Avoiding the unnecessary
At 352-licensed-bed Heartland Regional Medical Center in St. Joseph, Mo., Stacey Counts, process leader for Heartland's quality, risk, and safety division, says the MSPB is "an excellent measure."
"Although I can appreciate other stakeholders' opinions, and by all means it's not perfect, the reality is if you're coordinating care appropriately and you represent the largest portion of that spending for that particular episode of care, it only makes sense that you would ultimately be responsible—I think particularly for care that happens after discharge," Counts says.
Heartland's employed physicians are also patient-centered medical home doctors, Counts says, and as such are "trying to forgo the unnecessary avoidable ED visit and unnecessary diagnostic testing such as advanced imaging."
One focused effort is a pilot Hospital at Home program for heart failure patients who receive multiple home visits from midlevel practitioners after their acute care discharge. This is important for a segment of Heartland's patients who Counts says have "poor health literacy and don't have a good understanding about their disease processes.
"It used to be about getting the patient well and sending her on her way. Now, we're not just sending her on her way. We're saying, 'We're still here. We're still holding your hand and will hold your hand the whole way through.' "
So far, Heartland's efforts appear to be working. Its MSPB score for eight months in 2011 was 0.98. For calendar year 2012, it was down to 0.95.
DiLisi says that in a DRG environment, where hospitals get paid a flat rate for each inpatient stay based on the diagnosis, the new measure discourages game-playing in a few ways.
First, he says, "It's kind of a check on hospitals that might discharge someone too quickly. If the patient gets readmitted, now that's not going to help your metric."
Second, he and other hospital officials say the measure is designed to thwart some hospitals' practice of moving care that rightfully should be done during the DRG-covered inpatient stay to an outpatient setting. For example, certain tests or procedures might be ordered prior to an elective inpatient stay.
"Historically, maybe some hospitals have suggested that patients get a CT or MRI as an outpatient. Now that MRI that you scheduled for the patient as an outpatient three weeks after discharge is going to show up in your MSPB score. So if you don't do it in the hospital, you're going to get dinged," DiLisi says.