category one is diseases and disorders of the nervous system. And then they tell us whether it's a medical or surgical DRG. Next column gives our description. So for DRG 54, it's in major diagnostic category one. It's a medical DRG, and its description is nervous system neoplasm with MCC. MCC means major complications or comorbidities, and that's figured out by your coders. DRG 55 is right under it, and it's without major complications or comorbidities. So if you look at the weights, they're somewhat different, aren't they? The 54 is 1.4735, whereas 55 is 1.0732. And that makes sense because 54 has major complications and neoplasms built into it. The 55 does not. So they're allotting us some more money for those major complications and comorbidities. Geometric length of stay is next given, which eliminates outliers. So it's always lower than your arithmetic, which is a straight average length of stay. So you can see if your hospital uses geometric, it's a lot lower typically than arithmetic. And I have to tell you, those numbers did change. So you'll see, like, I put 652 down there on the bottom, which is kidney transplants, a weight of three. And that has come down because they're doing so much quicker work with transplants, as an example. The other big weighted DRGs are the NICU DRGs. So if you have a NICU, if you do transplants in your hospital, you're going to see an overall average case mix index much higher than you would otherwise. So the difference in dollars with or without those major complications or comorbidities comes out to some big buffs. So here on the left, you've got DRG 54. On the right, you've got DRG 55. We're going to talk about the same hospital with, I made these numbers up, base rate payment of $10,000 for both, and you look left and right. So we had our weight of 1.44735 for 54 and a weight of 1.0732 for 55. And then, so for our DRG 54, we're going to get paid $14,473.50 with that base rate of 10,000. I can tell you that's a low base rate. Most of you have much higher base rates. But for the patient without major complications or comorbidities, our payment is 10,732. So we have a difference of around $4,000. Extra payment, oh, sorry, I did the math below, 3,741.50 for a patient with a major complication or comorbidity. So again, that allotment difference, major difference with the new DRG system from 97. So what drives that DRG assignment? Well, it's documentation. So some of you may be coming up with a working DRG on admission. That is accurate only maybe 25% of the time for the reasons we've discussed. If you are going to base your working DRG on the admitting diagnosis, the admitting diagnosis can very well be incorrect. And now you're working off the wrong DRG. Because DRGs are assigned after discharge, which is kind of a misnomer. People get confused because it says prospective payment. Well, what they mean by prospective is that these payment amounts, the DRGs are determined prospectively. But the assignment of the DRG is based on all the documentation in the medical record after discharge. So your chart will go to your medical records department, to your coders, and they're going to go through all this, particularly physician documentation, but they do look at other things. They look at laboratory, they look at some nursing documentation and so forth. And what they're doing is they're looking for documentation to support the DRG assignment, but that's done by a computer system called a grouper. So all that data that they're collecting from the documentation goes into this grouper, and the grouper assigns the DRG. And that's what drives your reimbursement. So there is a direct correlation between documentation and how much your hospital is going to get paid. So some of your hospitals may have clinical documentation improvement programs, CDI programs. And the purpose of CDI staff is really to look for deficits in documentation to get your physicians to document accurately and completely. So that's the purpose of that in order to get the correct VRG assignment at the end of the day, when that chart is completed. And it drives all these things that you see here. Excuse me, some of you may have been around for the transition to ICD-10 codes. We had ICD-9 for a very long time. Today we have ICD-10, which increased the specificity required from the physician documentation and identifying specific disease processes, but also having the physician identify the interactions between the symptoms of the patient and that definitive diagnosis, which isn't really gonna happen, hopefully. Well, hopefully it'll happen as soon as it can happen. And then there's that grouper. So what I just wanted to show you on the table here is the big change that's amazing is the diagnosis codes went from about 14,000 to 69,000. So that's what is requiring your physicians to have much greater specificity in their documentation. Procedure codes went from 3,800 to almost 72,000. So this is again where documentation really becomes important. So you'll hear people talk about the case mix index, the CMI. All your CMI is, your case mix index is, is a sum of all your DRG weights for a period of time. So let's say we wanna know what your hospital's case mix index is for August, 2024. All we would do is count up all the DRG weights and divide by the number of discharges. So all it is, is an average relative weight for that time period. But documentation isn't good, it's gonna go down because the weights will go down. Documentation is better, maybe it'll go up. Maybe you're admitting more highly weighted surgical patients. So it does fluctuate somewhat and finance does keep a good eye on it. You have a CDI program, they're keeping an eye on it too. And then of course, measuring your length of stay. So of course, the average length of stay that we all talk about all the time refers to the average number of days that a patient would spend in the hospital. And so it is generally measured by dividing, and again, this is Medicare, dividing the total number of days stayed by all inpatients during a year by the number of admissions or discharges. Now your hospital is gonna use the same methodology to do your budget. So your finance department budgets your average length of stay based on last year's performance. As of 2023, the national average length of stay was 4.5 days. The other two things we saw on our table were the geometric mean length of stay, which as I said, reduces the effect of very high or very low values. So it can bias your average or your mean lower, usually lower because it takes out those very high lengths of stay. Arithmetic mean again, is just your mathematical average length of stay. You should always know which one your hospital is using. So as you're putting in expected lengths of stay, which I hope you are, that you know which one your hospital uses. Most hospitals, I'm gonna say most, most that I've experienced anyway use ALOS, not geometric, but some do. Why do we care about length of stay? Well, some of the obvious things are we're getting that base rate, case rate, excuse me, case rate payment, putting us on that budget saying, we have to manage our own resource consumption and length of stay. We don't want to expose patients to the acute care setting longer than they need to be because something untoward can happen to them. Our length of stay is now publicly reported. It's an indicator of our hospital efficiency. We have a better bargaining position with our managed care companies when we sit down and negotiate contracts. If we are doing well from an efficiency and length of stay perspective, which gives us that competitive edge and hopefully aligns us regionally and nationally with those benchmarks that we were just looking at. Of course, then the spending for Medicare beneficiary, which is one of the newer ones, which I think most clearly relates to our work because they're looking at cost and length of stay in the spending per Medicare beneficiary measure. So that's one that I think we can help have a positive impact on. So the expected length of stay, it gets real tricky, doesn't it? Because we don't know what the DRG assignment is gonna be. This is all after the patient's stay. So the codes assigned, those complications or comorbidities, the quality of your physician documentation and the effectiveness of your CDI program. So yeah, you can put an expected length of stay in at the start of your admission, but it is a guesstimate. And just that we all know that it's good to have some kind of framework for that, but we all have to remember that it may or may not be accurate at the end of the day. So what does impact our actual length of stay? The hospital length of stay or the average length of stay, these are metrics that can indicate your hospital's efficiency or patient case complexity. As I said earlier, you have some of those higher weighted DRGs discharged and you might see a difference even in your average length of stay. There's so many things that impact on the patient's average actual length of stay. So those comorbidities, the patient's acuity level, how your hospital is performing in terms of, and we'll be talking about this more when we talk about care coordination, but what is happening on the weekend? How much does case management get involved with care coordination and driving reductions in length of stay? Staffing levels, whether it's your hospitalist, your case management department, your physical therapists, nursing, everything can impact that way. Physician practice patterns. You may have some physicians who are not quite with the program and they have maybe a longer length of stay than we would like them to have. And then those gaps in care, as I mentioned, it might be a weekend or something else. So other factors, avoidable delays, delays in care, gaps in care that could have been prevented. Ineffective discharge planning or great discharge planning, positive or negatively. Those unfunded or underfunded patients with minimal resources in the post-discharge environment. So what happens? Maybe they have to stay in the hospital a little bit longer than we would have liked. Geographical lack of resources. Maybe you have a shortage in your area for psychiatry or even those physical therapists that may slow down their discharge. Hand-off communication. We'll be talking more about hand-off communication during this series, but it's obvious from the literature that when we don't have a team communicating with each other that we tend to see problems with length of stay and certainly cost of care. And then not treating patients for a reason other than the reason they were admitted to the hospital. So we don't wanna have rabbit trail treatments as we call them. Patient comes in for one thing, we start treating them for something else or working them up or doing a complementary colonoscopy or whatever it might be. Wanna stay away from that. Okay, let's talk a little bit more about managed care now. So managed care, it stepped in, became very popular. As I said earlier, when those costs went up, when prospective payment really didn't accomplish what it was supposed to, when providers, excuse me, insurers were able to provide those buying health insurance with lower cost payments. And so it became more and more and more popular. It brings together four delivery functions that had been siloed really. The financers, those like your boss who pays for your insurance, the insurers themselves, those that are insured. We are all insured by our employer, not everybody in the United States is. Providers, those providing the care and then the payer of course is the insurance plan. And that was one of the things that doctors didn't like about managed care was that now we have a payer, an insurance plan butting into the provider's arena. And I think maybe people don't complain about that so much, but in the beginning that was a big deal problem. So they are implementing control mechanisms in the delivery of those services because what they wanna do is reduce their costs. They're getting paid a certain amount and they don't want more spent. They also bring price competition as you sit down, your hospital folks sit down to negotiate managed care contracts. You can get into some price competition. I see mainly hospitals kind of take what they can get these days, but it can happen. Yeah, I'm just gonna have a quick sip of water here. Rotating Lindsay between water and coffee. Okay. Features common to managed care. We're all familiar with the pre-auths. Rigorous utilization reviews. So you'll have a managed care company, of course, that might want daily reviews from you. Even if they're paying you a case rate payment they still may want daily reviews. They want the patients to use primary care rather than using specialists, for example. If you stay within your plan you're financially incentivized to do so. Again, another way to manage cost. And then a few years back, they were mandated to initiate quality improvement programs that looked at the quality of medical services in an effort to be sure that by reducing costs the way that they do that they weren't impacting on quality of care. So there's a few products that you're gonna see most commonly. Preferred provider organization, PPO. High deductible health plans. This one's a little bit newer, HDHPs. Health maintenance organizations or HMOs and point of service plans. I'm sure you have one of these that should fit. Preferred provider organizations. These are the most similar to the old indemnity plans. No gatekeepers, no referrals required. If you stay in network, you are financially incentivized to do so as long as you stay on your list of preferred providers. You do have co-pays and deductibles. And sometimes an employer will start with one of these and then move on to an HMO or something tighter like that that's less expensive. These high deductible health plans are a type of health insurance that has higher deductibles and higher out-of-pocket maximum but they have lower monthly premiums. So it's kind of a gamble that the patients are taking. So yeah, I don't wanna pay a lot every month with the hope that maybe I won't have to actually use my health insurance where I might have to pay a huge deductible. So I just have an example below. Let's say you receive a medical bill for $5,000 under these high deductible health plans. Your deductible might be as high as $3,000. So that means you're gonna have to cover that first $3,000 deductible before your provider even considers covering the rest. Whereas with a PPO, you might only have to pay 1,500 or even less than that, maybe. So again, for younger, healthier folks, this might be more appealing. Health maintenance organizations, of course HMOs are the lowest cost of all the managed care plans. And you must stay in network. You do not have an option to go out of network. They have in the past used capitation. They still use case rates. Some capitation with certain specialty patient groupings like psychiatry and mental health, for example. No coverage if you go out of network unless it's an emergency. If you wanna see a specialist, you need a referral and you have a copayment for office visits. And then point of service plans, combination of a PPO and an HMO. I like a point of service plan because if I stay in network, then I have very little out of pocket. But if I wanna see a physician, let's say out of network, I can go to the PPO side and see who I wanna see. So they do give you strong incentives for staying in network, but you can also go out. Now I'm sure many of you have seen these commercials for your Medicare Advantage plans that have all these other benefits that you can get. So this was published earlier this year, which I thought was really interesting. So these are the percents of these Medicare Advantage plans that actually offer the things that you will hear in these commercials. Eye exams, 98% have that. Fitness programs, 97%, which I was surprised by. Telehealth, 95%. Hearing exams or AIDS, 95%. Dental, 94%. Remote access technology, 74%. Meal benefits, 67%. Transportation, which you will hear a lot about, 38% have that. In-home support services, 10% have that. Bathroom safety devices, 8% have that. So, and even in those, if you look to the left of the slide, a dental benefit might include only cleanings or preventive care with a dollar cap on that. So yes, you might get some of these, but they may be limited in scope. So it's really important that patients are counseled to know that they really need to understand exactly what they're gonna get when they sign up for one of these programs or not gonna get, we should say. We have lots of challenges with these MA plans, Medicare Advantage plans, because of access limitations sometimes. So it can be very challenging, certainly. So let's have a case example. Mr. C goes to the hospital. There was a movie. It was a hospital, like a little documentary similar to this. So I thought I'd use it. It was Mrs. Tibbles goes to the hospital. So we're gonna call this Mr. C goes to the hospital. So in October 21, otherwise healthy Mr. C, age 80, was hospitalized due to cardiac concerns and renal failure. Knowing his recovery would be lengthy, he asked for, but did not get a case coordinator from his managed care plan. After six weeks, it was time to leave the hospital, but he was deconditioned. So his doctors wrote orders for Mr. C to be transferred to an inpatient rehab facility for intense multidisciplinary therapy to regain his strength. But Mr. C's Medicare Advantage plan denied inpatient rehab prior to authorization stating your doctor must expect you to improve a lot in a reasonable amount of time. We're gonna talk about how we might deal with this specific example when we get to discharge planning module three. So see, now you gotta come back to see what the answer is, how we will get Mr. C placed in a rehab facility. So how does managed care look today? Well, believe it or not, look at that. HMOs way down from the last time I checked these numbers and your high deductible health plans rising in popularity up to 29%. PPO is still the most popular at 47%. So it's interesting that these high deductible plans are getting more and more popular. I think people, they just can't afford some of the other stuff if they're buying that plan themselves. So risk, you'll also hear the term risk thrown around and there's two kinds of risk, financial risk versus health risk. So financial risk is what a managed care company is looking at when they're talking about a population of patients. How many healthcare dollars are gonna be spent usually in a capitated program, but it could be in other programs as well. So if you're looking at a Medicare Advantage plan where it's seniors, well, hello, the financial risk is gonna be greater than a traditional commercial population of working people. And that it's hard to tease those apart because health risk, the possibility of poor health outcomes, the possibility of using more resources are interlinked with that financial risk. So in terms of your hospital's reimbursement in today's environment, so you have your case rates. So when you get that DRG assignment, your hospital's gonna get that lump sum payment. And that is used not only for Medicare and Medicaid, and by the way, your Medicaid program has a different table with different weights, I just wanna mention that. We looked at Medicare, but a lot of your managed care contracts are also using case rates. And as I mentioned before, and we'll talk more about this when we talk about utilization management, the problem is a lot of times, even though that managed care plan is paying you a case rate they still want daily reviews. The risk is really on the hospital at that point to manage that lump sum payment, and yet they want daily reviews. It always kind of boggles my mind. I get the admission review because we're trying to decide whether they're gonna pay for the stay at all. But after that, the risk really transfers to the hospital because you're gonna get that flat sum amount. So it's just an interesting thing that I don't know why it happens. You might have a contract with per diem payments. So the hospital gets paid each day and that's when carve-outs can happen. So if your hospital is not providing some patients with an acute level of care on Saturday and Sunday, well, you can get those days quote carved out or not paid. Percent of charges, I have seen some hospitals that still have percent of charges and that is a negotiated amount. So the hospital sends in the charges and maybe they'll get paid 60, 70% of those charges. That's not bad in today's world. And that's why they're not very common contracts anymore. Carve-out services, again, based on your contract, high cost services may be carved out not in the way I just talked about weekends, but they go into a separate category with a separate payment. Pay for performance, of course, in today's pay for performance world, if I can say that, you're gonna get paid extra or you're gonna get penalties based on your clinical outcomes. Global payments or bundle payments, which we'll be talking about, which may indeed carry across the continuum, many of them. Stop loss, if you have a patient, there are charge threshold amounts for some patients, DRGs, and this will be more money beyond that if you apply for that. Outlier payments can be really good, but your finance department has to do pretty complicated calculation to get paid for those, and you have to have both a high length of stay and high charges in order to qualify for outlier payments. So stop loss is kind of more automatic than an outlier payment. You don't need to worry about how that's done. It's kind of done behind the scenes. However, you should know it does exist. All right, so let's talk about our bundled payments. It's a brave new world out there. So what we're seeing is pretty much all your payers are trying out some sort of alternative payment model or method. So while we typically are thinking about CMS and Medicare, when we talk about some of these, we are starting to see some of the other plans taking a look at these too. So it's a transition to the value-based reimbursement. So you can go a single procedure to a full application for a population of payments. So we're seeing the whole gamut. Capitation originally meant per member per month. So we would get paid, let's say the hospital would get paid a flat amount per month for each patient, each client in that plan, regardless of whether they use the services or not. And so there's some of that still around. So with these bundled payment models, the payer collectively reimburses the providers involved. And when they mean collectively, they mean, for example, the hospital will get paid. And then the hospital has to pay out all the other providers along the continuum. And so everybody's kind of already in a position of trying to figure out how to deal with this because CMS has tested us and now they're moving on with some of this stuff. So the risk is on the hospital. Well, that's no different than DRGs or lots of other of the payment methodologies. The risk is on the hospital. And so some of our financial performance in a bundled payment is not just the hospital, but downstream providers. So your post-acute providers are in this calculation. And so we have to be more thoughtful and careful about where our patients are going for their next level of care, whether it be a nursing home, rehab, or home care. And now we get into issues where we have to provide those quality indicators to our patients when we give choice lists and we'll be talking about that. So we can't just say, we want you to go there, because they have better services, patients still have choice. So we do wanna have a better linkage with those that provide better quality care, more cost-effective care, but we also have to give our patients choice. So again, a balance. For the outcome measures for bundled payments, they look at length of stay, cost per case, readmission rates, patient satisfaction, and post-acute care availability and their outcomes, as I just said. So they're also looking at quality and cost on the post-acute side now. So CMS tells us, oh yes, there are many advantages to the bundled payment program. It incentivizes the providers to choose the most efficient mix of services and settings of care. I think that's true. It should reduce fragmentation, because if you think about it, if you're in a bundled payment that includes hospital and post-acute, everybody should be working together to control costs and improve quality. So it forces people out of those silos by, again, encouraging collaboration, and it improves accountability and quality of care, as CMS says. So extending that bundled payment beyond the hospital stay to include the post-acute care world is really the name of the game. And as I started off saying this morning, we can't just think about the hospital anymore as case managers. We really have to think about much more carefully where our patients are going and what the impact of that might be. So I'm sure most of you were involved in the first bundled payment program, which was the Comprehensive Care for Joint Replacement Program, CCJR. It's over. It began in 2016. It was projected to save $343 million over that five-year period. The actual savings turned out to be $143 million. Their gross savings after everything was paid out was $17.4 million. Okay, you know, they didn't quite make those big targets, but it was the first one. So of course it was mandatory for all acute care hospitals, furnishing services in 67 selected mandatory areas. So that was 800 hospitals in 33 states. I'm sure a lot of you were involved in CCJR. So it made sense that they looked at hip and knee replacement inpatient surgeries at that time. And now we're seeing knees moved outpatient and now hips is going to move outpatient. So it was, you know, the prelude, I think, to some of that movement. So it included inpatient, outpatient, readmissions, physician services, post-acute care providers, and Part B medications. So there's your bundle. So what were the lessons learned as the first bundled payment? 89% of the hospitals that responded to the survey reported implementing same-day post-surgery ambulation and physical therapy. Again, it was your hips and knees. 81% reported scheduling follow-up appointments prior to discharge. Yeah, we're going to talk more about that. 65% reported implementing repeated telephonic follow-up during the entire 90-day episode. Excellent. And 61% felt that physician engagement and care redesign activities had improved. All good stuff. Then they added additional years. So they had performance year 21 to 22, performance year seven, which was 23 to 23. So it was just that year. And eight was January 1st, 2024 to the end of this year. And then we'll see what those outcomes will be. They're projecting an additional savings of $217 million. So these are additional years that you may be involved with. And now we have the team for transforming episode accountability model. This will be a mandatory five-year episode-based alternative model. And selected acute care hospitals will be coordinating care for people with traditional Medicare, undergoing one of the surgical procedures included in the model. And I'll just tell you what those are shortly. And they will assume responsibility for cost and quality of care from surgery, and then 30 days after that Medicare beneficiary leaves the hospital. So CMS feels that patients who undergo surgery may experience fragmented care, which can lead to complications for recovery. I would add to that potential readmissions and potentially avoidable care that might include readmissions. So the team model, if you will, will aim to improve the patient experience. And they'll do that from surgery through recovery by supporting coordination of care and transition of care between providers. So again, that transition from acute to post-acute and use of the emergency department. So this is what's included in the team's model, for team model. Lower extremity joint replacement, surgical hip femur fractures, spinal fusions, coronary artery bypass grafts, and major bowel procedures. So yeah, they got some ortho in there. They got cabbages, spinal fusions, and major bowel procedures. That's a lot. For some hospitals, that's a lot of what they do. The participants will be required to refer patients to primary care. Good. To support patient continuity. Yes, that's all good. And they're looking at health equity. So the model offers certain flexibility, allowing safety net hospitals to participate and attract with lower levels of risk and reward in a pricing methodology, but includes adjustments to account for underserved. So if you happen to be in one of our safety net hospitals, perhaps, they're going to allow for that because safety net hospitals with these high populations of Medicaid and lower populations of Medicare, oftentimes feel a little bit left out. And this begins fiscal year 2025, which is today. Oh my God, I just realized that. October 1st begins fiscal year 2025. Wow. And this is how our value-based purchasing still looks. Honestly, I haven't looked at 2025 because today's the day, but right now I'm guessing it's going to be the same because this hasn't changed for a while. 25% split on our four domains, as we call them. So 25% goes to the efficiency and cost reduction measure, which I like to call the spending for Medicare beneficiary. And euphemistically, we've started to call it the efficiency measure. So it kind of looks like this. It's not for all diagnoses. However, it's for the similar ones that are in your 30-day readmission program. It does include part A and part B spending. It starts three days before your patient is admitted to the hospital. It includes the hospital admission and it includes 30 days after discharge. So that includes transfers and readmissions. So all of that, if your patient gets transferred or readmitted is bundled in, included in your scoring for this measure. They started off doing something similar to the DRGs. They had 1.0 as the frame of reference. As people did better, based on national averages, it was reduced to 0.99. In this score, lower is better. So if you happen to come up with a 0.85, you're gonna be 14% less than expected, which is 0.99, and higher is worse in your efficiency measure. And you can find all of this online at Hospital Complear to see how you are faring with this one. But this is one we can impact on because we do look at cost and we do look at length of stay. So how can you do that? Well, you wanna manage your resources while the patient's in the hospital. That's something we wanna work with our physician colleagues to have a better sense of not over-utilizing those hospital resources. When we get to discharge planning, we're gonna talk about how we can all improve our care transitions. And that's an important component of all of these models. And we'll talk about that. Hardwiring our multidisciplinary teams. Managing discharge planning from the minute the patient really comes into the hospital. We'll talk about that in our discharge planning webinar. And then once they're out, we wanna keep them out. We do not want patients bumping back to the ED. Either just be in the ED or to be readmitted. This is not a goal. So we'll talk about that as far as how we can impact on that as case management professionals. And then this alignment with next level of care providers is really important for all the reasons that we just went over. Now, one of our measures that we just saw, 25% went to HCAHPS, Hospital Consumer Assessment of Healthcare Providers and Systems Hospital Survey. I love it. People get paid to come up with these names. I'm just mentioning composite six, which is discharge planning. How well nurses and doctors communicate with patients? How responsive hospital staff are to the patient's needs? How well the staff communicates with patients about new medicines? Whether key information is provided at discharge, we are part of that. How well patients understand the type of care they will need after leaving the hospital? So four and five for sure are things that we can impact on. We may talk about medicines. I see that more as a staff nurse and physician responsibility, but we have some skin in the game on that one too. So these were your national averages on these back in 2020. There's always a lag in this data. While you look at that, I'm just gonna take a sip. Bye. Communication always comes up a little bit higher, doesn't it? But look at the care transition measure. Understood care for home, 54%. Not good, not good. We can do better than that. And then of course, we have the Hospital Readmission Reduction Program. It's been around a bit of time now, hasn't it? And there are still hospitals that are doing worse than others. It came under the Affordable Care Act. So we've had lots of years now to try to impact on this. Unfortunately, despite the penalties that come with this program, we haven't seen a huge impact. Unrelated and planned readmissions get in your score. So I always use the example of the patients discharged after heart failure admission, and then goes outside and breaks their hip. That would be considered a readmission, even though one had nothing to do with the other. It will give you a deem, as we say. But there are some exclusions. So we have in-hospital deaths are excluded, patients not enrolled in Medicare, traditional Medicare for at least 30 days after discharge, patients discharged against medical advice, patients under the age of 65, transfers to another acute care facility, or same-day discharges for AMI someone. So there are some readmission exclusions, but net-net, most of your patients are gonna be in this. This is just looking at maybe where your state fares, and it's a little difficult to interpret the colors. If you're good at colors, you'll do well. The very dark states, and I'll point out Florida, I'm in New York, we're pretty dark there. New Jersey has that dark maroon color, Connecticut, Massachusetts, New Hampshire. And then in the Midwest, I see Tennessee, Ohio, West Virginia, Illinois, and so forth, Missouri, and so on and so forth. So let's look at Georgia. Pretty close to, you know, the bad end. The bad end, whatever you wanna call that. So everybody's got readmissions. It's a matter of percentages. Indiana ranked 29th, so that's why they scored that one. 77, almost 78% of your admissions are gonna be medical, but believe it or not, 22% are gonna be surgical, getting to all of these bundled payment programs that are looking at surgery. Surgery is kind of the forgotten group to some extent, in the sense that we never really think about them as much in terms of those readmissions. So under Medicare, 20% of the beneficiaries were being readmitted within 30 days, and 34% within 90 days. So, you know, that was definitely a red flag. Physician visits. So when we talk about making those post-discharge appointments, why do we care so much? There's a lot of different reasons, but 50% of the patients who are rehospitalized within 30 days after a medical discharge did not see their doctor within those 30 days. So these are patients who went home, didn't see that doctor, high risk for rehospitalization. And when those patients get rehospitalized, we know statistically they're gonna have at least a 0.6 day longer length of stay on the same, on the readmission, if it's the same diagnosis. So, you know, something to do absolutely want to avoid. Readmission risk adjustment. There is some, so they will adjust for case-mix differences, demographics, for morbid diseases or indicators of patient frailty. And to be very honest with you, I don't know how they do that one. They don't adjust for complications. They don't adjust for where the patient is admitted from. Socioeconomic status, hospital size, hospital specialty, or location. Safety net hospitals complained about this because again, they're in kind of a different bucket. So now they have their own comparison group. So safety net hospitals will be compared to other safety net hospitals, not to everybody else. They have not changed in eight years in terms of, maybe it's even more on this than on that here. Probably, yeah, eight years. They haven't changed the diagnoses that they're looking at here. So I don't know why, I guess it's a good thing, but they have not changed this. So we do have a 3% penalty adjustment if we do poorly in this area. This penalty would be applied if you have performance worse than the national average on any of these conditions or procedures that we just looked at. So it's not a composite, it's any one of those. If you do worse than the national average, you're gonna get a penalty. And it's based on all your discharges, not just your readmitted patients. So this applies to a portion of your hospital's payment. So it's something you want to avoid. Now, there will always be readmissions. Please, I know that, but at the same time, we can do a little bit better on that one. All right, accountable care organizations, ACOs. You're also probably hearing lots about them. An accountable care organization is formed typically with a group of doctors and our hospitals and our healthcare providers who want to work together to improve quality and the patient's experience. So these organizations, and that's what they are, help doctors and other healthcare providers to understand their patient's health history, to communicate with one another about the patient's care and needs. They can save time, they can save money by avoiding repeated tests and unneeded appointments. We looked at that at the very start today about how much that's factoring into the cost of care or the unnecessary things that are done. Easier to spot potential problems before they become more serious, like drug interactions. I think electronic records has really helped with this. If you go see the doctor, the doctor can see another provider that you've seen, and that even sometimes goes beyond the ACOs, but certainly in the ACOs, it's helpful. This is not an insurance plan. It doesn't limit choice at all. It's not an advantage plan, it's not an HMO, it's not insurance at all. But in order to qualify to be a patient in an ACO, you must be an original, traditional Medicare patient. Even if your doctor or other provider is part of an ACO, you still have a right to go elsewhere. So it doesn't limit your choice as a patient. So as they form these organizations, they, they have responsibility for the cost and quality outcomes. Across the continuum of services that they're covering. They have 23 quality metrics. That they're responsible for. The 1st, pioneering sales, and that's literally what they were called back in. 2011, CMS often does this 1st, you just have to report data data. Like, when we talk later in our webinars, we're going to talk about social drivers of health. Right now, CMS is only looking at that data rate, so we can anticipate that in a couple of years. They're going to do more than just look at data, but that's what they did. With these 1st, pioneer. They would look at things like. Examples were mammograms and real missions in 30 days. Now. All these years later, there are financial consequences. When they don't do quite as well, so. They're incentivized to form these networks and providers. Because then if they do well, and the care is more efficient, they do get. Bonuses, and as of January 2020, there were 558. Only 26% are in the no risk track. Which is down from 82% back in 2018. So, let me just say. Is coming go and the ones that go. Typically did not have. A robust case management infrastructure. So, who's going to be the glue that's going to pull this all together and then across the continuum is going to be case management. So, when they start an ACO, and they have either poor case management or no case management, that's when these organizations struggle and sometimes. Go go defunct I've seen it more than once. And then we have the quote next generation ACO model. There are 35 participating in in this particular 1. This 1 was started for. ACOs that were experienced in coordinating care. So, they were allowed to assume higher levels of financial risk, but also. Reward by joining the next generation model. So, this model, you may have some ACOs. In this model, better smarter, healthier approach, they say to improving health care and setting clear measurable goals. They publicly, they have publicly reported the performance of the next generation with CEOs. On quality and other measures, patient experience being another 1. this is why when I say CMS is really pushing us to think of for us the continuum. These are all examples of where. Where that is true, and then they put in some waivers that I thought were kind of interesting and I had to look up the telehealth expansion waiver. So, if you're in a rural area in this waiver. It removes the rural area location requirements. And allows eligible Medicare beneficiaries to receive telehealth care in their homes. So, before you had to be in a rural area for them to. Pay for telehealth services that is. A waiver on that, which is good 3 day skilled nursing facility waiver. Can you imagine. So patients don't have to wait 3 days. This may be the beginning of them realizing how silly. That 3 day stay rule is we'll say cost sharing for part B Medicare services. Nice. Chronic disease management rewards gift cards for patients. Voluntary alignment frequently asked questions and post discharge and care management home visit waivers. So that means more patients would qualify for post. Discharge home visits, which is also nice. So, you know, I think they're testing whether or not they can eliminate some of these. These restrictions, if you will on care. A current ACO model is the reach model. The reach model is looking again at improving quality for traditional Medicare patients. By improving care coordination and increasing access to underserved communities. So this 1 is really focused on underserved communities wherever those might be. They're, they're looking at how. They can enhance Medicare benefits to the underserved, which I think is terrific. It for 2023, the reach model had 132. With 100 and almost 132,000 health care providers and organizations with 2.1M beneficiaries. In this program, and in 2023, they increased access to accountable care. In these underserved populations, which is really great. They'll have 124 federally qualified health centers. I'm a big fan of those rural health centers. Great and critical access hospitals. So, they've already doubled in size. I think this is 1 of the really great programs. For the underserved communities where we see those disparities and care, as I mentioned earlier. Racial, excuse me, and ethnic disparities. With the traditional Medicare population, so this is, you know, a good 1. I think we'll hear more about this. So, why do we have case management in hospitals as we start to wind down this morning? We want to provide quality, safe and cost effective care. I think that becomes very clear. We talk about all the ways in which we're getting paid these days and all the different. Models of payment, we want to promote utilization of available resources to get to those clinical and financial outcomes that we've looked at. Appropriate access to care, we want to work with patients, families, physicians, providers and payers. To implement plans of care that meet our patients, individual needs and goals. Now, that 1 I've said for a long time. However, CMS is now saying that when we talk about discharge planning and webinar 3, we'll talk about how seamless has changed that. Uh, that we must consider our patients goals. In our district planning process, we. Interject objectivity choice support. And self care whenever it is lacking and whenever it is possible. And, of course, we want to ensure compliance. We'll be talking about that a lot too. So, as I promised at the start, I just want to give you a little touch on. Community case management, some of you may interface with a community case manager. I'm seeing more and more of them in most federally qualified health centers in hospital clinics. Sometimes in physician offices, not as much. As as we do see in programs that are supported by the hospital. But the whole idea is to deploy case management professionals. To target high risk, high cost subgroups. With a population focused framework, so if you're working in the hospital. And you're passing a patient over to. A federally qualified health center, or some other program in the community that has case management. Well, that is a great thing because if these are higher stations. We don't want to just have them go out into a great whole black hole with all the community. We want to transition them to somebody who's going to continue to monitor. Their care, maybe it's an ACL these days too. It could be anything. The whole idea on the community side is to manage and coordinate care across the continuum. Track quality clinical and cost outcomes, same kind of stuff. It helps to keep patients connected as I said. Ensure that the energy and resources on the community side are matched. To the patient's actual needs and. Monitoring their outcomes and comparing to evidence based guidelines. So you have a heart failure patient. You might have a diabetic patient with typically the chronic conditions. Are the ones that we want to keep a good eye on to keep these patients from having exacerbations. Of their chronic condition. But nevertheless, patients. Mistreatments, they don't fill their prescriptions or they don't take the meds. Or they miss physician appointments. This results in admissions or visits to the. Because they're not able to well manage on the community side. They might have poor health care behaviors that nobody's taken a check on. Busy staff who aren't noticing these patterns. When I implement ED case management in hospitals. Right away, we start to see these patterns of patients with lots of recidivism. But the ED is focused on emergencies and they're not seeing necessarily they will see some. But they're not focused on on that particular issue. Whereas case management in the ED can do that. So we may not have a systematic way to assess and proactively deal with these issues for these patients. This is what community based case management brings. So we typically look for nurse case managers and social workers. In these community settings, working collaboratively. On patients with moderate and high risk. Staff are working, let's say, in a clinic are going to work with those low risk patients. Whereas the nurse case manager and the social worker are going to work with. Either clinically complex patients for the nurse. Or psychosocial or financially complex patients for the social workers. They both provide patient education. They both coordinate as needed. The other things that you'll see more often on the community side are electronic health records. Now, I'm saying the majority of hospitals I work with today. Have EMRs that link across the continuum. And we've been talking about that forever. And it's actually finally happening, which is, you know, really exciting. But you also have clinical registries. And what that means is if you have a diabetic patient and they have blood work. And they have an abnormal level of hemoglobin A1c or whatever it is. They're going to pop up on the registry for an intervention. Or if they're due for an appointment, that's going to pop up. They miss an appointment. Things like that. That will cause patients to otherwise return possibly to the emergency department. So you have provider and staff triggers. As I said, there's even psychiatric triggers. There's pretty much triggers for any crime condition. And so lists are generated for these high risk patients to be educated. I mean, there's all kinds of really cool stuff that happens for these high risk patients on a community side. Multiple providers send the same message to the patient. That they are part of the process. And we need to understand when patients are ready for education. You know, we try to do education in the hospital. But think about patients are anxious and pain sedated, whatever it might be. It's really hard to do a lot of good education on the hospital side. So what happens is we need to continue that education on the community side. So this is, again, an opportunity to do that. So checklists and templates, all that kind of stuff becomes really important. Self-management elements. And you know what? I talk about these based on community case management. However, they apply to your hospital patients as well. Health literacy, compliance versus adherence, and their own self-efficacy. And I think this is important for all of us to understand. Regardless of where we were along the continuum. Health literacy is a huge problem. It has nothing to do with your educational preparation, your socioeconomic level, how smart you are, how not smart you are. It has to do with your ability to read, to understand, and to act on health information. So I have very intelligent friends who are not in health care. And they do not understand, you know, what it means to skip a dose of medication or to stop taking their antibiotic when they start to feel better. I mean, and those are very simplistic examples. So believe it or not, only 17% of the U.S. population has a working level of health literacy. So when these patients leave the doctor's office, they're not leaving the doctor's office with a clear understanding of what is, what they're supposed to do, what their diagnosis really means. And the same thing happens to us when we discharge patients from the hospital. And when people have a poor health literacy, it can lead to medication errors, treatment errors, or they're not asking the doctor questions, all sorts of problematic issues arise. So we need to just appreciate that and meet the patient where they are when we try to educate them. And then there's compliance versus adherence. So compliance is the patient kind of passively following the doctor's orders versus adherence, where the patient acknowledges their role in making treatment decisions, participating in their diet, their medication administration, whatever it might be. And to get patients from compliance to adherence takes an active intervention on our part. And that can be not just in the community, but also in the hospital. As you're educating your patients about their discharge plan, you really do want to emphasize their role in making those decisions. And then self-efficacy. And this is the extent or how strongly a patient believes in their own ability to complete tasks and reach goals. So we want to work with them to help them to understand that through their participation in their own care, they can do a lot better. So on the community side, then we do a risk stratification. That simply means that we assess patients for their medical history, their current problems, their financial issues, their socioeconomic issues. And we put them in a low risk, moderate risk, or high risk category. We can't see all the patients in the community, but by risk stratifying them, we can focus in on the ones that have the greatest need. And so this is where the link across the continuum becomes really important. So if you've got these patients leaving the hospital, you want to make sure you have a very strong handoff between the hospital and the clinic, or the patient-centered medical home, or whatever it might be. Integrate appropriate services, making sure that we have home care where it's needed, where we have subacute where it's needed, or long-term care. So very consistent with some of those ACO and bundle payment models. So goals of case management integration across the continuum. So for you folks working on the hospital side, I want you to think about that handoff to the community not as a task, but as something very important for our patients. And this will result in less ED visits, hopefully less readmissions, and a shorter inpatient length of stay. Because should that patient appropriately need to be readmitted, if we catch that exacerbation earlier, hopefully they'll have a shorter inpatient length of stay. Improving coordination following discharge. We will talk more about this. Integrating, as we said, those acute episodes with community, improving quality and satisfaction of our patients, and improving coordination of care across all levels. So put a marker on that one, because we really are going to talk about that a lot. So again, this balance that I keep alluding to between quality and cost-effective care. Here's the big picture. If you look at my orange or gold arrow there, case management follows from community, through ancillary services, to direct care providers, through to physicians. And in the center of it all is the patient and family. I've given you some resources today. And I'm going to turn us back to Lindsay to see if there's any questions. Oh my God, Lindsay, this was a long one today. Nope, that's perfect. So it is absolutely perfect. So before I go over just kind of some wrap-up comments here, if you do have any questions for Dr. Sesta, go ahead and be typing those into the Q&A option found there at the bottom of your screen. Or if you don't see that, then you can, of course, just type your questions here in the chat as well. And I do see one question, Dr. Sesta, that asks, what is AMI? Acute myocardial infarction. AMI. Myocardial infarction. Perfect. I'm going to post some information here for you all in the chat. And while I am going over this, again, if you have any questions, don't hesitate to be typing those in so we can make sure to address those before we conclude today. So just as a reminder that you will all receive an email tomorrow morning if you have not joined us for webinar in the past. This is kind of our standard process. So you'll receive an email, but that does come from educationnoreplyatzoom.us. And so because it comes from that Zoom email domain, it very well may get caught in your spam, quarantine, your junk folder. So if you don't see that email in your inbox in the morning and you would just like to access the recording of today's session, you can just use that same Zoom link that you used to join today's live presentation to also access that recording. And just remember that the recording will be available for 60 days from today's date. And then we also have an additional security measure in place so that we're protecting Dr. Sesta's intellectual property here. So when you click on that Zoom link, you will need to enter your information and that will prompt an email to come to us. And as soon as we receive that email, typically, honestly, within a few moments, we do approve those recording access requests that we ask that you give us just one business day to grant those approvals. And then also included in that email tomorrow morning will be a link to the slides that Dr. Sesta presented today. But I did go ahead and provide that link there for you in the chat so you can have that as a resource now as well. And then if you are joining us as a member of the Georgia Hospital Association at the conclusion of this series, after the fifth session in the series, you will receive additional information regarding continuing education credits. And if you're joining us as a member of a partner state hospital association, I do encourage you to reach out to your state hospital association contact who'll be able to provide you with additional information regarding CEs for your state as well. You do see Dr. Sesta's contact information here on the screen. And I'll say that she is wonderful about responding to questions and being very, very thorough in her responses. And we so appreciate her going above and beyond in doing that. And so you're more than welcome to reach out to her directly there. Or you can always send any questions that you have at all to education at gha.org. We'll be happy to get those questions over to our system answers back to you or just answer any other questions that you have for us as well. Okay, I don't see any other questions at this time, Dr. Sesta. Yeah, yeah, I was just gonna say it was a lot of content. And I know once you have a chance to kind of think about it, you know, a little bit, chew on it, you know, you might you might come up with with some clarification questions. I'm always happy, you know, to respond, as you said, Lindsay. Absolutely. Yeah, a lot of content. Actually, all of our webinars seem to get bigger and bigger all the time. There's just so much more stuff that we have to talk about. And we so appreciate you taking the time and sharing your information with us. And we thank you all for joining us today. And we look forward to having you back with us for part two next week. And again, if we can be of any assistance, don't hesitate to reach us at education at gha.org. Thank you so much, Dr. Sesta. Hope you have a wonderful afternoon. Thank you. Thank you, Lindsay. Thanks, everybody. Talk to you next week. Okey-doke. Bye-bye. Bye.

case management

healthcare

Dr. Toni Sesta

payment methodologies

bundled payments

accountable care organizations

ACO models

resource utilization

value-based care

Medicare Advantage

health literacy

community care

patient self-management

care coordination

clinical outcomes