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BRIDGING THE GAP BETWEEN CONFUSION AND CLARITY IN HEALTHCARE National Physician Advisor Conference NPAC2019

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Page 1: National Physician Advisor Conference · Lesson #7, Second Example: What was it like in the 1960s when the Medicare program began? Sheehy and Courtney, J Hosp Med, 2017; Lowenstein,

BRIDGING THE GAP BETWEEN CONFUSION AND CLARITY IN HEALTHCARE

National Physician Advisor ConferenceNPAC2019

Page 2: National Physician Advisor Conference · Lesson #7, Second Example: What was it like in the 1960s when the Medicare program began? Sheehy and Courtney, J Hosp Med, 2017; Lowenstein,

From Clinical Practice to Legislative Action: Using Physician Experience, Data, and Research to Impact Health Policy

Ann M. Sheehy, MD, MSAssociate Professor and Division Head, Division of Hospital MedicineUniversity of Wisconsin Department of MedicineMadison, Wisconsin

Page 3: National Physician Advisor Conference · Lesson #7, Second Example: What was it like in the 1960s when the Medicare program began? Sheehy and Courtney, J Hosp Med, 2017; Lowenstein,

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• Observation Hospital Care: Perspective from a Practicing Hospitalist

• Ten Lessons in Health Policy

• Questions

Outline

Page 4: National Physician Advisor Conference · Lesson #7, Second Example: What was it like in the 1960s when the Medicare program began? Sheehy and Courtney, J Hosp Med, 2017; Lowenstein,

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• Most of my points refer to Original Medicare• Commercial insurance, Medicare Advantage, Medicaid is variable

• Medicare was created to at a time when half of Americans over age 65 did not have health insurance and seniors were the most likely demographic to be living in poverty• My comments are aimed to show how research can improve an

important program in our country

Perspective #1: Medicare

https://www.cms.gov: Medicare & Medicaid Milestones, 1937 to 2015.

https://www.cms.gov/
Page 5: National Physician Advisor Conference · Lesson #7, Second Example: What was it like in the 1960s when the Medicare program began? Sheehy and Courtney, J Hosp Med, 2017; Lowenstein,

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Observation Hospital Care: Perspective from a Practicing Hospitalist

Page 6: National Physician Advisor Conference · Lesson #7, Second Example: What was it like in the 1960s when the Medicare program began? Sheehy and Courtney, J Hosp Med, 2017; Lowenstein,

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• Perspective is hospital observation care, less so observation units• We have a unit at University Hospital

• Perspective is as a practicing hospitalist, researcher, and administrator• I have an MD and a Masters Degree in Clinical Research

• My administrative role has me looking at systems issues

• I am not a physician advisor!

• I greatly respect the work done to keep us compliant with regulations

Perspective #2: My Background and Influences

Page 7: National Physician Advisor Conference · Lesson #7, Second Example: What was it like in the 1960s when the Medicare program began? Sheehy and Courtney, J Hosp Med, 2017; Lowenstein,

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• New diagnosis of cancer

• Didn’t meet inpatient criteria, hospitalized as observation

• What does this mean?

Sometime Back in 2010…

Page 8: National Physician Advisor Conference · Lesson #7, Second Example: What was it like in the 1960s when the Medicare program began? Sheehy and Courtney, J Hosp Med, 2017; Lowenstein,

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• Patients may be hospitalized as inpatients or outpatients (observation)

• Medicare patients hospitalized as inpatients are covered by Medicare Part A hospital insurance and Medicare pays for post-discharge skilled nursing care• Deductible for 2019: $1364 per benefit period

• Medicare patients hospitalized under observation are covered by Part B, no skilled nursing benefit, no self-admin drug coverage• Limit of $1364 per service, no cumulative limit

• C-APC 8011…

Outpatient (Observation) vs Inpatient Hospital Care

This is an oversimplification…

Page 9: National Physician Advisor Conference · Lesson #7, Second Example: What was it like in the 1960s when the Medicare program began? Sheehy and Courtney, J Hosp Med, 2017; Lowenstein,

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Reviewed the literature and found a lack of information on observation

• Single institution data for 18 months

• Descriptive study with descriptive statistics only (number/%)

Page 10: National Physician Advisor Conference · Lesson #7, Second Example: What was it like in the 1960s when the Medicare program began? Sheehy and Courtney, J Hosp Med, 2017; Lowenstein,

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University of Wisconsin Hospital

July 2010-December 2011

Total 4,578 (10.4%) Observation Stays

Observation encounters by service and provider type: Why does a hospitalist care?

Medicine, 53%

SS Nonsurgical,

16%

Surgical, 17%

Pediatrics, 14%

Hospitalists, 59%

Traditional In/Outpatient,

21%

Cardiology, 10%

Emergency Medicine,

5%

Other, 5%

2012 Medicare Claims by Provider Type

Sheehy et al, JAMA Intern Med 2013. Observation white paper, http://www.hospitalmedicine.org/

Page 11: National Physician Advisor Conference · Lesson #7, Second Example: What was it like in the 1960s when the Medicare program began? Sheehy and Courtney, J Hosp Med, 2017; Lowenstein,

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Wouldn’t observation units solve the problems of observation?

Baugh et al. Health Affairs, 2012.

Page 12: National Physician Advisor Conference · Lesson #7, Second Example: What was it like in the 1960s when the Medicare program began? Sheehy and Courtney, J Hosp Med, 2017; Lowenstein,

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• Observation units should be used for select, low acuity patients without significant barriers to discharge

• If we could get back to Medicare’s definition of < 24 hours, rarely longer than 48 hours, observation units could be a bigger part of the solution

However…

• There may be diminishing returns on geographic co-location and resource prioritization for more complex observation patients with other discharge barriers

• Research studies and/or observation units may appropriately select for patients, but the hospital bottom line includes all patients, including those outside of the unit

Observation Units

Page 13: National Physician Advisor Conference · Lesson #7, Second Example: What was it like in the 1960s when the Medicare program began? Sheehy and Courtney, J Hosp Med, 2017; Lowenstein,

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• 4,064 spontaneous list service job postings from the American Case Management Association Learning Link 2011-2012

• Two most common job postings:• Observation and the accurate “leveling” of patients (935, 23%)

• CMS compliance (719 posts, 18%)

Reynolds J. Professional Case Management 2013;18(5) 246-254.

“The data suggest that hospital case managers’ time is inordinately leveraged by issues related to observation status/leveling of patients and the Centers for

Medicare and Medicaid Services compliance. The data also suggest that hospital case management has taken a conceptual trajectory that has deviated significantly

from what was initially conceived (quality, advocacy, and care coordination).”

What about our teams?

Page 14: National Physician Advisor Conference · Lesson #7, Second Example: What was it like in the 1960s when the Medicare program began? Sheehy and Courtney, J Hosp Med, 2017; Lowenstein,

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What is “Observation”?

• Observation is a billing distinction

• Not directly related to clinical diagnosis• Some diagnoses more common than others

• Not related to physical location in the hospital

• Does not define efficiency• Regardless of status, we try to care for patients in the most efficient

way possible

• Observation is an oxymoron• Oxymoron (n.): A figure of speech in which apparently contradictory

terms appear in conjunction (Google dictionary)

• Example: “Outpatient hospitalization” (Ann Sheehy)

Page 15: National Physician Advisor Conference · Lesson #7, Second Example: What was it like in the 1960s when the Medicare program began? Sheehy and Courtney, J Hosp Med, 2017; Lowenstein,

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Many things don’t make sense in healthcare…

Page 16: National Physician Advisor Conference · Lesson #7, Second Example: What was it like in the 1960s when the Medicare program began? Sheehy and Courtney, J Hosp Med, 2017; Lowenstein,

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Observation can be frustrating, but hospitalists need to own It

• Outpatient (observation) status is a billing distinction not necessarily linked to clinical care• ICU stays, time of day of admission

• When “outpatient” means “hospitalization”…

• It impacts our practice, writing orders to now specify why our patient needs to stay 2 midnights• Spending time on documentation that has little to do with patient care

• Zero sum game: the more time case managers spend on status and CMS compliance, the less they can spend in quality efforts, discharge planning

• It is hard to explain to patients how they can stay overnight and not be admitted

• It may impact our patients financially, especially with SNF benefit

• The majority of observation patients are cared for by hospitalists

Page 17: National Physician Advisor Conference · Lesson #7, Second Example: What was it like in the 1960s when the Medicare program began? Sheehy and Courtney, J Hosp Med, 2017; Lowenstein,

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Ten Lessons in Health Policy

Page 18: National Physician Advisor Conference · Lesson #7, Second Example: What was it like in the 1960s when the Medicare program began? Sheehy and Courtney, J Hosp Med, 2017; Lowenstein,

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Lesson #1: If you are seeing something over and over, chances

are others are, too. If it bothers you so much you lose sleep over

it, do something about it.

Page 19: National Physician Advisor Conference · Lesson #7, Second Example: What was it like in the 1960s when the Medicare program began? Sheehy and Courtney, J Hosp Med, 2017; Lowenstein,

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Lesson #2: Advocate through your national organization

Page 20: National Physician Advisor Conference · Lesson #7, Second Example: What was it like in the 1960s when the Medicare program began? Sheehy and Courtney, J Hosp Med, 2017; Lowenstein,

www.acpadvisors.org

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ACPA is well positioned to advocate for change

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Appointed to the Society of Hospital Medicine Public Policy Committee in 2013

• Two white papers

• Multiple congressional office visits

• Visits with CMS

• Observation coalition

Page 22: National Physician Advisor Conference · Lesson #7, Second Example: What was it like in the 1960s when the Medicare program began? Sheehy and Courtney, J Hosp Med, 2017; Lowenstein,

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May 20, 2014:House Ways and Means Health Subcommittee Hearing

Page 23: National Physician Advisor Conference · Lesson #7, Second Example: What was it like in the 1960s when the Medicare program began? Sheehy and Courtney, J Hosp Med, 2017; Lowenstein,

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Lesson #3: Seek unique collaborators and opportunities, and be lucky enough to have your

favorite attending from residency, Dr. Charles Locke, happen to be at the hearing you are

testifying at.

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• At the hearing, data about RAC success rates did not ring true to our experience

• Connected with Dr. Locke who introduced me to Dr. Jeannine Engel

• Each obtained institutional permission in different ways to share our audits and appeals data (legal, compliance, authority board)

• Connected the individuals at our respective institutions who tracked this data, and they made an incredible effort to merge our data

• IRB approval/exemptions at all three institutions

• Multiple conference calls and email exchanges

Collaborating with Johns Hopkins and University of Utah

Page 25: National Physician Advisor Conference · Lesson #7, Second Example: What was it like in the 1960s when the Medicare program began? Sheehy and Courtney, J Hosp Med, 2017; Lowenstein,

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Lesson #4: Institutional Review Board (IRB) research approval and organizational

approval are equally important

Page 26: National Physician Advisor Conference · Lesson #7, Second Example: What was it like in the 1960s when the Medicare program began? Sheehy and Courtney, J Hosp Med, 2017; Lowenstein,

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• All Complex Part A RA audits and appeals at three academic medical centers

• Dates of audits 2010-2013• Data abstracted June 30, 2014

Audit and Appeals 1 Study

Sheehy et al. J Hosp Med 2015

Page 27: National Physician Advisor Conference · Lesson #7, Second Example: What was it like in the 1960s when the Medicare program began? Sheehy and Courtney, J Hosp Med, 2017; Lowenstein,

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• Of 101,862 inpatient Medicare encounters

• RACs audited 8.0% and alleged overpayment in 31.3%• Hospitals disputed 91.0%

• The majority of claims were settled in discussion (33.3%)

• Time for cases still in appeals 555 days

• Hospitals lost 0.9% of decided cases by missing a filing deadline• No reciprocal case concession in the appeals process

• No overpayment determinations contested need for care delivered, rather that care should have been outpatient rather than inpatient

• 5.1 FTE at each hospital just to manage this process

Audit and Appeals 1 Study

Sheehy et al. J Hosp Med 2015

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• 219 appeals reached Level 3 of the 5 Level appeals process• 71% of decided appeals at Level 3 were favorable to the hospitals

• Mean time since date of service: 1663 days

• Government contractors and ALJs (Level 3) met legislative deadlines less than half (47.7%) of the time

Audit and Appeals 2 Study

Page 29: National Physician Advisor Conference · Lesson #7, Second Example: What was it like in the 1960s when the Medicare program began? Sheehy and Courtney, J Hosp Med, 2017; Lowenstein,

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Lesson #5: Data is Important!

Page 30: National Physician Advisor Conference · Lesson #7, Second Example: What was it like in the 1960s when the Medicare program began? Sheehy and Courtney, J Hosp Med, 2017; Lowenstein,

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RA audited 8.0% Complex Part A RA audit 0.3% total

The majority of decided claims were settled in discussionDiscussion not part of formal appeals process so not counted in RA

accuracy

Hospitals defaulted by missing a filing deadline, but appeals met legislative deadlines less than half of the time

RA report does not include missed filing deadlines or time in appeals

Hospitals consider an overturn a winRA report includes every level in the denominator, such that a hospital

win at Level 3 counts as a 33% overturn, inflating RA accuracy

Why was our data different than what was presented at the hearing and Included in the RAC Data Warehouse?

Page 31: National Physician Advisor Conference · Lesson #7, Second Example: What was it like in the 1960s when the Medicare program began? Sheehy and Courtney, J Hosp Med, 2017; Lowenstein,

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Were the Recovery Auditors lying at the hearing or in the report? NO.

But how do you present the weather in Madison on this day in January? As

a sunny day? Or as a day that is -23 with a wind chill of -47?

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Lesson #6: Policy makers use government reports and policy

journals to make decisions. Understand what is in them, and develop research questions and

where there are gaps.

Page 33: National Physician Advisor Conference · Lesson #7, Second Example: What was it like in the 1960s when the Medicare program began? Sheehy and Courtney, J Hosp Med, 2017; Lowenstein,

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Senate Finance Committee AFIRM bill

Page 34: National Physician Advisor Conference · Lesson #7, Second Example: What was it like in the 1960s when the Medicare program began? Sheehy and Courtney, J Hosp Med, 2017; Lowenstein,

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Senate Finance Committee AFIRM bill

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• Ben Cardin (D-MD) on Senate Finance

• Orrin Hatch (R-UT) chaired Senate Finance

• Dr. Locke and I met with Senator Cardin’s staff in Washington

• Senator Hatch was informed of the audit and appeals impact at University of Utah

AFIRM Bill Behind the Scenes

Page 36: National Physician Advisor Conference · Lesson #7, Second Example: What was it like in the 1960s when the Medicare program began? Sheehy and Courtney, J Hosp Med, 2017; Lowenstein,

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Lesson #7: Know and love your government relations team (aka

lobbyists)

Page 37: National Physician Advisor Conference · Lesson #7, Second Example: What was it like in the 1960s when the Medicare program began? Sheehy and Courtney, J Hosp Med, 2017; Lowenstein,

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Lesson #7, Second Example: What was it like in the 1960s when the Medicare program began?

Sheehy and Courtney, J Hosp Med, 2017; Lowenstein, Early effects of Medicare on the Health Care of the Aged, 1971

For those 65 and older:1965: Average inpatient LOS 14.2 days2012: Average inpatient LOS 5.2 days

Observation did not exist

3 consecutive inpatient midnights means something entirely different now compared to when the Medicare program began

Page 38: National Physician Advisor Conference · Lesson #7, Second Example: What was it like in the 1960s when the Medicare program began? Sheehy and Courtney, J Hosp Med, 2017; Lowenstein,

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Lesson #7: Continued…

Sheehy A, Courtney J. J Hosp Med 2017.

• Improving Access to Medicare Coverage Act of 2017

• Would guarantee SNF benefit to any Medicare beneficiary staying 3 or more midnights in the hospital, regardless if those nights are inpatient or observation

• Last Congress, had bipartisan support in both the Senate (18D, 4R, 1I) and House (82 D, 11R)

• Improving Access to Medicare Coverage Act of 2019 companion bills due to be released today, March 12, 2019

• House Sponsors: Representatives Joe Courtney (D-CT); Glenn ‘GT’ Thompson (R-PA)

• Senate Sponsors: Senators Sherrod Brown (D-OH); Susan Collins (R-ME); Sheldon Whitehouse (D-RI); Shelley Moore Capito (R-WV)

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Lesson #7: Continued…

Observation white paper, http://www.hospitalmedicine.org/

Page 40: National Physician Advisor Conference · Lesson #7, Second Example: What was it like in the 1960s when the Medicare program began? Sheehy and Courtney, J Hosp Med, 2017; Lowenstein,

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Lesson #7: Continued…

• In FY2014, 633,148 stays lasted 3 or more midnights but did not include 3 inpatientmidnights a 6% increase from FY2013• For 432,740 (68.3%): beneficiary spent nights as

outpatient and then switched to inpatient

• For 200,408 (31.7%): exclusively OP

• In a prior OIG report of FY 2012 data, 25,245 (4%) of 617,702 of patients with a non-qualifying 3 midnight stay discharged to SNF• Goldstein and colleagues:

• Single center study

• Only 20% of those observation patients recommended for SNF actually went

OIG, OEI-02-15-00020, 2016OIG, OEI-02-12-00040, 2013Goldstein et al, J Hosp Med, 2017

Page 41: National Physician Advisor Conference · Lesson #7, Second Example: What was it like in the 1960s when the Medicare program began? Sheehy and Courtney, J Hosp Med, 2017; Lowenstein,

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Lesson #8: Start small and grow

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• Type of data:• Started with single-center data

• Moved to a 3 hospital partnership

• Now working with claims data linked to census track data

• Type of publication:• Non-peer reviewed, like blogs and white papers: can get information out

quickly, can highlight opinions and/or promote a peer reviewed publication

• Peer reviewed journal publications: the gold standard in data integrity and research

• What topics to study:• Observation services C-APC?

• Medicare Advantage?

• Physician Advisor survey: State of PA/UR?

• Case management data?

Lesson #8: Start small and grow

Page 43: National Physician Advisor Conference · Lesson #7, Second Example: What was it like in the 1960s when the Medicare program began? Sheehy and Courtney, J Hosp Med, 2017; Lowenstein,

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• 2014 20% Sample Medicare Part A and B Claims

• Realized there was no standard observation case finding definition

• Literature search revealed 20 sources• 5 contained no information on

observation case finding• 1 obtained information via personal

communication

• 15 identified ORC, but not enough details to know how they dealt with status changes, ORC in the inpatient revenue center, or duplicate codes

Original Medicare FFS Claims Data

Sheehy A, Shi F, Kind A. J Hosp Med 2018.

Page 44: National Physician Advisor Conference · Lesson #7, Second Example: What was it like in the 1960s when the Medicare program began? Sheehy and Courtney, J Hosp Med, 2017; Lowenstein,

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• 125,920 observation revenue center codes found within 30 days of an inpatient stay• 75,502 ORC in the outpatient revenue center

• 47.3% (59,529) had some relationship with an inpatient stay, indicating a high level of status change

• Internal validity (MedPAC 2015 report):• 2012 Medicare claims: 30% of observation stays switched to inpatient

2014 Medicare Claims

Sheehy, Shi, Kind. J Hosp Med. 2018; MedPAC Report to Congress. Chapter 7: Hospital Short-Stay Policy Issues. June 2015.

Page 45: National Physician Advisor Conference · Lesson #7, Second Example: What was it like in the 1960s when the Medicare program began? Sheehy and Courtney, J Hosp Med, 2017; Lowenstein,

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• We established a new definition, “The University of Wisconsin Method” for observation case finding

• Proposes a way to research status changes

• Importantly, found that almost half of observation stays have some relation to an inpatient stay

• And, gained some insight into the C-APC…

2014 Medicare Claims

Sheehy, Shi, Kind. J Hosp Med. 2018; MedPAC Report to Congress. Chapter 7: Hospital Short-Stay Policy Issues. June 2015.

Page 46: National Physician Advisor Conference · Lesson #7, Second Example: What was it like in the 1960s when the Medicare program began? Sheehy and Courtney, J Hosp Med, 2017; Lowenstein,

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• Comprehensive Ambulatory Payment Classification for observation services• C-APC is to outpatient as DRG is to inpatient

• Bundles observation payment when certain conditions are met, and caps patient out of pocket liability• 2014 Medicare Claims: HCPCS G0378 found on 52% of claims

• Uncertain impact on entire observation picture

C-APC 8011

http://www.medpac.gov/docs/default-source/reports/mar18_medpac_entirereport_sec.pdf?sfvrsn=0Sheehy, Shi, Kind. J Hosp Med. 2018.

http://www.medpac.gov/docs/default-source/reports/mar18_medpac_entirereport_sec.pdf?sfvrsn=0
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Lesson #9: Don’t Forget the Regulatory Side!

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Lesson #9: Don’t Forget the Regulatory Side!

Page 49: National Physician Advisor Conference · Lesson #7, Second Example: What was it like in the 1960s when the Medicare program began? Sheehy and Courtney, J Hosp Med, 2017; Lowenstein,

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Lesson #10: Be Persistent!

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Lesson #10: Be Persistent!

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• If you are seeing something over and over, chances are others are, too. If it bothers you so much you lose sleep over it, do something about it• From a hospitalist perspective, observation is challenging for many reasons and merits reform

• Advocate through your national organization: ACPA has expertise that no other group has

• Seek unique collaborators and opportunities, and be lucky enough to have your favorite attending from residency, Dr. Charles Locke, happen to be at the hearing you are speaking at

• IRB and organizational approval are equally important

• Data is important!

• Policy makers use government reports and policy journals to make decisions, so understand what is in them, and develop research questions where there are gaps

• Know and love your Government Relations team (lobbyists)

• Start small and grow

• Don’t forget the regulatory side

• Be persistent!

Summary: Ten Lessons in Using Physician Experience, Data and Research to Impact Health Policy

Page 52: National Physician Advisor Conference · Lesson #7, Second Example: What was it like in the 1960s when the Medicare program began? Sheehy and Courtney, J Hosp Med, 2017; Lowenstein,

www.acpadvisors.org

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[email protected]

Charles Locke, MD

Jeannine Engel, MD

Amy Kind, MD, PhD

Andrew LaRocque

Bart Caponi, MD

Acknowledgements


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