When CDI Hit a Speed Bump

Clinical documentation improvement (CDI) failed to achieve improvement.

EDITOR’S NOTE: Hahnemann University Hospital is a 427-bed academic medical center affiliated with Drexel University located in Philadelphia that primarily serves the healthcare needs of Medicare and Medicaid patients. The hospital recently filed bankruptcy due to long-standing financial challenges that became unsustainable.

Hahnemann University Hospital is in the process of winding down operations, has recently filed Chapter 11 bankruptcy and is targeting a full closure date of Sept. 6 or earlier. Nurses and other staff are picketing to keep the hospital open, meanwhile, 40 residents affiliated with Drexel are scrambling to locate another academic medical center to continue their residencies. There is a myriad of factors that ultimately contributed to the hospital’s financial woes of continually losing $3 to $5 million per month and the ultimate decision to file bankruptcy and cease operations by early September. I call the reader’s attention to four primary factors cited by the CEO of American Academic Health Alliance, the parent company of the university hospital, back in April for the continual monthly losses that ultimately contributed to the death of the hospital. There has been speculation that the for-profit investment company, Paladin Healthcare, realized that the land the hospital sits on is worth quite valuable and can sell at a healthy profit, realizing sizeable gains and healthy profits for the investment company.

Four Primary Factors

Hahnemann’s four factors that put long-term viability in jeopardy as stated by Joe Freeman, the CEO of American Academic Health Alliance, as stated in early April:

  • The hospital, after executing short-time extensions with private payers after the leadership change, has not had any success in getting commercial insurers to negotiate new contracts.
  • Volume has dropped from an average of 300 patients per day to between 200 to 250, which has made it difficult to cover the costs of the 24-hour-a-day staffing levels required for the high-end services the hospital provides.
  • The academic training program it operates through its affiliation with the Drexel University School of Medicine, which has one of the largest medical school class sizes in the country, is on pace to lose $30 million this year. The hospital is only getting about 7 percent of its admission from physicians who are also faculty members. The vast majority of admissions are coming from patients coming into the emergency department who are on Medicaid or Medicare, which only pay a fraction of hospital charges. The high percentage of patients covered by government health insurance programs impacts the rate the hospitals get for services provided by faculty physicians.
  • The lack of clinical documentation training for physicians that has resulted in a “tremendous volume” of downgrades and denials from insurers. Freedman estimated that between denials and admissions being downgraded to observation status the hospital is probably being paid for 50 percent of the services it provides.

Let’s take a look and examine the relevance of “lack of clinical documentation training for physicians” as a contributing factor to the ongoing financial losses at Hahnemann with the decision to file bankruptcy and close. While the other three factors cited by the CEO played a major role in explaining financial losses, there can be no doubt that the hospital’s struggles with only being paid for 50 percent of the services it provides are partly attributable to ineffective and incomplete physician documentation. I have confirmed that the hospital indeed had a mature clinical documentation improvement program in place. This beckons the larger question of why a lack of clinical documentation training for physicians was there. Of note is that only 7percent of admissions to the hospital were from faculty physicians and their residents which means the majority of admissions came from private practice physicians. Clinical documentation improvement (CDI) programs are by definition supposed to improve documentation through provisions of physician education and training and the hospital invested in a full-fledged mature clinical documentation improvement program.

What Went Wrong?

What went wrong, why were the physicians not vetted in, familiar with and knowledgeable in practices of sound effective documentation and communication of patient care? Simply put, the majority of CDI programs are not set up nor intended to deliver the type of training and education for physicians on best practice standards and principles of clinical documentation that adequately convey and tell the true patient story. An effective patient story succinctly tells, describes, shows, tells, depicts, reflects and paints the clinical picture of the patient beginning in the emergency department, continuing throughout the patient stay as the patient progresses to discharge.

The limiting factor in clinical documentation contributing to medical necessity denials, adverse level of care determinations and clinical validation denials coupled with DRG down-grades is simply insufficient documentation, i.e., poor documentation. A quick review of the Medicare Improper Payment FFS Supplemental Data Report for 2018 highlights the extent of incomplete and insufficient documentation that made up the bulk of calculated improper payment rate for 2018 at 8.1 percent equating to $31.6 billion dollars in improper payment. Seventy-nine percent of improper payments were attributable to insufficient documentation and/or medical necessity. In my mind hospitals have not effectively addressed improper payments and continued avoidable costly medical necessity denials, adverse level of care determinations and clinical validation denials through investment in clinical documentation improvement programs. Case in point is the fact Hahnemann was only being paid for 50 percent of the services provided to patients by third-party payers due to lack of clinical documentation training to physicians.

CDI Program Goals- Incompatible with True Documentation Improvement

The underlying premise and fundamental goal of CDI programs are to increase reimbursement through the capture of CCs/MCCs supporting the coding and billing of higher weighted DRGs. CDI professionals task-based activities related to the query process driving CDI performance to overlook the opportunity to achieve real measurable improvement in clinical documentation that best tells the patient story, providing clear and accurate clinical information, clinical facts and context of the patient encounter justifying hospitalization under inpatient level of care versus observation from a medical necessity perspective. In my review of countless medical necessity and clinical validation denials, it is readily apparent that insufficient ED and H & P documentation are a contributing factor.

Current CDI processes are inarguably transactional, repetitive and reactive whereby the CDI professional reviews and opens a medical record after the fact, looking for clinical clues as to the basis for query clarification. What is gapingly absent is investment in time and effort in transitioning to proactivity in working with physicians, providing educational training and knowledge training on principles of documentation to accurately capture clinical acuity, tell the patient story clearly , report the physician’s clinical judgment and medical decision making as well as thought processes and show the progression of patient while hospitalized. CDI as a whole is not equipped to provide said physician documentation educational and training to the extent necessary to move the needle on the achievement of quality documentation.

Quality and completeness of documentation extend well beyond the reporting of diagnoses. Many clinical validation denials are caused by what I refer to as the mirage effect; a diagnosis appears out of nowhere with virtually little in the way of a patient story in the record in support of the diagnosis aside from clinical indicators used in the query process. In essence, the compliant query generated a clinical validation denials due to fact the CDI professional overlooked the opportunity to converse with the physician and provide feedback and thoughts to expand the patient story more closely approximating the patient’s History of Present Illness and physician’s clinical judgment, medical decision making and clinical rationale for the diagnosis. A physician answering a query for a diagnosis is such a small piece of communication of patient care.

Final Thoughts

The magnitude of CC/MCC changes announced under the proposed 2020 IPPS rule, 1,492 changes with 1,148 CCs slated to become non-CCs should provide the motivation for the CDI profession to embark on  an initiative to transform CDI to one that truly possesses the wherewithal to achieve real meaningful improvement in physician documentation and communication of patient care. The financial impact of this proposed wholesale change in the CC/MCC landscape dictates the profession do much more than sending in their comments to Medicare opposing the proposed movement to update the current CC/MCC structure.

Continued CDI processes upon chasing CC/MCCs are not a viable option, partly the closure of Hahnemann attributable to poor documentation is a further testimonial for immediate wholesale change for CDI processes, vision and mission.

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