Grassroots policymaking demands that hospitalists team up


– Alla Zilbering, MD, sat at attention for hours during HM17, jotting notes like a scribe about the myriad of federal rules that are pretty rapidly pushing hospitalists and health care as a whole away from fee-for-service payments to a world where doctors are paid for quality.

So, why did she do it? Why all that time on policy, instead of practice?

Because Dr. Zilbering felt compelled to get more involved. As a lead hospitalist at Cigna-HealthSpring, a Medicare Advantage program in Philadelphia, she’s already part of initiatives to improve transitions of care and reduce readmissions.

However, she said she wants to do more. “I’m feeling like, unless you actually address the policy, you can’t get that far in terms of what you can physically do with a patient.”

HM17 was the meeting for her, then. SHM, this year, unveiled its first Health Policy Mini Track, dedicated to updating attendees on the implementation of the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA), the Bundled Payments for Care Improvement initiative, and a host of other federal programs. Hospitalists were updated on a litany of advocacy efforts, including observation status, interoperability of electronic health records systems, and the recent launch of the first hospitalist billing code.

Two of the meeting’s three keynote speakers were Washington veterans who confirmed that, while nightly news reports may suggest that health care reforms contained in the Affordable Care Act are constantly in flux, the trajectory toward paying for higher quality care at lower costs shows no signs of abating.

New SHM president Ron Greeno, MD, MHM

New SHM president Ron Greeno, MD, MHM

“There is no appetite, I’m telling you, on either side of the aisle to move away from the plan to create tremendous incentives, to have us move away from fee-for-service and move into alternative payment models,” said new SHM president Ron Greeno, MD, MHM, who also chairs the society’s Public Policy Committee.

Plenary speaker Patrick Conway, MD, MSc, MHM, deputy administrator for innovation and quality at the Centers for Medicare & Medicaid Services and director of its Center for Medicare and Medicaid Innovation, noted that the proposed American Health Care Act doesn’t have a “single word dealing with the Innovation Center,” which is the government agency tasked with supporting the development and testing of new payment and service delivery models.

He added that the policy’s gravitation away from fee-for-service toward alternative payment models will ideally lead to better patient outcomes, more coordinated care, and financial savings. So, he urged hospitalists to continue to help design those new payment and care-delivery systems.

M.A. Williams, MD, FHM, the medical director of perioperative services at Porter Adventist Hospital in Denver, said that the way to help design those systems is to get involved. Policy may seem like an issue for C-suite denizens and wonks, but individual practitioners can make more impact than they think.

“Learn enough to be dangerous and go to your CMO [or] whoever you can get a meeting with because MACRA is going to effect all physicians in the organization, even if the system is not doing anything active about it,” Dr. Williams said. “If you show interest and show that you have a little bit of knowledge, you’d be surprised with what kind of traction you might be able to get.”

And that traction isn’t just within the walls of a given institution, Dr. Greeno said. He wants more hospitalists involved in the society’s overall advocacy efforts. That includes lobbying Congress both in person and with phone calls, letters, and emails and pressuring people at home via conduits like SHM’s Grassroots Network, which has nearly 1,200 members from 490 states.

Don’t think those things work? Dr. Greeno said, one need look no further than the new C6 Medicare billing code for hospitalists that went live in April. That didn’t come to pass without a concentrated effort.

“That was a ton of work by our staff and several years of lobbying,” he said. “We had to be able to explain to them why our data should be treated differently as a specialty and compared only to other hospitalists as opposed to other internists or family practitioners.”

The code will help differentiate hospitalists at a time when MACRA will force changes in how hospitalists are paid. But, it will also define the specialty in a way that has never before been accomplished.

“It is an identity within Medicare,” said Josh Boswell, SHM’s director of government affairs.

While the ACA and the potential repeal of its insurance reforms have taken center stage in the media, Dr. Greeno urged hospitalists to focus more on the implementation and rule-making via MACRA.

The bill, which eliminated the Sustainable Growth Rate formula, states that, starting in 2019, Medicare payments will be provided through one of two pathways. The first is the Merit-based Incentive Payment System that combines the Physician Quality Reporting System, the Physician Value-Based Modifier, and Meaningful Use into a single performance-based payment system.

The second option is Alternative Payment Models, which is meant to incentivize the adoption of payment models that move physicians away from fee-for-service models more quickly. To qualify in this pathway, the criteria require elements of “upside and downside financial risk,” as well as meeting threshold requirements for either patients or payments. Those physicians that meet the criteria qualify for a 5% incentive payment.

The first payments in 2019 are based on performance data for 2017. As most hospitalists won’t quality for APMs in the first year, they will default to the MIPS pathway, Dr. Greeno said.

“This bill will have a greater impact on ... providers than any piece of legislation in our lifetime,” he noted. “Now, the ACA had a bigger impact on consumers, but, in terms of us as providers, MACRA is a sea change.”

The topic is so important, SHM has created a website at that is meant to serve as a tutorial to the law’s basics. The guide is intended to educate hospitalists and to motivate them to get involved in the policy work that affects them all, Dr. Greeno said

“If you don’t know how the system works, you can’t influence it,” he added. “My view of the world is, if you’re not at the table, you’re on the menu.”

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