Accredited Chest Pain Centers Better At Meeting Standards For Increased CMS Reimbursement

Main Category: Medicare / Medicaid / SCHIP
Also Included In: Cardiovascular / Cardiology;  Pain / Anesthetics
Article Date: 23 Jan 2009 - 3:00 PDT

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With five million Americans visiting hospitals each year with chest pain, emergency department personnel must quickly identify patients with life-threatening conditions and treat them promptly. Only about 10% - 15% of patients entering the ED with chest pain symptoms actually have an acute myocardial infarction (AMI). Thus, determining the cause of a patient's pain in a timely and cost effective manner is critical to patient outcomes, efficiency of emergency rooms and a hospital's bottom line.

One of the key factors affecting a hospital's reimbursement for AMI treatment is the ability to meet measures established by the Centers for Medicare and Medicaid Services (CMS) for hospitals billing to Medicare or Medicaid. The CMS measures are considered to represent "best practices" for the care of patients with AMIs, and their reporting is required.1

Achieving Best Heart Patient Outcomes - Ensuring Maximum Reimbursement.

So how do hospitals best achieve positive patient outcomes while ensuring maximum reimbursement for services? Many hospitals are opting to adapt new protocols for chest pain patients. In fact, a recent study has shown that hospitals with Chest Pain Center accreditation from the Society of Chest Pain Centers (SCPC) are more likely to meet the CMS guidelines and thus, more likely to receive maximum reimbursement for both inpatient hospital stays as well as for patients re-entering the hospital with AMIs.

Why Are Hospitals Seeking Chest Pain Center Accreditation?

Better patient outcomes, improved bottom line, and improved integration between departments are some of the reasons hospitals are seeking accreditation. It is not surprising that missed AMI is the most expensive cause of malpractice litigation against emergency physicians, constituting 20% of all dollars paid.3 Research shows that 4 - 13 percent of patients are being released from the ED with false reassurance that coronary artery disease is not the cause of their symptoms. Many of these patients have complications from AMI and 11 - 25% die as a result.2

Thus, increasingly, hospitals are looking to improve standards and outcomes for heart patients presenting to the ED, as well as the bottom line for the hospital. For example, the website for the medical journal Critical Pathways in Cardiology has reported a significant increase in the number of downloads of the recently published SCPC recommendations for the management of acute heart failure patients in the short stay setting. Hospitals choose to pursue chest pain center accreditation for many reasons including pursuing a method to integrate departments in the care of patients with AMIs along with an external validation of the care processes for patients.

This, combined with the goal of providing the best patient care, has been the driving force behind the trend for EDs to establish accredited Chest Pain Centers (CPCs) with designated resources of personnel, protocol, space, and equipment for the patient presenting with chest pain.

Currently, about 420 hospitals in the U.S. are Chest Pain Centers and have earned SCPC accreditation. Trends Thomson Reuters recently confirmed the trend towards increased accredited CPCs with its annual study identifying the 100 U.S. hospitals that are setting the nation's benchmarks for cardiovascular care. Approximately one third of the hospitals on the list were SCPC accredited, versus the average percentage across all hospitals of 9 percent.

The purpose of accreditation for a Chest Pain Center is to improve the processes of specialized cardiac care that better determines whether a patient is suffering from a heart attack and should be admitted for further services quickly, or if the patient is low-risk and requires additional diagnosis to determine if they are at risk for a heart attack or simply suffering from a non-cardiac problem that can be treated and discharged without being admitted.

If all hospitals performed CMS core measures at levels reported by those with accredited chest pain centers, more heart attack patients would be treated with aspirin and beta blockers at both arrival and discharge from the hospital. Increased adherence to core measures might also lead to more heart attack patients receiving emergency angioplasty within 90 minutes - the so-called "door to balloon" benchmark often used.

Results Reported from Cardiology Programs.

"I know firsthand how the SCPC accreditation affects patient care delivery. Because of the impact on patient outcomes, specifically mortality, we estimate that an additional 48 patients per year have survived than would have two years ago and we have held this outcome. This did not happen by accident," said Carol L. Joseph, RN, Cardiology Program Manager, of Ascension Health Information Services, Grand Blanc, MI.

Accreditation for Best Practices and Improved Processes.

"To achieve accreditation, an institution must submit documentation and participate in a site visit conducted by SCPC reviewers. The number of centers that applied for and received accreditation has increased dramatically from June 2003 when the first hospital chest pain center was accredited, with 419 chest pain centers being accredited as of January 2009," explained Michael A, Ross, MD, FACEP, Board Trustee of SCPC.

The 'best practices' for positive patient outcomes in acute coronary syndromes (ACS) "heart attacks" were developed through a collaboration of physicians, nurses and health care experts from cardiology, emergency medicine, nuclear medicine, and clinical pathology. The hospital protocols focus on the following areas:

1. Emergency Department Integration with the Emergency Medical System: A formal relationship between the ED and the local EMS that links the care processes for patients with symptoms of possible ACS.

2. Emergency Assessment of Patients with Symptoms of ACS - Timely Diagnosis and Treatment of ACS: an ED attack program to minimize delays in institution of therapy for an AMI (thrombolytics, nitrates, heparin, aspirin, etc.).

3. Patients with Low Risk for ACS and No Assignable Cause for their Symptoms: an ED or hospital observation program that monitors and evaluates low-risk patients to avoid the inadvertent release home of patients with AMI or unstable angina.

4. Functional Facility Design: an ED CPU that has a functional design for chest pain evaluation to accomplish optimal patient care. It includes appropriate cardiovascular monitoring equipment.

5. Personnel, Competencies, and Training: Physicians and nursing staff in contact with patients with symptoms of ACS require certain core competencies and training. Leadership and management may require additional core competencies and training.

6. Process Improvement Orientation: CPU management structure based on continuous quality improvement program principles to ensure quality patient care and proper utilization of ED resources.

7. Organizational Structure and Commitment: The facility's administration, medical staff, and multidisciplinary committee must make a commitment to the establishment and support of a Chest Pain Center.

8. Community Outreach Program: An ED- or hospital-based community outreach program that educates the public to promptly seek medical care if they have symptoms of an AMI, such as chest pain, chest discomfort, shortness of breath, diaphoresis, syncope, and risk factors for coronary artery disease, particularly smoking.

"The preparation for SCPC accreditation allowed us to examine and benchmark our processes to the latest "evidence based" best practices. Without the SCPC resources, it would have been extremely difficult to bring together all the "pieces" necessary to establish a quality Chest Pain program. Also, the process allowed us to bring together groups that do not always work as a team. Now we enjoy working as a focused unit on providing quality Chest Pain care to our patients," said Daniel W. Sutton, RCP, MPA, Regional Director, Cardiopulmonary Services, Cleveland Clinic, East Market.

"The process of accreditation review was pleasant and non-threatening. Knowing that SCPC was there to help us succeed rather than looking for things that were wrong, makes a huge difference in how the whole process is viewed by all," explained Mary Seitenbach, BSN, RN, Chest Pain Coordinator, Exempla Good Samaratin Medical Center.

1. Werner RM, Bradlow ET. Relationship Between Medicare's Hospital Compare Performance Measures and Mortality Rates. JAMA 2006; 296: 2694-2702.

2., 3. American College of Emergency Physicians Information Paper: Chest Pain Units in Emergency Departments, A Report from the Short-Term Observation Services Section, Consensus Panel Members: Co-Chair, Louis Graff, MD, Co-Chair, Tony Joseph, MD, Robert Andelman, et, al., from the American College of Emergency Physicians, Dallas, Texas. Manuscript received April 20, 1995; revised manuscript received and accepted July 31, 1995. THE AMERICAN JOURNAL OF CARDIOLOGY® VOL. 76 NOVEMBER 15, 1995

Written by - Robert Weisenburger Lipetz, MBA, Executive Director, Society of Chest Pain Centers

http://www.scpcp.org

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