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A strong case for RAC reform

April 2015

Published in the April 2015 issue of Today’s Hospitalist

A strong case for RAC reform

HOW ONEROUS are RAC audits for hospitals? A study posted online in February by the Journal of Hospital Medicine reveals continuously aggressive RAC audit activity, even as hospitals are overturning a growing number of overpayment determinations.

Study authors looked at RAC audits of complex Medicare Part A payments at three academic centers from 2010 to 2013. They found that RACs audited 8% of encounters and alleged overpayments in 31.3% of those audits. Hospitals disputed more than 90% of those allegations.

Over the study period, the authors noted a greater than two-fold increase in RAC audits and a nearly three-fold rise in overpayment determinations. Researchers also found that one-third (33%) of settled claims were decided in hospitals’ favor in the discussion period, which represented errors on the part of the initial audit.

But hospitals withdrew almost half (49.1%) of contested claims, rebilling some of those claims under Medicare Part B to avoid an appeals process that currently exceeds 500 days. Each of the centers studied employs five FTE staff members in the audit process.

“Drip and ship” now covers 25% of tPA patients

ABOUT ONE-IN-FOUR PATIENTS (23.5%) who suffer an ischemic stroke and receive tPA are being administered “drip and ship” therapy before being transferred. That’s according to a retrospective analysis published online in February by Stroke. The authors looked at nearly 45,000 patients who between 2003 and 2010 received tPA within three hours of ischemic stroke symptoms.

Compared to stroke patients who received tPA but were not transferred, “drip and ship” patients had modestly higher rates of in-hospital mortality and intracranial hemorrhage. The authors noted, however, that such complications may be due to patient-selection bias or to post-tPA care differences.

“Drip and ship” patients also tended to be younger, male and white. Receiving hospitals were more likely to be academic medical centers and to be designated stroke centers.

Findings also indicate that community hospitals are becoming more comfortable with administering tPA. “The drip and ship paradigm,” authors wrote, “may facilitate widespread tPA use in patients with acute stroke.”

Not all patients need to be seen within a week

HOW SOON AFTER DISCHARGE should patients be seen for follow-up care? While common sense says as soon as possible, new research finds that only those patients with multiple chronic conditions showed significant benefit from follow-up care within seven days of discharge.

The study, which was published in the March/April issue of the Annals of Family Medicine, found that while early follow-up care did significantly reduce readmission rates for some patients, that rate reduction was as low as 1.5% in low-risk patients. For the highest-risk patients, by comparison, readmission rates were cut by as much as 19%. Researchers also found that about the same number of high- and low-risk patients “just over half ” received post-discharge care within 14 days, which points to a need to focus on patients at high-risk of readmissions.

Patients with multiple chronic conditions at the highest readmission risk represented 24% of discharged patients. According to the authors, “one-size-fits-all discharge protocols may be determining a follow-up time frame more than evidence-based decision making or clinical need.”

C. diff burden underestimated

A NEW CDC REPORT REVEALS that 453,000 patients in the U.S. in 2011 suffered C. diff infections “80% more than previously thought. According to the report, which was published in the Feb. 26 issue of the New England Journal of Medicine, C. diff infections that year caused more than 29,000 deaths and cost $4.8 billion.

The report also found that although two-thirds (65.8%) of C. diff infections were health care-associated, only 24.2% were inpatient-onset while 23% were nursing home-onset. Based on data extrapolated from lab-confirmed surveillance in 10 states, the report also found that one in five C. diff patients suffered a recurrence.

In related news, a study published online by JAMA Internal Medicine found that every 10% increase in antibiotic use on wards in a Toronto hospital led to a 34% jump in patients’ C. diff risk. Some patients who were infected had not taken antibiotics themselves but had been treated on wards with a high level of antibiotic use.

Face-to-face handoffs don’t reduce adverse events

IT STANDS TO REASON that face-to-face handoffs are better for patient care. But a new study finds that’s not necessarily the case.

Researchers from the Mayo Clinic looked at handoffs for patients admitted between 6:45 p.m. and midnight over the course of a year. Among those patients, 38% were signed off to day-shift doctors without a face-to-face handoff, while handoffs for the other 62% included a face-to-face encounter.

The research, which was published online in March by the Journal of Hospital Medicine, found that face-to-face handoffs produced no significant reduction in adverse events in the 12 hours after the handoff nor in the number of rapid response team calls, code team calls, transfers to a higher level of care or in-hospital mortality. Researchers also found no difference in 30-day readmission rates or lengths of stay between the two groups.

“A face-to-face interaction itself in a patient handoff,” researchers wrote, “may be less pertinent if key information can be communicated through other channels, such as an electronic handoff tool, email or phone.”

Access to medical records may reduce patient stress

WOULD GIVING INPATIENTS ACCESS to their medical records make patients less nervous? A story posted online in March by JAMA Internal Medicine asked that question and found mostly good news.

When researchers gave patients access to their electronic medical records via a tablet computer, most patients (82%) said that viewing their records helped them better understand the condition that put them in the hospital.

Sixty percent also said that access to their records helped them better understand their physicians’ instructions. In addition, the proportion of patients who were worried dropped to 18% from 42% after viewing their records, while the percentage who reported being confused fell from 52% to 32%.

However, about half the nurses reported that giving patients electronic access produced some extra work for them, a sentiment shared post-intervention by 36% of physicians. Researchers also pointed out that the study did not find that having electronic access enabled patients to detect medication errors, nor did it give them a better idea of when they’d be discharged.

Frustrated by hospital rankings? So are researchers

THE POPULAR SYSTEMS USED TO RANK HOSPITALS “think U.S. News & World Report’s annual list of top hospitals “not only produce contradictory information, but they are so complex and nontransparent that they are likely confusing consumers.

That’s according to a new analysis in the March issue of Health Affairs, which looks at four of the most popular national hospital ranking systems. A review of the ratings from 2012 to 2013 found that no hospital was named No. 1 by all four, and some hospitals were named tops by one system and a low performer by others.

Only 10% of the nearly 850 hospitals that were rated as a high performer by one rating system were rated as a high performer by any of the others. The analysis points out that the ranking systems look at different performance indicators, which one commentator says has produced a “Wild West” environment of performance measurement.

More doctors go right from training to locums

A SURPRISING NUMBER OF PHYSICIANS are beginning their working lives as locum tenens, bypassing a more traditional career in medicine. That’s far from the traditional locum doctor who often came out of semi-retirement to do some clinical work.

According to a survey of more than 2,000 locum tenens physicians, 21% went right from training to locum work. That number is up from 16% in a 2013 survey and 14% in 2012.

The surveys, which were conducted by the temporary staffing firm Staff Care, also found that between 6% and 7% of physicians consider locum to be their full-time job “a percentage the staffing company expects to grow to 11% in the next 18 months.

Primary care continues to be the specialty most in demand for locum slots, followed by psychiatrists and hospitalists. The survey also found that the demand for locum NPs and PAs is on the rise.