Mary Ellen Schneider

Twenty-five years after the first hospitalist programs began, the hospitalist model of dedicated, site-specific care is starting to make its way into post-acute care settings.

They may be called SNFists or post-acute care hospitalists, but whatever the name, physicians are staking out more of a physical presence in skilled nursing facilities (SNFs), inpatient rehabilitation facilities, long-term acute care hospitals, and other post-acute care settings.

In some cases, hospitalists are migrating into post-acute facilities part-time. Under this hybrid model, traditional hospitalists are continuing their work in the hospital, but may also care for patients in a nearby skilled nursing facility.

The other model that has been developing over the past 3-4 years looks more like the traditional hospitalist model of care, but may not always involve hospitalists. Under this dedicated model, physicians work exclusively in the post-acute care setting, providing coverage to these facilities anywhere from 3 to 7 days a week. Some of the physicians working under this model are former hospitalists, but others are geriatricians, intensivists, internists, and family physicians.

Nearly 27% of hospitalist medical groups provide services in either inpatient rehabilitation facilities, psychiatric facilities, or long-term acute care hospitals. And nearly 10% provide services in SNFs or extended-care facilities, according to the 2012 State of Hospital Medicine survey released by the Society of Hospital Medicine (SHM).

One reason for the shift in care is that the old model isn’t working, said Dr. Jerome Wilborn, the national medical director for post-acute care services at IPC The Hospitalist Company.

"Unfortunately, you look around the country, and doctors just don’t go to the nursing facility setting often enough to make an impact," Dr. Wilborn said. "How do we know that? A quarter of the patients who come here, bounce back to the hospital."

Beefing up the physician presence at SNFs and other post-acute care facilities has the potential to bring down those hospital readmission numbers, Dr. Wilborn said. In the post-acute care hospitalist programs that he oversees, the number of patient visits is driven by clinical acuity.

For example, in the first week, when patients are most vulnerable to bouncing back to the hospital, they may be seen by a physician three or four times. Some of that time is spent counseling family members, working on reducing medications, and coordinating care with the discharging physician, Dr. Wilborn said.

"It’s not so much the number of touches as it is the presence of the clinical team that’s there," Dr. Wilborn said. "You don’t know who you’re going to see, or who you should see, if you only go once a week."

IPC The Hospitalist Company recently made a big entrance into the post-acute care market. Over the past 4 years, they have begun practicing in about 650 post-acute care facilities. The facilities are mostly SNFs, but also include long-term acute care hospitals, inpatient rehabilitation facilities, assisted living facilities, and others, according to Todd Kislak, the vice president of marketing for IPC. This is in addition to the traditional hospital practices that the company has in about 350 acute care hospitals and long-term acute care hospitals around the country.

The IPC executives saw the holes in care in the post-acute care setting and saw an opportunity to use their experience with hospitalist programs, electronic health record technology, and advanced communications systems to surge ahead in the market, Mr. Kislak said. "IPC is playing an influential role in the organization and consolidation of these doctors in the post-acute space," he said.

IPC and other acute care hospitalist groups follow a fee-for-service business model. But there are other, more complex financial drivers that appear to be moving this model forward.

One driver is the Medicare 30-day readmission penalty, which went into effect on Oct. 1, 2012. Under the new policy, the Centers for Medicare and Medicaid Services is cutting Medicare payments to hospitals with excess readmissions in heart failure, pneumonia, and acute myocardial infarction.

Courtesy Diane Williams

The readmission policy incentivizes short-term acute care hospitals to use post-acute care services efficiently, safely, and effectively, said Dr. Sean R. Muldoon, the senior vice president and chief medical officer at Kindred Healthcare’s Hospital Division, which is a national network of long-term acute care hospitals headquartered in Louisville, Ky.

"Managing the transition and assuring that the patients go into settings that are likely to continue the patients’ improvement are in [the hospitals’] best patient, payment, and policy interests," said Dr. Muldoon, who cochairs the SHM Post-Acute Care Task Force.

And the movement by Medicare toward bundling payments for an entire episode of care means that hospitals will have another financial incentive to move patients into a less costly setting, while also ensuring that the quality of care is maintained.

For SNFs and other post-acute care facilities, there’s a growing recognition that they need help in managing the increasingly complex patients coming through their doors, he said.

"The post-acute care settings, particularly SNFs, have really asked physicians to be more involved, more present, and more coordinating in their care plans," Dr. Muldoon said. "Hospitalists have responded to that because those are core competencies that they have developed very well in short-term hospitals and are largely transferrable to the post-acute care setting."

As physicians take on a larger role in the post-acute care setting, the debate is growing over what model is best.

Each of the current models has some advantages, said Dr. Heather Zinzella-Cox, the practice group leader for the Delaware region for IPC and the cochair of the SHM Post-Acute Care Task Force.

The hybrid model offers continuity of care because the same physicians who are following patients in the hospital are also involved in their post-acute care. At her IPC practice in Delaware, the nursing facility contracts with some traditional hospitalists to serve as Medical Director Consultants. Since these physicians have a foot in each setting, they are able to use their post-acute knowledge to inform their work as hospitalists. For instance, many SNF pharmacies may not have access to certain medications or may need 24 hours to provide them. So the hospitalist needs to be aware of those challenges and take the necessary steps to provide a safe and effective handoff to the facility, she said.

But the hybrid model also comes with the typical disadvantages of trying to do too many different things at once.

"When a provider is stretched and has too many hats, something gives," Dr. Zinzella-Cox said. "And it’s typically the post-acute care space."

The hybrid model is most successful, she said, if the post-acute care facility is attached to the hospital or if the two facilities share an electronic health record system.

On the other hand, the dedicated model in the post-acute care setting keeps physicians from being pulled back and forth between different settings. "It allows me to stay engaged in my facility," she said.

Whatever model emerges, Dr. Zinzella-Cox predicted that the combination of Medicare readmission penalties and other new payment initiatives will force traditional hospitalists to pay closer attention to the post-acute care setting.

"Hospitalists will drive the care of their patients and, in combination with the social worker, determine where their patients are going to go after discharge," she said.

Hospitalists’ habits: Standardizing post-acute care

Hospitalists who have moved to the post-acute world are bringing some of the hospital culture with them.

Dr. Donald Quinn, who started three hospitalist groups in east Tennessee and is now the practice group leader for the Tennessee region of IPC The Hospitalist Company, said hospitalists bring a standardized approach to quality of care. One of the tools Dr. Quinn and his colleagues are using in skilled nursing facilities is pathways and protocols that help standardize the care provided for common clinical situations.

The use of clinical pathways has been especially helpful at night, when physicians aren’t on site but are available by phone. Being able to instruct the nursing staff to begin a preestablished clinical protocol can help keep patients out of the emergency department, safely, Dr. Quinn said.

Post-acute care hospitalists aren’t just standardizing the care. They are also standardizing their hours. Dr. Quinn said he and his IPC colleagues have set up regular visit schedules with the post-acute facilities they work with so patients and staff there know when a physician will be in the building. Typically, their post-acute care hospitalists visit two facilities per day, where they see patients and coordinate care with nurse practitioners and physician assistants. The group also cross-credentials its physicians so that when someone is sick or goes on vacation, a doctor is still available at the facility at the scheduled time.

"Once you get these folks used to this quality and this intensity of care, it does make a difference if no one shows up that day," Dr. Quinn said. "It’s a totally different practice."

[email protected]

Twenty-five years after the first hospitalist programs began, the hospitalist model of dedicated, site-specific care is starting to make its way into post-acute care settings.

They may be called SNFists or post-acute care hospitalists, but whatever the name, physicians are staking out more of a physical presence in skilled nursing facilities (SNFs), inpatient rehabilitation facilities, long-term acute care hospitals, and other post-acute care settings.

In some cases, hospitalists are migrating into post-acute facilities part-time. Under this hybrid model, traditional hospitalists are continuing their work in the hospital, but may also care for patients in a nearby skilled nursing facility.

The other model that has been developing over the past 3-4 years looks more like the traditional hospitalist model of care, but may not always involve hospitalists. Under this dedicated model, physicians work exclusively in the post-acute care setting, providing coverage to these facilities anywhere from 3 to 7 days a week. Some of the physicians working under this model are former hospitalists, but others are geriatricians, intensivists, internists, and family physicians.

Nearly 27% of hospitalist medical groups provide services in either inpatient rehabilitation facilities, psychiatric facilities, or long-term acute care hospitals. And nearly 10% provide services in SNFs or extended-care facilities, according to the 2012 State of Hospital Medicine survey released by the Society of Hospital Medicine (SHM).

One reason for the shift in care is that the old model isn’t working, said Dr. Jerome Wilborn, the national medical director for post-acute care services at IPC The Hospitalist Company.

"Unfortunately, you look around the country, and doctors just don’t go to the nursing facility setting often enough to make an impact," Dr. Wilborn said. "How do we know that? A quarter of the patients who come here, bounce back to the hospital."

Beefing up the physician presence at SNFs and other post-acute care facilities has the potential to bring down those hospital readmission numbers, Dr. Wilborn said. In the post-acute care hospitalist programs that he oversees, the number of patient visits is driven by clinical acuity.

For example, in the first week, when patients are most vulnerable to bouncing back to the hospital, they may be seen by a physician three or four times. Some of that time is spent counseling family members, working on reducing medications, and coordinating care with the discharging physician, Dr. Wilborn said.

"It’s not so much the number of touches as it is the presence of the clinical team that’s there," Dr. Wilborn said. "You don’t know who you’re going to see, or who you should see, if you only go once a week."

IPC The Hospitalist Company recently made a big entrance into the post-acute care market. Over the past 4 years, they have begun practicing in about 650 post-acute care facilities. The facilities are mostly SNFs, but also include long-term acute care hospitals, inpatient rehabilitation facilities, assisted living facilities, and others, according to Todd Kislak, the vice president of marketing for IPC. This is in addition to the traditional hospital practices that the company has in about 350 acute care hospitals and long-term acute care hospitals around the country.

The IPC executives saw the holes in care in the post-acute care setting and saw an opportunity to use their experience with hospitalist programs, electronic health record technology, and advanced communications systems to surge ahead in the market, Mr. Kislak said. "IPC is playing an influential role in the organization and consolidation of these doctors in the post-acute space," he said.

IPC and other acute care hospitalist groups follow a fee-for-service business model. But there are other, more complex financial drivers that appear to be moving this model forward.

One driver is the Medicare 30-day readmission penalty, which went into effect on Oct. 1, 2012. Under the new policy, the Centers for Medicare and Medicaid Services is cutting Medicare payments to hospitals with excess readmissions in heart failure, pneumonia, and acute myocardial infarction.

Courtesy Diane Williams

The readmission policy incentivizes short-term acute care hospitals to use post-acute care services efficiently, safely, and effectively, said Dr. Sean R. Muldoon, the senior vice president and chief medical officer at Kindred Healthcare’s Hospital Division, which is a national network of long-term acute care hospitals headquartered in Louisville, Ky.

"Managing the transition and assuring that the patients go into settings that are likely to continue the patients’ improvement are in [the hospitals’] best patient, payment, and policy interests," said Dr. Muldoon, who cochairs the SHM Post-Acute Care Task Force.

And the movement by Medicare toward bundling payments for an entire episode of care means that hospitals will have another financial incentive to move patients into a less costly setting, while also ensuring that the quality of care is maintained.

For SNFs and other post-acute care facilities, there’s a growing recognition that they need help in managing the increasingly complex patients coming through their doors, he said.

"The post-acute care settings, particularly SNFs, have really asked physicians to be more involved, more present, and more coordinating in their care plans," Dr. Muldoon said. "Hospitalists have responded to that because those are core competencies that they have developed very well in short-term hospitals and are largely transferrable to the post-acute care setting."

As physicians take on a larger role in the post-acute care setting, the debate is growing over what model is best.

Each of the current models has some advantages, said Dr. Heather Zinzella-Cox, the practice group leader for the Delaware region for IPC and the cochair of the SHM Post-Acute Care Task Force.

The hybrid model offers continuity of care because the same physicians who are following patients in the hospital are also involved in their post-acute care. At her IPC practice in Delaware, the nursing facility contracts with some traditional hospitalists to serve as Medical Director Consultants. Since these physicians have a foot in each setting, they are able to use their post-acute knowledge to inform their work as hospitalists. For instance, many SNF pharmacies may not have access to certain medications or may need 24 hours to provide them. So the hospitalist needs to be aware of those challenges and take the necessary steps to provide a safe and effective handoff to the facility, she said.

But the hybrid model also comes with the typical disadvantages of trying to do too many different things at once.

"When a provider is stretched and has too many hats, something gives," Dr. Zinzella-Cox said. "And it’s typically the post-acute care space."

The hybrid model is most successful, she said, if the post-acute care facility is attached to the hospital or if the two facilities share an electronic health record system.

On the other hand, the dedicated model in the post-acute care setting keeps physicians from being pulled back and forth between different settings. "It allows me to stay engaged in my facility," she said.

Whatever model emerges, Dr. Zinzella-Cox predicted that the combination of Medicare readmission penalties and other new payment initiatives will force traditional hospitalists to pay closer attention to the post-acute care setting.

"Hospitalists will drive the care of their patients and, in combination with the social worker, determine where their patients are going to go after discharge," she said.

Hospitalists’ habits: Standardizing post-acute care

Hospitalists who have moved to the post-acute world are bringing some of the hospital culture with them.

Dr. Donald Quinn, who started three hospitalist groups in east Tennessee and is now the practice group leader for the Tennessee region of IPC The Hospitalist Company, said hospitalists bring a standardized approach to quality of care. One of the tools Dr. Quinn and his colleagues are using in skilled nursing facilities is pathways and protocols that help standardize the care provided for common clinical situations.

The use of clinical pathways has been especially helpful at night, when physicians aren’t on site but are available by phone. Being able to instruct the nursing staff to begin a preestablished clinical protocol can help keep patients out of the emergency department, safely, Dr. Quinn said.

Post-acute care hospitalists aren’t just standardizing the care. They are also standardizing their hours. Dr. Quinn said he and his IPC colleagues have set up regular visit schedules with the post-acute facilities they work with so patients and staff there know when a physician will be in the building. Typically, their post-acute care hospitalists visit two facilities per day, where they see patients and coordinate care with nurse practitioners and physician assistants. The group also cross-credentials its physicians so that when someone is sick or goes on vacation, a doctor is still available at the facility at the scheduled time.

"Once you get these folks used to this quality and this intensity of care, it does make a difference if no one shows up that day," Dr. Quinn said. "It’s a totally different practice."

[email protected]

Twenty-five years after the first hospitalist programs began, the hospitalist model of dedicated, site-specific care is starting to make its way into post-acute care settings.

They may be called SNFists or post-acute care hospitalists, but whatever the name, physicians are staking out more of a physical presence in skilled nursing facilities (SNFs), inpatient rehabilitation facilities, long-term acute care hospitals, and other post-acute care settings.

In some cases, hospitalists are migrating into post-acute facilities part-time. Under this hybrid model, traditional hospitalists are continuing their work in the hospital, but may also care for patients in a nearby skilled nursing facility.

The other model that has been developing over the past 3-4 years looks more like the traditional hospitalist model of care, but may not always involve hospitalists. Under this dedicated model, physicians work exclusively in the post-acute care setting, providing coverage to these facilities anywhere from 3 to 7 days a week. Some of the physicians working under this model are former hospitalists, but others are geriatricians, intensivists, internists, and family physicians.

Nearly 27% of hospitalist medical groups provide services in either inpatient rehabilitation facilities, psychiatric facilities, or long-term acute care hospitals. And nearly 10% provide services in SNFs or extended-care facilities, according to the 2012 State of Hospital Medicine survey released by the Society of Hospital Medicine (SHM).

One reason for the shift in care is that the old model isn’t working, said Dr. Jerome Wilborn, the national medical director for post-acute care services at IPC The Hospitalist Company.

"Unfortunately, you look around the country, and doctors just don’t go to the nursing facility setting often enough to make an impact," Dr. Wilborn said. "How do we know that? A quarter of the patients who come here, bounce back to the hospital."

Beefing up the physician presence at SNFs and other post-acute care facilities has the potential to bring down those hospital readmission numbers, Dr. Wilborn said. In the post-acute care hospitalist programs that he oversees, the number of patient visits is driven by clinical acuity.

For example, in the first week, when patients are most vulnerable to bouncing back to the hospital, they may be seen by a physician three or four times. Some of that time is spent counseling family members, working on reducing medications, and coordinating care with the discharging physician, Dr. Wilborn said.

"It’s not so much the number of touches as it is the presence of the clinical team that’s there," Dr. Wilborn said. "You don’t know who you’re going to see, or who you should see, if you only go once a week."

IPC The Hospitalist Company recently made a big entrance into the post-acute care market. Over the past 4 years, they have begun practicing in about 650 post-acute care facilities. The facilities are mostly SNFs, but also include long-term acute care hospitals, inpatient rehabilitation facilities, assisted living facilities, and others, according to Todd Kislak, the vice president of marketing for IPC. This is in addition to the traditional hospital practices that the company has in about 350 acute care hospitals and long-term acute care hospitals around the country.

The IPC executives saw the holes in care in the post-acute care setting and saw an opportunity to use their experience with hospitalist programs, electronic health record technology, and advanced communications systems to surge ahead in the market, Mr. Kislak said. "IPC is playing an influential role in the organization and consolidation of these doctors in the post-acute space," he said.

IPC and other acute care hospitalist groups follow a fee-for-service business model. But there are other, more complex financial drivers that appear to be moving this model forward.

One driver is the Medicare 30-day readmission penalty, which went into effect on Oct. 1, 2012. Under the new policy, the Centers for Medicare and Medicaid Services is cutting Medicare payments to hospitals with excess readmissions in heart failure, pneumonia, and acute myocardial infarction.

Courtesy Diane Williams

The readmission policy incentivizes short-term acute care hospitals to use post-acute care services efficiently, safely, and effectively, said Dr. Sean R. Muldoon, the senior vice president and chief medical officer at Kindred Healthcare’s Hospital Division, which is a national network of long-term acute care hospitals headquartered in Louisville, Ky.

"Managing the transition and assuring that the patients go into settings that are likely to continue the patients’ improvement are in [the hospitals’] best patient, payment, and policy interests," said Dr. Muldoon, who cochairs the SHM Post-Acute Care Task Force.

And the movement by Medicare toward bundling payments for an entire episode of care means that hospitals will have another financial incentive to move patients into a less costly setting, while also ensuring that the quality of care is maintained.

For SNFs and other post-acute care facilities, there’s a growing recognition that they need help in managing the increasingly complex patients coming through their doors, he said.

"The post-acute care settings, particularly SNFs, have really asked physicians to be more involved, more present, and more coordinating in their care plans," Dr. Muldoon said. "Hospitalists have responded to that because those are core competencies that they have developed very well in short-term hospitals and are largely transferrable to the post-acute care setting."

As physicians take on a larger role in the post-acute care setting, the debate is growing over what model is best.

Each of the current models has some advantages, said Dr. Heather Zinzella-Cox, the practice group leader for the Delaware region for IPC and the cochair of the SHM Post-Acute Care Task Force.

The hybrid model offers continuity of care because the same physicians who are following patients in the hospital are also involved in their post-acute care. At her IPC practice in Delaware, the nursing facility contracts with some traditional hospitalists to serve as Medical Director Consultants. Since these physicians have a foot in each setting, they are able to use their post-acute knowledge to inform their work as hospitalists. For instance, many SNF pharmacies may not have access to certain medications or may need 24 hours to provide them. So the hospitalist needs to be aware of those challenges and take the necessary steps to provide a safe and effective handoff to the facility, she said.

But the hybrid model also comes with the typical disadvantages of trying to do too many different things at once.

"When a provider is stretched and has too many hats, something gives," Dr. Zinzella-Cox said. "And it’s typically the post-acute care space."

The hybrid model is most successful, she said, if the post-acute care facility is attached to the hospital or if the two facilities share an electronic health record system.

On the other hand, the dedicated model in the post-acute care setting keeps physicians from being pulled back and forth between different settings. "It allows me to stay engaged in my facility," she said.

Whatever model emerges, Dr. Zinzella-Cox predicted that the combination of Medicare readmission penalties and other new payment initiatives will force traditional hospitalists to pay closer attention to the post-acute care setting.

"Hospitalists will drive the care of their patients and, in combination with the social worker, determine where their patients are going to go after discharge," she said.

Hospitalists’ habits: Standardizing post-acute care

Hospitalists who have moved to the post-acute world are bringing some of the hospital culture with them.

Dr. Donald Quinn, who started three hospitalist groups in east Tennessee and is now the practice group leader for the Tennessee region of IPC The Hospitalist Company, said hospitalists bring a standardized approach to quality of care. One of the tools Dr. Quinn and his colleagues are using in skilled nursing facilities is pathways and protocols that help standardize the care provided for common clinical situations.

The use of clinical pathways has been especially helpful at night, when physicians aren’t on site but are available by phone. Being able to instruct the nursing staff to begin a preestablished clinical protocol can help keep patients out of the emergency department, safely, Dr. Quinn said.

Post-acute care hospitalists aren’t just standardizing the care. They are also standardizing their hours. Dr. Quinn said he and his IPC colleagues have set up regular visit schedules with the post-acute facilities they work with so patients and staff there know when a physician will be in the building. Typically, their post-acute care hospitalists visit two facilities per day, where they see patients and coordinate care with nurse practitioners and physician assistants. The group also cross-credentials its physicians so that when someone is sick or goes on vacation, a doctor is still available at the facility at the scheduled time.

"Once you get these folks used to this quality and this intensity of care, it does make a difference if no one shows up that day," Dr. Quinn said. "It’s a totally different practice."

[email protected]

The American College of Physicians is calling on all health care providers to be immunized against influenza and several other communicable diseases.

With severe flu activity widespread in most of the country, officials at the American College of Physicians (ACP) approved a policy recommendation that all health care providers be immunized against not only influenza; but also against diphtheria; hepatitis B; measles, mumps, and rubella; pertussis; and varicella. The policy follows the Advisory Committee on Immunization Practices Adult Immunization Schedule.

The ACP policy allows for exemptions for those with medical contraindications or religious objections.

"These transmissible infectious diseases represent a threat to health care providers and the patients we serve, who are often highly vulnerable to infection," Dr. David L. Bronson, ACP president, said in a statement. "Proper immunization safely and effectively prevents a significant number of infections, hospitalizations, and deaths among patients as well as preventing workplace disruption and medical errors by absent workers due to illness."

The ACP is currently working on a 3-year, evidence-based program to increase adult immunization rates in five states (Arizona, Delaware, Northern Illinois, Maryland, and New York). The program is funded by the Centers for Disease Control and Prevention.

[email protected]

The American College of Physicians is calling on all health care providers to be immunized against influenza and several other communicable diseases.

With severe flu activity widespread in most of the country, officials at the American College of Physicians (ACP) approved a policy recommendation that all health care providers be immunized against not only influenza; but also against diphtheria; hepatitis B; measles, mumps, and rubella; pertussis; and varicella. The policy follows the Advisory Committee on Immunization Practices Adult Immunization Schedule.

The ACP policy allows for exemptions for those with medical contraindications or religious objections.

"These transmissible infectious diseases represent a threat to health care providers and the patients we serve, who are often highly vulnerable to infection," Dr. David L. Bronson, ACP president, said in a statement. "Proper immunization safely and effectively prevents a significant number of infections, hospitalizations, and deaths among patients as well as preventing workplace disruption and medical errors by absent workers due to illness."

The ACP is currently working on a 3-year, evidence-based program to increase adult immunization rates in five states (Arizona, Delaware, Northern Illinois, Maryland, and New York). The program is funded by the Centers for Disease Control and Prevention.

[email protected]

The American College of Physicians is calling on all health care providers to be immunized against influenza and several other communicable diseases.

With severe flu activity widespread in most of the country, officials at the American College of Physicians (ACP) approved a policy recommendation that all health care providers be immunized against not only influenza; but also against diphtheria; hepatitis B; measles, mumps, and rubella; pertussis; and varicella. The policy follows the Advisory Committee on Immunization Practices Adult Immunization Schedule.

The ACP policy allows for exemptions for those with medical contraindications or religious objections.

"These transmissible infectious diseases represent a threat to health care providers and the patients we serve, who are often highly vulnerable to infection," Dr. David L. Bronson, ACP president, said in a statement. "Proper immunization safely and effectively prevents a significant number of infections, hospitalizations, and deaths among patients as well as preventing workplace disruption and medical errors by absent workers due to illness."

The ACP is currently working on a 3-year, evidence-based program to increase adult immunization rates in five states (Arizona, Delaware, Northern Illinois, Maryland, and New York). The program is funded by the Centers for Disease Control and Prevention.

[email protected]

The Joint Commission is putting hospital leaders on notice that boarding in the emergency department requires a hospital-wide solution.

In performance standards that went into effect on Jan. 1, the Joint Commission is requiring hospitals to set specific goals to improve patient flow, which include ensuring the availability of patient beds and maintaining proper throughput in laboratories, operating rooms, inpatient units, telemetry, radiology, and the postanesthesia care unit. The Joint Commission is also calling on hospitals to ensure the efficiency of nonclinical services such as housekeeping and transportation and to maintain access to case management and social work.

The standards specifically name the medical staff, the chief executive officer, and other senior hospital managers as having a responsibility to take action when patient flow goals are not met.

"We wanted to make sure that organizations were looking at patient flow hospital-wide, even if the manifestation of a flow problem seemed to be in the emergency room," said Lynne Bergero, project director in the division of health care quality evaluation at the Joint Commission.

"The emergency department isn’t an island," she added, "so looking at how everything interrelates is going to produce better flow for patients overall and better outcomes for the patient in terms of not having as much boarding."

The Joint Commission has had standards for patient flow in place for several years, but they weren’t specific about the need for hospital leaders to set goals for improvement. Without specific direction, most hospitals weren’t following through. "We just wanted to be much more explicit and say, ‘You need to set goals,’ " Ms. Bergero said.

The updated patient flow standards also include some brand new elements, though the new requirements won’t go into effect until Jan. 1, 2014. Under the new rules, hospitals must measure and set goals for curbing the boarding of patients in the ED. The new requirement defines boarding as the "practice of holding patients in the emergency department or another temporary location after the decision to admit or transfer has been made." Boarding goals should be based on patient acuity and best practice, the Joint Commission wrote, but it recommended that boarding times should not exceed 4 hours.

Hospitals won’t be scored on the 4-hour guideline during their surveys, Ms. Bergero said. The expectation is that hospitals will set their own time limits for boarding and they will be scored based on their own goals. Joint Commission surveyors, however, will question hospital leaders about what conditions require boarding times beyond 4 hours, she said.

While setting a time limit for ED boarding has been controversial, Dr. Frederick Blum said that he sees it as a move in the right direction. Dr. Blum, associate professor of emergency medicine at West Virginia University, Morgantown, was president of the American College of Emergency Physicians in 2005. At the time, he was working with regulators, including the Centers for Medicare and Medicaid Services, to establish a 4-hour boarding limit similar to that in place in the United Kingdom.

"The big frustration that emergency physicians all over the country have is that the ED is viewed as infinitely able to take care of patients, where everybody else has a hard limit," Dr. Blum said. "All of us realize there are limits to what we can do. So things like crowding and boarding need to be hospital-wide problems, not just ED problems."

The 4-hour guideline will be especially important for hospitals with prolonged boarding times, said Dr. Robert I. Broida, an emergency physician in Canton, Ohio, and an ACEP representative to the Joint Commission’s hospital professional and technical advisory committee.

As for those hospitals that are already top performers, Dr. Broida said that it’s unlikely to impact their performance. "If they’re already performing at that level, they’ll likely stay there."

The Joint Commission also set new rules for boarding related to behavioral health emergencies. A new requirement, which also takes effect on Jan. 1, 2014, calls on hospital leaders to work with behavioral health providers in the community on better care coordination for these patients.

Ms. Bergero said that the requirement recognizes the larger problem of limited community resources for mental health. "The pie isn’t going to get any bigger for a long time in a lot of communities and we recognize that," she said. "The idea is, how do you work more strategically with the resources and with the partners that are there to provide for a better continuum of care for these patients?"

Addressing this issue is critical, Dr. Blum said, because patients with mental health emergencies can get stuck in the ED for days, not hours, as ED staff scramble to find dwindling placements. The new requirement brings hospital leadership into the process as partners with the ED. "While hospitals can’t solve this issue by themselves, it will at least pull them into the boat with us and give us a larger voice in trying to develop the community resources that we need to care for these folks," he said.

Additionally, the Joint Commission released a new requirement that hospitals provide patients who are awaiting care for emotional illness or substance abuse with a safe, monitored location. Hospitals are also required to provide training to clinical and nonclinical staff on caring for these patients, including medication protocols and de-escalation techniques. These requirements took effect on Jan. 1, 2013.

[email protected]

The Joint Commission is putting hospital leaders on notice that boarding in the emergency department requires a hospital-wide solution.

In performance standards that went into effect on Jan. 1, the Joint Commission is requiring hospitals to set specific goals to improve patient flow, which include ensuring the availability of patient beds and maintaining proper throughput in laboratories, operating rooms, inpatient units, telemetry, radiology, and the postanesthesia care unit. The Joint Commission is also calling on hospitals to ensure the efficiency of nonclinical services such as housekeeping and transportation and to maintain access to case management and social work.

The standards specifically name the medical staff, the chief executive officer, and other senior hospital managers as having a responsibility to take action when patient flow goals are not met.

"We wanted to make sure that organizations were looking at patient flow hospital-wide, even if the manifestation of a flow problem seemed to be in the emergency room," said Lynne Bergero, project director in the division of health care quality evaluation at the Joint Commission.

"The emergency department isn’t an island," she added, "so looking at how everything interrelates is going to produce better flow for patients overall and better outcomes for the patient in terms of not having as much boarding."

The Joint Commission has had standards for patient flow in place for several years, but they weren’t specific about the need for hospital leaders to set goals for improvement. Without specific direction, most hospitals weren’t following through. "We just wanted to be much more explicit and say, ‘You need to set goals,’ " Ms. Bergero said.

The updated patient flow standards also include some brand new elements, though the new requirements won’t go into effect until Jan. 1, 2014. Under the new rules, hospitals must measure and set goals for curbing the boarding of patients in the ED. The new requirement defines boarding as the "practice of holding patients in the emergency department or another temporary location after the decision to admit or transfer has been made." Boarding goals should be based on patient acuity and best practice, the Joint Commission wrote, but it recommended that boarding times should not exceed 4 hours.

Hospitals won’t be scored on the 4-hour guideline during their surveys, Ms. Bergero said. The expectation is that hospitals will set their own time limits for boarding and they will be scored based on their own goals. Joint Commission surveyors, however, will question hospital leaders about what conditions require boarding times beyond 4 hours, she said.

While setting a time limit for ED boarding has been controversial, Dr. Frederick Blum said that he sees it as a move in the right direction. Dr. Blum, associate professor of emergency medicine at West Virginia University, Morgantown, was president of the American College of Emergency Physicians in 2005. At the time, he was working with regulators, including the Centers for Medicare and Medicaid Services, to establish a 4-hour boarding limit similar to that in place in the United Kingdom.

"The big frustration that emergency physicians all over the country have is that the ED is viewed as infinitely able to take care of patients, where everybody else has a hard limit," Dr. Blum said. "All of us realize there are limits to what we can do. So things like crowding and boarding need to be hospital-wide problems, not just ED problems."

The 4-hour guideline will be especially important for hospitals with prolonged boarding times, said Dr. Robert I. Broida, an emergency physician in Canton, Ohio, and an ACEP representative to the Joint Commission’s hospital professional and technical advisory committee.

As for those hospitals that are already top performers, Dr. Broida said that it’s unlikely to impact their performance. "If they’re already performing at that level, they’ll likely stay there."

The Joint Commission also set new rules for boarding related to behavioral health emergencies. A new requirement, which also takes effect on Jan. 1, 2014, calls on hospital leaders to work with behavioral health providers in the community on better care coordination for these patients.

Ms. Bergero said that the requirement recognizes the larger problem of limited community resources for mental health. "The pie isn’t going to get any bigger for a long time in a lot of communities and we recognize that," she said. "The idea is, how do you work more strategically with the resources and with the partners that are there to provide for a better continuum of care for these patients?"

Addressing this issue is critical, Dr. Blum said, because patients with mental health emergencies can get stuck in the ED for days, not hours, as ED staff scramble to find dwindling placements. The new requirement brings hospital leadership into the process as partners with the ED. "While hospitals can’t solve this issue by themselves, it will at least pull them into the boat with us and give us a larger voice in trying to develop the community resources that we need to care for these folks," he said.

Additionally, the Joint Commission released a new requirement that hospitals provide patients who are awaiting care for emotional illness or substance abuse with a safe, monitored location. Hospitals are also required to provide training to clinical and nonclinical staff on caring for these patients, including medication protocols and de-escalation techniques. These requirements took effect on Jan. 1, 2013.

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The Joint Commission is putting hospital leaders on notice that boarding in the emergency department requires a hospital-wide solution.

In performance standards that went into effect on Jan. 1, the Joint Commission is requiring hospitals to set specific goals to improve patient flow, which include ensuring the availability of patient beds and maintaining proper throughput in laboratories, operating rooms, inpatient units, telemetry, radiology, and the postanesthesia care unit. The Joint Commission is also calling on hospitals to ensure the efficiency of nonclinical services such as housekeeping and transportation and to maintain access to case management and social work.

The standards specifically name the medical staff, the chief executive officer, and other senior hospital managers as having a responsibility to take action when patient flow goals are not met.

"We wanted to make sure that organizations were looking at patient flow hospital-wide, even if the manifestation of a flow problem seemed to be in the emergency room," said Lynne Bergero, project director in the division of health care quality evaluation at the Joint Commission.

"The emergency department isn’t an island," she added, "so looking at how everything interrelates is going to produce better flow for patients overall and better outcomes for the patient in terms of not having as much boarding."

The Joint Commission has had standards for patient flow in place for several years, but they weren’t specific about the need for hospital leaders to set goals for improvement. Without specific direction, most hospitals weren’t following through. "We just wanted to be much more explicit and say, ‘You need to set goals,’ " Ms. Bergero said.

The updated patient flow standards also include some brand new elements, though the new requirements won’t go into effect until Jan. 1, 2014. Under the new rules, hospitals must measure and set goals for curbing the boarding of patients in the ED. The new requirement defines boarding as the "practice of holding patients in the emergency department or another temporary location after the decision to admit or transfer has been made." Boarding goals should be based on patient acuity and best practice, the Joint Commission wrote, but it recommended that boarding times should not exceed 4 hours.

Hospitals won’t be scored on the 4-hour guideline during their surveys, Ms. Bergero said. The expectation is that hospitals will set their own time limits for boarding and they will be scored based on their own goals. Joint Commission surveyors, however, will question hospital leaders about what conditions require boarding times beyond 4 hours, she said.

While setting a time limit for ED boarding has been controversial, Dr. Frederick Blum said that he sees it as a move in the right direction. Dr. Blum, associate professor of emergency medicine at West Virginia University, Morgantown, was president of the American College of Emergency Physicians in 2005. At the time, he was working with regulators, including the Centers for Medicare and Medicaid Services, to establish a 4-hour boarding limit similar to that in place in the United Kingdom.

"The big frustration that emergency physicians all over the country have is that the ED is viewed as infinitely able to take care of patients, where everybody else has a hard limit," Dr. Blum said. "All of us realize there are limits to what we can do. So things like crowding and boarding need to be hospital-wide problems, not just ED problems."

The 4-hour guideline will be especially important for hospitals with prolonged boarding times, said Dr. Robert I. Broida, an emergency physician in Canton, Ohio, and an ACEP representative to the Joint Commission’s hospital professional and technical advisory committee.

As for those hospitals that are already top performers, Dr. Broida said that it’s unlikely to impact their performance. "If they’re already performing at that level, they’ll likely stay there."

The Joint Commission also set new rules for boarding related to behavioral health emergencies. A new requirement, which also takes effect on Jan. 1, 2014, calls on hospital leaders to work with behavioral health providers in the community on better care coordination for these patients.

Ms. Bergero said that the requirement recognizes the larger problem of limited community resources for mental health. "The pie isn’t going to get any bigger for a long time in a lot of communities and we recognize that," she said. "The idea is, how do you work more strategically with the resources and with the partners that are there to provide for a better continuum of care for these patients?"

Addressing this issue is critical, Dr. Blum said, because patients with mental health emergencies can get stuck in the ED for days, not hours, as ED staff scramble to find dwindling placements. The new requirement brings hospital leadership into the process as partners with the ED. "While hospitals can’t solve this issue by themselves, it will at least pull them into the boat with us and give us a larger voice in trying to develop the community resources that we need to care for these folks," he said.

Additionally, the Joint Commission released a new requirement that hospitals provide patients who are awaiting care for emotional illness or substance abuse with a safe, monitored location. Hospitals are also required to provide training to clinical and nonclinical staff on caring for these patients, including medication protocols and de-escalation techniques. These requirements took effect on Jan. 1, 2013.

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There’s been little relief from the flu in the past week, with influenza activity remaining elevated in most parts of the United States.

Forty-seven states reported widespread influenza activity during the week of Dec. 30-Jan. 5, according to the latest data from the Centers for Disease Control and Prevention. The only parts of the country that aren’t reporting elevated levels of activity currently are in the West, though the flu may be headed in that direction soon, health officials said.

Dr. Thomas Frieden, director of the CDC, predicted that the high levels of influenza activity would likely continue for several more weeks, based on historic trends, but nothing is certain.

"But as we often say, the only thing predictable about flu is that it’s unpredictable," he said in a press conference on Jan. 11. "Only time will tell us how long our season will last and how moderate or how severe this season will be in the end."

Outpatient visits for influenza-like illness made up about 4.3% of patient visits during the first week of 2013, which is above the national baseline of 2.2%. Influenza also was associated with two more deaths among children, bringing the total number of pediatric deaths to 20 for this influenza season. One death, associated with influenza A (H3) virus, occurred during the week ending on Dec. 29, 2012, but was not reported until the next week. The second death, which occurred during the week ending Jan. 5, was associated with influenza A, but the subtype was not determined.

Since the start of the 2012-13 flu season, influenza A viruses have been the most common, followed by influenza B viruses. The H1N1 virus has been rare this year, according to the CDC data.

Because of the early onset of this year’s influenza season, the CDC also got an earlier-than-usual look at the effectiveness of the vaccine. Preliminary data show that this year’s vaccine is 62% effective overall. That means that if a person is vaccinated, they are about 62% less likely to have to see a physician to treat their illness, Dr. Frieden said. The vaccine effectiveness figure is based on early data from 1,155 children and adults with acute respiratory infection from Dec. 3, 2012 to Jan. 2, 2013 (MMWR 2013;62[early release]:1-4).

Despite the "moderate" effectiveness of the vaccine, Dr. Frieden still urged Americans to get vaccinated, if they haven’t already. "The flu vaccine is far from perfect, but it’s still by far the best tool we have to prevent the flu," he said.

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There’s been little relief from the flu in the past week, with influenza activity remaining elevated in most parts of the United States.

Forty-seven states reported widespread influenza activity during the week of Dec. 30-Jan. 5, according to the latest data from the Centers for Disease Control and Prevention. The only parts of the country that aren’t reporting elevated levels of activity currently are in the West, though the flu may be headed in that direction soon, health officials said.

Dr. Thomas Frieden, director of the CDC, predicted that the high levels of influenza activity would likely continue for several more weeks, based on historic trends, but nothing is certain.

"But as we often say, the only thing predictable about flu is that it’s unpredictable," he said in a press conference on Jan. 11. "Only time will tell us how long our season will last and how moderate or how severe this season will be in the end."

Outpatient visits for influenza-like illness made up about 4.3% of patient visits during the first week of 2013, which is above the national baseline of 2.2%. Influenza also was associated with two more deaths among children, bringing the total number of pediatric deaths to 20 for this influenza season. One death, associated with influenza A (H3) virus, occurred during the week ending on Dec. 29, 2012, but was not reported until the next week. The second death, which occurred during the week ending Jan. 5, was associated with influenza A, but the subtype was not determined.

Since the start of the 2012-13 flu season, influenza A viruses have been the most common, followed by influenza B viruses. The H1N1 virus has been rare this year, according to the CDC data.

Because of the early onset of this year’s influenza season, the CDC also got an earlier-than-usual look at the effectiveness of the vaccine. Preliminary data show that this year’s vaccine is 62% effective overall. That means that if a person is vaccinated, they are about 62% less likely to have to see a physician to treat their illness, Dr. Frieden said. The vaccine effectiveness figure is based on early data from 1,155 children and adults with acute respiratory infection from Dec. 3, 2012 to Jan. 2, 2013 (MMWR 2013;62[early release]:1-4).

Despite the "moderate" effectiveness of the vaccine, Dr. Frieden still urged Americans to get vaccinated, if they haven’t already. "The flu vaccine is far from perfect, but it’s still by far the best tool we have to prevent the flu," he said.

[email protected]

There’s been little relief from the flu in the past week, with influenza activity remaining elevated in most parts of the United States.

Forty-seven states reported widespread influenza activity during the week of Dec. 30-Jan. 5, according to the latest data from the Centers for Disease Control and Prevention. The only parts of the country that aren’t reporting elevated levels of activity currently are in the West, though the flu may be headed in that direction soon, health officials said.

Dr. Thomas Frieden, director of the CDC, predicted that the high levels of influenza activity would likely continue for several more weeks, based on historic trends, but nothing is certain.

"But as we often say, the only thing predictable about flu is that it’s unpredictable," he said in a press conference on Jan. 11. "Only time will tell us how long our season will last and how moderate or how severe this season will be in the end."

Outpatient visits for influenza-like illness made up about 4.3% of patient visits during the first week of 2013, which is above the national baseline of 2.2%. Influenza also was associated with two more deaths among children, bringing the total number of pediatric deaths to 20 for this influenza season. One death, associated with influenza A (H3) virus, occurred during the week ending on Dec. 29, 2012, but was not reported until the next week. The second death, which occurred during the week ending Jan. 5, was associated with influenza A, but the subtype was not determined.

Since the start of the 2012-13 flu season, influenza A viruses have been the most common, followed by influenza B viruses. The H1N1 virus has been rare this year, according to the CDC data.

Because of the early onset of this year’s influenza season, the CDC also got an earlier-than-usual look at the effectiveness of the vaccine. Preliminary data show that this year’s vaccine is 62% effective overall. That means that if a person is vaccinated, they are about 62% less likely to have to see a physician to treat their illness, Dr. Frieden said. The vaccine effectiveness figure is based on early data from 1,155 children and adults with acute respiratory infection from Dec. 3, 2012 to Jan. 2, 2013 (MMWR 2013;62[early release]:1-4).

Despite the "moderate" effectiveness of the vaccine, Dr. Frieden still urged Americans to get vaccinated, if they haven’t already. "The flu vaccine is far from perfect, but it’s still by far the best tool we have to prevent the flu," he said.

[email protected]

Americans are dying younger and living sicker than the residents of 16 other wealthy countries, according to a report from the Institute of Medicine and the National Research Council.

While the life expectancy for Americans has been rising, with men living on average to age 75 years and women to age 80 years, the United States trails most other wealthy countries (Australia, Austria, Canada, Denmark, Finland, France, Germany, Italy, Japan, Norway, Portugal, Spain, Sweden, Switzerland, the Netherlands, and the United Kingdom).

The United States ranked last among the 17 countries studied in life expectancy for men, with American men living about 4 years less than men in top-ranked Switzerland. Among women, the U.S. ranked 16 of 17 and life expectancy is about 5 years shorter than in top-ranked Japan.

"Quite frankly, our panel was struck by the gravity of our findings," Dr. Steven H. Woolf, chair of the panel and a professor of family medicine at Virginia Commonwealth University in Richmond, said during a Jan. 9 press briefing. "Life expectancy is shorter in Americans of all ages, young and old, up to age 75. Males and females are experiencing higher rates of disease and injury and are dying sooner than [are] similar people in other high-income countries."

Despite spending more per capita on health care than any other country, the United States also ranks at or near the bottom in infant mortality and low birth weight, injuries and homicides, teen pregnancy and sexually transmitted diseases, HIV and AIDS, drug-related deaths, obesity and diabetes, heart disease, chronic lung disease, and disability.

Health problems are more common among Americans who are poor or uninsured. But the panel also found that even healthy Americans who are insured, college educated, or have high incomes seemed to be in worse health than are similar groups in other countries.

The investigation did uncover a bit of good news: Americans have lower rates of cancer mortality, compared with the 16 other high-income countries, and better control of their blood pressure and cholesterol levels.

The panel, which examined several decades worth of historical health trends, found that the likely causes of the U.S. health deficiencies are widespread and span health systems, behaviors, social and economic conditions, and physical environments.

Specifically, likely factors include being uninsured, lack of primary care access, smoking, heavy drinking, drug abuse, and not using seat belts. But other factors, such as how communities are built around the use of cars, without places for walking and biking, may contribute to a lack of physical activity, they wrote.

"No single factor, but a combination, is likely to blame for the U.S. health disadvantage," Dr. Woolf said.

The panel recommended further research into what the other 16 countries are doing to improve their health status so that those strategies could be adapted to this country. But the panel members also warned policy makers not to wait for further research to start taking action.

"We already know what to do," Dr. Woolf said. "If we fail to act, the disadvantage will continue to worsen and our children will face shorter lives and greater rates of illness than their peers in other rich nations."

[email protected]

Americans are dying younger and living sicker than the residents of 16 other wealthy countries, according to a report from the Institute of Medicine and the National Research Council.

While the life expectancy for Americans has been rising, with men living on average to age 75 years and women to age 80 years, the United States trails most other wealthy countries (Australia, Austria, Canada, Denmark, Finland, France, Germany, Italy, Japan, Norway, Portugal, Spain, Sweden, Switzerland, the Netherlands, and the United Kingdom).

The United States ranked last among the 17 countries studied in life expectancy for men, with American men living about 4 years less than men in top-ranked Switzerland. Among women, the U.S. ranked 16 of 17 and life expectancy is about 5 years shorter than in top-ranked Japan.

"Quite frankly, our panel was struck by the gravity of our findings," Dr. Steven H. Woolf, chair of the panel and a professor of family medicine at Virginia Commonwealth University in Richmond, said during a Jan. 9 press briefing. "Life expectancy is shorter in Americans of all ages, young and old, up to age 75. Males and females are experiencing higher rates of disease and injury and are dying sooner than [are] similar people in other high-income countries."

Despite spending more per capita on health care than any other country, the United States also ranks at or near the bottom in infant mortality and low birth weight, injuries and homicides, teen pregnancy and sexually transmitted diseases, HIV and AIDS, drug-related deaths, obesity and diabetes, heart disease, chronic lung disease, and disability.

Health problems are more common among Americans who are poor or uninsured. But the panel also found that even healthy Americans who are insured, college educated, or have high incomes seemed to be in worse health than are similar groups in other countries.

The investigation did uncover a bit of good news: Americans have lower rates of cancer mortality, compared with the 16 other high-income countries, and better control of their blood pressure and cholesterol levels.

The panel, which examined several decades worth of historical health trends, found that the likely causes of the U.S. health deficiencies are widespread and span health systems, behaviors, social and economic conditions, and physical environments.

Specifically, likely factors include being uninsured, lack of primary care access, smoking, heavy drinking, drug abuse, and not using seat belts. But other factors, such as how communities are built around the use of cars, without places for walking and biking, may contribute to a lack of physical activity, they wrote.

"No single factor, but a combination, is likely to blame for the U.S. health disadvantage," Dr. Woolf said.

The panel recommended further research into what the other 16 countries are doing to improve their health status so that those strategies could be adapted to this country. But the panel members also warned policy makers not to wait for further research to start taking action.

"We already know what to do," Dr. Woolf said. "If we fail to act, the disadvantage will continue to worsen and our children will face shorter lives and greater rates of illness than their peers in other rich nations."

[email protected]

Americans are dying younger and living sicker than the residents of 16 other wealthy countries, according to a report from the Institute of Medicine and the National Research Council.

While the life expectancy for Americans has been rising, with men living on average to age 75 years and women to age 80 years, the United States trails most other wealthy countries (Australia, Austria, Canada, Denmark, Finland, France, Germany, Italy, Japan, Norway, Portugal, Spain, Sweden, Switzerland, the Netherlands, and the United Kingdom).

The United States ranked last among the 17 countries studied in life expectancy for men, with American men living about 4 years less than men in top-ranked Switzerland. Among women, the U.S. ranked 16 of 17 and life expectancy is about 5 years shorter than in top-ranked Japan.

"Quite frankly, our panel was struck by the gravity of our findings," Dr. Steven H. Woolf, chair of the panel and a professor of family medicine at Virginia Commonwealth University in Richmond, said during a Jan. 9 press briefing. "Life expectancy is shorter in Americans of all ages, young and old, up to age 75. Males and females are experiencing higher rates of disease and injury and are dying sooner than [are] similar people in other high-income countries."

Despite spending more per capita on health care than any other country, the United States also ranks at or near the bottom in infant mortality and low birth weight, injuries and homicides, teen pregnancy and sexually transmitted diseases, HIV and AIDS, drug-related deaths, obesity and diabetes, heart disease, chronic lung disease, and disability.

Health problems are more common among Americans who are poor or uninsured. But the panel also found that even healthy Americans who are insured, college educated, or have high incomes seemed to be in worse health than are similar groups in other countries.

The investigation did uncover a bit of good news: Americans have lower rates of cancer mortality, compared with the 16 other high-income countries, and better control of their blood pressure and cholesterol levels.

The panel, which examined several decades worth of historical health trends, found that the likely causes of the U.S. health deficiencies are widespread and span health systems, behaviors, social and economic conditions, and physical environments.

Specifically, likely factors include being uninsured, lack of primary care access, smoking, heavy drinking, drug abuse, and not using seat belts. But other factors, such as how communities are built around the use of cars, without places for walking and biking, may contribute to a lack of physical activity, they wrote.

"No single factor, but a combination, is likely to blame for the U.S. health disadvantage," Dr. Woolf said.

The panel recommended further research into what the other 16 countries are doing to improve their health status so that those strategies could be adapted to this country. But the panel members also warned policy makers not to wait for further research to start taking action.

"We already know what to do," Dr. Woolf said. "If we fail to act, the disadvantage will continue to worsen and our children will face shorter lives and greater rates of illness than their peers in other rich nations."

[email protected]

The use of frozen donor eggs to assist with in vitro fertilization is on the rise, and it could be headed toward a tipping point in terms of public awareness and acceptance.

Advances in an egg freezing method known as vitrification have shown encouraging results in terms of live births, rivaling the results seen with fresh egg donation cycles. Add to that the significantly lower cost of in vitro fertilization (IVF) using frozen eggs and the increasing acceptance in the medical community, and it’s a recipe for growth in frozen donor egg banking.

"There’s been very rapid and very wide acceptance of this," said Dr. Daniel B. Shapiro, the medical director of My Egg Bank North America, a multicenter network of egg banks with locations throughout the United States including Atlanta, Boston*, Orlando, and Seattle.

The technology to freeze eggs has been around for decades, with the first baby born as a result of a cryopreserved oocyte reported in 1986. But the process was inefficient then and between 100 and 150 eggs might be needed to get a single pregnancy, according to Zsolt Peter Nagy, Ph.D., the scientific director for Reproductive Biology Associates, which is a partner in My Egg Bank.

"That was the level of efficiency for about 20 years," said Dr. Nagy said.

But the landscape started to change when scientists began experimenting with improvements to the egg freezing technique. A breakthrough came around 2006 with the use of a new process called vitrification. Although there are various methods of vitrification, it generally involves using a cryo-protectant and rapid cooling to solidify the cell without forming ice crystals. Many of the vitrification methods call for directly exposing the oocytes to liquid nitrogen.

In a randomized controlled trial of 600 recipients, which compared vitrified to fresh oocytes, researchers found no significant differences in fertilization, implantation, or pregnancy rates. Pregnancy rates per transfer were 55.4% for vitrified eggs, compared to 55.6% for fresh eggs (Hum. Reprod. 2010;25:2239-46).

It’s these types of results that are fueling the interest in frozen donor egg banking, said Heidi Hayes, CEO of Donor Egg Bank USA, a Rockville, Md.–based bank that opened for recipient use in March 2012.

"That is what changed it. Now it can be done successfully," Ms. Hayes said. "It’s going to change the field as a whole because of the new technology."

The field got another boost when the American Society for Reproductive Medicine (ASRM) issued a new guideline saying that the cryopreservation of mature oocytes – using both vitrification and slow-freeze protocols – was no longer experimental.

Removing the experimental designation means that practices wishing to use frozen eggs in IVF cycles won’t have to counsel patients that the procedure is experimental. It also means that an Institutional Review Board (IRB) won’t have to be involved in the informed consent process. That’s a significant change because a lot of practices don’t have access to an IRB, said Dr. Samantha M. Pfeifer, chair of the Practice Committee of the ASRM, which wrote the guidelines.

But ASRM is not endorsing frozen egg banking. Although the guidelines state that much of the best data supporting the use of oocyte cryopreservation was in the setting of donor oocyte cycles, the group said it would need more clinic-specific data on the safety and efficiency in the donor population before it could recommend universal donor banking. The ASRM statement does recommend oocyte cryopreservation for cancer patients who are at high risk for infertility because of chemotherapy.

There are a lot of advantages to moving toward frozen eggs, Dr. Pfeifer said, such as the ability to quarantine eggs to check for communicable diseases. But there are also lingering questions about how to use frozen eggs, she said. For instance, how long can these eggs be frozen and still be viable?

The other concern with moving rapidly toward universal donor banking with frozen eggs is that not every practice has the capability to freeze eggs. "There was some concern that if there was a sudden mandate from the government that everyone [would have] to use frozen eggs; we’re not equipped to do that yet," said Dr. Pfeifer of the department of obstetrics and gynecology at the University of Pennsylvania, Philadelphia. "A lot of things have to happen before that can become a standard procedure in this country."

The first step is removing the experimental label, she said. "Now that it’s not experimental, the reality is that people will be using this technique."

Even without a full-scale endorsement from the ASRM, momentum for frozen donor egg banking has been picking up. The cost is a big part of that, Dr. Shapiro said.

The price tag for a cycle of IVF using fresh donor eggs can run anywhere between $26,000 and $44,000, depending on the local market and whether an agent has been hired to find a donor. The cost rises quickly because everyone has to get paid, Dr. Shapiro said, including the donor, the agent, and the clinic performing the procedure.

In contrast, My Egg Bank North America "sells" its cycles to its affiliate practices for $16,500, which includes all the donor costs, vitrification, and technical assistance with the thawing of the eggs. Other egg banks also advertise the availability of frozen cycles at about half the cost of fresh IVF cycles.

And many of the banks offer some type of guarantee. For instance, at My Egg Bank, recipient patients are guaranteed two high-quality embryos. About 20% of patients don’t get two high-quality embryos so they are offered another cycle at no cost if no pregnancy results, Dr. Shapiro said. My Egg Bank also offers a program called "Frozen Egg Advantage," which offers a money-back guarantee when patients pay for five cycles. Patients either go home with a baby or get full reimbursement of treatment expenses at the end of five cycles.

"People sit down and they do a simple little [math]," he said. "They quickly come to the conclusion that a couple of cycles with us gives a higher cumulative likelihood of pregnancy than one fresh cycle any place else, and it still comes out less."

Convenience is another factor. Traditionally with fresh egg donation, both the egg donor and recipient would have to synchronize their cycles so that once the eggs are retrieved, they could be immediately fertilized and transferred. "When you have the possibility to freeze the donor eggs, then basically you can disconnect the egg donation from receiving those eggs," Dr. Nagy said.

That has the potential to take some of the uncertainty and stress out of the process for patients, said Barbara Collura, president and CEO of RESOLVE: The National Infertility Association. She has heard first-hand from infertile women who have had to start over when their donor dropped out of the process.

"They pick out an egg donor, and then she gets into law school and her whole life changes and she’s no longer available," Ms. Collura said. "Those things happen and they sound very trite, but when you’re 38, 39, 40 and you’ve been at this already for several years, having the ability to use a vitrified donated oocyte and to be able to use that when you’re ready, is amazing."

Frozen egg banking also may offer women greater choice when it comes to choosing an egg donor. That’s another factor that is driving the increasing popularity of this option, said Ms. Hayes of Donor Egg Bank USA.

"Cost aside, the donor is the most important factor to them," she said.

It’s not just about numbers, Ms. Hayes said, it’s also about ethnic and racial diversity. With fresh donation, it can be difficult to match recipients with donors of certain ethnic backgrounds. With frozen donation, it becomes logistically easier for egg banks to spend time building a more diverse database. At Donor Egg Bank USA, they are working with an affiliate program in Hawaii with the hopes of getting more Asian donors into the bank.

"I think culturally there are some women of ethnic background that are less likely to donate eggs," Ms. Hayes said. "These recipients, they want a baby as much as any other couple does. You want your baby to mirror your family."

Despite the growing interest in select circles, general awareness of the frozen egg donation model is fairly low. Ms. Hayes said she thinks social media will help it get into the mainstream as more women talk online about their success with frozen donor eggs.

"The more women have babies, the more they’ll talk about it, and the more people will utilize a frozen egg as an option," she said.

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*Update: This article was updated 1/30/2013.

The use of frozen donor eggs to assist with in vitro fertilization is on the rise, and it could be headed toward a tipping point in terms of public awareness and acceptance.

Advances in an egg freezing method known as vitrification have shown encouraging results in terms of live births, rivaling the results seen with fresh egg donation cycles. Add to that the significantly lower cost of in vitro fertilization (IVF) using frozen eggs and the increasing acceptance in the medical community, and it’s a recipe for growth in frozen donor egg banking.

"There’s been very rapid and very wide acceptance of this," said Dr. Daniel B. Shapiro, the medical director of My Egg Bank North America, a multicenter network of egg banks with locations throughout the United States including Atlanta, Boston*, Orlando, and Seattle.

The technology to freeze eggs has been around for decades, with the first baby born as a result of a cryopreserved oocyte reported in 1986. But the process was inefficient then and between 100 and 150 eggs might be needed to get a single pregnancy, according to Zsolt Peter Nagy, Ph.D., the scientific director for Reproductive Biology Associates, which is a partner in My Egg Bank.

"That was the level of efficiency for about 20 years," said Dr. Nagy said.

But the landscape started to change when scientists began experimenting with improvements to the egg freezing technique. A breakthrough came around 2006 with the use of a new process called vitrification. Although there are various methods of vitrification, it generally involves using a cryo-protectant and rapid cooling to solidify the cell without forming ice crystals. Many of the vitrification methods call for directly exposing the oocytes to liquid nitrogen.

In a randomized controlled trial of 600 recipients, which compared vitrified to fresh oocytes, researchers found no significant differences in fertilization, implantation, or pregnancy rates. Pregnancy rates per transfer were 55.4% for vitrified eggs, compared to 55.6% for fresh eggs (Hum. Reprod. 2010;25:2239-46).

It’s these types of results that are fueling the interest in frozen donor egg banking, said Heidi Hayes, CEO of Donor Egg Bank USA, a Rockville, Md.–based bank that opened for recipient use in March 2012.

"That is what changed it. Now it can be done successfully," Ms. Hayes said. "It’s going to change the field as a whole because of the new technology."

The field got another boost when the American Society for Reproductive Medicine (ASRM) issued a new guideline saying that the cryopreservation of mature oocytes – using both vitrification and slow-freeze protocols – was no longer experimental.

Removing the experimental designation means that practices wishing to use frozen eggs in IVF cycles won’t have to counsel patients that the procedure is experimental. It also means that an Institutional Review Board (IRB) won’t have to be involved in the informed consent process. That’s a significant change because a lot of practices don’t have access to an IRB, said Dr. Samantha M. Pfeifer, chair of the Practice Committee of the ASRM, which wrote the guidelines.

But ASRM is not endorsing frozen egg banking. Although the guidelines state that much of the best data supporting the use of oocyte cryopreservation was in the setting of donor oocyte cycles, the group said it would need more clinic-specific data on the safety and efficiency in the donor population before it could recommend universal donor banking. The ASRM statement does recommend oocyte cryopreservation for cancer patients who are at high risk for infertility because of chemotherapy.

There are a lot of advantages to moving toward frozen eggs, Dr. Pfeifer said, such as the ability to quarantine eggs to check for communicable diseases. But there are also lingering questions about how to use frozen eggs, she said. For instance, how long can these eggs be frozen and still be viable?

The other concern with moving rapidly toward universal donor banking with frozen eggs is that not every practice has the capability to freeze eggs. "There was some concern that if there was a sudden mandate from the government that everyone [would have] to use frozen eggs; we’re not equipped to do that yet," said Dr. Pfeifer of the department of obstetrics and gynecology at the University of Pennsylvania, Philadelphia. "A lot of things have to happen before that can become a standard procedure in this country."

The first step is removing the experimental label, she said. "Now that it’s not experimental, the reality is that people will be using this technique."

Even without a full-scale endorsement from the ASRM, momentum for frozen donor egg banking has been picking up. The cost is a big part of that, Dr. Shapiro said.

The price tag for a cycle of IVF using fresh donor eggs can run anywhere between $26,000 and $44,000, depending on the local market and whether an agent has been hired to find a donor. The cost rises quickly because everyone has to get paid, Dr. Shapiro said, including the donor, the agent, and the clinic performing the procedure.

In contrast, My Egg Bank North America "sells" its cycles to its affiliate practices for $16,500, which includes all the donor costs, vitrification, and technical assistance with the thawing of the eggs. Other egg banks also advertise the availability of frozen cycles at about half the cost of fresh IVF cycles.

And many of the banks offer some type of guarantee. For instance, at My Egg Bank, recipient patients are guaranteed two high-quality embryos. About 20% of patients don’t get two high-quality embryos so they are offered another cycle at no cost if no pregnancy results, Dr. Shapiro said. My Egg Bank also offers a program called "Frozen Egg Advantage," which offers a money-back guarantee when patients pay for five cycles. Patients either go home with a baby or get full reimbursement of treatment expenses at the end of five cycles.

"People sit down and they do a simple little [math]," he said. "They quickly come to the conclusion that a couple of cycles with us gives a higher cumulative likelihood of pregnancy than one fresh cycle any place else, and it still comes out less."

Convenience is another factor. Traditionally with fresh egg donation, both the egg donor and recipient would have to synchronize their cycles so that once the eggs are retrieved, they could be immediately fertilized and transferred. "When you have the possibility to freeze the donor eggs, then basically you can disconnect the egg donation from receiving those eggs," Dr. Nagy said.

That has the potential to take some of the uncertainty and stress out of the process for patients, said Barbara Collura, president and CEO of RESOLVE: The National Infertility Association. She has heard first-hand from infertile women who have had to start over when their donor dropped out of the process.

"They pick out an egg donor, and then she gets into law school and her whole life changes and she’s no longer available," Ms. Collura said. "Those things happen and they sound very trite, but when you’re 38, 39, 40 and you’ve been at this already for several years, having the ability to use a vitrified donated oocyte and to be able to use that when you’re ready, is amazing."

Frozen egg banking also may offer women greater choice when it comes to choosing an egg donor. That’s another factor that is driving the increasing popularity of this option, said Ms. Hayes of Donor Egg Bank USA.

"Cost aside, the donor is the most important factor to them," she said.

It’s not just about numbers, Ms. Hayes said, it’s also about ethnic and racial diversity. With fresh donation, it can be difficult to match recipients with donors of certain ethnic backgrounds. With frozen donation, it becomes logistically easier for egg banks to spend time building a more diverse database. At Donor Egg Bank USA, they are working with an affiliate program in Hawaii with the hopes of getting more Asian donors into the bank.

"I think culturally there are some women of ethnic background that are less likely to donate eggs," Ms. Hayes said. "These recipients, they want a baby as much as any other couple does. You want your baby to mirror your family."

Despite the growing interest in select circles, general awareness of the frozen egg donation model is fairly low. Ms. Hayes said she thinks social media will help it get into the mainstream as more women talk online about their success with frozen donor eggs.

"The more women have babies, the more they’ll talk about it, and the more people will utilize a frozen egg as an option," she said.

[email protected]

*Update: This article was updated 1/30/2013.

The use of frozen donor eggs to assist with in vitro fertilization is on the rise, and it could be headed toward a tipping point in terms of public awareness and acceptance.

Advances in an egg freezing method known as vitrification have shown encouraging results in terms of live births, rivaling the results seen with fresh egg donation cycles. Add to that the significantly lower cost of in vitro fertilization (IVF) using frozen eggs and the increasing acceptance in the medical community, and it’s a recipe for growth in frozen donor egg banking.

"There’s been very rapid and very wide acceptance of this," said Dr. Daniel B. Shapiro, the medical director of My Egg Bank North America, a multicenter network of egg banks with locations throughout the United States including Atlanta, Boston*, Orlando, and Seattle.

The technology to freeze eggs has been around for decades, with the first baby born as a result of a cryopreserved oocyte reported in 1986. But the process was inefficient then and between 100 and 150 eggs might be needed to get a single pregnancy, according to Zsolt Peter Nagy, Ph.D., the scientific director for Reproductive Biology Associates, which is a partner in My Egg Bank.

"That was the level of efficiency for about 20 years," said Dr. Nagy said.

But the landscape started to change when scientists began experimenting with improvements to the egg freezing technique. A breakthrough came around 2006 with the use of a new process called vitrification. Although there are various methods of vitrification, it generally involves using a cryo-protectant and rapid cooling to solidify the cell without forming ice crystals. Many of the vitrification methods call for directly exposing the oocytes to liquid nitrogen.

In a randomized controlled trial of 600 recipients, which compared vitrified to fresh oocytes, researchers found no significant differences in fertilization, implantation, or pregnancy rates. Pregnancy rates per transfer were 55.4% for vitrified eggs, compared to 55.6% for fresh eggs (Hum. Reprod. 2010;25:2239-46).

It’s these types of results that are fueling the interest in frozen donor egg banking, said Heidi Hayes, CEO of Donor Egg Bank USA, a Rockville, Md.–based bank that opened for recipient use in March 2012.

"That is what changed it. Now it can be done successfully," Ms. Hayes said. "It’s going to change the field as a whole because of the new technology."

The field got another boost when the American Society for Reproductive Medicine (ASRM) issued a new guideline saying that the cryopreservation of mature oocytes – using both vitrification and slow-freeze protocols – was no longer experimental.

Removing the experimental designation means that practices wishing to use frozen eggs in IVF cycles won’t have to counsel patients that the procedure is experimental. It also means that an Institutional Review Board (IRB) won’t have to be involved in the informed consent process. That’s a significant change because a lot of practices don’t have access to an IRB, said Dr. Samantha M. Pfeifer, chair of the Practice Committee of the ASRM, which wrote the guidelines.

But ASRM is not endorsing frozen egg banking. Although the guidelines state that much of the best data supporting the use of oocyte cryopreservation was in the setting of donor oocyte cycles, the group said it would need more clinic-specific data on the safety and efficiency in the donor population before it could recommend universal donor banking. The ASRM statement does recommend oocyte cryopreservation for cancer patients who are at high risk for infertility because of chemotherapy.

There are a lot of advantages to moving toward frozen eggs, Dr. Pfeifer said, such as the ability to quarantine eggs to check for communicable diseases. But there are also lingering questions about how to use frozen eggs, she said. For instance, how long can these eggs be frozen and still be viable?

The other concern with moving rapidly toward universal donor banking with frozen eggs is that not every practice has the capability to freeze eggs. "There was some concern that if there was a sudden mandate from the government that everyone [would have] to use frozen eggs; we’re not equipped to do that yet," said Dr. Pfeifer of the department of obstetrics and gynecology at the University of Pennsylvania, Philadelphia. "A lot of things have to happen before that can become a standard procedure in this country."

The first step is removing the experimental label, she said. "Now that it’s not experimental, the reality is that people will be using this technique."

Even without a full-scale endorsement from the ASRM, momentum for frozen donor egg banking has been picking up. The cost is a big part of that, Dr. Shapiro said.

The price tag for a cycle of IVF using fresh donor eggs can run anywhere between $26,000 and $44,000, depending on the local market and whether an agent has been hired to find a donor. The cost rises quickly because everyone has to get paid, Dr. Shapiro said, including the donor, the agent, and the clinic performing the procedure.

In contrast, My Egg Bank North America "sells" its cycles to its affiliate practices for $16,500, which includes all the donor costs, vitrification, and technical assistance with the thawing of the eggs. Other egg banks also advertise the availability of frozen cycles at about half the cost of fresh IVF cycles.

And many of the banks offer some type of guarantee. For instance, at My Egg Bank, recipient patients are guaranteed two high-quality embryos. About 20% of patients don’t get two high-quality embryos so they are offered another cycle at no cost if no pregnancy results, Dr. Shapiro said. My Egg Bank also offers a program called "Frozen Egg Advantage," which offers a money-back guarantee when patients pay for five cycles. Patients either go home with a baby or get full reimbursement of treatment expenses at the end of five cycles.

"People sit down and they do a simple little [math]," he said. "They quickly come to the conclusion that a couple of cycles with us gives a higher cumulative likelihood of pregnancy than one fresh cycle any place else, and it still comes out less."

Convenience is another factor. Traditionally with fresh egg donation, both the egg donor and recipient would have to synchronize their cycles so that once the eggs are retrieved, they could be immediately fertilized and transferred. "When you have the possibility to freeze the donor eggs, then basically you can disconnect the egg donation from receiving those eggs," Dr. Nagy said.

That has the potential to take some of the uncertainty and stress out of the process for patients, said Barbara Collura, president and CEO of RESOLVE: The National Infertility Association. She has heard first-hand from infertile women who have had to start over when their donor dropped out of the process.

"They pick out an egg donor, and then she gets into law school and her whole life changes and she’s no longer available," Ms. Collura said. "Those things happen and they sound very trite, but when you’re 38, 39, 40 and you’ve been at this already for several years, having the ability to use a vitrified donated oocyte and to be able to use that when you’re ready, is amazing."

Frozen egg banking also may offer women greater choice when it comes to choosing an egg donor. That’s another factor that is driving the increasing popularity of this option, said Ms. Hayes of Donor Egg Bank USA.

"Cost aside, the donor is the most important factor to them," she said.

It’s not just about numbers, Ms. Hayes said, it’s also about ethnic and racial diversity. With fresh donation, it can be difficult to match recipients with donors of certain ethnic backgrounds. With frozen donation, it becomes logistically easier for egg banks to spend time building a more diverse database. At Donor Egg Bank USA, they are working with an affiliate program in Hawaii with the hopes of getting more Asian donors into the bank.

"I think culturally there are some women of ethnic background that are less likely to donate eggs," Ms. Hayes said. "These recipients, they want a baby as much as any other couple does. You want your baby to mirror your family."

Despite the growing interest in select circles, general awareness of the frozen egg donation model is fairly low. Ms. Hayes said she thinks social media will help it get into the mainstream as more women talk online about their success with frozen donor eggs.

"The more women have babies, the more they’ll talk about it, and the more people will utilize a frozen egg as an option," she said.

[email protected]

*Update: This article was updated 1/30/2013.

A last-minute deal by lawmakers means that physicians won’t be subject to a nearly 29% cut to their Medicare payments this year.

The deal to the avoid the so-called "fiscal cliff" will delay for 2 months an automatic 2% cut to Medicare fees that was part of an earlier plan to cut the deficit, known as sequestration. The deal also averts a 26.5% Medicare pay cut that was scheduled to take effect Jan. 1 because of the Sustainable Growth Rate (SGR) formula. The SGR cut will be delayed for 1 year, but physicians will face an even larger cut in 2014 unless Congress takes some action to alter or to eliminate the formula.

The American Taxpayer Relief Act of 2012 (H.R. 8), which delays deep cuts in federal spending and tax increases on the middle class, was passed by the House and Senate on Jan. 1; the President *signed the bill Jan. 2.

Reaction from physicians has been lukewarm.

"This patch temporarily alleviates the problem, but Congress’ work is not complete; it has simply delayed this massive, unsustainable cut for 1 year," Dr. Jeremy Lazarus, president of the American Medical Association, said in a statement. "Over the next months, it must act to eliminate this ongoing problem once and for all."

The SGR fix will be funded mainly through cuts to hospital funding, including reduced payments to disproportionate share hospitals, adjustments to documentation and coding, and cuts to end-stage renal disease payments. The cuts also include radiation oncology care and hospital outpatient payments for radiosurgery involving multisourced cobalt-60.

The American Hospital Association objected to the cuts.

"While fixing the physician payment formula is essential, it should not be done by jeopardizing hospitals’ ability to care for seniors and their communities," Rich Umbdenstock, the AHA’s president and CEO, said in a statement. "That’s why we are very disappointed at the approach taken in this measure."

The SGR fix is not paid for by cuts to the Affordable Care Act, as had been proposed late in 2012. In December, a proposal was circulating on Capitol Hill to pay for a 1-year fix by eliminating increases in Medicaid payments for primary care services. The physician community, including both primary care and specialty societies, wrote letters to House and Senate leaders urging that the proposal be rejected because it would preserve access for seniors at the risk of access for poor patients.

Despite the deal, Congress has plenty to do in the coming weeks. H.R. 8 only delays the sequestration cuts for 2 months to allow time for another deficit-reduction deal. The sequester includes not only an automatic 2% Medicare provider cut, but also deeper cuts to funding for health professions grants, the National Health Service Corps, and public health programs.

[email protected]

*UPDATE 01/03/13: This story was updated to reflect that President Barack Obama signed the bill on Jan. 2, 2013.

A last-minute deal by lawmakers means that physicians won’t be subject to a nearly 29% cut to their Medicare payments this year.

The deal to the avoid the so-called "fiscal cliff" will delay for 2 months an automatic 2% cut to Medicare fees that was part of an earlier plan to cut the deficit, known as sequestration. The deal also averts a 26.5% Medicare pay cut that was scheduled to take effect Jan. 1 because of the Sustainable Growth Rate (SGR) formula. The SGR cut will be delayed for 1 year, but physicians will face an even larger cut in 2014 unless Congress takes some action to alter or to eliminate the formula.

The American Taxpayer Relief Act of 2012 (H.R. 8), which delays deep cuts in federal spending and tax increases on the middle class, was passed by the House and Senate on Jan. 1; the President *signed the bill Jan. 2.

Reaction from physicians has been lukewarm.

"This patch temporarily alleviates the problem, but Congress’ work is not complete; it has simply delayed this massive, unsustainable cut for 1 year," Dr. Jeremy Lazarus, president of the American Medical Association, said in a statement. "Over the next months, it must act to eliminate this ongoing problem once and for all."

The SGR fix will be funded mainly through cuts to hospital funding, including reduced payments to disproportionate share hospitals, adjustments to documentation and coding, and cuts to end-stage renal disease payments. The cuts also include radiation oncology care and hospital outpatient payments for radiosurgery involving multisourced cobalt-60.

The American Hospital Association objected to the cuts.

"While fixing the physician payment formula is essential, it should not be done by jeopardizing hospitals’ ability to care for seniors and their communities," Rich Umbdenstock, the AHA’s president and CEO, said in a statement. "That’s why we are very disappointed at the approach taken in this measure."

The SGR fix is not paid for by cuts to the Affordable Care Act, as had been proposed late in 2012. In December, a proposal was circulating on Capitol Hill to pay for a 1-year fix by eliminating increases in Medicaid payments for primary care services. The physician community, including both primary care and specialty societies, wrote letters to House and Senate leaders urging that the proposal be rejected because it would preserve access for seniors at the risk of access for poor patients.

Despite the deal, Congress has plenty to do in the coming weeks. H.R. 8 only delays the sequestration cuts for 2 months to allow time for another deficit-reduction deal. The sequester includes not only an automatic 2% Medicare provider cut, but also deeper cuts to funding for health professions grants, the National Health Service Corps, and public health programs.

[email protected]

*UPDATE 01/03/13: This story was updated to reflect that President Barack Obama signed the bill on Jan. 2, 2013.

A last-minute deal by lawmakers means that physicians won’t be subject to a nearly 29% cut to their Medicare payments this year.

The deal to the avoid the so-called "fiscal cliff" will delay for 2 months an automatic 2% cut to Medicare fees that was part of an earlier plan to cut the deficit, known as sequestration. The deal also averts a 26.5% Medicare pay cut that was scheduled to take effect Jan. 1 because of the Sustainable Growth Rate (SGR) formula. The SGR cut will be delayed for 1 year, but physicians will face an even larger cut in 2014 unless Congress takes some action to alter or to eliminate the formula.

The American Taxpayer Relief Act of 2012 (H.R. 8), which delays deep cuts in federal spending and tax increases on the middle class, was passed by the House and Senate on Jan. 1; the President *signed the bill Jan. 2.

Reaction from physicians has been lukewarm.

"This patch temporarily alleviates the problem, but Congress’ work is not complete; it has simply delayed this massive, unsustainable cut for 1 year," Dr. Jeremy Lazarus, president of the American Medical Association, said in a statement. "Over the next months, it must act to eliminate this ongoing problem once and for all."

The SGR fix will be funded mainly through cuts to hospital funding, including reduced payments to disproportionate share hospitals, adjustments to documentation and coding, and cuts to end-stage renal disease payments. The cuts also include radiation oncology care and hospital outpatient payments for radiosurgery involving multisourced cobalt-60.

The American Hospital Association objected to the cuts.

"While fixing the physician payment formula is essential, it should not be done by jeopardizing hospitals’ ability to care for seniors and their communities," Rich Umbdenstock, the AHA’s president and CEO, said in a statement. "That’s why we are very disappointed at the approach taken in this measure."

The SGR fix is not paid for by cuts to the Affordable Care Act, as had been proposed late in 2012. In December, a proposal was circulating on Capitol Hill to pay for a 1-year fix by eliminating increases in Medicaid payments for primary care services. The physician community, including both primary care and specialty societies, wrote letters to House and Senate leaders urging that the proposal be rejected because it would preserve access for seniors at the risk of access for poor patients.

Despite the deal, Congress has plenty to do in the coming weeks. H.R. 8 only delays the sequestration cuts for 2 months to allow time for another deficit-reduction deal. The sequester includes not only an automatic 2% Medicare provider cut, but also deeper cuts to funding for health professions grants, the National Health Service Corps, and public health programs.

[email protected]

*UPDATE 01/03/13: This story was updated to reflect that President Barack Obama signed the bill on Jan. 2, 2013.

Could 2013 finally be the year to eliminate the Sustainable Growth Rate formula?

Officials at the American Medical Association say there’s a chance that Congress could decide to permanently scrap the unpopular formula, which drives payment under the Medicare physician fee schedule, as part of a larger deal to cut the federal deficit.

"The fact that we’ve got this big potential deficit-reduction package would make us more optimistic that we can get [the SGR] taken care of this coming year," said Dr. Jeremy A. Lazarus, president of the American Medical Association.

SGR repeal has been included in bipartisan deficit-reduction plans created by outside groups several times, including the Simpson-Bowles Commission, the Senate Gang of Six, and others.

Although complete SGR repeal carries a 10-year price tag of nearly $300 billion, physicians argue that, since Congress always acts to avert the pay cuts triggered by the formula, the federal government does not save any money by keeping it on the books. The large cost of repeal, however, means that it may be easier to get the SGR fix inserted into a larger bill than to get lawmakers to approve it separately, Dr. Lazarus said.

The AMA is asking Congress to not only repeal the SGR but also to establish a period of stable Medicare payments so that physicians can begin to transition to a new payment system that focuses on quality of care, Dr. Lazarus said. In the meantime, the AMA and other groups have been working on developing new delivery and payment reform options that could offer an alternative to the current fee for service system.

"We do hope we can start changing the equation on reimbursement and going from fee for service to accounting for quality," said Dr. William A. Zoghbi, president of the American College of Cardiology.

ACC officials are eager to move away from the SGR but they are concerned about where the money to do so might come from. Dr. Zoghbi said that he doesn’t want to see lawmakers robbing other health care priorities to pay for the fix. For instance, in December, lawmakers considered a proposal to pay for a 1-year SGR fix using money that was slated for increasing Medicaid payments to physicians providing primary care services.

"These fixes cannot be on the backs of the professionals providing care," he said.

ACA milestones

This year also will see some practice-impacting milestones under the Affordable Care Act.

Federal money now helps pay for preventive services for Medicaid patients, and many primary care services provided under Medicaid now are paid at the higher Medicare rate. Under the ACA, Medicaid payment increases to 100% of Medicare rates for family physicians, internists, and pediatricians when they provide certain primary care services. Subspecialists in these areas are also eligible for increased payments. The pay hike is for 2013 and 2014.

The law also provides an additional 2 years of funding to the Children’s Health Insurance Program to continue coverage for those children for eligible under the Medicaid program.

The Independent Payment Advisory Board is slated to start work this year, even though its members have yet to be named by President Obama. The controversial 15-member panel is charged with making recommendations on how to reduce Medicare spending. Dr. Lazarus said the AMA will continue to work toward eliminating the IPAB.

Some of the biggest changes under the ACA – the expansion of Medicaid eligibility and the creation of state-based health insurance exchanges – are coming in 2014, but physician leaders said that doctors need to start preparing this year.

Exactly how to get ready will vary by state since both the Medicaid expansion and the exchanges will be largely state-run. The AMA is pushing to give physicians greater say by getting them seats on the boards of state exchanges. But even as physicians await more information on these changes, they can prepare by becoming more familiar with the Medicaid program since they are likely to see more of those patients, said Robert Doherty, senior vice president for governmental affairs and public policy at the American College of Physicians.

Penalties kick in

This year the Physician Quality Reporting System (PQRS) transitions from a pure incentive program to a mixed incentive/disincentive program. Previously, PQRS offered small bonus payments to physicians for successfully reporting on quality measures. Now, physicians who don’t participate in the program will be assessed a penalty. The 1.5% cut to Medicare fees won’t come until 2015, but it will be based on participation this year. Physicians will see a 2% penalty in 2016 if they don’t successfully report data during 2014.

"People don’t realize that if they get past 2013, they won’t have an opportunity to fix it for the next year," said Dr. Bruce Bagley, medical director for quality improvement at the American Academy of Family Physicians.

There are also penalties coming in Medicare’s Electronic Prescribing (eRx) Incentive Program. To avoid a 2% penalty in 2014, physicians must meet Medicare’s e-prescribing requirements by June 30, 2013.

Penalties from the Medicare Electronic Health Record (EHR) Incentive Program aren’t coming until 2015, but Dr. Bagley said that physicians should take a good look at this program now to try to earn some money to offset the cost of EHR implementation. "The sooner you get going on this stuff, the better," he said.

A physician who starts participating this year can earn up to $39,000 over 4 years. Start next year and the bonus drops to $24,000. A 1% penalty takes effect in 2015, increasing to 2% the following year.

The transition to the ICD-10 coding set is another requirement that physicians need to keep in mind, ACP’s Mr. Doherty said. The Department of Health and Human Services delayed the move to ICD-10 until October 2014, but Mr. Doherty said physicians can’t afford to wait that long to prepare. The ACP is trying to convince federal officials to accept some alternative ways of coding that would both satisfy the ICD-10 requirements and be clinically relevant, he said.

Primary care gets a boost

Overall, the outlook for 2013 will probably vary by specialty. The 2013 Medicare Physician Fee Schedule dealt some tough blows to subspecialists, making deep payment cuts in interventional cardiology, neurology, and oncology.

Coding changes in primary care, though, could bolster that field, experts said.

The 2013 fee schedule included two new transitional care management services codes (99495 and 99496) that will pay physicians for managing complex patients who have recently been discharged from a hospital or skilled nursing facility.

CPT code 99495 requires physicians or their staffs to make direct contact, by phone or electronically, with the patient or caregiver within 2 business days of discharge. A face-to-face visit with the patient is required within 14 calendar days of discharge. CPT code 99496 requires direct contact with the patient or caregiver within 2 business days and a face-to-face visit within 7 calendar days.

Both codes may include several other non–face-to-face services that could be provided by clinical staff or physicians within 30 days after discharge.

"That’s the first step in what we hope will be a series of payment changes to pay physicians for the care coordination involved with complex chronic disease," Mr. Doherty said.

The ACP, the AMA, and other groups are developing a series of proposals calling on Medicare to begin paying for more of the non–face-to-face work involved in chronic care management. They hope to get some of them accepted for payment starting in 2014, he said.

"There’s never been a time when so many people from so many quarters recognize the value of primary care," Dr. Bagley said.

Could 2013 finally be the year to eliminate the Sustainable Growth Rate formula?

Officials at the American Medical Association say there’s a chance that Congress could decide to permanently scrap the unpopular formula, which drives payment under the Medicare physician fee schedule, as part of a larger deal to cut the federal deficit.

"The fact that we’ve got this big potential deficit-reduction package would make us more optimistic that we can get [the SGR] taken care of this coming year," said Dr. Jeremy A. Lazarus, president of the American Medical Association.

SGR repeal has been included in bipartisan deficit-reduction plans created by outside groups several times, including the Simpson-Bowles Commission, the Senate Gang of Six, and others.

Although complete SGR repeal carries a 10-year price tag of nearly $300 billion, physicians argue that, since Congress always acts to avert the pay cuts triggered by the formula, the federal government does not save any money by keeping it on the books. The large cost of repeal, however, means that it may be easier to get the SGR fix inserted into a larger bill than to get lawmakers to approve it separately, Dr. Lazarus said.

The AMA is asking Congress to not only repeal the SGR but also to establish a period of stable Medicare payments so that physicians can begin to transition to a new payment system that focuses on quality of care, Dr. Lazarus said. In the meantime, the AMA and other groups have been working on developing new delivery and payment reform options that could offer an alternative to the current fee for service system.

"We do hope we can start changing the equation on reimbursement and going from fee for service to accounting for quality," said Dr. William A. Zoghbi, president of the American College of Cardiology.

ACC officials are eager to move away from the SGR but they are concerned about where the money to do so might come from. Dr. Zoghbi said that he doesn’t want to see lawmakers robbing other health care priorities to pay for the fix. For instance, in December, lawmakers considered a proposal to pay for a 1-year SGR fix using money that was slated for increasing Medicaid payments to physicians providing primary care services.

"These fixes cannot be on the backs of the professionals providing care," he said.

ACA milestones

This year also will see some practice-impacting milestones under the Affordable Care Act.

Federal money now helps pay for preventive services for Medicaid patients, and many primary care services provided under Medicaid now are paid at the higher Medicare rate. Under the ACA, Medicaid payment increases to 100% of Medicare rates for family physicians, internists, and pediatricians when they provide certain primary care services. Subspecialists in these areas are also eligible for increased payments. The pay hike is for 2013 and 2014.

The law also provides an additional 2 years of funding to the Children’s Health Insurance Program to continue coverage for those children for eligible under the Medicaid program.

The Independent Payment Advisory Board is slated to start work this year, even though its members have yet to be named by President Obama. The controversial 15-member panel is charged with making recommendations on how to reduce Medicare spending. Dr. Lazarus said the AMA will continue to work toward eliminating the IPAB.

Some of the biggest changes under the ACA – the expansion of Medicaid eligibility and the creation of state-based health insurance exchanges – are coming in 2014, but physician leaders said that doctors need to start preparing this year.

Exactly how to get ready will vary by state since both the Medicaid expansion and the exchanges will be largely state-run. The AMA is pushing to give physicians greater say by getting them seats on the boards of state exchanges. But even as physicians await more information on these changes, they can prepare by becoming more familiar with the Medicaid program since they are likely to see more of those patients, said Robert Doherty, senior vice president for governmental affairs and public policy at the American College of Physicians.

Penalties kick in

This year the Physician Quality Reporting System (PQRS) transitions from a pure incentive program to a mixed incentive/disincentive program. Previously, PQRS offered small bonus payments to physicians for successfully reporting on quality measures. Now, physicians who don’t participate in the program will be assessed a penalty. The 1.5% cut to Medicare fees won’t come until 2015, but it will be based on participation this year. Physicians will see a 2% penalty in 2016 if they don’t successfully report data during 2014.

"People don’t realize that if they get past 2013, they won’t have an opportunity to fix it for the next year," said Dr. Bruce Bagley, medical director for quality improvement at the American Academy of Family Physicians.

There are also penalties coming in Medicare’s Electronic Prescribing (eRx) Incentive Program. To avoid a 2% penalty in 2014, physicians must meet Medicare’s e-prescribing requirements by June 30, 2013.

Penalties from the Medicare Electronic Health Record (EHR) Incentive Program aren’t coming until 2015, but Dr. Bagley said that physicians should take a good look at this program now to try to earn some money to offset the cost of EHR implementation. "The sooner you get going on this stuff, the better," he said.

A physician who starts participating this year can earn up to $39,000 over 4 years. Start next year and the bonus drops to $24,000. A 1% penalty takes effect in 2015, increasing to 2% the following year.

The transition to the ICD-10 coding set is another requirement that physicians need to keep in mind, ACP’s Mr. Doherty said. The Department of Health and Human Services delayed the move to ICD-10 until October 2014, but Mr. Doherty said physicians can’t afford to wait that long to prepare. The ACP is trying to convince federal officials to accept some alternative ways of coding that would both satisfy the ICD-10 requirements and be clinically relevant, he said.

Primary care gets a boost

Overall, the outlook for 2013 will probably vary by specialty. The 2013 Medicare Physician Fee Schedule dealt some tough blows to subspecialists, making deep payment cuts in interventional cardiology, neurology, and oncology.

Coding changes in primary care, though, could bolster that field, experts said.

The 2013 fee schedule included two new transitional care management services codes (99495 and 99496) that will pay physicians for managing complex patients who have recently been discharged from a hospital or skilled nursing facility.

CPT code 99495 requires physicians or their staffs to make direct contact, by phone or electronically, with the patient or caregiver within 2 business days of discharge. A face-to-face visit with the patient is required within 14 calendar days of discharge. CPT code 99496 requires direct contact with the patient or caregiver within 2 business days and a face-to-face visit within 7 calendar days.

Both codes may include several other non–face-to-face services that could be provided by clinical staff or physicians within 30 days after discharge.

"That’s the first step in what we hope will be a series of payment changes to pay physicians for the care coordination involved with complex chronic disease," Mr. Doherty said.

The ACP, the AMA, and other groups are developing a series of proposals calling on Medicare to begin paying for more of the non–face-to-face work involved in chronic care management. They hope to get some of them accepted for payment starting in 2014, he said.

"There’s never been a time when so many people from so many quarters recognize the value of primary care," Dr. Bagley said.

Could 2013 finally be the year to eliminate the Sustainable Growth Rate formula?

Officials at the American Medical Association say there’s a chance that Congress could decide to permanently scrap the unpopular formula, which drives payment under the Medicare physician fee schedule, as part of a larger deal to cut the federal deficit.

"The fact that we’ve got this big potential deficit-reduction package would make us more optimistic that we can get [the SGR] taken care of this coming year," said Dr. Jeremy A. Lazarus, president of the American Medical Association.

SGR repeal has been included in bipartisan deficit-reduction plans created by outside groups several times, including the Simpson-Bowles Commission, the Senate Gang of Six, and others.

Although complete SGR repeal carries a 10-year price tag of nearly $300 billion, physicians argue that, since Congress always acts to avert the pay cuts triggered by the formula, the federal government does not save any money by keeping it on the books. The large cost of repeal, however, means that it may be easier to get the SGR fix inserted into a larger bill than to get lawmakers to approve it separately, Dr. Lazarus said.

The AMA is asking Congress to not only repeal the SGR but also to establish a period of stable Medicare payments so that physicians can begin to transition to a new payment system that focuses on quality of care, Dr. Lazarus said. In the meantime, the AMA and other groups have been working on developing new delivery and payment reform options that could offer an alternative to the current fee for service system.

"We do hope we can start changing the equation on reimbursement and going from fee for service to accounting for quality," said Dr. William A. Zoghbi, president of the American College of Cardiology.

ACC officials are eager to move away from the SGR but they are concerned about where the money to do so might come from. Dr. Zoghbi said that he doesn’t want to see lawmakers robbing other health care priorities to pay for the fix. For instance, in December, lawmakers considered a proposal to pay for a 1-year SGR fix using money that was slated for increasing Medicaid payments to physicians providing primary care services.

"These fixes cannot be on the backs of the professionals providing care," he said.

ACA milestones

This year also will see some practice-impacting milestones under the Affordable Care Act.

Federal money now helps pay for preventive services for Medicaid patients, and many primary care services provided under Medicaid now are paid at the higher Medicare rate. Under the ACA, Medicaid payment increases to 100% of Medicare rates for family physicians, internists, and pediatricians when they provide certain primary care services. Subspecialists in these areas are also eligible for increased payments. The pay hike is for 2013 and 2014.

The law also provides an additional 2 years of funding to the Children’s Health Insurance Program to continue coverage for those children for eligible under the Medicaid program.

The Independent Payment Advisory Board is slated to start work this year, even though its members have yet to be named by President Obama. The controversial 15-member panel is charged with making recommendations on how to reduce Medicare spending. Dr. Lazarus said the AMA will continue to work toward eliminating the IPAB.

Some of the biggest changes under the ACA – the expansion of Medicaid eligibility and the creation of state-based health insurance exchanges – are coming in 2014, but physician leaders said that doctors need to start preparing this year.

Exactly how to get ready will vary by state since both the Medicaid expansion and the exchanges will be largely state-run. The AMA is pushing to give physicians greater say by getting them seats on the boards of state exchanges. But even as physicians await more information on these changes, they can prepare by becoming more familiar with the Medicaid program since they are likely to see more of those patients, said Robert Doherty, senior vice president for governmental affairs and public policy at the American College of Physicians.

Penalties kick in

This year the Physician Quality Reporting System (PQRS) transitions from a pure incentive program to a mixed incentive/disincentive program. Previously, PQRS offered small bonus payments to physicians for successfully reporting on quality measures. Now, physicians who don’t participate in the program will be assessed a penalty. The 1.5% cut to Medicare fees won’t come until 2015, but it will be based on participation this year. Physicians will see a 2% penalty in 2016 if they don’t successfully report data during 2014.

"People don’t realize that if they get past 2013, they won’t have an opportunity to fix it for the next year," said Dr. Bruce Bagley, medical director for quality improvement at the American Academy of Family Physicians.

There are also penalties coming in Medicare’s Electronic Prescribing (eRx) Incentive Program. To avoid a 2% penalty in 2014, physicians must meet Medicare’s e-prescribing requirements by June 30, 2013.

Penalties from the Medicare Electronic Health Record (EHR) Incentive Program aren’t coming until 2015, but Dr. Bagley said that physicians should take a good look at this program now to try to earn some money to offset the cost of EHR implementation. "The sooner you get going on this stuff, the better," he said.

A physician who starts participating this year can earn up to $39,000 over 4 years. Start next year and the bonus drops to $24,000. A 1% penalty takes effect in 2015, increasing to 2% the following year.

The transition to the ICD-10 coding set is another requirement that physicians need to keep in mind, ACP’s Mr. Doherty said. The Department of Health and Human Services delayed the move to ICD-10 until October 2014, but Mr. Doherty said physicians can’t afford to wait that long to prepare. The ACP is trying to convince federal officials to accept some alternative ways of coding that would both satisfy the ICD-10 requirements and be clinically relevant, he said.

Primary care gets a boost

Overall, the outlook for 2013 will probably vary by specialty. The 2013 Medicare Physician Fee Schedule dealt some tough blows to subspecialists, making deep payment cuts in interventional cardiology, neurology, and oncology.

Coding changes in primary care, though, could bolster that field, experts said.

The 2013 fee schedule included two new transitional care management services codes (99495 and 99496) that will pay physicians for managing complex patients who have recently been discharged from a hospital or skilled nursing facility.

CPT code 99495 requires physicians or their staffs to make direct contact, by phone or electronically, with the patient or caregiver within 2 business days of discharge. A face-to-face visit with the patient is required within 14 calendar days of discharge. CPT code 99496 requires direct contact with the patient or caregiver within 2 business days and a face-to-face visit within 7 calendar days.

Both codes may include several other non–face-to-face services that could be provided by clinical staff or physicians within 30 days after discharge.

"That’s the first step in what we hope will be a series of payment changes to pay physicians for the care coordination involved with complex chronic disease," Mr. Doherty said.

The ACP, the AMA, and other groups are developing a series of proposals calling on Medicare to begin paying for more of the non–face-to-face work involved in chronic care management. They hope to get some of them accepted for payment starting in 2014, he said.

"There’s never been a time when so many people from so many quarters recognize the value of primary care," Dr. Bagley said.

It’s been over a decade since Dr. Jeffrey Schnipper first realized the importance of reducing the number of unintentional medication changes that occur when patients enter and leave the hospital. Since then, he’s conducted several studies aimed at figuring out what tools and processes can help minimize these potentially harmful medication discrepancies.

Dr. Schnipper, director of clinical research for the hospitalist service at Brigham and Women’s Hospital in Boston, is the principal investigator for the Multi-Center Medication Reconciliation Quality Improvement Study (MARQUIS). The 3-year study seeks to improve the way medications are prescribed, documented, and reconciled at admission and discharge to the hospital. MARQUIS, which was launched in 2010, is sponsored by the Society of Hospital Medicine and is funded by a $1.5-million grant from the Agency for Healthcare Research and Quality.

In an interview with Hospitalist News, Dr. Schnipper explained what has been learned so far from the MARQUIS experience and what that means for medication reconciliation efforts around the country.

Hospitalist News: What is the status of MARQUIS and what are some of the preliminary results out of the six sites in the study?

Dr. Schnipper: The main outcome that we are looking at is the number of unintentional discrepancies in either admission orders or discharge orders. These are unintended differences in medication regimens across different sites of care, which are not done for medical reasons. Since we often don’t know what patients were taking when they came into the hospital, we sometimes write wrong orders for that reason. We call these "history errors." Sometimes we know what medications a patient was taking when he or she came into the hospital, but maybe we decide to hold the medication on admission for a good clinical reason and then forget to restart it at discharge. We call these types of errors "reconciliation errors."

What we’re finding is that the number of unintentional medication discrepancies for patients varies anywhere from 2.4 to 4.7 per patient, almost a twofold difference between our best performing and our worst performing hospitals across the six sites. We’re also finding, consistent with past studies, that history errors are more often the cause of the discrepancies than reconciliation errors.

HN: Is there a lot of variability in how hospitals perform when it comes to medication reconciliation?

Dr. Schnipper: In MARQUIS, we found a twofold difference between our best and worst hospitals, so I think there really is variability. Who performs each component of medication reconciliation is actually really variable. Where it’s done is also really different between our sites. It’s everywhere from pharmacy technicians doing it in the emergency department to nurses doing it on the floors to residents or attendings doing it on the floors. And in some hospitals it’s a combination. One thing that we’ve found is that at some hospitals there’s not a lot of clarity in terms of roles and responsibilities.

HN: What’s the best role for the hospitalist to improve this process?

Dr. Schnipper: I think there are a lot of people out there, including hospitalists, who feel like medication reconciliation is just a regulatory issue. It’s a box to check. It’s not really my problem. What I would say to them is that medication reconciliation is the process of making sure that, at the end of the day, your patients are being ordered the right medications.

As hospitalists, we are responsible for those orders being right. We are therefore responsible for the medication reconciliation process being done well. That does not mean we have to do the whole process ourselves and we shouldn’t, but we need to make sure that there are systems in place to do it well and we need to help our hospitals improve their systems. It’s a professionalism issue.

HN: Are there types of technology or systems that a hospital should have to perform medication reconciliation properly?

Dr. Schnipper: There are a few key features that good health information technology (HIT) systems should have. One feature is the ability to draw on electronic sources of information from the preadmission world, such as outpatient electronic medication records, pharmacy information, or a recent discharge from the hospital. The best systems take that information in and synthesize it in some way so that you’re not just getting this big jumble of medications from different sources. Second, taking the history and then deciding what you’re going to do with those medications should help you write the admission orders. If, for example, you’ve got a medication from the history and you decide that you want to continue it on admission, the HIT system should help you actually write that order. It’s very easy to do on paper; it’s actually been surprisingly hard to do with electronic systems. At discharge, the system should clearly lay out what the patient came in on, what the patient is currently on, and help to create the discharge order set. It should be able to produce a really coherent set of instructions for both the patients and the providers, showing how the discharge medication list is different from what the patient was taking prior to admission.

–Mary Ellen Schneider

Take us to your leader. Nominate a hospitalist whose work inspires you. E-mail suggestions to [email protected].

It’s been over a decade since Dr. Jeffrey Schnipper first realized the importance of reducing the number of unintentional medication changes that occur when patients enter and leave the hospital. Since then, he’s conducted several studies aimed at figuring out what tools and processes can help minimize these potentially harmful medication discrepancies.

Dr. Schnipper, director of clinical research for the hospitalist service at Brigham and Women’s Hospital in Boston, is the principal investigator for the Multi-Center Medication Reconciliation Quality Improvement Study (MARQUIS). The 3-year study seeks to improve the way medications are prescribed, documented, and reconciled at admission and discharge to the hospital. MARQUIS, which was launched in 2010, is sponsored by the Society of Hospital Medicine and is funded by a $1.5-million grant from the Agency for Healthcare Research and Quality.

In an interview with Hospitalist News, Dr. Schnipper explained what has been learned so far from the MARQUIS experience and what that means for medication reconciliation efforts around the country.

Hospitalist News: What is the status of MARQUIS and what are some of the preliminary results out of the six sites in the study?

Dr. Schnipper: The main outcome that we are looking at is the number of unintentional discrepancies in either admission orders or discharge orders. These are unintended differences in medication regimens across different sites of care, which are not done for medical reasons. Since we often don’t know what patients were taking when they came into the hospital, we sometimes write wrong orders for that reason. We call these "history errors." Sometimes we know what medications a patient was taking when he or she came into the hospital, but maybe we decide to hold the medication on admission for a good clinical reason and then forget to restart it at discharge. We call these types of errors "reconciliation errors."

What we’re finding is that the number of unintentional medication discrepancies for patients varies anywhere from 2.4 to 4.7 per patient, almost a twofold difference between our best performing and our worst performing hospitals across the six sites. We’re also finding, consistent with past studies, that history errors are more often the cause of the discrepancies than reconciliation errors.

HN: Is there a lot of variability in how hospitals perform when it comes to medication reconciliation?

Dr. Schnipper: In MARQUIS, we found a twofold difference between our best and worst hospitals, so I think there really is variability. Who performs each component of medication reconciliation is actually really variable. Where it’s done is also really different between our sites. It’s everywhere from pharmacy technicians doing it in the emergency department to nurses doing it on the floors to residents or attendings doing it on the floors. And in some hospitals it’s a combination. One thing that we’ve found is that at some hospitals there’s not a lot of clarity in terms of roles and responsibilities.

HN: What’s the best role for the hospitalist to improve this process?

Dr. Schnipper: I think there are a lot of people out there, including hospitalists, who feel like medication reconciliation is just a regulatory issue. It’s a box to check. It’s not really my problem. What I would say to them is that medication reconciliation is the process of making sure that, at the end of the day, your patients are being ordered the right medications.

As hospitalists, we are responsible for those orders being right. We are therefore responsible for the medication reconciliation process being done well. That does not mean we have to do the whole process ourselves and we shouldn’t, but we need to make sure that there are systems in place to do it well and we need to help our hospitals improve their systems. It’s a professionalism issue.

HN: Are there types of technology or systems that a hospital should have to perform medication reconciliation properly?

Dr. Schnipper: There are a few key features that good health information technology (HIT) systems should have. One feature is the ability to draw on electronic sources of information from the preadmission world, such as outpatient electronic medication records, pharmacy information, or a recent discharge from the hospital. The best systems take that information in and synthesize it in some way so that you’re not just getting this big jumble of medications from different sources. Second, taking the history and then deciding what you’re going to do with those medications should help you write the admission orders. If, for example, you’ve got a medication from the history and you decide that you want to continue it on admission, the HIT system should help you actually write that order. It’s very easy to do on paper; it’s actually been surprisingly hard to do with electronic systems. At discharge, the system should clearly lay out what the patient came in on, what the patient is currently on, and help to create the discharge order set. It should be able to produce a really coherent set of instructions for both the patients and the providers, showing how the discharge medication list is different from what the patient was taking prior to admission.

–Mary Ellen Schneider

Take us to your leader. Nominate a hospitalist whose work inspires you. E-mail suggestions to [email protected].

It’s been over a decade since Dr. Jeffrey Schnipper first realized the importance of reducing the number of unintentional medication changes that occur when patients enter and leave the hospital. Since then, he’s conducted several studies aimed at figuring out what tools and processes can help minimize these potentially harmful medication discrepancies.

Dr. Schnipper, director of clinical research for the hospitalist service at Brigham and Women’s Hospital in Boston, is the principal investigator for the Multi-Center Medication Reconciliation Quality Improvement Study (MARQUIS). The 3-year study seeks to improve the way medications are prescribed, documented, and reconciled at admission and discharge to the hospital. MARQUIS, which was launched in 2010, is sponsored by the Society of Hospital Medicine and is funded by a $1.5-million grant from the Agency for Healthcare Research and Quality.

In an interview with Hospitalist News, Dr. Schnipper explained what has been learned so far from the MARQUIS experience and what that means for medication reconciliation efforts around the country.

Hospitalist News: What is the status of MARQUIS and what are some of the preliminary results out of the six sites in the study?

Dr. Schnipper: The main outcome that we are looking at is the number of unintentional discrepancies in either admission orders or discharge orders. These are unintended differences in medication regimens across different sites of care, which are not done for medical reasons. Since we often don’t know what patients were taking when they came into the hospital, we sometimes write wrong orders for that reason. We call these "history errors." Sometimes we know what medications a patient was taking when he or she came into the hospital, but maybe we decide to hold the medication on admission for a good clinical reason and then forget to restart it at discharge. We call these types of errors "reconciliation errors."

What we’re finding is that the number of unintentional medication discrepancies for patients varies anywhere from 2.4 to 4.7 per patient, almost a twofold difference between our best performing and our worst performing hospitals across the six sites. We’re also finding, consistent with past studies, that history errors are more often the cause of the discrepancies than reconciliation errors.

HN: Is there a lot of variability in how hospitals perform when it comes to medication reconciliation?

Dr. Schnipper: In MARQUIS, we found a twofold difference between our best and worst hospitals, so I think there really is variability. Who performs each component of medication reconciliation is actually really variable. Where it’s done is also really different between our sites. It’s everywhere from pharmacy technicians doing it in the emergency department to nurses doing it on the floors to residents or attendings doing it on the floors. And in some hospitals it’s a combination. One thing that we’ve found is that at some hospitals there’s not a lot of clarity in terms of roles and responsibilities.

HN: What’s the best role for the hospitalist to improve this process?

Dr. Schnipper: I think there are a lot of people out there, including hospitalists, who feel like medication reconciliation is just a regulatory issue. It’s a box to check. It’s not really my problem. What I would say to them is that medication reconciliation is the process of making sure that, at the end of the day, your patients are being ordered the right medications.

As hospitalists, we are responsible for those orders being right. We are therefore responsible for the medication reconciliation process being done well. That does not mean we have to do the whole process ourselves and we shouldn’t, but we need to make sure that there are systems in place to do it well and we need to help our hospitals improve their systems. It’s a professionalism issue.

HN: Are there types of technology or systems that a hospital should have to perform medication reconciliation properly?

Dr. Schnipper: There are a few key features that good health information technology (HIT) systems should have. One feature is the ability to draw on electronic sources of information from the preadmission world, such as outpatient electronic medication records, pharmacy information, or a recent discharge from the hospital. The best systems take that information in and synthesize it in some way so that you’re not just getting this big jumble of medications from different sources. Second, taking the history and then deciding what you’re going to do with those medications should help you write the admission orders. If, for example, you’ve got a medication from the history and you decide that you want to continue it on admission, the HIT system should help you actually write that order. It’s very easy to do on paper; it’s actually been surprisingly hard to do with electronic systems. At discharge, the system should clearly lay out what the patient came in on, what the patient is currently on, and help to create the discharge order set. It should be able to produce a really coherent set of instructions for both the patients and the providers, showing how the discharge medication list is different from what the patient was taking prior to admission.

–Mary Ellen Schneider

Take us to your leader. Nominate a hospitalist whose work inspires you. E-mail suggestions to [email protected].

While many subspecialists are bracing for steep payment cuts due to coding changes set to take effect next year, primary care physicians could earn more money, thanks to the creation of new transitional care management codes.

Starting Jan. 1, physicians can get paid for the management of complex patients who have recently been discharged from a hospital or skilled nursing facility. Medicare will pay between $164 and $231, depending on the complexity of the patient, for care during the 30-day period after discharge.

"That is significant and it is enough to catch the attention of internists," said Shari Erickson, director of regulatory and insurer affairs at the American College of Physicians.

The American Medical Association Current Procedural Terminology (CPT) Editorial Panel created the transitional care management services codes (99495 and 99496) earlier this year; the codes were announced as part of the Medicare Physician Fee Schedule for next year.

CPT code 99495, designed for patients of moderate complexity, requires physicians or their staff to make direct contact, by phone or electronically, with the patient or caregiver within 2 business days of discharge. A face-to-face visit with the patient is required within 14 calendar days of discharge.

CPT code 99496 is meant to be used for patients requiring high-complexity medical decision making. This code requires direct contact with the patient or caregiver within 2 business days and a face-to-face visit within 7 calendar days.

Both codes may include several other non–face-to-face services that could be provided by clinical staff or physicians within the 30 days after discharge. Some staff services include assessment of medication adherence, education of patients and caregivers in self-management, and communication with home health agencies. Physician services include reviewing the discharge information, following up on diagnostic tests, establishing referrals for community resources, and educating patients and families.

For some physicians, the new codes will be a chance to get paid for work they are already doing, Ms. Erickson said. Others may start doing this work for the first time because of the new payment, she said.

For those starting out in transitional care, it’s a chance to move away from the traditional visit-based fee system and toward more of a patient-centered medical home model without being part of a pilot project. "It gives them an opportunity within the existing fee schedule to start to do this work and get paid for it," Ms. Erickson said.

The acceptance of the transitional care management codes by CMS is a move in the right direction, said Dr. Jeffrey J. Cain, president of the American Academy of Family Physicians.

"We know that if we can improve communication and improve collaboration as patients come out of the hospital, we can prevent unnecessary readmissions and increase quality of care," Dr. Cain said. "Previously there was no fiscal incentive to do that."

As with all new codes, documentation will be critical. Physicians should be vigilant about documenting appropriately, Ms. Erickson said.

Another challenge will be identifying these patients in a timely fashion – physicians will need to know which of their patients could benefit from these services as they transition home from inpatient or nursing home care, Ms. Erickson said.

Office-based physicians who don’t see patients in the hospital should start building their relationships with their hospitalist colleagues, Dr. Cain advised.

"This is a new way of thinking about those patients," Dr. Cain said. "You’re not waiting for them to walk in your door. You’re actively assisting in their management before they reach your door."

But next year’s fee schedule isn’t all good news. Officials at the Centers for Medicare and Medicaid Services refused to pay for a series of new complex chronic care coordination services codes that were also created by the CPT Editorial Panel earlier this year.

The new codes (99487, 99488, and 99489) were designed for highly complex patients with chronic conditions who are living at home or in an assisted-living facility. The codes would be reported only once per month and would include several non–face-to-face care coordination services such as communicating with the patient and caregiver, collecting health outcomes data and registry documentation, communicating with home health agencies, assessing medication management, and developing and maintaining a comprehensive care plan.

ACP officials plan to continue to push for the codes as part of the next fee schedule. "That’s going to be an ongoing effort," Ms. Erickson said.

While AAFP officials will also continue to lobby for the payment of these codes, Dr. Cain said the family doctors are working on advancing care coordination payment outside of the traditional fee schedule coding framework. For instance, the AAFP has been a big supporter of the Comprehensive Primary Care Initiative, a multipayer pilot project that allows primary care practices to earn a monthly care management fee in exchange for offering enhanced services such as extended hours, use of electronic health records, and coordination of care with other providers. The project is being spearheaded by the Center for Medicare and Medicaid Innovation and, if successful, could be rolled out nationally.

"The real future is moving away from just fee-for-service, hamster-wheel kind of medicine," Dr. Cain said.

While many subspecialists are bracing for steep payment cuts due to coding changes set to take effect next year, primary care physicians could earn more money, thanks to the creation of new transitional care management codes.

Starting Jan. 1, physicians can get paid for the management of complex patients who have recently been discharged from a hospital or skilled nursing facility. Medicare will pay between $164 and $231, depending on the complexity of the patient, for care during the 30-day period after discharge.

"That is significant and it is enough to catch the attention of internists," said Shari Erickson, director of regulatory and insurer affairs at the American College of Physicians.

The American Medical Association Current Procedural Terminology (CPT) Editorial Panel created the transitional care management services codes (99495 and 99496) earlier this year; the codes were announced as part of the Medicare Physician Fee Schedule for next year.

CPT code 99495, designed for patients of moderate complexity, requires physicians or their staff to make direct contact, by phone or electronically, with the patient or caregiver within 2 business days of discharge. A face-to-face visit with the patient is required within 14 calendar days of discharge.

CPT code 99496 is meant to be used for patients requiring high-complexity medical decision making. This code requires direct contact with the patient or caregiver within 2 business days and a face-to-face visit within 7 calendar days.

Both codes may include several other non–face-to-face services that could be provided by clinical staff or physicians within the 30 days after discharge. Some staff services include assessment of medication adherence, education of patients and caregivers in self-management, and communication with home health agencies. Physician services include reviewing the discharge information, following up on diagnostic tests, establishing referrals for community resources, and educating patients and families.

For some physicians, the new codes will be a chance to get paid for work they are already doing, Ms. Erickson said. Others may start doing this work for the first time because of the new payment, she said.

For those starting out in transitional care, it’s a chance to move away from the traditional visit-based fee system and toward more of a patient-centered medical home model without being part of a pilot project. "It gives them an opportunity within the existing fee schedule to start to do this work and get paid for it," Ms. Erickson said.

The acceptance of the transitional care management codes by CMS is a move in the right direction, said Dr. Jeffrey J. Cain, president of the American Academy of Family Physicians.

"We know that if we can improve communication and improve collaboration as patients come out of the hospital, we can prevent unnecessary readmissions and increase quality of care," Dr. Cain said. "Previously there was no fiscal incentive to do that."

As with all new codes, documentation will be critical. Physicians should be vigilant about documenting appropriately, Ms. Erickson said.

Another challenge will be identifying these patients in a timely fashion – physicians will need to know which of their patients could benefit from these services as they transition home from inpatient or nursing home care, Ms. Erickson said.

Office-based physicians who don’t see patients in the hospital should start building their relationships with their hospitalist colleagues, Dr. Cain advised.

"This is a new way of thinking about those patients," Dr. Cain said. "You’re not waiting for them to walk in your door. You’re actively assisting in their management before they reach your door."

But next year’s fee schedule isn’t all good news. Officials at the Centers for Medicare and Medicaid Services refused to pay for a series of new complex chronic care coordination services codes that were also created by the CPT Editorial Panel earlier this year.

The new codes (99487, 99488, and 99489) were designed for highly complex patients with chronic conditions who are living at home or in an assisted-living facility. The codes would be reported only once per month and would include several non–face-to-face care coordination services such as communicating with the patient and caregiver, collecting health outcomes data and registry documentation, communicating with home health agencies, assessing medication management, and developing and maintaining a comprehensive care plan.

ACP officials plan to continue to push for the codes as part of the next fee schedule. "That’s going to be an ongoing effort," Ms. Erickson said.

While AAFP officials will also continue to lobby for the payment of these codes, Dr. Cain said the family doctors are working on advancing care coordination payment outside of the traditional fee schedule coding framework. For instance, the AAFP has been a big supporter of the Comprehensive Primary Care Initiative, a multipayer pilot project that allows primary care practices to earn a monthly care management fee in exchange for offering enhanced services such as extended hours, use of electronic health records, and coordination of care with other providers. The project is being spearheaded by the Center for Medicare and Medicaid Innovation and, if successful, could be rolled out nationally.

"The real future is moving away from just fee-for-service, hamster-wheel kind of medicine," Dr. Cain said.

While many subspecialists are bracing for steep payment cuts due to coding changes set to take effect next year, primary care physicians could earn more money, thanks to the creation of new transitional care management codes.

Starting Jan. 1, physicians can get paid for the management of complex patients who have recently been discharged from a hospital or skilled nursing facility. Medicare will pay between $164 and $231, depending on the complexity of the patient, for care during the 30-day period after discharge.

"That is significant and it is enough to catch the attention of internists," said Shari Erickson, director of regulatory and insurer affairs at the American College of Physicians.

The American Medical Association Current Procedural Terminology (CPT) Editorial Panel created the transitional care management services codes (99495 and 99496) earlier this year; the codes were announced as part of the Medicare Physician Fee Schedule for next year.

CPT code 99495, designed for patients of moderate complexity, requires physicians or their staff to make direct contact, by phone or electronically, with the patient or caregiver within 2 business days of discharge. A face-to-face visit with the patient is required within 14 calendar days of discharge.

CPT code 99496 is meant to be used for patients requiring high-complexity medical decision making. This code requires direct contact with the patient or caregiver within 2 business days and a face-to-face visit within 7 calendar days.

Both codes may include several other non–face-to-face services that could be provided by clinical staff or physicians within the 30 days after discharge. Some staff services include assessment of medication adherence, education of patients and caregivers in self-management, and communication with home health agencies. Physician services include reviewing the discharge information, following up on diagnostic tests, establishing referrals for community resources, and educating patients and families.

For some physicians, the new codes will be a chance to get paid for work they are already doing, Ms. Erickson said. Others may start doing this work for the first time because of the new payment, she said.

For those starting out in transitional care, it’s a chance to move away from the traditional visit-based fee system and toward more of a patient-centered medical home model without being part of a pilot project. "It gives them an opportunity within the existing fee schedule to start to do this work and get paid for it," Ms. Erickson said.

The acceptance of the transitional care management codes by CMS is a move in the right direction, said Dr. Jeffrey J. Cain, president of the American Academy of Family Physicians.

"We know that if we can improve communication and improve collaboration as patients come out of the hospital, we can prevent unnecessary readmissions and increase quality of care," Dr. Cain said. "Previously there was no fiscal incentive to do that."

As with all new codes, documentation will be critical. Physicians should be vigilant about documenting appropriately, Ms. Erickson said.

Another challenge will be identifying these patients in a timely fashion – physicians will need to know which of their patients could benefit from these services as they transition home from inpatient or nursing home care, Ms. Erickson said.

Office-based physicians who don’t see patients in the hospital should start building their relationships with their hospitalist colleagues, Dr. Cain advised.

"This is a new way of thinking about those patients," Dr. Cain said. "You’re not waiting for them to walk in your door. You’re actively assisting in their management before they reach your door."

But next year’s fee schedule isn’t all good news. Officials at the Centers for Medicare and Medicaid Services refused to pay for a series of new complex chronic care coordination services codes that were also created by the CPT Editorial Panel earlier this year.

The new codes (99487, 99488, and 99489) were designed for highly complex patients with chronic conditions who are living at home or in an assisted-living facility. The codes would be reported only once per month and would include several non–face-to-face care coordination services such as communicating with the patient and caregiver, collecting health outcomes data and registry documentation, communicating with home health agencies, assessing medication management, and developing and maintaining a comprehensive care plan.

ACP officials plan to continue to push for the codes as part of the next fee schedule. "That’s going to be an ongoing effort," Ms. Erickson said.

While AAFP officials will also continue to lobby for the payment of these codes, Dr. Cain said the family doctors are working on advancing care coordination payment outside of the traditional fee schedule coding framework. For instance, the AAFP has been a big supporter of the Comprehensive Primary Care Initiative, a multipayer pilot project that allows primary care practices to earn a monthly care management fee in exchange for offering enhanced services such as extended hours, use of electronic health records, and coordination of care with other providers. The project is being spearheaded by the Center for Medicare and Medicaid Innovation and, if successful, could be rolled out nationally.

"The real future is moving away from just fee-for-service, hamster-wheel kind of medicine," Dr. Cain said.