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Double penalty on 30-day readmissions
The penalties are going up in Medicare’s hospital readmission reduction program.
Starting on Oct. 1, hospitals could face up to a 2% cut in Medicare payments if their 30-day readmission rates for acute myocardial infarction, heart failure, and pneumonia are too high. The program started on Oct. 1, 2012, with a 1% cap on penalties.
The penalty increase was outlined in Medicare’s proposed fiscal year 2014 inpatient prospective payment system rule, which was released April 26.
The Medicare proposal also outlines the government’s plans to expand the readmission reduction program to include two new readmission measures.
Starting on Oct. 1, 2014, the program would also include readmissions associated with an acute exacerbation of chronic obstructive pulmonary disease, as well as readmissions for elective total hip or knee arthroplasty.
The inclusion of COPD for fiscal year 2015 was expected since that condition was specifically highlighted by Congress in the Affordable Care Act (ACA), which created the readmission reduction program. However, lawmakers had also recommended adding coronary artery bypass graft (CABG) surgery, percutaneous coronary intervention (PCI), and other vascular conditions, which are not included in the Centers for Medicare and Medicaid Services (CMS) proposal.
The reasons for the switch were largely due to cost and volume, according to the proposal rule.
In 2005, annual hospital charges totaled $3.95 billion for primary total hip arthroplasty and $7.42 billion for total knee arthroplasty. When combined, the two procedures represent the largest procedures cost in the Medicare budget.
At the same time, inpatient admissions for PCI and other vascular conditions have been declining, according to Medicare officials, as more of those services are being shifted to hospital outpatient departments.
The fiscal 2014 payment proposal also includes a revised methodology for calculating hospital readmission rates in an effort to do a better job of accounting for certain planned readmissions.
The change is a mixed bag for hospitals, according to the Premier healthcare alliance. While the revised methodology will likely result in a more accurate payment calculation, it fails to take into consideration socioeconomic and community factors.
"Hospitals that serve high percentages of lower-income patients will be disproportionately penalized for circumstances outside their control," Blair Childs, senior vice president of public affairs at Premier, said in a statement.
"This places additional financial burdens on already stressed local health care systems in these communities."
The Medicare program is also moving forward with the Hospital-Acquired Condition Reduction Program, which was also created by the ACA.
The new program, which begins on Oct. 1, 2014, levies a 1% penalty on hospitals that rank in the lowest-performing quartile for eight hospital-acquired conditions. The proposed rule includes the quality measures, scoring methodology, and correction process that are planned for the program.
During the first year, officials plan to use quality measures that are calculated using claims data or are part of the Inpatient Quality Reporting program.
The eight measures are divided into two domains. Hospitals will receive a score for each measure, which will then be used to calculate a domain score. The two domains will be weighted equally to get a total score under the program, according to CMS.
The measures in the first of the two domains are pressure ulcer rate; volume of foreign object left in the body; iatrogenic pneumothorax rate; postoperative physiologic and metabolic derangement rate; postoperative pulmonary embolism or deep vein thrombosis rate; and accidental puncture and laceration rate.
CMS is also considering the use of a composite patient safety indicator measure set as an alternative to the first domain.
The second domain being used to get a total score under the new program includes two health care–associated infection measures: central line–associated bloodstream infection and catheter-associated urinary tract infection.
CMS plans to account for risk factors such as age, gender, and comorbidities when calculating the measure rates.
There are no surprises in the conditions chosen for the new program, said Erik Johnson, senior vice president at Avalere Health. However, the fact that CMS officials chose to include eight measures at the start of the program indicates how serious they are about hospital-acquired conditions, he said.
Mr. Johnson predicted that hospitals will take these quality programs seriously as well.
Through the combination of the hospital-acquired condition program, the readmission reduction program, value-based purchasing, and a few other programs, hospitals now have at least 7% of their Medicare payments at risk based on performance on quality measures, he said.
"It’s already starting to move behaviors," he added.
"Hospitals are by and large making a good-faith effort to get better at all of those things. But there are going to be winners and losers, and the losers may end up losing big on a lot of this stuff," according to Mr. Johnson
CMS will accept public comments on the proposal until June 25 at www.regulations.gov. The agency is scheduled to release its final rule by Aug. 1.
Medicare continues to drive hospitals toward greater transparency and financial accountability, with the goal being the delivery of higher-value care to our patients. This is a noble pursuit. As a health care system we must embrace the need to do better for our patients – greater effectiveness, safer care, and more efficient care.
To date, measures of success have largely been based upon process of care measures, such as the core measures for pneumonia, heart failure, and surgical patients. Hospitals (and hospitalists) will now begin to see a rapid movement toward accountability for outcomes and not just performance in processes of care. The inclusion of standardized and risk-adjusted hospital-acquired conditions such as central-line bloodstream infections and patient safety indicators (PSIs) are important examples.
Readmission rates are also included in these measured and reported outcomes. At first glance, penalizing hospitals for 30-day readmissions seems like an appropriate and laudable goal. However, this goal assumes that readmissions are avoidable.
Although some readmissions are clearly related to inefficient and unsafe care delivery that is amenable to intervention, many (if not most) are related to patient condition, poor compliance, and suboptimal post–acute care options in the community. Because of these complex clinical and socioeconomic factors, our understanding of how to effectively reduce readmissions remains limited, is generally resource intensive, and is not well compensated in the current payment structure.
These issues will present real challenges to hospitals in trying to meaningfully meet the goals laid out by CMS. For now, embracing approaches such as Project BOOST (Better Outcomes for Older Adults Through Safer Transitions) or Project RED (Re-Engineered Discharge), fostering greater patient engagement in the care transition process, and partnering more closely with our community clinic providers will begin making a positive impact.
However, only through a better understanding of the posthospital syndrome (N. Engl. J. Med. 2013;368:100-2) and meaningful payment reform will we gain the necessary additional tools to make a truly meaningful impact.
Dr. Robert Pendleton is chief medical quality officer for University of Utah Health Care, Salt Lake City.
Medicare continues to drive hospitals toward greater transparency and financial accountability, with the goal being the delivery of higher-value care to our patients. This is a noble pursuit. As a health care system we must embrace the need to do better for our patients – greater effectiveness, safer care, and more efficient care.
To date, measures of success have largely been based upon process of care measures, such as the core measures for pneumonia, heart failure, and surgical patients. Hospitals (and hospitalists) will now begin to see a rapid movement toward accountability for outcomes and not just performance in processes of care. The inclusion of standardized and risk-adjusted hospital-acquired conditions such as central-line bloodstream infections and patient safety indicators (PSIs) are important examples.
Readmission rates are also included in these measured and reported outcomes. At first glance, penalizing hospitals for 30-day readmissions seems like an appropriate and laudable goal. However, this goal assumes that readmissions are avoidable.
Although some readmissions are clearly related to inefficient and unsafe care delivery that is amenable to intervention, many (if not most) are related to patient condition, poor compliance, and suboptimal post–acute care options in the community. Because of these complex clinical and socioeconomic factors, our understanding of how to effectively reduce readmissions remains limited, is generally resource intensive, and is not well compensated in the current payment structure.
These issues will present real challenges to hospitals in trying to meaningfully meet the goals laid out by CMS. For now, embracing approaches such as Project BOOST (Better Outcomes for Older Adults Through Safer Transitions) or Project RED (Re-Engineered Discharge), fostering greater patient engagement in the care transition process, and partnering more closely with our community clinic providers will begin making a positive impact.
However, only through a better understanding of the posthospital syndrome (N. Engl. J. Med. 2013;368:100-2) and meaningful payment reform will we gain the necessary additional tools to make a truly meaningful impact.
Dr. Robert Pendleton is chief medical quality officer for University of Utah Health Care, Salt Lake City.
Medicare continues to drive hospitals toward greater transparency and financial accountability, with the goal being the delivery of higher-value care to our patients. This is a noble pursuit. As a health care system we must embrace the need to do better for our patients – greater effectiveness, safer care, and more efficient care.
To date, measures of success have largely been based upon process of care measures, such as the core measures for pneumonia, heart failure, and surgical patients. Hospitals (and hospitalists) will now begin to see a rapid movement toward accountability for outcomes and not just performance in processes of care. The inclusion of standardized and risk-adjusted hospital-acquired conditions such as central-line bloodstream infections and patient safety indicators (PSIs) are important examples.
Readmission rates are also included in these measured and reported outcomes. At first glance, penalizing hospitals for 30-day readmissions seems like an appropriate and laudable goal. However, this goal assumes that readmissions are avoidable.
Although some readmissions are clearly related to inefficient and unsafe care delivery that is amenable to intervention, many (if not most) are related to patient condition, poor compliance, and suboptimal post–acute care options in the community. Because of these complex clinical and socioeconomic factors, our understanding of how to effectively reduce readmissions remains limited, is generally resource intensive, and is not well compensated in the current payment structure.
These issues will present real challenges to hospitals in trying to meaningfully meet the goals laid out by CMS. For now, embracing approaches such as Project BOOST (Better Outcomes for Older Adults Through Safer Transitions) or Project RED (Re-Engineered Discharge), fostering greater patient engagement in the care transition process, and partnering more closely with our community clinic providers will begin making a positive impact.
However, only through a better understanding of the posthospital syndrome (N. Engl. J. Med. 2013;368:100-2) and meaningful payment reform will we gain the necessary additional tools to make a truly meaningful impact.
Dr. Robert Pendleton is chief medical quality officer for University of Utah Health Care, Salt Lake City.
The penalties are going up in Medicare’s hospital readmission reduction program.
Starting on Oct. 1, hospitals could face up to a 2% cut in Medicare payments if their 30-day readmission rates for acute myocardial infarction, heart failure, and pneumonia are too high. The program started on Oct. 1, 2012, with a 1% cap on penalties.
The penalty increase was outlined in Medicare’s proposed fiscal year 2014 inpatient prospective payment system rule, which was released April 26.
The Medicare proposal also outlines the government’s plans to expand the readmission reduction program to include two new readmission measures.
Starting on Oct. 1, 2014, the program would also include readmissions associated with an acute exacerbation of chronic obstructive pulmonary disease, as well as readmissions for elective total hip or knee arthroplasty.
The inclusion of COPD for fiscal year 2015 was expected since that condition was specifically highlighted by Congress in the Affordable Care Act (ACA), which created the readmission reduction program. However, lawmakers had also recommended adding coronary artery bypass graft (CABG) surgery, percutaneous coronary intervention (PCI), and other vascular conditions, which are not included in the Centers for Medicare and Medicaid Services (CMS) proposal.
The reasons for the switch were largely due to cost and volume, according to the proposal rule.
In 2005, annual hospital charges totaled $3.95 billion for primary total hip arthroplasty and $7.42 billion for total knee arthroplasty. When combined, the two procedures represent the largest procedures cost in the Medicare budget.
At the same time, inpatient admissions for PCI and other vascular conditions have been declining, according to Medicare officials, as more of those services are being shifted to hospital outpatient departments.
The fiscal 2014 payment proposal also includes a revised methodology for calculating hospital readmission rates in an effort to do a better job of accounting for certain planned readmissions.
The change is a mixed bag for hospitals, according to the Premier healthcare alliance. While the revised methodology will likely result in a more accurate payment calculation, it fails to take into consideration socioeconomic and community factors.
"Hospitals that serve high percentages of lower-income patients will be disproportionately penalized for circumstances outside their control," Blair Childs, senior vice president of public affairs at Premier, said in a statement.
"This places additional financial burdens on already stressed local health care systems in these communities."
The Medicare program is also moving forward with the Hospital-Acquired Condition Reduction Program, which was also created by the ACA.
The new program, which begins on Oct. 1, 2014, levies a 1% penalty on hospitals that rank in the lowest-performing quartile for eight hospital-acquired conditions. The proposed rule includes the quality measures, scoring methodology, and correction process that are planned for the program.
During the first year, officials plan to use quality measures that are calculated using claims data or are part of the Inpatient Quality Reporting program.
The eight measures are divided into two domains. Hospitals will receive a score for each measure, which will then be used to calculate a domain score. The two domains will be weighted equally to get a total score under the program, according to CMS.
The measures in the first of the two domains are pressure ulcer rate; volume of foreign object left in the body; iatrogenic pneumothorax rate; postoperative physiologic and metabolic derangement rate; postoperative pulmonary embolism or deep vein thrombosis rate; and accidental puncture and laceration rate.
CMS is also considering the use of a composite patient safety indicator measure set as an alternative to the first domain.
The second domain being used to get a total score under the new program includes two health care–associated infection measures: central line–associated bloodstream infection and catheter-associated urinary tract infection.
CMS plans to account for risk factors such as age, gender, and comorbidities when calculating the measure rates.
There are no surprises in the conditions chosen for the new program, said Erik Johnson, senior vice president at Avalere Health. However, the fact that CMS officials chose to include eight measures at the start of the program indicates how serious they are about hospital-acquired conditions, he said.
Mr. Johnson predicted that hospitals will take these quality programs seriously as well.
Through the combination of the hospital-acquired condition program, the readmission reduction program, value-based purchasing, and a few other programs, hospitals now have at least 7% of their Medicare payments at risk based on performance on quality measures, he said.
"It’s already starting to move behaviors," he added.
"Hospitals are by and large making a good-faith effort to get better at all of those things. But there are going to be winners and losers, and the losers may end up losing big on a lot of this stuff," according to Mr. Johnson
CMS will accept public comments on the proposal until June 25 at www.regulations.gov. The agency is scheduled to release its final rule by Aug. 1.
The penalties are going up in Medicare’s hospital readmission reduction program.
Starting on Oct. 1, hospitals could face up to a 2% cut in Medicare payments if their 30-day readmission rates for acute myocardial infarction, heart failure, and pneumonia are too high. The program started on Oct. 1, 2012, with a 1% cap on penalties.
The penalty increase was outlined in Medicare’s proposed fiscal year 2014 inpatient prospective payment system rule, which was released April 26.
The Medicare proposal also outlines the government’s plans to expand the readmission reduction program to include two new readmission measures.
Starting on Oct. 1, 2014, the program would also include readmissions associated with an acute exacerbation of chronic obstructive pulmonary disease, as well as readmissions for elective total hip or knee arthroplasty.
The inclusion of COPD for fiscal year 2015 was expected since that condition was specifically highlighted by Congress in the Affordable Care Act (ACA), which created the readmission reduction program. However, lawmakers had also recommended adding coronary artery bypass graft (CABG) surgery, percutaneous coronary intervention (PCI), and other vascular conditions, which are not included in the Centers for Medicare and Medicaid Services (CMS) proposal.
The reasons for the switch were largely due to cost and volume, according to the proposal rule.
In 2005, annual hospital charges totaled $3.95 billion for primary total hip arthroplasty and $7.42 billion for total knee arthroplasty. When combined, the two procedures represent the largest procedures cost in the Medicare budget.
At the same time, inpatient admissions for PCI and other vascular conditions have been declining, according to Medicare officials, as more of those services are being shifted to hospital outpatient departments.
The fiscal 2014 payment proposal also includes a revised methodology for calculating hospital readmission rates in an effort to do a better job of accounting for certain planned readmissions.
The change is a mixed bag for hospitals, according to the Premier healthcare alliance. While the revised methodology will likely result in a more accurate payment calculation, it fails to take into consideration socioeconomic and community factors.
"Hospitals that serve high percentages of lower-income patients will be disproportionately penalized for circumstances outside their control," Blair Childs, senior vice president of public affairs at Premier, said in a statement.
"This places additional financial burdens on already stressed local health care systems in these communities."
The Medicare program is also moving forward with the Hospital-Acquired Condition Reduction Program, which was also created by the ACA.
The new program, which begins on Oct. 1, 2014, levies a 1% penalty on hospitals that rank in the lowest-performing quartile for eight hospital-acquired conditions. The proposed rule includes the quality measures, scoring methodology, and correction process that are planned for the program.
During the first year, officials plan to use quality measures that are calculated using claims data or are part of the Inpatient Quality Reporting program.
The eight measures are divided into two domains. Hospitals will receive a score for each measure, which will then be used to calculate a domain score. The two domains will be weighted equally to get a total score under the program, according to CMS.
The measures in the first of the two domains are pressure ulcer rate; volume of foreign object left in the body; iatrogenic pneumothorax rate; postoperative physiologic and metabolic derangement rate; postoperative pulmonary embolism or deep vein thrombosis rate; and accidental puncture and laceration rate.
CMS is also considering the use of a composite patient safety indicator measure set as an alternative to the first domain.
The second domain being used to get a total score under the new program includes two health care–associated infection measures: central line–associated bloodstream infection and catheter-associated urinary tract infection.
CMS plans to account for risk factors such as age, gender, and comorbidities when calculating the measure rates.
There are no surprises in the conditions chosen for the new program, said Erik Johnson, senior vice president at Avalere Health. However, the fact that CMS officials chose to include eight measures at the start of the program indicates how serious they are about hospital-acquired conditions, he said.
Mr. Johnson predicted that hospitals will take these quality programs seriously as well.
Through the combination of the hospital-acquired condition program, the readmission reduction program, value-based purchasing, and a few other programs, hospitals now have at least 7% of their Medicare payments at risk based on performance on quality measures, he said.
"It’s already starting to move behaviors," he added.
"Hospitals are by and large making a good-faith effort to get better at all of those things. But there are going to be winners and losers, and the losers may end up losing big on a lot of this stuff," according to Mr. Johnson
CMS will accept public comments on the proposal until June 25 at www.regulations.gov. The agency is scheduled to release its final rule by Aug. 1.
Feds back down on emergency contraception
Women and girls of all ages will soon be able to purchase the Plan B One-Step emergency contraceptive pill without a prescription now that the federal government has dropped its legal challenge to making it more easily accessible to minors.
On June 10, the Food and Drug Administration announced that it would comply with a federal court order to make levonorgestrel-containing emergency contraceptives available as an over-the-counter product without restrictions based on age or point of sale.
Recently, the FDA approved Plan B One-Step for sale without a prescription for young women aged 15-16 years, provided they can verify their age. With the court battle over, the FDA has asked the Plan B One-Step manufacturer to submit a supplemental drug application to make the drug available OTC to all ages. "Once the FDA receives that supplemental application, the FDA intends to approve it promptly," according to an agency statement.
Nancy Northup, president and CEO of the Center for Reproductive Rights called the government’s reversal on Plan B One-Step a "significant step forward." But she said the FDA also needs to approve less-expensive, generic versions of the drug for over-the-counter sale.
"We are pleased that women should soon be able to buy Plan B One-Step without the arbitrary restrictions that kept it locked behind the pharmacy counter when they needed it most urgently," Ms. Northup said in a statement. "But we will continue to fight for fair treatment for women who want and need more affordable options."
The Obama administration has been criticized by many physicians and reproductive rights organizations over its decision to block minors’ OTC access to emergency contraception. The American Academy of Pediatrics, the American College of Obstetricians and Gynecologists, and the Society for Adolescent Health and Medicine all recently voiced their opposition to the government’s ongoing court battle.
On Twitter @MaryEllenNY
Women and girls of all ages will soon be able to purchase the Plan B One-Step emergency contraceptive pill without a prescription now that the federal government has dropped its legal challenge to making it more easily accessible to minors.
On June 10, the Food and Drug Administration announced that it would comply with a federal court order to make levonorgestrel-containing emergency contraceptives available as an over-the-counter product without restrictions based on age or point of sale.
Recently, the FDA approved Plan B One-Step for sale without a prescription for young women aged 15-16 years, provided they can verify their age. With the court battle over, the FDA has asked the Plan B One-Step manufacturer to submit a supplemental drug application to make the drug available OTC to all ages. "Once the FDA receives that supplemental application, the FDA intends to approve it promptly," according to an agency statement.
Nancy Northup, president and CEO of the Center for Reproductive Rights called the government’s reversal on Plan B One-Step a "significant step forward." But she said the FDA also needs to approve less-expensive, generic versions of the drug for over-the-counter sale.
"We are pleased that women should soon be able to buy Plan B One-Step without the arbitrary restrictions that kept it locked behind the pharmacy counter when they needed it most urgently," Ms. Northup said in a statement. "But we will continue to fight for fair treatment for women who want and need more affordable options."
The Obama administration has been criticized by many physicians and reproductive rights organizations over its decision to block minors’ OTC access to emergency contraception. The American Academy of Pediatrics, the American College of Obstetricians and Gynecologists, and the Society for Adolescent Health and Medicine all recently voiced their opposition to the government’s ongoing court battle.
On Twitter @MaryEllenNY
Women and girls of all ages will soon be able to purchase the Plan B One-Step emergency contraceptive pill without a prescription now that the federal government has dropped its legal challenge to making it more easily accessible to minors.
On June 10, the Food and Drug Administration announced that it would comply with a federal court order to make levonorgestrel-containing emergency contraceptives available as an over-the-counter product without restrictions based on age or point of sale.
Recently, the FDA approved Plan B One-Step for sale without a prescription for young women aged 15-16 years, provided they can verify their age. With the court battle over, the FDA has asked the Plan B One-Step manufacturer to submit a supplemental drug application to make the drug available OTC to all ages. "Once the FDA receives that supplemental application, the FDA intends to approve it promptly," according to an agency statement.
Nancy Northup, president and CEO of the Center for Reproductive Rights called the government’s reversal on Plan B One-Step a "significant step forward." But she said the FDA also needs to approve less-expensive, generic versions of the drug for over-the-counter sale.
"We are pleased that women should soon be able to buy Plan B One-Step without the arbitrary restrictions that kept it locked behind the pharmacy counter when they needed it most urgently," Ms. Northup said in a statement. "But we will continue to fight for fair treatment for women who want and need more affordable options."
The Obama administration has been criticized by many physicians and reproductive rights organizations over its decision to block minors’ OTC access to emergency contraception. The American Academy of Pediatrics, the American College of Obstetricians and Gynecologists, and the Society for Adolescent Health and Medicine all recently voiced their opposition to the government’s ongoing court battle.
On Twitter @MaryEllenNY
Few physicians use EHRs to exchange data
About 40% of physicians in the United States have adopted a basic electronic health record system, but few are able to use those systems to exchange clinical information with other offices or generate quality metrics, according to a survey of more than 1,800 physicians.
The Harris Interactive survey found that 45% of primary care physicians and 41% of specialists met the criteria for having a "basic" EHR system, defined as a system that allows physicians to maintain problem and medication lists, view laboratory and radiology results, record clinical notes, and order prescriptions electronically.
A much smaller portion of physicians – 10% of those surveyed – met the study’s criteria for achieving "meaningful use" of their electronic systems. More primary care physicians (11%) were able to perform all 11 meaningful use elements identified by researchers, compared to 8% of specialists who were surveyed. The findings were published in the June 4 issue of the Annals of Internal Medicine (2013;158:791-9 [doi:10.7326/0003-4819-158-11-201306040-00003]).
The meaningful use definition created by the researchers is similar, but slightly less stringent, than is the stage 1 meaningful use criteria used by Medicare for its EHR incentive program. Physicians were most likely to be able to meet the requirements for viewing laboratory results, e-prescribing, viewing radiology images, and recording clinical notes. But they had more difficulty exchanging clinical summaries and laboratory results with other offices, generating quality metrics, and providing patients with after-visit summaries or copies of their health information, the researcher found.
"Computerized systems for patient panel management and quality reporting do not seem widespread, and where they are implemented, physicians reported that they are not always easy to use," the researchers wrote.
The study’s meaningful use numbers are much lower than those cited in a recent report from the Health and Human Services department, which put meaningful use by eligible providers, who are mainly physicians, at more than 50% as of April 2013. Part of the difference has to do with the timing of the survey, according to Dr. Jason M. Mitchell, director of the American Academy of Family Physician’s Center for Health IT. The survey published in the Annals was conducted between October 2011 and March 2012. During a similar timeframe (May 2011 to September 2012), the number of eligible professionals qualifying for meaningful use payments was a little more than 82,000. But uptake of EHRs and compliance with meaningful use soared in 2012, bringing the number of eligible professionals up to more than 291,000 by April 2013, according to HHS.
Other surveys of physician adoption may have substantially larger numbers because they only ask physicians if they are using an EHR. Dr. Mitchell said surveys of AAFP members estimate EHR adoption at about 73% as of the end of 2012 using that type of general question.
The study also noted that physicians are having difficult time in successfully using some EHR functionality, especially functions related to population management. For instance, 25% of physicians said they had difficulty or could not generate a list of patients by laboratory result even though they had a system that was supposed to perform that task.
Only in the last year or so have more vendors started to understand the importance of population-management functions, such as registry capability, said Dr. Mitchell. "It is difficult to get to those more advanced kinds of functions."
Another issue is that many EHRs don’t store information in discreet fields that can be searched later to aid in prevention or disease management, Dr. Mitchell said. Instead, physicians often dictate information into large text blocks that aren’t searchable by the system. Moving to systems that would allow doctors to search for all patients with a specific lab value, for example, will require both technological changes and more time-intensive data entry by physicians.
"We’re still trying to sell that concept to the providers who are running on the treadmill as quick as they can to be able to get patients seen," he said. "They are beginning to see the value of being able to do that data aggregation and looking at populations, but it’s different from what we’ve been doing."
The study also looked at how physicians viewed the increased use of EHRs in terms of their potential to improve the quality, cost, and efficiency of care. When it comes to quality, 57% of physicians said EHRs would have a positive impact vs. 28% who said they would have no effect and 13% who said they would have a negative impact. Physicians had similar opinions about the efficiency of care with 56% responding that EHRs would have a positive effect.
Physicians were less enthusiastic about the impact on cost of care. Only 34% said EHRs would have a positive impact, with 27% saying they would have no impact, and 38% saying EHRs would have a negative effect on cost.
The Harris Interactive study was conducted by mail between Oct. 19, 2011, and March 16, 2012. Physicians were contacted by mail up to four times. The research was funded by the Robert Wood Johnson foundation and the Commonwealth Fund.
On Twitter @MaryEllenNY
What stands out about the survey results in the Annals of Internal Medicine is the gap between how many physicians are getting payments from the federal government for the "meaningful use" of EHRs and how few seem to meet the criteria for meaningful use in the current study.
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While the current study puts the percentage of physicians achieving meaningful use at about 10%, the federal government recently put that figure at more than 50%. But the discrepancy is likely explained by when the data was collected. The Annals survey was conducted from October 2011 to March 2012, whereas the government’s data is current as of April 2013.
A lot of the physicians who answered this survey were replying based on the EHR that they had at the time, which didn’t really have all of the software that was later developed to meet the meaningful use criteria. We are simply living in a new world every 6 months.
What isn’t changing is how unhappy physicians are with their EHR systems. Many really don’t feel that their system is helping them a lot, and in fact, many feel that it is hindering their ability to take care of patients.
Dr. Neil Skolnik is associate director of the family medicine residency program at Abington (Pa.) Memorial Hospital and professor of family and community medicine at Temple University, Philadelphia. He is editor-in-chief of Redi-Reference, a software company that creates medical handheld references. Dr. Skolnik also writes the "EHR Report" for Family Practice News.
What stands out about the survey results in the Annals of Internal Medicine is the gap between how many physicians are getting payments from the federal government for the "meaningful use" of EHRs and how few seem to meet the criteria for meaningful use in the current study.
|
|
While the current study puts the percentage of physicians achieving meaningful use at about 10%, the federal government recently put that figure at more than 50%. But the discrepancy is likely explained by when the data was collected. The Annals survey was conducted from October 2011 to March 2012, whereas the government’s data is current as of April 2013.
A lot of the physicians who answered this survey were replying based on the EHR that they had at the time, which didn’t really have all of the software that was later developed to meet the meaningful use criteria. We are simply living in a new world every 6 months.
What isn’t changing is how unhappy physicians are with their EHR systems. Many really don’t feel that their system is helping them a lot, and in fact, many feel that it is hindering their ability to take care of patients.
Dr. Neil Skolnik is associate director of the family medicine residency program at Abington (Pa.) Memorial Hospital and professor of family and community medicine at Temple University, Philadelphia. He is editor-in-chief of Redi-Reference, a software company that creates medical handheld references. Dr. Skolnik also writes the "EHR Report" for Family Practice News.
What stands out about the survey results in the Annals of Internal Medicine is the gap between how many physicians are getting payments from the federal government for the "meaningful use" of EHRs and how few seem to meet the criteria for meaningful use in the current study.
|
|
While the current study puts the percentage of physicians achieving meaningful use at about 10%, the federal government recently put that figure at more than 50%. But the discrepancy is likely explained by when the data was collected. The Annals survey was conducted from October 2011 to March 2012, whereas the government’s data is current as of April 2013.
A lot of the physicians who answered this survey were replying based on the EHR that they had at the time, which didn’t really have all of the software that was later developed to meet the meaningful use criteria. We are simply living in a new world every 6 months.
What isn’t changing is how unhappy physicians are with their EHR systems. Many really don’t feel that their system is helping them a lot, and in fact, many feel that it is hindering their ability to take care of patients.
Dr. Neil Skolnik is associate director of the family medicine residency program at Abington (Pa.) Memorial Hospital and professor of family and community medicine at Temple University, Philadelphia. He is editor-in-chief of Redi-Reference, a software company that creates medical handheld references. Dr. Skolnik also writes the "EHR Report" for Family Practice News.
About 40% of physicians in the United States have adopted a basic electronic health record system, but few are able to use those systems to exchange clinical information with other offices or generate quality metrics, according to a survey of more than 1,800 physicians.
The Harris Interactive survey found that 45% of primary care physicians and 41% of specialists met the criteria for having a "basic" EHR system, defined as a system that allows physicians to maintain problem and medication lists, view laboratory and radiology results, record clinical notes, and order prescriptions electronically.
A much smaller portion of physicians – 10% of those surveyed – met the study’s criteria for achieving "meaningful use" of their electronic systems. More primary care physicians (11%) were able to perform all 11 meaningful use elements identified by researchers, compared to 8% of specialists who were surveyed. The findings were published in the June 4 issue of the Annals of Internal Medicine (2013;158:791-9 [doi:10.7326/0003-4819-158-11-201306040-00003]).
The meaningful use definition created by the researchers is similar, but slightly less stringent, than is the stage 1 meaningful use criteria used by Medicare for its EHR incentive program. Physicians were most likely to be able to meet the requirements for viewing laboratory results, e-prescribing, viewing radiology images, and recording clinical notes. But they had more difficulty exchanging clinical summaries and laboratory results with other offices, generating quality metrics, and providing patients with after-visit summaries or copies of their health information, the researcher found.
"Computerized systems for patient panel management and quality reporting do not seem widespread, and where they are implemented, physicians reported that they are not always easy to use," the researchers wrote.
The study’s meaningful use numbers are much lower than those cited in a recent report from the Health and Human Services department, which put meaningful use by eligible providers, who are mainly physicians, at more than 50% as of April 2013. Part of the difference has to do with the timing of the survey, according to Dr. Jason M. Mitchell, director of the American Academy of Family Physician’s Center for Health IT. The survey published in the Annals was conducted between October 2011 and March 2012. During a similar timeframe (May 2011 to September 2012), the number of eligible professionals qualifying for meaningful use payments was a little more than 82,000. But uptake of EHRs and compliance with meaningful use soared in 2012, bringing the number of eligible professionals up to more than 291,000 by April 2013, according to HHS.
Other surveys of physician adoption may have substantially larger numbers because they only ask physicians if they are using an EHR. Dr. Mitchell said surveys of AAFP members estimate EHR adoption at about 73% as of the end of 2012 using that type of general question.
The study also noted that physicians are having difficult time in successfully using some EHR functionality, especially functions related to population management. For instance, 25% of physicians said they had difficulty or could not generate a list of patients by laboratory result even though they had a system that was supposed to perform that task.
Only in the last year or so have more vendors started to understand the importance of population-management functions, such as registry capability, said Dr. Mitchell. "It is difficult to get to those more advanced kinds of functions."
Another issue is that many EHRs don’t store information in discreet fields that can be searched later to aid in prevention or disease management, Dr. Mitchell said. Instead, physicians often dictate information into large text blocks that aren’t searchable by the system. Moving to systems that would allow doctors to search for all patients with a specific lab value, for example, will require both technological changes and more time-intensive data entry by physicians.
"We’re still trying to sell that concept to the providers who are running on the treadmill as quick as they can to be able to get patients seen," he said. "They are beginning to see the value of being able to do that data aggregation and looking at populations, but it’s different from what we’ve been doing."
The study also looked at how physicians viewed the increased use of EHRs in terms of their potential to improve the quality, cost, and efficiency of care. When it comes to quality, 57% of physicians said EHRs would have a positive impact vs. 28% who said they would have no effect and 13% who said they would have a negative impact. Physicians had similar opinions about the efficiency of care with 56% responding that EHRs would have a positive effect.
Physicians were less enthusiastic about the impact on cost of care. Only 34% said EHRs would have a positive impact, with 27% saying they would have no impact, and 38% saying EHRs would have a negative effect on cost.
The Harris Interactive study was conducted by mail between Oct. 19, 2011, and March 16, 2012. Physicians were contacted by mail up to four times. The research was funded by the Robert Wood Johnson foundation and the Commonwealth Fund.
On Twitter @MaryEllenNY
About 40% of physicians in the United States have adopted a basic electronic health record system, but few are able to use those systems to exchange clinical information with other offices or generate quality metrics, according to a survey of more than 1,800 physicians.
The Harris Interactive survey found that 45% of primary care physicians and 41% of specialists met the criteria for having a "basic" EHR system, defined as a system that allows physicians to maintain problem and medication lists, view laboratory and radiology results, record clinical notes, and order prescriptions electronically.
A much smaller portion of physicians – 10% of those surveyed – met the study’s criteria for achieving "meaningful use" of their electronic systems. More primary care physicians (11%) were able to perform all 11 meaningful use elements identified by researchers, compared to 8% of specialists who were surveyed. The findings were published in the June 4 issue of the Annals of Internal Medicine (2013;158:791-9 [doi:10.7326/0003-4819-158-11-201306040-00003]).
The meaningful use definition created by the researchers is similar, but slightly less stringent, than is the stage 1 meaningful use criteria used by Medicare for its EHR incentive program. Physicians were most likely to be able to meet the requirements for viewing laboratory results, e-prescribing, viewing radiology images, and recording clinical notes. But they had more difficulty exchanging clinical summaries and laboratory results with other offices, generating quality metrics, and providing patients with after-visit summaries or copies of their health information, the researcher found.
"Computerized systems for patient panel management and quality reporting do not seem widespread, and where they are implemented, physicians reported that they are not always easy to use," the researchers wrote.
The study’s meaningful use numbers are much lower than those cited in a recent report from the Health and Human Services department, which put meaningful use by eligible providers, who are mainly physicians, at more than 50% as of April 2013. Part of the difference has to do with the timing of the survey, according to Dr. Jason M. Mitchell, director of the American Academy of Family Physician’s Center for Health IT. The survey published in the Annals was conducted between October 2011 and March 2012. During a similar timeframe (May 2011 to September 2012), the number of eligible professionals qualifying for meaningful use payments was a little more than 82,000. But uptake of EHRs and compliance with meaningful use soared in 2012, bringing the number of eligible professionals up to more than 291,000 by April 2013, according to HHS.
Other surveys of physician adoption may have substantially larger numbers because they only ask physicians if they are using an EHR. Dr. Mitchell said surveys of AAFP members estimate EHR adoption at about 73% as of the end of 2012 using that type of general question.
The study also noted that physicians are having difficult time in successfully using some EHR functionality, especially functions related to population management. For instance, 25% of physicians said they had difficulty or could not generate a list of patients by laboratory result even though they had a system that was supposed to perform that task.
Only in the last year or so have more vendors started to understand the importance of population-management functions, such as registry capability, said Dr. Mitchell. "It is difficult to get to those more advanced kinds of functions."
Another issue is that many EHRs don’t store information in discreet fields that can be searched later to aid in prevention or disease management, Dr. Mitchell said. Instead, physicians often dictate information into large text blocks that aren’t searchable by the system. Moving to systems that would allow doctors to search for all patients with a specific lab value, for example, will require both technological changes and more time-intensive data entry by physicians.
"We’re still trying to sell that concept to the providers who are running on the treadmill as quick as they can to be able to get patients seen," he said. "They are beginning to see the value of being able to do that data aggregation and looking at populations, but it’s different from what we’ve been doing."
The study also looked at how physicians viewed the increased use of EHRs in terms of their potential to improve the quality, cost, and efficiency of care. When it comes to quality, 57% of physicians said EHRs would have a positive impact vs. 28% who said they would have no effect and 13% who said they would have a negative impact. Physicians had similar opinions about the efficiency of care with 56% responding that EHRs would have a positive effect.
Physicians were less enthusiastic about the impact on cost of care. Only 34% said EHRs would have a positive impact, with 27% saying they would have no impact, and 38% saying EHRs would have a negative effect on cost.
The Harris Interactive study was conducted by mail between Oct. 19, 2011, and March 16, 2012. Physicians were contacted by mail up to four times. The research was funded by the Robert Wood Johnson foundation and the Commonwealth Fund.
On Twitter @MaryEllenNY
FROM ANNALS OF INTERNAL MEDICINE
Major finding: About 40% of physicians are using a "basic" EHR and nearly 10% met the study’s criteria for "meaningful use" of the system.
Data source: A mailed survey of 1,820 U.S. physicians conducted between October 2011 and March 2012.
Disclosures: The study was funded by the Robert Wood Johnson Foundation and the Commonwealth Fund.
Patient expectations are missing ingredient in true satisfaction
NATIONAL HARBOR, MD. – Hospital and physician efforts to improve patient satisfaction are just scratching the surface, according to Dr. Shaun Frost, the outgoing president of the Society of Hospital Medicine.
The missing ingredient, Dr. Frost said, is understanding the patient’s personal expectations about the hospital stay.
For instance, a patient might have a preference for tolerating pain in order to stay alert versus accepting the sedating effects of treatment with narcotics. Another patient might prefer to be discharged from the emergency department and have follow-up testing performed in an outpatient setting rather than stay overnight under observation status.
"Where we sometimes come up short in health care is failing to recognize that patient expectations transcend interests such as having their call lights answered in a timely manner or receiving warm meals on a scheduled basis," Dr. Frost said at the annual meeting of the Society of Hospital Medicine. "Although these are obviously important expectations that need to be addressed, they are relatively easy to identify and act on."
The challenge in uncovering these personally held patient expectations is that physicians have to ask about them, he said.
"Providers must empower patients to express their expectations by taking time to inquire about the social, economic, cultural, and environmental issues that dictate personally held patient values, goals, needs, interests, and preferences for their care," said Dr. Frost, who is the associate medical director for care delivery systems at HealthPartners in Bloomington, Minn.
But it’s not enough to know what the patient wants. Physicians also need to bring patients into the decision-making process by objectively explaining treatment options and avoiding the temptation to act paternalistically, Dr. Frost said.
Based on an experience from early in his career, Dr. Frost offered an example of what not to do: As a third-year medical student, Dr. Frost observed his supervising resident advising a patient with heart failure about establishing an advanced directive. The resident skillfully outlined the technical details about cardiopulmonary resuscitation, Dr. Frost said, but the explanation seemed aimed at influencing the patient to decide against resuscitation. When the resident asked the patient what he would like the team to do, he surprised everyone by emphatically stating that he wanted to be resuscitated.
The conversation ended with the resident accepting the patient’s decision, but also advising him to think about it more because they would talk about it again the next day. The following day the patient had not changed his mind, but he seemed notably disengaged, Dr. Frost said. From that point on, the patient appeared "guarded and withdrawn" and reluctant to participate in his treatments, Dr. Frost said.
"The fundamental problem here was that we spoke to this patient about our experience in running cardiac arrest code, but we didn’t speak with this patient about what it’s like for him and his family to live with severe congestive heart failure and furthermore why it was he’d been admitted to the hospital three times in the past 3 months," Dr. Frost said. "Instead of engaging this patient by inviting him into the conversation, we left him with the impression that he didn’t have a choice."
As the evidence grows that patient engagement has a positive influence on quality, safety, and affordability, Dr. Frost said it’s time for the specialty of hospital medicine to take the lead by setting standards for physician-patient collaboration.
"Enhanced collaboration with patients, their families, and their loved ones, which focuses attention on their personal unique needs and preferences, is the next great opportunity in health care team work," he said.
NATIONAL HARBOR, MD. – Hospital and physician efforts to improve patient satisfaction are just scratching the surface, according to Dr. Shaun Frost, the outgoing president of the Society of Hospital Medicine.
The missing ingredient, Dr. Frost said, is understanding the patient’s personal expectations about the hospital stay.
For instance, a patient might have a preference for tolerating pain in order to stay alert versus accepting the sedating effects of treatment with narcotics. Another patient might prefer to be discharged from the emergency department and have follow-up testing performed in an outpatient setting rather than stay overnight under observation status.
"Where we sometimes come up short in health care is failing to recognize that patient expectations transcend interests such as having their call lights answered in a timely manner or receiving warm meals on a scheduled basis," Dr. Frost said at the annual meeting of the Society of Hospital Medicine. "Although these are obviously important expectations that need to be addressed, they are relatively easy to identify and act on."
The challenge in uncovering these personally held patient expectations is that physicians have to ask about them, he said.
"Providers must empower patients to express their expectations by taking time to inquire about the social, economic, cultural, and environmental issues that dictate personally held patient values, goals, needs, interests, and preferences for their care," said Dr. Frost, who is the associate medical director for care delivery systems at HealthPartners in Bloomington, Minn.
But it’s not enough to know what the patient wants. Physicians also need to bring patients into the decision-making process by objectively explaining treatment options and avoiding the temptation to act paternalistically, Dr. Frost said.
Based on an experience from early in his career, Dr. Frost offered an example of what not to do: As a third-year medical student, Dr. Frost observed his supervising resident advising a patient with heart failure about establishing an advanced directive. The resident skillfully outlined the technical details about cardiopulmonary resuscitation, Dr. Frost said, but the explanation seemed aimed at influencing the patient to decide against resuscitation. When the resident asked the patient what he would like the team to do, he surprised everyone by emphatically stating that he wanted to be resuscitated.
The conversation ended with the resident accepting the patient’s decision, but also advising him to think about it more because they would talk about it again the next day. The following day the patient had not changed his mind, but he seemed notably disengaged, Dr. Frost said. From that point on, the patient appeared "guarded and withdrawn" and reluctant to participate in his treatments, Dr. Frost said.
"The fundamental problem here was that we spoke to this patient about our experience in running cardiac arrest code, but we didn’t speak with this patient about what it’s like for him and his family to live with severe congestive heart failure and furthermore why it was he’d been admitted to the hospital three times in the past 3 months," Dr. Frost said. "Instead of engaging this patient by inviting him into the conversation, we left him with the impression that he didn’t have a choice."
As the evidence grows that patient engagement has a positive influence on quality, safety, and affordability, Dr. Frost said it’s time for the specialty of hospital medicine to take the lead by setting standards for physician-patient collaboration.
"Enhanced collaboration with patients, their families, and their loved ones, which focuses attention on their personal unique needs and preferences, is the next great opportunity in health care team work," he said.
NATIONAL HARBOR, MD. – Hospital and physician efforts to improve patient satisfaction are just scratching the surface, according to Dr. Shaun Frost, the outgoing president of the Society of Hospital Medicine.
The missing ingredient, Dr. Frost said, is understanding the patient’s personal expectations about the hospital stay.
For instance, a patient might have a preference for tolerating pain in order to stay alert versus accepting the sedating effects of treatment with narcotics. Another patient might prefer to be discharged from the emergency department and have follow-up testing performed in an outpatient setting rather than stay overnight under observation status.
"Where we sometimes come up short in health care is failing to recognize that patient expectations transcend interests such as having their call lights answered in a timely manner or receiving warm meals on a scheduled basis," Dr. Frost said at the annual meeting of the Society of Hospital Medicine. "Although these are obviously important expectations that need to be addressed, they are relatively easy to identify and act on."
The challenge in uncovering these personally held patient expectations is that physicians have to ask about them, he said.
"Providers must empower patients to express their expectations by taking time to inquire about the social, economic, cultural, and environmental issues that dictate personally held patient values, goals, needs, interests, and preferences for their care," said Dr. Frost, who is the associate medical director for care delivery systems at HealthPartners in Bloomington, Minn.
But it’s not enough to know what the patient wants. Physicians also need to bring patients into the decision-making process by objectively explaining treatment options and avoiding the temptation to act paternalistically, Dr. Frost said.
Based on an experience from early in his career, Dr. Frost offered an example of what not to do: As a third-year medical student, Dr. Frost observed his supervising resident advising a patient with heart failure about establishing an advanced directive. The resident skillfully outlined the technical details about cardiopulmonary resuscitation, Dr. Frost said, but the explanation seemed aimed at influencing the patient to decide against resuscitation. When the resident asked the patient what he would like the team to do, he surprised everyone by emphatically stating that he wanted to be resuscitated.
The conversation ended with the resident accepting the patient’s decision, but also advising him to think about it more because they would talk about it again the next day. The following day the patient had not changed his mind, but he seemed notably disengaged, Dr. Frost said. From that point on, the patient appeared "guarded and withdrawn" and reluctant to participate in his treatments, Dr. Frost said.
"The fundamental problem here was that we spoke to this patient about our experience in running cardiac arrest code, but we didn’t speak with this patient about what it’s like for him and his family to live with severe congestive heart failure and furthermore why it was he’d been admitted to the hospital three times in the past 3 months," Dr. Frost said. "Instead of engaging this patient by inviting him into the conversation, we left him with the impression that he didn’t have a choice."
As the evidence grows that patient engagement has a positive influence on quality, safety, and affordability, Dr. Frost said it’s time for the specialty of hospital medicine to take the lead by setting standards for physician-patient collaboration.
"Enhanced collaboration with patients, their families, and their loved ones, which focuses attention on their personal unique needs and preferences, is the next great opportunity in health care team work," he said.
AT HOSPITAL MEDICINE 13
Study: ACA means less uncompensated care in the ED
An Affordable Care Act provision that allows adults aged 19-25 years to remain on a parent’s health plan appears to be helping to decrease the amount of uncompensated care in the emergency department, according to a study published May 29 in the New England Journal of Medicine.
In 2011, following the implementation of the ACA’s dependent care provision, private insurance plans took on an additional $147 million in costs associated with nondiscretionary emergency department (ED) care compared with 2009, before the provision took effect (N. Engl. J. Med. 2013;368:2105-12). Without the dependent care coverage requirement, some of these costs would have been uncompensated and could have caused increased financial losses for hospitals and emergency care physicians, according to the researchers.
The study suggests that the "ACA’s dependent coverage provision increased financial protection for young adults, their parents, and hospitals by sheltering them from the potentially catastrophic cost of treating emergency medical conditions," the researchers wrote.
The study, which is narrowly focused on increases in private insurance coverage among young adults seeking emergency care, comes as other studies have estimated that between 3% and 10% of young adults under age 26 have gained coverage under the law.
In an effort to capture data on true emergencies, the researchers analyzed only ED visits for serious, painful, and unpredictable conditions for which individuals would seek care regardless of their insurance status, such as bone fractures, dislocations, and appendicitis. They collected data on the study group – 19- to 25-year-olds – and a control group – 26- to 31-year-olds. Between Jan. 1, 2009, and Dec. 31, 2011, 483,562 ED visits by 19- to 31-year-olds fit the study criteria. The researchers then weighted the data using publicly available data to approximate a nationally representative sample of ED visits.
In 2011, there was a 3.1% increase in the share of nondiscretionary emergency department visits made by 19- to 25-year-olds that were covered by private insurance compared with the control group of 26- to 31-year-olds.
The dependent care coverage provision also led to an additional 22,072 nondiscretionary ED visits in 2011 versus 2009, which were paid for by private insurance plans.
The study was conducted by researchers from RAND, IMS Health, and the Department of Health and Human Services and funded by a contract with the office of the assistant secretary for planning and evaluation in HHS. The investigators analyzed data from the IMS Health Charge Data Master database, which includes unadjudicated insurance claims from a geographically diverse sample of 392 general hospitals in the United States.
An Affordable Care Act provision that allows adults aged 19-25 years to remain on a parent’s health plan appears to be helping to decrease the amount of uncompensated care in the emergency department, according to a study published May 29 in the New England Journal of Medicine.
In 2011, following the implementation of the ACA’s dependent care provision, private insurance plans took on an additional $147 million in costs associated with nondiscretionary emergency department (ED) care compared with 2009, before the provision took effect (N. Engl. J. Med. 2013;368:2105-12). Without the dependent care coverage requirement, some of these costs would have been uncompensated and could have caused increased financial losses for hospitals and emergency care physicians, according to the researchers.
The study suggests that the "ACA’s dependent coverage provision increased financial protection for young adults, their parents, and hospitals by sheltering them from the potentially catastrophic cost of treating emergency medical conditions," the researchers wrote.
The study, which is narrowly focused on increases in private insurance coverage among young adults seeking emergency care, comes as other studies have estimated that between 3% and 10% of young adults under age 26 have gained coverage under the law.
In an effort to capture data on true emergencies, the researchers analyzed only ED visits for serious, painful, and unpredictable conditions for which individuals would seek care regardless of their insurance status, such as bone fractures, dislocations, and appendicitis. They collected data on the study group – 19- to 25-year-olds – and a control group – 26- to 31-year-olds. Between Jan. 1, 2009, and Dec. 31, 2011, 483,562 ED visits by 19- to 31-year-olds fit the study criteria. The researchers then weighted the data using publicly available data to approximate a nationally representative sample of ED visits.
In 2011, there was a 3.1% increase in the share of nondiscretionary emergency department visits made by 19- to 25-year-olds that were covered by private insurance compared with the control group of 26- to 31-year-olds.
The dependent care coverage provision also led to an additional 22,072 nondiscretionary ED visits in 2011 versus 2009, which were paid for by private insurance plans.
The study was conducted by researchers from RAND, IMS Health, and the Department of Health and Human Services and funded by a contract with the office of the assistant secretary for planning and evaluation in HHS. The investigators analyzed data from the IMS Health Charge Data Master database, which includes unadjudicated insurance claims from a geographically diverse sample of 392 general hospitals in the United States.
An Affordable Care Act provision that allows adults aged 19-25 years to remain on a parent’s health plan appears to be helping to decrease the amount of uncompensated care in the emergency department, according to a study published May 29 in the New England Journal of Medicine.
In 2011, following the implementation of the ACA’s dependent care provision, private insurance plans took on an additional $147 million in costs associated with nondiscretionary emergency department (ED) care compared with 2009, before the provision took effect (N. Engl. J. Med. 2013;368:2105-12). Without the dependent care coverage requirement, some of these costs would have been uncompensated and could have caused increased financial losses for hospitals and emergency care physicians, according to the researchers.
The study suggests that the "ACA’s dependent coverage provision increased financial protection for young adults, their parents, and hospitals by sheltering them from the potentially catastrophic cost of treating emergency medical conditions," the researchers wrote.
The study, which is narrowly focused on increases in private insurance coverage among young adults seeking emergency care, comes as other studies have estimated that between 3% and 10% of young adults under age 26 have gained coverage under the law.
In an effort to capture data on true emergencies, the researchers analyzed only ED visits for serious, painful, and unpredictable conditions for which individuals would seek care regardless of their insurance status, such as bone fractures, dislocations, and appendicitis. They collected data on the study group – 19- to 25-year-olds – and a control group – 26- to 31-year-olds. Between Jan. 1, 2009, and Dec. 31, 2011, 483,562 ED visits by 19- to 31-year-olds fit the study criteria. The researchers then weighted the data using publicly available data to approximate a nationally representative sample of ED visits.
In 2011, there was a 3.1% increase in the share of nondiscretionary emergency department visits made by 19- to 25-year-olds that were covered by private insurance compared with the control group of 26- to 31-year-olds.
The dependent care coverage provision also led to an additional 22,072 nondiscretionary ED visits in 2011 versus 2009, which were paid for by private insurance plans.
The study was conducted by researchers from RAND, IMS Health, and the Department of Health and Human Services and funded by a contract with the office of the assistant secretary for planning and evaluation in HHS. The investigators analyzed data from the IMS Health Charge Data Master database, which includes unadjudicated insurance claims from a geographically diverse sample of 392 general hospitals in the United States.
FROM THE NEW ENGLAND JOURNAL OF MEDICINE
Major finding: In 2011, there was a 3.1% increase in the proportion of nondiscretionary emergency department visits for 19- to 25-year-olds that were covered by private insurance compared with similar visits by 26- to 31-year-olds.
Data source: Retrospective claims analysis using data from the IMS Health Charge Master database. The database included unadjudicated insurance claims from 392 general hospitals.
Disclosures: The study was supported by a contract from the Department of Health and Human Services.
EHR use reaches 'tipping point'
More than half of the nation’s physicians and other health care providers use electronic health records in their practices, new statistics from the Health and Human Services department show.
"We have reached a tipping point in adoption of electronic health records," HHS Secretary Kathleen Sebelius said in a statement. "More than half of eligible professionals and 80% of eligible hospitals have adopted these systems, which are critical to modernizing our health care system."
As of the end of April, more than 291,000 physicians and other eligible professionals received incentive payments from the Medicare and Medicaid EHR Incentive Programs. This is a significant jump in adoption since the incentives were created under the 2009 Recovery Act. In 2008, only 17% of office-based physicians reported that they had a basic EHR system and 4.4% had a fully functional system, according to the Centers for Disease Control and Prevention.
The number of hospitals using EHRs is also reaching critical mass, according to HHS. More than 3,800 facilities have received incentive payments for their EHR use as of the end of April.
Under the Medicare program, physicians can earn up to $44,000 in bonus payments from the government over 5 years by using electronic systems to meet and report on a set of quality measures. Under Medicaid, the bonus payments add up to $63,750 over 6 years.
More than half of the nation’s physicians and other health care providers use electronic health records in their practices, new statistics from the Health and Human Services department show.
"We have reached a tipping point in adoption of electronic health records," HHS Secretary Kathleen Sebelius said in a statement. "More than half of eligible professionals and 80% of eligible hospitals have adopted these systems, which are critical to modernizing our health care system."
As of the end of April, more than 291,000 physicians and other eligible professionals received incentive payments from the Medicare and Medicaid EHR Incentive Programs. This is a significant jump in adoption since the incentives were created under the 2009 Recovery Act. In 2008, only 17% of office-based physicians reported that they had a basic EHR system and 4.4% had a fully functional system, according to the Centers for Disease Control and Prevention.
The number of hospitals using EHRs is also reaching critical mass, according to HHS. More than 3,800 facilities have received incentive payments for their EHR use as of the end of April.
Under the Medicare program, physicians can earn up to $44,000 in bonus payments from the government over 5 years by using electronic systems to meet and report on a set of quality measures. Under Medicaid, the bonus payments add up to $63,750 over 6 years.
More than half of the nation’s physicians and other health care providers use electronic health records in their practices, new statistics from the Health and Human Services department show.
"We have reached a tipping point in adoption of electronic health records," HHS Secretary Kathleen Sebelius said in a statement. "More than half of eligible professionals and 80% of eligible hospitals have adopted these systems, which are critical to modernizing our health care system."
As of the end of April, more than 291,000 physicians and other eligible professionals received incentive payments from the Medicare and Medicaid EHR Incentive Programs. This is a significant jump in adoption since the incentives were created under the 2009 Recovery Act. In 2008, only 17% of office-based physicians reported that they had a basic EHR system and 4.4% had a fully functional system, according to the Centers for Disease Control and Prevention.
The number of hospitals using EHRs is also reaching critical mass, according to HHS. More than 3,800 facilities have received incentive payments for their EHR use as of the end of April.
Under the Medicare program, physicians can earn up to $44,000 in bonus payments from the government over 5 years by using electronic systems to meet and report on a set of quality measures. Under Medicaid, the bonus payments add up to $63,750 over 6 years.
Contraception training in limbo for FPs
Proposed revisions to residency training requirements could leave future family doctors ill equipped to provide family planning services.
The proposal from the Accreditation Council for Graduate Medical Education would drop the current requirement that all residents be trained in family planning, contraception, options for counseling for unintended pregnancies, and related procedures.
Instead, residents would devote a certain amount of time or patient encounters "to the care of women with gynecologic issues, including well-woman care." They also would be expected to demonstrate competence in endometrial biopsy, pap smear, and wet mount.
Without explicit requirements that residency programs spend time on contraception, such training could be dropped by institutions with religious affiliations as well as by some individual program directors who may have personal moral objections to providing the training, according to Dr. Linda Prine, a family physician who is medical director for the Reproductive Health Access Project, New York. And that’s not a small number of institutions, she added.
"You just have no guarantees that we’re going to turn out a family medicine workforce that’s competent in birth control," she said. "This is something that women definitely expect from their primary care physician and should be able to expect."
The proposed changes are especially ill-timed, now that contraception is deemed a preventive care service under the Affordable Care Act and must be covered by health plans without copayments or other patient cost sharing, Dr. Prine noted.
Dr. Elaine Kang, a family physician who works in a community health center in New York City, said that family planning is an essential part of primary preventive care for her patients. It would be very inconvenient for them to have to see another physician simply for birth control counseling, which might cause them to miss school or work. It also would force them to discuss a potentially sensitive topic with a physician they didn’t know as well.
"It’s really important for patients to be able to go see someone that they trust to have [family planning] counseling," Dr. Kang said.
She predicted that the proposed changes would lead to an increase in unintended pregnancies.
The proposal is not a back-door attempt to shut out contraception, said Dr. Peter J. Carek, chair of the committee that is charged with updating the ACGME’s family medicine requirements. Instead, they reflect feedback from residency program directors that the requirements were "too detailed" and didn’t allow them to be "innovative," he said.
"In general, the review committee took that to heart," said Dr. Carek, vice chair of the department of family medicine at the Medical University of South Carolina, Charleston.
Family medicine residency requirements were last updated in June 2007. In this proposed revision, the review committee tried to reduce as much of the specific, detailed requirements as possible while still maintaining the ability of program directors to provide training on the broad patient population that family physicians treat, Dr. Carek said.
It is a difficult balancing act, and committee members expect that some of the specifics will make it back into the final document after public comments are considered, but he said it’s too early to know which specifics might be restored.
The review committee will spend the summer going over public comments and making final revisions. The document then will be reviewed by the ACGME Committee on Requirements and then the Board of Directors. The revisions are scheduled to go into effect in July 2014.
On Twitter @MaryEllenNY
Proposed revisions to residency training requirements could leave future family doctors ill equipped to provide family planning services.
The proposal from the Accreditation Council for Graduate Medical Education would drop the current requirement that all residents be trained in family planning, contraception, options for counseling for unintended pregnancies, and related procedures.
Instead, residents would devote a certain amount of time or patient encounters "to the care of women with gynecologic issues, including well-woman care." They also would be expected to demonstrate competence in endometrial biopsy, pap smear, and wet mount.
Without explicit requirements that residency programs spend time on contraception, such training could be dropped by institutions with religious affiliations as well as by some individual program directors who may have personal moral objections to providing the training, according to Dr. Linda Prine, a family physician who is medical director for the Reproductive Health Access Project, New York. And that’s not a small number of institutions, she added.
"You just have no guarantees that we’re going to turn out a family medicine workforce that’s competent in birth control," she said. "This is something that women definitely expect from their primary care physician and should be able to expect."
The proposed changes are especially ill-timed, now that contraception is deemed a preventive care service under the Affordable Care Act and must be covered by health plans without copayments or other patient cost sharing, Dr. Prine noted.
Dr. Elaine Kang, a family physician who works in a community health center in New York City, said that family planning is an essential part of primary preventive care for her patients. It would be very inconvenient for them to have to see another physician simply for birth control counseling, which might cause them to miss school or work. It also would force them to discuss a potentially sensitive topic with a physician they didn’t know as well.
"It’s really important for patients to be able to go see someone that they trust to have [family planning] counseling," Dr. Kang said.
She predicted that the proposed changes would lead to an increase in unintended pregnancies.
The proposal is not a back-door attempt to shut out contraception, said Dr. Peter J. Carek, chair of the committee that is charged with updating the ACGME’s family medicine requirements. Instead, they reflect feedback from residency program directors that the requirements were "too detailed" and didn’t allow them to be "innovative," he said.
"In general, the review committee took that to heart," said Dr. Carek, vice chair of the department of family medicine at the Medical University of South Carolina, Charleston.
Family medicine residency requirements were last updated in June 2007. In this proposed revision, the review committee tried to reduce as much of the specific, detailed requirements as possible while still maintaining the ability of program directors to provide training on the broad patient population that family physicians treat, Dr. Carek said.
It is a difficult balancing act, and committee members expect that some of the specifics will make it back into the final document after public comments are considered, but he said it’s too early to know which specifics might be restored.
The review committee will spend the summer going over public comments and making final revisions. The document then will be reviewed by the ACGME Committee on Requirements and then the Board of Directors. The revisions are scheduled to go into effect in July 2014.
On Twitter @MaryEllenNY
Proposed revisions to residency training requirements could leave future family doctors ill equipped to provide family planning services.
The proposal from the Accreditation Council for Graduate Medical Education would drop the current requirement that all residents be trained in family planning, contraception, options for counseling for unintended pregnancies, and related procedures.
Instead, residents would devote a certain amount of time or patient encounters "to the care of women with gynecologic issues, including well-woman care." They also would be expected to demonstrate competence in endometrial biopsy, pap smear, and wet mount.
Without explicit requirements that residency programs spend time on contraception, such training could be dropped by institutions with religious affiliations as well as by some individual program directors who may have personal moral objections to providing the training, according to Dr. Linda Prine, a family physician who is medical director for the Reproductive Health Access Project, New York. And that’s not a small number of institutions, she added.
"You just have no guarantees that we’re going to turn out a family medicine workforce that’s competent in birth control," she said. "This is something that women definitely expect from their primary care physician and should be able to expect."
The proposed changes are especially ill-timed, now that contraception is deemed a preventive care service under the Affordable Care Act and must be covered by health plans without copayments or other patient cost sharing, Dr. Prine noted.
Dr. Elaine Kang, a family physician who works in a community health center in New York City, said that family planning is an essential part of primary preventive care for her patients. It would be very inconvenient for them to have to see another physician simply for birth control counseling, which might cause them to miss school or work. It also would force them to discuss a potentially sensitive topic with a physician they didn’t know as well.
"It’s really important for patients to be able to go see someone that they trust to have [family planning] counseling," Dr. Kang said.
She predicted that the proposed changes would lead to an increase in unintended pregnancies.
The proposal is not a back-door attempt to shut out contraception, said Dr. Peter J. Carek, chair of the committee that is charged with updating the ACGME’s family medicine requirements. Instead, they reflect feedback from residency program directors that the requirements were "too detailed" and didn’t allow them to be "innovative," he said.
"In general, the review committee took that to heart," said Dr. Carek, vice chair of the department of family medicine at the Medical University of South Carolina, Charleston.
Family medicine residency requirements were last updated in June 2007. In this proposed revision, the review committee tried to reduce as much of the specific, detailed requirements as possible while still maintaining the ability of program directors to provide training on the broad patient population that family physicians treat, Dr. Carek said.
It is a difficult balancing act, and committee members expect that some of the specifics will make it back into the final document after public comments are considered, but he said it’s too early to know which specifics might be restored.
The review committee will spend the summer going over public comments and making final revisions. The document then will be reviewed by the ACGME Committee on Requirements and then the Board of Directors. The revisions are scheduled to go into effect in July 2014.
On Twitter @MaryEllenNY
Medicare CMO tips hat to hospitalists
Dr. Patrick Conway, the chief medical officer at the Centers for Medicare and Medicaid Services, recently congratulated hospitalists for their role in bringing down readmission rates.
For decades, hospital readmissions were "rock solid" at between 19% and 19.5%, according to Dr. Conway. But starting in 2012 and continuing into 2013, readmission rates have fallen to about 17.7% nationally.
"That is hundreds of thousands of Medicare beneficiaries that are not readmitted every year," he said.
Speaking at the annual meeting of the Society of Hospital Medicine, Dr. Conway, who still works on a volunteer basis as a pediatric hospitalist on weekends, said the drop in readmissions is a credit to the work of hospitalists and other frontline providers.
The change coincides with the implementation in October 2012 of Medicare’s Readmissions Reduction Program, which reduces payments to hospitals with excess readmissions in the areas of pneumonia, acute myocardial infarction, and heart failure. But Dr. Conway disagrees with those who say that the penalty is solely responsible for the change.
"I think it’s a combination of interventions," Dr. Conway said. "We’re doing QI interventions in the field; there’s payment; there’s support structures; there’s investments in communities. But overall, the major point is we’re moving the national needle."
So what’s next? The CMS is putting readmission measures in place in every setting, including nursing homes, home health settings, and for physicians. The idea is to drive "shared accountability and focus," he said. Also coming down the pike are plans from the CMS to tie a small amount of hospital payments to lowering admission rates. Dr. Conway said that the Medicare officials don’t just want hospitals to be focused on readmissions, but to begin focusing on how to prevent admissions as well.
Dr. Patrick Conway, the chief medical officer at the Centers for Medicare and Medicaid Services, recently congratulated hospitalists for their role in bringing down readmission rates.
For decades, hospital readmissions were "rock solid" at between 19% and 19.5%, according to Dr. Conway. But starting in 2012 and continuing into 2013, readmission rates have fallen to about 17.7% nationally.
"That is hundreds of thousands of Medicare beneficiaries that are not readmitted every year," he said.
Speaking at the annual meeting of the Society of Hospital Medicine, Dr. Conway, who still works on a volunteer basis as a pediatric hospitalist on weekends, said the drop in readmissions is a credit to the work of hospitalists and other frontline providers.
The change coincides with the implementation in October 2012 of Medicare’s Readmissions Reduction Program, which reduces payments to hospitals with excess readmissions in the areas of pneumonia, acute myocardial infarction, and heart failure. But Dr. Conway disagrees with those who say that the penalty is solely responsible for the change.
"I think it’s a combination of interventions," Dr. Conway said. "We’re doing QI interventions in the field; there’s payment; there’s support structures; there’s investments in communities. But overall, the major point is we’re moving the national needle."
So what’s next? The CMS is putting readmission measures in place in every setting, including nursing homes, home health settings, and for physicians. The idea is to drive "shared accountability and focus," he said. Also coming down the pike are plans from the CMS to tie a small amount of hospital payments to lowering admission rates. Dr. Conway said that the Medicare officials don’t just want hospitals to be focused on readmissions, but to begin focusing on how to prevent admissions as well.
Dr. Patrick Conway, the chief medical officer at the Centers for Medicare and Medicaid Services, recently congratulated hospitalists for their role in bringing down readmission rates.
For decades, hospital readmissions were "rock solid" at between 19% and 19.5%, according to Dr. Conway. But starting in 2012 and continuing into 2013, readmission rates have fallen to about 17.7% nationally.
"That is hundreds of thousands of Medicare beneficiaries that are not readmitted every year," he said.
Speaking at the annual meeting of the Society of Hospital Medicine, Dr. Conway, who still works on a volunteer basis as a pediatric hospitalist on weekends, said the drop in readmissions is a credit to the work of hospitalists and other frontline providers.
The change coincides with the implementation in October 2012 of Medicare’s Readmissions Reduction Program, which reduces payments to hospitals with excess readmissions in the areas of pneumonia, acute myocardial infarction, and heart failure. But Dr. Conway disagrees with those who say that the penalty is solely responsible for the change.
"I think it’s a combination of interventions," Dr. Conway said. "We’re doing QI interventions in the field; there’s payment; there’s support structures; there’s investments in communities. But overall, the major point is we’re moving the national needle."
So what’s next? The CMS is putting readmission measures in place in every setting, including nursing homes, home health settings, and for physicians. The idea is to drive "shared accountability and focus," he said. Also coming down the pike are plans from the CMS to tie a small amount of hospital payments to lowering admission rates. Dr. Conway said that the Medicare officials don’t just want hospitals to be focused on readmissions, but to begin focusing on how to prevent admissions as well.
MARQUIS project marches toward better med reconciliation
NATIONAL HARBOR, MD. – How confident are you that the medication list your patient is discharged with is completely accurate?
Dr. Jason Stein, a hospitalist at Emory University in Atlanta, said that most physicians don’t know if they’re dealing with "gold" or "garbage."
Dr. Stein, who is a mentor in the Multi-Center Medication Reconciliation Quality Improvement Study (MARQUIS), said that hospitalists are often faced with either taking a "leap of faith" that the medication list is complete and accurate or throwing out the list at discharge and starting over.
MARQUIS, which was launched in 2010 by the Society of Hospital Medicine, is funded by a $1.5-million grant from the Agency for Healthcare Research and Quality. The study seeks to identify and disseminate evidence-based techniques for getting the best possible medication history from hospitalized patients with the ultimate goal of preventing medication errors. Data collection is scheduled to end this year.
The first part of the study was a literature review to cull the best available evidence on medication reconciliation practices in the hospital. That information was then used to develop a toolkit synthesizing those best practices for clinicians.
The toolkit, available online from the Society of Hospital Medicine, includes a manual on best practices and how to adapt them to individual sites, a video on how to take a good medication history, another video comparing the usual versus the optimal approach to discharge counseling, and pocket cards with questions to ask when taking a medication history.
Listen, ‘don’t lead’
"One thing that we’ve found really valuable is to not lead the witness," Dr. Jeffrey L. Schnipper, the MARQUIS principal investigator, said at the annual meeting of the Society of Hospital Medicine.
Don’t just sit there and read the medication list because the patient will likely just say yes to everything, said Dr. Schnipper, who is a hospitalist at Brigham and Women’s Hospital and assistant professor of medicine at Harvard Medical School in Boston. Instead, ask patients to explain what they are taking. The toolkit also provides some standard prompts to use to get patients to remember certain medications, such as ones they take only once a week or medications that are over the counter.
"You will learn a lot more," Dr. Schnipper said. "You will learn about the discrepancies that are really there and you will also be able to assess the patient’s knowledge."
The mentor method
Another big piece of MARQUIS is a mentored implementation project across six hospitals. The mentored implementation was kicked off about a year and a half ago, and the sites are now actively experimenting with interventions aimed at decreasing the number of unintentional medication discrepancies among their noncritical medical and surgical patients.
Each hospital identified a local champion, typically a hospitalist, who formed an interdisciplinary quality improvement team. That team then worked with a MARQUIS mentor, a hospitalist outside the institution with experience in both quality improvement and medication safety. The mentors had monthly phone calls with each of the sites to talk about their processes, successes, and challenges. There are also two site visits built into the study.
During the study, teams at each participating site chose from a menu of interventions recommended by the MARQUIS researchers to try to improve their medication reconciliation process. The menu includes:
• Defining medication reconciliation at their individual site.
• Assigning roles and responsibilities related to medication reconciliation.
• Improving access to preadmission medication information sources.
• Encouraging patients to keep their own up-to-date medication lists.
• Educating providers about how to take the best possible medication history.
• Implementing discharge counseling that includes patient education tools and teach back.
• Stratifying patients as low, intermediate, or high-risk based on disease state and number of medications.
• Improving information technology capability.
The sites are making progress, said Dr. Stein, who serves as a mentor to three of the six hospitals.
Presbyterian Medical Center in Charlotte already had a fairly robust program aimed at improving the medication reconciliation process. Pharmacy technicians, called medication reconciliation assistants (MRAs), are stationed in the emergency department to take a best possible medication history. The MRAs have a thorough process that includes interviewing the patient and then verifying the information with the pharmacy, the primary care physician, or the skilled nursing facility.
But they found that they were still missing patients who came in through the intensive care unit or were directly admitted. Now the center has trained a nurse to take the medication history for any patients who haven’t already seen the MRA and they’ve developed automated systems to identify those patients quickly. The hospital also created an automated system to identify high-risk patients who need a high-intensity discharge counseling session with a clinical pharmacist.
The hospital also has faced hurdles such as the fact that most of the clinicians involved in this process have never been trained on taking a thorough medication history. And even more have never received feedback on the quality of their preadmission medication histories. "This is a core competency that none of us have really ever been trained around," Dr. Stein said.
Another barrier is being clear about who is responsible for making sure each patient has an accurate medication list. "Is it the admitting provider? Unless you’ve actually explicitly outlined whose role that is, it’s nobody’s," Dr. Stein said.
The MARQUIS researchers are collecting data on the number of potentially harmful unintentional medication discrepancies per patient. The researchers collect the raw data from each of the sites and then send it on to physicians who consider the context for the discrepancies and the potential for harm.
Another goal of the project is to try to figure out why certain interventions work in certain places. The researchers are conducting surveys, interviews, direct observation, and focus groups to get these answers. "That will help us understand what components work in what settings," said MARQUIS investigator Amanda H. Salanitro, a hospitalist and health services researcher at Vanderbilt University Medical Center and the VA Tennessee Valley Healthcare System.
On Twitter @MaryEllenNY
NATIONAL HARBOR, MD. – How confident are you that the medication list your patient is discharged with is completely accurate?
Dr. Jason Stein, a hospitalist at Emory University in Atlanta, said that most physicians don’t know if they’re dealing with "gold" or "garbage."
Dr. Stein, who is a mentor in the Multi-Center Medication Reconciliation Quality Improvement Study (MARQUIS), said that hospitalists are often faced with either taking a "leap of faith" that the medication list is complete and accurate or throwing out the list at discharge and starting over.
MARQUIS, which was launched in 2010 by the Society of Hospital Medicine, is funded by a $1.5-million grant from the Agency for Healthcare Research and Quality. The study seeks to identify and disseminate evidence-based techniques for getting the best possible medication history from hospitalized patients with the ultimate goal of preventing medication errors. Data collection is scheduled to end this year.
The first part of the study was a literature review to cull the best available evidence on medication reconciliation practices in the hospital. That information was then used to develop a toolkit synthesizing those best practices for clinicians.
The toolkit, available online from the Society of Hospital Medicine, includes a manual on best practices and how to adapt them to individual sites, a video on how to take a good medication history, another video comparing the usual versus the optimal approach to discharge counseling, and pocket cards with questions to ask when taking a medication history.
Listen, ‘don’t lead’
"One thing that we’ve found really valuable is to not lead the witness," Dr. Jeffrey L. Schnipper, the MARQUIS principal investigator, said at the annual meeting of the Society of Hospital Medicine.
Don’t just sit there and read the medication list because the patient will likely just say yes to everything, said Dr. Schnipper, who is a hospitalist at Brigham and Women’s Hospital and assistant professor of medicine at Harvard Medical School in Boston. Instead, ask patients to explain what they are taking. The toolkit also provides some standard prompts to use to get patients to remember certain medications, such as ones they take only once a week or medications that are over the counter.
"You will learn a lot more," Dr. Schnipper said. "You will learn about the discrepancies that are really there and you will also be able to assess the patient’s knowledge."
The mentor method
Another big piece of MARQUIS is a mentored implementation project across six hospitals. The mentored implementation was kicked off about a year and a half ago, and the sites are now actively experimenting with interventions aimed at decreasing the number of unintentional medication discrepancies among their noncritical medical and surgical patients.
Each hospital identified a local champion, typically a hospitalist, who formed an interdisciplinary quality improvement team. That team then worked with a MARQUIS mentor, a hospitalist outside the institution with experience in both quality improvement and medication safety. The mentors had monthly phone calls with each of the sites to talk about their processes, successes, and challenges. There are also two site visits built into the study.
During the study, teams at each participating site chose from a menu of interventions recommended by the MARQUIS researchers to try to improve their medication reconciliation process. The menu includes:
• Defining medication reconciliation at their individual site.
• Assigning roles and responsibilities related to medication reconciliation.
• Improving access to preadmission medication information sources.
• Encouraging patients to keep their own up-to-date medication lists.
• Educating providers about how to take the best possible medication history.
• Implementing discharge counseling that includes patient education tools and teach back.
• Stratifying patients as low, intermediate, or high-risk based on disease state and number of medications.
• Improving information technology capability.
The sites are making progress, said Dr. Stein, who serves as a mentor to three of the six hospitals.
Presbyterian Medical Center in Charlotte already had a fairly robust program aimed at improving the medication reconciliation process. Pharmacy technicians, called medication reconciliation assistants (MRAs), are stationed in the emergency department to take a best possible medication history. The MRAs have a thorough process that includes interviewing the patient and then verifying the information with the pharmacy, the primary care physician, or the skilled nursing facility.
But they found that they were still missing patients who came in through the intensive care unit or were directly admitted. Now the center has trained a nurse to take the medication history for any patients who haven’t already seen the MRA and they’ve developed automated systems to identify those patients quickly. The hospital also created an automated system to identify high-risk patients who need a high-intensity discharge counseling session with a clinical pharmacist.
The hospital also has faced hurdles such as the fact that most of the clinicians involved in this process have never been trained on taking a thorough medication history. And even more have never received feedback on the quality of their preadmission medication histories. "This is a core competency that none of us have really ever been trained around," Dr. Stein said.
Another barrier is being clear about who is responsible for making sure each patient has an accurate medication list. "Is it the admitting provider? Unless you’ve actually explicitly outlined whose role that is, it’s nobody’s," Dr. Stein said.
The MARQUIS researchers are collecting data on the number of potentially harmful unintentional medication discrepancies per patient. The researchers collect the raw data from each of the sites and then send it on to physicians who consider the context for the discrepancies and the potential for harm.
Another goal of the project is to try to figure out why certain interventions work in certain places. The researchers are conducting surveys, interviews, direct observation, and focus groups to get these answers. "That will help us understand what components work in what settings," said MARQUIS investigator Amanda H. Salanitro, a hospitalist and health services researcher at Vanderbilt University Medical Center and the VA Tennessee Valley Healthcare System.
On Twitter @MaryEllenNY
NATIONAL HARBOR, MD. – How confident are you that the medication list your patient is discharged with is completely accurate?
Dr. Jason Stein, a hospitalist at Emory University in Atlanta, said that most physicians don’t know if they’re dealing with "gold" or "garbage."
Dr. Stein, who is a mentor in the Multi-Center Medication Reconciliation Quality Improvement Study (MARQUIS), said that hospitalists are often faced with either taking a "leap of faith" that the medication list is complete and accurate or throwing out the list at discharge and starting over.
MARQUIS, which was launched in 2010 by the Society of Hospital Medicine, is funded by a $1.5-million grant from the Agency for Healthcare Research and Quality. The study seeks to identify and disseminate evidence-based techniques for getting the best possible medication history from hospitalized patients with the ultimate goal of preventing medication errors. Data collection is scheduled to end this year.
The first part of the study was a literature review to cull the best available evidence on medication reconciliation practices in the hospital. That information was then used to develop a toolkit synthesizing those best practices for clinicians.
The toolkit, available online from the Society of Hospital Medicine, includes a manual on best practices and how to adapt them to individual sites, a video on how to take a good medication history, another video comparing the usual versus the optimal approach to discharge counseling, and pocket cards with questions to ask when taking a medication history.
Listen, ‘don’t lead’
"One thing that we’ve found really valuable is to not lead the witness," Dr. Jeffrey L. Schnipper, the MARQUIS principal investigator, said at the annual meeting of the Society of Hospital Medicine.
Don’t just sit there and read the medication list because the patient will likely just say yes to everything, said Dr. Schnipper, who is a hospitalist at Brigham and Women’s Hospital and assistant professor of medicine at Harvard Medical School in Boston. Instead, ask patients to explain what they are taking. The toolkit also provides some standard prompts to use to get patients to remember certain medications, such as ones they take only once a week or medications that are over the counter.
"You will learn a lot more," Dr. Schnipper said. "You will learn about the discrepancies that are really there and you will also be able to assess the patient’s knowledge."
The mentor method
Another big piece of MARQUIS is a mentored implementation project across six hospitals. The mentored implementation was kicked off about a year and a half ago, and the sites are now actively experimenting with interventions aimed at decreasing the number of unintentional medication discrepancies among their noncritical medical and surgical patients.
Each hospital identified a local champion, typically a hospitalist, who formed an interdisciplinary quality improvement team. That team then worked with a MARQUIS mentor, a hospitalist outside the institution with experience in both quality improvement and medication safety. The mentors had monthly phone calls with each of the sites to talk about their processes, successes, and challenges. There are also two site visits built into the study.
During the study, teams at each participating site chose from a menu of interventions recommended by the MARQUIS researchers to try to improve their medication reconciliation process. The menu includes:
• Defining medication reconciliation at their individual site.
• Assigning roles and responsibilities related to medication reconciliation.
• Improving access to preadmission medication information sources.
• Encouraging patients to keep their own up-to-date medication lists.
• Educating providers about how to take the best possible medication history.
• Implementing discharge counseling that includes patient education tools and teach back.
• Stratifying patients as low, intermediate, or high-risk based on disease state and number of medications.
• Improving information technology capability.
The sites are making progress, said Dr. Stein, who serves as a mentor to three of the six hospitals.
Presbyterian Medical Center in Charlotte already had a fairly robust program aimed at improving the medication reconciliation process. Pharmacy technicians, called medication reconciliation assistants (MRAs), are stationed in the emergency department to take a best possible medication history. The MRAs have a thorough process that includes interviewing the patient and then verifying the information with the pharmacy, the primary care physician, or the skilled nursing facility.
But they found that they were still missing patients who came in through the intensive care unit or were directly admitted. Now the center has trained a nurse to take the medication history for any patients who haven’t already seen the MRA and they’ve developed automated systems to identify those patients quickly. The hospital also created an automated system to identify high-risk patients who need a high-intensity discharge counseling session with a clinical pharmacist.
The hospital also has faced hurdles such as the fact that most of the clinicians involved in this process have never been trained on taking a thorough medication history. And even more have never received feedback on the quality of their preadmission medication histories. "This is a core competency that none of us have really ever been trained around," Dr. Stein said.
Another barrier is being clear about who is responsible for making sure each patient has an accurate medication list. "Is it the admitting provider? Unless you’ve actually explicitly outlined whose role that is, it’s nobody’s," Dr. Stein said.
The MARQUIS researchers are collecting data on the number of potentially harmful unintentional medication discrepancies per patient. The researchers collect the raw data from each of the sites and then send it on to physicians who consider the context for the discrepancies and the potential for harm.
Another goal of the project is to try to figure out why certain interventions work in certain places. The researchers are conducting surveys, interviews, direct observation, and focus groups to get these answers. "That will help us understand what components work in what settings," said MARQUIS investigator Amanda H. Salanitro, a hospitalist and health services researcher at Vanderbilt University Medical Center and the VA Tennessee Valley Healthcare System.
On Twitter @MaryEllenNY
AT HOSPITAL MEDICINE 13
Hospitalists' role in ACOs is changing, vital
NATIONAL HARBOR, MD. – Accountable Care Organizations are designed around wellness with primary care physicians at the center, but hospitalists still have a major role to play by improving quality and decreasing costs, according to Dr. Emily Mallin.
A look at the 33 quality measures that Medicare requires ACOs to meet shows how integral hospitalists are to the success of these new care delivery models, said Dr. Mallin, a hospitalist at one of the Pioneer ACOs approved by Medicare in 2012. Hospitalists are involved in nearly half of those quality measures, from preventive health to care coordination to the treatment of at-risk populations.
"While ACOs seem to be population based and outpatient based, the truth of the matter is that [hospitalists] are involved in this," Dr. Mallin, medical director of the academic medical service at Banner Good Samaritan Medical Center in Phoenix, said at the annual meeting of the Society of Hospital Medicine.
Dr. Mallin is part of Banner Health’s Pioneer ACO, a Medicare program that allows mature ACOs, usually located at integrated health systems, a chance to share in the savings generated through better-coordinated care. But this isn't the only type of ACO model.
"ACOs come in all shapes and sizes," Dr. Mallin said.
Officials at the Centers for Medicare and Medicaid Services have also approved more than 220 organizations for the Medicare Shared Savings program, which offers organizations the chance to share in savings only or to take on financial risk but potentially reap higher financial rewards. A third Medicare ACO model, called the Advance Payment Model, allows some small physician-run ACOs to receive up-front, monthly payments to help invest in care coordination. There are also several private payers that have been forming ACOs around the country.
Regardless of the specific structure, all ACOs are designed around the concept of making health care providers accountable for the quality, cost, and overall care of patients.
While the idea of taking on financial risk for the total care of patients sounds similar to the HMO heyday of the 1990s, Dr. Mallin said there are key differences: For instance, the move to HMOs was driven by insurance companies whose sole goal was reducing costs. With today’s ACOs, there is a greater attempt to involve physicians and other health care providers. And while there is a definite focus on reducing costs, ACOs are paid for outcomes, quality, and value. Another key difference, she said, is that there are now significantly more data available at the point of care to help coordinate care.
In the developing ACO world, hospitalists are considered "specialists," Dr. Mallin said. As specialists, hospitalists can participate in more than one ACO at a time. They are also entitled to share in the savings generated by the ACO but exactly how that is done depends on the where they work and how their ACO is structured, she said.
At Banner Health, hospitalists are taking on some new roles with the goal of better care coordination in the ACO. For example, they have an inpatient transitionalist physician who sees patients in the hospital before discharge and then follows them for 30 days after they leave the hospital. He makes house calls and follow-up phone calls to make sure they are receiving adequate care in the community and prevent them from bouncing back to the hospital. "He is extremely patient centered," Dr. Mallin said.
Banner also has a "triage-ist" who is stationed in the emergency department of the hospital and helps in deciding if patients should be admitted, Dr. Mallin said.
The biggest thing to keep in mind about the hospitalist role in ACOs is that this is evolving, said Dr. Edward J. Merrens, a hospitalist and the chief medical officer at Dartmouth-Hitchcock Medical Center in Hanover, N.H., one of the Medicare Pioneer ACOs.
"We don’t have it all figured out yet," he told attendees at the SHM meeting. "This is a new endeavor."
But hospitalists should start to think differently about the care they provide, he said. For instance, ACOs are reversing some long-standing ideas about health care costs, turning hospitals from "profit centers" to "cost centers," he said.
Under the ACO model, ordering an MRI is now a cost to the ACO, not a way to generate revenue for the hospital. Medicare is applying that same principle to hospital readmissions, by penalizing hospitals for having excess return hospitalizations. Dr. Merrins said hospitalists need to start thinking about admissions that way too and trying to prevent them in those patients who return frequently to the hospital for multiple reasons.
"Think about an admission as a readmission," he said.
On Twitter @MaryEllenNY
NATIONAL HARBOR, MD. – Accountable Care Organizations are designed around wellness with primary care physicians at the center, but hospitalists still have a major role to play by improving quality and decreasing costs, according to Dr. Emily Mallin.
A look at the 33 quality measures that Medicare requires ACOs to meet shows how integral hospitalists are to the success of these new care delivery models, said Dr. Mallin, a hospitalist at one of the Pioneer ACOs approved by Medicare in 2012. Hospitalists are involved in nearly half of those quality measures, from preventive health to care coordination to the treatment of at-risk populations.
"While ACOs seem to be population based and outpatient based, the truth of the matter is that [hospitalists] are involved in this," Dr. Mallin, medical director of the academic medical service at Banner Good Samaritan Medical Center in Phoenix, said at the annual meeting of the Society of Hospital Medicine.
Dr. Mallin is part of Banner Health’s Pioneer ACO, a Medicare program that allows mature ACOs, usually located at integrated health systems, a chance to share in the savings generated through better-coordinated care. But this isn't the only type of ACO model.
"ACOs come in all shapes and sizes," Dr. Mallin said.
Officials at the Centers for Medicare and Medicaid Services have also approved more than 220 organizations for the Medicare Shared Savings program, which offers organizations the chance to share in savings only or to take on financial risk but potentially reap higher financial rewards. A third Medicare ACO model, called the Advance Payment Model, allows some small physician-run ACOs to receive up-front, monthly payments to help invest in care coordination. There are also several private payers that have been forming ACOs around the country.
Regardless of the specific structure, all ACOs are designed around the concept of making health care providers accountable for the quality, cost, and overall care of patients.
While the idea of taking on financial risk for the total care of patients sounds similar to the HMO heyday of the 1990s, Dr. Mallin said there are key differences: For instance, the move to HMOs was driven by insurance companies whose sole goal was reducing costs. With today’s ACOs, there is a greater attempt to involve physicians and other health care providers. And while there is a definite focus on reducing costs, ACOs are paid for outcomes, quality, and value. Another key difference, she said, is that there are now significantly more data available at the point of care to help coordinate care.
In the developing ACO world, hospitalists are considered "specialists," Dr. Mallin said. As specialists, hospitalists can participate in more than one ACO at a time. They are also entitled to share in the savings generated by the ACO but exactly how that is done depends on the where they work and how their ACO is structured, she said.
At Banner Health, hospitalists are taking on some new roles with the goal of better care coordination in the ACO. For example, they have an inpatient transitionalist physician who sees patients in the hospital before discharge and then follows them for 30 days after they leave the hospital. He makes house calls and follow-up phone calls to make sure they are receiving adequate care in the community and prevent them from bouncing back to the hospital. "He is extremely patient centered," Dr. Mallin said.
Banner also has a "triage-ist" who is stationed in the emergency department of the hospital and helps in deciding if patients should be admitted, Dr. Mallin said.
The biggest thing to keep in mind about the hospitalist role in ACOs is that this is evolving, said Dr. Edward J. Merrens, a hospitalist and the chief medical officer at Dartmouth-Hitchcock Medical Center in Hanover, N.H., one of the Medicare Pioneer ACOs.
"We don’t have it all figured out yet," he told attendees at the SHM meeting. "This is a new endeavor."
But hospitalists should start to think differently about the care they provide, he said. For instance, ACOs are reversing some long-standing ideas about health care costs, turning hospitals from "profit centers" to "cost centers," he said.
Under the ACO model, ordering an MRI is now a cost to the ACO, not a way to generate revenue for the hospital. Medicare is applying that same principle to hospital readmissions, by penalizing hospitals for having excess return hospitalizations. Dr. Merrins said hospitalists need to start thinking about admissions that way too and trying to prevent them in those patients who return frequently to the hospital for multiple reasons.
"Think about an admission as a readmission," he said.
On Twitter @MaryEllenNY
NATIONAL HARBOR, MD. – Accountable Care Organizations are designed around wellness with primary care physicians at the center, but hospitalists still have a major role to play by improving quality and decreasing costs, according to Dr. Emily Mallin.
A look at the 33 quality measures that Medicare requires ACOs to meet shows how integral hospitalists are to the success of these new care delivery models, said Dr. Mallin, a hospitalist at one of the Pioneer ACOs approved by Medicare in 2012. Hospitalists are involved in nearly half of those quality measures, from preventive health to care coordination to the treatment of at-risk populations.
"While ACOs seem to be population based and outpatient based, the truth of the matter is that [hospitalists] are involved in this," Dr. Mallin, medical director of the academic medical service at Banner Good Samaritan Medical Center in Phoenix, said at the annual meeting of the Society of Hospital Medicine.
Dr. Mallin is part of Banner Health’s Pioneer ACO, a Medicare program that allows mature ACOs, usually located at integrated health systems, a chance to share in the savings generated through better-coordinated care. But this isn't the only type of ACO model.
"ACOs come in all shapes and sizes," Dr. Mallin said.
Officials at the Centers for Medicare and Medicaid Services have also approved more than 220 organizations for the Medicare Shared Savings program, which offers organizations the chance to share in savings only or to take on financial risk but potentially reap higher financial rewards. A third Medicare ACO model, called the Advance Payment Model, allows some small physician-run ACOs to receive up-front, monthly payments to help invest in care coordination. There are also several private payers that have been forming ACOs around the country.
Regardless of the specific structure, all ACOs are designed around the concept of making health care providers accountable for the quality, cost, and overall care of patients.
While the idea of taking on financial risk for the total care of patients sounds similar to the HMO heyday of the 1990s, Dr. Mallin said there are key differences: For instance, the move to HMOs was driven by insurance companies whose sole goal was reducing costs. With today’s ACOs, there is a greater attempt to involve physicians and other health care providers. And while there is a definite focus on reducing costs, ACOs are paid for outcomes, quality, and value. Another key difference, she said, is that there are now significantly more data available at the point of care to help coordinate care.
In the developing ACO world, hospitalists are considered "specialists," Dr. Mallin said. As specialists, hospitalists can participate in more than one ACO at a time. They are also entitled to share in the savings generated by the ACO but exactly how that is done depends on the where they work and how their ACO is structured, she said.
At Banner Health, hospitalists are taking on some new roles with the goal of better care coordination in the ACO. For example, they have an inpatient transitionalist physician who sees patients in the hospital before discharge and then follows them for 30 days after they leave the hospital. He makes house calls and follow-up phone calls to make sure they are receiving adequate care in the community and prevent them from bouncing back to the hospital. "He is extremely patient centered," Dr. Mallin said.
Banner also has a "triage-ist" who is stationed in the emergency department of the hospital and helps in deciding if patients should be admitted, Dr. Mallin said.
The biggest thing to keep in mind about the hospitalist role in ACOs is that this is evolving, said Dr. Edward J. Merrens, a hospitalist and the chief medical officer at Dartmouth-Hitchcock Medical Center in Hanover, N.H., one of the Medicare Pioneer ACOs.
"We don’t have it all figured out yet," he told attendees at the SHM meeting. "This is a new endeavor."
But hospitalists should start to think differently about the care they provide, he said. For instance, ACOs are reversing some long-standing ideas about health care costs, turning hospitals from "profit centers" to "cost centers," he said.
Under the ACO model, ordering an MRI is now a cost to the ACO, not a way to generate revenue for the hospital. Medicare is applying that same principle to hospital readmissions, by penalizing hospitals for having excess return hospitalizations. Dr. Merrins said hospitalists need to start thinking about admissions that way too and trying to prevent them in those patients who return frequently to the hospital for multiple reasons.
"Think about an admission as a readmission," he said.
On Twitter @MaryEllenNY
AT HOSPITAL MEDICINE 2013
