James LaBelle, MD, chief medical officer and senior vice president of five-hospital-campus, 1,409-bed Scripps Health in San Diego, acknowledges that he's heard "a lot of whining" from hospital officials questioning why they should be responsible for efficiency of care beyond the discharge or before the admission.
"Honestly, I think that's abdicating the responsibility and trust that communities have in their hospital," LaBelle says, adding that with this efficiency measure, CMS should "bring it on."
He says Scripps itself has some work to do. With one Scripps hospital showing significantly lower than expected spending, but three showing significantly higher, there's unexplained variation and the potential for loss of incentive payments come this October.
"I can guarantee you my chief financial officer is not going to be happy when he has to give up dollars, and he'll be having a conversation with me about that and it won't feel good. But this gives me the power to talk with our leadership team and the rest of the organization on how we organize care," LaBelle says.
He emphasizes that the new efficiency measure is not about chasing a number, but using the data CMS now provides to "engineer care."
One strategy, LaBelle says, is an experiment underway at two Scripps hospitals in which software programs are used to categorize patients by comorbidities and disease states to better understand what's an appropriate length of stay, and to determine if the patient is better off going to home with home health assistance or to a skilled nursing facility.
So far they're employing the strategy for patients with congestive heart failure, but plan to work with other diseases in which "you need a lot more resources to appropriately manage those patients."
"This is powerful stuff. It's another indication that the bright line that has divided inpatient and outpatient, hospitalized and ambulatory care, just needs to go away. Completely."
Designing decision rules
Another hospital that began taking the MSPB measure concept seriously a long time ago, first for its commercial plans, is Seattle-based 336-licensed-bed Virginia Mason Hospital, which launched a project in 2005 to reduce inappropriate imaging, says Robert Mecklenburg, MD, medical director for the organization's Center for Health Care Solutions. Over the years, he says, they've instituted hard-stop policies that prohibited doctors from ordering unnecessary MRIs and other high-end imaging tests without good reason, and dropped unnecessary scans by more than 23%.
Because of its success, the integrated healthcare delivery system is now designing decision rules for elective surgery, such as joint replacement or spine surgery.