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Understanding Case Mix Beyond the Number
Huntsville Hospital's Journey
Vincent Bonetti
Executive Director – PFS
Huntsville Hospital
2009 Annual Institute
June 2009
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Today’s Presentation Ground Rules
We don’t have all the answers -This is just one
hospital’s journey
We incorporated processes learned from other
facilities along the way
We have not finished our journey
We want to continue to learn from other experts –
please share.
We are open to interaction during the hour
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Assumptions we made
CMI is primarily measuring Medicare, but the process will affect
all patients
CMI is not just a Finance number
CMI is not just a HIM/Coding outcome
CMI is more vital than ever since MS-DRG’s
CMI is more dangerous than ever – RAC/MAC/OIG/overdrawn
government
CMI can be affected by focus and attention
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Our Original Objectives
Develop a management tool for month to month
analysis of CMI by both finance and administrative
clinical teams
Provide confidence that monthly numbers truly
reflect actual acuity of the patients we treat
Educate clinical leaders as to how they can use this
tool and impact CMI
Make the tool easy to use and relevant to outcome
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Our Actual Unstated Objective
Stop blaming or celebrating ‘coding’ when CMI numbers
change – stop the insanity
We kept doing what we were doing expecting different results
Be assured that we are maximizing the recently deployed
expense of ‘Documentation Specialists’
Educate ourselves
Educate non-finance leadership team(s)
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Journey: Background
By starting in the middle of the The traditional large team
course traditional long standing approach was being utilized:
reports were our only tools: COO
CFO
Month over month CMI charts CIO
and graphs CMO
The month’s volume of cases CNO
per MS-DRG COEE (chiefs of everything else)
Physicians’ profile of MS- HIM
DRG’s with case volumes
Revenue cycle
Cases with CC’s, MCC’s, etc.
Decision support
MDC charts and graphs
Case Management
Etc.
Physician Advisor
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Example – month over month
Medicare Monthly Case Mix Index:
1.7700
1.7200
1.6700
1.6200
1.5700
1.5200
Apr-07 May-07 Jun-07 Jul-07 Aug-07 Sep-07 Oct-07 Nov-07 Dec-07 Jan-08 Feb-08 Mar-08 Apr-08
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Example – MDC month over month
MDC MDC Description Oct-07 Nov-07 Dec-07 Jan-08 Feb-08 Mar-08 Apr-08 Total % Total
0 Other MDC's 8.6635 6.8964 9.7439 6.8151 6.7530 9.5465 7.1906 7.8496 6.7%
1 NERVOUS SYSTEM 1.5033 1.4589 1.5260 1.4673 1.4498 1.3930 1.4104 1.4608 7.4%
2 EYE - - 0.6608 0.6792 1.4141 0.7224 - 0.8275 0.0%
3 EAR,NOSE,MOUTH AND THROAT 1.1320 0.8420 0.9609 0.6847 0.6544 0.8246 0.8452 0.8019 0.2%
4 RESPIRATORY SYSTEM 1.4049 1.5252 1.5607 1.5460 1.4404 1.4289 1.4711 1.4816 12.1%
5 CIRCULATORY SYSTEM 1.8236 1.7233 1.9289 1.7619 1.7389 1.7779 1.7623 1.7876 28.7%
6 DIGESTIVE SYSTEM 1.6295 1.4456 1.3629 1.5300 1.5046 1.6080 1.4105 1.4964 8.4%
7 HEPATOBILIARY SYSTEM 1.7577 1.4181 1.3771 1.5347 1.4475 1.3207 1.4859 1.4869 2.1%
8 MUSCULOSKELETAL & CONN. TISSUE 1.9107 1.8883 1.8679 1.7994 1.9225 1.9503 1.8131 1.8785 16.7%
9 SKIN,SUBCUTANEOUS TIS & BREAST 0.9631 1.0937 1.0941 0.9688 1.1680 1.1362 1.0106 1.0571 0.9%
10 ENDOCRINE,NUTRITIONAL&METABOLI 1.0302 1.0083 1.0510 0.9118 1.0277 0.9864 0.9896 1.0042 1.9%
11 KIDNEY AND URINARY TRACT 1.2232 1.2352 1.3563 1.3121 1.2348 1.3237 1.2366 1.2730 4.1%
12 MALE REPRODUCTIVE SYSTEM 1.1326 1.1310 0.9429 1.0624 0.9210 0.9580 1.0699 1.0267 0.4%
13 FEMALE REPRODUCTIVE SYSTEM 0.9972 1.1204 1.1367 1.1636 1.0881 1.0977 1.1036 1.0971 0.8%
14 PREGNANCY, CHILDBIRTH, PUER. 0.4461 0.4461 0.4461 - - - 0.4461 0.4461 0.0%
15 NEWBORNS AND NEONATES - - - - - - - - 0.0%
16 BLOOD&FORMING ORGANS, IMMUNOLO 0.9339 1.0546 0.9910 0.9321 1.1505 0.9700 1.1322 1.0132 1.0%
17 MYELOPROLIFERATIVE DISEASES 2.4461 2.2258 2.6882 1.9666 1.9643 2.0939 2.4532 2.2905 1.2%
18 INFECTIOUS AND PARASITIC DIS. 2.1301 2.3446 2.1412 2.0853 2.1008 2.2504 2.3170 2.1857 5.3%
19 MENTAL DISEASES AND DISORDERS 0.7649 0.7166 0.7713 0.7622 0.7711 0.7679 0.8042 0.7636 0.2%
20 ALCOHOL/DRUG USE 1.0419 0.6145 0.4858 0.7855 1.0419 0.6145 0.7570 0.7361 0.1%
21 INJURY,POSIONING AND TOXIC 1.3119 1.3276 1.2033 1.2945 1.4593 1.0624 1.4962 1.3183 1.0%
22 BURNS - - 1.1605 - - 1.1605 - 1.1605 0.0%
23 FACTORS INFLUENCING HEALTH 0.6542 0.8872 1.1683 0.6721 0.7376 0.7655 0.6542 0.7389 0.1%
24 MULTIPLE SIGNIFICANT TRAUMA 4.0473 2.2985 3.3476 3.6171 - 2.3733 2.6942 3.2099 0.4%
25 HIV INFECTIONS - 1.9376 - 1.7717 - 1.5918 - 1.8321 0.1%
Grand Total 1.7422 1.6827 1.7579 1.6606 1.6406 1.6830 1.7017 1.6947 100.0%
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The Journey Taken: Realizing a need for
change
Many large group meetings were painful
Large group acknowledged we were spinning our wheels
We were fortunate that CMI increased after MS-DRG’s went
live, but no one actually knew why
We agreed to go small – allow five representatives to report
back to large group now to be known as “The Group of
Five”
We agreed to Case Mgmt, Bed Capacity, HIM, Rev Cycle
and Decision Support
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Small Group: The Group of Five
The initial few meetings focused on educating ourselves:
Did we understand all that went into CMI?
How could we ascertain the level of understanding of others?
Could we connect the dots between the CMI financial impact and
the staff on the floor?
How could we fully understand the processes of day-to-day life of
our patients?
What was the value of reviewing literally hundreds of data
elements sliced and diced in hundreds of ways?
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Enterprise CMI Gears
CMI/Expenses
CMI Matrix Documentation
DNFB Discharge
Disposition
POA Discharge
Planning
Revenue Integrity
Vice President
Goals DRG/MSDRG
Education
Model Unit Admission
Case Status
Coding Query Never Events
Management
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Small Group
The Group of Five reached out to key leaders of
Surgery, Cardiology, Emergency Department's, Direct
Admits, Labor and Delivery
The Group of Five conveyed what was learned and
asked for feedback while inviting participation from
unit leaders
Leaders acknowledged importance of this ‘project’ – mostly!
Leaders cooperated in instructing Group of Five about day
to day processes of each area involved
Leaders agreed to provide input about how to best convey
objectives to others
12
Small Group
After four meetings with each service unit
The Group discovered the difficulty of blending CMI with the daily life on the unit –
their focus is each patient’s need at that moment (painful realization)
The Group also discovered what not to make important (the actual case mix number)
Created present day process flow
Created future state desired
Created ‘gap’ report
Included process change needs
Included Technology needs
Included FTE’s required to accomplish objectives
Discovered outside tool
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Outside Tool
Worked with vendor; Real Time Medical Data
Uses real paid claim data
Has data for all claims paid by Alabama FI
RTMD has the ability to make comparisons of all essential
data.
HOWEVER – is strictly a reactive reporting tool based
on previous experience within your institution.
The tool provides the facts, it does not provide the analysis
and possible needed changes – The Group of Five does this.
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Gap Report
Presented ‘gap’ report to large group
Educated large group
Convinced them of the need to spend money and
support change's with Medical staff, Case Mgmt,
Nursing, etc.
Asked VP’s to schedule us for any and all
staff/physician meetings
Created ‘road show’ for hospital departments and
physician offices/groups
Created high level ‘is it working’ review
Incorporated Real Time Medical Data
Left it up to individual VP’s to ask for support
19
The original goal was to understand
case mix beyond the number
How one hospital determined to drive expertise and
understanding of Case Mix. The goal was to provide the
enterprise a 'report card' that drove more than
conversation. We discovered it truly does take a village to
understand and respond to this increasingly important
number. Ultimately winding up with physician participation,
outcomes management, finance, intake management, HIM,
nursing, decision support, quality and administration as routine
partners in this routine discussion. We started from a single
report with lots of data to a multi-disciplinary team that reviews
and reports monthly on information learned from many levels
of data. Ultimately we understood the most important question
to be answered was.............you will have to come listen to find
out.
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Question and Answer
How do you monitor
The answer is…
and measure the daily quality of
all providers that treat our
patients?
CMI is a merely a result, not what is to be managed.
CMI can’t be managed, people and processes must.
21
Conclusion reached and moving forward
Quality of documentation is essential
This indicator cannot be effected – only patient care
can/should be.
Individual unit needs must be the focus
Everyone CANNOT be educated about everything
Especially outside daily core role of individual
STRONG leadership required
Talk about the process to all individuals – often
Talk honestly about process
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QUESTIONS !!!
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