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GSK expands two-dimensional barcoding for vaccines
GlaxoSmithKline will be rolling out two-dimensional barcodes for most of its U.S.-licensed vaccines over the next several months, significantly increasing the number of vaccines carrying the high-tech labels.
Current vaccine labels include linear, one-dimensional barcodes that contain the National Drug Code number, as required by the Food and Drug Administration. With the addition of seven vaccines from GSK later this year and early next year, however, the move to 2D barcoding is getting a big boost.
Previously, eight Sanofi Pasteur vaccines were available with the 2D barcodes, along with three vaccines from GSK. And more vaccine makers are preparing for the move to 2D barcodes.
"We’re committed and we’re on our way to have all of the U.S.-packaged vaccines with the 2D barcodes," said Dr. Leonard Friedland, vice president of scientific affairs and public policy for GSK Vaccines, North America. "In the future, we’ll have all of our vaccines [using 2D barcodes] as well, even those that are manufactured outside of the United States."
Today’s standard – linear barcodes – contain information on the National Drug Code number, but the lot number and expiration date of the vaccine are printed separately on the label. With the 2D data matrix technology, all of that information is contained within the barcode and can be transmitted electronically to either an electronic health record (EHR) system or a practice management system used to track inventory.
Supporters of the move to the 2D technology say that cutting down on the manual transcription of the lot number and expiration date has the potential to boost patient safety by improving the completeness of reports to the FDA’s Vaccine Adverse Events Reporting System (VAERS) or by making it easier to identify expired or recalled lots of vaccine.
It also has the potential to improve practice workflow, even in practices using paper records, by eliminating the need to record the information once into the paper chart and again into the state vaccine registry. The 2D barcoding allows practices to scan it directly into the registry. For practices with an EHR, there’s also the possibility of improved billing and just-in-time ordering, according to the American Academy of Pediatrics, which has been pushing vaccine manufacturers to adopt 2D barcodes for several years.
Dr. Edward Zissman, a pediatrician in Altamonte Springs, Fla., and cochair of the AAP’s Vaccine Barcoding Project, said that the primary motivator for pushing for the change in labeling was improving patient safety. A significant number of the primary reports to VAERS have an incorrect or unreadable lot number, he said.
If the manufacturer tried to recall a vaccine by lot number, it would be difficult to carry out at best, said Dr. Zissman.
Another driver in the move to 2D barcodes is the potential for making vaccine administration simpler for physicians and their staff. Entering the name, expiration date, lot number, and site of administration for multiple vaccines is time consuming and labor intensive, whether the office is working with paper records or an EHR. When there are shortages in a combination vaccine, as there are currently, and many children are getting a partial series of the vaccine, it becomes a "documentation nightmare," he said.
Whether the 2D barcodes will produce all the efficiency and cost savings that the AAP hopes is still an open question. Last year, the Centers for Disease Control and Prevention launched a pilot project to test how practices would do with the new barcodes and to determine best practices for tracking vaccines with the new technology. The early reports show that, by scanning 2D barcodes, practices are able to increase both the completeness and accuracy of the information they store and transmit on the vaccines. Practices also saw efficiency gains for inventory and administration.
But Dr. Zissman said the pilot’s results don’t tell the whole story because the study was limited to practices with an EHR, which may not reflect the experiences of the many paper-based offices across the United States, including Dr. Zissman’s own practice. The gains for paper-based practices will primarily be in the areas of inventory management and in the Immunization Information Systems (IIS), he said.
Although most vaccine manufacturers are now expediting implementation of the 2D barcodes, only two companies have rolled out the new labeling so far. It will now be up to the EHR vendors and the individual IISs to adopt 2D technology. Dr. Zissman said it’s his opinion that, where physicians have choices in purchasing vaccines they will buy from companies using the 2D barcodes. Unfortunately, he said, many vaccines are supplied by a single company, leaving physicians with no alternate choice.
Dr. Zissman has been a member of the Merck vaccine advisory board and is the principal investigator for pediatric clinical research studies for GSK, Merck, Novartis, and Medimmune.
On Twitter @MaryEllenNY
GlaxoSmithKline will be rolling out two-dimensional barcodes for most of its U.S.-licensed vaccines over the next several months, significantly increasing the number of vaccines carrying the high-tech labels.
Current vaccine labels include linear, one-dimensional barcodes that contain the National Drug Code number, as required by the Food and Drug Administration. With the addition of seven vaccines from GSK later this year and early next year, however, the move to 2D barcoding is getting a big boost.
Previously, eight Sanofi Pasteur vaccines were available with the 2D barcodes, along with three vaccines from GSK. And more vaccine makers are preparing for the move to 2D barcodes.
"We’re committed and we’re on our way to have all of the U.S.-packaged vaccines with the 2D barcodes," said Dr. Leonard Friedland, vice president of scientific affairs and public policy for GSK Vaccines, North America. "In the future, we’ll have all of our vaccines [using 2D barcodes] as well, even those that are manufactured outside of the United States."
Today’s standard – linear barcodes – contain information on the National Drug Code number, but the lot number and expiration date of the vaccine are printed separately on the label. With the 2D data matrix technology, all of that information is contained within the barcode and can be transmitted electronically to either an electronic health record (EHR) system or a practice management system used to track inventory.
Supporters of the move to the 2D technology say that cutting down on the manual transcription of the lot number and expiration date has the potential to boost patient safety by improving the completeness of reports to the FDA’s Vaccine Adverse Events Reporting System (VAERS) or by making it easier to identify expired or recalled lots of vaccine.
It also has the potential to improve practice workflow, even in practices using paper records, by eliminating the need to record the information once into the paper chart and again into the state vaccine registry. The 2D barcoding allows practices to scan it directly into the registry. For practices with an EHR, there’s also the possibility of improved billing and just-in-time ordering, according to the American Academy of Pediatrics, which has been pushing vaccine manufacturers to adopt 2D barcodes for several years.
Dr. Edward Zissman, a pediatrician in Altamonte Springs, Fla., and cochair of the AAP’s Vaccine Barcoding Project, said that the primary motivator for pushing for the change in labeling was improving patient safety. A significant number of the primary reports to VAERS have an incorrect or unreadable lot number, he said.
If the manufacturer tried to recall a vaccine by lot number, it would be difficult to carry out at best, said Dr. Zissman.
Another driver in the move to 2D barcodes is the potential for making vaccine administration simpler for physicians and their staff. Entering the name, expiration date, lot number, and site of administration for multiple vaccines is time consuming and labor intensive, whether the office is working with paper records or an EHR. When there are shortages in a combination vaccine, as there are currently, and many children are getting a partial series of the vaccine, it becomes a "documentation nightmare," he said.
Whether the 2D barcodes will produce all the efficiency and cost savings that the AAP hopes is still an open question. Last year, the Centers for Disease Control and Prevention launched a pilot project to test how practices would do with the new barcodes and to determine best practices for tracking vaccines with the new technology. The early reports show that, by scanning 2D barcodes, practices are able to increase both the completeness and accuracy of the information they store and transmit on the vaccines. Practices also saw efficiency gains for inventory and administration.
But Dr. Zissman said the pilot’s results don’t tell the whole story because the study was limited to practices with an EHR, which may not reflect the experiences of the many paper-based offices across the United States, including Dr. Zissman’s own practice. The gains for paper-based practices will primarily be in the areas of inventory management and in the Immunization Information Systems (IIS), he said.
Although most vaccine manufacturers are now expediting implementation of the 2D barcodes, only two companies have rolled out the new labeling so far. It will now be up to the EHR vendors and the individual IISs to adopt 2D technology. Dr. Zissman said it’s his opinion that, where physicians have choices in purchasing vaccines they will buy from companies using the 2D barcodes. Unfortunately, he said, many vaccines are supplied by a single company, leaving physicians with no alternate choice.
Dr. Zissman has been a member of the Merck vaccine advisory board and is the principal investigator for pediatric clinical research studies for GSK, Merck, Novartis, and Medimmune.
On Twitter @MaryEllenNY
GlaxoSmithKline will be rolling out two-dimensional barcodes for most of its U.S.-licensed vaccines over the next several months, significantly increasing the number of vaccines carrying the high-tech labels.
Current vaccine labels include linear, one-dimensional barcodes that contain the National Drug Code number, as required by the Food and Drug Administration. With the addition of seven vaccines from GSK later this year and early next year, however, the move to 2D barcoding is getting a big boost.
Previously, eight Sanofi Pasteur vaccines were available with the 2D barcodes, along with three vaccines from GSK. And more vaccine makers are preparing for the move to 2D barcodes.
"We’re committed and we’re on our way to have all of the U.S.-packaged vaccines with the 2D barcodes," said Dr. Leonard Friedland, vice president of scientific affairs and public policy for GSK Vaccines, North America. "In the future, we’ll have all of our vaccines [using 2D barcodes] as well, even those that are manufactured outside of the United States."
Today’s standard – linear barcodes – contain information on the National Drug Code number, but the lot number and expiration date of the vaccine are printed separately on the label. With the 2D data matrix technology, all of that information is contained within the barcode and can be transmitted electronically to either an electronic health record (EHR) system or a practice management system used to track inventory.
Supporters of the move to the 2D technology say that cutting down on the manual transcription of the lot number and expiration date has the potential to boost patient safety by improving the completeness of reports to the FDA’s Vaccine Adverse Events Reporting System (VAERS) or by making it easier to identify expired or recalled lots of vaccine.
It also has the potential to improve practice workflow, even in practices using paper records, by eliminating the need to record the information once into the paper chart and again into the state vaccine registry. The 2D barcoding allows practices to scan it directly into the registry. For practices with an EHR, there’s also the possibility of improved billing and just-in-time ordering, according to the American Academy of Pediatrics, which has been pushing vaccine manufacturers to adopt 2D barcodes for several years.
Dr. Edward Zissman, a pediatrician in Altamonte Springs, Fla., and cochair of the AAP’s Vaccine Barcoding Project, said that the primary motivator for pushing for the change in labeling was improving patient safety. A significant number of the primary reports to VAERS have an incorrect or unreadable lot number, he said.
If the manufacturer tried to recall a vaccine by lot number, it would be difficult to carry out at best, said Dr. Zissman.
Another driver in the move to 2D barcodes is the potential for making vaccine administration simpler for physicians and their staff. Entering the name, expiration date, lot number, and site of administration for multiple vaccines is time consuming and labor intensive, whether the office is working with paper records or an EHR. When there are shortages in a combination vaccine, as there are currently, and many children are getting a partial series of the vaccine, it becomes a "documentation nightmare," he said.
Whether the 2D barcodes will produce all the efficiency and cost savings that the AAP hopes is still an open question. Last year, the Centers for Disease Control and Prevention launched a pilot project to test how practices would do with the new barcodes and to determine best practices for tracking vaccines with the new technology. The early reports show that, by scanning 2D barcodes, practices are able to increase both the completeness and accuracy of the information they store and transmit on the vaccines. Practices also saw efficiency gains for inventory and administration.
But Dr. Zissman said the pilot’s results don’t tell the whole story because the study was limited to practices with an EHR, which may not reflect the experiences of the many paper-based offices across the United States, including Dr. Zissman’s own practice. The gains for paper-based practices will primarily be in the areas of inventory management and in the Immunization Information Systems (IIS), he said.
Although most vaccine manufacturers are now expediting implementation of the 2D barcodes, only two companies have rolled out the new labeling so far. It will now be up to the EHR vendors and the individual IISs to adopt 2D technology. Dr. Zissman said it’s his opinion that, where physicians have choices in purchasing vaccines they will buy from companies using the 2D barcodes. Unfortunately, he said, many vaccines are supplied by a single company, leaving physicians with no alternate choice.
Dr. Zissman has been a member of the Merck vaccine advisory board and is the principal investigator for pediatric clinical research studies for GSK, Merck, Novartis, and Medimmune.
On Twitter @MaryEllenNY
CMS reverses course, allows modifier for newborn care
Physicians can continue to bill for two separate birth-related services on the same day using the "modifier 25," thanks to a recent reversal by officials at the Centers for Medicare and Medicaid Services.
The CMS had changed the coding rules, effective July 1, and barred physicians from using the modifier 25 to bill for both initial inpatient neonatal critical care for evaluation and management (CPT code 99468) and initial hospital or birthing center care for evaluation and management of a normal newborn (CPT code 99460). The agency had said it would not pay physicians for both services when they were performed on the same day.
But after receiving pushback from physicians groups, including the American Academy of Family Physicians, the CMS reversed the decision. In a letter to the medical director of the National Correct Coding Initiative, the AAFP argued that it is not uncommon for family physicians and pediatricians to provide both initial care and ongoing management for a newborn who is initially healthy but deteriorates within hours and needs neonatal intensive care services.
The agency plans to pay physicians retroactively to July 1 for any claims that may be denied. This latest change will be published Oct. 1 in the National Correct Coding Initiative.
On Twitter MaryEllenNY
Physicians can continue to bill for two separate birth-related services on the same day using the "modifier 25," thanks to a recent reversal by officials at the Centers for Medicare and Medicaid Services.
The CMS had changed the coding rules, effective July 1, and barred physicians from using the modifier 25 to bill for both initial inpatient neonatal critical care for evaluation and management (CPT code 99468) and initial hospital or birthing center care for evaluation and management of a normal newborn (CPT code 99460). The agency had said it would not pay physicians for both services when they were performed on the same day.
But after receiving pushback from physicians groups, including the American Academy of Family Physicians, the CMS reversed the decision. In a letter to the medical director of the National Correct Coding Initiative, the AAFP argued that it is not uncommon for family physicians and pediatricians to provide both initial care and ongoing management for a newborn who is initially healthy but deteriorates within hours and needs neonatal intensive care services.
The agency plans to pay physicians retroactively to July 1 for any claims that may be denied. This latest change will be published Oct. 1 in the National Correct Coding Initiative.
On Twitter MaryEllenNY
Physicians can continue to bill for two separate birth-related services on the same day using the "modifier 25," thanks to a recent reversal by officials at the Centers for Medicare and Medicaid Services.
The CMS had changed the coding rules, effective July 1, and barred physicians from using the modifier 25 to bill for both initial inpatient neonatal critical care for evaluation and management (CPT code 99468) and initial hospital or birthing center care for evaluation and management of a normal newborn (CPT code 99460). The agency had said it would not pay physicians for both services when they were performed on the same day.
But after receiving pushback from physicians groups, including the American Academy of Family Physicians, the CMS reversed the decision. In a letter to the medical director of the National Correct Coding Initiative, the AAFP argued that it is not uncommon for family physicians and pediatricians to provide both initial care and ongoing management for a newborn who is initially healthy but deteriorates within hours and needs neonatal intensive care services.
The agency plans to pay physicians retroactively to July 1 for any claims that may be denied. This latest change will be published Oct. 1 in the National Correct Coding Initiative.
On Twitter MaryEllenNY
Lowering readmissions means getting to know your SNF
When hospitalists at Northwestern University in Chicago began working on reducing hospital readmissions from post-acute care facilities, it didn’t take long to realize that they didn’t know that much about what actually goes on inside a skilled nursing facility.
So they began a "field trip" program in which interested hospitalists could visit some of the skilled nursing facilities (SNFs) where they commonly refer patients. It was a chance for the hospitalists to see firsthand the wide variation in nursing home staffing, the capabilities in terms of testing and treatment, and which facilities had specialty units for conditions such as heart failure or hip fracture.
"You have to engage the skilled nursing facilities," said Dr. Robert Young, a hospitalist at Northwestern who conducts research on post-acute care transitions. "That means you have to figure out what the skilled nursing facility looks like."
The field trips are important, Dr. Young said, because physicians only get a limited exposure to post-acute care settings during residency training. Physicians may have a "geriatrics week" in residency, during which they spend a small amount of a time at a SNF and take care of a few of the patients there, but it doesn’t provide a chance for a deep understanding of the setting, he said.
Northwestern is also pilot-testing an exercise in which their hospitalists will get a chance to see how their transfer instructions are translated into care. The experience has been eye opening so far, said Dr. Young, who is also a mentor for the Society of Hospital Medicine’s Project BOOST.
Before they arrive, the staff at the SNF de-identifies a set of transfer paperwork from the Northwestern hospitalists. Then the hospitalists are asked to write orders based on the information they provided to the SNF. "Usually, this knocks people’s socks off," Dr. Young said. "They say, ‘How am I supposed to admit the patient? I don’t know this, this, and this.’ "
The exercise was developed by Dr. Heather Zinzella Cox, the director of post-acute care services at IPC–the Hospitalist Company in Delaware. It’s one of the ways that Northwestern is working to improve the transition between the hospital and post-acute care settings such as SNFs.
Readmissions, ACOs drive change
The interaction between hospitals and SNFs is an area ripe for improvement. Data show that in 2006, the readmission rate for patients who were readmitted to the hospital from a SNF was more than 26%, compared with about 19% for patients who were readmitted after being discharged home (Health Aff. 2010;29:57-64). That means that preventing patient bounce-back from SNFs and other post-acute care settings is a real opportunity for hospitals to improve readmission rates overall and protect themselves from penalties from Medicare’s Readmissions Reduction Program. Starting in October 2013, the maximum penalties in the program will jump from 1% of base operating payments to 2%.
The good news is that SNFs are willing partners when in comes to reducing readmissions, said Dr. Amy Boutwell, president of Collaborative Healthcare Strategies based in Lexington, Mass. Not only do SNFs count on hospitals as a referral source, but Medicare officials have signaled that it won’t be long before SNFs will be subject to readmission penalties themselves, she said.
But readmission penalties are only a small driver in terms of what is motivating hospital administrators to look at the hospital-SNF relationship with interest. The bigger push is coming from Accountable Care Organizations, Dr. Boutwell said.
The medical directors of ACOs, who are charged with managing the total cost of care across settings, see readmissions from SNFs as one of the biggest opportunities for immediate savings.
"It makes a lot of sense strategically for the ACOs to say ‘we need to save money this year, where’s the first, best place,’" she said. "And one of the first, best places is in SNF readmissions."
Start talking to SNF physicians
Dr. Boutwell advises hospitalists who aren’t already actively engaged with their SNFs to start now. It’s not something that needs signoff from the CEO. "This is collaboration between providers over the care of shared patients," she said.
And it’s a leadership opportunity for hospitalists who are willing to step up and become a champion for reducing readmissions in this area, she said.
"If there’s one thing to start on it’s the hand-off to SNFs because they are motivated," Dr. Boutwell said. "They understand the landscape is changing."
At Christiana Hospital in Newark, Del., they have seen a significant decrease in their readmissions from SNFs for certain conditions after making some relatively minor changes, said Dr. Thomas Mathew, a hospitalist with IPC who works at the hospital and is a medical director at two area SNFs.
They started by bringing a small group of hospitalists, nurses, and patient care facilitators over to a nearby SNF and talking about how the facility works and what information the SNF providers needed. The result was that they streamlined the discharge information that they sent over to the SNF and instituted standard provider-to-provider phone calls before patients were discharged from the hospital.
Instead of a stack of information from the patient’s stay, the hospitalists now identify some key information about the patient: an up-to-date medication history, a discharge summary, and a disease-specific clinical summary. For instance, heart failure patients are now discharged with a clinical summary sheet that includes their medications, current lab results, results of critical tests, the name of the cardiologist, and the patient’s recent weights, Dr. Mathew said.
Understand the SNF
Part of the reason that Dr. Young and others suggest that hospitalists visit SNFs when they can is to learn the capabilities of the facility as well as what unique workflow or regulatory issues could be preventing the providers there from following through on some of the hospitalists’ discharge instructions.
Often, patients end up being readmitted to the hospital because they have higher acuity needs than the SNF can handle, said Dr. Zinzella Cox. And some facilities are better at managing patients with dementia, for example, either because they specialize in that type of care or they have a different staffing model. "[Hospitalists] really do need to become knowledgeable about their nursing home facility partners," said Dr. Zinzella Cox, who serves as medical director at several post-acute care facilities in Delaware.
Another common issue arises when transferring patients who need narcotics. The Drug Enforcement Administration doesn’t allow physicians to voice order Schedule II drugs over the phone, and since many patients arrive at SNFs in the evening when a physician isn’t on site, they can’t immediately get the narcotics they need. Some hospitalists get around this issue by premedicating patients before they leave the hospital and then sending them to the SNF with a prescription already written.
Hospitalists are asked to write orders based on the information they provided to the SNF. "Usually this knocks people's socks off. They say, "How am I supposed to admit the patient? I don't know this, this, and this."
This is a good start, Dr. Zinzella Cox said, but hospitalists need to be sure that the prescription is written for a specific quantity administered at specific time intervals. Prescriptions that include ranges for administration don’t comply with SNF regulations, she said. If the prescription isn’t valid, the physician at the SNF will have to write another, which can lead to delays.
It all gets back to talking with the SNF providers, she said. "We really do need to communicate issues between the two care settings so we can work collaboratively together," Dr. Zinzella Cox said.
Practical tips for improving transitions to SNFs
Dr. Young offered some pointers on how to improve the transition from the hospital to skilled nursing facilities:
• Know the environment to which you’re sending patients. There is a large variation in capability, ownership, specialty units, and staffing among SNFs. Ask if they have access to your hospital’s electronic health record.
• Be thoughtful about the discharge paperwork you send. Ask the SNF physicians what information they need.
• Do a postdischarge follow-up phone call. Does the facility need more information? Were the discharge orders implemented?
• Educate patients and families. Patients need to understand that a SNF is not a hospital and they likely won’t be seen by a physician every day.
• Use your tools. Work with a state Quality Improvement Organization to get data on the readmission rates for post-acute care facilities in your area.
For hospitalists interested in starting a quality improvement project with their SNF colleagues, the Society of Hospital Medicine will be posting resources online this fall. The SHM Post-Acute Care Task Force is designing an online toolkit that will include best practices and recommendations on how to get started, Dr. Young said.
On Twitter @MaryEllenNY
When hospitalists at Northwestern University in Chicago began working on reducing hospital readmissions from post-acute care facilities, it didn’t take long to realize that they didn’t know that much about what actually goes on inside a skilled nursing facility.
So they began a "field trip" program in which interested hospitalists could visit some of the skilled nursing facilities (SNFs) where they commonly refer patients. It was a chance for the hospitalists to see firsthand the wide variation in nursing home staffing, the capabilities in terms of testing and treatment, and which facilities had specialty units for conditions such as heart failure or hip fracture.
"You have to engage the skilled nursing facilities," said Dr. Robert Young, a hospitalist at Northwestern who conducts research on post-acute care transitions. "That means you have to figure out what the skilled nursing facility looks like."
The field trips are important, Dr. Young said, because physicians only get a limited exposure to post-acute care settings during residency training. Physicians may have a "geriatrics week" in residency, during which they spend a small amount of a time at a SNF and take care of a few of the patients there, but it doesn’t provide a chance for a deep understanding of the setting, he said.
Northwestern is also pilot-testing an exercise in which their hospitalists will get a chance to see how their transfer instructions are translated into care. The experience has been eye opening so far, said Dr. Young, who is also a mentor for the Society of Hospital Medicine’s Project BOOST.
Before they arrive, the staff at the SNF de-identifies a set of transfer paperwork from the Northwestern hospitalists. Then the hospitalists are asked to write orders based on the information they provided to the SNF. "Usually, this knocks people’s socks off," Dr. Young said. "They say, ‘How am I supposed to admit the patient? I don’t know this, this, and this.’ "
The exercise was developed by Dr. Heather Zinzella Cox, the director of post-acute care services at IPC–the Hospitalist Company in Delaware. It’s one of the ways that Northwestern is working to improve the transition between the hospital and post-acute care settings such as SNFs.
Readmissions, ACOs drive change
The interaction between hospitals and SNFs is an area ripe for improvement. Data show that in 2006, the readmission rate for patients who were readmitted to the hospital from a SNF was more than 26%, compared with about 19% for patients who were readmitted after being discharged home (Health Aff. 2010;29:57-64). That means that preventing patient bounce-back from SNFs and other post-acute care settings is a real opportunity for hospitals to improve readmission rates overall and protect themselves from penalties from Medicare’s Readmissions Reduction Program. Starting in October 2013, the maximum penalties in the program will jump from 1% of base operating payments to 2%.
The good news is that SNFs are willing partners when in comes to reducing readmissions, said Dr. Amy Boutwell, president of Collaborative Healthcare Strategies based in Lexington, Mass. Not only do SNFs count on hospitals as a referral source, but Medicare officials have signaled that it won’t be long before SNFs will be subject to readmission penalties themselves, she said.
But readmission penalties are only a small driver in terms of what is motivating hospital administrators to look at the hospital-SNF relationship with interest. The bigger push is coming from Accountable Care Organizations, Dr. Boutwell said.
The medical directors of ACOs, who are charged with managing the total cost of care across settings, see readmissions from SNFs as one of the biggest opportunities for immediate savings.
"It makes a lot of sense strategically for the ACOs to say ‘we need to save money this year, where’s the first, best place,’" she said. "And one of the first, best places is in SNF readmissions."
Start talking to SNF physicians
Dr. Boutwell advises hospitalists who aren’t already actively engaged with their SNFs to start now. It’s not something that needs signoff from the CEO. "This is collaboration between providers over the care of shared patients," she said.
And it’s a leadership opportunity for hospitalists who are willing to step up and become a champion for reducing readmissions in this area, she said.
"If there’s one thing to start on it’s the hand-off to SNFs because they are motivated," Dr. Boutwell said. "They understand the landscape is changing."
At Christiana Hospital in Newark, Del., they have seen a significant decrease in their readmissions from SNFs for certain conditions after making some relatively minor changes, said Dr. Thomas Mathew, a hospitalist with IPC who works at the hospital and is a medical director at two area SNFs.
They started by bringing a small group of hospitalists, nurses, and patient care facilitators over to a nearby SNF and talking about how the facility works and what information the SNF providers needed. The result was that they streamlined the discharge information that they sent over to the SNF and instituted standard provider-to-provider phone calls before patients were discharged from the hospital.
Instead of a stack of information from the patient’s stay, the hospitalists now identify some key information about the patient: an up-to-date medication history, a discharge summary, and a disease-specific clinical summary. For instance, heart failure patients are now discharged with a clinical summary sheet that includes their medications, current lab results, results of critical tests, the name of the cardiologist, and the patient’s recent weights, Dr. Mathew said.
Understand the SNF
Part of the reason that Dr. Young and others suggest that hospitalists visit SNFs when they can is to learn the capabilities of the facility as well as what unique workflow or regulatory issues could be preventing the providers there from following through on some of the hospitalists’ discharge instructions.
Often, patients end up being readmitted to the hospital because they have higher acuity needs than the SNF can handle, said Dr. Zinzella Cox. And some facilities are better at managing patients with dementia, for example, either because they specialize in that type of care or they have a different staffing model. "[Hospitalists] really do need to become knowledgeable about their nursing home facility partners," said Dr. Zinzella Cox, who serves as medical director at several post-acute care facilities in Delaware.
Another common issue arises when transferring patients who need narcotics. The Drug Enforcement Administration doesn’t allow physicians to voice order Schedule II drugs over the phone, and since many patients arrive at SNFs in the evening when a physician isn’t on site, they can’t immediately get the narcotics they need. Some hospitalists get around this issue by premedicating patients before they leave the hospital and then sending them to the SNF with a prescription already written.
Hospitalists are asked to write orders based on the information they provided to the SNF. "Usually this knocks people's socks off. They say, "How am I supposed to admit the patient? I don't know this, this, and this."
This is a good start, Dr. Zinzella Cox said, but hospitalists need to be sure that the prescription is written for a specific quantity administered at specific time intervals. Prescriptions that include ranges for administration don’t comply with SNF regulations, she said. If the prescription isn’t valid, the physician at the SNF will have to write another, which can lead to delays.
It all gets back to talking with the SNF providers, she said. "We really do need to communicate issues between the two care settings so we can work collaboratively together," Dr. Zinzella Cox said.
Practical tips for improving transitions to SNFs
Dr. Young offered some pointers on how to improve the transition from the hospital to skilled nursing facilities:
• Know the environment to which you’re sending patients. There is a large variation in capability, ownership, specialty units, and staffing among SNFs. Ask if they have access to your hospital’s electronic health record.
• Be thoughtful about the discharge paperwork you send. Ask the SNF physicians what information they need.
• Do a postdischarge follow-up phone call. Does the facility need more information? Were the discharge orders implemented?
• Educate patients and families. Patients need to understand that a SNF is not a hospital and they likely won’t be seen by a physician every day.
• Use your tools. Work with a state Quality Improvement Organization to get data on the readmission rates for post-acute care facilities in your area.
For hospitalists interested in starting a quality improvement project with their SNF colleagues, the Society of Hospital Medicine will be posting resources online this fall. The SHM Post-Acute Care Task Force is designing an online toolkit that will include best practices and recommendations on how to get started, Dr. Young said.
On Twitter @MaryEllenNY
When hospitalists at Northwestern University in Chicago began working on reducing hospital readmissions from post-acute care facilities, it didn’t take long to realize that they didn’t know that much about what actually goes on inside a skilled nursing facility.
So they began a "field trip" program in which interested hospitalists could visit some of the skilled nursing facilities (SNFs) where they commonly refer patients. It was a chance for the hospitalists to see firsthand the wide variation in nursing home staffing, the capabilities in terms of testing and treatment, and which facilities had specialty units for conditions such as heart failure or hip fracture.
"You have to engage the skilled nursing facilities," said Dr. Robert Young, a hospitalist at Northwestern who conducts research on post-acute care transitions. "That means you have to figure out what the skilled nursing facility looks like."
The field trips are important, Dr. Young said, because physicians only get a limited exposure to post-acute care settings during residency training. Physicians may have a "geriatrics week" in residency, during which they spend a small amount of a time at a SNF and take care of a few of the patients there, but it doesn’t provide a chance for a deep understanding of the setting, he said.
Northwestern is also pilot-testing an exercise in which their hospitalists will get a chance to see how their transfer instructions are translated into care. The experience has been eye opening so far, said Dr. Young, who is also a mentor for the Society of Hospital Medicine’s Project BOOST.
Before they arrive, the staff at the SNF de-identifies a set of transfer paperwork from the Northwestern hospitalists. Then the hospitalists are asked to write orders based on the information they provided to the SNF. "Usually, this knocks people’s socks off," Dr. Young said. "They say, ‘How am I supposed to admit the patient? I don’t know this, this, and this.’ "
The exercise was developed by Dr. Heather Zinzella Cox, the director of post-acute care services at IPC–the Hospitalist Company in Delaware. It’s one of the ways that Northwestern is working to improve the transition between the hospital and post-acute care settings such as SNFs.
Readmissions, ACOs drive change
The interaction between hospitals and SNFs is an area ripe for improvement. Data show that in 2006, the readmission rate for patients who were readmitted to the hospital from a SNF was more than 26%, compared with about 19% for patients who were readmitted after being discharged home (Health Aff. 2010;29:57-64). That means that preventing patient bounce-back from SNFs and other post-acute care settings is a real opportunity for hospitals to improve readmission rates overall and protect themselves from penalties from Medicare’s Readmissions Reduction Program. Starting in October 2013, the maximum penalties in the program will jump from 1% of base operating payments to 2%.
The good news is that SNFs are willing partners when in comes to reducing readmissions, said Dr. Amy Boutwell, president of Collaborative Healthcare Strategies based in Lexington, Mass. Not only do SNFs count on hospitals as a referral source, but Medicare officials have signaled that it won’t be long before SNFs will be subject to readmission penalties themselves, she said.
But readmission penalties are only a small driver in terms of what is motivating hospital administrators to look at the hospital-SNF relationship with interest. The bigger push is coming from Accountable Care Organizations, Dr. Boutwell said.
The medical directors of ACOs, who are charged with managing the total cost of care across settings, see readmissions from SNFs as one of the biggest opportunities for immediate savings.
"It makes a lot of sense strategically for the ACOs to say ‘we need to save money this year, where’s the first, best place,’" she said. "And one of the first, best places is in SNF readmissions."
Start talking to SNF physicians
Dr. Boutwell advises hospitalists who aren’t already actively engaged with their SNFs to start now. It’s not something that needs signoff from the CEO. "This is collaboration between providers over the care of shared patients," she said.
And it’s a leadership opportunity for hospitalists who are willing to step up and become a champion for reducing readmissions in this area, she said.
"If there’s one thing to start on it’s the hand-off to SNFs because they are motivated," Dr. Boutwell said. "They understand the landscape is changing."
At Christiana Hospital in Newark, Del., they have seen a significant decrease in their readmissions from SNFs for certain conditions after making some relatively minor changes, said Dr. Thomas Mathew, a hospitalist with IPC who works at the hospital and is a medical director at two area SNFs.
They started by bringing a small group of hospitalists, nurses, and patient care facilitators over to a nearby SNF and talking about how the facility works and what information the SNF providers needed. The result was that they streamlined the discharge information that they sent over to the SNF and instituted standard provider-to-provider phone calls before patients were discharged from the hospital.
Instead of a stack of information from the patient’s stay, the hospitalists now identify some key information about the patient: an up-to-date medication history, a discharge summary, and a disease-specific clinical summary. For instance, heart failure patients are now discharged with a clinical summary sheet that includes their medications, current lab results, results of critical tests, the name of the cardiologist, and the patient’s recent weights, Dr. Mathew said.
Understand the SNF
Part of the reason that Dr. Young and others suggest that hospitalists visit SNFs when they can is to learn the capabilities of the facility as well as what unique workflow or regulatory issues could be preventing the providers there from following through on some of the hospitalists’ discharge instructions.
Often, patients end up being readmitted to the hospital because they have higher acuity needs than the SNF can handle, said Dr. Zinzella Cox. And some facilities are better at managing patients with dementia, for example, either because they specialize in that type of care or they have a different staffing model. "[Hospitalists] really do need to become knowledgeable about their nursing home facility partners," said Dr. Zinzella Cox, who serves as medical director at several post-acute care facilities in Delaware.
Another common issue arises when transferring patients who need narcotics. The Drug Enforcement Administration doesn’t allow physicians to voice order Schedule II drugs over the phone, and since many patients arrive at SNFs in the evening when a physician isn’t on site, they can’t immediately get the narcotics they need. Some hospitalists get around this issue by premedicating patients before they leave the hospital and then sending them to the SNF with a prescription already written.
Hospitalists are asked to write orders based on the information they provided to the SNF. "Usually this knocks people's socks off. They say, "How am I supposed to admit the patient? I don't know this, this, and this."
This is a good start, Dr. Zinzella Cox said, but hospitalists need to be sure that the prescription is written for a specific quantity administered at specific time intervals. Prescriptions that include ranges for administration don’t comply with SNF regulations, she said. If the prescription isn’t valid, the physician at the SNF will have to write another, which can lead to delays.
It all gets back to talking with the SNF providers, she said. "We really do need to communicate issues between the two care settings so we can work collaboratively together," Dr. Zinzella Cox said.
Practical tips for improving transitions to SNFs
Dr. Young offered some pointers on how to improve the transition from the hospital to skilled nursing facilities:
• Know the environment to which you’re sending patients. There is a large variation in capability, ownership, specialty units, and staffing among SNFs. Ask if they have access to your hospital’s electronic health record.
• Be thoughtful about the discharge paperwork you send. Ask the SNF physicians what information they need.
• Do a postdischarge follow-up phone call. Does the facility need more information? Were the discharge orders implemented?
• Educate patients and families. Patients need to understand that a SNF is not a hospital and they likely won’t be seen by a physician every day.
• Use your tools. Work with a state Quality Improvement Organization to get data on the readmission rates for post-acute care facilities in your area.
For hospitalists interested in starting a quality improvement project with their SNF colleagues, the Society of Hospital Medicine will be posting resources online this fall. The SHM Post-Acute Care Task Force is designing an online toolkit that will include best practices and recommendations on how to get started, Dr. Young said.
On Twitter @MaryEllenNY
Report: 90% of doctors seeing new Medicare patients
Nearly 90% of physicians accept new Medicare patients, a percentage that has held steady for the last several years, according to an analysis released by the Department of Health and Human Services.
In 2012, 90.7% of physicians were accepting new Medicare patients, compared with 87.9% in 2005. The HHS report, released Aug. 22, relies on data from the National Ambulatory Medical Care Survey, a nationally representative survey of office-based medical doctors and osteopaths. It excludes radiologists, anesthesiologists, and pathologists. As of 2011, about 650,000 physicians were participating in the Medicare program.
The figures reported by the HHS are similar to the percentage of physicians who were accepting private health insurance between 2005 and 2012. However, preliminary data from the National Ambulatory Medical Care Survey suggests that between 2011 and 2012, the percentage of doctors seeing new Medicare patients was slightly higher than the percentage accepting new privately-insured patients.
Medicare officials said the report confirms that physician participation in the Medicare program remains strong despite reports that a growing number of physicians are choosing to opt out. As a percentage of the total physicians participating in Medicare, those opting out represent only about 1% each year and are greatly outpaced by physicians choosing to participate in the program, according to the Centers for Medicare and Medicaid Services.
On Twitter @MaryEllenNY
Nearly 90% of physicians accept new Medicare patients, a percentage that has held steady for the last several years, according to an analysis released by the Department of Health and Human Services.
In 2012, 90.7% of physicians were accepting new Medicare patients, compared with 87.9% in 2005. The HHS report, released Aug. 22, relies on data from the National Ambulatory Medical Care Survey, a nationally representative survey of office-based medical doctors and osteopaths. It excludes radiologists, anesthesiologists, and pathologists. As of 2011, about 650,000 physicians were participating in the Medicare program.
The figures reported by the HHS are similar to the percentage of physicians who were accepting private health insurance between 2005 and 2012. However, preliminary data from the National Ambulatory Medical Care Survey suggests that between 2011 and 2012, the percentage of doctors seeing new Medicare patients was slightly higher than the percentage accepting new privately-insured patients.
Medicare officials said the report confirms that physician participation in the Medicare program remains strong despite reports that a growing number of physicians are choosing to opt out. As a percentage of the total physicians participating in Medicare, those opting out represent only about 1% each year and are greatly outpaced by physicians choosing to participate in the program, according to the Centers for Medicare and Medicaid Services.
On Twitter @MaryEllenNY
Nearly 90% of physicians accept new Medicare patients, a percentage that has held steady for the last several years, according to an analysis released by the Department of Health and Human Services.
In 2012, 90.7% of physicians were accepting new Medicare patients, compared with 87.9% in 2005. The HHS report, released Aug. 22, relies on data from the National Ambulatory Medical Care Survey, a nationally representative survey of office-based medical doctors and osteopaths. It excludes radiologists, anesthesiologists, and pathologists. As of 2011, about 650,000 physicians were participating in the Medicare program.
The figures reported by the HHS are similar to the percentage of physicians who were accepting private health insurance between 2005 and 2012. However, preliminary data from the National Ambulatory Medical Care Survey suggests that between 2011 and 2012, the percentage of doctors seeing new Medicare patients was slightly higher than the percentage accepting new privately-insured patients.
Medicare officials said the report confirms that physician participation in the Medicare program remains strong despite reports that a growing number of physicians are choosing to opt out. As a percentage of the total physicians participating in Medicare, those opting out represent only about 1% each year and are greatly outpaced by physicians choosing to participate in the program, according to the Centers for Medicare and Medicaid Services.
On Twitter @MaryEllenNY
ACOG endorses recognition of gay marriage in all states
The American College of Obstetricians and Gynecologists formally endorsed marriage equality for all same-sex couples, saying legally recognized marriage promotes women’s health by easing stress and promoting financial security.
In a policy statement released on Aug. 20, the College praised the recent Supreme Court ruling that struck down the federal Defense of Marriage Act and gave equal protection to same-sex marriages under federal law. But the College also called for additional work to ensure that same-sex couples in all states can receive the same benefits. While the Supreme Court ruling in United States v. Windsor provides federal recognition to states that currently have civil marriage for same-sex couples, it does not require other states to recognize those marriages.
"As a society, we have made enormous progress, but we won’t have full marriage equality until same-sex marriage is legal in every state," Dr. Jeanne A. Conry, president of the College, said in a statement.
Marriage has a number of positive health outcomes for both heterosexual and same-sex couples, including fewer symptoms of depression and lower levels of stress, compared with couples who are in long-term relationships that aren’t legally recognized marriages, according to the policy statement crafted by the College’s Committee on Health Care for Underserved Women. The policy statement will be published in the September issue of Obstetrics and Gynecology.
"As ob.gyns., we must be strong advocates for all of our patients’ health and well-being," Dr. Conry continued. "We know that access to health care and the health of women and their families is tied to financial security. Marriage helps provide this financial security for many women, regardless of sexual orientation."
The Supreme Court ruling will mean increased access to the federal Family Medical Leave Act. Same-sex couples who are married and live in states that legally recognize their marriage will be able to take up to 12 weeks of unpaid leave each year to care for immediate family members under the Family Medical Leave Act.
Compared with married heterosexual couples, same-sex couples are less likely to receive employer-sponsored dependent health care coverage, so they are more than twice as likely to be uninsured. "This has real consequences for our lesbian patients," Dr. Conry said. "When women don’t have health insurance, they may not get screened for cervical and breast cancer or receive other important well-woman care."
The latest policy statement from the College updates a policy issued in 2009. The earlier policy called for lesbian couples to get the same legal protections as married couples (Obstet. Gynecol. 2009;113;469-72).
On Twitter @MaryEllenNY
The American College of Obstetricians and Gynecologists formally endorsed marriage equality for all same-sex couples, saying legally recognized marriage promotes women’s health by easing stress and promoting financial security.
In a policy statement released on Aug. 20, the College praised the recent Supreme Court ruling that struck down the federal Defense of Marriage Act and gave equal protection to same-sex marriages under federal law. But the College also called for additional work to ensure that same-sex couples in all states can receive the same benefits. While the Supreme Court ruling in United States v. Windsor provides federal recognition to states that currently have civil marriage for same-sex couples, it does not require other states to recognize those marriages.
"As a society, we have made enormous progress, but we won’t have full marriage equality until same-sex marriage is legal in every state," Dr. Jeanne A. Conry, president of the College, said in a statement.
Marriage has a number of positive health outcomes for both heterosexual and same-sex couples, including fewer symptoms of depression and lower levels of stress, compared with couples who are in long-term relationships that aren’t legally recognized marriages, according to the policy statement crafted by the College’s Committee on Health Care for Underserved Women. The policy statement will be published in the September issue of Obstetrics and Gynecology.
"As ob.gyns., we must be strong advocates for all of our patients’ health and well-being," Dr. Conry continued. "We know that access to health care and the health of women and their families is tied to financial security. Marriage helps provide this financial security for many women, regardless of sexual orientation."
The Supreme Court ruling will mean increased access to the federal Family Medical Leave Act. Same-sex couples who are married and live in states that legally recognize their marriage will be able to take up to 12 weeks of unpaid leave each year to care for immediate family members under the Family Medical Leave Act.
Compared with married heterosexual couples, same-sex couples are less likely to receive employer-sponsored dependent health care coverage, so they are more than twice as likely to be uninsured. "This has real consequences for our lesbian patients," Dr. Conry said. "When women don’t have health insurance, they may not get screened for cervical and breast cancer or receive other important well-woman care."
The latest policy statement from the College updates a policy issued in 2009. The earlier policy called for lesbian couples to get the same legal protections as married couples (Obstet. Gynecol. 2009;113;469-72).
On Twitter @MaryEllenNY
The American College of Obstetricians and Gynecologists formally endorsed marriage equality for all same-sex couples, saying legally recognized marriage promotes women’s health by easing stress and promoting financial security.
In a policy statement released on Aug. 20, the College praised the recent Supreme Court ruling that struck down the federal Defense of Marriage Act and gave equal protection to same-sex marriages under federal law. But the College also called for additional work to ensure that same-sex couples in all states can receive the same benefits. While the Supreme Court ruling in United States v. Windsor provides federal recognition to states that currently have civil marriage for same-sex couples, it does not require other states to recognize those marriages.
"As a society, we have made enormous progress, but we won’t have full marriage equality until same-sex marriage is legal in every state," Dr. Jeanne A. Conry, president of the College, said in a statement.
Marriage has a number of positive health outcomes for both heterosexual and same-sex couples, including fewer symptoms of depression and lower levels of stress, compared with couples who are in long-term relationships that aren’t legally recognized marriages, according to the policy statement crafted by the College’s Committee on Health Care for Underserved Women. The policy statement will be published in the September issue of Obstetrics and Gynecology.
"As ob.gyns., we must be strong advocates for all of our patients’ health and well-being," Dr. Conry continued. "We know that access to health care and the health of women and their families is tied to financial security. Marriage helps provide this financial security for many women, regardless of sexual orientation."
The Supreme Court ruling will mean increased access to the federal Family Medical Leave Act. Same-sex couples who are married and live in states that legally recognize their marriage will be able to take up to 12 weeks of unpaid leave each year to care for immediate family members under the Family Medical Leave Act.
Compared with married heterosexual couples, same-sex couples are less likely to receive employer-sponsored dependent health care coverage, so they are more than twice as likely to be uninsured. "This has real consequences for our lesbian patients," Dr. Conry said. "When women don’t have health insurance, they may not get screened for cervical and breast cancer or receive other important well-woman care."
The latest policy statement from the College updates a policy issued in 2009. The earlier policy called for lesbian couples to get the same legal protections as married couples (Obstet. Gynecol. 2009;113;469-72).
On Twitter @MaryEllenNY
New society seeks to fill void in academic ob.gyn
For many general ob.gyns. pursuing a career in academics, there’s a lot they need to learn on their own.
Subspecialists in other areas like maternal-fetal medicine or gynecologic oncology undergo fellowship training that provides them with the know-how they need to succeed both in research and when climbing the academic ladder. They also have longstanding subspecialty societies to support them after training and advance the subspecialty. Academic specialists in general ob.gyn., however, have always been expected to hit the ground running straight out of residency and have never had a specialty organization to call their own.
Now a newly minted organization is seeking to make that transition easier by providing resources on research methods, academic leadership, and networking opportunities.
The Society for Academic Specialists in General Obstetrics and Gynecology (SASGOG) held its first meeting last May in New Orleans. The half-day inaugural meeting, which featured presentations on health care reform, research, and academic administration, drew about 200 attendees from academic institutions across the country.
"It was a tremendous response," said Dr. David P. Chelmow, the new president of SASGOG.
Dr. Chelmow, who is professor and chair of the Virginia Commonwealth University department of obstetrics and gynecology, Richmond, said that the new group plans to give academic specialists in general ob.gyn. tools on how to get promoted from assistant professor to associate professor, tips on how to mentor and be mentored, and some basics on research design and how to pursue funding. It also aims to provide a forum for career academic generalists and division chiefs.
There’s been a need for a group like SASGOG for at least as long as his 20-year career in medicine, Dr. Chelmow said in an interview.
So why did it take so long? "I don’t have a good answer to that," he said. "When we started reaching out to people, our fear was that all we would hear was ‘You’re kidding, another society?’ Actually, the response was ‘Yes, this is a great idea.’ "
"I wish we had done it a lot sooner," Dr. Chelmow added. "We probably would have had the same energy behind us if we had."
The work to launch SASGOG began several years ago with conversations between Dr. W. Chuck Hitt of the University of Arkansas, Little Rock, and Dr. L. Chesney Thompson of the University of Colorado, Aurora. As the idea for the group began to take shape, they organized special interest groups and informal gatherings at meetings of the American College of Obstetricians and Gynecologists (ACOG) and other forums for academic ob.gyns.
From there, a core group of organizers, including Dr. Hitt, Dr. Thompson, and Dr. Chelmow, as well as Dr. Tony Ogburn from the University of New Mexico, Albuquerque, and Dr. Lee Learman from Indiana University, Indianapolis, met weekly by phone for months to prepare for an organizational meeting. At that meeting, held in October 2012, they selected officers and board members and set out a plan to get the group off the ground, like getting 501(c)(3) tax exempt status.
"Things kind of snowballed from there," Dr. Chelmow said.
In addition to the success of the first meeting, SASGOG has also attracted 90 academic departments to support the organization as "founding departments" – each contributing $1,000 and sending members to the inaugural meeting. The American Board of Obstetrics and Gynecology (ABOG) Educational Foundation also awarded SASGOG a grant to support educational activities during the first 2 years.
"Both ACOG and ABOG have been unbelievably supportive to us," Dr. Chelmow said.
It’s still a good time to get in on the ground floor of SASGOG. A lot of the focus over the next year will be on the organization itself, he said, forming essential committees for membership and communication. They need to build the infrastructure to get the word out, bring in new members, and have resources and activities for them once they are on board.
For starters, SASGOG’s annual meeting is expanding. The 2014 meeting, which will be held in Chicago in conjunction with the ACOG annual meeting, will feature a full day of educational sessions and a healthy dose of networking, Dr. Chelmow said. They also are developing some webinars that will be offered before then, along with a listserv and an online forum.
Networking, which offers physicians the chance to share best practices, is one of the big selling points for the new organization. "We tried doing a whole bunch of things at our first meeting, and the things that clearly people found the most useful were not just our talks and our breakout sessions, but the fact that they could all get in a room and talk to each other," Dr. Chelmow noted.
And as they get the word out, SASGOG leaders plan on reaching out beyond current faculty to students and residents who are interested in careers as academic generalists.
On Twitter @MaryEllenNY
For many general ob.gyns. pursuing a career in academics, there’s a lot they need to learn on their own.
Subspecialists in other areas like maternal-fetal medicine or gynecologic oncology undergo fellowship training that provides them with the know-how they need to succeed both in research and when climbing the academic ladder. They also have longstanding subspecialty societies to support them after training and advance the subspecialty. Academic specialists in general ob.gyn., however, have always been expected to hit the ground running straight out of residency and have never had a specialty organization to call their own.
Now a newly minted organization is seeking to make that transition easier by providing resources on research methods, academic leadership, and networking opportunities.
The Society for Academic Specialists in General Obstetrics and Gynecology (SASGOG) held its first meeting last May in New Orleans. The half-day inaugural meeting, which featured presentations on health care reform, research, and academic administration, drew about 200 attendees from academic institutions across the country.
"It was a tremendous response," said Dr. David P. Chelmow, the new president of SASGOG.
Dr. Chelmow, who is professor and chair of the Virginia Commonwealth University department of obstetrics and gynecology, Richmond, said that the new group plans to give academic specialists in general ob.gyn. tools on how to get promoted from assistant professor to associate professor, tips on how to mentor and be mentored, and some basics on research design and how to pursue funding. It also aims to provide a forum for career academic generalists and division chiefs.
There’s been a need for a group like SASGOG for at least as long as his 20-year career in medicine, Dr. Chelmow said in an interview.
So why did it take so long? "I don’t have a good answer to that," he said. "When we started reaching out to people, our fear was that all we would hear was ‘You’re kidding, another society?’ Actually, the response was ‘Yes, this is a great idea.’ "
"I wish we had done it a lot sooner," Dr. Chelmow added. "We probably would have had the same energy behind us if we had."
The work to launch SASGOG began several years ago with conversations between Dr. W. Chuck Hitt of the University of Arkansas, Little Rock, and Dr. L. Chesney Thompson of the University of Colorado, Aurora. As the idea for the group began to take shape, they organized special interest groups and informal gatherings at meetings of the American College of Obstetricians and Gynecologists (ACOG) and other forums for academic ob.gyns.
From there, a core group of organizers, including Dr. Hitt, Dr. Thompson, and Dr. Chelmow, as well as Dr. Tony Ogburn from the University of New Mexico, Albuquerque, and Dr. Lee Learman from Indiana University, Indianapolis, met weekly by phone for months to prepare for an organizational meeting. At that meeting, held in October 2012, they selected officers and board members and set out a plan to get the group off the ground, like getting 501(c)(3) tax exempt status.
"Things kind of snowballed from there," Dr. Chelmow said.
In addition to the success of the first meeting, SASGOG has also attracted 90 academic departments to support the organization as "founding departments" – each contributing $1,000 and sending members to the inaugural meeting. The American Board of Obstetrics and Gynecology (ABOG) Educational Foundation also awarded SASGOG a grant to support educational activities during the first 2 years.
"Both ACOG and ABOG have been unbelievably supportive to us," Dr. Chelmow said.
It’s still a good time to get in on the ground floor of SASGOG. A lot of the focus over the next year will be on the organization itself, he said, forming essential committees for membership and communication. They need to build the infrastructure to get the word out, bring in new members, and have resources and activities for them once they are on board.
For starters, SASGOG’s annual meeting is expanding. The 2014 meeting, which will be held in Chicago in conjunction with the ACOG annual meeting, will feature a full day of educational sessions and a healthy dose of networking, Dr. Chelmow said. They also are developing some webinars that will be offered before then, along with a listserv and an online forum.
Networking, which offers physicians the chance to share best practices, is one of the big selling points for the new organization. "We tried doing a whole bunch of things at our first meeting, and the things that clearly people found the most useful were not just our talks and our breakout sessions, but the fact that they could all get in a room and talk to each other," Dr. Chelmow noted.
And as they get the word out, SASGOG leaders plan on reaching out beyond current faculty to students and residents who are interested in careers as academic generalists.
On Twitter @MaryEllenNY
For many general ob.gyns. pursuing a career in academics, there’s a lot they need to learn on their own.
Subspecialists in other areas like maternal-fetal medicine or gynecologic oncology undergo fellowship training that provides them with the know-how they need to succeed both in research and when climbing the academic ladder. They also have longstanding subspecialty societies to support them after training and advance the subspecialty. Academic specialists in general ob.gyn., however, have always been expected to hit the ground running straight out of residency and have never had a specialty organization to call their own.
Now a newly minted organization is seeking to make that transition easier by providing resources on research methods, academic leadership, and networking opportunities.
The Society for Academic Specialists in General Obstetrics and Gynecology (SASGOG) held its first meeting last May in New Orleans. The half-day inaugural meeting, which featured presentations on health care reform, research, and academic administration, drew about 200 attendees from academic institutions across the country.
"It was a tremendous response," said Dr. David P. Chelmow, the new president of SASGOG.
Dr. Chelmow, who is professor and chair of the Virginia Commonwealth University department of obstetrics and gynecology, Richmond, said that the new group plans to give academic specialists in general ob.gyn. tools on how to get promoted from assistant professor to associate professor, tips on how to mentor and be mentored, and some basics on research design and how to pursue funding. It also aims to provide a forum for career academic generalists and division chiefs.
There’s been a need for a group like SASGOG for at least as long as his 20-year career in medicine, Dr. Chelmow said in an interview.
So why did it take so long? "I don’t have a good answer to that," he said. "When we started reaching out to people, our fear was that all we would hear was ‘You’re kidding, another society?’ Actually, the response was ‘Yes, this is a great idea.’ "
"I wish we had done it a lot sooner," Dr. Chelmow added. "We probably would have had the same energy behind us if we had."
The work to launch SASGOG began several years ago with conversations between Dr. W. Chuck Hitt of the University of Arkansas, Little Rock, and Dr. L. Chesney Thompson of the University of Colorado, Aurora. As the idea for the group began to take shape, they organized special interest groups and informal gatherings at meetings of the American College of Obstetricians and Gynecologists (ACOG) and other forums for academic ob.gyns.
From there, a core group of organizers, including Dr. Hitt, Dr. Thompson, and Dr. Chelmow, as well as Dr. Tony Ogburn from the University of New Mexico, Albuquerque, and Dr. Lee Learman from Indiana University, Indianapolis, met weekly by phone for months to prepare for an organizational meeting. At that meeting, held in October 2012, they selected officers and board members and set out a plan to get the group off the ground, like getting 501(c)(3) tax exempt status.
"Things kind of snowballed from there," Dr. Chelmow said.
In addition to the success of the first meeting, SASGOG has also attracted 90 academic departments to support the organization as "founding departments" – each contributing $1,000 and sending members to the inaugural meeting. The American Board of Obstetrics and Gynecology (ABOG) Educational Foundation also awarded SASGOG a grant to support educational activities during the first 2 years.
"Both ACOG and ABOG have been unbelievably supportive to us," Dr. Chelmow said.
It’s still a good time to get in on the ground floor of SASGOG. A lot of the focus over the next year will be on the organization itself, he said, forming essential committees for membership and communication. They need to build the infrastructure to get the word out, bring in new members, and have resources and activities for them once they are on board.
For starters, SASGOG’s annual meeting is expanding. The 2014 meeting, which will be held in Chicago in conjunction with the ACOG annual meeting, will feature a full day of educational sessions and a healthy dose of networking, Dr. Chelmow said. They also are developing some webinars that will be offered before then, along with a listserv and an online forum.
Networking, which offers physicians the chance to share best practices, is one of the big selling points for the new organization. "We tried doing a whole bunch of things at our first meeting, and the things that clearly people found the most useful were not just our talks and our breakout sessions, but the fact that they could all get in a room and talk to each other," Dr. Chelmow noted.
And as they get the word out, SASGOG leaders plan on reaching out beyond current faculty to students and residents who are interested in careers as academic generalists.
On Twitter @MaryEllenNY
Public Citizen: Malpractice payouts hit record lows
Malpractice lawsuit awards are at an all-time low, according to an analysis from the consumer watchdog group Public Citizen.
But the news isn’t all good. Despite the fact that malpractice awards fell 28.8% between 2003 and 2012, the drop in payments isn’t translating into a decline in overall health care costs or improvements in safety, according to Public Citizen.
"We now have a decade’s worth of data debunking the litigation canard," said Taylor Lincoln, research director for Public Citizen’s Congress Watch division and the report’s author. "Policy makers need to focus on reducing medical errors, not reducing accountability for medical errors."
Examining data from the National Practitioner Data Bank, Public Citizen found that in 2012, both the number of awards (9,379) and the amount of those payouts ($3.1 billion) was the lowest on record, once adjusted for inflation. In 2012, the average payment was about $335,000.
The big driver for the drop in malpractice awards is likely state laws that have imposed caps on the amount of noneconomic damages that patients can receive, according to Public Citizen.
The decline in litigation awards appears to be good news for doctors, who overall experienced a decrease in medical liability insurance premiums during the same period. Physician premiums fell to 0.36% of health care costs, the lowest amount in a decade, the report said.
But consumers are losing out, Public Citizen argued, because health care costs are up 58.3% over the last decade. And reports continue to be published showing high rates of adverse events in U.S. hospitals.
Public Citizen cited a 2010 report from the inspector general of the federal Department of Health and Human Services that found that one in seven hospitalized Medicare beneficiaries experienced a serious adverse event, which contributed to death in 1.5% of patients.
But Texas Medical Association President Stephen L. Brotherton countered that medical liability reform actually creates a safer health care environment by improving access to care.
Texas voters approved comprehensive medical liability reform in 2003, including a cap on noneconomic damages. Before that law was enacted, the state had been losing physicians who couldn’t afford their rising malpractice premiums or feared the personal and professional upheaval of a lawsuit, said Dr. Brotherton, an orthopedic surgeon in Fort Worth.
"We were losing people in the prime of their practice," Dr. Brotherton explained.
Many Texas counties had no access to high-risk specialty care, including ob.gyns and neurosurgeons, he noted. And hospitals were having difficulty finding physicians willing to take call in the emergency department. As a result, patients in rural areas couldn’t get access to high-risk specialty care, and some physicians were increasing the volume in their practice to unsafe levels to meet financial pressures from rising insurance premiums, Dr. Brotherton said.
A decade after medical liability reform was passed, physicians are returning to Texas, according to the TMA. Since Texas voters passed Proposition 12 in 2003, Texas has licensed more than 28,000 new physicians, an average of about 3,135 per year. And many of these new doctors are filling the gaps in high-risk areas such as obstetrics, Dr. Brotherton said. Since 2003, 35 rural counties have added at least one obstetrician, including 16 counties that previously had no obstetricians.
There’s no evidence that having an active plaintiff’s bar in a state promotes safer medicine, Dr. Brotherton asserted. "Good doctors are going to where they are wanted," he said.
Dr. Brotherton didn’t dispute the Public Citizen charge that medical liability reform has not brought down health care costs. There are many factors driving rising health care costs, he said, from lifestyle and diet to medication compliance. But reducing overall health care costs was never an argument in favor of reforming the tort system, at least not in Texas, he said.
"No tort reform in the world is going to reduce the number of diabetics," Dr. Brotherton noted.
On Twitter @MaryEllenNY
Malpractice lawsuit awards are at an all-time low, according to an analysis from the consumer watchdog group Public Citizen.
But the news isn’t all good. Despite the fact that malpractice awards fell 28.8% between 2003 and 2012, the drop in payments isn’t translating into a decline in overall health care costs or improvements in safety, according to Public Citizen.
"We now have a decade’s worth of data debunking the litigation canard," said Taylor Lincoln, research director for Public Citizen’s Congress Watch division and the report’s author. "Policy makers need to focus on reducing medical errors, not reducing accountability for medical errors."
Examining data from the National Practitioner Data Bank, Public Citizen found that in 2012, both the number of awards (9,379) and the amount of those payouts ($3.1 billion) was the lowest on record, once adjusted for inflation. In 2012, the average payment was about $335,000.
The big driver for the drop in malpractice awards is likely state laws that have imposed caps on the amount of noneconomic damages that patients can receive, according to Public Citizen.
The decline in litigation awards appears to be good news for doctors, who overall experienced a decrease in medical liability insurance premiums during the same period. Physician premiums fell to 0.36% of health care costs, the lowest amount in a decade, the report said.
But consumers are losing out, Public Citizen argued, because health care costs are up 58.3% over the last decade. And reports continue to be published showing high rates of adverse events in U.S. hospitals.
Public Citizen cited a 2010 report from the inspector general of the federal Department of Health and Human Services that found that one in seven hospitalized Medicare beneficiaries experienced a serious adverse event, which contributed to death in 1.5% of patients.
But Texas Medical Association President Stephen L. Brotherton countered that medical liability reform actually creates a safer health care environment by improving access to care.
Texas voters approved comprehensive medical liability reform in 2003, including a cap on noneconomic damages. Before that law was enacted, the state had been losing physicians who couldn’t afford their rising malpractice premiums or feared the personal and professional upheaval of a lawsuit, said Dr. Brotherton, an orthopedic surgeon in Fort Worth.
"We were losing people in the prime of their practice," Dr. Brotherton explained.
Many Texas counties had no access to high-risk specialty care, including ob.gyns and neurosurgeons, he noted. And hospitals were having difficulty finding physicians willing to take call in the emergency department. As a result, patients in rural areas couldn’t get access to high-risk specialty care, and some physicians were increasing the volume in their practice to unsafe levels to meet financial pressures from rising insurance premiums, Dr. Brotherton said.
A decade after medical liability reform was passed, physicians are returning to Texas, according to the TMA. Since Texas voters passed Proposition 12 in 2003, Texas has licensed more than 28,000 new physicians, an average of about 3,135 per year. And many of these new doctors are filling the gaps in high-risk areas such as obstetrics, Dr. Brotherton said. Since 2003, 35 rural counties have added at least one obstetrician, including 16 counties that previously had no obstetricians.
There’s no evidence that having an active plaintiff’s bar in a state promotes safer medicine, Dr. Brotherton asserted. "Good doctors are going to where they are wanted," he said.
Dr. Brotherton didn’t dispute the Public Citizen charge that medical liability reform has not brought down health care costs. There are many factors driving rising health care costs, he said, from lifestyle and diet to medication compliance. But reducing overall health care costs was never an argument in favor of reforming the tort system, at least not in Texas, he said.
"No tort reform in the world is going to reduce the number of diabetics," Dr. Brotherton noted.
On Twitter @MaryEllenNY
Malpractice lawsuit awards are at an all-time low, according to an analysis from the consumer watchdog group Public Citizen.
But the news isn’t all good. Despite the fact that malpractice awards fell 28.8% between 2003 and 2012, the drop in payments isn’t translating into a decline in overall health care costs or improvements in safety, according to Public Citizen.
"We now have a decade’s worth of data debunking the litigation canard," said Taylor Lincoln, research director for Public Citizen’s Congress Watch division and the report’s author. "Policy makers need to focus on reducing medical errors, not reducing accountability for medical errors."
Examining data from the National Practitioner Data Bank, Public Citizen found that in 2012, both the number of awards (9,379) and the amount of those payouts ($3.1 billion) was the lowest on record, once adjusted for inflation. In 2012, the average payment was about $335,000.
The big driver for the drop in malpractice awards is likely state laws that have imposed caps on the amount of noneconomic damages that patients can receive, according to Public Citizen.
The decline in litigation awards appears to be good news for doctors, who overall experienced a decrease in medical liability insurance premiums during the same period. Physician premiums fell to 0.36% of health care costs, the lowest amount in a decade, the report said.
But consumers are losing out, Public Citizen argued, because health care costs are up 58.3% over the last decade. And reports continue to be published showing high rates of adverse events in U.S. hospitals.
Public Citizen cited a 2010 report from the inspector general of the federal Department of Health and Human Services that found that one in seven hospitalized Medicare beneficiaries experienced a serious adverse event, which contributed to death in 1.5% of patients.
But Texas Medical Association President Stephen L. Brotherton countered that medical liability reform actually creates a safer health care environment by improving access to care.
Texas voters approved comprehensive medical liability reform in 2003, including a cap on noneconomic damages. Before that law was enacted, the state had been losing physicians who couldn’t afford their rising malpractice premiums or feared the personal and professional upheaval of a lawsuit, said Dr. Brotherton, an orthopedic surgeon in Fort Worth.
"We were losing people in the prime of their practice," Dr. Brotherton explained.
Many Texas counties had no access to high-risk specialty care, including ob.gyns and neurosurgeons, he noted. And hospitals were having difficulty finding physicians willing to take call in the emergency department. As a result, patients in rural areas couldn’t get access to high-risk specialty care, and some physicians were increasing the volume in their practice to unsafe levels to meet financial pressures from rising insurance premiums, Dr. Brotherton said.
A decade after medical liability reform was passed, physicians are returning to Texas, according to the TMA. Since Texas voters passed Proposition 12 in 2003, Texas has licensed more than 28,000 new physicians, an average of about 3,135 per year. And many of these new doctors are filling the gaps in high-risk areas such as obstetrics, Dr. Brotherton said. Since 2003, 35 rural counties have added at least one obstetrician, including 16 counties that previously had no obstetricians.
There’s no evidence that having an active plaintiff’s bar in a state promotes safer medicine, Dr. Brotherton asserted. "Good doctors are going to where they are wanted," he said.
Dr. Brotherton didn’t dispute the Public Citizen charge that medical liability reform has not brought down health care costs. There are many factors driving rising health care costs, he said, from lifestyle and diet to medication compliance. But reducing overall health care costs was never an argument in favor of reforming the tort system, at least not in Texas, he said.
"No tort reform in the world is going to reduce the number of diabetics," Dr. Brotherton noted.
On Twitter @MaryEllenNY
Medicare doubles readmission penalties, changes observation status rules
Beginning in October, Medicare will double the penalties for preventable hospital readmissions and change the rules for determining when to admit patients or place them in observation status.
Under the fiscal year 2014 Hospital Inpatient Prospective Payment System rule, Medicare is raising the maximum penalties for preventable, unplanned hospital readmissions from 1% of base operating payments to 2%, starting in October 2013. Details of the payment hike, which is mandated by the Affordable Care Act, were announced Aug. 2 and will be published Aug. 19 in the Federal Register.
The changes impact the Hospital Readmissions Reduction Program, which was originally launched in October 2012. That program penalizes hospitals with excess 30-day Medicare readmissions for acute myocardial infarction, heart failure, and pneumonia.
The new payment rule exempts more types of planned readmissions from the program. It also expands the program to include total hip and knee arthroplasty and acute chronic obstructive pulmonary disease, starting in October 2014.
In response to concerns from hospitals and patients, the hospital inpatient payment rule also provides greater guidance about which patients are appropriate for admission to the hospital and thus covered under Part A, and which patients should be considered for observation status, which is covered under Medicare Part B. The criteria now will be based on the amount of time the physician expects the patient to spend as an inpatient.
Starting in October 2013, Medicare contractors will assume that a hospital stay is eligible for Part A payment if the physician expects the patient to stay as an inpatient in the hospital for at least 2 midnights. The inpatient stay is not triggered until the physician formally admits the patient.
However, officials at the Centers for Medicare and Medicaid Services said physicians may consider the patient’s time in observation, the emergency department, the operating room, and other in-hospital treatment areas when deciding if it is appropriate to expect the patient to stay for at least 2 midnights.
"This rule helps improve hospital care and establishes clearer guidance to hospitals for when we will consider inpatient care to be appropriate so the system works better for patients and providers," CMS Administrator Marilyn Tavenner said in a statement.
The CMS estimates that the policy change will increase spending by approximately $220 million because of increases in inpatient admissions, so the agency is reducing hospital payments accordingly.
Medicare’s changed admission policy is already drawing some critics.
The new criteria will do nothing to protect hospitals from "burdensome" audits and appeals, and it will require physicians to have a "sixth sense and predict the future treatment needs for patients," warned Blair Childs, senior vice president of public affairs for Premier, an alliance of hospitals and other health facilities.
"Moreover, these changes add insult to injury, imposing an associated 0.2% payment reduction to offset what CMS believes will be an increased inpatient volume," Mr. Childs said in a statement. "We expect that this will result in even more confusion around what constitutes an appropriate inpatient hospital admission, all while cutting payments for following CMS’s rules."
On Twitter @MaryEllenNY
Beginning in October, Medicare will double the penalties for preventable hospital readmissions and change the rules for determining when to admit patients or place them in observation status.
Under the fiscal year 2014 Hospital Inpatient Prospective Payment System rule, Medicare is raising the maximum penalties for preventable, unplanned hospital readmissions from 1% of base operating payments to 2%, starting in October 2013. Details of the payment hike, which is mandated by the Affordable Care Act, were announced Aug. 2 and will be published Aug. 19 in the Federal Register.
The changes impact the Hospital Readmissions Reduction Program, which was originally launched in October 2012. That program penalizes hospitals with excess 30-day Medicare readmissions for acute myocardial infarction, heart failure, and pneumonia.
The new payment rule exempts more types of planned readmissions from the program. It also expands the program to include total hip and knee arthroplasty and acute chronic obstructive pulmonary disease, starting in October 2014.
In response to concerns from hospitals and patients, the hospital inpatient payment rule also provides greater guidance about which patients are appropriate for admission to the hospital and thus covered under Part A, and which patients should be considered for observation status, which is covered under Medicare Part B. The criteria now will be based on the amount of time the physician expects the patient to spend as an inpatient.
Starting in October 2013, Medicare contractors will assume that a hospital stay is eligible for Part A payment if the physician expects the patient to stay as an inpatient in the hospital for at least 2 midnights. The inpatient stay is not triggered until the physician formally admits the patient.
However, officials at the Centers for Medicare and Medicaid Services said physicians may consider the patient’s time in observation, the emergency department, the operating room, and other in-hospital treatment areas when deciding if it is appropriate to expect the patient to stay for at least 2 midnights.
"This rule helps improve hospital care and establishes clearer guidance to hospitals for when we will consider inpatient care to be appropriate so the system works better for patients and providers," CMS Administrator Marilyn Tavenner said in a statement.
The CMS estimates that the policy change will increase spending by approximately $220 million because of increases in inpatient admissions, so the agency is reducing hospital payments accordingly.
Medicare’s changed admission policy is already drawing some critics.
The new criteria will do nothing to protect hospitals from "burdensome" audits and appeals, and it will require physicians to have a "sixth sense and predict the future treatment needs for patients," warned Blair Childs, senior vice president of public affairs for Premier, an alliance of hospitals and other health facilities.
"Moreover, these changes add insult to injury, imposing an associated 0.2% payment reduction to offset what CMS believes will be an increased inpatient volume," Mr. Childs said in a statement. "We expect that this will result in even more confusion around what constitutes an appropriate inpatient hospital admission, all while cutting payments for following CMS’s rules."
On Twitter @MaryEllenNY
Beginning in October, Medicare will double the penalties for preventable hospital readmissions and change the rules for determining when to admit patients or place them in observation status.
Under the fiscal year 2014 Hospital Inpatient Prospective Payment System rule, Medicare is raising the maximum penalties for preventable, unplanned hospital readmissions from 1% of base operating payments to 2%, starting in October 2013. Details of the payment hike, which is mandated by the Affordable Care Act, were announced Aug. 2 and will be published Aug. 19 in the Federal Register.
The changes impact the Hospital Readmissions Reduction Program, which was originally launched in October 2012. That program penalizes hospitals with excess 30-day Medicare readmissions for acute myocardial infarction, heart failure, and pneumonia.
The new payment rule exempts more types of planned readmissions from the program. It also expands the program to include total hip and knee arthroplasty and acute chronic obstructive pulmonary disease, starting in October 2014.
In response to concerns from hospitals and patients, the hospital inpatient payment rule also provides greater guidance about which patients are appropriate for admission to the hospital and thus covered under Part A, and which patients should be considered for observation status, which is covered under Medicare Part B. The criteria now will be based on the amount of time the physician expects the patient to spend as an inpatient.
Starting in October 2013, Medicare contractors will assume that a hospital stay is eligible for Part A payment if the physician expects the patient to stay as an inpatient in the hospital for at least 2 midnights. The inpatient stay is not triggered until the physician formally admits the patient.
However, officials at the Centers for Medicare and Medicaid Services said physicians may consider the patient’s time in observation, the emergency department, the operating room, and other in-hospital treatment areas when deciding if it is appropriate to expect the patient to stay for at least 2 midnights.
"This rule helps improve hospital care and establishes clearer guidance to hospitals for when we will consider inpatient care to be appropriate so the system works better for patients and providers," CMS Administrator Marilyn Tavenner said in a statement.
The CMS estimates that the policy change will increase spending by approximately $220 million because of increases in inpatient admissions, so the agency is reducing hospital payments accordingly.
Medicare’s changed admission policy is already drawing some critics.
The new criteria will do nothing to protect hospitals from "burdensome" audits and appeals, and it will require physicians to have a "sixth sense and predict the future treatment needs for patients," warned Blair Childs, senior vice president of public affairs for Premier, an alliance of hospitals and other health facilities.
"Moreover, these changes add insult to injury, imposing an associated 0.2% payment reduction to offset what CMS believes will be an increased inpatient volume," Mr. Childs said in a statement. "We expect that this will result in even more confusion around what constitutes an appropriate inpatient hospital admission, all while cutting payments for following CMS’s rules."
On Twitter @MaryEllenNY
Defensive medicine tied to physician perceptions, not damage caps
Physicians’ fears of malpractice lawsuits appear to drive them to order more diagnostic tests, even in states with medical liability damage caps, according to a new study in the Aug. 5 issue of Health Affairs.
The study, which linked survey data on physician perceptions of malpractice risk to their ordering data, found that physicians had higher rates of diagnostic imaging ordering for patients with lower back pain and headache if they were more concerned about their malpractice risk. But the researchers did not find that defensive ordering declined when states enacted tort reforms such as damage caps.
"Our paper suggests that physicians’ self-report of their defensive concerns may have a stronger impact than was previously suspected, but it definitely doesn’t answer the question of specifically how strong that effect is," said Dr. Emily Carrier, a senior health researcher at the Center for Studying Health System Change. Dr. Carrier is an emergency physician.
The researchers examined the use of diagnostic tests, referrals to the emergency department, and admissions to the hospital for ambulatory patients who saw a physician with complaints of chest pain, headache, or lower back pain. The researchers said they chose these conditions because they represent a range of underlying problems, and because physicians have considerable discretion in how they treat these cases.
Patients with chest pain had a significantly higher chance of being referred to the emergency department, rather than having an outpatient stress test, if their physicians had a high or medium level of malpractice concern. The researchers also observed somewhat higher ordering rates for advanced imaging and hospitalization by physicians with higher malpractice concerns, but the figures were not significantly higher.
Headache patients whose physicians had high levels of malpractice concern were significantly more likely to receive advanced imaging than were those whose physicians had a low level of concern (11.5% versus 6.4%). But rates of conventional imaging and hospitalization were extremely low for headache patients and were not associated with the level of malpractice concern. Also, the researchers failed to find a significant association between the level of malpractice concern and referrals to the emergency department for headache patients.
Patients with lower back pain were more likely to receive both conventional and advanced imaging services if their physicians had high levels of concern about malpractice lawsuits, compared with patients whose physicians had fewer concerns. There was no significant difference in the likelihood that these patients would be admitted to the hospital for their complaints.
The study also found that damage caps don’t seem to be impacting defensive medicine practices.
When the researchers analyzed Medicare claims with the state data on the presence of medical liability damage caps, they found that services often went up in states with caps. The finding may be a case of "reverse causality," the researchers said. In states where there are high levels of defensive medicine, lawmakers are more likely to adopt a damage cap.
Dr. Carrier said she suspects that advocates on both sides of the medical liability reform debate will find data points to bolster their arguments from the study. But she hopes that there will be more study of alternative tort reform strategies such as "safe harbors" for physicians who follow evidence-based practice guidelines.
"We certainly aren’t coming down on one side or the other," she said. "We’re just showing that given our data, we may need to rethink some previous conclusions and find a different approach."
Another area where the researchers did not find a clear association was in the emergency department. There was no significant link observed between emergency physicians’ levels of malpractice concern and the services they ordered when patients came to the emergency department first.
"It’s possible that at this point in specialties like emergency medicine, defensive care has been so baked into training and routine that even people who think they are not very defensive are still being defensive," Dr. Carrier said.
The retrospective study includes Medicare Part A and B claims data on nearly 1.9 million beneficiaries who received services from 2007 to 2009. The claims are linked to data from the 2008 Center for Studying Health System Change Health Tracking Physician Survey, which includes concerns about malpractice suits.
Survey data on physician perceptions of their malpractice risk have been published before, but they have not been linked to claims data showing physicians’ actual ordering behavior.
"It’s an idea that makes intuitive sense," Dr. Carrier said. "It’s just that the data set to test it didn’t exist until now."
But there is still a lot that the data set can’t explain. "There are many reasons why someone might order a test or not order a test," she added.
The National Institute for Health Care Reform funded the study. The authors had no conflicts to disclose.
On Twitter @MaryEllenNY
Physicians’ fears of malpractice lawsuits appear to drive them to order more diagnostic tests, even in states with medical liability damage caps, according to a new study in the Aug. 5 issue of Health Affairs.
The study, which linked survey data on physician perceptions of malpractice risk to their ordering data, found that physicians had higher rates of diagnostic imaging ordering for patients with lower back pain and headache if they were more concerned about their malpractice risk. But the researchers did not find that defensive ordering declined when states enacted tort reforms such as damage caps.
"Our paper suggests that physicians’ self-report of their defensive concerns may have a stronger impact than was previously suspected, but it definitely doesn’t answer the question of specifically how strong that effect is," said Dr. Emily Carrier, a senior health researcher at the Center for Studying Health System Change. Dr. Carrier is an emergency physician.
The researchers examined the use of diagnostic tests, referrals to the emergency department, and admissions to the hospital for ambulatory patients who saw a physician with complaints of chest pain, headache, or lower back pain. The researchers said they chose these conditions because they represent a range of underlying problems, and because physicians have considerable discretion in how they treat these cases.
Patients with chest pain had a significantly higher chance of being referred to the emergency department, rather than having an outpatient stress test, if their physicians had a high or medium level of malpractice concern. The researchers also observed somewhat higher ordering rates for advanced imaging and hospitalization by physicians with higher malpractice concerns, but the figures were not significantly higher.
Headache patients whose physicians had high levels of malpractice concern were significantly more likely to receive advanced imaging than were those whose physicians had a low level of concern (11.5% versus 6.4%). But rates of conventional imaging and hospitalization were extremely low for headache patients and were not associated with the level of malpractice concern. Also, the researchers failed to find a significant association between the level of malpractice concern and referrals to the emergency department for headache patients.
Patients with lower back pain were more likely to receive both conventional and advanced imaging services if their physicians had high levels of concern about malpractice lawsuits, compared with patients whose physicians had fewer concerns. There was no significant difference in the likelihood that these patients would be admitted to the hospital for their complaints.
The study also found that damage caps don’t seem to be impacting defensive medicine practices.
When the researchers analyzed Medicare claims with the state data on the presence of medical liability damage caps, they found that services often went up in states with caps. The finding may be a case of "reverse causality," the researchers said. In states where there are high levels of defensive medicine, lawmakers are more likely to adopt a damage cap.
Dr. Carrier said she suspects that advocates on both sides of the medical liability reform debate will find data points to bolster their arguments from the study. But she hopes that there will be more study of alternative tort reform strategies such as "safe harbors" for physicians who follow evidence-based practice guidelines.
"We certainly aren’t coming down on one side or the other," she said. "We’re just showing that given our data, we may need to rethink some previous conclusions and find a different approach."
Another area where the researchers did not find a clear association was in the emergency department. There was no significant link observed between emergency physicians’ levels of malpractice concern and the services they ordered when patients came to the emergency department first.
"It’s possible that at this point in specialties like emergency medicine, defensive care has been so baked into training and routine that even people who think they are not very defensive are still being defensive," Dr. Carrier said.
The retrospective study includes Medicare Part A and B claims data on nearly 1.9 million beneficiaries who received services from 2007 to 2009. The claims are linked to data from the 2008 Center for Studying Health System Change Health Tracking Physician Survey, which includes concerns about malpractice suits.
Survey data on physician perceptions of their malpractice risk have been published before, but they have not been linked to claims data showing physicians’ actual ordering behavior.
"It’s an idea that makes intuitive sense," Dr. Carrier said. "It’s just that the data set to test it didn’t exist until now."
But there is still a lot that the data set can’t explain. "There are many reasons why someone might order a test or not order a test," she added.
The National Institute for Health Care Reform funded the study. The authors had no conflicts to disclose.
On Twitter @MaryEllenNY
Physicians’ fears of malpractice lawsuits appear to drive them to order more diagnostic tests, even in states with medical liability damage caps, according to a new study in the Aug. 5 issue of Health Affairs.
The study, which linked survey data on physician perceptions of malpractice risk to their ordering data, found that physicians had higher rates of diagnostic imaging ordering for patients with lower back pain and headache if they were more concerned about their malpractice risk. But the researchers did not find that defensive ordering declined when states enacted tort reforms such as damage caps.
"Our paper suggests that physicians’ self-report of their defensive concerns may have a stronger impact than was previously suspected, but it definitely doesn’t answer the question of specifically how strong that effect is," said Dr. Emily Carrier, a senior health researcher at the Center for Studying Health System Change. Dr. Carrier is an emergency physician.
The researchers examined the use of diagnostic tests, referrals to the emergency department, and admissions to the hospital for ambulatory patients who saw a physician with complaints of chest pain, headache, or lower back pain. The researchers said they chose these conditions because they represent a range of underlying problems, and because physicians have considerable discretion in how they treat these cases.
Patients with chest pain had a significantly higher chance of being referred to the emergency department, rather than having an outpatient stress test, if their physicians had a high or medium level of malpractice concern. The researchers also observed somewhat higher ordering rates for advanced imaging and hospitalization by physicians with higher malpractice concerns, but the figures were not significantly higher.
Headache patients whose physicians had high levels of malpractice concern were significantly more likely to receive advanced imaging than were those whose physicians had a low level of concern (11.5% versus 6.4%). But rates of conventional imaging and hospitalization were extremely low for headache patients and were not associated with the level of malpractice concern. Also, the researchers failed to find a significant association between the level of malpractice concern and referrals to the emergency department for headache patients.
Patients with lower back pain were more likely to receive both conventional and advanced imaging services if their physicians had high levels of concern about malpractice lawsuits, compared with patients whose physicians had fewer concerns. There was no significant difference in the likelihood that these patients would be admitted to the hospital for their complaints.
The study also found that damage caps don’t seem to be impacting defensive medicine practices.
When the researchers analyzed Medicare claims with the state data on the presence of medical liability damage caps, they found that services often went up in states with caps. The finding may be a case of "reverse causality," the researchers said. In states where there are high levels of defensive medicine, lawmakers are more likely to adopt a damage cap.
Dr. Carrier said she suspects that advocates on both sides of the medical liability reform debate will find data points to bolster their arguments from the study. But she hopes that there will be more study of alternative tort reform strategies such as "safe harbors" for physicians who follow evidence-based practice guidelines.
"We certainly aren’t coming down on one side or the other," she said. "We’re just showing that given our data, we may need to rethink some previous conclusions and find a different approach."
Another area where the researchers did not find a clear association was in the emergency department. There was no significant link observed between emergency physicians’ levels of malpractice concern and the services they ordered when patients came to the emergency department first.
"It’s possible that at this point in specialties like emergency medicine, defensive care has been so baked into training and routine that even people who think they are not very defensive are still being defensive," Dr. Carrier said.
The retrospective study includes Medicare Part A and B claims data on nearly 1.9 million beneficiaries who received services from 2007 to 2009. The claims are linked to data from the 2008 Center for Studying Health System Change Health Tracking Physician Survey, which includes concerns about malpractice suits.
Survey data on physician perceptions of their malpractice risk have been published before, but they have not been linked to claims data showing physicians’ actual ordering behavior.
"It’s an idea that makes intuitive sense," Dr. Carrier said. "It’s just that the data set to test it didn’t exist until now."
But there is still a lot that the data set can’t explain. "There are many reasons why someone might order a test or not order a test," she added.
The National Institute for Health Care Reform funded the study. The authors had no conflicts to disclose.
On Twitter @MaryEllenNY
FROM HEALTH AFFAIRS
Major finding: Among headache patients, the likelihood of ordering advanced imaging was 11.5% among physicians with high-level concerns about malpractice, compared with 6.4% among physicians with lesser concerns.
Data source: A retrospective study of Medicare Part A and B claims data on nearly 1.9 million beneficiaries from 2007 to 2009. The claims are linked to data from the 2008 Center for Studying Health System Change Health Tracking Physician Survey.
Disclosures: The National Institute for Health Care Reform funded the study. The authors had no conflicts to disclose.
Hospitalists seek help on Medicare's 3-day rule
Fed up with the uncertainty and confusion surrounding Medicare’s rules for when a patient should be admitted to the hospital or classified as under observation status, hospitalist leaders are urging Congress to address one key piece of the issue – the 3-day inpatient hospitalization requirement for coverage of a skilled nursing facility stay.
Earlier this year, a small group of lawmakers introduced bills in both the House and Senate to alter the requirement that Medicare beneficiaries must be hospital inpatients for at least 3 days in a row to qualify for Medicare coverage of their stay in a skilled nursing facility (SNF). Under the proposals, time spent in observation status at the hospital, which Medicare considers to be "outpatient" treatment, would be counted toward Medicare’s 3-day requirement.
UPDATE: "CMS changes observation status rules"
The bills (H.R. 1179/S. 569), introduced in March, are slowly gaining steam on Capitol Hill, said Dr. Ron Greeno, chief medical officer at Cogent HMG and chairman of the Society of Hospital Medicine’s Public Policy Committee.
Dr. Greeno said there are a number of reasons why he’s optimistic that the bills will move faster than some other health care issues currently before Congress. For starters, the bills have at least some bipartisan support and the legislation is circulating in both houses of Congress. Another reason the bills could be successful in Congress is that the issue is easy to understand and will help seniors, a key voting demographic.
"It’s very hard for legislators at this point to say that they aren’t going to correct this really clear inequity in the system," Dr. Greeno said.
Forced to choose
The biggest impact of the current 3-day requirement falls on Medicare patients who are facing either a significant cost burden or potentially less than ideal care. Patients who don’t meet the 3-day inpatient requirement must pay out of pocket for their SNF stay or come up with a less comprehensive plan of care at home.
"We try to piecemeal a plan together that may not be entirely safe for them," said Dr. Ann M. Sheehy, head of the division of hospital medicine at the University of Wisconsin and a member of SHM’s Public Policy Committee. "I certainly think that we end up sending patients home that are more likely to be readmitted."
But the legislation could hit a snag in Congress due to cost.
"It will increase the number of patients who qualify to have their SNF care covered by Medicare and so there’s a cost," Dr. Greeno said. "I don’t think there would be any resistance to either of these bills if it didn’t come with a pretty hefty bill. That’s where the push-back will come."
The Congressional Budget Office, which produces cost estimates on legislative proposals, has not yet scored the cost of the bill, Dr. Greeno said, but it’s safe to say the price tag will be significant over the next decade since it will qualify more patients for the SNF benefit. That leaves lawmakers to agree on a way to offset the cost, something that has already stalled progress on other issues with bipartisan support, such as repealing Medicare’s Sustainable Growth Rate (SGR) formula.
If the 3-day rule legislation passes this year, it will be a "huge victory" and send the signal that Congress is serious about reforming observation status, said Dr. Sheehy. But it will still leave hospitalists and other admitting physicians with a set of dysfunctional rules on when to employ observation status, she said.
The problem, Dr. Sheehy said, is that observation status has expanded dramatically in recent years as Medicare auditors have returned hundreds of millions of dollars to the Medicare program by deeming many inpatient admissions as inappropriate. Perhaps as a result of the aggressive auditing by Medicare, the number of Medicare beneficiaries classified as receiving observation services for more than 48 hours has grown from about 3% in 2006 to about 8% in 2011, according to the CMS.
"Observation status right now is so dysfunctional because it has expanded greatly under audits to include so many patients that it’s almost hard to envision a way that it can become functional again," Dr. Sheehy said. "It’s so far from where it was intended to be that I don’t know how it could be fixed."
Two midnights
In May, the agency proposed to simplify the current observation rules by creating a "time-based presumption" of medical necessity for hospital inpatient services based on the patient’s length of stay. The plan was floated as part of the 2014 Hospital Inpatient Prospective Payment System proposed rule.
Under the rule, Medicare’s external review contractors would presume that inpatient admissions were necessary for patients who require more than one Medicare utilization day (or 2 "midnights" in the hospital). The policy would also assume that hospital stays of less than 2 midnights should be classified as observation status.
Dr. Sheehy said it’s a positive move that Medicare wants to move away from the status quo. "But it’s hard to know how the rule change might play out," she added. "Only time will tell if these rules are going to be beneficial or not."
Dr. Greeno predicted that the issue isn’t going to fade away. The Center for Medicare Advocacy, a consumer group, has filed a class action lawsuit against the CMS on behalf of 14 Medicare beneficiaries seeking to remove the observation status designation. In Bagnall v. Sebelius, filed in November 2011, the Center for Medicare Advocacy states that the use of observation status violates federal law and beneficiaries’ constitutional right to due process.
In the meantime, hospitalists will continue to struggle with how to abide by Medicare rules, while still looking out for the best interests of patients.
"People feel terrible because they know when they’re writing that order that they are inflicting a significant financial burden on that patient and their family," Dr. Greeno said.
Dr. Sheehy said that patients will sometimes ask if they can be admitted as inpatients when they find out that they are in observation status and will be paying more out of pocket. "The honest answer is, we can’t," she said.
Physicians can insist on admitting patients that the hospital’s case manager says don’t meet Medicare criteria, Dr. Greeno said, but the likelihood is that the hospital will later be denied payment by Medicare.
"So what it does is it puts the doctor between the patient and the hospital," Dr. Greeno said. "That’s a bad position to be in for a hospitalist. You’re trying to do right by both and you can’t."
Fed up with the uncertainty and confusion surrounding Medicare’s rules for when a patient should be admitted to the hospital or classified as under observation status, hospitalist leaders are urging Congress to address one key piece of the issue – the 3-day inpatient hospitalization requirement for coverage of a skilled nursing facility stay.
Earlier this year, a small group of lawmakers introduced bills in both the House and Senate to alter the requirement that Medicare beneficiaries must be hospital inpatients for at least 3 days in a row to qualify for Medicare coverage of their stay in a skilled nursing facility (SNF). Under the proposals, time spent in observation status at the hospital, which Medicare considers to be "outpatient" treatment, would be counted toward Medicare’s 3-day requirement.
UPDATE: "CMS changes observation status rules"
The bills (H.R. 1179/S. 569), introduced in March, are slowly gaining steam on Capitol Hill, said Dr. Ron Greeno, chief medical officer at Cogent HMG and chairman of the Society of Hospital Medicine’s Public Policy Committee.
Dr. Greeno said there are a number of reasons why he’s optimistic that the bills will move faster than some other health care issues currently before Congress. For starters, the bills have at least some bipartisan support and the legislation is circulating in both houses of Congress. Another reason the bills could be successful in Congress is that the issue is easy to understand and will help seniors, a key voting demographic.
"It’s very hard for legislators at this point to say that they aren’t going to correct this really clear inequity in the system," Dr. Greeno said.
Forced to choose
The biggest impact of the current 3-day requirement falls on Medicare patients who are facing either a significant cost burden or potentially less than ideal care. Patients who don’t meet the 3-day inpatient requirement must pay out of pocket for their SNF stay or come up with a less comprehensive plan of care at home.
"We try to piecemeal a plan together that may not be entirely safe for them," said Dr. Ann M. Sheehy, head of the division of hospital medicine at the University of Wisconsin and a member of SHM’s Public Policy Committee. "I certainly think that we end up sending patients home that are more likely to be readmitted."
But the legislation could hit a snag in Congress due to cost.
"It will increase the number of patients who qualify to have their SNF care covered by Medicare and so there’s a cost," Dr. Greeno said. "I don’t think there would be any resistance to either of these bills if it didn’t come with a pretty hefty bill. That’s where the push-back will come."
The Congressional Budget Office, which produces cost estimates on legislative proposals, has not yet scored the cost of the bill, Dr. Greeno said, but it’s safe to say the price tag will be significant over the next decade since it will qualify more patients for the SNF benefit. That leaves lawmakers to agree on a way to offset the cost, something that has already stalled progress on other issues with bipartisan support, such as repealing Medicare’s Sustainable Growth Rate (SGR) formula.
If the 3-day rule legislation passes this year, it will be a "huge victory" and send the signal that Congress is serious about reforming observation status, said Dr. Sheehy. But it will still leave hospitalists and other admitting physicians with a set of dysfunctional rules on when to employ observation status, she said.
The problem, Dr. Sheehy said, is that observation status has expanded dramatically in recent years as Medicare auditors have returned hundreds of millions of dollars to the Medicare program by deeming many inpatient admissions as inappropriate. Perhaps as a result of the aggressive auditing by Medicare, the number of Medicare beneficiaries classified as receiving observation services for more than 48 hours has grown from about 3% in 2006 to about 8% in 2011, according to the CMS.
"Observation status right now is so dysfunctional because it has expanded greatly under audits to include so many patients that it’s almost hard to envision a way that it can become functional again," Dr. Sheehy said. "It’s so far from where it was intended to be that I don’t know how it could be fixed."
Two midnights
In May, the agency proposed to simplify the current observation rules by creating a "time-based presumption" of medical necessity for hospital inpatient services based on the patient’s length of stay. The plan was floated as part of the 2014 Hospital Inpatient Prospective Payment System proposed rule.
Under the rule, Medicare’s external review contractors would presume that inpatient admissions were necessary for patients who require more than one Medicare utilization day (or 2 "midnights" in the hospital). The policy would also assume that hospital stays of less than 2 midnights should be classified as observation status.
Dr. Sheehy said it’s a positive move that Medicare wants to move away from the status quo. "But it’s hard to know how the rule change might play out," she added. "Only time will tell if these rules are going to be beneficial or not."
Dr. Greeno predicted that the issue isn’t going to fade away. The Center for Medicare Advocacy, a consumer group, has filed a class action lawsuit against the CMS on behalf of 14 Medicare beneficiaries seeking to remove the observation status designation. In Bagnall v. Sebelius, filed in November 2011, the Center for Medicare Advocacy states that the use of observation status violates federal law and beneficiaries’ constitutional right to due process.
In the meantime, hospitalists will continue to struggle with how to abide by Medicare rules, while still looking out for the best interests of patients.
"People feel terrible because they know when they’re writing that order that they are inflicting a significant financial burden on that patient and their family," Dr. Greeno said.
Dr. Sheehy said that patients will sometimes ask if they can be admitted as inpatients when they find out that they are in observation status and will be paying more out of pocket. "The honest answer is, we can’t," she said.
Physicians can insist on admitting patients that the hospital’s case manager says don’t meet Medicare criteria, Dr. Greeno said, but the likelihood is that the hospital will later be denied payment by Medicare.
"So what it does is it puts the doctor between the patient and the hospital," Dr. Greeno said. "That’s a bad position to be in for a hospitalist. You’re trying to do right by both and you can’t."
Fed up with the uncertainty and confusion surrounding Medicare’s rules for when a patient should be admitted to the hospital or classified as under observation status, hospitalist leaders are urging Congress to address one key piece of the issue – the 3-day inpatient hospitalization requirement for coverage of a skilled nursing facility stay.
Earlier this year, a small group of lawmakers introduced bills in both the House and Senate to alter the requirement that Medicare beneficiaries must be hospital inpatients for at least 3 days in a row to qualify for Medicare coverage of their stay in a skilled nursing facility (SNF). Under the proposals, time spent in observation status at the hospital, which Medicare considers to be "outpatient" treatment, would be counted toward Medicare’s 3-day requirement.
UPDATE: "CMS changes observation status rules"
The bills (H.R. 1179/S. 569), introduced in March, are slowly gaining steam on Capitol Hill, said Dr. Ron Greeno, chief medical officer at Cogent HMG and chairman of the Society of Hospital Medicine’s Public Policy Committee.
Dr. Greeno said there are a number of reasons why he’s optimistic that the bills will move faster than some other health care issues currently before Congress. For starters, the bills have at least some bipartisan support and the legislation is circulating in both houses of Congress. Another reason the bills could be successful in Congress is that the issue is easy to understand and will help seniors, a key voting demographic.
"It’s very hard for legislators at this point to say that they aren’t going to correct this really clear inequity in the system," Dr. Greeno said.
Forced to choose
The biggest impact of the current 3-day requirement falls on Medicare patients who are facing either a significant cost burden or potentially less than ideal care. Patients who don’t meet the 3-day inpatient requirement must pay out of pocket for their SNF stay or come up with a less comprehensive plan of care at home.
"We try to piecemeal a plan together that may not be entirely safe for them," said Dr. Ann M. Sheehy, head of the division of hospital medicine at the University of Wisconsin and a member of SHM’s Public Policy Committee. "I certainly think that we end up sending patients home that are more likely to be readmitted."
But the legislation could hit a snag in Congress due to cost.
"It will increase the number of patients who qualify to have their SNF care covered by Medicare and so there’s a cost," Dr. Greeno said. "I don’t think there would be any resistance to either of these bills if it didn’t come with a pretty hefty bill. That’s where the push-back will come."
The Congressional Budget Office, which produces cost estimates on legislative proposals, has not yet scored the cost of the bill, Dr. Greeno said, but it’s safe to say the price tag will be significant over the next decade since it will qualify more patients for the SNF benefit. That leaves lawmakers to agree on a way to offset the cost, something that has already stalled progress on other issues with bipartisan support, such as repealing Medicare’s Sustainable Growth Rate (SGR) formula.
If the 3-day rule legislation passes this year, it will be a "huge victory" and send the signal that Congress is serious about reforming observation status, said Dr. Sheehy. But it will still leave hospitalists and other admitting physicians with a set of dysfunctional rules on when to employ observation status, she said.
The problem, Dr. Sheehy said, is that observation status has expanded dramatically in recent years as Medicare auditors have returned hundreds of millions of dollars to the Medicare program by deeming many inpatient admissions as inappropriate. Perhaps as a result of the aggressive auditing by Medicare, the number of Medicare beneficiaries classified as receiving observation services for more than 48 hours has grown from about 3% in 2006 to about 8% in 2011, according to the CMS.
"Observation status right now is so dysfunctional because it has expanded greatly under audits to include so many patients that it’s almost hard to envision a way that it can become functional again," Dr. Sheehy said. "It’s so far from where it was intended to be that I don’t know how it could be fixed."
Two midnights
In May, the agency proposed to simplify the current observation rules by creating a "time-based presumption" of medical necessity for hospital inpatient services based on the patient’s length of stay. The plan was floated as part of the 2014 Hospital Inpatient Prospective Payment System proposed rule.
Under the rule, Medicare’s external review contractors would presume that inpatient admissions were necessary for patients who require more than one Medicare utilization day (or 2 "midnights" in the hospital). The policy would also assume that hospital stays of less than 2 midnights should be classified as observation status.
Dr. Sheehy said it’s a positive move that Medicare wants to move away from the status quo. "But it’s hard to know how the rule change might play out," she added. "Only time will tell if these rules are going to be beneficial or not."
Dr. Greeno predicted that the issue isn’t going to fade away. The Center for Medicare Advocacy, a consumer group, has filed a class action lawsuit against the CMS on behalf of 14 Medicare beneficiaries seeking to remove the observation status designation. In Bagnall v. Sebelius, filed in November 2011, the Center for Medicare Advocacy states that the use of observation status violates federal law and beneficiaries’ constitutional right to due process.
In the meantime, hospitalists will continue to struggle with how to abide by Medicare rules, while still looking out for the best interests of patients.
"People feel terrible because they know when they’re writing that order that they are inflicting a significant financial burden on that patient and their family," Dr. Greeno said.
Dr. Sheehy said that patients will sometimes ask if they can be admitted as inpatients when they find out that they are in observation status and will be paying more out of pocket. "The honest answer is, we can’t," she said.
Physicians can insist on admitting patients that the hospital’s case manager says don’t meet Medicare criteria, Dr. Greeno said, but the likelihood is that the hospital will later be denied payment by Medicare.
"So what it does is it puts the doctor between the patient and the hospital," Dr. Greeno said. "That’s a bad position to be in for a hospitalist. You’re trying to do right by both and you can’t."
