Bryn Nelson, PhD

Many of the buzzwords being bandied about in discussions of the Affordable Care Act, or ACA, already are familiar to hospitalists. HM providers regularly operate in an interdisciplinary environment and have been leading the charge in quality improvement initiatives over the past few years. But as the ACA kicks into high gear, hospitalists say it will ramp up the emphasis on tighter cost controls (especially identifying and eliminating waste), greater efficiency, and smoother transitions of care.

Supporters of the law have advanced the moral and ethical argument that everyone deserves at least basic healthcare.

“Money is not going to magically appear to pay for that,”

Dr. Hilger says. “So we’re all responsible for looking at what we do and where’s the waste in the system to help improve the care for the most at-risk patients.”

Some fundamentals of the work environment haven’t changed dramatically.

“Even before the ACA, there were core measures and coding and documentation requirements,” Dr. Hilger says. What’s different now, he says, is an added sense of urgency in scrutinizing quality and cost. That expectation may be especially acute for HM providers. “I think there’s a lot of pressure on hospitalists because organizations and hospitals are expecting us to be the primary care doctors in the hospital and to eliminate waste,” he says. That mandate dovetails with campaigns like Choosing Wisely that ask doctors to ponder the necessity of often overused or misused tests and procedures.

There’s going to be two steps forward, one step back, but the simple question is: Was it ever OK to have tens of millions of patients who had no insurance or were underinsured and were using the emergency room as their primary care? I think, no matter what your political affiliation, that, in general, the answer is no.

—Rick Hilger, MD, SFHM,medical director for care management, Regions Hospital, St. Paul, Minn., hospitalist, HealthPartners, member, SHM Public Policy Committee.

Another area of added emphasis is transitioning patients out of the hospital in a high-quality, low-cost way.

“That’s something we should have been doing 10 years ago,” Dr. Hilger says. “So that’s definitely a trend in the right direction that the ACA is helping to further.”

In effect, the heightened profile of ACOs, the rise of quality-based metrics, and the shift toward pay-for-performance models are extending the expectations around what happens to patients before, during, and after a hospital stay.

“We’re expected to not only provide excellent care to the patient while they’re in the hospital, but we’re expected to make sure that there is a good transition plan at discharge,” Dr. Hilger explains. “We’re expected to make sure that the patient has appropriate appointments lined up, that they’re getting appropriate services either at home or that we try to get them appropriately to a skilled nursing facility.”

Dr. Lenchus says a major objective of healthcare reform—at least in principle—is to devote more energy to preventive care to help ward off more expensive acute care.

“If we assume the hypothesis that the ACA really tries to keep people out of the hospital, that makes their time in the hospital that much more focused and concentrated, to the point where quality, cost control, and efficiency are really going to come into play,” he says.

And, at least initially, patients who have chronic conditions or were excluded from the healthcare system due to pre-existing illnesses or an inability to pay are likely to be clamoring for access the most. Consequently, those who do end up in the hospital will require more complex care.

“With respect to the workload, I believe we’ll see patients who are farther along in their disease process, in more acute, more dire need for healthcare,” Dr. Lenchus says.

Providers already accustomed to working in teams to improve quality and to communicating with a hospital’s chief medical officer and other C-suite executives over matters of cost will have a clear advantage.

“The ACA is not perfect, and it’s going to take time to figure out what works and what doesn’t, but what we have control over on a daily basis is to really focus on high-quality, low-cost, standardized best practices,” Dr. Hilger says.

What does that mean in practice? “Really work on perfecting or maximizing your transitions of care,” he says. “Really work with care management and social workers, and work with your hospital to try to develop relationships—if you haven’t already—with the primary care systems in your community.”

Bryn Nelson is a freelance medical writer in Seattle.

Many of the buzzwords being bandied about in discussions of the Affordable Care Act, or ACA, already are familiar to hospitalists. HM providers regularly operate in an interdisciplinary environment and have been leading the charge in quality improvement initiatives over the past few years. But as the ACA kicks into high gear, hospitalists say it will ramp up the emphasis on tighter cost controls (especially identifying and eliminating waste), greater efficiency, and smoother transitions of care.

Supporters of the law have advanced the moral and ethical argument that everyone deserves at least basic healthcare.

“Money is not going to magically appear to pay for that,”

Dr. Hilger says. “So we’re all responsible for looking at what we do and where’s the waste in the system to help improve the care for the most at-risk patients.”

Some fundamentals of the work environment haven’t changed dramatically.

“Even before the ACA, there were core measures and coding and documentation requirements,” Dr. Hilger says. What’s different now, he says, is an added sense of urgency in scrutinizing quality and cost. That expectation may be especially acute for HM providers. “I think there’s a lot of pressure on hospitalists because organizations and hospitals are expecting us to be the primary care doctors in the hospital and to eliminate waste,” he says. That mandate dovetails with campaigns like Choosing Wisely that ask doctors to ponder the necessity of often overused or misused tests and procedures.

There’s going to be two steps forward, one step back, but the simple question is: Was it ever OK to have tens of millions of patients who had no insurance or were underinsured and were using the emergency room as their primary care? I think, no matter what your political affiliation, that, in general, the answer is no.

—Rick Hilger, MD, SFHM,medical director for care management, Regions Hospital, St. Paul, Minn., hospitalist, HealthPartners, member, SHM Public Policy Committee.

Another area of added emphasis is transitioning patients out of the hospital in a high-quality, low-cost way.

“That’s something we should have been doing 10 years ago,” Dr. Hilger says. “So that’s definitely a trend in the right direction that the ACA is helping to further.”

In effect, the heightened profile of ACOs, the rise of quality-based metrics, and the shift toward pay-for-performance models are extending the expectations around what happens to patients before, during, and after a hospital stay.

“We’re expected to not only provide excellent care to the patient while they’re in the hospital, but we’re expected to make sure that there is a good transition plan at discharge,” Dr. Hilger explains. “We’re expected to make sure that the patient has appropriate appointments lined up, that they’re getting appropriate services either at home or that we try to get them appropriately to a skilled nursing facility.”

Dr. Lenchus says a major objective of healthcare reform—at least in principle—is to devote more energy to preventive care to help ward off more expensive acute care.

“If we assume the hypothesis that the ACA really tries to keep people out of the hospital, that makes their time in the hospital that much more focused and concentrated, to the point where quality, cost control, and efficiency are really going to come into play,” he says.

And, at least initially, patients who have chronic conditions or were excluded from the healthcare system due to pre-existing illnesses or an inability to pay are likely to be clamoring for access the most. Consequently, those who do end up in the hospital will require more complex care.

“With respect to the workload, I believe we’ll see patients who are farther along in their disease process, in more acute, more dire need for healthcare,” Dr. Lenchus says.

Providers already accustomed to working in teams to improve quality and to communicating with a hospital’s chief medical officer and other C-suite executives over matters of cost will have a clear advantage.

“The ACA is not perfect, and it’s going to take time to figure out what works and what doesn’t, but what we have control over on a daily basis is to really focus on high-quality, low-cost, standardized best practices,” Dr. Hilger says.

What does that mean in practice? “Really work on perfecting or maximizing your transitions of care,” he says. “Really work with care management and social workers, and work with your hospital to try to develop relationships—if you haven’t already—with the primary care systems in your community.”

Bryn Nelson is a freelance medical writer in Seattle.

Many of the buzzwords being bandied about in discussions of the Affordable Care Act, or ACA, already are familiar to hospitalists. HM providers regularly operate in an interdisciplinary environment and have been leading the charge in quality improvement initiatives over the past few years. But as the ACA kicks into high gear, hospitalists say it will ramp up the emphasis on tighter cost controls (especially identifying and eliminating waste), greater efficiency, and smoother transitions of care.

Supporters of the law have advanced the moral and ethical argument that everyone deserves at least basic healthcare.

“Money is not going to magically appear to pay for that,”

Dr. Hilger says. “So we’re all responsible for looking at what we do and where’s the waste in the system to help improve the care for the most at-risk patients.”

Some fundamentals of the work environment haven’t changed dramatically.

“Even before the ACA, there were core measures and coding and documentation requirements,” Dr. Hilger says. What’s different now, he says, is an added sense of urgency in scrutinizing quality and cost. That expectation may be especially acute for HM providers. “I think there’s a lot of pressure on hospitalists because organizations and hospitals are expecting us to be the primary care doctors in the hospital and to eliminate waste,” he says. That mandate dovetails with campaigns like Choosing Wisely that ask doctors to ponder the necessity of often overused or misused tests and procedures.

There’s going to be two steps forward, one step back, but the simple question is: Was it ever OK to have tens of millions of patients who had no insurance or were underinsured and were using the emergency room as their primary care? I think, no matter what your political affiliation, that, in general, the answer is no.

—Rick Hilger, MD, SFHM,medical director for care management, Regions Hospital, St. Paul, Minn., hospitalist, HealthPartners, member, SHM Public Policy Committee.

Another area of added emphasis is transitioning patients out of the hospital in a high-quality, low-cost way.

“That’s something we should have been doing 10 years ago,” Dr. Hilger says. “So that’s definitely a trend in the right direction that the ACA is helping to further.”

In effect, the heightened profile of ACOs, the rise of quality-based metrics, and the shift toward pay-for-performance models are extending the expectations around what happens to patients before, during, and after a hospital stay.

“We’re expected to not only provide excellent care to the patient while they’re in the hospital, but we’re expected to make sure that there is a good transition plan at discharge,” Dr. Hilger explains. “We’re expected to make sure that the patient has appropriate appointments lined up, that they’re getting appropriate services either at home or that we try to get them appropriately to a skilled nursing facility.”

Dr. Lenchus says a major objective of healthcare reform—at least in principle—is to devote more energy to preventive care to help ward off more expensive acute care.

“If we assume the hypothesis that the ACA really tries to keep people out of the hospital, that makes their time in the hospital that much more focused and concentrated, to the point where quality, cost control, and efficiency are really going to come into play,” he says.

And, at least initially, patients who have chronic conditions or were excluded from the healthcare system due to pre-existing illnesses or an inability to pay are likely to be clamoring for access the most. Consequently, those who do end up in the hospital will require more complex care.

“With respect to the workload, I believe we’ll see patients who are farther along in their disease process, in more acute, more dire need for healthcare,” Dr. Lenchus says.

Providers already accustomed to working in teams to improve quality and to communicating with a hospital’s chief medical officer and other C-suite executives over matters of cost will have a clear advantage.

“The ACA is not perfect, and it’s going to take time to figure out what works and what doesn’t, but what we have control over on a daily basis is to really focus on high-quality, low-cost, standardized best practices,” Dr. Hilger says.

What does that mean in practice? “Really work on perfecting or maximizing your transitions of care,” he says. “Really work with care management and social workers, and work with your hospital to try to develop relationships—if you haven’t already—with the primary care systems in your community.”

Bryn Nelson is a freelance medical writer in Seattle.

Dr. O’Malley

It has survived a bitterly divided Congress and a polarized public, a narrow Supreme Court ruling, and a 16-day government shutdown triggered by an effort to defund or repeal it. Hailed by some as the most significant healthcare reform in a half-century, it is also roundly scorned by others as an ill-advised debacle.

With some of its most hotly contested provisions now taking effect, the Affordable Care Act—or Obamacare, as both backers and detractors now call it—has been the object of admiration and animosity, of optimism and consternation. Its supporters have pointed to the promise of unprecedented access to healthcare for millions, while its critics have pointed to the trickle of consumers able to access the main web portal during an error-plagued rollout.

Beyond the heated rhetoric, however, what will the complicated and quickly evolving elements of Obamacare actually mean for hospitalists and for healthcare access, affordability, capacity, and delivery? In the short term, analysts say so much change is happening all at once that it’s nearly impossible to predict how it might turn out.

“Everyone’s kind of holding their breath to see what happens,” says Ann O’Malley, MD, MPH, a senior fellow at the Washington, D.C.-based Center for Studying Health System Change.

One thing is certain: more reliance on hospital-based providers.

Dr. O’Malley

“I think there are a lot of things on a hospitalist’s plate right now. And hospitals, because of the cost pressures, are definitely looking to us to lead the way through this uncertain time,” says Rick Hilger, MD, SFHM, medical director for care management at Regions Hospital in St. Paul, Minn., and a hospitalist for HealthPartners.

Amid the upheaval, experts are seeing the signs of a few major trends. In the short term, one emerging theme is considerable geographical variation in consumer access and costs, and in pressure on providers.

“How this is going to feel will depend, to a great extent, on where you live,” says Leighton Ku, PhD, MPH, director of the Center for Health Policy Research at George Washington University School of Public Health and Health Services in Washington, D.C.

Dr. Ku

Analysts also have seen hints of more universal changes, including an accelerated trend toward the consolidation of provider groups, an added emphasis on team-based care, and significant momentum toward a pay-for-performance delivery model.

An Uneven Exchange

One of the law’s most visible and controversial elements, the health insurance exchange or marketplace, got off to a rocky start Oct. 1, 2013, when computer glitches hobbled the main healthcare.gov portal for 36 state exchanges and plagued many state-run sites as well.

While some state-run exchanges have generally earned high marks, others have struggled. Analysts are most worried about the balkiness of the main web-based portal, through which the majority of enrollees will have to pass. While older and sicker patients are generally more motivated to keep trying, the same isn’t necessarily true for younger and healthier people whose participation will be vital to help balance each state’s risk pool. Analysts sometimes call these people, “young invincibles.” Because they generally seek out care far less often than older consumers, their lower medical costs can help compensate for higher expenditures elsewhere.

If too few sign up, however, a state’s risk pool may be imbalanced toward costlier patients, causing insurance premiums to rise and creating a vicious cycle that destabilizes the market and makes more expensive insurance less attractive to younger people. Economists say the carrot-and-stick approach—offering subsidies to help lower-income people pay for premiums and gradually increasing financial penalties for those who choose not to buy any coverage—is likely to help. Nevertheless, supporters are nervous that malfunctioning exchange sites could cause would-be enrollees to delay or drop out, and, at the end of 2013, a worried Obama administration was scrambling to address the cascade of glitches.

Because the health insurance exchanges were highly controversial already, says Dr. Ku, who sits on the board of the Washington, D.C. Health Benefits Exchange Authority, every problem is likely to be magnified by critics. Although he doesn’t expect “huge changes” in physician payment rates from plans in the exchanges, he says varying degrees of competition could drive down insurers’ prices in some markets.

Doctors also are likely to encounter plenty of confusion among the newly insured, and Dr. Ku hopes educational sessions will help healthcare professionals take more of a leading role in helping patients navigate an often bewildering system.

“One of the most important things that a hospital can do to help in the beginning is to help on the enrollment end of things,” he says. “Help patients who don’t quite understand how to get in, how to use these systems.”

It’s too early to say whether the exchanges can still meet the Congressional Budget Office’s prediction of 7 million enrollees by the end of the 2014 enrollment period (and 13 million by 2015). But analysts say the composition of the risk pool—something that should be clearer this spring—may provide a glimpse into the ACA’s long-term financial viability.

Instead of a consistent pattern across the country, the exchanges will be shaped by local market forces, such as the number of competitors and the extent to which cheaper plans will try to limit access to providers. To minimize their costs, some exchange-based plans are promising in-network hospitals higher patient volumes in exchange for discounted reimbursements. Other hospitals now find themselves excluded from most private plans in favor of cheaper options.

In exchange for lower premiums, some of these insurers are offering “skinny networks” that give consumers more limited provider options.

“A primary objective in the marketplace is to offer the cheapest plan possible, and to do that the insurers are going to look at who are the least expensive providers,” says Christiane Mitchell, director of federal affairs for the Association of American Medical Colleges. Not surprisingly, some of the costliest providers tend to take care of sicker or higher-risk patients.

“It’s a very, very strong concern, and it’s one that we have been very vocal on since the enactment of the Affordable Care Act,” Mitchell says. The association also has expressed concern that lower-income patients buying into the cheapest plans may not have access to the specialty services they need the most. That possibility, she says, increases the importance of navigators helping the newly insured pick out the best plans.

A Question of Access

Another big question is how the healthcare system will accommodate the influx of newly insured. Because hospitals already have been the safety net for many patients lacking access to preventive and primary care, urgent and specialty care may go through a bigger adjustment period, says Dr. Hilger, who sits on SHM’s Public Policy Committee.

The growing provider shortage certainly won’t help. By 2015, the AAMC predicts a shortfall of 63,000 doctors, almost evenly split between primary and specialty care. By 2025, that number is expected to more than double.

Mitchell says the gap between supply and demand is worsening due to the sheer number of baby boomers entering Medicare. At the same time, she says, one in three doctors in the U.S. is now over the age of 60 and nearing retirement age. Whether through Medicaid or the marketplace, the ACA’s coverage expansion will exacerbate the shortages. “It’s not to the level of the boomers entering Medicare, but it certainly is having a major impact on access issues and exacerbating the shortage, again, across specialties,” she says.

Other analysts say the extent of the capacity problem will depend in large part on location.

“The truth is that the extent to which there are enough doctors or enough hospital beds is largely a function of geography,” Dr. Ku says. “So, if you’re in an urban area with lots of teaching hospitals, you probably have enough doctors and you probably have enough hospital beds. If, on the other hand, you’re in a poor, rural area, chances are you don’t.”

As both insurance and demand for healthcare expand, those areas that were having problems already “are going to be stretched even more,” Dr. Ku says.

Meeting demand also means training more doctors, and Mitchell worries about a pipeline that already is underfunded. Although medical school enrollment is at a record high, federal support for residency training has been frozen since 1997, meaning that the funded residency slots may not be sufficient to accommodate future graduates. Further declines in the clinical income that subsidizes training would place additional pressure on the educational mission of teaching hospitals, Mitchell says.

Joshua Lenchus, DO, RPh, FACP, SFHM, associate professor of clinical medicine in the division of hospital medicine at the University of Miami, says existing doctor deficits, the ACA’s new demands, and the growing medical training gap could swirl into a “perfect storm” of access problems. Longer delays in accessing primary and specialty care, in turn, could prevent timely interventions earlier during the course of a disease or condition.

“What it’s going to mean for hospitalists is that we’re going to see—over the short-term, maybe even the next three to five years—a real impact on when patients present, in terms of the acuity of their disease,” Dr. Lenchus says. That means sicker patients in the hospital.

Given the massive changes, observers like Mitchell and Dr. Hilger acknowledge that ironing out the rough spots will take time.

“There’s going to be two steps forward, one step back, but the simple question is: Was it ever OK to have tens of millions of patients who had no insurance or were underinsured and were using the emergency room as their primary care?” Dr. Hilger says. “I think, no matter what your political affiliation, that, in general, the answer is no.”

What it’s going to mean for hospitalists is that we’re going to see—over the short-term, maybe even the next three to five years—a real impact on when patients present, in terms of the acuity of their disease. That means sicker patients in the hospital.

—Joshua Lenchus, DO, RPh, FACP, SFHM, associate professor of clinical medicine, division of hospital medicine, University of Miami, member, SHM Public Policy Committee.

Costs All Over the Map

One of the plan’s biggest goals and part of its name—affordability for those patients—also seems to vary considerably by geography. A recent analysis by The New York Times, for example, found that 58% of all counties served by the federal-run exchanges offer plans from only one or two insurance carriers. The relative lack of competition in many markets has created some huge cost disparities in premiums between neighboring states, and even neighboring counties.

With so many factors influencing costs, both proponents and opponents have found fodder to bolster their case that the law is either making insurance more affordable or sharply increasing premiums. One important consideration, Dr. Ku says, is that all plans must now include 10 “essential health benefits,” such as maternity care and medications, for example, and cannot allow gender to be a rating factor. As a result, he says, the cheapest plans for a relatively healthy young man may cost more now, while costs for a woman or an older person with a chronic condition like diabetes may go down.

Although the new mandates were designed to improve insurance standards, they sparked another firestorm when millions of Americans began receiving policy cancellation notices in 2013. Because many private insurance plans sold to individuals no longer met the ACA’s minimum requirements, insurers began dropping those plans or requiring enrollees to switch to other, often more expensive, ones. In November, in an effort to stem the mass cancellations, President Barack Obama bowed to mounting political pressure and announced a reprieve that allows insurance companies to renew existing policies for another year. That attempted fix has not been so straightforward, however. Many insurers were reluctant to reissue cancelled policies, and multiple states, which have the authority to regulate insurance sold within their borders, declined the administration’s request.

If, in fact, the exchanges offer good insurance products that the public begins to accept and find that they have good information to make choices, it could affect the prevalence of employer-based insurance.

—Robert Berenson, MD, senior fellow, Urban Institute, Washington, D.C.

The Long View

Despite the intense focus on the first few months of health insurance enrollment, it may take several years before the markets begin to settle and other insurers waiting on the sidelines decide whether to participate. If they eventually succeed, the ACA exchanges could have several long-term consequences.

“If, in fact, the exchanges offer good insurance products that the public begins to accept and find that they have good information to make choices, it could affect the prevalence of employer-based insurance,” says Robert Berenson, MD, a senior fellow at the Washington, D.C.-based Urban Institute, a nonpartisan think tank focused on social and economic policy. Over many years, employers could begin moving their employees into exchanges rather than providing direct healthcare benefits.

If they prove viable, the exchanges also may help accelerate the trend toward more consolidation of physician practices or increase pressure to align with larger entities. Despite concerns over skinnier networks, for example, the more tightly controlled access to providers under certain plans dovetails with the ACA’s heightened emphasis on more integrated accountable care organizations (ACOs).

In fact, ACOs and other lower-profile provisions that enjoy more bipartisan support could ultimately play key roles in reshaping how healthcare is delivered in the U.S. Many of these reform efforts have been launched as pilots or demonstration projects. Salt Lake City-based healthcare consulting firm Leavitt Partners tallied nearly 500 ACOs through the end of July 2013, more than double the total in June 2012.

Other Obamacare provisions are levying fines based on excessive hospital-acquired conditions or readmissions and adjusting reimbursements based on e-prescribing, the Physician Quality Reporting System (PQRS), value-based purchasing, meaningful use of electronic health records, and other mandates.

“The overall theme is that the ACA is speeding up the move away from fee-for-service payment toward new payment methodologies that are going to be increasingly based on quality measures,” Dr. O’Malley says. “All of these are basically efforts to shift incentives away from rewarding volume of services toward value and quality of care for patients. And the crux of all of them is to try to get physicians to work together, not only with other specialists and their primary care colleagues, but also with other inter-professional members of their team.”

For hospitalists, it means relying more on nurses, physician assistants, and other support staff.

“In a collaborative agreement, where it’s a physician-led healthcare team, I think non-physician healthcare providers could help to support the physician hospitalists,” Dr. Lenchus says.

That extra help may be essential.

“I do think the workload will increase, and not just because we’ll have more people clamoring for healthcare and more patients who are sicker—remember, there are no more pre-existing conditions,” Dr. Lenchus says. “The other piece to this that goes outside the patient-physician interaction is that there’s a lot of additional regulations and administrative burdens, if you will, as individual hospitalists and as hospitals on the whole.”

The need to share resources to cut down on doctors’ workloads, Dr. O’Malley says, may be yet another factor in the accelerated rate of practice consolidation.

“There’s pressure among docs not just to function as teams but to consolidate among themselves either through physicians’ organizations like IPAs [independent practice associations] or becoming employees of hospitals,” she says. “That’s where you get economies of scale and shared infrastructure to do a lot of the things that the ACA is requiring of them.”

Consolidation or not, she sees plenty of potential for increased efficiency. Some medical groups may need to hire more support staff, whereas others may simply require more coordination and delegation among existing personnel to lighten the load and focus on priorities. The trick, Dr. Hilger says, is finding the right balance amid the dramatic change.

“Bottom line, it goes back to the triple aim that hospitalists should be aiming for: high quality, low-cost, patient-centered care,” he says. “I think the challenge over the next 10 years is how to find the sweet spot between all of those.”

Bryn Nelson is a freelance medical writer in Seattle.

Dr. O’Malley

It has survived a bitterly divided Congress and a polarized public, a narrow Supreme Court ruling, and a 16-day government shutdown triggered by an effort to defund or repeal it. Hailed by some as the most significant healthcare reform in a half-century, it is also roundly scorned by others as an ill-advised debacle.

With some of its most hotly contested provisions now taking effect, the Affordable Care Act—or Obamacare, as both backers and detractors now call it—has been the object of admiration and animosity, of optimism and consternation. Its supporters have pointed to the promise of unprecedented access to healthcare for millions, while its critics have pointed to the trickle of consumers able to access the main web portal during an error-plagued rollout.

Beyond the heated rhetoric, however, what will the complicated and quickly evolving elements of Obamacare actually mean for hospitalists and for healthcare access, affordability, capacity, and delivery? In the short term, analysts say so much change is happening all at once that it’s nearly impossible to predict how it might turn out.

“Everyone’s kind of holding their breath to see what happens,” says Ann O’Malley, MD, MPH, a senior fellow at the Washington, D.C.-based Center for Studying Health System Change.

One thing is certain: more reliance on hospital-based providers.

Dr. O’Malley

“I think there are a lot of things on a hospitalist’s plate right now. And hospitals, because of the cost pressures, are definitely looking to us to lead the way through this uncertain time,” says Rick Hilger, MD, SFHM, medical director for care management at Regions Hospital in St. Paul, Minn., and a hospitalist for HealthPartners.

Amid the upheaval, experts are seeing the signs of a few major trends. In the short term, one emerging theme is considerable geographical variation in consumer access and costs, and in pressure on providers.

“How this is going to feel will depend, to a great extent, on where you live,” says Leighton Ku, PhD, MPH, director of the Center for Health Policy Research at George Washington University School of Public Health and Health Services in Washington, D.C.

Dr. Ku

Analysts also have seen hints of more universal changes, including an accelerated trend toward the consolidation of provider groups, an added emphasis on team-based care, and significant momentum toward a pay-for-performance delivery model.

An Uneven Exchange

One of the law’s most visible and controversial elements, the health insurance exchange or marketplace, got off to a rocky start Oct. 1, 2013, when computer glitches hobbled the main healthcare.gov portal for 36 state exchanges and plagued many state-run sites as well.

While some state-run exchanges have generally earned high marks, others have struggled. Analysts are most worried about the balkiness of the main web-based portal, through which the majority of enrollees will have to pass. While older and sicker patients are generally more motivated to keep trying, the same isn’t necessarily true for younger and healthier people whose participation will be vital to help balance each state’s risk pool. Analysts sometimes call these people, “young invincibles.” Because they generally seek out care far less often than older consumers, their lower medical costs can help compensate for higher expenditures elsewhere.

If too few sign up, however, a state’s risk pool may be imbalanced toward costlier patients, causing insurance premiums to rise and creating a vicious cycle that destabilizes the market and makes more expensive insurance less attractive to younger people. Economists say the carrot-and-stick approach—offering subsidies to help lower-income people pay for premiums and gradually increasing financial penalties for those who choose not to buy any coverage—is likely to help. Nevertheless, supporters are nervous that malfunctioning exchange sites could cause would-be enrollees to delay or drop out, and, at the end of 2013, a worried Obama administration was scrambling to address the cascade of glitches.

Because the health insurance exchanges were highly controversial already, says Dr. Ku, who sits on the board of the Washington, D.C. Health Benefits Exchange Authority, every problem is likely to be magnified by critics. Although he doesn’t expect “huge changes” in physician payment rates from plans in the exchanges, he says varying degrees of competition could drive down insurers’ prices in some markets.

Doctors also are likely to encounter plenty of confusion among the newly insured, and Dr. Ku hopes educational sessions will help healthcare professionals take more of a leading role in helping patients navigate an often bewildering system.

“One of the most important things that a hospital can do to help in the beginning is to help on the enrollment end of things,” he says. “Help patients who don’t quite understand how to get in, how to use these systems.”

It’s too early to say whether the exchanges can still meet the Congressional Budget Office’s prediction of 7 million enrollees by the end of the 2014 enrollment period (and 13 million by 2015). But analysts say the composition of the risk pool—something that should be clearer this spring—may provide a glimpse into the ACA’s long-term financial viability.

Instead of a consistent pattern across the country, the exchanges will be shaped by local market forces, such as the number of competitors and the extent to which cheaper plans will try to limit access to providers. To minimize their costs, some exchange-based plans are promising in-network hospitals higher patient volumes in exchange for discounted reimbursements. Other hospitals now find themselves excluded from most private plans in favor of cheaper options.

In exchange for lower premiums, some of these insurers are offering “skinny networks” that give consumers more limited provider options.

“A primary objective in the marketplace is to offer the cheapest plan possible, and to do that the insurers are going to look at who are the least expensive providers,” says Christiane Mitchell, director of federal affairs for the Association of American Medical Colleges. Not surprisingly, some of the costliest providers tend to take care of sicker or higher-risk patients.

“It’s a very, very strong concern, and it’s one that we have been very vocal on since the enactment of the Affordable Care Act,” Mitchell says. The association also has expressed concern that lower-income patients buying into the cheapest plans may not have access to the specialty services they need the most. That possibility, she says, increases the importance of navigators helping the newly insured pick out the best plans.

A Question of Access

Another big question is how the healthcare system will accommodate the influx of newly insured. Because hospitals already have been the safety net for many patients lacking access to preventive and primary care, urgent and specialty care may go through a bigger adjustment period, says Dr. Hilger, who sits on SHM’s Public Policy Committee.

The growing provider shortage certainly won’t help. By 2015, the AAMC predicts a shortfall of 63,000 doctors, almost evenly split between primary and specialty care. By 2025, that number is expected to more than double.

Mitchell says the gap between supply and demand is worsening due to the sheer number of baby boomers entering Medicare. At the same time, she says, one in three doctors in the U.S. is now over the age of 60 and nearing retirement age. Whether through Medicaid or the marketplace, the ACA’s coverage expansion will exacerbate the shortages. “It’s not to the level of the boomers entering Medicare, but it certainly is having a major impact on access issues and exacerbating the shortage, again, across specialties,” she says.

Other analysts say the extent of the capacity problem will depend in large part on location.

“The truth is that the extent to which there are enough doctors or enough hospital beds is largely a function of geography,” Dr. Ku says. “So, if you’re in an urban area with lots of teaching hospitals, you probably have enough doctors and you probably have enough hospital beds. If, on the other hand, you’re in a poor, rural area, chances are you don’t.”

As both insurance and demand for healthcare expand, those areas that were having problems already “are going to be stretched even more,” Dr. Ku says.

Meeting demand also means training more doctors, and Mitchell worries about a pipeline that already is underfunded. Although medical school enrollment is at a record high, federal support for residency training has been frozen since 1997, meaning that the funded residency slots may not be sufficient to accommodate future graduates. Further declines in the clinical income that subsidizes training would place additional pressure on the educational mission of teaching hospitals, Mitchell says.

Joshua Lenchus, DO, RPh, FACP, SFHM, associate professor of clinical medicine in the division of hospital medicine at the University of Miami, says existing doctor deficits, the ACA’s new demands, and the growing medical training gap could swirl into a “perfect storm” of access problems. Longer delays in accessing primary and specialty care, in turn, could prevent timely interventions earlier during the course of a disease or condition.

“What it’s going to mean for hospitalists is that we’re going to see—over the short-term, maybe even the next three to five years—a real impact on when patients present, in terms of the acuity of their disease,” Dr. Lenchus says. That means sicker patients in the hospital.

Given the massive changes, observers like Mitchell and Dr. Hilger acknowledge that ironing out the rough spots will take time.

“There’s going to be two steps forward, one step back, but the simple question is: Was it ever OK to have tens of millions of patients who had no insurance or were underinsured and were using the emergency room as their primary care?” Dr. Hilger says. “I think, no matter what your political affiliation, that, in general, the answer is no.”

What it’s going to mean for hospitalists is that we’re going to see—over the short-term, maybe even the next three to five years—a real impact on when patients present, in terms of the acuity of their disease. That means sicker patients in the hospital.

—Joshua Lenchus, DO, RPh, FACP, SFHM, associate professor of clinical medicine, division of hospital medicine, University of Miami, member, SHM Public Policy Committee.

Costs All Over the Map

One of the plan’s biggest goals and part of its name—affordability for those patients—also seems to vary considerably by geography. A recent analysis by The New York Times, for example, found that 58% of all counties served by the federal-run exchanges offer plans from only one or two insurance carriers. The relative lack of competition in many markets has created some huge cost disparities in premiums between neighboring states, and even neighboring counties.

With so many factors influencing costs, both proponents and opponents have found fodder to bolster their case that the law is either making insurance more affordable or sharply increasing premiums. One important consideration, Dr. Ku says, is that all plans must now include 10 “essential health benefits,” such as maternity care and medications, for example, and cannot allow gender to be a rating factor. As a result, he says, the cheapest plans for a relatively healthy young man may cost more now, while costs for a woman or an older person with a chronic condition like diabetes may go down.

Although the new mandates were designed to improve insurance standards, they sparked another firestorm when millions of Americans began receiving policy cancellation notices in 2013. Because many private insurance plans sold to individuals no longer met the ACA’s minimum requirements, insurers began dropping those plans or requiring enrollees to switch to other, often more expensive, ones. In November, in an effort to stem the mass cancellations, President Barack Obama bowed to mounting political pressure and announced a reprieve that allows insurance companies to renew existing policies for another year. That attempted fix has not been so straightforward, however. Many insurers were reluctant to reissue cancelled policies, and multiple states, which have the authority to regulate insurance sold within their borders, declined the administration’s request.

If, in fact, the exchanges offer good insurance products that the public begins to accept and find that they have good information to make choices, it could affect the prevalence of employer-based insurance.

—Robert Berenson, MD, senior fellow, Urban Institute, Washington, D.C.

The Long View

Despite the intense focus on the first few months of health insurance enrollment, it may take several years before the markets begin to settle and other insurers waiting on the sidelines decide whether to participate. If they eventually succeed, the ACA exchanges could have several long-term consequences.

“If, in fact, the exchanges offer good insurance products that the public begins to accept and find that they have good information to make choices, it could affect the prevalence of employer-based insurance,” says Robert Berenson, MD, a senior fellow at the Washington, D.C.-based Urban Institute, a nonpartisan think tank focused on social and economic policy. Over many years, employers could begin moving their employees into exchanges rather than providing direct healthcare benefits.

If they prove viable, the exchanges also may help accelerate the trend toward more consolidation of physician practices or increase pressure to align with larger entities. Despite concerns over skinnier networks, for example, the more tightly controlled access to providers under certain plans dovetails with the ACA’s heightened emphasis on more integrated accountable care organizations (ACOs).

In fact, ACOs and other lower-profile provisions that enjoy more bipartisan support could ultimately play key roles in reshaping how healthcare is delivered in the U.S. Many of these reform efforts have been launched as pilots or demonstration projects. Salt Lake City-based healthcare consulting firm Leavitt Partners tallied nearly 500 ACOs through the end of July 2013, more than double the total in June 2012.

Other Obamacare provisions are levying fines based on excessive hospital-acquired conditions or readmissions and adjusting reimbursements based on e-prescribing, the Physician Quality Reporting System (PQRS), value-based purchasing, meaningful use of electronic health records, and other mandates.

“The overall theme is that the ACA is speeding up the move away from fee-for-service payment toward new payment methodologies that are going to be increasingly based on quality measures,” Dr. O’Malley says. “All of these are basically efforts to shift incentives away from rewarding volume of services toward value and quality of care for patients. And the crux of all of them is to try to get physicians to work together, not only with other specialists and their primary care colleagues, but also with other inter-professional members of their team.”

For hospitalists, it means relying more on nurses, physician assistants, and other support staff.

“In a collaborative agreement, where it’s a physician-led healthcare team, I think non-physician healthcare providers could help to support the physician hospitalists,” Dr. Lenchus says.

That extra help may be essential.

“I do think the workload will increase, and not just because we’ll have more people clamoring for healthcare and more patients who are sicker—remember, there are no more pre-existing conditions,” Dr. Lenchus says. “The other piece to this that goes outside the patient-physician interaction is that there’s a lot of additional regulations and administrative burdens, if you will, as individual hospitalists and as hospitals on the whole.”

The need to share resources to cut down on doctors’ workloads, Dr. O’Malley says, may be yet another factor in the accelerated rate of practice consolidation.

“There’s pressure among docs not just to function as teams but to consolidate among themselves either through physicians’ organizations like IPAs [independent practice associations] or becoming employees of hospitals,” she says. “That’s where you get economies of scale and shared infrastructure to do a lot of the things that the ACA is requiring of them.”

Consolidation or not, she sees plenty of potential for increased efficiency. Some medical groups may need to hire more support staff, whereas others may simply require more coordination and delegation among existing personnel to lighten the load and focus on priorities. The trick, Dr. Hilger says, is finding the right balance amid the dramatic change.

“Bottom line, it goes back to the triple aim that hospitalists should be aiming for: high quality, low-cost, patient-centered care,” he says. “I think the challenge over the next 10 years is how to find the sweet spot between all of those.”

Bryn Nelson is a freelance medical writer in Seattle.

Dr. O’Malley

It has survived a bitterly divided Congress and a polarized public, a narrow Supreme Court ruling, and a 16-day government shutdown triggered by an effort to defund or repeal it. Hailed by some as the most significant healthcare reform in a half-century, it is also roundly scorned by others as an ill-advised debacle.

With some of its most hotly contested provisions now taking effect, the Affordable Care Act—or Obamacare, as both backers and detractors now call it—has been the object of admiration and animosity, of optimism and consternation. Its supporters have pointed to the promise of unprecedented access to healthcare for millions, while its critics have pointed to the trickle of consumers able to access the main web portal during an error-plagued rollout.

Beyond the heated rhetoric, however, what will the complicated and quickly evolving elements of Obamacare actually mean for hospitalists and for healthcare access, affordability, capacity, and delivery? In the short term, analysts say so much change is happening all at once that it’s nearly impossible to predict how it might turn out.

“Everyone’s kind of holding their breath to see what happens,” says Ann O’Malley, MD, MPH, a senior fellow at the Washington, D.C.-based Center for Studying Health System Change.

One thing is certain: more reliance on hospital-based providers.

Dr. O’Malley

“I think there are a lot of things on a hospitalist’s plate right now. And hospitals, because of the cost pressures, are definitely looking to us to lead the way through this uncertain time,” says Rick Hilger, MD, SFHM, medical director for care management at Regions Hospital in St. Paul, Minn., and a hospitalist for HealthPartners.

Amid the upheaval, experts are seeing the signs of a few major trends. In the short term, one emerging theme is considerable geographical variation in consumer access and costs, and in pressure on providers.

“How this is going to feel will depend, to a great extent, on where you live,” says Leighton Ku, PhD, MPH, director of the Center for Health Policy Research at George Washington University School of Public Health and Health Services in Washington, D.C.

Dr. Ku

Analysts also have seen hints of more universal changes, including an accelerated trend toward the consolidation of provider groups, an added emphasis on team-based care, and significant momentum toward a pay-for-performance delivery model.

An Uneven Exchange

One of the law’s most visible and controversial elements, the health insurance exchange or marketplace, got off to a rocky start Oct. 1, 2013, when computer glitches hobbled the main healthcare.gov portal for 36 state exchanges and plagued many state-run sites as well.

While some state-run exchanges have generally earned high marks, others have struggled. Analysts are most worried about the balkiness of the main web-based portal, through which the majority of enrollees will have to pass. While older and sicker patients are generally more motivated to keep trying, the same isn’t necessarily true for younger and healthier people whose participation will be vital to help balance each state’s risk pool. Analysts sometimes call these people, “young invincibles.” Because they generally seek out care far less often than older consumers, their lower medical costs can help compensate for higher expenditures elsewhere.

If too few sign up, however, a state’s risk pool may be imbalanced toward costlier patients, causing insurance premiums to rise and creating a vicious cycle that destabilizes the market and makes more expensive insurance less attractive to younger people. Economists say the carrot-and-stick approach—offering subsidies to help lower-income people pay for premiums and gradually increasing financial penalties for those who choose not to buy any coverage—is likely to help. Nevertheless, supporters are nervous that malfunctioning exchange sites could cause would-be enrollees to delay or drop out, and, at the end of 2013, a worried Obama administration was scrambling to address the cascade of glitches.

Because the health insurance exchanges were highly controversial already, says Dr. Ku, who sits on the board of the Washington, D.C. Health Benefits Exchange Authority, every problem is likely to be magnified by critics. Although he doesn’t expect “huge changes” in physician payment rates from plans in the exchanges, he says varying degrees of competition could drive down insurers’ prices in some markets.

Doctors also are likely to encounter plenty of confusion among the newly insured, and Dr. Ku hopes educational sessions will help healthcare professionals take more of a leading role in helping patients navigate an often bewildering system.

“One of the most important things that a hospital can do to help in the beginning is to help on the enrollment end of things,” he says. “Help patients who don’t quite understand how to get in, how to use these systems.”

It’s too early to say whether the exchanges can still meet the Congressional Budget Office’s prediction of 7 million enrollees by the end of the 2014 enrollment period (and 13 million by 2015). But analysts say the composition of the risk pool—something that should be clearer this spring—may provide a glimpse into the ACA’s long-term financial viability.

Instead of a consistent pattern across the country, the exchanges will be shaped by local market forces, such as the number of competitors and the extent to which cheaper plans will try to limit access to providers. To minimize their costs, some exchange-based plans are promising in-network hospitals higher patient volumes in exchange for discounted reimbursements. Other hospitals now find themselves excluded from most private plans in favor of cheaper options.

In exchange for lower premiums, some of these insurers are offering “skinny networks” that give consumers more limited provider options.

“A primary objective in the marketplace is to offer the cheapest plan possible, and to do that the insurers are going to look at who are the least expensive providers,” says Christiane Mitchell, director of federal affairs for the Association of American Medical Colleges. Not surprisingly, some of the costliest providers tend to take care of sicker or higher-risk patients.

“It’s a very, very strong concern, and it’s one that we have been very vocal on since the enactment of the Affordable Care Act,” Mitchell says. The association also has expressed concern that lower-income patients buying into the cheapest plans may not have access to the specialty services they need the most. That possibility, she says, increases the importance of navigators helping the newly insured pick out the best plans.

A Question of Access

Another big question is how the healthcare system will accommodate the influx of newly insured. Because hospitals already have been the safety net for many patients lacking access to preventive and primary care, urgent and specialty care may go through a bigger adjustment period, says Dr. Hilger, who sits on SHM’s Public Policy Committee.

The growing provider shortage certainly won’t help. By 2015, the AAMC predicts a shortfall of 63,000 doctors, almost evenly split between primary and specialty care. By 2025, that number is expected to more than double.

Mitchell says the gap between supply and demand is worsening due to the sheer number of baby boomers entering Medicare. At the same time, she says, one in three doctors in the U.S. is now over the age of 60 and nearing retirement age. Whether through Medicaid or the marketplace, the ACA’s coverage expansion will exacerbate the shortages. “It’s not to the level of the boomers entering Medicare, but it certainly is having a major impact on access issues and exacerbating the shortage, again, across specialties,” she says.

Other analysts say the extent of the capacity problem will depend in large part on location.

“The truth is that the extent to which there are enough doctors or enough hospital beds is largely a function of geography,” Dr. Ku says. “So, if you’re in an urban area with lots of teaching hospitals, you probably have enough doctors and you probably have enough hospital beds. If, on the other hand, you’re in a poor, rural area, chances are you don’t.”

As both insurance and demand for healthcare expand, those areas that were having problems already “are going to be stretched even more,” Dr. Ku says.

Meeting demand also means training more doctors, and Mitchell worries about a pipeline that already is underfunded. Although medical school enrollment is at a record high, federal support for residency training has been frozen since 1997, meaning that the funded residency slots may not be sufficient to accommodate future graduates. Further declines in the clinical income that subsidizes training would place additional pressure on the educational mission of teaching hospitals, Mitchell says.

Joshua Lenchus, DO, RPh, FACP, SFHM, associate professor of clinical medicine in the division of hospital medicine at the University of Miami, says existing doctor deficits, the ACA’s new demands, and the growing medical training gap could swirl into a “perfect storm” of access problems. Longer delays in accessing primary and specialty care, in turn, could prevent timely interventions earlier during the course of a disease or condition.

“What it’s going to mean for hospitalists is that we’re going to see—over the short-term, maybe even the next three to five years—a real impact on when patients present, in terms of the acuity of their disease,” Dr. Lenchus says. That means sicker patients in the hospital.

Given the massive changes, observers like Mitchell and Dr. Hilger acknowledge that ironing out the rough spots will take time.

“There’s going to be two steps forward, one step back, but the simple question is: Was it ever OK to have tens of millions of patients who had no insurance or were underinsured and were using the emergency room as their primary care?” Dr. Hilger says. “I think, no matter what your political affiliation, that, in general, the answer is no.”

What it’s going to mean for hospitalists is that we’re going to see—over the short-term, maybe even the next three to five years—a real impact on when patients present, in terms of the acuity of their disease. That means sicker patients in the hospital.

—Joshua Lenchus, DO, RPh, FACP, SFHM, associate professor of clinical medicine, division of hospital medicine, University of Miami, member, SHM Public Policy Committee.

Costs All Over the Map

One of the plan’s biggest goals and part of its name—affordability for those patients—also seems to vary considerably by geography. A recent analysis by The New York Times, for example, found that 58% of all counties served by the federal-run exchanges offer plans from only one or two insurance carriers. The relative lack of competition in many markets has created some huge cost disparities in premiums between neighboring states, and even neighboring counties.

With so many factors influencing costs, both proponents and opponents have found fodder to bolster their case that the law is either making insurance more affordable or sharply increasing premiums. One important consideration, Dr. Ku says, is that all plans must now include 10 “essential health benefits,” such as maternity care and medications, for example, and cannot allow gender to be a rating factor. As a result, he says, the cheapest plans for a relatively healthy young man may cost more now, while costs for a woman or an older person with a chronic condition like diabetes may go down.

Although the new mandates were designed to improve insurance standards, they sparked another firestorm when millions of Americans began receiving policy cancellation notices in 2013. Because many private insurance plans sold to individuals no longer met the ACA’s minimum requirements, insurers began dropping those plans or requiring enrollees to switch to other, often more expensive, ones. In November, in an effort to stem the mass cancellations, President Barack Obama bowed to mounting political pressure and announced a reprieve that allows insurance companies to renew existing policies for another year. That attempted fix has not been so straightforward, however. Many insurers were reluctant to reissue cancelled policies, and multiple states, which have the authority to regulate insurance sold within their borders, declined the administration’s request.

If, in fact, the exchanges offer good insurance products that the public begins to accept and find that they have good information to make choices, it could affect the prevalence of employer-based insurance.

—Robert Berenson, MD, senior fellow, Urban Institute, Washington, D.C.

The Long View

Despite the intense focus on the first few months of health insurance enrollment, it may take several years before the markets begin to settle and other insurers waiting on the sidelines decide whether to participate. If they eventually succeed, the ACA exchanges could have several long-term consequences.

“If, in fact, the exchanges offer good insurance products that the public begins to accept and find that they have good information to make choices, it could affect the prevalence of employer-based insurance,” says Robert Berenson, MD, a senior fellow at the Washington, D.C.-based Urban Institute, a nonpartisan think tank focused on social and economic policy. Over many years, employers could begin moving their employees into exchanges rather than providing direct healthcare benefits.

If they prove viable, the exchanges also may help accelerate the trend toward more consolidation of physician practices or increase pressure to align with larger entities. Despite concerns over skinnier networks, for example, the more tightly controlled access to providers under certain plans dovetails with the ACA’s heightened emphasis on more integrated accountable care organizations (ACOs).

In fact, ACOs and other lower-profile provisions that enjoy more bipartisan support could ultimately play key roles in reshaping how healthcare is delivered in the U.S. Many of these reform efforts have been launched as pilots or demonstration projects. Salt Lake City-based healthcare consulting firm Leavitt Partners tallied nearly 500 ACOs through the end of July 2013, more than double the total in June 2012.

Other Obamacare provisions are levying fines based on excessive hospital-acquired conditions or readmissions and adjusting reimbursements based on e-prescribing, the Physician Quality Reporting System (PQRS), value-based purchasing, meaningful use of electronic health records, and other mandates.

“The overall theme is that the ACA is speeding up the move away from fee-for-service payment toward new payment methodologies that are going to be increasingly based on quality measures,” Dr. O’Malley says. “All of these are basically efforts to shift incentives away from rewarding volume of services toward value and quality of care for patients. And the crux of all of them is to try to get physicians to work together, not only with other specialists and their primary care colleagues, but also with other inter-professional members of their team.”

For hospitalists, it means relying more on nurses, physician assistants, and other support staff.

“In a collaborative agreement, where it’s a physician-led healthcare team, I think non-physician healthcare providers could help to support the physician hospitalists,” Dr. Lenchus says.

That extra help may be essential.

“I do think the workload will increase, and not just because we’ll have more people clamoring for healthcare and more patients who are sicker—remember, there are no more pre-existing conditions,” Dr. Lenchus says. “The other piece to this that goes outside the patient-physician interaction is that there’s a lot of additional regulations and administrative burdens, if you will, as individual hospitalists and as hospitals on the whole.”

The need to share resources to cut down on doctors’ workloads, Dr. O’Malley says, may be yet another factor in the accelerated rate of practice consolidation.

“There’s pressure among docs not just to function as teams but to consolidate among themselves either through physicians’ organizations like IPAs [independent practice associations] or becoming employees of hospitals,” she says. “That’s where you get economies of scale and shared infrastructure to do a lot of the things that the ACA is requiring of them.”

Consolidation or not, she sees plenty of potential for increased efficiency. Some medical groups may need to hire more support staff, whereas others may simply require more coordination and delegation among existing personnel to lighten the load and focus on priorities. The trick, Dr. Hilger says, is finding the right balance amid the dramatic change.

“Bottom line, it goes back to the triple aim that hospitalists should be aiming for: high quality, low-cost, patient-centered care,” he says. “I think the challenge over the next 10 years is how to find the sweet spot between all of those.”

Bryn Nelson is a freelance medical writer in Seattle.

Click here to listen to more of our interview with Paul Roscoe, CEO of the Washington, D.C.-based Advisory Board Company

Click here to listen to more of our interview with Paul Roscoe, CEO of the Washington, D.C.-based Advisory Board Company

Click here to listen to more of our interview with Paul Roscoe, CEO of the Washington, D.C.-based Advisory Board Company

Click here to listen to excerpts of our interview with Dr. Deitelzweig, chair of SHM’s Practice Analysis Committee.

Click here to listen to excerpts of our interview with Dr. Deitelzweig, chair of SHM’s Practice Analysis Committee.

Click here to listen to excerpts of our interview with Dr. Deitelzweig, chair of SHM’s Practice Analysis Committee.

Ensuring data quality and equivalency can present major challenges in data analytics, especially given the field’s dearth of uniform standards.

“The joke is that the great thing about health-care data standards is that there’s so many to choose from,” says Brett Davis, general manager of Deloitte Health Informatics. If data integration remains a big challenge, however, Davis says the cost and complexity of the technology is dropping rapidly.

A lack of electronic health records (EHR) can limit more advanced data-mining functions. But that’s no excuse for not exploring the technology, says Steven Deitelzweig, MD, SFHM, system chairman for hospital medicine at Ochsner Health System in New Orleans and chair of SHM’s Practice Analysis Committee.

Deployment of that partial prerequisite also seems to be happening quickly around the country. The Office of the National Coordinator for Health IT (ONC) estimates that hospital adoption of at least a basic EHR system more than tripled between 2009 and 2012, to 44% from 12%. Meanwhile, an estimated 85% of hospitals were at least in possession of certified EHR technology by 2012.

Despite the falling barriers, Davis cautions that users should have clear goals in mind when setting up a new system. “There is the risk of building bridges to nowhere, where you just integrate data for the sake of integrating data but not knowing what questions and insights you want to glean from it,” he says.

ONC spokesman Peter Ashkenaz agrees, citing governance within a hospital or health center and education of all participants as important elements of any data-analytics plan. Among the questions that must be addressed, he says, are these: “Have we collected the right information? Are we doing so efficiently and securely with respect to privacy requirements? Are we sharing the data with the appropriate parties? Are we doing so in a way that is easily understood? Are we asking the right questions about how to use the information?”

The most fundamental question, Dr. Deitelzweig says, may be whether a hospitalist group, hospital, or health system is truly committed to using the technology. “If you’re going to make the investment in such things, then you really better be dedicated to understanding them and how best to utilize them. And give it some time,” he says. “I think people want solutions fast, and often they don’t take the time to individualize it or customize it.” TH

Bryn Nelson is a freelance medical writer in Seattle.

Ensuring data quality and equivalency can present major challenges in data analytics, especially given the field’s dearth of uniform standards.

“The joke is that the great thing about health-care data standards is that there’s so many to choose from,” says Brett Davis, general manager of Deloitte Health Informatics. If data integration remains a big challenge, however, Davis says the cost and complexity of the technology is dropping rapidly.

A lack of electronic health records (EHR) can limit more advanced data-mining functions. But that’s no excuse for not exploring the technology, says Steven Deitelzweig, MD, SFHM, system chairman for hospital medicine at Ochsner Health System in New Orleans and chair of SHM’s Practice Analysis Committee.

Deployment of that partial prerequisite also seems to be happening quickly around the country. The Office of the National Coordinator for Health IT (ONC) estimates that hospital adoption of at least a basic EHR system more than tripled between 2009 and 2012, to 44% from 12%. Meanwhile, an estimated 85% of hospitals were at least in possession of certified EHR technology by 2012.

Despite the falling barriers, Davis cautions that users should have clear goals in mind when setting up a new system. “There is the risk of building bridges to nowhere, where you just integrate data for the sake of integrating data but not knowing what questions and insights you want to glean from it,” he says.

ONC spokesman Peter Ashkenaz agrees, citing governance within a hospital or health center and education of all participants as important elements of any data-analytics plan. Among the questions that must be addressed, he says, are these: “Have we collected the right information? Are we doing so efficiently and securely with respect to privacy requirements? Are we sharing the data with the appropriate parties? Are we doing so in a way that is easily understood? Are we asking the right questions about how to use the information?”

The most fundamental question, Dr. Deitelzweig says, may be whether a hospitalist group, hospital, or health system is truly committed to using the technology. “If you’re going to make the investment in such things, then you really better be dedicated to understanding them and how best to utilize them. And give it some time,” he says. “I think people want solutions fast, and often they don’t take the time to individualize it or customize it.” TH

Bryn Nelson is a freelance medical writer in Seattle.

Ensuring data quality and equivalency can present major challenges in data analytics, especially given the field’s dearth of uniform standards.

“The joke is that the great thing about health-care data standards is that there’s so many to choose from,” says Brett Davis, general manager of Deloitte Health Informatics. If data integration remains a big challenge, however, Davis says the cost and complexity of the technology is dropping rapidly.

A lack of electronic health records (EHR) can limit more advanced data-mining functions. But that’s no excuse for not exploring the technology, says Steven Deitelzweig, MD, SFHM, system chairman for hospital medicine at Ochsner Health System in New Orleans and chair of SHM’s Practice Analysis Committee.

Deployment of that partial prerequisite also seems to be happening quickly around the country. The Office of the National Coordinator for Health IT (ONC) estimates that hospital adoption of at least a basic EHR system more than tripled between 2009 and 2012, to 44% from 12%. Meanwhile, an estimated 85% of hospitals were at least in possession of certified EHR technology by 2012.

Despite the falling barriers, Davis cautions that users should have clear goals in mind when setting up a new system. “There is the risk of building bridges to nowhere, where you just integrate data for the sake of integrating data but not knowing what questions and insights you want to glean from it,” he says.

ONC spokesman Peter Ashkenaz agrees, citing governance within a hospital or health center and education of all participants as important elements of any data-analytics plan. Among the questions that must be addressed, he says, are these: “Have we collected the right information? Are we doing so efficiently and securely with respect to privacy requirements? Are we sharing the data with the appropriate parties? Are we doing so in a way that is easily understood? Are we asking the right questions about how to use the information?”

The most fundamental question, Dr. Deitelzweig says, may be whether a hospitalist group, hospital, or health system is truly committed to using the technology. “If you’re going to make the investment in such things, then you really better be dedicated to understanding them and how best to utilize them. And give it some time,” he says. “I think people want solutions fast, and often they don’t take the time to individualize it or customize it.” TH

Bryn Nelson is a freelance medical writer in Seattle.

In one recently publicized demonstration of data mining’s potential, Austin, Texas-based Seton Healthcare Family used software developed by IBM to pore over doctors’ notes and predict the risk of readmission among patients with congestive heart failure. Among the shortlist of biggest predictors, the analysis pointed to a lack of emotional support and a bulging jugular vein—factors that could be easily identified through inpatient screening but might otherwise be overlooked by staff.

Similarly, New York-Presbyterian Hospital used a system by Microsoft to help reduce the rates of blood clotting in patients through an objective analysis of such risk factors as cancer, smoking, and bed confinement.

In June, Deloitte and Utah-based Intermountain Healthcare announced the launch of OutcomesMiner, an analytics tool that uses electronic health records to ferret out important variations and associations among patient populations. Brett Davis, general manager of Deloitte Health Informatics, says understanding asthma patients who are in different age brackets, have different comorbidities, and are on different drugs, for example, can allow providers to better manage the population. Merely using ICD-9 codes often results in inaccurate patient classifications, he warns. Instead, capturing and analyzing data from medications and clinical encounters can be vital for properly defining an asthma patient and separating the signal from the noise.

In one recently publicized demonstration of data mining’s potential, Austin, Texas-based Seton Healthcare Family used software developed by IBM to pore over doctors’ notes and predict the risk of readmission among patients with congestive heart failure. Among the shortlist of biggest predictors, the analysis pointed to a lack of emotional support and a bulging jugular vein—factors that could be easily identified through inpatient screening but might otherwise be overlooked by staff.

Similarly, New York-Presbyterian Hospital used a system by Microsoft to help reduce the rates of blood clotting in patients through an objective analysis of such risk factors as cancer, smoking, and bed confinement.

In June, Deloitte and Utah-based Intermountain Healthcare announced the launch of OutcomesMiner, an analytics tool that uses electronic health records to ferret out important variations and associations among patient populations. Brett Davis, general manager of Deloitte Health Informatics, says understanding asthma patients who are in different age brackets, have different comorbidities, and are on different drugs, for example, can allow providers to better manage the population. Merely using ICD-9 codes often results in inaccurate patient classifications, he warns. Instead, capturing and analyzing data from medications and clinical encounters can be vital for properly defining an asthma patient and separating the signal from the noise.

In one recently publicized demonstration of data mining’s potential, Austin, Texas-based Seton Healthcare Family used software developed by IBM to pore over doctors’ notes and predict the risk of readmission among patients with congestive heart failure. Among the shortlist of biggest predictors, the analysis pointed to a lack of emotional support and a bulging jugular vein—factors that could be easily identified through inpatient screening but might otherwise be overlooked by staff.

Similarly, New York-Presbyterian Hospital used a system by Microsoft to help reduce the rates of blood clotting in patients through an objective analysis of such risk factors as cancer, smoking, and bed confinement.

In June, Deloitte and Utah-based Intermountain Healthcare announced the launch of OutcomesMiner, an analytics tool that uses electronic health records to ferret out important variations and associations among patient populations. Brett Davis, general manager of Deloitte Health Informatics, says understanding asthma patients who are in different age brackets, have different comorbidities, and are on different drugs, for example, can allow providers to better manage the population. Merely using ICD-9 codes often results in inaccurate patient classifications, he warns. Instead, capturing and analyzing data from medications and clinical encounters can be vital for properly defining an asthma patient and separating the signal from the noise.

One hospital wanted to reduce readmissions among patients with congestive heart failure. Another hoped to improve upon its sepsis mortality rates. A third sought to determine whether its doctors were providing cost-effective care for pneumonia patients. All of them adopted the same type of technology to help identify a solution.

As the healthcare industry tilts toward accountable care, pay for performance and an increasingly

cost-conscious mindset, hospitalists and other providers are tapping into a fast-growing analytical tool collectively known as data mining to help make sense of the growing mounds of information. Although no single technology can be considered a cure-all, HM leaders are so optimistic about data mining’s potential to address cost, outcome, and performance issues that some have labeled it a “game changer” for hospitalists.

Karim Godamunne, MD, MBA, SFHM, chief medical officer at North Fulton Hospital in Roswell, Ga., and a member of SHM’s Practice Management Committee, says he can’t overstate the importance of hospitalists’ involvement in physician data mining. “From my perspective, we’re looking to hospitalists to help drive this quality-utilization bandwagon, to be the real leaders in it,” he says. With the tremendous value that can be generated through understanding and using the information, “it’s good for your group and can be good to your hospital as a whole.”

So what is data mining? The technology fully emerged in the mid-1990s as a way to help scientists analyze large and often disparate bodies of data, present relevant information in new ways, and illuminate previously unknown relationships.¹ In the healthcare industry, early adopters realized that the insights gleaned from data mining could help inform their clinical decision-making; organizations used the new tools to help predict health insurance fraud and identify at-risk patients, for example.

Cynthia Burghard, research director of Accountable Care IT Strategies at IDC Health Insights in Framingham, Mass., says researchers in academic medical centers initially conducted most of the clinical analytical work. Within the past few years, however, the increasing availability of data has allowed more hospitals to begin analyzing chronic disease, readmissions, and other areas of concern. In addition, Burghard says, new tools based on natural language processing are giving hospitals better access to unstructured clinical data, such as notes written by doctors and nurses.

“What I’m seeing both in my surveys as well as in conversations with hospitals is that analytics is the top of the investment priority for both hospitals and health plans,” Burghard says. According to IDC estimates, total spending for clinical analytics in the U.S. reached $3.7 billion in 2012 and is expected to grow to $5.14 billion by 2016. Much of the growth, she notes, is being driven by healthcare reform. “If your mandate is to manage populations of patients, it behooves you to know who those patients are and what their illnesses are, and to monitor what you’re doing for them,” she says.

Practice Improvement

Accordingly, a major goal of all this data-mining technology is to change practice behavior in a way that achieves the triple aim of improving quality of care, controlling costs, and bettering patient outcomes.

A growing number of companies are releasing tools that can compile and analyze the separate bits of information captured from claims and billing systems, Medicare reporting requirements, internal benchmarks, and other sources. Unlike passive data sources, such as Medicare’s Hospital Compare website, more active analytics can help their users zoom down to the level of an individual doctor or patient, pan out to the level of a hospitalist group, or expand out even more for a broader comparison among peer institutions.

Some newer data-mining tools with names like CRIMSON, Truven, Iodine, and Imagine are billing themselves as hospitalist-friendly performance-improvement aids and giving individual providers the ability to access and analyze the data themselves. A few of these applications can even provide real-time data via mobile devices (see “Physician Performance Aids,”).

Thomas Frederickson, MD, MBA, SFHM, medical director of the HM service at Alegent Creighton Health in Omaha, Neb., and a member of SHM’s Practice Management Committee, sees the biggest potential of this data-mining technology in its ability to help drive practice consistency. “You can use the database to analyze practice patterns of large groups, or even individuals, and see where variability exists,” he says. “And then, based on that, you can analyze why the variability exists and begin to address whether it’s variability that’s clinically indicated or not.”

When Alegent Creighton Health was scrutinizing the care of its pneumonia patients, for example, officials could compare the number of chest X-rays per pneumonia patient by hospital or across the entire CRIMSON database. At a deeper level, the officials could see how often individual providers ordered the tests compared to their peers. For outliers, they could follow up to determine whether the variability was warranted.

As champions of process improvement, Dr. Frederickson says, hospitalists can make particularly good use of database analytics. “It’s part of the process of making hospitalists invaluable to their hospitals and their systems,” he says. “Part of that is building up expertise on process improvement and safety, and familiarity with these kinds of tools is one thing that will help us do that.”

North Fulton Hospital used CRIMSON to analyze how its doctors care for patients with sepsis and to establish new benchmarks. Dr. Godamunne says the tools allowed the hospital to track its doctors’ progress over time and identify potential problems. “If a patient with sepsis is staying too long, you can see who admitted the patient and see if, a few months ago, the same physician was having similar problems,” he says. Similarly, the hospital was able to track the top DRGs resulting in excess length of stay among patients, to identify potential bottlenecks in the care and discharge processes.

Some tools require only two-day training sessions for basic proficiency, though more advanced manipulations often require a bigger commitment, like the 12-week training session that Dr. Godamunne completed. That training included one hour of online learning and one hour of homework every week, and most of the cases highlighted during his coursework, he says, focused on hospitalists—another sign of the major role he believes HM will play in harnessing data to improve performance quality.

You can use the database to analyze practice patterns of large groups, or even individuals, and see where variability exists. And then, based on that, you can analyze why the variability exists and begin to address whether it’s variability that’s clinically indicated or not.

—Thomas Frederickson, MD, MBA, SFHM, medical director, hospital medicine service, Alegent Creighton Health, Omaha, Neb., SHM Practice Management Committee member

Slow—Construction Ahead

The best information is meaningful, individualized, and timely, says Steven Deitelzweig, MD, SFHM, system chairman for hospital medicine and medical director of regional business development at Ochsner Health System in New Orleans. “If you get something back six months after you’ve delivered the care, you’ll have a limited opportunity to improve, versus if you get it back in a week or two, or ideally, in real time,” says Dr. Deitelzweig, chair of SHM’s Practice Management Committee.

In examining length of stay, Dr. Deitelzweig says doctors could use data mining to look at time-stamped elements of patient flow and the timeliness of provider response: how patients go through the ED, and when they receive written orders or lab results. “It could be really powerful, and right now it’s a little bit of a black hole,” he says.

Based on her conversations with hospital executives and leaders, however, Burghard cautions that some real-time mobile applications, although technologically impressive, may be less useful or necessary in practice. “If it’s performance measurement, why do you need that in real time? It’s not going to change your behavior in the moment,” she says. “What you may want to get is an alert that your patient, who is in the hospital, has had some sort of negative event.”

Data mining has other potential limitations. “There’s always going to be questions of attribution, and you need to have clinical knowledge of your location,” Dr. Godamunne says. And data mining is only as good as the data that have been documented, underscoring the importance of securing provider cooperation.

Dr. Frederickson says physician acceptance, in fact, might be one of the biggest obstacles—a major reason why he recommends introducing the technology slowly and explaining why and how it will be used. If introduced too quickly and without adequate explanation about what a hospital or health system hopes to accomplish, he says, “there certainly is the potential for suspicion.” The key, he says, is to emphasize that the tools provide a valuable mechanism for gleaning new insights into doctors’ practice patterns, “not something that’s going to be used against them.”

Paul Roscoe, CEO of the Washington, D.C.-based Advisory Board Company's Crimson division, agrees that personally engaging physicians is essential for a good return on investment in analytical tools like his company’s suite of CRIMSON products. “If you can’t work with the physicians to get them to understand the data and actively use the data in their practice patterns, it becomes a bit meaningless,” he says.

We’re looking to hospitalists to help drive this quality utilization bandwagon, to be the real leaders in it.…It’s good for your group and can be good to your hospital as a whole.

—Karim Godamunne, MD, MBA, SFHM, chief medical officer, North Fulton Hospital, Roswell, Ga., SHM Practice Management Committee member

Roscoe sees big opportunities in prospectively examining information while a patient is still in the hospital and when a change of course by providers could avert a bad outcome. “Suggesting a set of interventions that they could do differently is really the value-add,” he says. But he cautions that those suggestions must be worded carefully to avoid alienating physicians.

“If doctors don’t feel like they’re being judged, they’ll engage with you,” Roscoe says.

Similar nuances can affect how users perceive the tools themselves. After hearing feedback from members that the words “data mining” didn’t conjure trust and confidence, the Advisory Board Company dropped the phrase altogether in favor of “data analytics,” “physician engagement,” and similar descriptors. “It’s simple things like that that can very quickly either turn a physician on or off,” Roscoe says.

Once users take the time to understand data-mining tools and how they can be properly harnessed, advocates say, the technology can lead to a host of unanticipated benefits. When a hospital bills the federal government for a Medicare patient, for example, it must submit an HCC code that describes the patient’s condition. By doing a better job of mining the data, Burghard says, a hospital can more accurately reflect that patient’s contdition. For example, if a hospital is treating a diabetic who comes in with a broken leg, the hospital could receive a lower payment rate if it does not properly identify and record both conditions.

And by using the tools prospectively, Burghard says, “I think there’s the opportunity to make a quantum leap from what we’re doing today. We usually just report on facts, and usually retrospectively. With some of the new technology that’s available, the healthcare industry can begin to do discovery analytics—you’re identifying insights, patterns, and relationships.”

Better integration of computerized physician order entry with data-mining ports, Dr. Godamunne predicts, will allow for much better attribution and finer parsing of the data. As the transparency increases, though, hospitalists will have to adapt to a new reality in which stronger analytical tools may point out individual outliers. And that level of detail, in turn, will require some hospitalists to justify why they’re different than their peers.

Even so, Roscoe says, he’s found that hospitalists are very open to using data to improve performance and that they make up a high percentage of CRIMSON users. “There isn’t a physician group that is in a better position to help drive this quality- and data-driven culture,” he says.

Bryn Nelson is a freelance medical writer in Seattle.

Physician Performance Aids

Company: The Advisory Board Company

Sample product: CRIMSON Continuum of Care

Claim: “Places credible, severity-adjusted performance profiles directly in the hands of physicians, enabling the hospital-physician collaboration needed to advance quality goals and secure cost savings.”

Number of users: More than 850 hospitals

Real-time data? No, but available as add-on service

To learn more: www.advisory.com/Technology/Crimson-Continuum-of-Care

Company: Panacea Developments

Sample product: Iodine

Claim: “An easy-to-use mobile system that analyzes a hospital’s sea of data for knowledge that physicians, case managers, and documentation specialists can act upon to improve length-of-stay, readmissions, and documentation.”

Number of users: More than 50 hospitals

Real-time data? Yes

To learn more: www.panaceadevelopments.com/iodine

Company: Truven Health

Sample product: CareDiscovery

Claim: “Provides powerful insights into a hospital’s or health system’s quality measures and resource utilization to support improvement with objective, fact-based information.”

Real-time data? No

Number of users: More than 3,000 users in 400 hospitals

To learn more: http://truvenhealth.com/products/carediscovery

Company: Ingenious Med

Sample product: Imagine

Claim: “A comprehensive analytics dashboard platform that provides actionable decision making data to optimize physician performance and revenue.”

Real-time data? Yes

Number of users: 25,000 total users (not separated by individual products)

To learn more: http://ingeniousmed.com/what-we-do/imagine

Reference

1. Yoo I, Alafaireet P, Marinov M, et al. Data mining in healthcare and biomedicine: a survey of the literature. J Med Syst. 2012;36:2431-2448.

One hospital wanted to reduce readmissions among patients with congestive heart failure. Another hoped to improve upon its sepsis mortality rates. A third sought to determine whether its doctors were providing cost-effective care for pneumonia patients. All of them adopted the same type of technology to help identify a solution.

As the healthcare industry tilts toward accountable care, pay for performance and an increasingly

cost-conscious mindset, hospitalists and other providers are tapping into a fast-growing analytical tool collectively known as data mining to help make sense of the growing mounds of information. Although no single technology can be considered a cure-all, HM leaders are so optimistic about data mining’s potential to address cost, outcome, and performance issues that some have labeled it a “game changer” for hospitalists.

Karim Godamunne, MD, MBA, SFHM, chief medical officer at North Fulton Hospital in Roswell, Ga., and a member of SHM’s Practice Management Committee, says he can’t overstate the importance of hospitalists’ involvement in physician data mining. “From my perspective, we’re looking to hospitalists to help drive this quality-utilization bandwagon, to be the real leaders in it,” he says. With the tremendous value that can be generated through understanding and using the information, “it’s good for your group and can be good to your hospital as a whole.”

So what is data mining? The technology fully emerged in the mid-1990s as a way to help scientists analyze large and often disparate bodies of data, present relevant information in new ways, and illuminate previously unknown relationships.¹ In the healthcare industry, early adopters realized that the insights gleaned from data mining could help inform their clinical decision-making; organizations used the new tools to help predict health insurance fraud and identify at-risk patients, for example.

Cynthia Burghard, research director of Accountable Care IT Strategies at IDC Health Insights in Framingham, Mass., says researchers in academic medical centers initially conducted most of the clinical analytical work. Within the past few years, however, the increasing availability of data has allowed more hospitals to begin analyzing chronic disease, readmissions, and other areas of concern. In addition, Burghard says, new tools based on natural language processing are giving hospitals better access to unstructured clinical data, such as notes written by doctors and nurses.

“What I’m seeing both in my surveys as well as in conversations with hospitals is that analytics is the top of the investment priority for both hospitals and health plans,” Burghard says. According to IDC estimates, total spending for clinical analytics in the U.S. reached $3.7 billion in 2012 and is expected to grow to $5.14 billion by 2016. Much of the growth, she notes, is being driven by healthcare reform. “If your mandate is to manage populations of patients, it behooves you to know who those patients are and what their illnesses are, and to monitor what you’re doing for them,” she says.

Practice Improvement

Accordingly, a major goal of all this data-mining technology is to change practice behavior in a way that achieves the triple aim of improving quality of care, controlling costs, and bettering patient outcomes.

A growing number of companies are releasing tools that can compile and analyze the separate bits of information captured from claims and billing systems, Medicare reporting requirements, internal benchmarks, and other sources. Unlike passive data sources, such as Medicare’s Hospital Compare website, more active analytics can help their users zoom down to the level of an individual doctor or patient, pan out to the level of a hospitalist group, or expand out even more for a broader comparison among peer institutions.

Some newer data-mining tools with names like CRIMSON, Truven, Iodine, and Imagine are billing themselves as hospitalist-friendly performance-improvement aids and giving individual providers the ability to access and analyze the data themselves. A few of these applications can even provide real-time data via mobile devices (see “Physician Performance Aids,”).

Thomas Frederickson, MD, MBA, SFHM, medical director of the HM service at Alegent Creighton Health in Omaha, Neb., and a member of SHM’s Practice Management Committee, sees the biggest potential of this data-mining technology in its ability to help drive practice consistency. “You can use the database to analyze practice patterns of large groups, or even individuals, and see where variability exists,” he says. “And then, based on that, you can analyze why the variability exists and begin to address whether it’s variability that’s clinically indicated or not.”

When Alegent Creighton Health was scrutinizing the care of its pneumonia patients, for example, officials could compare the number of chest X-rays per pneumonia patient by hospital or across the entire CRIMSON database. At a deeper level, the officials could see how often individual providers ordered the tests compared to their peers. For outliers, they could follow up to determine whether the variability was warranted.

As champions of process improvement, Dr. Frederickson says, hospitalists can make particularly good use of database analytics. “It’s part of the process of making hospitalists invaluable to their hospitals and their systems,” he says. “Part of that is building up expertise on process improvement and safety, and familiarity with these kinds of tools is one thing that will help us do that.”

North Fulton Hospital used CRIMSON to analyze how its doctors care for patients with sepsis and to establish new benchmarks. Dr. Godamunne says the tools allowed the hospital to track its doctors’ progress over time and identify potential problems. “If a patient with sepsis is staying too long, you can see who admitted the patient and see if, a few months ago, the same physician was having similar problems,” he says. Similarly, the hospital was able to track the top DRGs resulting in excess length of stay among patients, to identify potential bottlenecks in the care and discharge processes.

Some tools require only two-day training sessions for basic proficiency, though more advanced manipulations often require a bigger commitment, like the 12-week training session that Dr. Godamunne completed. That training included one hour of online learning and one hour of homework every week, and most of the cases highlighted during his coursework, he says, focused on hospitalists—another sign of the major role he believes HM will play in harnessing data to improve performance quality.

You can use the database to analyze practice patterns of large groups, or even individuals, and see where variability exists. And then, based on that, you can analyze why the variability exists and begin to address whether it’s variability that’s clinically indicated or not.

—Thomas Frederickson, MD, MBA, SFHM, medical director, hospital medicine service, Alegent Creighton Health, Omaha, Neb., SHM Practice Management Committee member

Slow—Construction Ahead

The best information is meaningful, individualized, and timely, says Steven Deitelzweig, MD, SFHM, system chairman for hospital medicine and medical director of regional business development at Ochsner Health System in New Orleans. “If you get something back six months after you’ve delivered the care, you’ll have a limited opportunity to improve, versus if you get it back in a week or two, or ideally, in real time,” says Dr. Deitelzweig, chair of SHM’s Practice Management Committee.

In examining length of stay, Dr. Deitelzweig says doctors could use data mining to look at time-stamped elements of patient flow and the timeliness of provider response: how patients go through the ED, and when they receive written orders or lab results. “It could be really powerful, and right now it’s a little bit of a black hole,” he says.

Based on her conversations with hospital executives and leaders, however, Burghard cautions that some real-time mobile applications, although technologically impressive, may be less useful or necessary in practice. “If it’s performance measurement, why do you need that in real time? It’s not going to change your behavior in the moment,” she says. “What you may want to get is an alert that your patient, who is in the hospital, has had some sort of negative event.”

Data mining has other potential limitations. “There’s always going to be questions of attribution, and you need to have clinical knowledge of your location,” Dr. Godamunne says. And data mining is only as good as the data that have been documented, underscoring the importance of securing provider cooperation.

Dr. Frederickson says physician acceptance, in fact, might be one of the biggest obstacles—a major reason why he recommends introducing the technology slowly and explaining why and how it will be used. If introduced too quickly and without adequate explanation about what a hospital or health system hopes to accomplish, he says, “there certainly is the potential for suspicion.” The key, he says, is to emphasize that the tools provide a valuable mechanism for gleaning new insights into doctors’ practice patterns, “not something that’s going to be used against them.”

Paul Roscoe, CEO of the Washington, D.C.-based Advisory Board Company's Crimson division, agrees that personally engaging physicians is essential for a good return on investment in analytical tools like his company’s suite of CRIMSON products. “If you can’t work with the physicians to get them to understand the data and actively use the data in their practice patterns, it becomes a bit meaningless,” he says.

We’re looking to hospitalists to help drive this quality utilization bandwagon, to be the real leaders in it.…It’s good for your group and can be good to your hospital as a whole.

—Karim Godamunne, MD, MBA, SFHM, chief medical officer, North Fulton Hospital, Roswell, Ga., SHM Practice Management Committee member

Roscoe sees big opportunities in prospectively examining information while a patient is still in the hospital and when a change of course by providers could avert a bad outcome. “Suggesting a set of interventions that they could do differently is really the value-add,” he says. But he cautions that those suggestions must be worded carefully to avoid alienating physicians.

“If doctors don’t feel like they’re being judged, they’ll engage with you,” Roscoe says.

Similar nuances can affect how users perceive the tools themselves. After hearing feedback from members that the words “data mining” didn’t conjure trust and confidence, the Advisory Board Company dropped the phrase altogether in favor of “data analytics,” “physician engagement,” and similar descriptors. “It’s simple things like that that can very quickly either turn a physician on or off,” Roscoe says.

Once users take the time to understand data-mining tools and how they can be properly harnessed, advocates say, the technology can lead to a host of unanticipated benefits. When a hospital bills the federal government for a Medicare patient, for example, it must submit an HCC code that describes the patient’s condition. By doing a better job of mining the data, Burghard says, a hospital can more accurately reflect that patient’s contdition. For example, if a hospital is treating a diabetic who comes in with a broken leg, the hospital could receive a lower payment rate if it does not properly identify and record both conditions.

And by using the tools prospectively, Burghard says, “I think there’s the opportunity to make a quantum leap from what we’re doing today. We usually just report on facts, and usually retrospectively. With some of the new technology that’s available, the healthcare industry can begin to do discovery analytics—you’re identifying insights, patterns, and relationships.”

Better integration of computerized physician order entry with data-mining ports, Dr. Godamunne predicts, will allow for much better attribution and finer parsing of the data. As the transparency increases, though, hospitalists will have to adapt to a new reality in which stronger analytical tools may point out individual outliers. And that level of detail, in turn, will require some hospitalists to justify why they’re different than their peers.

Even so, Roscoe says, he’s found that hospitalists are very open to using data to improve performance and that they make up a high percentage of CRIMSON users. “There isn’t a physician group that is in a better position to help drive this quality- and data-driven culture,” he says.

Bryn Nelson is a freelance medical writer in Seattle.

Physician Performance Aids

Company: The Advisory Board Company

Sample product: CRIMSON Continuum of Care

Claim: “Places credible, severity-adjusted performance profiles directly in the hands of physicians, enabling the hospital-physician collaboration needed to advance quality goals and secure cost savings.”

Number of users: More than 850 hospitals

Real-time data? No, but available as add-on service

To learn more: www.advisory.com/Technology/Crimson-Continuum-of-Care

Company: Panacea Developments

Sample product: Iodine

Claim: “An easy-to-use mobile system that analyzes a hospital’s sea of data for knowledge that physicians, case managers, and documentation specialists can act upon to improve length-of-stay, readmissions, and documentation.”

Number of users: More than 50 hospitals

Real-time data? Yes

To learn more: www.panaceadevelopments.com/iodine

Company: Truven Health

Sample product: CareDiscovery

Claim: “Provides powerful insights into a hospital’s or health system’s quality measures and resource utilization to support improvement with objective, fact-based information.”

Real-time data? No

Number of users: More than 3,000 users in 400 hospitals

To learn more: http://truvenhealth.com/products/carediscovery

Company: Ingenious Med

Sample product: Imagine

Claim: “A comprehensive analytics dashboard platform that provides actionable decision making data to optimize physician performance and revenue.”

Real-time data? Yes

Number of users: 25,000 total users (not separated by individual products)

To learn more: http://ingeniousmed.com/what-we-do/imagine

Reference

1. Yoo I, Alafaireet P, Marinov M, et al. Data mining in healthcare and biomedicine: a survey of the literature. J Med Syst. 2012;36:2431-2448.

One hospital wanted to reduce readmissions among patients with congestive heart failure. Another hoped to improve upon its sepsis mortality rates. A third sought to determine whether its doctors were providing cost-effective care for pneumonia patients. All of them adopted the same type of technology to help identify a solution.

As the healthcare industry tilts toward accountable care, pay for performance and an increasingly

cost-conscious mindset, hospitalists and other providers are tapping into a fast-growing analytical tool collectively known as data mining to help make sense of the growing mounds of information. Although no single technology can be considered a cure-all, HM leaders are so optimistic about data mining’s potential to address cost, outcome, and performance issues that some have labeled it a “game changer” for hospitalists.

Karim Godamunne, MD, MBA, SFHM, chief medical officer at North Fulton Hospital in Roswell, Ga., and a member of SHM’s Practice Management Committee, says he can’t overstate the importance of hospitalists’ involvement in physician data mining. “From my perspective, we’re looking to hospitalists to help drive this quality-utilization bandwagon, to be the real leaders in it,” he says. With the tremendous value that can be generated through understanding and using the information, “it’s good for your group and can be good to your hospital as a whole.”

So what is data mining? The technology fully emerged in the mid-1990s as a way to help scientists analyze large and often disparate bodies of data, present relevant information in new ways, and illuminate previously unknown relationships.¹ In the healthcare industry, early adopters realized that the insights gleaned from data mining could help inform their clinical decision-making; organizations used the new tools to help predict health insurance fraud and identify at-risk patients, for example.

Cynthia Burghard, research director of Accountable Care IT Strategies at IDC Health Insights in Framingham, Mass., says researchers in academic medical centers initially conducted most of the clinical analytical work. Within the past few years, however, the increasing availability of data has allowed more hospitals to begin analyzing chronic disease, readmissions, and other areas of concern. In addition, Burghard says, new tools based on natural language processing are giving hospitals better access to unstructured clinical data, such as notes written by doctors and nurses.

“What I’m seeing both in my surveys as well as in conversations with hospitals is that analytics is the top of the investment priority for both hospitals and health plans,” Burghard says. According to IDC estimates, total spending for clinical analytics in the U.S. reached $3.7 billion in 2012 and is expected to grow to $5.14 billion by 2016. Much of the growth, she notes, is being driven by healthcare reform. “If your mandate is to manage populations of patients, it behooves you to know who those patients are and what their illnesses are, and to monitor what you’re doing for them,” she says.

Practice Improvement

Accordingly, a major goal of all this data-mining technology is to change practice behavior in a way that achieves the triple aim of improving quality of care, controlling costs, and bettering patient outcomes.

A growing number of companies are releasing tools that can compile and analyze the separate bits of information captured from claims and billing systems, Medicare reporting requirements, internal benchmarks, and other sources. Unlike passive data sources, such as Medicare’s Hospital Compare website, more active analytics can help their users zoom down to the level of an individual doctor or patient, pan out to the level of a hospitalist group, or expand out even more for a broader comparison among peer institutions.

Some newer data-mining tools with names like CRIMSON, Truven, Iodine, and Imagine are billing themselves as hospitalist-friendly performance-improvement aids and giving individual providers the ability to access and analyze the data themselves. A few of these applications can even provide real-time data via mobile devices (see “Physician Performance Aids,”).

Thomas Frederickson, MD, MBA, SFHM, medical director of the HM service at Alegent Creighton Health in Omaha, Neb., and a member of SHM’s Practice Management Committee, sees the biggest potential of this data-mining technology in its ability to help drive practice consistency. “You can use the database to analyze practice patterns of large groups, or even individuals, and see where variability exists,” he says. “And then, based on that, you can analyze why the variability exists and begin to address whether it’s variability that’s clinically indicated or not.”

When Alegent Creighton Health was scrutinizing the care of its pneumonia patients, for example, officials could compare the number of chest X-rays per pneumonia patient by hospital or across the entire CRIMSON database. At a deeper level, the officials could see how often individual providers ordered the tests compared to their peers. For outliers, they could follow up to determine whether the variability was warranted.

As champions of process improvement, Dr. Frederickson says, hospitalists can make particularly good use of database analytics. “It’s part of the process of making hospitalists invaluable to their hospitals and their systems,” he says. “Part of that is building up expertise on process improvement and safety, and familiarity with these kinds of tools is one thing that will help us do that.”

North Fulton Hospital used CRIMSON to analyze how its doctors care for patients with sepsis and to establish new benchmarks. Dr. Godamunne says the tools allowed the hospital to track its doctors’ progress over time and identify potential problems. “If a patient with sepsis is staying too long, you can see who admitted the patient and see if, a few months ago, the same physician was having similar problems,” he says. Similarly, the hospital was able to track the top DRGs resulting in excess length of stay among patients, to identify potential bottlenecks in the care and discharge processes.

Some tools require only two-day training sessions for basic proficiency, though more advanced manipulations often require a bigger commitment, like the 12-week training session that Dr. Godamunne completed. That training included one hour of online learning and one hour of homework every week, and most of the cases highlighted during his coursework, he says, focused on hospitalists—another sign of the major role he believes HM will play in harnessing data to improve performance quality.

You can use the database to analyze practice patterns of large groups, or even individuals, and see where variability exists. And then, based on that, you can analyze why the variability exists and begin to address whether it’s variability that’s clinically indicated or not.

—Thomas Frederickson, MD, MBA, SFHM, medical director, hospital medicine service, Alegent Creighton Health, Omaha, Neb., SHM Practice Management Committee member

Slow—Construction Ahead

The best information is meaningful, individualized, and timely, says Steven Deitelzweig, MD, SFHM, system chairman for hospital medicine and medical director of regional business development at Ochsner Health System in New Orleans. “If you get something back six months after you’ve delivered the care, you’ll have a limited opportunity to improve, versus if you get it back in a week or two, or ideally, in real time,” says Dr. Deitelzweig, chair of SHM’s Practice Management Committee.

In examining length of stay, Dr. Deitelzweig says doctors could use data mining to look at time-stamped elements of patient flow and the timeliness of provider response: how patients go through the ED, and when they receive written orders or lab results. “It could be really powerful, and right now it’s a little bit of a black hole,” he says.

Based on her conversations with hospital executives and leaders, however, Burghard cautions that some real-time mobile applications, although technologically impressive, may be less useful or necessary in practice. “If it’s performance measurement, why do you need that in real time? It’s not going to change your behavior in the moment,” she says. “What you may want to get is an alert that your patient, who is in the hospital, has had some sort of negative event.”

Data mining has other potential limitations. “There’s always going to be questions of attribution, and you need to have clinical knowledge of your location,” Dr. Godamunne says. And data mining is only as good as the data that have been documented, underscoring the importance of securing provider cooperation.

Dr. Frederickson says physician acceptance, in fact, might be one of the biggest obstacles—a major reason why he recommends introducing the technology slowly and explaining why and how it will be used. If introduced too quickly and without adequate explanation about what a hospital or health system hopes to accomplish, he says, “there certainly is the potential for suspicion.” The key, he says, is to emphasize that the tools provide a valuable mechanism for gleaning new insights into doctors’ practice patterns, “not something that’s going to be used against them.”

Paul Roscoe, CEO of the Washington, D.C.-based Advisory Board Company's Crimson division, agrees that personally engaging physicians is essential for a good return on investment in analytical tools like his company’s suite of CRIMSON products. “If you can’t work with the physicians to get them to understand the data and actively use the data in their practice patterns, it becomes a bit meaningless,” he says.

We’re looking to hospitalists to help drive this quality utilization bandwagon, to be the real leaders in it.…It’s good for your group and can be good to your hospital as a whole.

—Karim Godamunne, MD, MBA, SFHM, chief medical officer, North Fulton Hospital, Roswell, Ga., SHM Practice Management Committee member

Roscoe sees big opportunities in prospectively examining information while a patient is still in the hospital and when a change of course by providers could avert a bad outcome. “Suggesting a set of interventions that they could do differently is really the value-add,” he says. But he cautions that those suggestions must be worded carefully to avoid alienating physicians.

“If doctors don’t feel like they’re being judged, they’ll engage with you,” Roscoe says.

Similar nuances can affect how users perceive the tools themselves. After hearing feedback from members that the words “data mining” didn’t conjure trust and confidence, the Advisory Board Company dropped the phrase altogether in favor of “data analytics,” “physician engagement,” and similar descriptors. “It’s simple things like that that can very quickly either turn a physician on or off,” Roscoe says.

Once users take the time to understand data-mining tools and how they can be properly harnessed, advocates say, the technology can lead to a host of unanticipated benefits. When a hospital bills the federal government for a Medicare patient, for example, it must submit an HCC code that describes the patient’s condition. By doing a better job of mining the data, Burghard says, a hospital can more accurately reflect that patient’s contdition. For example, if a hospital is treating a diabetic who comes in with a broken leg, the hospital could receive a lower payment rate if it does not properly identify and record both conditions.

And by using the tools prospectively, Burghard says, “I think there’s the opportunity to make a quantum leap from what we’re doing today. We usually just report on facts, and usually retrospectively. With some of the new technology that’s available, the healthcare industry can begin to do discovery analytics—you’re identifying insights, patterns, and relationships.”

Better integration of computerized physician order entry with data-mining ports, Dr. Godamunne predicts, will allow for much better attribution and finer parsing of the data. As the transparency increases, though, hospitalists will have to adapt to a new reality in which stronger analytical tools may point out individual outliers. And that level of detail, in turn, will require some hospitalists to justify why they’re different than their peers.

Even so, Roscoe says, he’s found that hospitalists are very open to using data to improve performance and that they make up a high percentage of CRIMSON users. “There isn’t a physician group that is in a better position to help drive this quality- and data-driven culture,” he says.

Bryn Nelson is a freelance medical writer in Seattle.

Physician Performance Aids

Company: The Advisory Board Company

Sample product: CRIMSON Continuum of Care

Claim: “Places credible, severity-adjusted performance profiles directly in the hands of physicians, enabling the hospital-physician collaboration needed to advance quality goals and secure cost savings.”

Number of users: More than 850 hospitals

Real-time data? No, but available as add-on service

To learn more: www.advisory.com/Technology/Crimson-Continuum-of-Care

Company: Panacea Developments

Sample product: Iodine

Claim: “An easy-to-use mobile system that analyzes a hospital’s sea of data for knowledge that physicians, case managers, and documentation specialists can act upon to improve length-of-stay, readmissions, and documentation.”

Number of users: More than 50 hospitals

Real-time data? Yes

To learn more: www.panaceadevelopments.com/iodine

Company: Truven Health

Sample product: CareDiscovery

Claim: “Provides powerful insights into a hospital’s or health system’s quality measures and resource utilization to support improvement with objective, fact-based information.”

Real-time data? No

Number of users: More than 3,000 users in 400 hospitals

To learn more: http://truvenhealth.com/products/carediscovery

Company: Ingenious Med

Sample product: Imagine

Claim: “A comprehensive analytics dashboard platform that provides actionable decision making data to optimize physician performance and revenue.”

Real-time data? Yes

Number of users: 25,000 total users (not separated by individual products)

To learn more: http://ingeniousmed.com/what-we-do/imagine

Reference

1. Yoo I, Alafaireet P, Marinov M, et al. Data mining in healthcare and biomedicine: a survey of the literature. J Med Syst. 2012;36:2431-2448.

Click here to listen to excerpts of Dr. Duke's interview with The Hospitalist

Click here to listen to excerpts of Dr. Duke's interview with The Hospitalist

Click here to listen to excerpts of Dr. Duke's interview with The Hospitalist

Many health-care-reform initiatives are so new that few data are available to assess whether they are working as intended. The Centers for Medicare & Medicaid Services (CMS), however, has touted the early numbers from its Hospital Readmission Reduction Program to suggest that the policy is making a difference in curbing bounce-backs. The overall impact, however, might be decidedly more nuanced and provides a telling example of the challenges that such programs can present to hospitalists and other health-care providers.

At a Senate Finance Committee Hearing in February, Jonathan Blum, deputy administrator and director for the Center of Medicare at CMS, released data suggesting that 30-day readmission rates for all causes dropped to 17.8% of hospitalizations near the end of 2012 after remaining at roughly 19% in each of the five previous years. The difference translates into 70,000 fewer readmissions annually.

During the first round of penalties, CMS dinged 2,213 hospitals for an estimated $280 million, or an average of about $126,500 per hospital, for excessive readmissions linked to heart attack, heart failure, and pneumonia care. Blum made the case that the penalties—or the threat thereof—are helping to improve rates.

Those arguing that the policy could disproportionately impact institutions caring for more vulnerable, high-risk patients also found new support in a recent New England Journal of Medicine perspective suggesting that academic medical centers and safety-net hospitals were more likely to be penalized.¹ Among their suggestions, the perspective’s co-authors, from Harvard’s School of Public Health, suggested that the policy take patient socioeconomic status into account to provide a fairer basis of comparison.

A second recent study suggested that even the reduced readmission rates might not be telling the whole story. An analysis of patients released in 2010 from safety-net hospital Boston Medical Center showed that nearly 1 in 4 returned to the ED within a month of discharge.2 But more than half of those patients weren’t readmitted as inpatients, meaning that they wouldn’t show up under Medicare’s readmissions statistics.

Along with the mixed early reviews of EHR rollouts and the HCAHPS portion of the Hospital Value-Based Purchasing program, it’s another reminder that CMS metrics and incentives might not always add up as envisioned. In the near future, it seems, hospitals and health-care providers might have to contend with some imperfect numbers. TH

Bryn Nelson is a freelance medical writer in Seattle.

References

1. Joynt KE, Jha AK. Thirty-day readmissions–truth and consequences. N Engl J Med. 2012;366:1366-1369.

2. Rising KL, White LF, Fernandez WG, Boutwell, AE. Emergency department visits after hospital discharge: a missing part of the equation. Ann Emerg Med. 2013; in press.

Many health-care-reform initiatives are so new that few data are available to assess whether they are working as intended. The Centers for Medicare & Medicaid Services (CMS), however, has touted the early numbers from its Hospital Readmission Reduction Program to suggest that the policy is making a difference in curbing bounce-backs. The overall impact, however, might be decidedly more nuanced and provides a telling example of the challenges that such programs can present to hospitalists and other health-care providers.

At a Senate Finance Committee Hearing in February, Jonathan Blum, deputy administrator and director for the Center of Medicare at CMS, released data suggesting that 30-day readmission rates for all causes dropped to 17.8% of hospitalizations near the end of 2012 after remaining at roughly 19% in each of the five previous years. The difference translates into 70,000 fewer readmissions annually.

During the first round of penalties, CMS dinged 2,213 hospitals for an estimated $280 million, or an average of about $126,500 per hospital, for excessive readmissions linked to heart attack, heart failure, and pneumonia care. Blum made the case that the penalties—or the threat thereof—are helping to improve rates.

Those arguing that the policy could disproportionately impact institutions caring for more vulnerable, high-risk patients also found new support in a recent New England Journal of Medicine perspective suggesting that academic medical centers and safety-net hospitals were more likely to be penalized.¹ Among their suggestions, the perspective’s co-authors, from Harvard’s School of Public Health, suggested that the policy take patient socioeconomic status into account to provide a fairer basis of comparison.

A second recent study suggested that even the reduced readmission rates might not be telling the whole story. An analysis of patients released in 2010 from safety-net hospital Boston Medical Center showed that nearly 1 in 4 returned to the ED within a month of discharge.2 But more than half of those patients weren’t readmitted as inpatients, meaning that they wouldn’t show up under Medicare’s readmissions statistics.

Along with the mixed early reviews of EHR rollouts and the HCAHPS portion of the Hospital Value-Based Purchasing program, it’s another reminder that CMS metrics and incentives might not always add up as envisioned. In the near future, it seems, hospitals and health-care providers might have to contend with some imperfect numbers. TH

Bryn Nelson is a freelance medical writer in Seattle.

References

1. Joynt KE, Jha AK. Thirty-day readmissions–truth and consequences. N Engl J Med. 2012;366:1366-1369.

2. Rising KL, White LF, Fernandez WG, Boutwell, AE. Emergency department visits after hospital discharge: a missing part of the equation. Ann Emerg Med. 2013; in press.

Many health-care-reform initiatives are so new that few data are available to assess whether they are working as intended. The Centers for Medicare & Medicaid Services (CMS), however, has touted the early numbers from its Hospital Readmission Reduction Program to suggest that the policy is making a difference in curbing bounce-backs. The overall impact, however, might be decidedly more nuanced and provides a telling example of the challenges that such programs can present to hospitalists and other health-care providers.

At a Senate Finance Committee Hearing in February, Jonathan Blum, deputy administrator and director for the Center of Medicare at CMS, released data suggesting that 30-day readmission rates for all causes dropped to 17.8% of hospitalizations near the end of 2012 after remaining at roughly 19% in each of the five previous years. The difference translates into 70,000 fewer readmissions annually.

During the first round of penalties, CMS dinged 2,213 hospitals for an estimated $280 million, or an average of about $126,500 per hospital, for excessive readmissions linked to heart attack, heart failure, and pneumonia care. Blum made the case that the penalties—or the threat thereof—are helping to improve rates.

Those arguing that the policy could disproportionately impact institutions caring for more vulnerable, high-risk patients also found new support in a recent New England Journal of Medicine perspective suggesting that academic medical centers and safety-net hospitals were more likely to be penalized.¹ Among their suggestions, the perspective’s co-authors, from Harvard’s School of Public Health, suggested that the policy take patient socioeconomic status into account to provide a fairer basis of comparison.

A second recent study suggested that even the reduced readmission rates might not be telling the whole story. An analysis of patients released in 2010 from safety-net hospital Boston Medical Center showed that nearly 1 in 4 returned to the ED within a month of discharge.2 But more than half of those patients weren’t readmitted as inpatients, meaning that they wouldn’t show up under Medicare’s readmissions statistics.

Along with the mixed early reviews of EHR rollouts and the HCAHPS portion of the Hospital Value-Based Purchasing program, it’s another reminder that CMS metrics and incentives might not always add up as envisioned. In the near future, it seems, hospitals and health-care providers might have to contend with some imperfect numbers. TH

Bryn Nelson is a freelance medical writer in Seattle.

References

1. Joynt KE, Jha AK. Thirty-day readmissions–truth and consequences. N Engl J Med. 2012;366:1366-1369.

2. Rising KL, White LF, Fernandez WG, Boutwell, AE. Emergency department visits after hospital discharge: a missing part of the equation. Ann Emerg Med. 2013; in press.

Dr. Tierza

VBP. ACO. HAC. EHR. Suddenly, Medicare-derived acronyms are everywhere, and many of them are attached to a growing set of programs aimed at boosting efficiency and quality. Some are optional; others are mandatory. Some have carrots as incentives; others have sticks. Some seem well-designed; others seemingly work at cross-purposes.

Love or hate these initiatives, the combined time, money, and resources needed to address all of them could put hospitals and hospitalists under considerable duress.

“It can either prove or dismantle the whole hospitalist movement,” says Brian Hazen, MD, medical director of the hospitalist division at Inova Fairfax Hospital in Falls Church, Va. “Hospitals expect us to be agile and adapt to the pressures to keep them alive. If we cannot adapt and provide that, then why give us a job?”

Whether or not the focus is on lowering readmission rates, decreasing the incidence of hospital-acquired conditions, or improving efficiencies, Dr. Hazen tends to lump most of the sticks and carrots together. “I throw them all into one basket because for the most part, they’re all reflective of good care,” he says.

The basket is growing, however, and the bundle of sticks could deliver a financial beating to the unwary.

It’s possible that some low-margin hospitals that are facing big penalties could actually have their solvency threatened. If hospitals that are a vital part of the community are threatened with insolvency because of these programs, we may need to take a second look at how we structure the penalties.

—Win Whitcomb, MD, MHM, medical director of healthcare quality, Baystate Medical Center, Springfield, Mass.; SHM Performance and Measurement Reporting Committee member; co-founder and past president of SHM; author of The Hospitalist’s “On the Horizon” column

At What Cost?

For the lowest-performing hospitals, the top readmission penalties will grow to 2% of Medicare reimbursements in fiscal year 2014 and 3% in 2015. Meanwhile, CMS’ Hospital-Acquired Conditions (HAC) program will begin assessing a 1% penalty on the worst performing hospitals in 2015, and the amount withheld under the Hospital Value-Based Purchasing (VBP) program will reach 2% in 2017 (top-performing hospitals can recoup the withhold and more, depending on performance). By that year, the three programs alone could result in a 6% loss of reimbursements.

Win Whitcomb, MD, MHM, medical director of healthcare quality at Baystate Medical Center in Springfield, Mass., and a member of SHM’s Performance and Measurement Reporting Committee, estimates that by 2017, the total at-risk payments could reach about $10 million for a 650-bed academic medical center. The tally for a 90-bed community hospital, he estimates, might run a bit less than $1 million. Although the combined penalty is probably enough to get the attention of most hospitals, very few institutions are likely to be dinged for the entire amount.

Nevertheless, the cumulative loss of reimbursements could be a tipping point for hospitals already in dire straits. “It’s possible that some low-margin hospitals that are facing big penalties could actually have their solvency threatened,” Dr. Whitcomb says. “If hospitals that are a vital part of the community are threatened with insolvency because of these programs, we may need to take a second look at how we structure the penalties.”

The necessary investment in infrastructure, he says, could prove to be a far bigger concern—at least initially.

“What is more expensive is just putting out the effort to do the work to improve and perform well under these programs,” says Dr. Whitcomb, co-founder and past president of SHM and author of The Hospitalist’s “On the Horizon” column. “That’s a big unreported hidden expense of all of these programs.”

With the fairly rapid implementation of multiple measures mandated by the Accountable Care Act, Medicare may be disinclined to dramatically ramp up the programs in play until it has a better sense of what’s working well. Then again, analysts like Laurence Baker, PhD, professor of health research and policy at Stanford University, say it’s doubtful that the agency will scale back its efforts given the widely held perception that plenty of waste can yet be wrung from the system.

“If I was a hospitalist, I would expect more of this coming,” Dr. Baker says.

Of course, rolling out new incentive programs is always a difficult balancing act in which the creators must be careful not to focus too much attention on the wrong measure or create unintended disincentives.

“That’s one of the great challenges: making a program that’s going to be successful when we know that people will do what’s measured and maybe even, without thinking about it, do less of what’s not measured. So we have to be careful about that,” Dr. Baker says.

We’re getting a lot of traction to get physicians to work together to improve care, where before there wasn’t an incentive to do this. So we see this as a good thing, and I think it has potential to reduce expenses in high-cost areas.

—Monty Duke, MD, chief physician executive, Lancaster General Hospital, Lancaster, Pa.

Out of Alignment

Beyond cost and infrastructure, the proliferation of new measures also presents challenges for alignment. Monty Duke, MD, chief physician executive at Lancaster General Hospital in Lancaster, Pa., says the targets are changing so rapidly that tension can arise between hospitals and hospitalists in aligning expectations about priorities and considering how much time, resources, and staffing will be required to address them.

Likewise, the impetus to install new infrastructure can sometimes have unintended consequences, as Dr. Duke has seen firsthand with his hospital’s recent implementation of electronic health records (EHRs).

“In many ways, the electronic health record has changed the dynamic of rounding between physicians and nurses, and it’s really challenging communication,” he says. How so? “Because people spend more time communicating with the computer than they do talking to one another,” he says. The discordant communication, in turn, can conspire against a clear plan of care and overall goals as well as challenge efforts that emphasize a team-based approach.

Despite federal meaningful-use incentives, a recent survey also suggested that a majority of healthcare practices still may not achieve a positive return on investment for EHRs unless they can figure out how to use the systems to increase revenue.¹ A minority of providers have succeeded by seeing more patients every day or by improving their billing process so the codes are more accurate and fewer claims are rejected.

Similarly, hospitalists like Dr. Hazen contend that some patient-satisfaction measures in the HCAHPS section of the VBP program can work against good clinical care. “That one drives me crazy because we’re not waiters or waitresses in a five-star restaurant,” he says. “Health care is complicated; it’s not like sending back a bowl of cold soup the way you can in a restaurant.”

Increasing satisfaction by keeping patients in the hospital longer than warranted or leaving in a Foley catheter for patient convenience, for example, can negatively impact actual outcomes.

“Physicians and nurses get put in this catch-22 where we have to choose between patient satisfaction and by-the-book clinical care,” Dr. Hazen says. “And our job is to try to mitigate that, but you’re kind of damned if you do and damned if you don’t.”

A new study, on the other hand, suggests that HCAHPS scores reflecting lower staff responsiveness are associated with an increased risk of HACs like central line–associated bloodstream infections and that lower scores may be a symptom of hospitals “with a multitude of problems.”²

A 10-Step Program

As existing rules and metrics are revised, new ones added, and others merged or discontinued, hospitalists are likely to encounter more hiccups and headaches. So what’s the solution? Beyond establishing good personal habits like hand-washing when entering and leaving a patient’s room, hospitalist leaders and healthcare analysts point to 10 strategies that may help keep HM providers from getting squeezed by all the demands:

1) Keep everyone on the same page. Because hospitals and health systems often take a subset of CMS core measures and make them strategic priorities, Dr. Whitcomb says hospitalists must thoroughly understand their own institutions’ internal system-level quality and safety goals. He stresses the need for hospitalists to develop and maintain close working connections with their organization’s safety- and quality-improvement (QI) teams “to understand exactly what the rules of the road are.”

Dr. Whitcomb says hospitals should compensate hospitalists for time spent working with these teams on feasible solutions. Hospitalist representatives can then champion specific safety or quality issues and keep them foremost in the minds of their colleagues. “I’m a big believer in paying people to do that work,” he says.

2) Take a wider view. It’s clear that most providers wouldn’t have chosen some of the performance indicators that Medicare and other third-party payors are asking them to meet, and many physicians have been more focused on outcomes than on clinical measures. Like it or not, however, thriving in the new era of health care means accepting more benchmarks. “We’ve had to broaden our scope to say, ‘OK, these other things matter, too,’” Dr. Duke says.

3) Use visual cues. Hospitalists can’t rely on memory to keep track of the dozens of measures for which they are being held accountable. “Every hospitalist program should have a dashboard of priority measures that they’re paying attention to and that’s out in front of them on a regular basis,” Dr. Whitcomb says. “It could be presented to them at monthly meetings, or it could be in a prominent place in their office, but there needs to be a set of cues.”

4) Use bonuses for alignment. Dr. Hazen says hospitals also may find success in using bonuses as a positive reinforcement for well-aligned care. Inova Fairfax’s bonuses include a clinical component that aligns with many of CMS’s core measures, and the financial incentives ensure that discharge summaries are completed and distributed in a timely manner.

5) Emphasize a team approach. Espousing a multidisciplinary approach to care can give patients the confidence that all providers are on the same page, thereby aiding patient-satisfaction scores and easing throughput. And as Dr. Hazen points out, avoiding a silo mentality can pay dividends for improving patient safety.

Dr. Tierza

6) Offer the right information. Tierza Stephan, MD, regional hospitalist medical director for Allina Health in Minneapolis and the incoming chair of SHM’s Practice Analysis Committee, says Allina has worked hard to ensure that hospitalists complete their discharge summaries within 24 hours of a patient’s release from the hospital. Beyond timeliness, the health system is emphasizing content that informs without overwhelming the patient, caregiver, or follow-up provider with unnecessary details.

The discharge summary, for example, includes a section called “Recommendations for the Outpatient Provider,” which provides a checklist of sorts so those providers don’t miss the forest for the trees. The same is true for patients. “The hospital is probably not the best place to be educating patients, so we really focus more on patient instruction at discharge and then timely follow-up,” Dr. Stephan says.

In addition to allowing better care coordination between inpatient and outpatient providers, she says, “it cuts across patient experience and readmissions, and it helps patients to be engaged because they have very clear, easy-to-read information.” Paying attention to such details may have outsized impacts: In a recent study, researchers found that patients who are actively engaged in their own health care are significantly less costly to treat, on average.³

7) Follow through after discharge. Inova Fairfax is setting up an outpatient follow-up clinic as a safety net for patients at the highest risk of being readmitted. Many of these target patients are uninsured or underinsured and battling complex medical problems like heart failure or pneumonia. Establishing a physical location for follow-ups and direct communication with primary-care providers, the hospital hopes, might reduce noncompliance among these outpatients and thereby curtail subsequent readmissions.

8) Optimize EHR. When optimized, experts say, electronic medical records can help hospitals ensure that their providers are following core measures and preventing hospital-acquired conditions while leaving channels of communication open and keeping revenue streams flowing.

“Luckily, we just switched to electronic medical records so we can monitor who has a Foley catheter in, who does or doesn’t have DVT prophylaxis, because even really good docs sometimes make these knucklehead mistakes every once in a while,” Dr. Hazen says. “So we try to use systems to back ourselves up. But for the most part, there’s just no substitute for having good docs do the right thing and documenting that.”

9) Bundle up. Although bundled payments represent yet another CMS initiative, Dr. Duke says the model has the potential to reduce waste, standardize care, and monitor outcomes. Lancaster General has been working on the approach for the past few years, with an initial focus on cardiovascular medicine, orthopedics, and neurosurgery. “We’re getting a lot of traction to get physicians to work together to improve care, where before there wasn’t an incentive to do this,” Dr. Duke says. “So we see this as a good thing, and I think it has potential to reduce expenses in high-cost areas.”

10) Connect the dots. Joane Goodroe, an independent healthcare consultant based in Atlanta, says CMS expects providers to connect the dots and combine their efforts in the separate incentive programs to maximize their resources. By providing consistent care coordination and setting patients on the right track, then, she says hospitalists might help boost savings across the board—a benefit that wouldn’t necessarily be apparent based solely on improved quality metrics in specific programs.

Even here, though, the current fee-for-service model can create awkward side effects. For example, Goodroe recommends following the path that many care groups delving into accountable care and bundled payment systems are already taking: connecting those models to efforts aimed at reducing hospital readmissions. Without the proper financial incentives, however, those efforts may be constrained due to a significant increase in expended resources and a potential decrease in overall revenues.

Some of the kinks may work themselves out of the system over time, but experts say the era of multiple metrics—and additional pressure—is just beginning. Combined, they will require providers to be much better at working as a system and coordinating care across multiple environments beyond the hospital, Dr. Stephan says.

One main question boils down to this, she says: “How do we get more efficient as a system and eliminate waste? I think the hospitalists really play a vital role, and it’s mainly through communication and transfer of information. Hospitalists have to be really well-connected with the different physicians and venues that send the patients into the hospital so that we’re not duplicating services and so that we can get right to the crux of the problem.”

Doing so, regardless of which CMS program is on tap, may be the very best way to avoid getting squeezed.

Bryn Nelson is a freelance medical writer in Seattle.

References

1. Adler-Milstein J, Green CE, Bates DW. A survey analysis suggests that electronic health records will yield revenue gains for some practices and losses for many. Health Affairs. 2013;32(3):562-570.
2. Saman DM, Kavanagh KT, Johnson B, Lutfiyya MN. Can inpatient hospital experiences predict central line-associated bloodstream infections? PLoS ONE. 2013;8(4):e61097.
3. Hibbard JH, Greene J, Overton V. Patients with lower activation associated with higher costs; delivery systems should know their patients’ ‘scores.’ Health Affairs. 2013; 32(2):216-222.

Dr. Tierza

VBP. ACO. HAC. EHR. Suddenly, Medicare-derived acronyms are everywhere, and many of them are attached to a growing set of programs aimed at boosting efficiency and quality. Some are optional; others are mandatory. Some have carrots as incentives; others have sticks. Some seem well-designed; others seemingly work at cross-purposes.

Love or hate these initiatives, the combined time, money, and resources needed to address all of them could put hospitals and hospitalists under considerable duress.

“It can either prove or dismantle the whole hospitalist movement,” says Brian Hazen, MD, medical director of the hospitalist division at Inova Fairfax Hospital in Falls Church, Va. “Hospitals expect us to be agile and adapt to the pressures to keep them alive. If we cannot adapt and provide that, then why give us a job?”

Whether or not the focus is on lowering readmission rates, decreasing the incidence of hospital-acquired conditions, or improving efficiencies, Dr. Hazen tends to lump most of the sticks and carrots together. “I throw them all into one basket because for the most part, they’re all reflective of good care,” he says.

The basket is growing, however, and the bundle of sticks could deliver a financial beating to the unwary.

It’s possible that some low-margin hospitals that are facing big penalties could actually have their solvency threatened. If hospitals that are a vital part of the community are threatened with insolvency because of these programs, we may need to take a second look at how we structure the penalties.

—Win Whitcomb, MD, MHM, medical director of healthcare quality, Baystate Medical Center, Springfield, Mass.; SHM Performance and Measurement Reporting Committee member; co-founder and past president of SHM; author of The Hospitalist’s “On the Horizon” column

At What Cost?

For the lowest-performing hospitals, the top readmission penalties will grow to 2% of Medicare reimbursements in fiscal year 2014 and 3% in 2015. Meanwhile, CMS’ Hospital-Acquired Conditions (HAC) program will begin assessing a 1% penalty on the worst performing hospitals in 2015, and the amount withheld under the Hospital Value-Based Purchasing (VBP) program will reach 2% in 2017 (top-performing hospitals can recoup the withhold and more, depending on performance). By that year, the three programs alone could result in a 6% loss of reimbursements.

Win Whitcomb, MD, MHM, medical director of healthcare quality at Baystate Medical Center in Springfield, Mass., and a member of SHM’s Performance and Measurement Reporting Committee, estimates that by 2017, the total at-risk payments could reach about $10 million for a 650-bed academic medical center. The tally for a 90-bed community hospital, he estimates, might run a bit less than $1 million. Although the combined penalty is probably enough to get the attention of most hospitals, very few institutions are likely to be dinged for the entire amount.

Nevertheless, the cumulative loss of reimbursements could be a tipping point for hospitals already in dire straits. “It’s possible that some low-margin hospitals that are facing big penalties could actually have their solvency threatened,” Dr. Whitcomb says. “If hospitals that are a vital part of the community are threatened with insolvency because of these programs, we may need to take a second look at how we structure the penalties.”

The necessary investment in infrastructure, he says, could prove to be a far bigger concern—at least initially.

“What is more expensive is just putting out the effort to do the work to improve and perform well under these programs,” says Dr. Whitcomb, co-founder and past president of SHM and author of The Hospitalist’s “On the Horizon” column. “That’s a big unreported hidden expense of all of these programs.”

With the fairly rapid implementation of multiple measures mandated by the Accountable Care Act, Medicare may be disinclined to dramatically ramp up the programs in play until it has a better sense of what’s working well. Then again, analysts like Laurence Baker, PhD, professor of health research and policy at Stanford University, say it’s doubtful that the agency will scale back its efforts given the widely held perception that plenty of waste can yet be wrung from the system.

“If I was a hospitalist, I would expect more of this coming,” Dr. Baker says.

Of course, rolling out new incentive programs is always a difficult balancing act in which the creators must be careful not to focus too much attention on the wrong measure or create unintended disincentives.

“That’s one of the great challenges: making a program that’s going to be successful when we know that people will do what’s measured and maybe even, without thinking about it, do less of what’s not measured. So we have to be careful about that,” Dr. Baker says.

We’re getting a lot of traction to get physicians to work together to improve care, where before there wasn’t an incentive to do this. So we see this as a good thing, and I think it has potential to reduce expenses in high-cost areas.

—Monty Duke, MD, chief physician executive, Lancaster General Hospital, Lancaster, Pa.

Out of Alignment

Beyond cost and infrastructure, the proliferation of new measures also presents challenges for alignment. Monty Duke, MD, chief physician executive at Lancaster General Hospital in Lancaster, Pa., says the targets are changing so rapidly that tension can arise between hospitals and hospitalists in aligning expectations about priorities and considering how much time, resources, and staffing will be required to address them.

Likewise, the impetus to install new infrastructure can sometimes have unintended consequences, as Dr. Duke has seen firsthand with his hospital’s recent implementation of electronic health records (EHRs).

“In many ways, the electronic health record has changed the dynamic of rounding between physicians and nurses, and it’s really challenging communication,” he says. How so? “Because people spend more time communicating with the computer than they do talking to one another,” he says. The discordant communication, in turn, can conspire against a clear plan of care and overall goals as well as challenge efforts that emphasize a team-based approach.

Despite federal meaningful-use incentives, a recent survey also suggested that a majority of healthcare practices still may not achieve a positive return on investment for EHRs unless they can figure out how to use the systems to increase revenue.¹ A minority of providers have succeeded by seeing more patients every day or by improving their billing process so the codes are more accurate and fewer claims are rejected.

Similarly, hospitalists like Dr. Hazen contend that some patient-satisfaction measures in the HCAHPS section of the VBP program can work against good clinical care. “That one drives me crazy because we’re not waiters or waitresses in a five-star restaurant,” he says. “Health care is complicated; it’s not like sending back a bowl of cold soup the way you can in a restaurant.”

Increasing satisfaction by keeping patients in the hospital longer than warranted or leaving in a Foley catheter for patient convenience, for example, can negatively impact actual outcomes.

“Physicians and nurses get put in this catch-22 where we have to choose between patient satisfaction and by-the-book clinical care,” Dr. Hazen says. “And our job is to try to mitigate that, but you’re kind of damned if you do and damned if you don’t.”

A new study, on the other hand, suggests that HCAHPS scores reflecting lower staff responsiveness are associated with an increased risk of HACs like central line–associated bloodstream infections and that lower scores may be a symptom of hospitals “with a multitude of problems.”²

A 10-Step Program

As existing rules and metrics are revised, new ones added, and others merged or discontinued, hospitalists are likely to encounter more hiccups and headaches. So what’s the solution? Beyond establishing good personal habits like hand-washing when entering and leaving a patient’s room, hospitalist leaders and healthcare analysts point to 10 strategies that may help keep HM providers from getting squeezed by all the demands:

1) Keep everyone on the same page. Because hospitals and health systems often take a subset of CMS core measures and make them strategic priorities, Dr. Whitcomb says hospitalists must thoroughly understand their own institutions’ internal system-level quality and safety goals. He stresses the need for hospitalists to develop and maintain close working connections with their organization’s safety- and quality-improvement (QI) teams “to understand exactly what the rules of the road are.”

Dr. Whitcomb says hospitals should compensate hospitalists for time spent working with these teams on feasible solutions. Hospitalist representatives can then champion specific safety or quality issues and keep them foremost in the minds of their colleagues. “I’m a big believer in paying people to do that work,” he says.

2) Take a wider view. It’s clear that most providers wouldn’t have chosen some of the performance indicators that Medicare and other third-party payors are asking them to meet, and many physicians have been more focused on outcomes than on clinical measures. Like it or not, however, thriving in the new era of health care means accepting more benchmarks. “We’ve had to broaden our scope to say, ‘OK, these other things matter, too,’” Dr. Duke says.

3) Use visual cues. Hospitalists can’t rely on memory to keep track of the dozens of measures for which they are being held accountable. “Every hospitalist program should have a dashboard of priority measures that they’re paying attention to and that’s out in front of them on a regular basis,” Dr. Whitcomb says. “It could be presented to them at monthly meetings, or it could be in a prominent place in their office, but there needs to be a set of cues.”

4) Use bonuses for alignment. Dr. Hazen says hospitals also may find success in using bonuses as a positive reinforcement for well-aligned care. Inova Fairfax’s bonuses include a clinical component that aligns with many of CMS’s core measures, and the financial incentives ensure that discharge summaries are completed and distributed in a timely manner.

5) Emphasize a team approach. Espousing a multidisciplinary approach to care can give patients the confidence that all providers are on the same page, thereby aiding patient-satisfaction scores and easing throughput. And as Dr. Hazen points out, avoiding a silo mentality can pay dividends for improving patient safety.

Dr. Tierza

6) Offer the right information. Tierza Stephan, MD, regional hospitalist medical director for Allina Health in Minneapolis and the incoming chair of SHM’s Practice Analysis Committee, says Allina has worked hard to ensure that hospitalists complete their discharge summaries within 24 hours of a patient’s release from the hospital. Beyond timeliness, the health system is emphasizing content that informs without overwhelming the patient, caregiver, or follow-up provider with unnecessary details.

The discharge summary, for example, includes a section called “Recommendations for the Outpatient Provider,” which provides a checklist of sorts so those providers don’t miss the forest for the trees. The same is true for patients. “The hospital is probably not the best place to be educating patients, so we really focus more on patient instruction at discharge and then timely follow-up,” Dr. Stephan says.

In addition to allowing better care coordination between inpatient and outpatient providers, she says, “it cuts across patient experience and readmissions, and it helps patients to be engaged because they have very clear, easy-to-read information.” Paying attention to such details may have outsized impacts: In a recent study, researchers found that patients who are actively engaged in their own health care are significantly less costly to treat, on average.³

7) Follow through after discharge. Inova Fairfax is setting up an outpatient follow-up clinic as a safety net for patients at the highest risk of being readmitted. Many of these target patients are uninsured or underinsured and battling complex medical problems like heart failure or pneumonia. Establishing a physical location for follow-ups and direct communication with primary-care providers, the hospital hopes, might reduce noncompliance among these outpatients and thereby curtail subsequent readmissions.

8) Optimize EHR. When optimized, experts say, electronic medical records can help hospitals ensure that their providers are following core measures and preventing hospital-acquired conditions while leaving channels of communication open and keeping revenue streams flowing.

“Luckily, we just switched to electronic medical records so we can monitor who has a Foley catheter in, who does or doesn’t have DVT prophylaxis, because even really good docs sometimes make these knucklehead mistakes every once in a while,” Dr. Hazen says. “So we try to use systems to back ourselves up. But for the most part, there’s just no substitute for having good docs do the right thing and documenting that.”

9) Bundle up. Although bundled payments represent yet another CMS initiative, Dr. Duke says the model has the potential to reduce waste, standardize care, and monitor outcomes. Lancaster General has been working on the approach for the past few years, with an initial focus on cardiovascular medicine, orthopedics, and neurosurgery. “We’re getting a lot of traction to get physicians to work together to improve care, where before there wasn’t an incentive to do this,” Dr. Duke says. “So we see this as a good thing, and I think it has potential to reduce expenses in high-cost areas.”

10) Connect the dots. Joane Goodroe, an independent healthcare consultant based in Atlanta, says CMS expects providers to connect the dots and combine their efforts in the separate incentive programs to maximize their resources. By providing consistent care coordination and setting patients on the right track, then, she says hospitalists might help boost savings across the board—a benefit that wouldn’t necessarily be apparent based solely on improved quality metrics in specific programs.

Even here, though, the current fee-for-service model can create awkward side effects. For example, Goodroe recommends following the path that many care groups delving into accountable care and bundled payment systems are already taking: connecting those models to efforts aimed at reducing hospital readmissions. Without the proper financial incentives, however, those efforts may be constrained due to a significant increase in expended resources and a potential decrease in overall revenues.

Some of the kinks may work themselves out of the system over time, but experts say the era of multiple metrics—and additional pressure—is just beginning. Combined, they will require providers to be much better at working as a system and coordinating care across multiple environments beyond the hospital, Dr. Stephan says.

One main question boils down to this, she says: “How do we get more efficient as a system and eliminate waste? I think the hospitalists really play a vital role, and it’s mainly through communication and transfer of information. Hospitalists have to be really well-connected with the different physicians and venues that send the patients into the hospital so that we’re not duplicating services and so that we can get right to the crux of the problem.”

Doing so, regardless of which CMS program is on tap, may be the very best way to avoid getting squeezed.

Bryn Nelson is a freelance medical writer in Seattle.

References

1. Adler-Milstein J, Green CE, Bates DW. A survey analysis suggests that electronic health records will yield revenue gains for some practices and losses for many. Health Affairs. 2013;32(3):562-570.
2. Saman DM, Kavanagh KT, Johnson B, Lutfiyya MN. Can inpatient hospital experiences predict central line-associated bloodstream infections? PLoS ONE. 2013;8(4):e61097.
3. Hibbard JH, Greene J, Overton V. Patients with lower activation associated with higher costs; delivery systems should know their patients’ ‘scores.’ Health Affairs. 2013; 32(2):216-222.

Dr. Tierza

VBP. ACO. HAC. EHR. Suddenly, Medicare-derived acronyms are everywhere, and many of them are attached to a growing set of programs aimed at boosting efficiency and quality. Some are optional; others are mandatory. Some have carrots as incentives; others have sticks. Some seem well-designed; others seemingly work at cross-purposes.

Love or hate these initiatives, the combined time, money, and resources needed to address all of them could put hospitals and hospitalists under considerable duress.

“It can either prove or dismantle the whole hospitalist movement,” says Brian Hazen, MD, medical director of the hospitalist division at Inova Fairfax Hospital in Falls Church, Va. “Hospitals expect us to be agile and adapt to the pressures to keep them alive. If we cannot adapt and provide that, then why give us a job?”

Whether or not the focus is on lowering readmission rates, decreasing the incidence of hospital-acquired conditions, or improving efficiencies, Dr. Hazen tends to lump most of the sticks and carrots together. “I throw them all into one basket because for the most part, they’re all reflective of good care,” he says.

The basket is growing, however, and the bundle of sticks could deliver a financial beating to the unwary.

It’s possible that some low-margin hospitals that are facing big penalties could actually have their solvency threatened. If hospitals that are a vital part of the community are threatened with insolvency because of these programs, we may need to take a second look at how we structure the penalties.

—Win Whitcomb, MD, MHM, medical director of healthcare quality, Baystate Medical Center, Springfield, Mass.; SHM Performance and Measurement Reporting Committee member; co-founder and past president of SHM; author of The Hospitalist’s “On the Horizon” column

At What Cost?

For the lowest-performing hospitals, the top readmission penalties will grow to 2% of Medicare reimbursements in fiscal year 2014 and 3% in 2015. Meanwhile, CMS’ Hospital-Acquired Conditions (HAC) program will begin assessing a 1% penalty on the worst performing hospitals in 2015, and the amount withheld under the Hospital Value-Based Purchasing (VBP) program will reach 2% in 2017 (top-performing hospitals can recoup the withhold and more, depending on performance). By that year, the three programs alone could result in a 6% loss of reimbursements.

Win Whitcomb, MD, MHM, medical director of healthcare quality at Baystate Medical Center in Springfield, Mass., and a member of SHM’s Performance and Measurement Reporting Committee, estimates that by 2017, the total at-risk payments could reach about $10 million for a 650-bed academic medical center. The tally for a 90-bed community hospital, he estimates, might run a bit less than $1 million. Although the combined penalty is probably enough to get the attention of most hospitals, very few institutions are likely to be dinged for the entire amount.

Nevertheless, the cumulative loss of reimbursements could be a tipping point for hospitals already in dire straits. “It’s possible that some low-margin hospitals that are facing big penalties could actually have their solvency threatened,” Dr. Whitcomb says. “If hospitals that are a vital part of the community are threatened with insolvency because of these programs, we may need to take a second look at how we structure the penalties.”

The necessary investment in infrastructure, he says, could prove to be a far bigger concern—at least initially.

“What is more expensive is just putting out the effort to do the work to improve and perform well under these programs,” says Dr. Whitcomb, co-founder and past president of SHM and author of The Hospitalist’s “On the Horizon” column. “That’s a big unreported hidden expense of all of these programs.”

With the fairly rapid implementation of multiple measures mandated by the Accountable Care Act, Medicare may be disinclined to dramatically ramp up the programs in play until it has a better sense of what’s working well. Then again, analysts like Laurence Baker, PhD, professor of health research and policy at Stanford University, say it’s doubtful that the agency will scale back its efforts given the widely held perception that plenty of waste can yet be wrung from the system.

“If I was a hospitalist, I would expect more of this coming,” Dr. Baker says.

Of course, rolling out new incentive programs is always a difficult balancing act in which the creators must be careful not to focus too much attention on the wrong measure or create unintended disincentives.

“That’s one of the great challenges: making a program that’s going to be successful when we know that people will do what’s measured and maybe even, without thinking about it, do less of what’s not measured. So we have to be careful about that,” Dr. Baker says.

We’re getting a lot of traction to get physicians to work together to improve care, where before there wasn’t an incentive to do this. So we see this as a good thing, and I think it has potential to reduce expenses in high-cost areas.

—Monty Duke, MD, chief physician executive, Lancaster General Hospital, Lancaster, Pa.

Out of Alignment

Beyond cost and infrastructure, the proliferation of new measures also presents challenges for alignment. Monty Duke, MD, chief physician executive at Lancaster General Hospital in Lancaster, Pa., says the targets are changing so rapidly that tension can arise between hospitals and hospitalists in aligning expectations about priorities and considering how much time, resources, and staffing will be required to address them.

Likewise, the impetus to install new infrastructure can sometimes have unintended consequences, as Dr. Duke has seen firsthand with his hospital’s recent implementation of electronic health records (EHRs).

“In many ways, the electronic health record has changed the dynamic of rounding between physicians and nurses, and it’s really challenging communication,” he says. How so? “Because people spend more time communicating with the computer than they do talking to one another,” he says. The discordant communication, in turn, can conspire against a clear plan of care and overall goals as well as challenge efforts that emphasize a team-based approach.

Despite federal meaningful-use incentives, a recent survey also suggested that a majority of healthcare practices still may not achieve a positive return on investment for EHRs unless they can figure out how to use the systems to increase revenue.¹ A minority of providers have succeeded by seeing more patients every day or by improving their billing process so the codes are more accurate and fewer claims are rejected.

Similarly, hospitalists like Dr. Hazen contend that some patient-satisfaction measures in the HCAHPS section of the VBP program can work against good clinical care. “That one drives me crazy because we’re not waiters or waitresses in a five-star restaurant,” he says. “Health care is complicated; it’s not like sending back a bowl of cold soup the way you can in a restaurant.”

Increasing satisfaction by keeping patients in the hospital longer than warranted or leaving in a Foley catheter for patient convenience, for example, can negatively impact actual outcomes.

“Physicians and nurses get put in this catch-22 where we have to choose between patient satisfaction and by-the-book clinical care,” Dr. Hazen says. “And our job is to try to mitigate that, but you’re kind of damned if you do and damned if you don’t.”

A new study, on the other hand, suggests that HCAHPS scores reflecting lower staff responsiveness are associated with an increased risk of HACs like central line–associated bloodstream infections and that lower scores may be a symptom of hospitals “with a multitude of problems.”²

A 10-Step Program

As existing rules and metrics are revised, new ones added, and others merged or discontinued, hospitalists are likely to encounter more hiccups and headaches. So what’s the solution? Beyond establishing good personal habits like hand-washing when entering and leaving a patient’s room, hospitalist leaders and healthcare analysts point to 10 strategies that may help keep HM providers from getting squeezed by all the demands:

1) Keep everyone on the same page. Because hospitals and health systems often take a subset of CMS core measures and make them strategic priorities, Dr. Whitcomb says hospitalists must thoroughly understand their own institutions’ internal system-level quality and safety goals. He stresses the need for hospitalists to develop and maintain close working connections with their organization’s safety- and quality-improvement (QI) teams “to understand exactly what the rules of the road are.”

Dr. Whitcomb says hospitals should compensate hospitalists for time spent working with these teams on feasible solutions. Hospitalist representatives can then champion specific safety or quality issues and keep them foremost in the minds of their colleagues. “I’m a big believer in paying people to do that work,” he says.

2) Take a wider view. It’s clear that most providers wouldn’t have chosen some of the performance indicators that Medicare and other third-party payors are asking them to meet, and many physicians have been more focused on outcomes than on clinical measures. Like it or not, however, thriving in the new era of health care means accepting more benchmarks. “We’ve had to broaden our scope to say, ‘OK, these other things matter, too,’” Dr. Duke says.

3) Use visual cues. Hospitalists can’t rely on memory to keep track of the dozens of measures for which they are being held accountable. “Every hospitalist program should have a dashboard of priority measures that they’re paying attention to and that’s out in front of them on a regular basis,” Dr. Whitcomb says. “It could be presented to them at monthly meetings, or it could be in a prominent place in their office, but there needs to be a set of cues.”

4) Use bonuses for alignment. Dr. Hazen says hospitals also may find success in using bonuses as a positive reinforcement for well-aligned care. Inova Fairfax’s bonuses include a clinical component that aligns with many of CMS’s core measures, and the financial incentives ensure that discharge summaries are completed and distributed in a timely manner.

5) Emphasize a team approach. Espousing a multidisciplinary approach to care can give patients the confidence that all providers are on the same page, thereby aiding patient-satisfaction scores and easing throughput. And as Dr. Hazen points out, avoiding a silo mentality can pay dividends for improving patient safety.

Dr. Tierza

6) Offer the right information. Tierza Stephan, MD, regional hospitalist medical director for Allina Health in Minneapolis and the incoming chair of SHM’s Practice Analysis Committee, says Allina has worked hard to ensure that hospitalists complete their discharge summaries within 24 hours of a patient’s release from the hospital. Beyond timeliness, the health system is emphasizing content that informs without overwhelming the patient, caregiver, or follow-up provider with unnecessary details.

The discharge summary, for example, includes a section called “Recommendations for the Outpatient Provider,” which provides a checklist of sorts so those providers don’t miss the forest for the trees. The same is true for patients. “The hospital is probably not the best place to be educating patients, so we really focus more on patient instruction at discharge and then timely follow-up,” Dr. Stephan says.

In addition to allowing better care coordination between inpatient and outpatient providers, she says, “it cuts across patient experience and readmissions, and it helps patients to be engaged because they have very clear, easy-to-read information.” Paying attention to such details may have outsized impacts: In a recent study, researchers found that patients who are actively engaged in their own health care are significantly less costly to treat, on average.³

7) Follow through after discharge. Inova Fairfax is setting up an outpatient follow-up clinic as a safety net for patients at the highest risk of being readmitted. Many of these target patients are uninsured or underinsured and battling complex medical problems like heart failure or pneumonia. Establishing a physical location for follow-ups and direct communication with primary-care providers, the hospital hopes, might reduce noncompliance among these outpatients and thereby curtail subsequent readmissions.

8) Optimize EHR. When optimized, experts say, electronic medical records can help hospitals ensure that their providers are following core measures and preventing hospital-acquired conditions while leaving channels of communication open and keeping revenue streams flowing.

“Luckily, we just switched to electronic medical records so we can monitor who has a Foley catheter in, who does or doesn’t have DVT prophylaxis, because even really good docs sometimes make these knucklehead mistakes every once in a while,” Dr. Hazen says. “So we try to use systems to back ourselves up. But for the most part, there’s just no substitute for having good docs do the right thing and documenting that.”

9) Bundle up. Although bundled payments represent yet another CMS initiative, Dr. Duke says the model has the potential to reduce waste, standardize care, and monitor outcomes. Lancaster General has been working on the approach for the past few years, with an initial focus on cardiovascular medicine, orthopedics, and neurosurgery. “We’re getting a lot of traction to get physicians to work together to improve care, where before there wasn’t an incentive to do this,” Dr. Duke says. “So we see this as a good thing, and I think it has potential to reduce expenses in high-cost areas.”

10) Connect the dots. Joane Goodroe, an independent healthcare consultant based in Atlanta, says CMS expects providers to connect the dots and combine their efforts in the separate incentive programs to maximize their resources. By providing consistent care coordination and setting patients on the right track, then, she says hospitalists might help boost savings across the board—a benefit that wouldn’t necessarily be apparent based solely on improved quality metrics in specific programs.

Even here, though, the current fee-for-service model can create awkward side effects. For example, Goodroe recommends following the path that many care groups delving into accountable care and bundled payment systems are already taking: connecting those models to efforts aimed at reducing hospital readmissions. Without the proper financial incentives, however, those efforts may be constrained due to a significant increase in expended resources and a potential decrease in overall revenues.

Some of the kinks may work themselves out of the system over time, but experts say the era of multiple metrics—and additional pressure—is just beginning. Combined, they will require providers to be much better at working as a system and coordinating care across multiple environments beyond the hospital, Dr. Stephan says.

One main question boils down to this, she says: “How do we get more efficient as a system and eliminate waste? I think the hospitalists really play a vital role, and it’s mainly through communication and transfer of information. Hospitalists have to be really well-connected with the different physicians and venues that send the patients into the hospital so that we’re not duplicating services and so that we can get right to the crux of the problem.”

Doing so, regardless of which CMS program is on tap, may be the very best way to avoid getting squeezed.

Bryn Nelson is a freelance medical writer in Seattle.

References

1. Adler-Milstein J, Green CE, Bates DW. A survey analysis suggests that electronic health records will yield revenue gains for some practices and losses for many. Health Affairs. 2013;32(3):562-570.
2. Saman DM, Kavanagh KT, Johnson B, Lutfiyya MN. Can inpatient hospital experiences predict central line-associated bloodstream infections? PLoS ONE. 2013;8(4):e61097.
3. Hibbard JH, Greene J, Overton V. Patients with lower activation associated with higher costs; delivery systems should know their patients’ ‘scores.’ Health Affairs. 2013; 32(2):216-222.