Briefing: RVUs and RWPs, An Advanced View Speaker: Rich Holmes, Wendy Funk Date: 22 March 2007

1. Briefing: RVUs and RWPs, An Advanced View Speaker: Rich Holmes, Wendy Funk Date: 22 March 2007 Time: 1010 - 1100 – Track 1 1110 - 1200 – Track 2

2. MANAGEMENT DATA WKLD

3. Objectives Part 1 – RWPs • Describe the role of coding in MHS management as effected through weighted workload measures • Describe how WWR, MEPRS, and Appointment Data allow ready detection of uncoded services • Describe RWPs, including their basis in claims • Describe how SIDRs get RWPs assigned, and the damage poor coding can cause Part 2 – RVUs • Describe RVUs and their components, and contrast to APGs and APCs • Describe how RVUs are assigned to SADRs • Describe limitations to RVU measurements in direct care, to include differences from civilian coding and the absence of needed fields

4. DIRECT CARE PURCH CARE Introduction • Weighted Workload is available in both direct and purchased care data • This session focuses on the application of workload to direct care data • Cannot generalize to purchased care • Data collection techniques are too different! • Wisdom course, TFMEP for more info

5. Chronology of the Can Health Services

6. Captured Never Coded Lost Chronology of the Can Health Services

7. Health Services Miscoded Captured Never Coded Well coded Lost Chronology of the Can

8. UnPaid Health Services Miscoded Underpaid $- Captured Never Coded Well coded Lost Paid $ UnPaid Chronology of the Can Paid $

9. Management Based on Workload Ignore Lost Workload Impute Workload

10. Cooking from the Can • Weighted Workload is used in the MHS for all sorts of “high-stakes” purposes: • Budget Development (PPS) • Business Planning • Productivity Reporting / Analysis • Venture Capital Program • Make vs. Buy Studies • TRICARE for Life (MERHCF) Program • GWOT tracking and funding

11. Workload and Reporting Systems

12. Basic Workload 20 Quarters 100 Pennies Pile A Pile B

13. Raw Workload Pick a Pile: • If you get to keep the pile and spend it! • If you have to carry the pile in your pocket Pile A

14. Raw Workload • Raw workload: • Counts of services • Very common for basic statistical reporting • Some limited types of productivity InpatientAmbulatoryOther Admissions Encounters Scripts Dispositions Visits Lab Tests Days

15. Raw Workload • Cost per Bed Day: • Normal newborns: $1,000 • All other newborns: $2,000 • Cost per encounter • Ambulatory Procedure Visit: $2,015 • Family Practice: $ 190 • Cost per radiology exam • X Ray: $ 25 • MRI: $ 321

16. Weighted Workload 20 Quarters = $5.00 100 Pennies = $1.00 Pile A Pile B

17. Worldwide Workload Report • WWR contains monthly tabulated workload counts • Summary data: Treatment DMISID, Work center, Bencat, workload amount • Admissions • Dispositions • Bed days • Countable outpatient visits • Countable inpatient visits

18. Worldwide Workload Report WWR Workload for FY 06

19. MEPRS • Financial system with workload data from CHCS • Conceptually the same as WWR, but without bencat • May not get updated for minor changes • Much slower than WWR • Days & Dispositions, IPV and OPV, lab and rad RVUs • Treats ICUs differently

20. WWR vs. MEPRS – FY06 As of 6 March 2007, several sizable MTFs have not reported all the MEPRS for FY06

21. ICU Days in “A” MEPRS Codes

22. WWR vs. MEPRS Labor, supplies, etc, are all captured in MEPRS with the “D” codes ($ ‘stepdown’ in costing, but not labor hours)

23. ‘More Interesting’ Workload

24. Many Different Sources • MEPRS and WWR are both designed to report tabulated workload statistics at MTFs • No weighted inpatient or ambulatory • Other sources contain data that allow for more detailed analysis of workload • Encounters • Dispositions • MEPRS and WWR still have a role in spotting missing records!

25. Inpatient Care Relative Weighted Products

26. Direct Care Inpatient • Standard Inpatient Data Records (SIDR) • Each record is a hospital stay at an MTF • Each record is both an admission and a disposition • There can be a significant lag in record completion • Contains bed days and relative weighted products (RWPs) • Can tabulate records to generate workload statistics

27. Direct Care Inpatient • Standard Inpatient Data Records (SIDR) • Case may span multiple months and even years • MEPRS & WWR split workload into the month where it occurs…. • And do not have the RWPs found in SIDRs for the “whole stay”

28. RWPs • Relative Weighted Products • Measure of intensity of hospital care in an acutecare setting • Has nothing to do with the providers • Incorporates room and board, OR, recovery, labs, etc. • RWPs are applied to records based on: • DRG • Disposition Date • Length Of Stay (LOS) • Admission Source • Discharge Status

29. DRG-Based Payment • For each DRG, TRICARE publishes a: • DRG Weight: represents the relative costliness of that DRG. vs all others in TRICARE acute care claims data • Mean length of stay for TRICARE • Short- and long-stay thresholds for TRICARE • Relative costliness only incorporates acute care hospital charges • Direct care data is not used in determining DRG weights • Think barracks effects, war injuries

30. tricare.osd.mil/drgrates

31. DRG Weight Examples • Higher weight for surgical care! Incorporates charges for OR, recovery, etc. • Higher weights for complicated care

32. High-weight DRGs Low birthweight newborns Tracheostomy Burns Transplants Heart Procedures Low-weight DRGs Normal newborns Medical admissions Normal deliveries & antenatal care Minor surgeries DRG Weight Examples

33. DRG-Based Payment • Relative Weighted Product is usually the DRG weight • But less if you stay shorter than normal • And more if you stay longer than normal • The next several slides describe the basic logic of calculating RWPs • Uses a cardiac procedural DRG

34. RWP Calculation

35. RWP Calculation If you stay a “normal” length of time, then RWP equals the DRG weight Normal is defined by short and long stay thresholds

36. RWP Calculation The RWP for short stay outliers is never greater than the DRG weight Outlier RWPs depend on length of stay “First day gets twice per diem, each additional day gets per diem, up to the DRG weight”

37. RWP Calculation The RWP for long stay outliers is always >= DRG weight. Outlier RWPs depend on length of stay. “DRG weight + 1/3rd the per diem weight for each day in excess of long- stay threshold”

38. Example Calculation • DRG 371 – C Section w/o CC Daily Weight: Total Weight / LOS

39. RWP • Unusual RWPs may result for: • Extensive rehab of wounded active duty • Infections, tooth extractions, “barracks effects” • There are some special rules for transfers and very low birthweight newborns in addition to the basic logic described • Note that all inlier cases receive the same credit for RWPs, regardless of length of stay • Excruciating details available in documentation. . .

40. Top 10 DRGs by Volume—FY06 Direct Care Only

41. Top 10 DRGs by RWP—MTFs Only

42. Case Mix Index (CMI)—Top 10 MTFs Case Mix = Average RWP

43. Miscoding Affecting RWPs • Bad or missing diagnoses • Wrong gender or age • Missing procedures and diagnoses • Typographical errors, such as dates UNGROUPABLE UNDERCODED LAUGHABLE

44. Questions Questions?

45. Contact Information Dr. Richard Holmes richard.holmes@nc.rr.com Ms. Wendy Funk wfunk@kennelinc.com

46. Ambulatory and Other Care Relative Value Units

47. Professional Encounters Standard Ambulatory Data Records • One SADR record per MTF provided care: • Routine Outpatient Visits • Ambulatory Procedure Visits • Emergency Room • Documented Telephone Consults • Inpatient Rounds • Inpatient surgical encounter records are NOT required to be captured at MTFs

48. Professional Encounters • Hospital records (SIDRs) are captured for inpatient surgeries, but not provider records (SADRs)! • Providers earn no RVUs for this type of care! • Inpatient surgeries are A LOT of work! • Leads to a significant understatement of workload for surgeons…… • There are compliance problems with the SADR where there is policy! • You cannot assume that more SADRs means more workload! • It may be that compliance is improving! • An M2 User can check this using Appointment data

49. More about RVUs….

50. RVUs • Designed to pay Providers, mostly working in their offices • If working elsewhere, a separate bills pays the facility • Relative Value Units • RVU assignment designed to be based on the procedure code, location, modifiers and units of service