Medicare, Money, More

“Some of this stuff will be easy. Some cases, like ‘object left in patient during surgery’ are so obvious as to be laughable,” says Dr. Siegal. “Others are a tougher call, such as a catheter-associated UTI. These are not always as clear-cut as [CMS] says they will be. Philosophically, I think this is the right thing to do—it’s not right to pay a hospital for treating something they caused.”

Hospitalists and hospital staff are likely to see added paperwork as a result of this rule. “I can guarantee that there will be an added checklist for these conditions on admission,” says Dr. Siegal. “We’ll have to check for pressure ulcer, UTI, etc.—and that’s not necessarily a bad thing.”

Key Role for Hospitalists

When hospital payment based on reporting is involved, hospitalists are quickly drawn in. “This puts more money for hospitals at risk,” explains Dr. Siegal. “There’s a clear imperative to document better, and to identify who’s really sick. This will all land squarely on the shoulders of hospitalists—and, in fact, it already [has].”

On average, hospitals that comply with all provisions of the rule will earn an additional 3.5% in Medicare payments. This is really a result of the 3.3% market basket increase.

“The difference between doing this well and doing it poorly can add up to the margin for some hospitals,” stresses Dr. Siegal. “There’s absolutely no question that if I’m a hospital and I’m shelling out for a hospital medicine program, the single thing I want them to do and do well is report properly on these measures.”

Careful documentation includes the DRGs. Dr. Siegal points out that there’s a $4,000 swing between the DRG for low-acuity heart failure (a $3,900 payment) and high-acuity heart failure (a $7,900 payment). “Clearly, there will be a shift in reimbursement to those hospitals with sicker patients—or those that do a better job of documenting those patients,” he says. “You can bet that hospitals will make this a priority. They’re going to get much more finicky about how we document.”

Here’s an example: If presented with a patient with sepsis and a UTI, different physicians will have different diagnoses—or rather, use different terms, whether it’s sepsis, severe sepsis, urosepsis, SIRS, or something else. “Hospitals will try to force all physicians to get more crisp in their definitions,” says Dr. Siegal. “This could be good, because we’ll all be using the same language. But some aspects of this will just be a pain … like any other broadly applied rule. If you admit someone with chest pains, you will no longer be able to note ‘chest pains’; you’ll have to describe the pains.”

Starting now, the new IPPS will force hospitalists to perform more—and more careful—documentation for each patient. “It feels like one more hoop to jump through,” says Dr. Siegal. “But there should be no doubt that this is the future of healthcare, like it or not.” TH

Jane Jerrard has been writing for The Hospitalist since 2005.