WIFM? Engaging physicians in quality outcomes improvement

Sept. 4, 2015 / By Cheryl Manchenton, RN

WIFM (what’s in it for me) is a common question in health care. With too many patients and not enough hours in the day, compounded by requests for additional documentation regarding medical necessity/continued need for inpatient admission, quality outcomes data can quickly fall down to the bottom of the provider’s to-do list.

Let me be clear on one thing. Providers do care about quality data and how their care is perceived, some more than others. Asking any surgeon to comment on a potential complication is fairly easy. But providers need better, more detailed information about how quality beyond operative complications impacts them and their practice of medicine. What follows is a partial list of WIFMs for providers from a quality perspective:

  1. Accurate reflection of the patient’s severity and risk of mortality

Risk adjusted severity and mortality supports the belief that “my patients are really sick” and helps explain why some patients did not stay the usual length of time or expired during this stay. It also justifies a patient still needing to be inpatient and not ready for discharge due to additional diagnoses or complexity of their conditions.

  1. Justifies the inpatient status of a patient

The complete list of conditions that must be treated emergently or intensively in this stay and utilized to determine the need for inpatient care can decrease the likelihood of medical necessity denials.

  1. Justifies all of the resources expended caring for a patient

Proving the provider and the institution are good stewards of resources to both commercial and government payers (e.g. spending per beneficiary) is essential, as this is now a portion of many metrics including value-based purchasing.

  1. Accurate quality profile for the institution

Having an accurate institutional scorecard supports the provider choosing to practice at their institution. Whether they like it or not, the provider’s assessed quality of care is linked to the institution at which they provide the most care. This can be advantageous or disadvantageous to a provider.

  1. Accurate reimbursement for the provider

With the transition from fee-for-service to value-based care, accurate documentation supports quality outcomes reporting and hence, appropriate reimbursement through physician quality databases such as PRQS.

Many external audits now include assessment of evaluation and management (E&M) bills for inpatient visits to ensure that the hospital record’s documentation supports the E&M level claim submitted by the provider. If there appears to be a mismatch between the severity of illness in the medical record and the E&M level submitted, the professional fee claim may be denied or recouped.

6. Most importantly, an accurate story

The medical record viewed by all providers and caregivers in various healthcare realms provides a complete picture of what occurred during the stay and how the patient was cared for to ensure appropriate follow up items are completed and that appropriate medications and treatments/therapies are continued.

Of course, there is a great deal of provider frustration in that quality metrics do not always align with each other. For example, the Society of Thoracic Surgeons’ list of complications is very different than that of the Orthopedic or Trauma Registry databases and they are definitely different than those of CMS, Healthgrades, and U.S. News & World Reports. So providers are often conflicted as to which metrics to attend to and which set of scores to “believe.” Being honest with providers about the nuances and differences in each profiling system is the first step. The second step is convincing them of the WIFM. Only at that point can an honest discussion about improving quality outcomes occur.

Cheryl Manchenton is a Senior Inpatient Consultant and Project Manager for 3M Health Information Systems.

Today’s value-based care models require a different kind of quality measure. Learn which quality measures lead to improved patient outcomes.