Disclaimer: The opinion expressed in this post are of the author, and do not necessarily represent the views of the RT Cave nor the institutions the author may work for. This post was written by an anonymous respiratory therapist who wanted to share his name but the editors of the RT Cave opted to keep him anonymous. It is a very good post, however, worthy of reading.
I have written before on this blog that quite often breathing treatments are ordered in order to meet criteria. Generally speaking, the more appropriate term for me to use would be Intensity of Service.
Intensity of Service basically means that the patient is sick enough to require an admission to the hospital. Generally, according to American College of Chest Physicians (acep.org) these are the qualifications for any specific Diagnosis Related Group (DRG) that ultimately determines payment for the patient's admission.
Likewise, acep.org notes, "With short inpatient hospital stays (less than the average length of stay) Medicare is concerned about overpayment and appropriateness of the admission. As a result, The Center for Medicare and Medicaid Services (CMS) and a state's Quality Improvement Organization (QIO) monitor hospital discharge data and specifically target short hospital stays."
Bacially, CMS wants to make sure a patient needs to be admitted. So it has created a recommended length of stay and certain criteria (particularly for the first 24 hours of an admission) to put pressure on emergency room doctors and admitting doctors "to make sure that each hospital admission is medically necessary and will pass the fiscal intermediary or Medicare Area Contractor (MAC) scrutiny."
An MAC, according to the Research Data Assistance Center (ResDAC) are entities that process claims and records of services for hospitals and other institutions.
Generally, short stays are noted as suspicious. Therefore, hospitals in a certain jurisdiction will often create their own list of procedures -- or screening criteria -- that are determined by updated best-practice evidence to improve patient care and outcomes and reduce costs.
The companies that create the criteria focus on best practice evidence criteria based on core measures set forth by CMS in an attempt to improve patient outcomes, avoid unnecessary care and reduce costs to payers (at least that's the stated goal).
The hospital's quality assurance (QA) analyzer will check charts to make sure Intensity of Service is met based on the standards set forth by whatever company they are using. Shoreline's QA analyzer carries a book with her. I cannot name it. However, there is such a book.
I interviewed our QA analyzer, Sue Running, and she said the book is very complicated, and the Intensity of Service criteria set forth by CMS changes all the time, and therefore the "book is very complicated."
It must be, because as I watch her thumb through charts she's constantly referring to the book.
"It's really hard to keep up with everything," she said. "I've been doing this for 10 years, and I still don't fully understand the process. Basically, instead of treating patients based on individual needs, we treat all patients the same. Patient care should not be based on a cookbook, which this book basically is."
All doctors responsible for admitting patients to hospitals in that geographic region will want to be aware of the screening criteria for the region, which is basically criteria set forth by the company that region (or hospital) uses. InterQual is one such company, there are a few others.
If a hospital is not reimbursed, then it is up to the hospital to determine the reason, and many times it's because the hospital did not meet Intensity of Service.
To make things even more complicated, Runnings noted there are no clear cut screening tool for hospitals, yet the geographic (regional) screening tools set by Interqual (or some other company), and whether or not they are met, can play an integral part as to whether or not the hospital is reimbursed by CMS or some HMO.
Just to give an example, Runnings gave me an example of some old criteria that are no longer used. It is more complicated than this, yet this will give you an idea.
1. Pneumonia/ COPD: Bronchodilators nebulizer treatments must be ordered at least every six hours for at least 24 hours or any of the following three: IVs greater than 75 cc/hour, oxygen at least at 28% FiO2, IV/IM antibiotics, and 3 bronchodilator nebulizer treatments in the first 24 hours.
2. CHF/ Syncope: Two or more cardiac drugs or telemetry with documented dyspnea or syncope. EKG should also be ordered.
Actually, Runnings said the criteria is actually more complicated than this, and "it's changing all the time. Yet this is a general idea of what I do, and what Intensity of Service is."
There's a few of the respiratory screening tools for Intensity of Service that are set right into our order sets along with the core measures to make sure everything that needs to be ordered is getting ordered.
Note that the ultimate goal of core measures (I write about core measures here) is to save money and improve patient outcomes, and the goal of Intensity of Service is to make sure the patient needs to be admitted and that CMS or HMO is not paying for unnecessary inpatient stays.
"The biggest problem with Intensity of Service," Runnings siad, "is instead of a doctor just ordering things based on individual needs, the physician is often challenged to order things not just based on need, but also to make sure they get paid."
There are various companies that produce books and websites for hospitals to use to make sure their patients are meeting such criteria. We have such a book located in various locations at Shoreline for physicians to use.
I will not name any such book on this blog, so I encourage you to do your homework. The best person to talk to is your QA analyzer (a post on what they do coming 11/24/10) or utilization review (post coming 11/17/10). Actually, you can probably just talk with your boss, any administrator, or look for such a book where doctors hang out.
Any further questions you may inquire within. I will reserve my opinions for a later post.
Click here to learn about the charting nazis!
Authors note: Please note that any therapies ordered to meet criteria are only done to meet hospital regulations. This is not the fault of the staff, and definitely not the fault of the hospital administrators. It is mainly the way the system is set up because people who are making decisions do not consider unsuspected consequences of the laws and regulations they create.