Note from the ACDIS Director: Volume to value is coming in healthcare, and outpatient CDI can get you there

by Brian Murphy

Sometimes it feels like its been discussed ad nauseum—the transition from fee-for-service to pay-for-performance. It’s a tired line, and it’s fair to ask: When is it going to happen (if ever)?

But when you pull the camera back and see the big picture, a major change in how healthcare is delivered and paid for is going on, right now, right under our noses. A recent survey indicated that 75% of hospital executives were concerned about their financial viability without an effective COVID-19 treatment or vaccine. Grim news, and we hope that the forthcoming vaccines deliver on their promise, but the same survey also shows where the new opportunities for growth lie: “Looking forward, hospital executives report that digital and ambulatory strategies will play an even more significant role at most organizations. For instance, 31% of respondents said that competitive dynamics in their market had been affected as more consumers sought out care from retail-based clinics.”

The good news is that some of your peers are already elbow deep in outpatient CDI and this new world of risk-based contracting, capitated payment, and reviews of encounters in clinics and private practices. If your organization has a risk-based contract in play, works with Accountable Care Organizations, or is experiencing denials in its emergency department, opportunities await.

For aspiring CDI leaders who believe they ought to be in this space but currently are not, a good place to start is with your finance or contracting department. Ask if you have any Medicare Advantage, population health, or risk-based private payer contracts in play. Outpatient CDI requires a close relationship with payers, with whom you are sharing risk.

There are some inherent obstacles in getting started. Proving the return on investment (ROI) is one of the biggest. In comparison, the ROI inpatient CDI is linear and straightforward—impact a case with a diagnosis clarification, change a DRG, and you see an immediate change in the claim. But with outpatient CDI/risk adjustment contract with gain sharing provisions, you might not see any financial or quality outcomes to your organization until a year and a half later. You need faith that your efforts will bear fruit in 18-24 months. Other obstacles include finding the right staff, and the right review cadence. A lack of end-to-end tools and technologies is another.

But the good news is you can get started, and make a big difference, if you’re willing to invest the time and learn. If you’re interested in hearing straight from peers who have made the leap, please consider joining us for ACDIS Online: Uncovering Outpatient CDI Opportunities. We believe outpatient CDI discipline is so different than traditional inpatient/acute CDI that it warrants its own event.

Over the course of the program you’ll hear from successful outpatient programs at organizations like the Mayo Clinic, Wake Forest Baptist Health, Novant Health, and Baptist Health System in Kentucky. You’ll get an in-depth look at Hierarchical Condition Categories (HCCs), help with managing the problem list and the risks of provider self-coding, strategies for positioning CDI to review observation cases, and learn the major changes coming next year to physician E/M coding and billing. You’ll walk away with ideas to either get started, or to make tangible improvements to your existing outpatient CDI program.

In closing, there is always more to learn in CDI, and we believe that the COVID-19 pandemic is only going to accelerate the change to value-based healthcare. That means, outpatient opportunities await!

Editor’s note: Murphy is the director for ACDIS. Contact him at bmurphy@acdis.org. The Kaufman Hall article on impact of COVID-19 can be found here.