Josh Boswell

A cornerstone of hospital medicine is the delivery of high-quality inpatient care by improving the performance of the systems and facilities in which hospitalists work. By extension, hospitalists are often held accountable, in varying ways, for improving the performance of facility metrics, such as those in the Hospital Value-Based Purchasing (HVBP), Inpatient Quality Reporting, and Hospital Readmissions Reduction programs.

Despite the work hospitalists were already doing to improve both efficiency and quality within their institutions, the 2010 Affordable Care Act introduced penalties for clinicians who did not submit qualifying provider-level data via the Physician Quality Reporting System program. Initially only an incentive program, PQRS was ultimately incorporated into the Physician Value-Based Payment (VBP) Modifier to make performance-based payment adjustments to Medicare physician payment. At this point, many hospitalists were not only accountable for helping to improve the metrics of their facilities, but also required to report individually or within their groups on provider-level measures, many of which were irrelevant to hospital medicine practice.

With this dual burden becoming evident, the Society of Hospital Medicine approached the Centers for Medicare & Medicaid Services with a possible solution. Could hospitalists elect to use their facilities’ metrics as a stand-in for the provider level metrics? Not only would this reduce the burden of reporting irrelevant metrics, but it would also help alleviate some of the disadvantages hospitalists face within Physician VBP.

The CMS was initially very supportive of the concept, but informed the SHM such alignment was not possible under existing law. In brief, the law required Physician VBP to remain completely within the Physician Fee Schedule and its related metrics; facility level metrics from a different payment system could not be used.

Undeterred, the SHM sought opportunities to change the law. As Congress was developing the Medicare Access and Chip Reauthorization Act (MACRA), the SHM worked closely with lawmakers to include language that would permit measures in “other payment systems” to be used for physician performance assessment. This language was retained in the final version of MACRA that was signed into law on April 16, 2015.

The SHM continued its advocacy, working closely with the CMS and its new authority to shape an option to align Medicare’s facility metrics and scores with provider reporting. Today that idea is a reality. Beginning this year, the CMS will have a new Merit-based Incentive Payment System (MIPS) reporting option available for hospitalists: facility-based measurement.

Facility-based measurement enables clinicians to receive a score for the Quality and Cost categories of the MIPS, without the need to collect and report on measures separately. Eligible providers would receive the MIPS score in those categories associated with the same percentile as their hospital’s score in HVBP. No more administrative work necessary to collect, clean and report on data for quality measures in the MIPS. If you are eligible, the CMS will automatically calculate a Quality and Cost score and combine this with your score from Improvement Activities and Promoting Interoperability (if you are not exempt) to give you a final MIPS score. If you decide to report on quality measures through the traditional MIPS pathway as well, the CMS will give you the higher of the scores.

There are certainly trade-offs associated with the facility-based measurement option. You do not have the burden of reporting measures on your own, but you do not get to pick what measures and what facility’s score you receive. Facility-level measures may be more difficult to improve performance, particularly as an individual, but the automatic application of facility-based measurement to eligible clinicians and groups serves as a backstop for MIPS reporting.

Aligning facility and clinician performance should encourage collaboration and innovation to meet these shared goals. As such, facility-based measurement represents a massive philosophical and practical shift in CMS measure reporting. As we enter these uncharted waters together, we hope to continue learning from your experiences and perspectives and working to refine facility-based measurement in the future.

For more information about facility-based reporting and the MIPS in general, visit www.macraforhm.org.

Mr. Lapps is government relations senior manager and Mr. Boswell is government relations director at the Society of Hospital Medicine.

Who is eligible for facility-based measurement?

• Individual providers who bill more than 75% of their Medicare Part B professional services in Place of Service 21 (Emergency Department), 22 (Hospital Outpatient), and 23 (Inpatient Hospital), billing at least one service in POS 21 or 23, and work in a hospital with an HVBP score.
• Groups who have at least 75% of their individual clinicians who meet the eligibility criteria.
• Nearly all hospitalists should qualify for facility-based measurement as individuals, while group eligibility depends on the demographics of their staff.

A cornerstone of hospital medicine is the delivery of high-quality inpatient care by improving the performance of the systems and facilities in which hospitalists work. By extension, hospitalists are often held accountable, in varying ways, for improving the performance of facility metrics, such as those in the Hospital Value-Based Purchasing (HVBP), Inpatient Quality Reporting, and Hospital Readmissions Reduction programs.

Despite the work hospitalists were already doing to improve both efficiency and quality within their institutions, the 2010 Affordable Care Act introduced penalties for clinicians who did not submit qualifying provider-level data via the Physician Quality Reporting System program. Initially only an incentive program, PQRS was ultimately incorporated into the Physician Value-Based Payment (VBP) Modifier to make performance-based payment adjustments to Medicare physician payment. At this point, many hospitalists were not only accountable for helping to improve the metrics of their facilities, but also required to report individually or within their groups on provider-level measures, many of which were irrelevant to hospital medicine practice.

With this dual burden becoming evident, the Society of Hospital Medicine approached the Centers for Medicare & Medicaid Services with a possible solution. Could hospitalists elect to use their facilities’ metrics as a stand-in for the provider level metrics? Not only would this reduce the burden of reporting irrelevant metrics, but it would also help alleviate some of the disadvantages hospitalists face within Physician VBP.

The CMS was initially very supportive of the concept, but informed the SHM such alignment was not possible under existing law. In brief, the law required Physician VBP to remain completely within the Physician Fee Schedule and its related metrics; facility level metrics from a different payment system could not be used.

Undeterred, the SHM sought opportunities to change the law. As Congress was developing the Medicare Access and Chip Reauthorization Act (MACRA), the SHM worked closely with lawmakers to include language that would permit measures in “other payment systems” to be used for physician performance assessment. This language was retained in the final version of MACRA that was signed into law on April 16, 2015.

The SHM continued its advocacy, working closely with the CMS and its new authority to shape an option to align Medicare’s facility metrics and scores with provider reporting. Today that idea is a reality. Beginning this year, the CMS will have a new Merit-based Incentive Payment System (MIPS) reporting option available for hospitalists: facility-based measurement.

Facility-based measurement enables clinicians to receive a score for the Quality and Cost categories of the MIPS, without the need to collect and report on measures separately. Eligible providers would receive the MIPS score in those categories associated with the same percentile as their hospital’s score in HVBP. No more administrative work necessary to collect, clean and report on data for quality measures in the MIPS. If you are eligible, the CMS will automatically calculate a Quality and Cost score and combine this with your score from Improvement Activities and Promoting Interoperability (if you are not exempt) to give you a final MIPS score. If you decide to report on quality measures through the traditional MIPS pathway as well, the CMS will give you the higher of the scores.

There are certainly trade-offs associated with the facility-based measurement option. You do not have the burden of reporting measures on your own, but you do not get to pick what measures and what facility’s score you receive. Facility-level measures may be more difficult to improve performance, particularly as an individual, but the automatic application of facility-based measurement to eligible clinicians and groups serves as a backstop for MIPS reporting.

Aligning facility and clinician performance should encourage collaboration and innovation to meet these shared goals. As such, facility-based measurement represents a massive philosophical and practical shift in CMS measure reporting. As we enter these uncharted waters together, we hope to continue learning from your experiences and perspectives and working to refine facility-based measurement in the future.

For more information about facility-based reporting and the MIPS in general, visit www.macraforhm.org.

Mr. Lapps is government relations senior manager and Mr. Boswell is government relations director at the Society of Hospital Medicine.

Who is eligible for facility-based measurement?

• Individual providers who bill more than 75% of their Medicare Part B professional services in Place of Service 21 (Emergency Department), 22 (Hospital Outpatient), and 23 (Inpatient Hospital), billing at least one service in POS 21 or 23, and work in a hospital with an HVBP score.
• Groups who have at least 75% of their individual clinicians who meet the eligibility criteria.
• Nearly all hospitalists should qualify for facility-based measurement as individuals, while group eligibility depends on the demographics of their staff.

A cornerstone of hospital medicine is the delivery of high-quality inpatient care by improving the performance of the systems and facilities in which hospitalists work. By extension, hospitalists are often held accountable, in varying ways, for improving the performance of facility metrics, such as those in the Hospital Value-Based Purchasing (HVBP), Inpatient Quality Reporting, and Hospital Readmissions Reduction programs.

Despite the work hospitalists were already doing to improve both efficiency and quality within their institutions, the 2010 Affordable Care Act introduced penalties for clinicians who did not submit qualifying provider-level data via the Physician Quality Reporting System program. Initially only an incentive program, PQRS was ultimately incorporated into the Physician Value-Based Payment (VBP) Modifier to make performance-based payment adjustments to Medicare physician payment. At this point, many hospitalists were not only accountable for helping to improve the metrics of their facilities, but also required to report individually or within their groups on provider-level measures, many of which were irrelevant to hospital medicine practice.

With this dual burden becoming evident, the Society of Hospital Medicine approached the Centers for Medicare & Medicaid Services with a possible solution. Could hospitalists elect to use their facilities’ metrics as a stand-in for the provider level metrics? Not only would this reduce the burden of reporting irrelevant metrics, but it would also help alleviate some of the disadvantages hospitalists face within Physician VBP.

The CMS was initially very supportive of the concept, but informed the SHM such alignment was not possible under existing law. In brief, the law required Physician VBP to remain completely within the Physician Fee Schedule and its related metrics; facility level metrics from a different payment system could not be used.

Undeterred, the SHM sought opportunities to change the law. As Congress was developing the Medicare Access and Chip Reauthorization Act (MACRA), the SHM worked closely with lawmakers to include language that would permit measures in “other payment systems” to be used for physician performance assessment. This language was retained in the final version of MACRA that was signed into law on April 16, 2015.

The SHM continued its advocacy, working closely with the CMS and its new authority to shape an option to align Medicare’s facility metrics and scores with provider reporting. Today that idea is a reality. Beginning this year, the CMS will have a new Merit-based Incentive Payment System (MIPS) reporting option available for hospitalists: facility-based measurement.

Facility-based measurement enables clinicians to receive a score for the Quality and Cost categories of the MIPS, without the need to collect and report on measures separately. Eligible providers would receive the MIPS score in those categories associated with the same percentile as their hospital’s score in HVBP. No more administrative work necessary to collect, clean and report on data for quality measures in the MIPS. If you are eligible, the CMS will automatically calculate a Quality and Cost score and combine this with your score from Improvement Activities and Promoting Interoperability (if you are not exempt) to give you a final MIPS score. If you decide to report on quality measures through the traditional MIPS pathway as well, the CMS will give you the higher of the scores.

There are certainly trade-offs associated with the facility-based measurement option. You do not have the burden of reporting measures on your own, but you do not get to pick what measures and what facility’s score you receive. Facility-level measures may be more difficult to improve performance, particularly as an individual, but the automatic application of facility-based measurement to eligible clinicians and groups serves as a backstop for MIPS reporting.

Aligning facility and clinician performance should encourage collaboration and innovation to meet these shared goals. As such, facility-based measurement represents a massive philosophical and practical shift in CMS measure reporting. As we enter these uncharted waters together, we hope to continue learning from your experiences and perspectives and working to refine facility-based measurement in the future.

For more information about facility-based reporting and the MIPS in general, visit www.macraforhm.org.

Mr. Lapps is government relations senior manager and Mr. Boswell is government relations director at the Society of Hospital Medicine.

Who is eligible for facility-based measurement?

• Individual providers who bill more than 75% of their Medicare Part B professional services in Place of Service 21 (Emergency Department), 22 (Hospital Outpatient), and 23 (Inpatient Hospital), billing at least one service in POS 21 or 23, and work in a hospital with an HVBP score.
• Groups who have at least 75% of their individual clinicians who meet the eligibility criteria.
• Nearly all hospitalists should qualify for facility-based measurement as individuals, while group eligibility depends on the demographics of their staff.

Laws and regulations regularly impact hospitalists and hospitalized patients, which is why SHM’s Advocacy Department and Public Policy Committee (PPC) work on behalf of SHM membership, the hospital medicine movement, and its patients.

This year has seen significant positive movement within several key policy areas for all of these groups. Some of these issues have made headlines, while others happened under the radar, but SHM and its members have played an important role within each of them.

In general, observation care and related issues have received increased attention from lawmakers in no small part as a result of SHM’s efforts in this area. Early in the summer, the Centers for Medicare and Medicaid Services (CMS) responded to SHM’s efforts by proposing changes to the two-midnight rule—softening yet still retaining the rule. SHM commented positively on the proposed changes but signaled to both CMS and Congress that still more needs to be done to address problems inherent within observation policy.

As CMS and Congress work on a long-term solution to issues related to observation stays, SHM will play an important role in both proposing solutions and providing feedback for potential changes.

In July 2015, CMS proposed to pay for advance care planning (ACP). This proposal, assuming it is finalized at press time, is one that SHM has advocated for and supported for almost two years. Hospitalists should consider it a victory. The PPC, SHM members, and staff have consistently advocated for improved ACP policies in urging Medicare to recognize the value in ACP and reimburse for these critical services.

Hospitalists have also played a major part in the advocacy efforts on the Congressional level, dispelling misconceptions surrounding ACP by educating members of Congress and their staff and explaining the importance of these conversations within the healthcare system. Consistent advocacy and hospitalist involvement have led to a positive response that has been a long time coming.

These are just a few examples of areas in which SHM has seen tangible accomplishments, but there are also issues that have yet to play out and require SHM’s efforts to remain consistent in the coming years.

One of these issues is a hospitalist-specific problem within the meaningful use program. Hospital-based physicians are exempt from meaningful use and associated penalties based on their percentages of inpatient services; however, due to the way the law was written and changes in the healthcare landscape since passage, an unintended consequence has arisen.

Hospitalists who care for significant numbers of “observation” and skilled nursing facility patients (coded as outpatient services) do not qualify as hospital-based under the law and are finding themselves subject to unfair penalties. In response to SHM advocacy, CMS provided a limited hardship exception for hospitalists in 2015 and extended it into 2016. This exception saved numerous hospitalist groups an estimated $2,000 to $3,000 per hospitalist per year.

The temporary exception was limited in scope, however, and a legislative fix is needed to ensure a permanent solution. SHM will continue to meet with legislators to discuss this issue and garner interest in what we hope will result in a permanent resolution to this issue.

Finally, passage of the Medicare Access and CHIP Reauthorization Act (MACRA) in April 2015 was one of the most important laws impacting physicians to pass in years. While it finally repealed the broken sustainable growth rate, its passage was just the beginning of SHM’s advocacy efforts on the legislation.

MACRA will fundamentally change the way in which physicians are compensated and will accelerate the transition away from fee-for-service (FFS) by encouraging alternative payment model (APM) participation; however, many details remain unclear and are in need of hospitalist-specific clarification. SHM has already begun engaging with federal agencies and lawmakers as the regulations for MACRA are developed, including initiating multi-stakeholder conversations about problems facing facility-based providers in pay-for-performance programs.

SHM’s Performance Measurement and Reporting Committee has been working closely with the PPC to devise concrete proposals that will allow physician/hospital alignment within mandated quality reporting programs, and the PPC has launched an APM workgroup that is exploring the most effective avenues for hospitalists to move away from FFS and take advantage of incentives that will be available under MACRA.

Successful advocacy efforts often take time, persistence, and most importantly, patience; these victories demonstrate that endurance pays off.

SHM is clearly making headway on behalf of hospitalists and patients, and will build off of the momentum that these victories have generated. As SHM Public Policy Committee chair, Ron Greeno, stated after SHM’s most recent victories, “There are times when we all ask if our efforts are all worth it, and the clear message that we have heard in the past few weeks is a resounding ‘Yes!’”

Success does take time, however, and help from SHM members is a critical part of the equation. Your voice does make a difference.

To stay up to date and get involved with SHM’s advocacy efforts, connect with SHM’s Grassroots Network at www.hospitalmedicine.org/grassroots, and join the policy discussions in the Advocacy and Public Policy community on HMX.

Josh Boswell is SHM’s director of government relations.

Laws and regulations regularly impact hospitalists and hospitalized patients, which is why SHM’s Advocacy Department and Public Policy Committee (PPC) work on behalf of SHM membership, the hospital medicine movement, and its patients.

This year has seen significant positive movement within several key policy areas for all of these groups. Some of these issues have made headlines, while others happened under the radar, but SHM and its members have played an important role within each of them.

In general, observation care and related issues have received increased attention from lawmakers in no small part as a result of SHM’s efforts in this area. Early in the summer, the Centers for Medicare and Medicaid Services (CMS) responded to SHM’s efforts by proposing changes to the two-midnight rule—softening yet still retaining the rule. SHM commented positively on the proposed changes but signaled to both CMS and Congress that still more needs to be done to address problems inherent within observation policy.

As CMS and Congress work on a long-term solution to issues related to observation stays, SHM will play an important role in both proposing solutions and providing feedback for potential changes.

In July 2015, CMS proposed to pay for advance care planning (ACP). This proposal, assuming it is finalized at press time, is one that SHM has advocated for and supported for almost two years. Hospitalists should consider it a victory. The PPC, SHM members, and staff have consistently advocated for improved ACP policies in urging Medicare to recognize the value in ACP and reimburse for these critical services.

Hospitalists have also played a major part in the advocacy efforts on the Congressional level, dispelling misconceptions surrounding ACP by educating members of Congress and their staff and explaining the importance of these conversations within the healthcare system. Consistent advocacy and hospitalist involvement have led to a positive response that has been a long time coming.

These are just a few examples of areas in which SHM has seen tangible accomplishments, but there are also issues that have yet to play out and require SHM’s efforts to remain consistent in the coming years.

One of these issues is a hospitalist-specific problem within the meaningful use program. Hospital-based physicians are exempt from meaningful use and associated penalties based on their percentages of inpatient services; however, due to the way the law was written and changes in the healthcare landscape since passage, an unintended consequence has arisen.

Hospitalists who care for significant numbers of “observation” and skilled nursing facility patients (coded as outpatient services) do not qualify as hospital-based under the law and are finding themselves subject to unfair penalties. In response to SHM advocacy, CMS provided a limited hardship exception for hospitalists in 2015 and extended it into 2016. This exception saved numerous hospitalist groups an estimated $2,000 to $3,000 per hospitalist per year.

The temporary exception was limited in scope, however, and a legislative fix is needed to ensure a permanent solution. SHM will continue to meet with legislators to discuss this issue and garner interest in what we hope will result in a permanent resolution to this issue.

Finally, passage of the Medicare Access and CHIP Reauthorization Act (MACRA) in April 2015 was one of the most important laws impacting physicians to pass in years. While it finally repealed the broken sustainable growth rate, its passage was just the beginning of SHM’s advocacy efforts on the legislation.

MACRA will fundamentally change the way in which physicians are compensated and will accelerate the transition away from fee-for-service (FFS) by encouraging alternative payment model (APM) participation; however, many details remain unclear and are in need of hospitalist-specific clarification. SHM has already begun engaging with federal agencies and lawmakers as the regulations for MACRA are developed, including initiating multi-stakeholder conversations about problems facing facility-based providers in pay-for-performance programs.

SHM’s Performance Measurement and Reporting Committee has been working closely with the PPC to devise concrete proposals that will allow physician/hospital alignment within mandated quality reporting programs, and the PPC has launched an APM workgroup that is exploring the most effective avenues for hospitalists to move away from FFS and take advantage of incentives that will be available under MACRA.

Successful advocacy efforts often take time, persistence, and most importantly, patience; these victories demonstrate that endurance pays off.

SHM is clearly making headway on behalf of hospitalists and patients, and will build off of the momentum that these victories have generated. As SHM Public Policy Committee chair, Ron Greeno, stated after SHM’s most recent victories, “There are times when we all ask if our efforts are all worth it, and the clear message that we have heard in the past few weeks is a resounding ‘Yes!’”

Success does take time, however, and help from SHM members is a critical part of the equation. Your voice does make a difference.

To stay up to date and get involved with SHM’s advocacy efforts, connect with SHM’s Grassroots Network at www.hospitalmedicine.org/grassroots, and join the policy discussions in the Advocacy and Public Policy community on HMX.

Josh Boswell is SHM’s director of government relations.

Laws and regulations regularly impact hospitalists and hospitalized patients, which is why SHM’s Advocacy Department and Public Policy Committee (PPC) work on behalf of SHM membership, the hospital medicine movement, and its patients.

This year has seen significant positive movement within several key policy areas for all of these groups. Some of these issues have made headlines, while others happened under the radar, but SHM and its members have played an important role within each of them.

In general, observation care and related issues have received increased attention from lawmakers in no small part as a result of SHM’s efforts in this area. Early in the summer, the Centers for Medicare and Medicaid Services (CMS) responded to SHM’s efforts by proposing changes to the two-midnight rule—softening yet still retaining the rule. SHM commented positively on the proposed changes but signaled to both CMS and Congress that still more needs to be done to address problems inherent within observation policy.

As CMS and Congress work on a long-term solution to issues related to observation stays, SHM will play an important role in both proposing solutions and providing feedback for potential changes.

In July 2015, CMS proposed to pay for advance care planning (ACP). This proposal, assuming it is finalized at press time, is one that SHM has advocated for and supported for almost two years. Hospitalists should consider it a victory. The PPC, SHM members, and staff have consistently advocated for improved ACP policies in urging Medicare to recognize the value in ACP and reimburse for these critical services.

Hospitalists have also played a major part in the advocacy efforts on the Congressional level, dispelling misconceptions surrounding ACP by educating members of Congress and their staff and explaining the importance of these conversations within the healthcare system. Consistent advocacy and hospitalist involvement have led to a positive response that has been a long time coming.

These are just a few examples of areas in which SHM has seen tangible accomplishments, but there are also issues that have yet to play out and require SHM’s efforts to remain consistent in the coming years.

One of these issues is a hospitalist-specific problem within the meaningful use program. Hospital-based physicians are exempt from meaningful use and associated penalties based on their percentages of inpatient services; however, due to the way the law was written and changes in the healthcare landscape since passage, an unintended consequence has arisen.

Hospitalists who care for significant numbers of “observation” and skilled nursing facility patients (coded as outpatient services) do not qualify as hospital-based under the law and are finding themselves subject to unfair penalties. In response to SHM advocacy, CMS provided a limited hardship exception for hospitalists in 2015 and extended it into 2016. This exception saved numerous hospitalist groups an estimated $2,000 to $3,000 per hospitalist per year.

The temporary exception was limited in scope, however, and a legislative fix is needed to ensure a permanent solution. SHM will continue to meet with legislators to discuss this issue and garner interest in what we hope will result in a permanent resolution to this issue.

Finally, passage of the Medicare Access and CHIP Reauthorization Act (MACRA) in April 2015 was one of the most important laws impacting physicians to pass in years. While it finally repealed the broken sustainable growth rate, its passage was just the beginning of SHM’s advocacy efforts on the legislation.

MACRA will fundamentally change the way in which physicians are compensated and will accelerate the transition away from fee-for-service (FFS) by encouraging alternative payment model (APM) participation; however, many details remain unclear and are in need of hospitalist-specific clarification. SHM has already begun engaging with federal agencies and lawmakers as the regulations for MACRA are developed, including initiating multi-stakeholder conversations about problems facing facility-based providers in pay-for-performance programs.

SHM’s Performance Measurement and Reporting Committee has been working closely with the PPC to devise concrete proposals that will allow physician/hospital alignment within mandated quality reporting programs, and the PPC has launched an APM workgroup that is exploring the most effective avenues for hospitalists to move away from FFS and take advantage of incentives that will be available under MACRA.

Successful advocacy efforts often take time, persistence, and most importantly, patience; these victories demonstrate that endurance pays off.

SHM is clearly making headway on behalf of hospitalists and patients, and will build off of the momentum that these victories have generated. As SHM Public Policy Committee chair, Ron Greeno, stated after SHM’s most recent victories, “There are times when we all ask if our efforts are all worth it, and the clear message that we have heard in the past few weeks is a resounding ‘Yes!’”

Success does take time, however, and help from SHM members is a critical part of the equation. Your voice does make a difference.

To stay up to date and get involved with SHM’s advocacy efforts, connect with SHM’s Grassroots Network at www.hospitalmedicine.org/grassroots, and join the policy discussions in the Advocacy and Public Policy community on HMX.

Josh Boswell is SHM’s director of government relations.

On Oct. 31, 2014, the Centers for Medicare and Medicaid Services (CMS) published the 2015 Medicare Physician Fee Schedule (MPFS) Proposed Rule. Included in the rule was an interesting discussion about the potential for Medicare to begin paying for advance care planning services.

CMS describes these services as “the explanation and discussion of advance directives, such as standard forms [with completion of such forms, when performed], by the physician or other qualified healthcare professional; face-to-face with the patient, family member[s], and/or surrogate.”

To enable billing for these services, CMS suggested the use of two new AMA-created CPT codes (99497 and 99498), which allow providers to be reimbursed for their consultation in end-of-life care conversations and also encourage the conversations to occur prior to their being clinically necessary. The codes are designed to cover substantive discussions about goals of care, treatment options, values, and preferences when it comes to end-of-life care planning.

This development was welcome news for many hospitalists who, too often, are called upon to participate in end-of-life care conversations that are long overdue. Hospitalists know these conversations help to ensure that patient wishes are respected at the end of life and also prevent the use of unwanted treatments or interventions.

In the best scenario, not only will Medicare payment for these codes encourage physicians to start these conversations prior to a stressful inpatient stay, but reimbursement also allows hospitalists and other relevant specialists to provide patients with the proper time, space, and expertise these important conversations require.

Disappointingly, CMS did not agree to start reimbursing the advance care planning codes for 2015; however, they did signal openness to the idea of reimbursing them in the future, leaving this aspect of an otherwise final rule open for further comment.

For its part, SHM responded with follow-up comments that both express disappointment with the CMS decision and further elaborate on the value of these codes for both hospitalists and patients.

Moving forward, hospitalists can be assured this is not a one-off issue for SHM.

For well over a year, SHM’s Public Policy Committee has been actively supporting legislation introduced by Rep. Earl Blumenauer (D-Ore.). The Personalize Your Care Act (H.R. 1173), similar to the CMS proposal, would establish Medicare reimbursement for voluntary advance care planning consultations, along with other beneficial treatment of advance care plans.

Nearly 200 members of SHM’s Grassroots Network have supported these efforts by sending letters to their own representatives in favor of Rep. Blumenauer’s bill. Moving into the new year and the 114th Congress, continued pressure will be placed on CMS, and plans are in motion to continue SHM support for a reintroduced Personalize Your Care Act.

Hospitalists wishing to assist in these efforts need only join SHM’s Grassroots Network and keep their eyes open for opportunities to help—they will be forthcoming.

To get involved today, visit www.hospitalmedicine.org/advocacy.

Josh Boswell is SHM’s director of government relations.

On Oct. 31, 2014, the Centers for Medicare and Medicaid Services (CMS) published the 2015 Medicare Physician Fee Schedule (MPFS) Proposed Rule. Included in the rule was an interesting discussion about the potential for Medicare to begin paying for advance care planning services.

CMS describes these services as “the explanation and discussion of advance directives, such as standard forms [with completion of such forms, when performed], by the physician or other qualified healthcare professional; face-to-face with the patient, family member[s], and/or surrogate.”

To enable billing for these services, CMS suggested the use of two new AMA-created CPT codes (99497 and 99498), which allow providers to be reimbursed for their consultation in end-of-life care conversations and also encourage the conversations to occur prior to their being clinically necessary. The codes are designed to cover substantive discussions about goals of care, treatment options, values, and preferences when it comes to end-of-life care planning.

This development was welcome news for many hospitalists who, too often, are called upon to participate in end-of-life care conversations that are long overdue. Hospitalists know these conversations help to ensure that patient wishes are respected at the end of life and also prevent the use of unwanted treatments or interventions.

In the best scenario, not only will Medicare payment for these codes encourage physicians to start these conversations prior to a stressful inpatient stay, but reimbursement also allows hospitalists and other relevant specialists to provide patients with the proper time, space, and expertise these important conversations require.

Disappointingly, CMS did not agree to start reimbursing the advance care planning codes for 2015; however, they did signal openness to the idea of reimbursing them in the future, leaving this aspect of an otherwise final rule open for further comment.

For its part, SHM responded with follow-up comments that both express disappointment with the CMS decision and further elaborate on the value of these codes for both hospitalists and patients.

Moving forward, hospitalists can be assured this is not a one-off issue for SHM.

For well over a year, SHM’s Public Policy Committee has been actively supporting legislation introduced by Rep. Earl Blumenauer (D-Ore.). The Personalize Your Care Act (H.R. 1173), similar to the CMS proposal, would establish Medicare reimbursement for voluntary advance care planning consultations, along with other beneficial treatment of advance care plans.

Nearly 200 members of SHM’s Grassroots Network have supported these efforts by sending letters to their own representatives in favor of Rep. Blumenauer’s bill. Moving into the new year and the 114th Congress, continued pressure will be placed on CMS, and plans are in motion to continue SHM support for a reintroduced Personalize Your Care Act.

Hospitalists wishing to assist in these efforts need only join SHM’s Grassroots Network and keep their eyes open for opportunities to help—they will be forthcoming.

To get involved today, visit www.hospitalmedicine.org/advocacy.

Josh Boswell is SHM’s director of government relations.

On Oct. 31, 2014, the Centers for Medicare and Medicaid Services (CMS) published the 2015 Medicare Physician Fee Schedule (MPFS) Proposed Rule. Included in the rule was an interesting discussion about the potential for Medicare to begin paying for advance care planning services.

CMS describes these services as “the explanation and discussion of advance directives, such as standard forms [with completion of such forms, when performed], by the physician or other qualified healthcare professional; face-to-face with the patient, family member[s], and/or surrogate.”

To enable billing for these services, CMS suggested the use of two new AMA-created CPT codes (99497 and 99498), which allow providers to be reimbursed for their consultation in end-of-life care conversations and also encourage the conversations to occur prior to their being clinically necessary. The codes are designed to cover substantive discussions about goals of care, treatment options, values, and preferences when it comes to end-of-life care planning.

This development was welcome news for many hospitalists who, too often, are called upon to participate in end-of-life care conversations that are long overdue. Hospitalists know these conversations help to ensure that patient wishes are respected at the end of life and also prevent the use of unwanted treatments or interventions.

In the best scenario, not only will Medicare payment for these codes encourage physicians to start these conversations prior to a stressful inpatient stay, but reimbursement also allows hospitalists and other relevant specialists to provide patients with the proper time, space, and expertise these important conversations require.

Disappointingly, CMS did not agree to start reimbursing the advance care planning codes for 2015; however, they did signal openness to the idea of reimbursing them in the future, leaving this aspect of an otherwise final rule open for further comment.

For its part, SHM responded with follow-up comments that both express disappointment with the CMS decision and further elaborate on the value of these codes for both hospitalists and patients.

Moving forward, hospitalists can be assured this is not a one-off issue for SHM.

For well over a year, SHM’s Public Policy Committee has been actively supporting legislation introduced by Rep. Earl Blumenauer (D-Ore.). The Personalize Your Care Act (H.R. 1173), similar to the CMS proposal, would establish Medicare reimbursement for voluntary advance care planning consultations, along with other beneficial treatment of advance care plans.

Nearly 200 members of SHM’s Grassroots Network have supported these efforts by sending letters to their own representatives in favor of Rep. Blumenauer’s bill. Moving into the new year and the 114th Congress, continued pressure will be placed on CMS, and plans are in motion to continue SHM support for a reintroduced Personalize Your Care Act.

Hospitalists wishing to assist in these efforts need only join SHM’s Grassroots Network and keep their eyes open for opportunities to help—they will be forthcoming.

To get involved today, visit www.hospitalmedicine.org/advocacy.

Josh Boswell is SHM’s director of government relations.

As many hospitalists are probably acutely aware, the Centers for Medicare & Medicaid Services (CMS) is putting a new rule into effect that will greatly impact how inpatient admission decisions are made. The rule, known as the “two-midnight rule,” states that if the admitting practitioner admits a Medicare beneficiary as an inpatient with the reasonable expectation that the beneficiary will require care that “crosses two midnights” and this decision is justified in the medical record, Medicare Part A payment is “generally appropriate.”

While there are multiple caveats, exceptions, and details, this rule can be simply articulated: If the admitting physician feels a patient will be in the hospital for a period longer than two midnights and the medical record supports this determination, the patient is an inpatient. Stays expected to be shorter than two midnights should be under observation status.

This new policy is an attempt to respond both to hospital calls for more guidance about when a beneficiary is appropriately treated as an inpatient—and paid by Medicare—and concerns about increasingly long hospital stays under observation status. Most hospitalists wrestle with status determination issues on a daily basis.

SHM is aware of the struggle and has been advocating on behalf of hospitalists to help shape observation status and the two-midnight rule. When the rule was first proposed, SHM voiced serious concerns about its utility and how it was unlikely to solve the overall confusion surrounding inpatient status determinations. Nevertheless, CMS finalized the rule as an attempt to begin addressing the problem.

Faced with an increasingly loud chorus of providers and hospitals concerned about the implementation of the new policy, CMS agreed to delay full enforcement from the original date of Oct. 1, 2013, until March 31, 2014.

During the delayed enforcement period, hospitals will be expected to begin implementing the two-midnight rule, and auditors will be giving hospitals non-punitive feedback on their application of the policy. To accomplish this, CMS is instructing Medicare Administrative Contractors (MACs) to review a sample of 10 to 25 inpatient hospital claims spanning less than two midnights after admission for each hospital. This probe sample will be used to assist hospitals with implementing the new requirements correctly. To give an additional level of comfort during this adjustment period, CMS has announced that it will not conduct post-payment patient status reviews for claims with dates of admission Oct. 1, 2013, through March 31, 2014.

Unfortunately, beyond the vague guidance CMS has offered thus far, there is no foolproof guide to establishing new hospital admissions policies that comply with the rule. As a result, there likely will be wide variation among hospitals.

To assist in sorting out the confusion, SHM will be hosting a webinar this month with case studies from several hospitals. The focus will be on the internal processes each hospital is using to implement the rule and how they were developed. Sharing and learning from national implementation experiences is a valuable way for hospitalists to gain new perspectives and to bring those experiences to their home institutions when considering their own roles in meeting the new admissions criteria head on.

For more information about the webinar and to register, visit www.hospitalmedicine.org today.

Josh Boswell is SHM’s senior manager of government relations.

As many hospitalists are probably acutely aware, the Centers for Medicare & Medicaid Services (CMS) is putting a new rule into effect that will greatly impact how inpatient admission decisions are made. The rule, known as the “two-midnight rule,” states that if the admitting practitioner admits a Medicare beneficiary as an inpatient with the reasonable expectation that the beneficiary will require care that “crosses two midnights” and this decision is justified in the medical record, Medicare Part A payment is “generally appropriate.”

While there are multiple caveats, exceptions, and details, this rule can be simply articulated: If the admitting physician feels a patient will be in the hospital for a period longer than two midnights and the medical record supports this determination, the patient is an inpatient. Stays expected to be shorter than two midnights should be under observation status.

This new policy is an attempt to respond both to hospital calls for more guidance about when a beneficiary is appropriately treated as an inpatient—and paid by Medicare—and concerns about increasingly long hospital stays under observation status. Most hospitalists wrestle with status determination issues on a daily basis.

SHM is aware of the struggle and has been advocating on behalf of hospitalists to help shape observation status and the two-midnight rule. When the rule was first proposed, SHM voiced serious concerns about its utility and how it was unlikely to solve the overall confusion surrounding inpatient status determinations. Nevertheless, CMS finalized the rule as an attempt to begin addressing the problem.

Faced with an increasingly loud chorus of providers and hospitals concerned about the implementation of the new policy, CMS agreed to delay full enforcement from the original date of Oct. 1, 2013, until March 31, 2014.

During the delayed enforcement period, hospitals will be expected to begin implementing the two-midnight rule, and auditors will be giving hospitals non-punitive feedback on their application of the policy. To accomplish this, CMS is instructing Medicare Administrative Contractors (MACs) to review a sample of 10 to 25 inpatient hospital claims spanning less than two midnights after admission for each hospital. This probe sample will be used to assist hospitals with implementing the new requirements correctly. To give an additional level of comfort during this adjustment period, CMS has announced that it will not conduct post-payment patient status reviews for claims with dates of admission Oct. 1, 2013, through March 31, 2014.

Unfortunately, beyond the vague guidance CMS has offered thus far, there is no foolproof guide to establishing new hospital admissions policies that comply with the rule. As a result, there likely will be wide variation among hospitals.

To assist in sorting out the confusion, SHM will be hosting a webinar this month with case studies from several hospitals. The focus will be on the internal processes each hospital is using to implement the rule and how they were developed. Sharing and learning from national implementation experiences is a valuable way for hospitalists to gain new perspectives and to bring those experiences to their home institutions when considering their own roles in meeting the new admissions criteria head on.

For more information about the webinar and to register, visit www.hospitalmedicine.org today.

Josh Boswell is SHM’s senior manager of government relations.

As many hospitalists are probably acutely aware, the Centers for Medicare & Medicaid Services (CMS) is putting a new rule into effect that will greatly impact how inpatient admission decisions are made. The rule, known as the “two-midnight rule,” states that if the admitting practitioner admits a Medicare beneficiary as an inpatient with the reasonable expectation that the beneficiary will require care that “crosses two midnights” and this decision is justified in the medical record, Medicare Part A payment is “generally appropriate.”

While there are multiple caveats, exceptions, and details, this rule can be simply articulated: If the admitting physician feels a patient will be in the hospital for a period longer than two midnights and the medical record supports this determination, the patient is an inpatient. Stays expected to be shorter than two midnights should be under observation status.

This new policy is an attempt to respond both to hospital calls for more guidance about when a beneficiary is appropriately treated as an inpatient—and paid by Medicare—and concerns about increasingly long hospital stays under observation status. Most hospitalists wrestle with status determination issues on a daily basis.

SHM is aware of the struggle and has been advocating on behalf of hospitalists to help shape observation status and the two-midnight rule. When the rule was first proposed, SHM voiced serious concerns about its utility and how it was unlikely to solve the overall confusion surrounding inpatient status determinations. Nevertheless, CMS finalized the rule as an attempt to begin addressing the problem.

Faced with an increasingly loud chorus of providers and hospitals concerned about the implementation of the new policy, CMS agreed to delay full enforcement from the original date of Oct. 1, 2013, until March 31, 2014.

During the delayed enforcement period, hospitals will be expected to begin implementing the two-midnight rule, and auditors will be giving hospitals non-punitive feedback on their application of the policy. To accomplish this, CMS is instructing Medicare Administrative Contractors (MACs) to review a sample of 10 to 25 inpatient hospital claims spanning less than two midnights after admission for each hospital. This probe sample will be used to assist hospitals with implementing the new requirements correctly. To give an additional level of comfort during this adjustment period, CMS has announced that it will not conduct post-payment patient status reviews for claims with dates of admission Oct. 1, 2013, through March 31, 2014.

Unfortunately, beyond the vague guidance CMS has offered thus far, there is no foolproof guide to establishing new hospital admissions policies that comply with the rule. As a result, there likely will be wide variation among hospitals.

To assist in sorting out the confusion, SHM will be hosting a webinar this month with case studies from several hospitals. The focus will be on the internal processes each hospital is using to implement the rule and how they were developed. Sharing and learning from national implementation experiences is a valuable way for hospitalists to gain new perspectives and to bring those experiences to their home institutions when considering their own roles in meeting the new admissions criteria head on.

For more information about the webinar and to register, visit www.hospitalmedicine.org today.

Josh Boswell is SHM’s senior manager of government relations.

With the voluntary and incentive period for participating in the Physician Quality Reporting System (PQRS) quickly coming to a close, hospitalists are finding a limited number of PQRS measures broadly applicable to their practice. SHM, through its Performance Measurement and Reporting Committee (PMRC), is actively working on behalf of hospitalists to change that. At the same time, it is critical that hospitalists be proactive and participate in PQRS, not just to avoid the 2015 penalty, but to position themselves for success as the Value-Based Payment Modifier (VBPM) expands to all physicians by 2017.

In the current PQRS, the PMRC has identified the following measures that have appropriate inpatient codes for reporting and have potential relevance to hospitalists:

• Congestive Heart Failure (CHF): #5, ACE/ARB for LV systolic dysfunction; #8, beta-blocker prescribed for LV systolic dysfunction; #228, assessment of LV function.
• Stroke: #31, DVT prophylaxis; #32, discharge on antiplatelet therapy; #33, anticoagulation for atrial fibrillation; #35, dysphagia screening; #36, consideration of rehab; #187, thrombolytic therapy.
• Others: #47, advance care plan documented; #76, use of a central venous catheter insertion protocol.

Some of these measures are only reportable by registry. For groups who do not take care of stroke patients, the field is clearly limited. More detail on PQRS reporting and available codes can be found at the Centers for Medicare and Medicaid Services (CMS) website (www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/PQRS/MeasuresCodes.html).

The committee is deeply concerned about the limited number of PQRS measures broadly applicable to hospitalists, and we are working to change this disparity. Over the past several months, the PMRC has successfully advocated to add inpatient codes to existing measures that will expand the field for hospitalists. So far, we have achieved the following changes for future PQRS reporting years:

• Community-acquired pneumonia (CAP): Measures #56 (vital signs) and #59 (empiric antibiotics) will have admission codes 99221, 99222, and 99223 added to the denominator.
• Osteoporosis/fractures: Measure #24 (communication with the outpatient provider) and #40 (DXA scan ordered or therapy initiated) will have discharge codes 99238 and 99239 added to their denominator, in recognition of the fact that many hospitalists partner with their orthopedic colleagues in the care of patients post-hip fracture.
• Medication reconciliation: Measure #130 (documentation of current medication list) will have admission codes 99221, 99222, and 99223 added to the denominator.
• Anticoagulation for acute pulmonary embolism:  Measure #252, intended for use by ED physicians, is being retired by CMS due to a loss of National Quality Forum endorsement. SHM is working with the American College of Emergency Physicians (ACEP) to appeal the decision, possibly maintain the measure, and add inpatient admission codes to the denominator. This remains a work in progress.

Finally, in response to SHM advocacy efforts, the recent FY2014 Physician Fee Schedule proposed rule sought comments from stakeholders about retooling certain hospital-based measures to allow for physician-level reporting. SHM supports the concept of allowing physician-level performance reporting on hospital metrics and recommended the inclusion of multiple measures from the Inpatient Quality Reporting Program.

The PMRC is charged with monitoring the rapidly evolving provider performance and measurement landscape to ensure that hospitalists are adequately represented. We will continue to work diligently with key stakeholders on behalf of our field.

Dr. Seymann is chief of the division of hospital medicine at the University of California San Diego and chair of SHM’s Performance Measurement and Reporting Committee. Josh Boswell is SHM’s senior manager of government relations.

With the voluntary and incentive period for participating in the Physician Quality Reporting System (PQRS) quickly coming to a close, hospitalists are finding a limited number of PQRS measures broadly applicable to their practice. SHM, through its Performance Measurement and Reporting Committee (PMRC), is actively working on behalf of hospitalists to change that. At the same time, it is critical that hospitalists be proactive and participate in PQRS, not just to avoid the 2015 penalty, but to position themselves for success as the Value-Based Payment Modifier (VBPM) expands to all physicians by 2017.

In the current PQRS, the PMRC has identified the following measures that have appropriate inpatient codes for reporting and have potential relevance to hospitalists:

• Congestive Heart Failure (CHF): #5, ACE/ARB for LV systolic dysfunction; #8, beta-blocker prescribed for LV systolic dysfunction; #228, assessment of LV function.
• Stroke: #31, DVT prophylaxis; #32, discharge on antiplatelet therapy; #33, anticoagulation for atrial fibrillation; #35, dysphagia screening; #36, consideration of rehab; #187, thrombolytic therapy.
• Others: #47, advance care plan documented; #76, use of a central venous catheter insertion protocol.

Some of these measures are only reportable by registry. For groups who do not take care of stroke patients, the field is clearly limited. More detail on PQRS reporting and available codes can be found at the Centers for Medicare and Medicaid Services (CMS) website (www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/PQRS/MeasuresCodes.html).

The committee is deeply concerned about the limited number of PQRS measures broadly applicable to hospitalists, and we are working to change this disparity. Over the past several months, the PMRC has successfully advocated to add inpatient codes to existing measures that will expand the field for hospitalists. So far, we have achieved the following changes for future PQRS reporting years:

• Community-acquired pneumonia (CAP): Measures #56 (vital signs) and #59 (empiric antibiotics) will have admission codes 99221, 99222, and 99223 added to the denominator.
• Osteoporosis/fractures: Measure #24 (communication with the outpatient provider) and #40 (DXA scan ordered or therapy initiated) will have discharge codes 99238 and 99239 added to their denominator, in recognition of the fact that many hospitalists partner with their orthopedic colleagues in the care of patients post-hip fracture.
• Medication reconciliation: Measure #130 (documentation of current medication list) will have admission codes 99221, 99222, and 99223 added to the denominator.
• Anticoagulation for acute pulmonary embolism:  Measure #252, intended for use by ED physicians, is being retired by CMS due to a loss of National Quality Forum endorsement. SHM is working with the American College of Emergency Physicians (ACEP) to appeal the decision, possibly maintain the measure, and add inpatient admission codes to the denominator. This remains a work in progress.

Finally, in response to SHM advocacy efforts, the recent FY2014 Physician Fee Schedule proposed rule sought comments from stakeholders about retooling certain hospital-based measures to allow for physician-level reporting. SHM supports the concept of allowing physician-level performance reporting on hospital metrics and recommended the inclusion of multiple measures from the Inpatient Quality Reporting Program.

The PMRC is charged with monitoring the rapidly evolving provider performance and measurement landscape to ensure that hospitalists are adequately represented. We will continue to work diligently with key stakeholders on behalf of our field.

Dr. Seymann is chief of the division of hospital medicine at the University of California San Diego and chair of SHM’s Performance Measurement and Reporting Committee. Josh Boswell is SHM’s senior manager of government relations.

With the voluntary and incentive period for participating in the Physician Quality Reporting System (PQRS) quickly coming to a close, hospitalists are finding a limited number of PQRS measures broadly applicable to their practice. SHM, through its Performance Measurement and Reporting Committee (PMRC), is actively working on behalf of hospitalists to change that. At the same time, it is critical that hospitalists be proactive and participate in PQRS, not just to avoid the 2015 penalty, but to position themselves for success as the Value-Based Payment Modifier (VBPM) expands to all physicians by 2017.

In the current PQRS, the PMRC has identified the following measures that have appropriate inpatient codes for reporting and have potential relevance to hospitalists:

• Congestive Heart Failure (CHF): #5, ACE/ARB for LV systolic dysfunction; #8, beta-blocker prescribed for LV systolic dysfunction; #228, assessment of LV function.
• Stroke: #31, DVT prophylaxis; #32, discharge on antiplatelet therapy; #33, anticoagulation for atrial fibrillation; #35, dysphagia screening; #36, consideration of rehab; #187, thrombolytic therapy.
• Others: #47, advance care plan documented; #76, use of a central venous catheter insertion protocol.

Some of these measures are only reportable by registry. For groups who do not take care of stroke patients, the field is clearly limited. More detail on PQRS reporting and available codes can be found at the Centers for Medicare and Medicaid Services (CMS) website (www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/PQRS/MeasuresCodes.html).

The committee is deeply concerned about the limited number of PQRS measures broadly applicable to hospitalists, and we are working to change this disparity. Over the past several months, the PMRC has successfully advocated to add inpatient codes to existing measures that will expand the field for hospitalists. So far, we have achieved the following changes for future PQRS reporting years:

• Community-acquired pneumonia (CAP): Measures #56 (vital signs) and #59 (empiric antibiotics) will have admission codes 99221, 99222, and 99223 added to the denominator.
• Osteoporosis/fractures: Measure #24 (communication with the outpatient provider) and #40 (DXA scan ordered or therapy initiated) will have discharge codes 99238 and 99239 added to their denominator, in recognition of the fact that many hospitalists partner with their orthopedic colleagues in the care of patients post-hip fracture.
• Medication reconciliation: Measure #130 (documentation of current medication list) will have admission codes 99221, 99222, and 99223 added to the denominator.
• Anticoagulation for acute pulmonary embolism:  Measure #252, intended for use by ED physicians, is being retired by CMS due to a loss of National Quality Forum endorsement. SHM is working with the American College of Emergency Physicians (ACEP) to appeal the decision, possibly maintain the measure, and add inpatient admission codes to the denominator. This remains a work in progress.

Finally, in response to SHM advocacy efforts, the recent FY2014 Physician Fee Schedule proposed rule sought comments from stakeholders about retooling certain hospital-based measures to allow for physician-level reporting. SHM supports the concept of allowing physician-level performance reporting on hospital metrics and recommended the inclusion of multiple measures from the Inpatient Quality Reporting Program.

The PMRC is charged with monitoring the rapidly evolving provider performance and measurement landscape to ensure that hospitalists are adequately represented. We will continue to work diligently with key stakeholders on behalf of our field.

Dr. Seymann is chief of the division of hospital medicine at the University of California San Diego and chair of SHM’s Performance Measurement and Reporting Committee. Josh Boswell is SHM’s senior manager of government relations.

On March 7, the Centers for Medicare & Medicaid Services (CMS) released a proposed rule: Medicare and Medicaid Programs; Electronic Health Record Incentive Program—Stage 2. This rule is more commonly known as “Stage 2 of meaningful use.” At more than 130 pages, the rule builds upon Stage 1 of the program mainly by increasing measurement thresholds and requiring higher levels of system functionality.

Although there are no major surprises within the proposed rule, there is always one very basic yet very important question that surfaces when meaningful use makes headlines: Are hospitalists eligible for health information technology (HIT) incentives and thus subject to the meaningful use requirements?

“No” is the short answer to this question. Although physicians, including hospitalists, are considered eligible professionals (EPs) under the HIT incentive program, a subset of EPs are defined as hospital-based EPs and, therefore, are not subject to the program’s requirements. CMS defines a hospital-based eligible professional as an EP who furnishes 90% or more of their covered professional services in either the inpatient division or ED of a hospital.

While some may call this an exemption for hospitalists, it is not that definitive. Hospitalists are still “eligible,” and the determination is not made by specialty, but by pattern of practice. This means that hospitalists could find themselves on the hook for future penalties if their practice patterns expand beyond CMS’ 90% threshold.

An example of this would be a hospitalist who spends time doing rounds at a nursing home. Today, this might constitute only a small percentage of a hospitalist’s practice, but with an increasingly aging population, it is not inconceivable that this small percentage could exceed 10% within five or 10 years.

With this in mind, and a similar scenario also present in the Electronic Prescribing Incentive Program (eRx), SHM has consistently pointed out the issue to CMS and is working to find an acceptable solution.

Although hospitalists are not currently subject to physician meaningful-use requirements, the program has another category of eligibility that will certainly affect hospitalists: the eligible hospital, or EH. Many hospitalists are directly involved with HIT implementation efforts at their institutions or are indirectly working with these systems as they are implemented and expanded in hospitals across the country.

Given the 90% eligibility threshold and the role of HIT in hospitals, it is important for hospitalists to stay current and informed on meaningful use and HIT policy. Involvement with one of SHM’s HIT related committees is a clear way to stay informed in this ever-evolving area, and SHM’s efforts can be reviewed on the Advocacy page of SHM’s website: www.hospitalmedicine.org/advocacy.

For the most up-to-date information on what is being done at the federal level, the Office of the National Coordinator (ONC) has a wealth of information available at www.healthit.gov/.

SHM will continue to monitor and analyze developments and changes to EHR policy, but it also looks to you, its members, for experience and insight.

On March 7, the Centers for Medicare & Medicaid Services (CMS) released a proposed rule: Medicare and Medicaid Programs; Electronic Health Record Incentive Program—Stage 2. This rule is more commonly known as “Stage 2 of meaningful use.” At more than 130 pages, the rule builds upon Stage 1 of the program mainly by increasing measurement thresholds and requiring higher levels of system functionality.

Although there are no major surprises within the proposed rule, there is always one very basic yet very important question that surfaces when meaningful use makes headlines: Are hospitalists eligible for health information technology (HIT) incentives and thus subject to the meaningful use requirements?

“No” is the short answer to this question. Although physicians, including hospitalists, are considered eligible professionals (EPs) under the HIT incentive program, a subset of EPs are defined as hospital-based EPs and, therefore, are not subject to the program’s requirements. CMS defines a hospital-based eligible professional as an EP who furnishes 90% or more of their covered professional services in either the inpatient division or ED of a hospital.

While some may call this an exemption for hospitalists, it is not that definitive. Hospitalists are still “eligible,” and the determination is not made by specialty, but by pattern of practice. This means that hospitalists could find themselves on the hook for future penalties if their practice patterns expand beyond CMS’ 90% threshold.

An example of this would be a hospitalist who spends time doing rounds at a nursing home. Today, this might constitute only a small percentage of a hospitalist’s practice, but with an increasingly aging population, it is not inconceivable that this small percentage could exceed 10% within five or 10 years.

With this in mind, and a similar scenario also present in the Electronic Prescribing Incentive Program (eRx), SHM has consistently pointed out the issue to CMS and is working to find an acceptable solution.

Although hospitalists are not currently subject to physician meaningful-use requirements, the program has another category of eligibility that will certainly affect hospitalists: the eligible hospital, or EH. Many hospitalists are directly involved with HIT implementation efforts at their institutions or are indirectly working with these systems as they are implemented and expanded in hospitals across the country.

Given the 90% eligibility threshold and the role of HIT in hospitals, it is important for hospitalists to stay current and informed on meaningful use and HIT policy. Involvement with one of SHM’s HIT related committees is a clear way to stay informed in this ever-evolving area, and SHM’s efforts can be reviewed on the Advocacy page of SHM’s website: www.hospitalmedicine.org/advocacy.

For the most up-to-date information on what is being done at the federal level, the Office of the National Coordinator (ONC) has a wealth of information available at www.healthit.gov/.

SHM will continue to monitor and analyze developments and changes to EHR policy, but it also looks to you, its members, for experience and insight.

On March 7, the Centers for Medicare & Medicaid Services (CMS) released a proposed rule: Medicare and Medicaid Programs; Electronic Health Record Incentive Program—Stage 2. This rule is more commonly known as “Stage 2 of meaningful use.” At more than 130 pages, the rule builds upon Stage 1 of the program mainly by increasing measurement thresholds and requiring higher levels of system functionality.

Although there are no major surprises within the proposed rule, there is always one very basic yet very important question that surfaces when meaningful use makes headlines: Are hospitalists eligible for health information technology (HIT) incentives and thus subject to the meaningful use requirements?

“No” is the short answer to this question. Although physicians, including hospitalists, are considered eligible professionals (EPs) under the HIT incentive program, a subset of EPs are defined as hospital-based EPs and, therefore, are not subject to the program’s requirements. CMS defines a hospital-based eligible professional as an EP who furnishes 90% or more of their covered professional services in either the inpatient division or ED of a hospital.

While some may call this an exemption for hospitalists, it is not that definitive. Hospitalists are still “eligible,” and the determination is not made by specialty, but by pattern of practice. This means that hospitalists could find themselves on the hook for future penalties if their practice patterns expand beyond CMS’ 90% threshold.

An example of this would be a hospitalist who spends time doing rounds at a nursing home. Today, this might constitute only a small percentage of a hospitalist’s practice, but with an increasingly aging population, it is not inconceivable that this small percentage could exceed 10% within five or 10 years.

With this in mind, and a similar scenario also present in the Electronic Prescribing Incentive Program (eRx), SHM has consistently pointed out the issue to CMS and is working to find an acceptable solution.

Although hospitalists are not currently subject to physician meaningful-use requirements, the program has another category of eligibility that will certainly affect hospitalists: the eligible hospital, or EH. Many hospitalists are directly involved with HIT implementation efforts at their institutions or are indirectly working with these systems as they are implemented and expanded in hospitals across the country.

Given the 90% eligibility threshold and the role of HIT in hospitals, it is important for hospitalists to stay current and informed on meaningful use and HIT policy. Involvement with one of SHM’s HIT related committees is a clear way to stay informed in this ever-evolving area, and SHM’s efforts can be reviewed on the Advocacy page of SHM’s website: www.hospitalmedicine.org/advocacy.

For the most up-to-date information on what is being done at the federal level, the Office of the National Coordinator (ONC) has a wealth of information available at www.healthit.gov/.

SHM will continue to monitor and analyze developments and changes to EHR policy, but it also looks to you, its members, for experience and insight.

“A auick glance at the CMMI website didn’t provide much detail beyond uplifting language about the promise that the center represents.” —Policy Corner, January 2011

Alittle over a year ago, this column made the above statement about the launch of the Center for Medicare and Medicaid Innovation (CMMI) and its charge under the Affordable Care Act (ACA) to test ways to reduce costs while preserving or enhancing the quality of healthcare. A lot has happened in the past year at CMMI, and many details can now be filled in. Some of those details directly relate to the work of hospitalists.

The first and most-often-cited action taken by CMMI is the launch of the Pioneer ACO initiative. The Pioneer ACO model is designed specifically for groups of providers with experience working together to coordinate care for patients. The initiative is designed to test the effectiveness of several payment models and how they can provide better care for beneficiaries, work in coordination with private payors, and reduce Medicare cost growth.

In December 2011, 32 Pioneer ACOs were announced; a performance period began on Jan. 12. Thus, Pioneer ACOs are a reality, and several hospitalists have informed SHM that their institutions are participating.

Also on the ACO front, CMMI has made an effort to answer one of the most-cited barriers to ACO formation: start-up funding. In trying to answer this concern, CMMI has established the Advance Payment ACO Model. It is designed to provide support to rural and physician-owned organizations whose ability to successfully start an ACO would be improved with additional access to capital. This program will provide upfront payments and monthly payments to ACOs based on certain criteria. The first application period ended Feb. 1, so we should soon know which organizations are taking advantage of the opportunity.

A final example of CMMI activity is a $1 billion investment in the Partnership for Patients, an initiative to reduce preventable hospital-acquired conditions by 40% and hospital readmissions by 20% by 2013. The partnership has chosen 26 Hospital Engagement Networks to help identify solutions that already are working and spread those solutions to other hospitals and healthcare providers. Because the goals of the program cover areas in which hospitalists have both expertise and success, SHM is partnering with Hospital Engagement Networks to help achieve the goals of the program.

This update is by no means comprehensive. CMMI has started quite a few other programs over the past year, and all of them can be viewed in detail at http://innovations.cms.gov/.

Please let us know if you are involved with any of these initiatives. Your experience and insight could be helpful in advocating for the needs of hospitalists, and might also be useful to others who find themselves involved in the near future.

Joshua Boswell, interim senior manager, government relations

“A auick glance at the CMMI website didn’t provide much detail beyond uplifting language about the promise that the center represents.” —Policy Corner, January 2011

Alittle over a year ago, this column made the above statement about the launch of the Center for Medicare and Medicaid Innovation (CMMI) and its charge under the Affordable Care Act (ACA) to test ways to reduce costs while preserving or enhancing the quality of healthcare. A lot has happened in the past year at CMMI, and many details can now be filled in. Some of those details directly relate to the work of hospitalists.

The first and most-often-cited action taken by CMMI is the launch of the Pioneer ACO initiative. The Pioneer ACO model is designed specifically for groups of providers with experience working together to coordinate care for patients. The initiative is designed to test the effectiveness of several payment models and how they can provide better care for beneficiaries, work in coordination with private payors, and reduce Medicare cost growth.

In December 2011, 32 Pioneer ACOs were announced; a performance period began on Jan. 12. Thus, Pioneer ACOs are a reality, and several hospitalists have informed SHM that their institutions are participating.

Also on the ACO front, CMMI has made an effort to answer one of the most-cited barriers to ACO formation: start-up funding. In trying to answer this concern, CMMI has established the Advance Payment ACO Model. It is designed to provide support to rural and physician-owned organizations whose ability to successfully start an ACO would be improved with additional access to capital. This program will provide upfront payments and monthly payments to ACOs based on certain criteria. The first application period ended Feb. 1, so we should soon know which organizations are taking advantage of the opportunity.

A final example of CMMI activity is a $1 billion investment in the Partnership for Patients, an initiative to reduce preventable hospital-acquired conditions by 40% and hospital readmissions by 20% by 2013. The partnership has chosen 26 Hospital Engagement Networks to help identify solutions that already are working and spread those solutions to other hospitals and healthcare providers. Because the goals of the program cover areas in which hospitalists have both expertise and success, SHM is partnering with Hospital Engagement Networks to help achieve the goals of the program.

This update is by no means comprehensive. CMMI has started quite a few other programs over the past year, and all of them can be viewed in detail at http://innovations.cms.gov/.

Please let us know if you are involved with any of these initiatives. Your experience and insight could be helpful in advocating for the needs of hospitalists, and might also be useful to others who find themselves involved in the near future.

Joshua Boswell, interim senior manager, government relations

“A auick glance at the CMMI website didn’t provide much detail beyond uplifting language about the promise that the center represents.” —Policy Corner, January 2011

Alittle over a year ago, this column made the above statement about the launch of the Center for Medicare and Medicaid Innovation (CMMI) and its charge under the Affordable Care Act (ACA) to test ways to reduce costs while preserving or enhancing the quality of healthcare. A lot has happened in the past year at CMMI, and many details can now be filled in. Some of those details directly relate to the work of hospitalists.

The first and most-often-cited action taken by CMMI is the launch of the Pioneer ACO initiative. The Pioneer ACO model is designed specifically for groups of providers with experience working together to coordinate care for patients. The initiative is designed to test the effectiveness of several payment models and how they can provide better care for beneficiaries, work in coordination with private payors, and reduce Medicare cost growth.

In December 2011, 32 Pioneer ACOs were announced; a performance period began on Jan. 12. Thus, Pioneer ACOs are a reality, and several hospitalists have informed SHM that their institutions are participating.

Also on the ACO front, CMMI has made an effort to answer one of the most-cited barriers to ACO formation: start-up funding. In trying to answer this concern, CMMI has established the Advance Payment ACO Model. It is designed to provide support to rural and physician-owned organizations whose ability to successfully start an ACO would be improved with additional access to capital. This program will provide upfront payments and monthly payments to ACOs based on certain criteria. The first application period ended Feb. 1, so we should soon know which organizations are taking advantage of the opportunity.

A final example of CMMI activity is a $1 billion investment in the Partnership for Patients, an initiative to reduce preventable hospital-acquired conditions by 40% and hospital readmissions by 20% by 2013. The partnership has chosen 26 Hospital Engagement Networks to help identify solutions that already are working and spread those solutions to other hospitals and healthcare providers. Because the goals of the program cover areas in which hospitalists have both expertise and success, SHM is partnering with Hospital Engagement Networks to help achieve the goals of the program.

This update is by no means comprehensive. CMMI has started quite a few other programs over the past year, and all of them can be viewed in detail at http://innovations.cms.gov/.

Please let us know if you are involved with any of these initiatives. Your experience and insight could be helpful in advocating for the needs of hospitalists, and might also be useful to others who find themselves involved in the near future.

Joshua Boswell, interim senior manager, government relations

Faced with a looming 27% cut in Medicare physician payment rates and a one-year timeline to find a solution, 2011 was the year Congress was going to stop the vicious circle of short-term “doc fix” patches and finally put an end to the Sustainable Growth Rate (SGR) formula. A serious solution really did seem possible when the House Energy and Commerce Committee solicited ideas on how to solve the problem.

SHM and other healthcare groups responded, and there seemed to be genuine interest in acting on the various plans that were presented.

What happened?

In reality, 2011 became the year of deficit reduction (if not in actions, at least in words). Every discussion in Congress seemed to come back to the deficit. Hearings were held, countless bills were introduced, blame was cast, and, eventually, the powerful Joint Deficit Deduction Committee, or “supercommittee,” was charged with finding at least $1.5 trillion in savings. At one point, the committee was even urged to “go big” and come up with $4 trillion in savings.

The deficit-reduction-or-bust mentality suddenly made an SGR fix and its $300 billion price tag seem like a pretty hard sell.

Undaunted, groups representing caregivers tried to turn the focus on the deficit into an opportunity and even approached the supercommittee to resolve the SGR matter—an illogical step at first glance, but the reasoning did make long-term sense. The cost of fixing the SGR will only increase with time, and it is estimated that elimination will cost $600 billion in 2016. A timely fix will be cheaper, as delay will only serve to further increase the deficit.

In an effort to appeal to the deficit committee, SHM worked closely with U.S. Rep. Allyson Schwartz (D-Pa.) to develop and submit a framework for eliminating the SGR and eventually phasing out fee-for-service. Despite these efforts, the deficit committee failed, and lawmakers were left with limited time before the scheduled SGR payment cuts were to take effect on Jan. 1.

As 2011 came to a close, a short-term extension that would last until the end of February was all that Congress could agree to. The SGR cycle began anew.

The positive in all this is that, although an SGR replacement did not happen in 2011 and action in 2012 might turn out to be exceedingly difficult, there are now realistic replacement plans out there. For example, Schwartz is looking to introduce legislation based on her above-mentioned framework, but doing so will need broad support.

Moving forward, it will be imperative for societies like SHM and practitioners like hospitalists to keep pressure on Congress. Individual hospitalists will continue to play an important role by contacting their elected officials. This can be done through personal phone calls and letters, or by responding to SHM’s legislative action alerts. You can even act now by visiting SHM’s legislative action center.

For more public policy information and resources, visit www.hospitalmedicine.org/advocacy

Faced with a looming 27% cut in Medicare physician payment rates and a one-year timeline to find a solution, 2011 was the year Congress was going to stop the vicious circle of short-term “doc fix” patches and finally put an end to the Sustainable Growth Rate (SGR) formula. A serious solution really did seem possible when the House Energy and Commerce Committee solicited ideas on how to solve the problem.

SHM and other healthcare groups responded, and there seemed to be genuine interest in acting on the various plans that were presented.

What happened?

In reality, 2011 became the year of deficit reduction (if not in actions, at least in words). Every discussion in Congress seemed to come back to the deficit. Hearings were held, countless bills were introduced, blame was cast, and, eventually, the powerful Joint Deficit Deduction Committee, or “supercommittee,” was charged with finding at least $1.5 trillion in savings. At one point, the committee was even urged to “go big” and come up with $4 trillion in savings.

The deficit-reduction-or-bust mentality suddenly made an SGR fix and its $300 billion price tag seem like a pretty hard sell.

Undaunted, groups representing caregivers tried to turn the focus on the deficit into an opportunity and even approached the supercommittee to resolve the SGR matter—an illogical step at first glance, but the reasoning did make long-term sense. The cost of fixing the SGR will only increase with time, and it is estimated that elimination will cost $600 billion in 2016. A timely fix will be cheaper, as delay will only serve to further increase the deficit.

In an effort to appeal to the deficit committee, SHM worked closely with U.S. Rep. Allyson Schwartz (D-Pa.) to develop and submit a framework for eliminating the SGR and eventually phasing out fee-for-service. Despite these efforts, the deficit committee failed, and lawmakers were left with limited time before the scheduled SGR payment cuts were to take effect on Jan. 1.

As 2011 came to a close, a short-term extension that would last until the end of February was all that Congress could agree to. The SGR cycle began anew.

The positive in all this is that, although an SGR replacement did not happen in 2011 and action in 2012 might turn out to be exceedingly difficult, there are now realistic replacement plans out there. For example, Schwartz is looking to introduce legislation based on her above-mentioned framework, but doing so will need broad support.

Moving forward, it will be imperative for societies like SHM and practitioners like hospitalists to keep pressure on Congress. Individual hospitalists will continue to play an important role by contacting their elected officials. This can be done through personal phone calls and letters, or by responding to SHM’s legislative action alerts. You can even act now by visiting SHM’s legislative action center.

For more public policy information and resources, visit www.hospitalmedicine.org/advocacy

Faced with a looming 27% cut in Medicare physician payment rates and a one-year timeline to find a solution, 2011 was the year Congress was going to stop the vicious circle of short-term “doc fix” patches and finally put an end to the Sustainable Growth Rate (SGR) formula. A serious solution really did seem possible when the House Energy and Commerce Committee solicited ideas on how to solve the problem.

SHM and other healthcare groups responded, and there seemed to be genuine interest in acting on the various plans that were presented.

What happened?

In reality, 2011 became the year of deficit reduction (if not in actions, at least in words). Every discussion in Congress seemed to come back to the deficit. Hearings were held, countless bills were introduced, blame was cast, and, eventually, the powerful Joint Deficit Deduction Committee, or “supercommittee,” was charged with finding at least $1.5 trillion in savings. At one point, the committee was even urged to “go big” and come up with $4 trillion in savings.

The deficit-reduction-or-bust mentality suddenly made an SGR fix and its $300 billion price tag seem like a pretty hard sell.

Undaunted, groups representing caregivers tried to turn the focus on the deficit into an opportunity and even approached the supercommittee to resolve the SGR matter—an illogical step at first glance, but the reasoning did make long-term sense. The cost of fixing the SGR will only increase with time, and it is estimated that elimination will cost $600 billion in 2016. A timely fix will be cheaper, as delay will only serve to further increase the deficit.

In an effort to appeal to the deficit committee, SHM worked closely with U.S. Rep. Allyson Schwartz (D-Pa.) to develop and submit a framework for eliminating the SGR and eventually phasing out fee-for-service. Despite these efforts, the deficit committee failed, and lawmakers were left with limited time before the scheduled SGR payment cuts were to take effect on Jan. 1.

As 2011 came to a close, a short-term extension that would last until the end of February was all that Congress could agree to. The SGR cycle began anew.

The positive in all this is that, although an SGR replacement did not happen in 2011 and action in 2012 might turn out to be exceedingly difficult, there are now realistic replacement plans out there. For example, Schwartz is looking to introduce legislation based on her above-mentioned framework, but doing so will need broad support.

Moving forward, it will be imperative for societies like SHM and practitioners like hospitalists to keep pressure on Congress. Individual hospitalists will continue to play an important role by contacting their elected officials. This can be done through personal phone calls and letters, or by responding to SHM’s legislative action alerts. You can even act now by visiting SHM’s legislative action center.

For more public policy information and resources, visit www.hospitalmedicine.org/advocacy

In early November, the Institute of Medicine (IOM) released a report on the current status of health information technology (HIT). Although the report was developed at the request of the Office of the National Coordinator (ONC), the arm within the Department of Health and Human Services (HHS) responsible for promoting the use of HIT, not everything in the report was positive—and could leave the impression that HIT is not quite as successful as some think.

The report recommends that the ONC should work with the private and public sectors to make comparative user experiences across vendors publicly available.

Many hospitalists have developed significant expertise with HIT, played significant roles in its effective implementation and use, and are acutely aware of implementation pitfalls. This practical experience could be very helpful in working with the ONC to develop solutions. It is for this reason that hospitalists should reach out to the ONC and offer their expertise instead of waiting for the ONC to act.

The report, “Patient Safety and Health IT: Building Safer Systems for Better Care,” did praise HIT’s potential for eventual cost savings and increased patient safety but stopped short of being a ringing endorsement of the pace HM is taking toward implementation initiatives, such as meaningful use. An overall theme of the report is that greater oversight of HIT is needed to protect patients from potential medical errors associated with its use.

A few of the recommendations given by the IOM to achieve a greater level of safety range from the establishment of a mechanism for vendors and users to report health IT-related deaths, injuries, or unsafe conditions to possible FDA regulation of the systems themselves.

Information-sharing and reporting in a nonpunitive environment, as recommended by the IOM, would go a long way when it comes to remedying or avoiding IT-related problems, and hospitalists probably have some ideas about how this could be done.

Unfortunately, IT vendor contracts often prevent the open sharing of information, so working toward doing away with such contract terms might be a worthy step before making a push toward overall FDA regulation and the unintended consequences that may come with it.

At first glance, FDA regulation seems like the easiest solution because the FDA can theoretically control every aspect of what might go wrong with HIT, but at what cost would such regulation come? FDA approval can be long, complicated and expensive. The whole process could result in cutting-edge technology becoming outdated by the time approval is granted or innovations being overlooked entirely because of a negative cost-benefit analysis. Furthermore, the expense associated with FDA approval could in turn increase the cost of already costly electronic health records (EHR).

Despite the myriad problems that can arise if implementation moves too fast, HIT holds promise and has shown success when done well.

SHM is currently working to position hospitalists as a resource for the ONC, so hospitalists with expertise in this area should not hesitate to come forward with ideas on how to make HIT work better and more safely. HIT is not going to go away, so the best option is to help make it better.

In early November, the Institute of Medicine (IOM) released a report on the current status of health information technology (HIT). Although the report was developed at the request of the Office of the National Coordinator (ONC), the arm within the Department of Health and Human Services (HHS) responsible for promoting the use of HIT, not everything in the report was positive—and could leave the impression that HIT is not quite as successful as some think.

The report recommends that the ONC should work with the private and public sectors to make comparative user experiences across vendors publicly available.

Many hospitalists have developed significant expertise with HIT, played significant roles in its effective implementation and use, and are acutely aware of implementation pitfalls. This practical experience could be very helpful in working with the ONC to develop solutions. It is for this reason that hospitalists should reach out to the ONC and offer their expertise instead of waiting for the ONC to act.

The report, “Patient Safety and Health IT: Building Safer Systems for Better Care,” did praise HIT’s potential for eventual cost savings and increased patient safety but stopped short of being a ringing endorsement of the pace HM is taking toward implementation initiatives, such as meaningful use. An overall theme of the report is that greater oversight of HIT is needed to protect patients from potential medical errors associated with its use.

A few of the recommendations given by the IOM to achieve a greater level of safety range from the establishment of a mechanism for vendors and users to report health IT-related deaths, injuries, or unsafe conditions to possible FDA regulation of the systems themselves.

Information-sharing and reporting in a nonpunitive environment, as recommended by the IOM, would go a long way when it comes to remedying or avoiding IT-related problems, and hospitalists probably have some ideas about how this could be done.

Unfortunately, IT vendor contracts often prevent the open sharing of information, so working toward doing away with such contract terms might be a worthy step before making a push toward overall FDA regulation and the unintended consequences that may come with it.

At first glance, FDA regulation seems like the easiest solution because the FDA can theoretically control every aspect of what might go wrong with HIT, but at what cost would such regulation come? FDA approval can be long, complicated and expensive. The whole process could result in cutting-edge technology becoming outdated by the time approval is granted or innovations being overlooked entirely because of a negative cost-benefit analysis. Furthermore, the expense associated with FDA approval could in turn increase the cost of already costly electronic health records (EHR).

Despite the myriad problems that can arise if implementation moves too fast, HIT holds promise and has shown success when done well.

SHM is currently working to position hospitalists as a resource for the ONC, so hospitalists with expertise in this area should not hesitate to come forward with ideas on how to make HIT work better and more safely. HIT is not going to go away, so the best option is to help make it better.

In early November, the Institute of Medicine (IOM) released a report on the current status of health information technology (HIT). Although the report was developed at the request of the Office of the National Coordinator (ONC), the arm within the Department of Health and Human Services (HHS) responsible for promoting the use of HIT, not everything in the report was positive—and could leave the impression that HIT is not quite as successful as some think.

The report recommends that the ONC should work with the private and public sectors to make comparative user experiences across vendors publicly available.

Many hospitalists have developed significant expertise with HIT, played significant roles in its effective implementation and use, and are acutely aware of implementation pitfalls. This practical experience could be very helpful in working with the ONC to develop solutions. It is for this reason that hospitalists should reach out to the ONC and offer their expertise instead of waiting for the ONC to act.

The report, “Patient Safety and Health IT: Building Safer Systems for Better Care,” did praise HIT’s potential for eventual cost savings and increased patient safety but stopped short of being a ringing endorsement of the pace HM is taking toward implementation initiatives, such as meaningful use. An overall theme of the report is that greater oversight of HIT is needed to protect patients from potential medical errors associated with its use.

A few of the recommendations given by the IOM to achieve a greater level of safety range from the establishment of a mechanism for vendors and users to report health IT-related deaths, injuries, or unsafe conditions to possible FDA regulation of the systems themselves.

Information-sharing and reporting in a nonpunitive environment, as recommended by the IOM, would go a long way when it comes to remedying or avoiding IT-related problems, and hospitalists probably have some ideas about how this could be done.

Unfortunately, IT vendor contracts often prevent the open sharing of information, so working toward doing away with such contract terms might be a worthy step before making a push toward overall FDA regulation and the unintended consequences that may come with it.

At first glance, FDA regulation seems like the easiest solution because the FDA can theoretically control every aspect of what might go wrong with HIT, but at what cost would such regulation come? FDA approval can be long, complicated and expensive. The whole process could result in cutting-edge technology becoming outdated by the time approval is granted or innovations being overlooked entirely because of a negative cost-benefit analysis. Furthermore, the expense associated with FDA approval could in turn increase the cost of already costly electronic health records (EHR).

Despite the myriad problems that can arise if implementation moves too fast, HIT holds promise and has shown success when done well.

SHM is currently working to position hospitalists as a resource for the ONC, so hospitalists with expertise in this area should not hesitate to come forward with ideas on how to make HIT work better and more safely. HIT is not going to go away, so the best option is to help make it better.

The final rule on accountable-care organizations (ACOs) indicates that the government has taken comments from SHM and other organizations to heart.

ACOs are one of the central vehicles in the 2010 Affordable Care Act (ACA) touted as having the potential to achieve improved care delivery while reducing costs. The theory is that through shared savings, ACOs will provide the financial incentive for providers to develop high-quality, integrated models of care, which will result in the efficiencies needed to reduce overall costs to Medicare.

On March 31, the Centers for Medicare & Medicaid Services (CMS) released a proposed rule designed to turn the ACO theory into reality. In crafting their proposal, CMS had to walk a fine line between establishing sufficient patient protections while still making ACO participation appealing to providers. In the eyes of providers, that proposal flopped. Providers of all types were unified in opposition due to inflexible, overly burdensome requirements that allowed for very little return on an enormous upfront investment.

In commenting on the proposed rule, SHM challenged CMS by stating that limiting the provider incentive within ACOs also will limit the results. Thus, CMS was faced with a choice: Address concerns or risk implementing a program that would likely have very little participation.

Six months later, CMS released a response in the form of a final rule. At 696 pages, the details cannot be covered here, but it appears that CMS has listened. They have made many of the requested changes and it seems as if they have attempted to meet providers halfway in areas where they have not fully adopted suggestions.

For example, the initial proposal would have forced ACOs choosing the one-sided risk model to take downside risk during the third year of their three-year contract period. Providers opposed this proposal because they felt it would not be enough time for some ACOs to develop before taking on risk. The final rule allows ACOs choosing the one-sided model to remain free of risk for the duration of their first contract. Also notable is the elimination of a proposed 25% payment withholding on shared savings.

CMS also is showing some flexibility in areas where they might not have fully made desired changes. A key example can be found in the reduced number of quality measures for ACOs. Although fewer measures would certainly be welcome, it is hard to deny that cutting 65 proposed measures down to 33 is significant. Additionally, CMS has increased the cap on shared savings to 10% from 7.5% in the one-sided model, and to 15% from 10% in the two-sided model. This may seem like a small increase, but it should be remembered that the goal of the program is to save Medicare dollars, and any such increase ultimately reduces the savings that can be realized by Medicare. By making these and many other changes, it is clear that CMS has taken public comments seriously—and acted upon them. The final rule is a major improvement on what was originally proposed; it will breathe new life into the ACO concept.

It is too early to tell how much interest this rule will generate, but with the first round of applications due in early 2012 and the first ACOs slated to become operational April 1, 2012, hospitalists should not be surprised by renewed ACO discussions among colleagues and hospital administrators.

For more information on ACOs and other advocacy issues affecting hospitalists, visit www.hospitalmedicine.org/advocacy.

The final rule on accountable-care organizations (ACOs) indicates that the government has taken comments from SHM and other organizations to heart.

ACOs are one of the central vehicles in the 2010 Affordable Care Act (ACA) touted as having the potential to achieve improved care delivery while reducing costs. The theory is that through shared savings, ACOs will provide the financial incentive for providers to develop high-quality, integrated models of care, which will result in the efficiencies needed to reduce overall costs to Medicare.

On March 31, the Centers for Medicare & Medicaid Services (CMS) released a proposed rule designed to turn the ACO theory into reality. In crafting their proposal, CMS had to walk a fine line between establishing sufficient patient protections while still making ACO participation appealing to providers. In the eyes of providers, that proposal flopped. Providers of all types were unified in opposition due to inflexible, overly burdensome requirements that allowed for very little return on an enormous upfront investment.

In commenting on the proposed rule, SHM challenged CMS by stating that limiting the provider incentive within ACOs also will limit the results. Thus, CMS was faced with a choice: Address concerns or risk implementing a program that would likely have very little participation.

Six months later, CMS released a response in the form of a final rule. At 696 pages, the details cannot be covered here, but it appears that CMS has listened. They have made many of the requested changes and it seems as if they have attempted to meet providers halfway in areas where they have not fully adopted suggestions.

For example, the initial proposal would have forced ACOs choosing the one-sided risk model to take downside risk during the third year of their three-year contract period. Providers opposed this proposal because they felt it would not be enough time for some ACOs to develop before taking on risk. The final rule allows ACOs choosing the one-sided model to remain free of risk for the duration of their first contract. Also notable is the elimination of a proposed 25% payment withholding on shared savings.

CMS also is showing some flexibility in areas where they might not have fully made desired changes. A key example can be found in the reduced number of quality measures for ACOs. Although fewer measures would certainly be welcome, it is hard to deny that cutting 65 proposed measures down to 33 is significant. Additionally, CMS has increased the cap on shared savings to 10% from 7.5% in the one-sided model, and to 15% from 10% in the two-sided model. This may seem like a small increase, but it should be remembered that the goal of the program is to save Medicare dollars, and any such increase ultimately reduces the savings that can be realized by Medicare. By making these and many other changes, it is clear that CMS has taken public comments seriously—and acted upon them. The final rule is a major improvement on what was originally proposed; it will breathe new life into the ACO concept.

It is too early to tell how much interest this rule will generate, but with the first round of applications due in early 2012 and the first ACOs slated to become operational April 1, 2012, hospitalists should not be surprised by renewed ACO discussions among colleagues and hospital administrators.

For more information on ACOs and other advocacy issues affecting hospitalists, visit www.hospitalmedicine.org/advocacy.

The final rule on accountable-care organizations (ACOs) indicates that the government has taken comments from SHM and other organizations to heart.

ACOs are one of the central vehicles in the 2010 Affordable Care Act (ACA) touted as having the potential to achieve improved care delivery while reducing costs. The theory is that through shared savings, ACOs will provide the financial incentive for providers to develop high-quality, integrated models of care, which will result in the efficiencies needed to reduce overall costs to Medicare.

On March 31, the Centers for Medicare & Medicaid Services (CMS) released a proposed rule designed to turn the ACO theory into reality. In crafting their proposal, CMS had to walk a fine line between establishing sufficient patient protections while still making ACO participation appealing to providers. In the eyes of providers, that proposal flopped. Providers of all types were unified in opposition due to inflexible, overly burdensome requirements that allowed for very little return on an enormous upfront investment.

In commenting on the proposed rule, SHM challenged CMS by stating that limiting the provider incentive within ACOs also will limit the results. Thus, CMS was faced with a choice: Address concerns or risk implementing a program that would likely have very little participation.

Six months later, CMS released a response in the form of a final rule. At 696 pages, the details cannot be covered here, but it appears that CMS has listened. They have made many of the requested changes and it seems as if they have attempted to meet providers halfway in areas where they have not fully adopted suggestions.

For example, the initial proposal would have forced ACOs choosing the one-sided risk model to take downside risk during the third year of their three-year contract period. Providers opposed this proposal because they felt it would not be enough time for some ACOs to develop before taking on risk. The final rule allows ACOs choosing the one-sided model to remain free of risk for the duration of their first contract. Also notable is the elimination of a proposed 25% payment withholding on shared savings.

CMS also is showing some flexibility in areas where they might not have fully made desired changes. A key example can be found in the reduced number of quality measures for ACOs. Although fewer measures would certainly be welcome, it is hard to deny that cutting 65 proposed measures down to 33 is significant. Additionally, CMS has increased the cap on shared savings to 10% from 7.5% in the one-sided model, and to 15% from 10% in the two-sided model. This may seem like a small increase, but it should be remembered that the goal of the program is to save Medicare dollars, and any such increase ultimately reduces the savings that can be realized by Medicare. By making these and many other changes, it is clear that CMS has taken public comments seriously—and acted upon them. The final rule is a major improvement on what was originally proposed; it will breathe new life into the ACO concept.

It is too early to tell how much interest this rule will generate, but with the first round of applications due in early 2012 and the first ACOs slated to become operational April 1, 2012, hospitalists should not be surprised by renewed ACO discussions among colleagues and hospital administrators.

For more information on ACOs and other advocacy issues affecting hospitalists, visit www.hospitalmedicine.org/advocacy.