Missouri’s MO HealthNet Medicaid program recently shifted to an All Patient Refined Diagnosis Related Groups payment system for acute hospital inpatient services — a shift that is reshaping operations at St. Louis-based SSM Health.
The model replaces a per diem structure with a fixed-payment model tied to patient severity. Under the system, inpatient stays are classified based on a patient’s primary diagnosis, procedures performed and four levels of illness severity. Payments are determined by the assigned APR-DRG and its severity level, rather than length of stay.
“The longer the patient stays in the hospital, the less they are going to get,” Becky Dvorak, MSN, RN, regional vice president of behavioral health, told Becker’s. “Hospitals are a business as well. SSM is not for profit, so we will take care of anyone so while we are focused on it, that is not our ultimate [goal].”
The updated approach places greater emphasis on documenting all care provided — including medical treatment — and ensuring patients are discharged to the appropriate level of care, she said.
Two of SSM Health’s hospitals have been particularly affected by the Medicaid payment model changes, prompting leaders to closely review inpatient operations, especially lengths of stay.
“I don’t wholly agree with it, because it’s forcing hospitals to really speed up the services they’re providing to the patient,” Ms. Dvorak said. “Psychiatry is not the same as a medical illness.”
For many chronic medical diseases, she noted, there is a more defined treatment pathway.
“You go into the hospital with diabetes or something medical going on, there’s a pretty prescriptive standard of care. You’re going to get your insulin, you’re going to do this and then you get discharged,” she said. “Psychiatry is so variable because what works for one doesn’t work for another, and those are big differences.”
In response, SSM Health has expanded its collaborative care approach.
“We are having more collaborative treatment planning teams for our units to make sure that the physician, nurses, social workers and pharmacists are in those conversations to ensure we are getting the patient’s care as quickly as possible, documenting that care and discharging them when it’s appropriate,” Ms. Dvorak said.
To help reduce repeat hospitalization, the system is also increasing use of long-acting injectable medications for some behavioral health patients, particularly those who struggle with taking daily medication.
“To try to help and deter them from ending up in the hospital, we put them on a long-acting injectable, and so they only have to come into the clinic once a month to get those medications,” she said.
The system is focused on redirecting patients to lower-acuity settings when possible to curve wait times.
“From a payment perspective, if we can get our patients familiar with our urgent care, so when they are struggling, they’ll go into the urgent care sooner rather than having to wait and end up in the ED then end up in the inpatient unit,” she said.
It is strengthening partnerships with community mental health centers as well.
“We partner with those community mental health centers that we need to partner with to make sure that our patients get what they need and to move them as quickly as possible,” Ms. Dvorak said.
