Jim Alexander

In its latest advisory, the Centers for Medicare and Medicaid Services (CMS) has told hospitals, in so many words, that customer relationship management (CRM) is the wave of the future.

What? Has CMS entered the consulting world? CMS's advisory sure has the look and feel of a consultant's report. And it clearly spells out some ways CRM can deliver benefits to the Medicare program. Where can you get this advisory? It's nestled in the 1,200 pages of the FY09 Medicare proposed hospital inpatient payment rule (IPPS) on the CMS web site. (Go to www.cms.gov, search on CMS-1390-P, and click on "Acute Inpatient PPS.")

OK, CMS hasn't actually assumed a consulting role. The agency's objective is simply to save Medicare money. But if we stay with the CRM tack, the positives are definitely there-for everyone.

Exhibit 1

exhibit-1-CMS Issues Management Advisory Report

It Starts with Readmission Rates

From the Medicare savings perspective, the evidence has been in for some time. Readmissions are a problem. The Medicare Payment Advisory Commission (MedPAC), the nonpartisan (honest!) agency that advises Congress on Medicare policy, estimates that 17.6 percent of all Medicare patients were readmitted within 30 days of their discharge in 2005. Now that's an attention-getter!

You might argue that readmissions are inevitable. CMS would not disagree, but MedPAC also estimates that 13.3 percent appear to have been preventable. And further analysis has put a price tag on the problem-roughly $12 billion, according to the MedPAC June 2007 Report to Congress: Promoting Greater Efficiency in Medicare
Where does CRM come in? It enters with CMS's remedial action plan.

CMS's Proposed Solution

CMS sees the savings potential as residing in the actions of the stakeholders in patient care-that is, in us, as providers of care. And CMS is casting about for a way to get us to comply with its vision for a solution-a vision that entails, to a large degree, CRM. Consider CMS's words from the proposed rule:

Beyond cost considerations, readmissions may reflect poor quality of care and affect beneficiaries' quality of life. Though not all readmissions are avoidable, hospitals should share accountability for readmission rates that could be much lower through the application of evidence-based best practices. Interventions that have been shown to reduce readmissions include better quality of care during the hospitalization, more complete care plans, emphasis on coordination of care at the point of transitions to home or postacute care, better use of after-hospital care, and more active involvement of patients and caregivers in decision making.

In most instances, CMS would have already pursued intervention through regulations. But at least part of its plan requires enabling legislation. So as part of a case-building preliminary to a law change, CMS is putting the issue before the industry in the proposed IPPS rule with a request for comment.

CMS has given us three scenarios, two of which will require Congress to act:

  • Direct adjustment to hospital DRG payments for avoidable readmissions
  • Adjustments to hospital DRG payments through a performance-based payment methodology
  • Public reporting of readmission rates

The adjustments to hospital payments are where new statutory authority would be needed.
CMS also recognizes that the remediating action would need to be aligned across the care continuum. "Hospitals are not the only providers that affect the occurrence of readmissions. For example, the care delivered by SNFs and HHAs also has an important impact on whether a beneficiary is readmitted."

Everyone involved in a patient's care, including the patient, has some responsibility. Again, quoting CMS:

Shared accountability is another important consideration. Hospitals are clearly accountable for the care provided during hospitalization and can also affect the quality of care provided after the hospitalization, but hospitals are not the only accountable entity. Both during and after hospitalization, physicians and other health professionals share accountability for the quality of care. Other provider entities, including skilled nursing facilities, rehabilitation facilities, home health agencies, and end-stage renal disease facilities, also share accountability for avoidable readmissions. Medicare beneficiaries themselves and their caregivers and social support systems play important roles in avoiding readmissions, particularly when beneficiaries have been discharged to home.

Accountability, to me the prospective patient, means, "Healthcare provider, show me you're into CRM." If you are, then you are probably offering the kind of service that CMS envisions and I expect:

  • Better, safer care during the hospitalization
  • Improved communication among providers and with the patient and caregivers
  • Care planning that begins with assessment at admission
  • Clear discharge instructions, with specific attention to medication management
  • Shared accountability for care coordination, with attention to transitions and hand-offs
  • Discharge to a proper setting of care
  • Better, safer care in the post-acute care setting
  • Appropriate use of palliative care and honest planning for the likely course
  • Timely physician follow-up visits

And don't forget active involvement of patients and their caregivers.

Providers that are not delivering this kind of service are not only behind the curve with their patients; they'll be catching up when CMS applies teeth to a correction plan.

Just Around the Corner ...

CMS is already authorized to do one thing: distribute a discharge checklist to help beneficiaries and their caregivers prepare for discharge from a hospital or nursing home. The checklist will include a range of issues to address with physicians and other healthcare providers to ease patients' transition to home or the postacute care setting.

As patients, we are going to be asking more of providers. As providers, we should already be doing all we can. Those who understand what "doing all we can" entails should take a few minutes to give CMS the provider perspective.


Jim Alexander is a technical director in HFMA's Washington, D.C., office.

Publication Date: Thursday, May 01, 2008

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