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BRIDGING THE GAP BETWEEN CONFUSION AND CLARITY IN HEALTHCARE

National Physician Advisor ConferenceNPAC2019

Bridging the Gap between Clinical Documentation and Safety Scores:Expanding the role of the Physician Advisor

Nate Henderson, DO CPE FACPDirector, Clinical UtilizationAssociate Medical Director, Hospital MedicinePrisma Health-MidlandsColumbia, South Carolina

• Brief history

• Physician Advisor (PA) value locally

• PA Process to HIM and CDI

• PA Value to CDI

Agenda

• Locally owned, nonprofit integrated health care system

• Hospitals (1,639 beds)• Baptist• Baptist Parkridge• Children’s Hospital• Heart Hospital• Richland (Level 1 Trauma)• Tuomey

• PH USC Medical Group ambulatory practices

• 1,000 Physicians and 500 Advanced Practice Providers

Prisma Health–Midlands (formerly Palmetto Health)

Prisma Health Baptist Parkridge, Opened March 2014

A Brief History

• Established internal Physician Advisor (PA) program 11/1/15 for second level review

•Added PA, Denials & Appeals 10/1/16

A Brief History

• > 3400 Medicare 2nd level reviews in FY 18• General structure of program/overview

• $2M in cost savings to Prisma Health Midlands

Physician Advisor ROI

• General Program Structure Overview

• 500 cases reviewed FY 18• 340 Peer to peer calls

• $1.4M returned as a result of Appeals work in FY 18

(and counting)

PA Appeals Specialist & ROI

• A task from the CFO

• Understanding the needs of HIM/CDI

• Building a business case• Who has a need for a Physician Reviewer?

Entering the CDI world

Are these PSIs real? What is a PSI?

Leapfrog and PSI

Leapfrog and PSI

Leapfrog and PSI

CMS Star Rating and PSI

Reporting Period for January 2019 CMS Star Rating

Domain

Domain

Weight

(%) Metric/Measure Q2

'14

Q3

'14

Q4

'14

Q1

'15

Q2

'15

Q3

'15

Q4

'15

Q1

'16

Q2

'16

Q3

'16

Q4

'16

Q1

'17

Q2

'17

Q3

'17

Q4

'17

Q1

'18

Lag

Time

COMP-HIP-KNEE 4-5 years

PSI-90-SAFETY 3-4 years

HAIs 1-6 2-3 years

AMI, CABG, COPD, HF, PN, STK 4-5 years

PSI-4-SURG-COMP 3-4 years

CABG, COPD, Hip/Knee, STK

EDAC: AMI, HF, PN 4-5 years

HOSPITAL WIDE 2-3 years

OP-32 1-2 years

Patient

Experience22% H-COMP 1,2,3,5,6,7,

Clean, Quiet, Rating, Recom 1-2 years

Efficient Use of

Medical Imaging4% OP-8,10,11,13,14

2-3 years

OP-22,29,30,33 1-2 years

OP-4,23,PC-01,SEP-1,VTE-6 1-2 years

IMM-2,3/OP-27 1-2 years

Timeliness of

Care4% ED-1b,2b,3

OP-1,2,3b,5,18b,20,21 1-2 years

4%

Readmission

(30 Day)

22%Safety of Care

22%Mortality

22%

Effectiveness of

Care

Entering the CDI world

Entering the CDI world

Mapping it Out

Mapping it Out

• Assembling the team• “PA CDI”

• 1 trauma surgeon

• 4 hospitalists

• Scheduling and communications

• Started May 2017

Creating a New Physician Advisor

PA CDI Distribution of Work

• Case Examples• PSI 11 Post op respiratory failure

• PSI 09 Post op hemorrhage

• PSI 12 Peri op PE/DVT

• PSI 06 Iatrogenic Pneumothorax

Physician Advisor PSI Reviews

46

14

26

CONFIRMED PSI CONFIRMED PSI, BUT DISAGREE NOT A PSI

PSI Reviews, FY 18

CDI queries

PA CDI- Medical Staff Affairs Reviews

106

38

90

35

ACCEPTABLE NOT ACCEPTABLE ACCEPTABLE NOT ACCEPTABLE

HISTORY & PHYSICAL POST OP NOTES

Note Reviews, FY 18

• Common Diagnoses Queried• Respiratory Failure

• Sepsis

• ATN

• Encephalopathy

PA CDI- Clinical Validation (DRG Denials)

51

76

Proceed with Appeal Agree with Denial, do not Appeal

Clinical Validation Reviews, FY 18

• How much do PSIs cost?

• PSI Reduction and Leapfrog/CMS Star Rating Improvement

• Value to the medical staff office and HIM

• DRG Appeals have true value

PA CDI ROI

PA CDI ROI

26 18 35

$117,004

$-

$20,000

$40,000

$60,000

$80,000

$100,000

$120,000

$140,000

OVERTURNED PENDING UPHELD

CDI DRG Appeal ReviewsMay 2017- Dec 2018

PA CDI ROI

www.acpadvisors.org

Nathan.Henderson@palmettohealth.org

Thank you!

Contact Info