WIN-STAT Analyst Helps Hospitals Identify Coding Problems
A new generation of analytical tools is helping hospitals to review discharge data and identify coding problems by comparing their coding patterns to their peers. Hospitals are using these data analysis tools to identify patient records with improper severity levels that result in reduced reimbursement levels. The data is also very useful in helping to determine demand for various services such as planning for a new treatment center. Additionally, hospitals may evaluate the performance of existing and prospective staff physicians.
The WIN-Stat Analyst, healthcare decision support software from Information Management Systems, Inc. (IMS), Miami, Florida, is an analytical tool that allows clients to profile hospitals based on DRG, ADRG (severity adjusted "DRGs"), payer mix, physician, product line, ICD-9 procedures or diagnoses, or patient demographic information. Several states now collect patient discharge data from hospitals within their borders. This public data provides the information required to drive the IMS analytical tools. Generating reports by hospital provides an in-depth analysis of the hospital's competitive opportunities and relative performance. Reports contained in a typical hospital summary series include: primary service area by ZIP code; market share by hospital; payer or product line mix; DRG or physician market share; discharge status trend; and severity analysis by ADRG.
Physician analysis reports reflect physician performance and discharge trends. Reports are based on hospital, DRG, ICD-9 diagnosis and procedure, discharge status, patient age, etc. Clients produce attending or operating physician summaries, physician discharges by hospital and physician comparison reports.
Much of the raw data received from the states is not DRG grouped or is grouped inconsistently and may or may not be severity adjusted. A key to the success of the WIN-Stat Analyst is the use of severity adjusted grouping software from Information Resource Products (IRP), Woburn, Massachusetts. IRP produces guaranteed accurate groupers for most hardware platforms that are fully tested and ready to integrate into IBM mainframe, AS/400, Unix, Windows and DOS environments. The groupings are certified to match federally approved Medicare grouper data issued each October 1 by the Health Care Financing Administration (HCFA). IMS has fully integrated the IRP Grouper values into the WIN-Stat Analyst. "The IRP Grouping product runs very quickly and efficiently. We can group and severity adjust over 300,000 records per hour on an inexpensive PC and be assured that the results are current, correct, and consistent", says Jim Puglise, IMS President.
The WIN-Stat Analyst is being used to make decisions that improve the quality of service and ability to plan in hospitals. For example, managers of one large teaching hospital were unhappy because surveys showed that, when acuity of patients was considered, their mortality rate was higher than would be expected. Hospital managers compared their severity levels to other hospitals in the area and discovered that their patients were consistently ranked as lower severity, and therefore lower risk. The managers felt this was incorrect based on what they knew of the hospital's demographics and patient mix. Zeroing in on key areas, managers determined that physicians were not adequately coding some conditions, such as smoking and obesity in the case of cardiac patients. By putting together a checklist for physicians, managers improved coding standards and increased the hospitals measured performance to near the top of its peer group.
The WIN-Stat Analyst also helps ensure that hospitals comply with Medicare standards. For example, HCFA examines what percentage of a hospital's cases fall into the complicated DRG of a pair versus the percentage reported for other hospitals. A very high CC ratio may be a "red flag" item for HCFA auditors. An example of a DRG pair is DRG 141-142. DRG 141 is syncope & collapse with complications & comorbidities (CC); DRG 142 is syncope & collapse without CC. The software reports the percentage of discharges with CC versus without CC by DRG pair. This report is then used to give an overview of a particular facility or group of facilities compared to a norm group.
Analysis of data leads to better management decisions. One hospital was already approved to put in a delivery suite. By using the software to evaluate demand for this service by payer in their area, they discovered that existing providers were underutilized. They cancelled their plans in time to avoid an expensive mistake. Another teaching hospital used the WIN-Stat Analyst to examine where trauma patients were being transported by helicopter. They discovered that a helicopter company, owned by a private hospital chain, was determining which hospital patients would be taken to by payer, which was a violation of the county's trauma plan. The analysis was used to better define the regional trauma network.
The ability to incorporate severity adjusted DRG grouping into the state discharge data makes it relatively easy to calculate actual versus expected outcomes for any patient group. The software also generates reports of coding patterns by hospital, physician, DRG, ADRG, etc. Typically, a hospital that hasn't carefully monitored its coding operation will rank very low on comparative measurements with other hospitals. The WIN-Stat Analyst can be used to look at coding practices at the individual ICD-9 level in order to identify instances of poor coding. For example, in one situation, a major hospital reported 70% of cardiac surgery patients with acute post hemorrhagic anemia compared to another hospital that reported only 5% for the same condition. Further study showed that the coding staff's lack of familiarity with several relevant conditions resulted in the lower reported percentage.
Data analysis is clearly an idea whose time has come. These tools help hospitals comply with government regulations, improve their coding practices and allocate capital more efficiently. They substantially improve the ability of hospitals to provide superior care at a reasonable cost in today's challenging healthcare environment.