According to Donald Berwick in a recent Wall Street Journal article, “…the formula for ACO success is clear: keep quality high, save money by improving - not by restricting - care, and remain attractive to beneficiaries, who could go anywhere for care. That's an edgy and promising design. It will work because it is set up to reward the right combination of goals for our time: transparency, coordination, consumer power and intolerance of waste. Smart entrants, focused on seamless care, outcomes and beneficiary satisfaction, will both reduce Medicare's expenditures and reap financial rewards for themselves."
Decreasing cost while improving quality is a delicate balancing act, and of primary concern to any financial officer looking to participate in an ACO model. In order to achieve this balance, ACOs need to manage their populations in an optimal way and that will mean being able to proactively severity adjust and stratify patients.
In anticipation of accelerating changes in the healthcare market, optimal clinical documentation, a critical core competency for current hospital revenue cycle management, must also be viewed as a strategic initiative for future clinical and quality care success.
Clinical Documentation a Strategic Asset
The role of the clinical documentation specialist (CDS) must grow dynamically to support the critical function of these individuals as active members of the clinical team. Clinical integration is, in fact, essential for success under models such as the ACOs. Whether incrementally evolving through current clinical documentation systems or approached as a discreet strategic initiative within evolving delivery models, clinical documentation specialists must take on a greater role as active members of the clinical team under an ACO model.
Rather than just focusing on DRG or coding support, these clinically trained professionals, who are vigilant about assessing and communicating significant entries or clinical patterns within the patient medical record, track patients for correct patient status from point of entry to discharge. This translates into the type of seamless, coordinated, efficient and high quality clinical care to which Mr Berwick was referring.
Historically, clinical documentation specialists have served as a conduit of information communication between physicians and coders, requesting clarification of clinical documentation when terminology used by physicians is ambiguous or inconsistent with ICD-9 coding. This role will clearly expand with the additional complexity of ICD-10.
As important as this historical role has been to maintaining appropriate Case Mix Index (CMI) and supporting appropriate payment under current reimbursement methodologies, the role of the CDS is being increasingly recognized as critical for evolving reimbursement methodologies as well.
Quality-based payment has broad support in Washington, D.C. and across the country. The specific methodology to severity adjust populations for future bundled payment initiatives has not yet been proposed, however, the current CMS-HCC (Hierarchical Condition Category) methodology provides insight into the significance of accurate clinical documentation to capture appropriate severity of illness. This methodology system, currently used for Medicare Advantage program payment, is clearly adaptable to the ACO model and would provide a valid infrastructure for ACO payment for integrated care of a severity-adjusted population.
Physicians Need Air Traffic Control
Innovative organizations are currently expanding the role of the CDS to function as conduits of information flow, not only between physicians and coders, but also between all members of the clinical team. Rarely do physicians have the time to read all clinically relevant documentation by dieticians, physical therapists, nursing and other clinical services rendering care. That very documentation, however, may contain critical information not only for severity capture but also for continuity and quality of patient care.
To draw an analogy, instrument-rated pilots are grateful for the support provided by air traffic control (those other airplanes “in the clouds” are of significant concern to the pilot). Similarly, particularly in the electronic medical record environment, documentation specialists provide treating physicians with “situational awareness” regarding clinical issues identified by other providers.
Under emerging ACO models, where physicians and hospitals are subject to substantially greater accountability for quality, cost and patient satisfaction, awareness of all clinical parameters becomes essential for efficient and effective clinical care. The role of the clinical documentation specialist must further evolve to meet these expanded demands. The CDS has the capacity to emerge as “integrators of clinical information,” benefitting the clinical team, the ACO and, most importantly, the patient.
Paul Weygandt, MD, JD, is vice president physician services at J. A. Thomas & Associates.