Although 2019 may seem like a long way away, it isn’t too soon to start thinking about and preparing for the Merit-based Incentive Payment System (MIPS) or its (seemingly preferable) alternative, participation in an alternative payment model (APM) such as an ACO, a medical home, or a bundled payment program.

In April, Congress permanently repealed Medicare’s sustainable growth rate (SGR) formula for controlling physician payment. In yet another sign that we are in the midst of the biggest healthcare transformation in a generation, the 18-year-old SGR formula will be replaced by a far-reaching package of payment reforms. Here we will focus on the MIPS and its alternative, an APM, which involves assuming risk for financial loss or gain and measuring and reporting on quality.

The MIPS replaces three existing quality measurement programs that, to greater and lesser degrees, physicians have struggled with:

• Physician Quality Reporting System (PQRS);
• Value-based payment modifier; and
• Meaningful use of electronic health records.

MIPS will not totally eliminate these programs but will instead incorporate yet-to-be-defined elements of them and, presumably, though it is yet unclear, add new elements. For 2015-2018, the current payment system will remain intact. For 2019, physicians will have a choice. Either they must participate in MIPS, which will likely be complex and involve some administrative burden, or derive at least 25% of their practice revenue from an APM.

For those participating in MIPS, physician payment rates will be subject to an up or down adjustment based on performance in four categories: quality, meaningful use of EHRs, resource use, and clinical practice improvement.

There is an opportunity to avoid MIPS altogether, however. One of the most notable elements of the SGR fix is its push for physicians to participate in APMs such as ACOs, medical homes, bundled payment arrangements, and other payment models now being evaluated by the CMS Innovation Center. Physicians who gain a substantial portion—this means 25% in 2019 and 2020, and likely more thereafter—of their revenue through APMs like these will have the dual benefit of being exempt from MIPS participation and receiving a 5% annual bonus through 2024. After that, physicians in APMs will receive annual fee increases of 0.75%, while all other physicians will receive only a 0.25% increase.¹

Strategic Thinking for Hospitalists: Enter an APM

If you’re asking yourself where you want your hospitalist practice to be in three years, I would suggest the answer is “in an alternative payment model of one kind or another.”

If you are an employed practice, strategic planning will involve assessing the APMs your hospital or health system is participating in and planning how your hospitalist practice can become a formal member of the arrangement.

If you are a freestanding practice, you should become a student of the APM policy coming from the CMS Innovation Center, and determine the best “insertion point” for your practice, such that you gain at least a quarter of your revenue through an APM within three years.

Reference

1. Steinbrook R. The repeal of Medicare’s sustainable growth rate for physician payment. JAMA. 2015;313(20):2025-2026.

Obituary

Remembering Frank Michota, 1967-2015

On June 6, 2015, we lost one of hospital medicine’s original and most creative figures. Frank Michota, MD, FACP, FHM, established the Cleveland Clinic hospital medicine “lineage’” in 1997 and paved the way for hospitalists to be leaders in peri-operative medicine and related disciplines.

Frank founded the “Update in Hospital Medicine” series at SHM annual meetings and in the Annals of Internal Medicine. He was a prolific speaker, writer, and teacher. More than that, Frank was an original kind of persona, one who collaborated often and led frequently, but rarely followed. Yet he had the humility to engage and contribute whenever he was asked.

I had the good fortune of working with him on a number of speaking and writing projects in the early days. I recall his charisma, irreverence, and larger-than-life presence whenever he addressed an audience.

Frank’s signature is etched forever on hospital medicine; our patients and hospitalists everywhere are the lucky beneficiaries of his work.

Although 2019 may seem like a long way away, it isn’t too soon to start thinking about and preparing for the Merit-based Incentive Payment System (MIPS) or its (seemingly preferable) alternative, participation in an alternative payment model (APM) such as an ACO, a medical home, or a bundled payment program.

In April, Congress permanently repealed Medicare’s sustainable growth rate (SGR) formula for controlling physician payment. In yet another sign that we are in the midst of the biggest healthcare transformation in a generation, the 18-year-old SGR formula will be replaced by a far-reaching package of payment reforms. Here we will focus on the MIPS and its alternative, an APM, which involves assuming risk for financial loss or gain and measuring and reporting on quality.

The MIPS replaces three existing quality measurement programs that, to greater and lesser degrees, physicians have struggled with:

• Physician Quality Reporting System (PQRS);
• Value-based payment modifier; and
• Meaningful use of electronic health records.

MIPS will not totally eliminate these programs but will instead incorporate yet-to-be-defined elements of them and, presumably, though it is yet unclear, add new elements. For 2015-2018, the current payment system will remain intact. For 2019, physicians will have a choice. Either they must participate in MIPS, which will likely be complex and involve some administrative burden, or derive at least 25% of their practice revenue from an APM.

For those participating in MIPS, physician payment rates will be subject to an up or down adjustment based on performance in four categories: quality, meaningful use of EHRs, resource use, and clinical practice improvement.

There is an opportunity to avoid MIPS altogether, however. One of the most notable elements of the SGR fix is its push for physicians to participate in APMs such as ACOs, medical homes, bundled payment arrangements, and other payment models now being evaluated by the CMS Innovation Center. Physicians who gain a substantial portion—this means 25% in 2019 and 2020, and likely more thereafter—of their revenue through APMs like these will have the dual benefit of being exempt from MIPS participation and receiving a 5% annual bonus through 2024. After that, physicians in APMs will receive annual fee increases of 0.75%, while all other physicians will receive only a 0.25% increase.¹

Strategic Thinking for Hospitalists: Enter an APM

If you’re asking yourself where you want your hospitalist practice to be in three years, I would suggest the answer is “in an alternative payment model of one kind or another.”

If you are an employed practice, strategic planning will involve assessing the APMs your hospital or health system is participating in and planning how your hospitalist practice can become a formal member of the arrangement.

If you are a freestanding practice, you should become a student of the APM policy coming from the CMS Innovation Center, and determine the best “insertion point” for your practice, such that you gain at least a quarter of your revenue through an APM within three years.

Reference

1. Steinbrook R. The repeal of Medicare’s sustainable growth rate for physician payment. JAMA. 2015;313(20):2025-2026.

Obituary

Remembering Frank Michota, 1967-2015

On June 6, 2015, we lost one of hospital medicine’s original and most creative figures. Frank Michota, MD, FACP, FHM, established the Cleveland Clinic hospital medicine “lineage’” in 1997 and paved the way for hospitalists to be leaders in peri-operative medicine and related disciplines.

Frank founded the “Update in Hospital Medicine” series at SHM annual meetings and in the Annals of Internal Medicine. He was a prolific speaker, writer, and teacher. More than that, Frank was an original kind of persona, one who collaborated often and led frequently, but rarely followed. Yet he had the humility to engage and contribute whenever he was asked.

I had the good fortune of working with him on a number of speaking and writing projects in the early days. I recall his charisma, irreverence, and larger-than-life presence whenever he addressed an audience.

Frank’s signature is etched forever on hospital medicine; our patients and hospitalists everywhere are the lucky beneficiaries of his work.

Although 2019 may seem like a long way away, it isn’t too soon to start thinking about and preparing for the Merit-based Incentive Payment System (MIPS) or its (seemingly preferable) alternative, participation in an alternative payment model (APM) such as an ACO, a medical home, or a bundled payment program.

In April, Congress permanently repealed Medicare’s sustainable growth rate (SGR) formula for controlling physician payment. In yet another sign that we are in the midst of the biggest healthcare transformation in a generation, the 18-year-old SGR formula will be replaced by a far-reaching package of payment reforms. Here we will focus on the MIPS and its alternative, an APM, which involves assuming risk for financial loss or gain and measuring and reporting on quality.

The MIPS replaces three existing quality measurement programs that, to greater and lesser degrees, physicians have struggled with:

• Physician Quality Reporting System (PQRS);
• Value-based payment modifier; and
• Meaningful use of electronic health records.

MIPS will not totally eliminate these programs but will instead incorporate yet-to-be-defined elements of them and, presumably, though it is yet unclear, add new elements. For 2015-2018, the current payment system will remain intact. For 2019, physicians will have a choice. Either they must participate in MIPS, which will likely be complex and involve some administrative burden, or derive at least 25% of their practice revenue from an APM.

For those participating in MIPS, physician payment rates will be subject to an up or down adjustment based on performance in four categories: quality, meaningful use of EHRs, resource use, and clinical practice improvement.

There is an opportunity to avoid MIPS altogether, however. One of the most notable elements of the SGR fix is its push for physicians to participate in APMs such as ACOs, medical homes, bundled payment arrangements, and other payment models now being evaluated by the CMS Innovation Center. Physicians who gain a substantial portion—this means 25% in 2019 and 2020, and likely more thereafter—of their revenue through APMs like these will have the dual benefit of being exempt from MIPS participation and receiving a 5% annual bonus through 2024. After that, physicians in APMs will receive annual fee increases of 0.75%, while all other physicians will receive only a 0.25% increase.¹

Strategic Thinking for Hospitalists: Enter an APM

If you’re asking yourself where you want your hospitalist practice to be in three years, I would suggest the answer is “in an alternative payment model of one kind or another.”

If you are an employed practice, strategic planning will involve assessing the APMs your hospital or health system is participating in and planning how your hospitalist practice can become a formal member of the arrangement.

If you are a freestanding practice, you should become a student of the APM policy coming from the CMS Innovation Center, and determine the best “insertion point” for your practice, such that you gain at least a quarter of your revenue through an APM within three years.

Reference

1. Steinbrook R. The repeal of Medicare’s sustainable growth rate for physician payment. JAMA. 2015;313(20):2025-2026.

Obituary

Remembering Frank Michota, 1967-2015

On June 6, 2015, we lost one of hospital medicine’s original and most creative figures. Frank Michota, MD, FACP, FHM, established the Cleveland Clinic hospital medicine “lineage’” in 1997 and paved the way for hospitalists to be leaders in peri-operative medicine and related disciplines.

Frank founded the “Update in Hospital Medicine” series at SHM annual meetings and in the Annals of Internal Medicine. He was a prolific speaker, writer, and teacher. More than that, Frank was an original kind of persona, one who collaborated often and led frequently, but rarely followed. Yet he had the humility to engage and contribute whenever he was asked.

I had the good fortune of working with him on a number of speaking and writing projects in the early days. I recall his charisma, irreverence, and larger-than-life presence whenever he addressed an audience.

Frank’s signature is etched forever on hospital medicine; our patients and hospitalists everywhere are the lucky beneficiaries of his work.

Ever since 1997, when the federal Balanced Budget Act froze Medicare’s overall funding for graduate medical education, debates have flared regularly over whether and how the U.S. government should support medical resident training.

Discussions about the possible redistribution of billions of dollars are bound to make people nervous, but the controversy reached a fever pitch in 2014 when the Institute of Medicine released a report penned by a 21-member committee that recommended significant—and contentious—changes to the existing graduate medical education (GME) financing and governance structure to “address current deficiencies and better shape the physician workforce for the future.”

Should Medicare shake up the system to redistribute existing training slots to where they’re needed most, as the report recommends? Should it instead lift its funding cap to avert a potential bottleneck in the physician pipeline, as several medical associations have requested? One year later, the report has gained little traction amid a largely unchanged status quo that few experts believe is ultimately sustainable. The continuing debate, however, has prompted fresh questions about whether the current GME structure is adequately supporting the nation’s healthcare needs and has spurred widespread agreement on the need for greater transparency, accountability, and innovation.

Deborah Powell, MD, dean emerita of the University of Minnesota Medical School and one of the report’s co-authors, says she has seen firsthand the challenges arising from a lack of physicians in multiple specialties, especially in rural areas. “We believed that simply adding new money to a system that is outdated would not solve the issues in physician education and physician workforce,” she says.

Some HM leaders and other physicians’ groups have cautiously welcomed the report’s focus on better equipping doctors for a rapidly changing reality.

“It wasn’t wrong for them to look at this,” says Darlene B. Tad-y, MD, FHM, chair of the SHM Physicians in Training Committee and assistant professor of medicine at the University of Colorado in Denver. “And it’s probably not wrong for them to propose new ways to think about how we fund GME.”

In fact, she says, efforts to align such funding with healthcare funding in general could be timely in the face of added pressures like ensuring that new insurance beneficiaries have access to primary care.

Scott Sears, MD, FACP, MBA, chief clinical officer of Tacoma, Wash.-based hospitalist management firm Sound Physicians, says healthcare is also moving rapidly toward managing populations as part of team-based care that increases quality while lowering costs. So why not better align GME with innovative Medicare initiatives like bundled payments, he asks, and then use the savings to reward those training programs that accept the risk and achieve results?

“Shifting some of our education to match what Medicare is trying to drive out in the real world, I think, is long overdue,” Dr. Sears says.

Other groups, such as the Association of American Medical Colleges, however, contend that the report’s prescriptions are far less helpful than its diagnoses. “Politically, there’s just stuff in there for everybody to hate,” says Atul Grover, MD, PhD, FACP, FCCP, the AAMC’s chief public policy officer. “I think [the IOM report] did a decent job of pointing out some of the things that we want to improve moving forward, but I’m not sure that the answers are quite right.”

An Uneven Funding Landscape

The strong opinions engendered by the topic underscore the high stakes involved in GME. Every year, the federal government doles out about $15 billion for residency training, including about $10 billion from Medicare coffers. Medicare’s share is divided into two main funding streams that flow primarily to academic medical centers: direct graduate medical education (DGME) and indirect medical education (IME) payments. The first covers training expenses, while the second reimburses teaching hospitals that care for Medicare patients while training residents.

Some skeptics have questioned whether the government should be funding medical education at all, noting that the arrangement is utterly unique to the field. Advocates have countered that the funding concept was embedded in the original Medicare legislation and that it correctly recognized the added cost of offering GME training while providing more complex Medicare beneficiaries with specialty services.

Nearly everyone acknowledges that there are still enough residency slots for all U.S. graduates, but Dr. Grover says residency programs aren’t growing nearly fast enough to keep pace with medical school enrollment, creating a growing mismatch and a looming bottleneck in the supply chain. Compared to medical school numbers in 2002, for example, the AAMC says enrollment is on track to expand 29% by 2019, while osteopathic schools are set to expand by 162% over the same timeframe.

It wasn’t wrong for the [Institute of Medicine] to look at this. And it’s probably not wrong for them to propose new ways to think about how we fund GME.

—Darlene B. Tad-y, MD, FHM, assistant professor of medicine, University of Colorado, Denver, chair, SHM Physicians in Training Committee

Fundamentally, the idea is not a bad one, to say that programs that were more aligned with national needs and priorities in terms of how they train physicians would get more funding, and those that did not wouldn’t. I think the challenge is that the devil’s in the details of how you do that.

—Vikas Parekh, MD, FACP, SFHM, associate director, hospitalist program, University of Michigan, Ann Arbor, chair, SHM Academic Hospitalist Committee

Despite the continued freeze in Medicare funding, many large medical institutions continue to add residency spots.

“We’ve been hundreds of residency positions over our cap for a very long time,” says Vikas Parekh, MD, FACP, SFHM, associate director of the hospitalist program at the University of Michigan in Ann Arbor. “The hospital funds them through hospital operating margin because in the net, they still view the investment as worthwhile.”

Alternatively, some non-university-based training programs have secured money from other sources to fund their residency positions, potentially creating new funding models for the future if the programs can demonstrate both quality and stability.

One key rationale for the IOM report’s proposed overhaul, however, is the longstanding and sizeable geographical disparity in Medicare’s per capita GME spending, which has skewed heavily toward the Northeast. A 2013 study, in fact, found that one-fifth of all DGME funding in 2010—an estimated $2 billion—went to New York State alone.¹ Florida, which recently overtook New York as the third most populous state, received only one-eighth as much money. And Mississippi—the state with the lowest doctor-to-patient ratio—received only $22 million, or about one-ninetieth as much.

The IOM report also suggests that the long-standing GME payment plan has yielded little data on whether it actually accomplishes what it was designed to do: help establish a well-prepared medical workforce in a cost-effective way. In response, one major IOM recommendation is to maintain the overall level of Medicare support but tie some of the payments to performance to ensure oversight and accountability, and provide new incentives for innovation in the content and financing of training programs.

As with other CMS initiatives, however, getting everyone to agree on which quality metrics to use in evaluating GME training could take awhile. For example, should Medicare judge the performance of the trainees, the GME programs, or even the sponsoring institutions? Despite the proliferation of performance-based carrots and sticks elsewhere in healthcare, Dr. Tad-y says, such incentives may work less well for GME.

“One thing that’s inherent with trainees is that they’re trainees,” she says. “They’re not as efficient or as effective as someone who’s an expert, right? That’s why it’s training.”

Dr. Parekh, who also serves as chair of the SHM Academic Hospitalist Committee, agrees that finding the right outcome measures could be tough. “It gets very dicey, because how do you define who’s a good doctor?” he says. Currently, residents often are assessed via the reputation and history of the training program. “People say, ‘I know that the people coming out of that program are good because they’ve always been good, and it’s a reputable program and has a big name.’ But it’s not objective data,” he says.

Dr. Sears, of Sound Physicians, notes that it’s also often difficult to attribute patients to specific providers.

“Many times in graduate medical education, patients are going in and out of the program or in and out of the hospital, and how do you attribute?” he says. “I think it becomes very complex.”

A New Take on Transformation

Another IOM recommendation would create a single GME fund with two subsidiaries: an operational fund for ongoing support and a transformation fund. The latter fund would finance four new initiatives to:

• Develop and evaluate innovative GME programs;
• Determine and validate appropriate performance measures;
• Establish pilot projects to test out alternative payment methods; and
• Award new training positions based on priority disciplines—such as primary care—and underserved geographic areas.

A related recommendation seeks to modernize the GME payment methodology. For example, the committee urged Medicare to combine the indirect and direct funding streams into one payment based on a national per-resident amount and adjusted according to each location. In addition, the report endorsed performance-based payments based on the results of pilots launched under the transformation fund.

Dr. Sears says he appreciates the report’s effort to address shortfalls in primary care providers relative to specialists. “That’s not to say that specialty medicine isn’t incredibly important, because it is,” he says. “But I think incentivizing or reallocating spots to ensure that we have adequate primary care physician coverage throughout the country will have tremendous impact on the ability to care for an aging population in the United States, at least.”

I have had physicians tell me that they do not understand why our report said that there was not a physician shortage, and I try to point out that we did NOT say that. Rather, the report [and the committee] said that we could not find compelling evidence of an impending physician shortage and that physician workforce projections had been and are quite unreliable. —Deborah Powell, MD, dean emerita, University of Minnesota Medical School, IOM committee member

Shifting some of our [medical] education to match what Medicare is trying to drive out in the real world, I think, is long overdue. —Scott Sears, MD, FACP, MBA, chief clinical officer, Sound Physicians, Tacoma, Wash.

Dr. Parekh agrees, at least in part.

“Fundamentally, the idea is not a bad one, to say that programs that were more aligned with national needs and priorities in terms of how they train physicians would get more funding, and those that did not wouldn’t,” he says. “I think the challenge is that the devil’s in the details of how you do that.”

A priority-based GME system, he continues, could potentially influence what type of physicians are trained.

“In my mind, it’s not irrational to think that if GME funding was more targeted around expanding slots in certain specialties and not expanding slots in other specialties, that there would be some ability to influence the workforce,” Dr. Parekh says. Influencing where residents go may be more difficult, though a growing mismatch between medical graduates and available residency slots might add a new wrinkle to that debate, as well.

Currently, U.S. medical graduates fill only about 60% of residency slots for specialties like internal medicine—a main conduit for hospital medicine—while foreign graduates make up the remainder.

“So who’s the first that’s going to be squeezed out? It will be foreign medical graduates,” Dr. Parekh says. Many of those graduates come to the U.S. on J-1 visas, which carry a payback requirement: practicing in underserved areas. “One worry is, will rural and underserved areas suffer from a physician shortage because U.S. grads won’t want to work there after you start squeezing out all of the foreign medical grads?” he asks.

Clear Line of Sight?

Dr. Parekh also supports efforts to establish a clearer connection between the funding’s intent and where the money actually goes. The IOM report’s proposal to do so, however, raises yet another controversy around the true purpose of IME funding. Teaching hospitals argue that the money should continue to be used to reimburse them for the added costs of providing comprehensive and specialized care like level I trauma centers to their more complex Medicare patient populations.

Number one, [the IOM] came out and said, ‘We don’t know that there’s a shortage of physicians and we’re, if anything, going to remove money from the training system rather than putting in additional resources. We found that problematic, given all the evidence we have of the growing, aging population. —Atul Grover, MD, PhD, FACP, FCCP, chief public policy officer, Association of American Medical Colleges

A big part of the problem here is that people are free agents. If you make more residency spots, but the economics are such that people decide to become cardiologists because cardiologists make twice or more what hospitalists make, then you may have increased residency spots but [added only] a very small increment in the number of hospitalists. —Daniel Brotman, MD, FACP, SFHM, chair, SHM Education Committee, director, hospitalist program, Johns Hopkins Hospital, Baltimore

Accordingly, the AAMC panned the report’s recommendation to replace separate IME funding with a single fund directed toward the GME sponsoring institution and subdivided instead into the operational and transformation funds. Dr. Grover says setting up a transformation fund with new money would make sense, but not as a carve-out from existing support.

“You’re removing those resources from the system and not replacing them, which is a challenge,” he says.

Medical schools are more inclined to want the money directed toward training goals, especially if they are to be held accountable for GME outcomes. “Right now, the hospital gets it, and it’s basically somewhere in the bottom line,” Dr. Parekh says. “No one really knows where that money goes. There’s very little accountability or clarity of purpose for that dollar.”

Amid the ongoing debate, the call for more transparency and accountability in GME seems to be gaining the most ground. “I don’t see tons of downside from it,” Dr. Parekh says. “I think it sheds light on the current funding environment and makes people have to justify a little bit more what they’re doing with that money.”

Dr. Tad-y puts it this way: “If you made your own budget at home, the first thing you’d do is try to figure out where all your money goes and what you’re spending your money on.” If Medicare is concerned that its GME money isn’t being spent wisely, then, the first step would be to do some accounting. “And that means a little bit of transparency,” she says. “I don’t think that’s a bad thing, to know exactly what we’re paying for; that makes sense. I mean, we do that for everything else.”

SHM and most other medical associations also agree on the necessary goal of increasing the nation’s primary care capacity, even if they differ on the details of how best to do so. In the long run, however, some observers say growing the workforce—whether that of primary care providers or of hospitalists—may depend less on the total number of residency spots and more on the enthusiasm of program leadership and the attractiveness of job conditions such as salary and workload.

“A big part of the problem here is that people are free agents,” says Daniel Brotman, MD, FACP, SFHM, chair of the SHM Education Committee and director of the hospitalist program at the Johns Hopkins Hospital in Baltimore. “If you make more residency spots, but the economics are such that people decide to become cardiologists because cardiologists make twice or more what hospitalists make, then you may have increased residency spots but [added only] a very small increment in the number of hospitalists.”

Whatever happens, Dr. Parekh says hospitalists are well positioned to be integral parts of improving quality, accountability, and innovation in residency training programs.

“I think if more GME money is targeted toward the outcomes of the GME programs, hospitalists are going to be tapped to help with that work, in terms of training and broadening their skill sets,” he says. “So I think it’s a great opportunity.”

Bryn Nelson is a freelance medical writer in Seattle.

References

1. Mullan F, Chen C, Steinmetz E. The geography of graduate medical education: imbalances signal need for new distribution policies. Health Aff. 2013;32(11):1914-1921.

Ever since 1997, when the federal Balanced Budget Act froze Medicare’s overall funding for graduate medical education, debates have flared regularly over whether and how the U.S. government should support medical resident training.

Discussions about the possible redistribution of billions of dollars are bound to make people nervous, but the controversy reached a fever pitch in 2014 when the Institute of Medicine released a report penned by a 21-member committee that recommended significant—and contentious—changes to the existing graduate medical education (GME) financing and governance structure to “address current deficiencies and better shape the physician workforce for the future.”

Should Medicare shake up the system to redistribute existing training slots to where they’re needed most, as the report recommends? Should it instead lift its funding cap to avert a potential bottleneck in the physician pipeline, as several medical associations have requested? One year later, the report has gained little traction amid a largely unchanged status quo that few experts believe is ultimately sustainable. The continuing debate, however, has prompted fresh questions about whether the current GME structure is adequately supporting the nation’s healthcare needs and has spurred widespread agreement on the need for greater transparency, accountability, and innovation.

Deborah Powell, MD, dean emerita of the University of Minnesota Medical School and one of the report’s co-authors, says she has seen firsthand the challenges arising from a lack of physicians in multiple specialties, especially in rural areas. “We believed that simply adding new money to a system that is outdated would not solve the issues in physician education and physician workforce,” she says.

Some HM leaders and other physicians’ groups have cautiously welcomed the report’s focus on better equipping doctors for a rapidly changing reality.

“It wasn’t wrong for them to look at this,” says Darlene B. Tad-y, MD, FHM, chair of the SHM Physicians in Training Committee and assistant professor of medicine at the University of Colorado in Denver. “And it’s probably not wrong for them to propose new ways to think about how we fund GME.”

In fact, she says, efforts to align such funding with healthcare funding in general could be timely in the face of added pressures like ensuring that new insurance beneficiaries have access to primary care.

Scott Sears, MD, FACP, MBA, chief clinical officer of Tacoma, Wash.-based hospitalist management firm Sound Physicians, says healthcare is also moving rapidly toward managing populations as part of team-based care that increases quality while lowering costs. So why not better align GME with innovative Medicare initiatives like bundled payments, he asks, and then use the savings to reward those training programs that accept the risk and achieve results?

“Shifting some of our education to match what Medicare is trying to drive out in the real world, I think, is long overdue,” Dr. Sears says.

Other groups, such as the Association of American Medical Colleges, however, contend that the report’s prescriptions are far less helpful than its diagnoses. “Politically, there’s just stuff in there for everybody to hate,” says Atul Grover, MD, PhD, FACP, FCCP, the AAMC’s chief public policy officer. “I think [the IOM report] did a decent job of pointing out some of the things that we want to improve moving forward, but I’m not sure that the answers are quite right.”

An Uneven Funding Landscape

The strong opinions engendered by the topic underscore the high stakes involved in GME. Every year, the federal government doles out about $15 billion for residency training, including about $10 billion from Medicare coffers. Medicare’s share is divided into two main funding streams that flow primarily to academic medical centers: direct graduate medical education (DGME) and indirect medical education (IME) payments. The first covers training expenses, while the second reimburses teaching hospitals that care for Medicare patients while training residents.

Some skeptics have questioned whether the government should be funding medical education at all, noting that the arrangement is utterly unique to the field. Advocates have countered that the funding concept was embedded in the original Medicare legislation and that it correctly recognized the added cost of offering GME training while providing more complex Medicare beneficiaries with specialty services.

Nearly everyone acknowledges that there are still enough residency slots for all U.S. graduates, but Dr. Grover says residency programs aren’t growing nearly fast enough to keep pace with medical school enrollment, creating a growing mismatch and a looming bottleneck in the supply chain. Compared to medical school numbers in 2002, for example, the AAMC says enrollment is on track to expand 29% by 2019, while osteopathic schools are set to expand by 162% over the same timeframe.

It wasn’t wrong for the [Institute of Medicine] to look at this. And it’s probably not wrong for them to propose new ways to think about how we fund GME.

—Darlene B. Tad-y, MD, FHM, assistant professor of medicine, University of Colorado, Denver, chair, SHM Physicians in Training Committee

Fundamentally, the idea is not a bad one, to say that programs that were more aligned with national needs and priorities in terms of how they train physicians would get more funding, and those that did not wouldn’t. I think the challenge is that the devil’s in the details of how you do that.

—Vikas Parekh, MD, FACP, SFHM, associate director, hospitalist program, University of Michigan, Ann Arbor, chair, SHM Academic Hospitalist Committee

Despite the continued freeze in Medicare funding, many large medical institutions continue to add residency spots.

“We’ve been hundreds of residency positions over our cap for a very long time,” says Vikas Parekh, MD, FACP, SFHM, associate director of the hospitalist program at the University of Michigan in Ann Arbor. “The hospital funds them through hospital operating margin because in the net, they still view the investment as worthwhile.”

Alternatively, some non-university-based training programs have secured money from other sources to fund their residency positions, potentially creating new funding models for the future if the programs can demonstrate both quality and stability.

One key rationale for the IOM report’s proposed overhaul, however, is the longstanding and sizeable geographical disparity in Medicare’s per capita GME spending, which has skewed heavily toward the Northeast. A 2013 study, in fact, found that one-fifth of all DGME funding in 2010—an estimated $2 billion—went to New York State alone.¹ Florida, which recently overtook New York as the third most populous state, received only one-eighth as much money. And Mississippi—the state with the lowest doctor-to-patient ratio—received only $22 million, or about one-ninetieth as much.

The IOM report also suggests that the long-standing GME payment plan has yielded little data on whether it actually accomplishes what it was designed to do: help establish a well-prepared medical workforce in a cost-effective way. In response, one major IOM recommendation is to maintain the overall level of Medicare support but tie some of the payments to performance to ensure oversight and accountability, and provide new incentives for innovation in the content and financing of training programs.

As with other CMS initiatives, however, getting everyone to agree on which quality metrics to use in evaluating GME training could take awhile. For example, should Medicare judge the performance of the trainees, the GME programs, or even the sponsoring institutions? Despite the proliferation of performance-based carrots and sticks elsewhere in healthcare, Dr. Tad-y says, such incentives may work less well for GME.

“One thing that’s inherent with trainees is that they’re trainees,” she says. “They’re not as efficient or as effective as someone who’s an expert, right? That’s why it’s training.”

Dr. Parekh, who also serves as chair of the SHM Academic Hospitalist Committee, agrees that finding the right outcome measures could be tough. “It gets very dicey, because how do you define who’s a good doctor?” he says. Currently, residents often are assessed via the reputation and history of the training program. “People say, ‘I know that the people coming out of that program are good because they’ve always been good, and it’s a reputable program and has a big name.’ But it’s not objective data,” he says.

Dr. Sears, of Sound Physicians, notes that it’s also often difficult to attribute patients to specific providers.

“Many times in graduate medical education, patients are going in and out of the program or in and out of the hospital, and how do you attribute?” he says. “I think it becomes very complex.”

A New Take on Transformation

Another IOM recommendation would create a single GME fund with two subsidiaries: an operational fund for ongoing support and a transformation fund. The latter fund would finance four new initiatives to:

• Develop and evaluate innovative GME programs;
• Determine and validate appropriate performance measures;
• Establish pilot projects to test out alternative payment methods; and
• Award new training positions based on priority disciplines—such as primary care—and underserved geographic areas.

A related recommendation seeks to modernize the GME payment methodology. For example, the committee urged Medicare to combine the indirect and direct funding streams into one payment based on a national per-resident amount and adjusted according to each location. In addition, the report endorsed performance-based payments based on the results of pilots launched under the transformation fund.

Dr. Sears says he appreciates the report’s effort to address shortfalls in primary care providers relative to specialists. “That’s not to say that specialty medicine isn’t incredibly important, because it is,” he says. “But I think incentivizing or reallocating spots to ensure that we have adequate primary care physician coverage throughout the country will have tremendous impact on the ability to care for an aging population in the United States, at least.”

I have had physicians tell me that they do not understand why our report said that there was not a physician shortage, and I try to point out that we did NOT say that. Rather, the report [and the committee] said that we could not find compelling evidence of an impending physician shortage and that physician workforce projections had been and are quite unreliable. —Deborah Powell, MD, dean emerita, University of Minnesota Medical School, IOM committee member

Shifting some of our [medical] education to match what Medicare is trying to drive out in the real world, I think, is long overdue. —Scott Sears, MD, FACP, MBA, chief clinical officer, Sound Physicians, Tacoma, Wash.

Dr. Parekh agrees, at least in part.

“Fundamentally, the idea is not a bad one, to say that programs that were more aligned with national needs and priorities in terms of how they train physicians would get more funding, and those that did not wouldn’t,” he says. “I think the challenge is that the devil’s in the details of how you do that.”

A priority-based GME system, he continues, could potentially influence what type of physicians are trained.

“In my mind, it’s not irrational to think that if GME funding was more targeted around expanding slots in certain specialties and not expanding slots in other specialties, that there would be some ability to influence the workforce,” Dr. Parekh says. Influencing where residents go may be more difficult, though a growing mismatch between medical graduates and available residency slots might add a new wrinkle to that debate, as well.

Currently, U.S. medical graduates fill only about 60% of residency slots for specialties like internal medicine—a main conduit for hospital medicine—while foreign graduates make up the remainder.

“So who’s the first that’s going to be squeezed out? It will be foreign medical graduates,” Dr. Parekh says. Many of those graduates come to the U.S. on J-1 visas, which carry a payback requirement: practicing in underserved areas. “One worry is, will rural and underserved areas suffer from a physician shortage because U.S. grads won’t want to work there after you start squeezing out all of the foreign medical grads?” he asks.

Clear Line of Sight?

Dr. Parekh also supports efforts to establish a clearer connection between the funding’s intent and where the money actually goes. The IOM report’s proposal to do so, however, raises yet another controversy around the true purpose of IME funding. Teaching hospitals argue that the money should continue to be used to reimburse them for the added costs of providing comprehensive and specialized care like level I trauma centers to their more complex Medicare patient populations.

Number one, [the IOM] came out and said, ‘We don’t know that there’s a shortage of physicians and we’re, if anything, going to remove money from the training system rather than putting in additional resources. We found that problematic, given all the evidence we have of the growing, aging population. —Atul Grover, MD, PhD, FACP, FCCP, chief public policy officer, Association of American Medical Colleges

A big part of the problem here is that people are free agents. If you make more residency spots, but the economics are such that people decide to become cardiologists because cardiologists make twice or more what hospitalists make, then you may have increased residency spots but [added only] a very small increment in the number of hospitalists. —Daniel Brotman, MD, FACP, SFHM, chair, SHM Education Committee, director, hospitalist program, Johns Hopkins Hospital, Baltimore

Accordingly, the AAMC panned the report’s recommendation to replace separate IME funding with a single fund directed toward the GME sponsoring institution and subdivided instead into the operational and transformation funds. Dr. Grover says setting up a transformation fund with new money would make sense, but not as a carve-out from existing support.

“You’re removing those resources from the system and not replacing them, which is a challenge,” he says.

Medical schools are more inclined to want the money directed toward training goals, especially if they are to be held accountable for GME outcomes. “Right now, the hospital gets it, and it’s basically somewhere in the bottom line,” Dr. Parekh says. “No one really knows where that money goes. There’s very little accountability or clarity of purpose for that dollar.”

Amid the ongoing debate, the call for more transparency and accountability in GME seems to be gaining the most ground. “I don’t see tons of downside from it,” Dr. Parekh says. “I think it sheds light on the current funding environment and makes people have to justify a little bit more what they’re doing with that money.”

Dr. Tad-y puts it this way: “If you made your own budget at home, the first thing you’d do is try to figure out where all your money goes and what you’re spending your money on.” If Medicare is concerned that its GME money isn’t being spent wisely, then, the first step would be to do some accounting. “And that means a little bit of transparency,” she says. “I don’t think that’s a bad thing, to know exactly what we’re paying for; that makes sense. I mean, we do that for everything else.”

SHM and most other medical associations also agree on the necessary goal of increasing the nation’s primary care capacity, even if they differ on the details of how best to do so. In the long run, however, some observers say growing the workforce—whether that of primary care providers or of hospitalists—may depend less on the total number of residency spots and more on the enthusiasm of program leadership and the attractiveness of job conditions such as salary and workload.

“A big part of the problem here is that people are free agents,” says Daniel Brotman, MD, FACP, SFHM, chair of the SHM Education Committee and director of the hospitalist program at the Johns Hopkins Hospital in Baltimore. “If you make more residency spots, but the economics are such that people decide to become cardiologists because cardiologists make twice or more what hospitalists make, then you may have increased residency spots but [added only] a very small increment in the number of hospitalists.”

Whatever happens, Dr. Parekh says hospitalists are well positioned to be integral parts of improving quality, accountability, and innovation in residency training programs.

“I think if more GME money is targeted toward the outcomes of the GME programs, hospitalists are going to be tapped to help with that work, in terms of training and broadening their skill sets,” he says. “So I think it’s a great opportunity.”

Bryn Nelson is a freelance medical writer in Seattle.

References

1. Mullan F, Chen C, Steinmetz E. The geography of graduate medical education: imbalances signal need for new distribution policies. Health Aff. 2013;32(11):1914-1921.

Ever since 1997, when the federal Balanced Budget Act froze Medicare’s overall funding for graduate medical education, debates have flared regularly over whether and how the U.S. government should support medical resident training.

Discussions about the possible redistribution of billions of dollars are bound to make people nervous, but the controversy reached a fever pitch in 2014 when the Institute of Medicine released a report penned by a 21-member committee that recommended significant—and contentious—changes to the existing graduate medical education (GME) financing and governance structure to “address current deficiencies and better shape the physician workforce for the future.”

Should Medicare shake up the system to redistribute existing training slots to where they’re needed most, as the report recommends? Should it instead lift its funding cap to avert a potential bottleneck in the physician pipeline, as several medical associations have requested? One year later, the report has gained little traction amid a largely unchanged status quo that few experts believe is ultimately sustainable. The continuing debate, however, has prompted fresh questions about whether the current GME structure is adequately supporting the nation’s healthcare needs and has spurred widespread agreement on the need for greater transparency, accountability, and innovation.

Deborah Powell, MD, dean emerita of the University of Minnesota Medical School and one of the report’s co-authors, says she has seen firsthand the challenges arising from a lack of physicians in multiple specialties, especially in rural areas. “We believed that simply adding new money to a system that is outdated would not solve the issues in physician education and physician workforce,” she says.

Some HM leaders and other physicians’ groups have cautiously welcomed the report’s focus on better equipping doctors for a rapidly changing reality.

“It wasn’t wrong for them to look at this,” says Darlene B. Tad-y, MD, FHM, chair of the SHM Physicians in Training Committee and assistant professor of medicine at the University of Colorado in Denver. “And it’s probably not wrong for them to propose new ways to think about how we fund GME.”

In fact, she says, efforts to align such funding with healthcare funding in general could be timely in the face of added pressures like ensuring that new insurance beneficiaries have access to primary care.

Scott Sears, MD, FACP, MBA, chief clinical officer of Tacoma, Wash.-based hospitalist management firm Sound Physicians, says healthcare is also moving rapidly toward managing populations as part of team-based care that increases quality while lowering costs. So why not better align GME with innovative Medicare initiatives like bundled payments, he asks, and then use the savings to reward those training programs that accept the risk and achieve results?

“Shifting some of our education to match what Medicare is trying to drive out in the real world, I think, is long overdue,” Dr. Sears says.

Other groups, such as the Association of American Medical Colleges, however, contend that the report’s prescriptions are far less helpful than its diagnoses. “Politically, there’s just stuff in there for everybody to hate,” says Atul Grover, MD, PhD, FACP, FCCP, the AAMC’s chief public policy officer. “I think [the IOM report] did a decent job of pointing out some of the things that we want to improve moving forward, but I’m not sure that the answers are quite right.”

An Uneven Funding Landscape

The strong opinions engendered by the topic underscore the high stakes involved in GME. Every year, the federal government doles out about $15 billion for residency training, including about $10 billion from Medicare coffers. Medicare’s share is divided into two main funding streams that flow primarily to academic medical centers: direct graduate medical education (DGME) and indirect medical education (IME) payments. The first covers training expenses, while the second reimburses teaching hospitals that care for Medicare patients while training residents.

Some skeptics have questioned whether the government should be funding medical education at all, noting that the arrangement is utterly unique to the field. Advocates have countered that the funding concept was embedded in the original Medicare legislation and that it correctly recognized the added cost of offering GME training while providing more complex Medicare beneficiaries with specialty services.

Nearly everyone acknowledges that there are still enough residency slots for all U.S. graduates, but Dr. Grover says residency programs aren’t growing nearly fast enough to keep pace with medical school enrollment, creating a growing mismatch and a looming bottleneck in the supply chain. Compared to medical school numbers in 2002, for example, the AAMC says enrollment is on track to expand 29% by 2019, while osteopathic schools are set to expand by 162% over the same timeframe.

It wasn’t wrong for the [Institute of Medicine] to look at this. And it’s probably not wrong for them to propose new ways to think about how we fund GME.

—Darlene B. Tad-y, MD, FHM, assistant professor of medicine, University of Colorado, Denver, chair, SHM Physicians in Training Committee

Fundamentally, the idea is not a bad one, to say that programs that were more aligned with national needs and priorities in terms of how they train physicians would get more funding, and those that did not wouldn’t. I think the challenge is that the devil’s in the details of how you do that.

—Vikas Parekh, MD, FACP, SFHM, associate director, hospitalist program, University of Michigan, Ann Arbor, chair, SHM Academic Hospitalist Committee

Despite the continued freeze in Medicare funding, many large medical institutions continue to add residency spots.

“We’ve been hundreds of residency positions over our cap for a very long time,” says Vikas Parekh, MD, FACP, SFHM, associate director of the hospitalist program at the University of Michigan in Ann Arbor. “The hospital funds them through hospital operating margin because in the net, they still view the investment as worthwhile.”

Alternatively, some non-university-based training programs have secured money from other sources to fund their residency positions, potentially creating new funding models for the future if the programs can demonstrate both quality and stability.

One key rationale for the IOM report’s proposed overhaul, however, is the longstanding and sizeable geographical disparity in Medicare’s per capita GME spending, which has skewed heavily toward the Northeast. A 2013 study, in fact, found that one-fifth of all DGME funding in 2010—an estimated $2 billion—went to New York State alone.¹ Florida, which recently overtook New York as the third most populous state, received only one-eighth as much money. And Mississippi—the state with the lowest doctor-to-patient ratio—received only $22 million, or about one-ninetieth as much.

The IOM report also suggests that the long-standing GME payment plan has yielded little data on whether it actually accomplishes what it was designed to do: help establish a well-prepared medical workforce in a cost-effective way. In response, one major IOM recommendation is to maintain the overall level of Medicare support but tie some of the payments to performance to ensure oversight and accountability, and provide new incentives for innovation in the content and financing of training programs.

As with other CMS initiatives, however, getting everyone to agree on which quality metrics to use in evaluating GME training could take awhile. For example, should Medicare judge the performance of the trainees, the GME programs, or even the sponsoring institutions? Despite the proliferation of performance-based carrots and sticks elsewhere in healthcare, Dr. Tad-y says, such incentives may work less well for GME.

“One thing that’s inherent with trainees is that they’re trainees,” she says. “They’re not as efficient or as effective as someone who’s an expert, right? That’s why it’s training.”

Dr. Parekh, who also serves as chair of the SHM Academic Hospitalist Committee, agrees that finding the right outcome measures could be tough. “It gets very dicey, because how do you define who’s a good doctor?” he says. Currently, residents often are assessed via the reputation and history of the training program. “People say, ‘I know that the people coming out of that program are good because they’ve always been good, and it’s a reputable program and has a big name.’ But it’s not objective data,” he says.

Dr. Sears, of Sound Physicians, notes that it’s also often difficult to attribute patients to specific providers.

“Many times in graduate medical education, patients are going in and out of the program or in and out of the hospital, and how do you attribute?” he says. “I think it becomes very complex.”

A New Take on Transformation

Another IOM recommendation would create a single GME fund with two subsidiaries: an operational fund for ongoing support and a transformation fund. The latter fund would finance four new initiatives to:

• Develop and evaluate innovative GME programs;
• Determine and validate appropriate performance measures;
• Establish pilot projects to test out alternative payment methods; and
• Award new training positions based on priority disciplines—such as primary care—and underserved geographic areas.

A related recommendation seeks to modernize the GME payment methodology. For example, the committee urged Medicare to combine the indirect and direct funding streams into one payment based on a national per-resident amount and adjusted according to each location. In addition, the report endorsed performance-based payments based on the results of pilots launched under the transformation fund.

Dr. Sears says he appreciates the report’s effort to address shortfalls in primary care providers relative to specialists. “That’s not to say that specialty medicine isn’t incredibly important, because it is,” he says. “But I think incentivizing or reallocating spots to ensure that we have adequate primary care physician coverage throughout the country will have tremendous impact on the ability to care for an aging population in the United States, at least.”

I have had physicians tell me that they do not understand why our report said that there was not a physician shortage, and I try to point out that we did NOT say that. Rather, the report [and the committee] said that we could not find compelling evidence of an impending physician shortage and that physician workforce projections had been and are quite unreliable. —Deborah Powell, MD, dean emerita, University of Minnesota Medical School, IOM committee member

Shifting some of our [medical] education to match what Medicare is trying to drive out in the real world, I think, is long overdue. —Scott Sears, MD, FACP, MBA, chief clinical officer, Sound Physicians, Tacoma, Wash.

Dr. Parekh agrees, at least in part.

“Fundamentally, the idea is not a bad one, to say that programs that were more aligned with national needs and priorities in terms of how they train physicians would get more funding, and those that did not wouldn’t,” he says. “I think the challenge is that the devil’s in the details of how you do that.”

A priority-based GME system, he continues, could potentially influence what type of physicians are trained.

“In my mind, it’s not irrational to think that if GME funding was more targeted around expanding slots in certain specialties and not expanding slots in other specialties, that there would be some ability to influence the workforce,” Dr. Parekh says. Influencing where residents go may be more difficult, though a growing mismatch between medical graduates and available residency slots might add a new wrinkle to that debate, as well.

Currently, U.S. medical graduates fill only about 60% of residency slots for specialties like internal medicine—a main conduit for hospital medicine—while foreign graduates make up the remainder.

“So who’s the first that’s going to be squeezed out? It will be foreign medical graduates,” Dr. Parekh says. Many of those graduates come to the U.S. on J-1 visas, which carry a payback requirement: practicing in underserved areas. “One worry is, will rural and underserved areas suffer from a physician shortage because U.S. grads won’t want to work there after you start squeezing out all of the foreign medical grads?” he asks.

Clear Line of Sight?

Dr. Parekh also supports efforts to establish a clearer connection between the funding’s intent and where the money actually goes. The IOM report’s proposal to do so, however, raises yet another controversy around the true purpose of IME funding. Teaching hospitals argue that the money should continue to be used to reimburse them for the added costs of providing comprehensive and specialized care like level I trauma centers to their more complex Medicare patient populations.

Number one, [the IOM] came out and said, ‘We don’t know that there’s a shortage of physicians and we’re, if anything, going to remove money from the training system rather than putting in additional resources. We found that problematic, given all the evidence we have of the growing, aging population. —Atul Grover, MD, PhD, FACP, FCCP, chief public policy officer, Association of American Medical Colleges

A big part of the problem here is that people are free agents. If you make more residency spots, but the economics are such that people decide to become cardiologists because cardiologists make twice or more what hospitalists make, then you may have increased residency spots but [added only] a very small increment in the number of hospitalists. —Daniel Brotman, MD, FACP, SFHM, chair, SHM Education Committee, director, hospitalist program, Johns Hopkins Hospital, Baltimore

Accordingly, the AAMC panned the report’s recommendation to replace separate IME funding with a single fund directed toward the GME sponsoring institution and subdivided instead into the operational and transformation funds. Dr. Grover says setting up a transformation fund with new money would make sense, but not as a carve-out from existing support.

“You’re removing those resources from the system and not replacing them, which is a challenge,” he says.

Medical schools are more inclined to want the money directed toward training goals, especially if they are to be held accountable for GME outcomes. “Right now, the hospital gets it, and it’s basically somewhere in the bottom line,” Dr. Parekh says. “No one really knows where that money goes. There’s very little accountability or clarity of purpose for that dollar.”

Amid the ongoing debate, the call for more transparency and accountability in GME seems to be gaining the most ground. “I don’t see tons of downside from it,” Dr. Parekh says. “I think it sheds light on the current funding environment and makes people have to justify a little bit more what they’re doing with that money.”

Dr. Tad-y puts it this way: “If you made your own budget at home, the first thing you’d do is try to figure out where all your money goes and what you’re spending your money on.” If Medicare is concerned that its GME money isn’t being spent wisely, then, the first step would be to do some accounting. “And that means a little bit of transparency,” she says. “I don’t think that’s a bad thing, to know exactly what we’re paying for; that makes sense. I mean, we do that for everything else.”

SHM and most other medical associations also agree on the necessary goal of increasing the nation’s primary care capacity, even if they differ on the details of how best to do so. In the long run, however, some observers say growing the workforce—whether that of primary care providers or of hospitalists—may depend less on the total number of residency spots and more on the enthusiasm of program leadership and the attractiveness of job conditions such as salary and workload.

“A big part of the problem here is that people are free agents,” says Daniel Brotman, MD, FACP, SFHM, chair of the SHM Education Committee and director of the hospitalist program at the Johns Hopkins Hospital in Baltimore. “If you make more residency spots, but the economics are such that people decide to become cardiologists because cardiologists make twice or more what hospitalists make, then you may have increased residency spots but [added only] a very small increment in the number of hospitalists.”

Whatever happens, Dr. Parekh says hospitalists are well positioned to be integral parts of improving quality, accountability, and innovation in residency training programs.

“I think if more GME money is targeted toward the outcomes of the GME programs, hospitalists are going to be tapped to help with that work, in terms of training and broadening their skill sets,” he says. “So I think it’s a great opportunity.”

Bryn Nelson is a freelance medical writer in Seattle.

References

1. Mullan F, Chen C, Steinmetz E. The geography of graduate medical education: imbalances signal need for new distribution policies. Health Aff. 2013;32(11):1914-1921.

“Number one, they came out and said, ‘We don’t know that there’s a shortage of physicians and we’re, if anything, going to remove money from the training system rather than putting in additional resources,” says Atul Grover, MD, PhD, FACP, FCCP, chief public policy officer for the Association of American Medical Colleges. “So we found that problematic, given all the evidence we have of the growing, aging population.”

Census figures indeed suggest a rapidly growing population of seniors: By 2030, one in five U.S. residents will be at least 65 years old. The estimated size of a future doctor shortage, however, has proven far more contentious.

Vikas I. Parekh, MD, FACP, SFHM, chair of the SHM Academic Hospitalist Committee, says most observers agree on a few basic points: that the pool of U.S. physicians leans more toward specialty than primary care and that significant workforce gaps exist in certain geographic locations—both in primary care and in other specialties.

Dr. Grover says the uneven distribution and an overall shortfall are both problematic; the AAMC has projected a shortage of up to 90,000 doctors by 2025. But Dr. Parekh says predicting future workforce numbers has always been a challenge.

“Historically, the projections of what the shortages might be have not been reliable or accurate,” he says.

In a recent outlook published by the National Institute of Healthcare Management, IOM committee co-chair Gail Wilensky, PhD, a senior fellow at Project HOPE and former Medicare administrator, goes a step farther. “We concluded that attempts to forecast physician supply and demand, both in the aggregate and by broad specialty types, have been singularly unsuccessful in the past,” she writes. “In fact, past projections have not always been even directionally correct.”

Deborah Powell, MD, dean emerita of the University of Minnesota Medical School and another IOM committee member, likewise defended the report’s analysis.

“I have had physicians tell me that they do not understand why our report said that there was not a physician shortage, and I try to point out that we did NOT say that,” she writes in an e-mail to The Hospitalist. “Rather, the report [and the committee] said that we could not find compelling evidence of an impending physician shortage and that physician workforce projections had been and are quite unreliable.

“However, we were agreed, and stated multiple times, that there were and are striking physician shortages by geography and specialty in multiple areas of the country, and we suggested a specific system change aimed at beginning to address these geographic and specialty shortages.”

The committee members decided against the “one size fits all” solution of simply expanding the current system, she says, because they believed the existing structure had contributed to the disparities in the first place.

“Number one, they came out and said, ‘We don’t know that there’s a shortage of physicians and we’re, if anything, going to remove money from the training system rather than putting in additional resources,” says Atul Grover, MD, PhD, FACP, FCCP, chief public policy officer for the Association of American Medical Colleges. “So we found that problematic, given all the evidence we have of the growing, aging population.”

Census figures indeed suggest a rapidly growing population of seniors: By 2030, one in five U.S. residents will be at least 65 years old. The estimated size of a future doctor shortage, however, has proven far more contentious.

Vikas I. Parekh, MD, FACP, SFHM, chair of the SHM Academic Hospitalist Committee, says most observers agree on a few basic points: that the pool of U.S. physicians leans more toward specialty than primary care and that significant workforce gaps exist in certain geographic locations—both in primary care and in other specialties.

Dr. Grover says the uneven distribution and an overall shortfall are both problematic; the AAMC has projected a shortage of up to 90,000 doctors by 2025. But Dr. Parekh says predicting future workforce numbers has always been a challenge.

“Historically, the projections of what the shortages might be have not been reliable or accurate,” he says.

In a recent outlook published by the National Institute of Healthcare Management, IOM committee co-chair Gail Wilensky, PhD, a senior fellow at Project HOPE and former Medicare administrator, goes a step farther. “We concluded that attempts to forecast physician supply and demand, both in the aggregate and by broad specialty types, have been singularly unsuccessful in the past,” she writes. “In fact, past projections have not always been even directionally correct.”

Deborah Powell, MD, dean emerita of the University of Minnesota Medical School and another IOM committee member, likewise defended the report’s analysis.

“I have had physicians tell me that they do not understand why our report said that there was not a physician shortage, and I try to point out that we did NOT say that,” she writes in an e-mail to The Hospitalist. “Rather, the report [and the committee] said that we could not find compelling evidence of an impending physician shortage and that physician workforce projections had been and are quite unreliable.

“However, we were agreed, and stated multiple times, that there were and are striking physician shortages by geography and specialty in multiple areas of the country, and we suggested a specific system change aimed at beginning to address these geographic and specialty shortages.”

The committee members decided against the “one size fits all” solution of simply expanding the current system, she says, because they believed the existing structure had contributed to the disparities in the first place.

“Number one, they came out and said, ‘We don’t know that there’s a shortage of physicians and we’re, if anything, going to remove money from the training system rather than putting in additional resources,” says Atul Grover, MD, PhD, FACP, FCCP, chief public policy officer for the Association of American Medical Colleges. “So we found that problematic, given all the evidence we have of the growing, aging population.”

Census figures indeed suggest a rapidly growing population of seniors: By 2030, one in five U.S. residents will be at least 65 years old. The estimated size of a future doctor shortage, however, has proven far more contentious.

Vikas I. Parekh, MD, FACP, SFHM, chair of the SHM Academic Hospitalist Committee, says most observers agree on a few basic points: that the pool of U.S. physicians leans more toward specialty than primary care and that significant workforce gaps exist in certain geographic locations—both in primary care and in other specialties.

Dr. Grover says the uneven distribution and an overall shortfall are both problematic; the AAMC has projected a shortage of up to 90,000 doctors by 2025. But Dr. Parekh says predicting future workforce numbers has always been a challenge.

“Historically, the projections of what the shortages might be have not been reliable or accurate,” he says.

In a recent outlook published by the National Institute of Healthcare Management, IOM committee co-chair Gail Wilensky, PhD, a senior fellow at Project HOPE and former Medicare administrator, goes a step farther. “We concluded that attempts to forecast physician supply and demand, both in the aggregate and by broad specialty types, have been singularly unsuccessful in the past,” she writes. “In fact, past projections have not always been even directionally correct.”

Deborah Powell, MD, dean emerita of the University of Minnesota Medical School and another IOM committee member, likewise defended the report’s analysis.

“I have had physicians tell me that they do not understand why our report said that there was not a physician shortage, and I try to point out that we did NOT say that,” she writes in an e-mail to The Hospitalist. “Rather, the report [and the committee] said that we could not find compelling evidence of an impending physician shortage and that physician workforce projections had been and are quite unreliable.

“However, we were agreed, and stated multiple times, that there were and are striking physician shortages by geography and specialty in multiple areas of the country, and we suggested a specific system change aimed at beginning to address these geographic and specialty shortages.”

The committee members decided against the “one size fits all” solution of simply expanding the current system, she says, because they believed the existing structure had contributed to the disparities in the first place.

Clinical question: What are the updated recommendations for treating first unprovoked seizure in adults?

Background: Approximately 150,000 adults present with an unprovoked first seizure in the U.S. annually, and these events are associated with physical and psychological trauma. Prior guidelines discussed evaluation of unprovoked first seizures in adults but did not address management. This publication aims to analyze existing evidence regarding prognosis and therapy with antiepileptic drugs (AEDs).

Study design: Evidence-based appraisal of a systematic review.

Setting: Literature published from 1966 to 2013 on MEDLINE, EMBASE, and Cochrane Central Register of Controlled Trials.

Synopsis: Ten prognostic studies describing risk of recurrence were found. Generalized tonic-clonic seizures were the major seizure type. Cumulative incidence of recurrent seizure increased over time, with the majority occurring within the first two years, regardless of treatment with AED; however, there were treatment differences among these studies and wide variation in recurrence rates.

Recurrence risk was lower with AED therapy, though patients were not randomized. Increased risk of recurrence was associated with prior brain lesion causing the seizure, EEG with epileptiform abnormalities, imaging abnormality, and nocturnal seizure.

Five studies were reviewed for prognosis following immediate AED therapy. Immediate AED treatment reduced risk of recurrence by 35% over the first two years. Among studies, “immediate” ranged from within one week to up to three months. Two studies described long-term prognosis, concluding that immediate AED treatment was unlikely to improve the chance of sustained seizure remission.

Five studies were used to describe adverse events in patients treated with AED. Adverse event incidence varied from 7% to 31%, and the incidents that occurred were largely mild and were reversible.

Bottom line: In adults presenting with unprovoked first seizure, the risk of recurrence is highest in the first two years and can be reduced with immediate AED therapy, though AED therapy was not shown to improve long-term prognosis.

Citation: Krumholz A, Wiebe S, Gronseth GS, et al. Evidence-based guideline: management of an unprovoked first seizure in adults. Report of the Guideline Development Subcommittee of the American Academy of Neurology and the American Epilepsy Society. Neurology. 2015;84(16):1705-1713.

Clinical question: What are the updated recommendations for treating first unprovoked seizure in adults?

Background: Approximately 150,000 adults present with an unprovoked first seizure in the U.S. annually, and these events are associated with physical and psychological trauma. Prior guidelines discussed evaluation of unprovoked first seizures in adults but did not address management. This publication aims to analyze existing evidence regarding prognosis and therapy with antiepileptic drugs (AEDs).

Study design: Evidence-based appraisal of a systematic review.

Setting: Literature published from 1966 to 2013 on MEDLINE, EMBASE, and Cochrane Central Register of Controlled Trials.

Synopsis: Ten prognostic studies describing risk of recurrence were found. Generalized tonic-clonic seizures were the major seizure type. Cumulative incidence of recurrent seizure increased over time, with the majority occurring within the first two years, regardless of treatment with AED; however, there were treatment differences among these studies and wide variation in recurrence rates.

Recurrence risk was lower with AED therapy, though patients were not randomized. Increased risk of recurrence was associated with prior brain lesion causing the seizure, EEG with epileptiform abnormalities, imaging abnormality, and nocturnal seizure.

Five studies were reviewed for prognosis following immediate AED therapy. Immediate AED treatment reduced risk of recurrence by 35% over the first two years. Among studies, “immediate” ranged from within one week to up to three months. Two studies described long-term prognosis, concluding that immediate AED treatment was unlikely to improve the chance of sustained seizure remission.

Five studies were used to describe adverse events in patients treated with AED. Adverse event incidence varied from 7% to 31%, and the incidents that occurred were largely mild and were reversible.

Bottom line: In adults presenting with unprovoked first seizure, the risk of recurrence is highest in the first two years and can be reduced with immediate AED therapy, though AED therapy was not shown to improve long-term prognosis.

Citation: Krumholz A, Wiebe S, Gronseth GS, et al. Evidence-based guideline: management of an unprovoked first seizure in adults. Report of the Guideline Development Subcommittee of the American Academy of Neurology and the American Epilepsy Society. Neurology. 2015;84(16):1705-1713.

Clinical question: What are the updated recommendations for treating first unprovoked seizure in adults?

Background: Approximately 150,000 adults present with an unprovoked first seizure in the U.S. annually, and these events are associated with physical and psychological trauma. Prior guidelines discussed evaluation of unprovoked first seizures in adults but did not address management. This publication aims to analyze existing evidence regarding prognosis and therapy with antiepileptic drugs (AEDs).

Study design: Evidence-based appraisal of a systematic review.

Setting: Literature published from 1966 to 2013 on MEDLINE, EMBASE, and Cochrane Central Register of Controlled Trials.

Synopsis: Ten prognostic studies describing risk of recurrence were found. Generalized tonic-clonic seizures were the major seizure type. Cumulative incidence of recurrent seizure increased over time, with the majority occurring within the first two years, regardless of treatment with AED; however, there were treatment differences among these studies and wide variation in recurrence rates.

Recurrence risk was lower with AED therapy, though patients were not randomized. Increased risk of recurrence was associated with prior brain lesion causing the seizure, EEG with epileptiform abnormalities, imaging abnormality, and nocturnal seizure.

Five studies were reviewed for prognosis following immediate AED therapy. Immediate AED treatment reduced risk of recurrence by 35% over the first two years. Among studies, “immediate” ranged from within one week to up to three months. Two studies described long-term prognosis, concluding that immediate AED treatment was unlikely to improve the chance of sustained seizure remission.

Five studies were used to describe adverse events in patients treated with AED. Adverse event incidence varied from 7% to 31%, and the incidents that occurred were largely mild and were reversible.

Bottom line: In adults presenting with unprovoked first seizure, the risk of recurrence is highest in the first two years and can be reduced with immediate AED therapy, though AED therapy was not shown to improve long-term prognosis.

Citation: Krumholz A, Wiebe S, Gronseth GS, et al. Evidence-based guideline: management of an unprovoked first seizure in adults. Report of the Guideline Development Subcommittee of the American Academy of Neurology and the American Epilepsy Society. Neurology. 2015;84(16):1705-1713.

A new book by three leading hospital medicine advocates for maximizing efficiency and outcomes while managing costs and avoiding waste in healthcare—also known as value-based healthcare—offers a primer filled with practical advice for doctors and other clinicians.¹ The hospitalist authors of Understanding Value-Based Healthcare, Christopher Moriates, MD, of the University of California-San Francisco, Vineet Arora, MD, MAPP, of the University of Chicago, and Neel Shah, MD, MPP, of Harvard Medical School, all have leadership positions in Costs of Care, a nonprofit organization formed in 2009 to help empower patients and their caregivers to deflate medical bills.

In a recent op-ed piece at MedPage Today, the book’s authors emphasize the harms for patients when doctors fail to consider the impact of medical bills or screen patients for financial harm.² Doctors should help their patients navigate tradeoffs of lower-cost treatment options. The authors hope to embed principles of value-based care into the apprenticeship of health professional education through initiatives such as Costs of Care’s “Teaching Value & Choosing Wisely Challenge,” which received 80 submissions from medical students and faculty from across the United States and Canada presenting bright ideas and innovations for integrating value into education.

References

1. Moriates C, Arora V, Shah N. Understanding Value-Based Healthcare. New York City: McGraw Hill Education; 2015.
2. Moriates C, Arora V, Shah N. Op-ed: how to rein in out-of-control healthcare costs. May 5, 2015. MedPage Today. Accessed July 2, 2015.

A new book by three leading hospital medicine advocates for maximizing efficiency and outcomes while managing costs and avoiding waste in healthcare—also known as value-based healthcare—offers a primer filled with practical advice for doctors and other clinicians.¹ The hospitalist authors of Understanding Value-Based Healthcare, Christopher Moriates, MD, of the University of California-San Francisco, Vineet Arora, MD, MAPP, of the University of Chicago, and Neel Shah, MD, MPP, of Harvard Medical School, all have leadership positions in Costs of Care, a nonprofit organization formed in 2009 to help empower patients and their caregivers to deflate medical bills.

In a recent op-ed piece at MedPage Today, the book’s authors emphasize the harms for patients when doctors fail to consider the impact of medical bills or screen patients for financial harm.² Doctors should help their patients navigate tradeoffs of lower-cost treatment options. The authors hope to embed principles of value-based care into the apprenticeship of health professional education through initiatives such as Costs of Care’s “Teaching Value & Choosing Wisely Challenge,” which received 80 submissions from medical students and faculty from across the United States and Canada presenting bright ideas and innovations for integrating value into education.

References

1. Moriates C, Arora V, Shah N. Understanding Value-Based Healthcare. New York City: McGraw Hill Education; 2015.
2. Moriates C, Arora V, Shah N. Op-ed: how to rein in out-of-control healthcare costs. May 5, 2015. MedPage Today. Accessed July 2, 2015.

A new book by three leading hospital medicine advocates for maximizing efficiency and outcomes while managing costs and avoiding waste in healthcare—also known as value-based healthcare—offers a primer filled with practical advice for doctors and other clinicians.¹ The hospitalist authors of Understanding Value-Based Healthcare, Christopher Moriates, MD, of the University of California-San Francisco, Vineet Arora, MD, MAPP, of the University of Chicago, and Neel Shah, MD, MPP, of Harvard Medical School, all have leadership positions in Costs of Care, a nonprofit organization formed in 2009 to help empower patients and their caregivers to deflate medical bills.

In a recent op-ed piece at MedPage Today, the book’s authors emphasize the harms for patients when doctors fail to consider the impact of medical bills or screen patients for financial harm.² Doctors should help their patients navigate tradeoffs of lower-cost treatment options. The authors hope to embed principles of value-based care into the apprenticeship of health professional education through initiatives such as Costs of Care’s “Teaching Value & Choosing Wisely Challenge,” which received 80 submissions from medical students and faculty from across the United States and Canada presenting bright ideas and innovations for integrating value into education.

References

1. Moriates C, Arora V, Shah N. Understanding Value-Based Healthcare. New York City: McGraw Hill Education; 2015.
2. Moriates C, Arora V, Shah N. Op-ed: how to rein in out-of-control healthcare costs. May 5, 2015. MedPage Today. Accessed July 2, 2015.

Hospitalists spend too little time working at the top of their license. Put differently, I think a hospitalist often spends only about 1.5 to two hours in a 10- or 12-hour workday making use of the knowledge base and skills developed in training. (I wrote about this and referenced some hospitalist time-motion studies in my December 2010 column.)

The remaining hours are typically spent in activities such as figuring out which surgeon is on call and tracking her down, managing patient lists, filling out paper or electronic forms, explaining observation status to patients, and so on.

When I first became a hospitalist in the 1980s, there was already a lot of talk about the paperwork burden faced by doctors across all specialties. I recall the gnashing of teeth that ensued—lots of articles and seminars, and it seems to me even a few legislative proposals, focused on the topic. It appears that nearly every recruitment ad at the time mentioned something like “Let us take care of running the business, so you can focus solely on patient care.” Clearly, doctors were seeking relief from the burden of nonclinical work even back then.

I can’t recall reading or hearing anyone talk about the “paperwork” burden of physician practice in the past few years. This isn’t because things have gotten better; in fact, I think the burden of “non-doctoring activities” has steadily increased. We hear less about the problem of excessive paperwork simply because, more recently, it has been framed differently—it is now typically referred to as the problem of too little time spent practicing at the top of license.

Search the Internet for “top of license” and a number of interesting things turn up. Most are healthcare related—maybe other professions don’t use the term—and there are just as many links referring to nurses as physicians. Much is written about the need for primary care physicians to spend more time working at the top of their license, but I couldn’t find anything addressing this issue specifically for hospitalists.

What Can Be Done?

Moving your work as a hospitalist more to the top of your license isn’t a simple thing, and our whole field will need to work on this over time. The most effective interventions will vary some from place to place, but here are some ideas that may be relevant for many hospitalist groups.

Medication reconciliation. I fully support the idea of careful medication reconciliation, but, given that such a large portion of hospitalist patients are on so many medications, this is a time-consuming task. And, in many or most hospitals, the task suffers from diffusion of responsibility; for example, the ED nurse makes only a half-hearted attempt to get an accurate list, and the hospitalist believes that whatever the ED nurse entered into the record regarding patient medications is probably the best obtainable list.

A pharmacy technician stationed in the ED and charged with recording the best obtainable list of medicines on patient arrival can address both of these problems (for more information, the American Society of Health-System Pharmacists offers webinars and other resources on this topic). This would include calling family members, pharmacies, and physician offices for clarification in some cases. Hospitalists working in such an environment nearly always say it is extremely valuable in reducing inaccuracies in the pre-hospital medication list, as well as saving hospitalists time when they are admitting patients.

Unfortunately, hospitals may resist adding pharmacy technicians because of the expense or, in some cases, because of concerns that such work may exceed the legal scope of work for technicians.

Post-hospital appointments. I think arranging post-hospital appointments should be no more difficult for the hospitalist than ordering a complete blood count (CBC). It shouldn’t matter whether I want the patient to follow up with the PCP he has been seeing for years, or see a neurologist or diabetes educator as a new patient consult. Any treating doctor in the hospital should be able to arrange such post-hospital visits with just a click or two in the EHR, or a stroke of the pen. And the patient should leave the hospital with a written date and time of the appointment that has been made for them.

Few hospitals can reliably provide this, however, so, all too often, hospitalists spend their time calling clerical staff at outpatient clinics to arrange appointments, writing them down, and delivering them to patients. This is far from what anyone would consider top of license work. (I wrote a little more about this in last month’s column.)

Medicare benefits specialist. Many hospitalists end up spending significant time explaining to patients and families the reason a patient is on observation status and trying to defuse the resulting frustration and anger. As I stated in my November 2014 column, I think observation status is so frustrating to patients that it is often the root cause of complaints about care and, potentially, the source of malpractice suits.

Physicians have an unavoidable role in determining observation versus inpatient status, but I think hospitals should work hard to ensure that someone other than the doctor is available to explain to patients and families the reason for observation status, along with its implications, and to provide sympathy for their frustrations. This allows the doctor to stay focused on clinical care.

Limit reliance on a “triage hospitalist.” Hospitalist groups larger than about 20 providers often have one provider devoted through much of a daytime shift to triaging and assigning new referrals across all providers working that day. For larger practices, this triage work may consume all of the provider’s shift, so that person has no time left for clinical care. It is hard for me to see this as top of license work that only a physician or advanced practice clinician can do. In my December 2010 column, I provided some potential alternatives to dedicating a physician or other provider to a triage role.

Your list of important changes that are needed to move hospitalists toward more time spent working at the top of their license will likely differ a lot from the issues above. But every group could benefit from deliberately thinking about what would be most valuable for them and trying to make that a reality.

Hospitalists spend too little time working at the top of their license. Put differently, I think a hospitalist often spends only about 1.5 to two hours in a 10- or 12-hour workday making use of the knowledge base and skills developed in training. (I wrote about this and referenced some hospitalist time-motion studies in my December 2010 column.)

The remaining hours are typically spent in activities such as figuring out which surgeon is on call and tracking her down, managing patient lists, filling out paper or electronic forms, explaining observation status to patients, and so on.

When I first became a hospitalist in the 1980s, there was already a lot of talk about the paperwork burden faced by doctors across all specialties. I recall the gnashing of teeth that ensued—lots of articles and seminars, and it seems to me even a few legislative proposals, focused on the topic. It appears that nearly every recruitment ad at the time mentioned something like “Let us take care of running the business, so you can focus solely on patient care.” Clearly, doctors were seeking relief from the burden of nonclinical work even back then.

I can’t recall reading or hearing anyone talk about the “paperwork” burden of physician practice in the past few years. This isn’t because things have gotten better; in fact, I think the burden of “non-doctoring activities” has steadily increased. We hear less about the problem of excessive paperwork simply because, more recently, it has been framed differently—it is now typically referred to as the problem of too little time spent practicing at the top of license.

Search the Internet for “top of license” and a number of interesting things turn up. Most are healthcare related—maybe other professions don’t use the term—and there are just as many links referring to nurses as physicians. Much is written about the need for primary care physicians to spend more time working at the top of their license, but I couldn’t find anything addressing this issue specifically for hospitalists.

What Can Be Done?

Moving your work as a hospitalist more to the top of your license isn’t a simple thing, and our whole field will need to work on this over time. The most effective interventions will vary some from place to place, but here are some ideas that may be relevant for many hospitalist groups.

Medication reconciliation. I fully support the idea of careful medication reconciliation, but, given that such a large portion of hospitalist patients are on so many medications, this is a time-consuming task. And, in many or most hospitals, the task suffers from diffusion of responsibility; for example, the ED nurse makes only a half-hearted attempt to get an accurate list, and the hospitalist believes that whatever the ED nurse entered into the record regarding patient medications is probably the best obtainable list.

A pharmacy technician stationed in the ED and charged with recording the best obtainable list of medicines on patient arrival can address both of these problems (for more information, the American Society of Health-System Pharmacists offers webinars and other resources on this topic). This would include calling family members, pharmacies, and physician offices for clarification in some cases. Hospitalists working in such an environment nearly always say it is extremely valuable in reducing inaccuracies in the pre-hospital medication list, as well as saving hospitalists time when they are admitting patients.

Unfortunately, hospitals may resist adding pharmacy technicians because of the expense or, in some cases, because of concerns that such work may exceed the legal scope of work for technicians.

Post-hospital appointments. I think arranging post-hospital appointments should be no more difficult for the hospitalist than ordering a complete blood count (CBC). It shouldn’t matter whether I want the patient to follow up with the PCP he has been seeing for years, or see a neurologist or diabetes educator as a new patient consult. Any treating doctor in the hospital should be able to arrange such post-hospital visits with just a click or two in the EHR, or a stroke of the pen. And the patient should leave the hospital with a written date and time of the appointment that has been made for them.

Few hospitals can reliably provide this, however, so, all too often, hospitalists spend their time calling clerical staff at outpatient clinics to arrange appointments, writing them down, and delivering them to patients. This is far from what anyone would consider top of license work. (I wrote a little more about this in last month’s column.)

Medicare benefits specialist. Many hospitalists end up spending significant time explaining to patients and families the reason a patient is on observation status and trying to defuse the resulting frustration and anger. As I stated in my November 2014 column, I think observation status is so frustrating to patients that it is often the root cause of complaints about care and, potentially, the source of malpractice suits.

Physicians have an unavoidable role in determining observation versus inpatient status, but I think hospitals should work hard to ensure that someone other than the doctor is available to explain to patients and families the reason for observation status, along with its implications, and to provide sympathy for their frustrations. This allows the doctor to stay focused on clinical care.

Limit reliance on a “triage hospitalist.” Hospitalist groups larger than about 20 providers often have one provider devoted through much of a daytime shift to triaging and assigning new referrals across all providers working that day. For larger practices, this triage work may consume all of the provider’s shift, so that person has no time left for clinical care. It is hard for me to see this as top of license work that only a physician or advanced practice clinician can do. In my December 2010 column, I provided some potential alternatives to dedicating a physician or other provider to a triage role.

Your list of important changes that are needed to move hospitalists toward more time spent working at the top of their license will likely differ a lot from the issues above. But every group could benefit from deliberately thinking about what would be most valuable for them and trying to make that a reality.

Hospitalists spend too little time working at the top of their license. Put differently, I think a hospitalist often spends only about 1.5 to two hours in a 10- or 12-hour workday making use of the knowledge base and skills developed in training. (I wrote about this and referenced some hospitalist time-motion studies in my December 2010 column.)

The remaining hours are typically spent in activities such as figuring out which surgeon is on call and tracking her down, managing patient lists, filling out paper or electronic forms, explaining observation status to patients, and so on.

When I first became a hospitalist in the 1980s, there was already a lot of talk about the paperwork burden faced by doctors across all specialties. I recall the gnashing of teeth that ensued—lots of articles and seminars, and it seems to me even a few legislative proposals, focused on the topic. It appears that nearly every recruitment ad at the time mentioned something like “Let us take care of running the business, so you can focus solely on patient care.” Clearly, doctors were seeking relief from the burden of nonclinical work even back then.

I can’t recall reading or hearing anyone talk about the “paperwork” burden of physician practice in the past few years. This isn’t because things have gotten better; in fact, I think the burden of “non-doctoring activities” has steadily increased. We hear less about the problem of excessive paperwork simply because, more recently, it has been framed differently—it is now typically referred to as the problem of too little time spent practicing at the top of license.

Search the Internet for “top of license” and a number of interesting things turn up. Most are healthcare related—maybe other professions don’t use the term—and there are just as many links referring to nurses as physicians. Much is written about the need for primary care physicians to spend more time working at the top of their license, but I couldn’t find anything addressing this issue specifically for hospitalists.

What Can Be Done?

Moving your work as a hospitalist more to the top of your license isn’t a simple thing, and our whole field will need to work on this over time. The most effective interventions will vary some from place to place, but here are some ideas that may be relevant for many hospitalist groups.

Medication reconciliation. I fully support the idea of careful medication reconciliation, but, given that such a large portion of hospitalist patients are on so many medications, this is a time-consuming task. And, in many or most hospitals, the task suffers from diffusion of responsibility; for example, the ED nurse makes only a half-hearted attempt to get an accurate list, and the hospitalist believes that whatever the ED nurse entered into the record regarding patient medications is probably the best obtainable list.

A pharmacy technician stationed in the ED and charged with recording the best obtainable list of medicines on patient arrival can address both of these problems (for more information, the American Society of Health-System Pharmacists offers webinars and other resources on this topic). This would include calling family members, pharmacies, and physician offices for clarification in some cases. Hospitalists working in such an environment nearly always say it is extremely valuable in reducing inaccuracies in the pre-hospital medication list, as well as saving hospitalists time when they are admitting patients.

Unfortunately, hospitals may resist adding pharmacy technicians because of the expense or, in some cases, because of concerns that such work may exceed the legal scope of work for technicians.

Post-hospital appointments. I think arranging post-hospital appointments should be no more difficult for the hospitalist than ordering a complete blood count (CBC). It shouldn’t matter whether I want the patient to follow up with the PCP he has been seeing for years, or see a neurologist or diabetes educator as a new patient consult. Any treating doctor in the hospital should be able to arrange such post-hospital visits with just a click or two in the EHR, or a stroke of the pen. And the patient should leave the hospital with a written date and time of the appointment that has been made for them.

Few hospitals can reliably provide this, however, so, all too often, hospitalists spend their time calling clerical staff at outpatient clinics to arrange appointments, writing them down, and delivering them to patients. This is far from what anyone would consider top of license work. (I wrote a little more about this in last month’s column.)

Medicare benefits specialist. Many hospitalists end up spending significant time explaining to patients and families the reason a patient is on observation status and trying to defuse the resulting frustration and anger. As I stated in my November 2014 column, I think observation status is so frustrating to patients that it is often the root cause of complaints about care and, potentially, the source of malpractice suits.

Physicians have an unavoidable role in determining observation versus inpatient status, but I think hospitals should work hard to ensure that someone other than the doctor is available to explain to patients and families the reason for observation status, along with its implications, and to provide sympathy for their frustrations. This allows the doctor to stay focused on clinical care.

Limit reliance on a “triage hospitalist.” Hospitalist groups larger than about 20 providers often have one provider devoted through much of a daytime shift to triaging and assigning new referrals across all providers working that day. For larger practices, this triage work may consume all of the provider’s shift, so that person has no time left for clinical care. It is hard for me to see this as top of license work that only a physician or advanced practice clinician can do. In my December 2010 column, I provided some potential alternatives to dedicating a physician or other provider to a triage role.

Your list of important changes that are needed to move hospitalists toward more time spent working at the top of their license will likely differ a lot from the issues above. But every group could benefit from deliberately thinking about what would be most valuable for them and trying to make that a reality.

On the last day of 2014, a provision of the Affordable Care Act (ACA) that increased payments to some physicians providing primary care services to the country’s poorest patients expired. The Medicaid payment parity program, under section 1202 of the ACA, increased to Medicare levels Medicaid reimbursement for primary care services rendered by internists, pediatricians, family medicine physicians, some subspecialists, and hospitalists in all states in 2013 and 2014.

A bill introduced in 2015, the Ensuring Access to Primary Care for Women and Children Act—sponsored by Sherrod Brown (D-Ohio) and Patty Murray, (D-W. Va.) in the Senate and Kathy Castor (D-Fla.) in the House—seeks to extend the parity program another two years and expand it to other providers, like obstetricians and nurse practitioners.

The parity program was intended to improve access to healthcare for the millions of Americans newly eligible for Medicaid under the ACA. Currently, one in five Americans is on Medicaid.

Fewer physicians in the U.S. participate in Medicaid than in Medicare or private insurance, and low reimbursement rates are sometimes cited as a cause.1,2 In 2012, fee-for-service Medicaid reimbursement for primary care averaged just 59% of Medicare fee levels nationally, but during the years of increased payment, eligible physicians saw a 73% boost in reimbursement for Medicaid primary care services.^1,2

The new bill is similar to one introduced unsuccessfully last year in the Senate, which sought to avoid a lapse in the program. Initially beset by delays, some experts say the program did not last long enough to gather sufficient data or to demonstrate its effectiveness. Others say the short duration of the program prevented new providers from accepting Medicaid patients.³

An extension “would give people the chance to get more data and show the payment increase resulted in a more cost-effective healthcare system,” says Ron Greeno, MD, FCCP, MHM, an SHM board member, chair of SHM’s Public Policy Committee, and chief strategy officer at IPC Healthcare. “Ideally, there would be permanent parity.”

From a healthcare policy standpoint, it seems intellectually inconsistent, and from a public health standpoint, is it really justifiable? At the end of the day, the fundamental question is, do we really want to have two classes of access to American healthcare?

–Dr. Greeno

In February, Dan Polsky, PhD, the Robert D. Eilers professor in healthcare management and economics at the University of Pennsylvania Perelman School of Medicine in Philadelphia, and colleagues published a study in the New England Journal of Medicine that showed an increase in primary care appointments for new Medicaid patients correlating with the temporary increase in reimbursement.⁴

“We saw a 10% increase in the number of providers willing to see new Medicaid patients,” Dr. Polsky says. “It was an economic behavior test to see how physicians respond to changes in payment rates, because in a lot of states, policy makers are being asked to extend parity, and the typical comment was: ‘We don’t know if it works; it’s not cheap.’”

Indeed, the Congressional Budget Office estimated that the two-year pay increase would cost between $11 and $12 billion.¹

“We came up with evidence it works,” Dr. Polsky says.

However, further measures of the parity program’s success remain a challenge, according to the author of a Kaiser Family Foundation brief, because it’s difficult to separate it from other elements of the healthcare law. Studies have also conflicted with regard to the ability of payment boosts to improve access, and the reimbursement increase may not be compatible with a shift away from the fee-for-service model.¹

Yet, experts like Dr. Polsky say that to encourage greater participation in Medicaid, some type of parity is needed. “If we’re going to maintain better provider availability, I think you would need something like this,” he says.

For hospitalists, the two-year boost meant the ability to provide better care for hospitalized patients, Dr. Greeno says. Anecdotally, hospitalists reported that it was easier to discharge Medicaid patients to primary care follow-up in the community, he says, and better pay meant better staffing ratios were possible.

As of Jan. 1, 2015, 16 states and the District of Columbia reported that they will continue to reimburse Medicaid primary care services at Medicare levels.² Dr. Greeno says the disparity between states that reimburse at higher rates for Medicaid and those that won’t could start changing the macroeconomics of medical practice, similar to the situation that occurred when states differentially imposed caps on malpractice liability.

A May 2015 Health Affairs policy brief indicates that, despite the House and Senate bill, Congress is unlikely to act soon on increasing Medicaid reimbursement rates again. Dr. Greeno believes this a mistake.

“From a healthcare policy standpoint, it seems intellectually inconsistent, and from a public health standpoint, is it really justifiable?” he asks. “At the end of the day, the fundamental question is, do we really want to have two classes of access to American healthcare?”

Kelly April Tyrrell is a freelance writer in Madison, Wis.

References

1. Paradise J. Henry J. Kaiser Family Foundation. The Kaiser Commission on Medicaid and the Uninsured. Medicaid moving forward. March 9, 2015. Accessed July 7, 2015.
2. Tollen L. Medicaid primary care parity. May 11, 2015. Health Affairs online. Accessed July 7, 2015.
3. Medicaid and CHIP Payment and Access Commission (MACPAC). March 2015 report to Congress on Medicaid and CHIP, chapter 8: an update on the Medicaid primary care payment increase. Accessed July 7, 2015.
4. Polsky D, Richards M, Basseyn S, et al. Appointment availability after increases in Medicaid payments for primary care. N Engl J Med. 2015;372:537-545. doi: 10.1056/NEJMsa1413299.

On the last day of 2014, a provision of the Affordable Care Act (ACA) that increased payments to some physicians providing primary care services to the country’s poorest patients expired. The Medicaid payment parity program, under section 1202 of the ACA, increased to Medicare levels Medicaid reimbursement for primary care services rendered by internists, pediatricians, family medicine physicians, some subspecialists, and hospitalists in all states in 2013 and 2014.

A bill introduced in 2015, the Ensuring Access to Primary Care for Women and Children Act—sponsored by Sherrod Brown (D-Ohio) and Patty Murray, (D-W. Va.) in the Senate and Kathy Castor (D-Fla.) in the House—seeks to extend the parity program another two years and expand it to other providers, like obstetricians and nurse practitioners.

The parity program was intended to improve access to healthcare for the millions of Americans newly eligible for Medicaid under the ACA. Currently, one in five Americans is on Medicaid.

Fewer physicians in the U.S. participate in Medicaid than in Medicare or private insurance, and low reimbursement rates are sometimes cited as a cause.1,2 In 2012, fee-for-service Medicaid reimbursement for primary care averaged just 59% of Medicare fee levels nationally, but during the years of increased payment, eligible physicians saw a 73% boost in reimbursement for Medicaid primary care services.^1,2

The new bill is similar to one introduced unsuccessfully last year in the Senate, which sought to avoid a lapse in the program. Initially beset by delays, some experts say the program did not last long enough to gather sufficient data or to demonstrate its effectiveness. Others say the short duration of the program prevented new providers from accepting Medicaid patients.³

An extension “would give people the chance to get more data and show the payment increase resulted in a more cost-effective healthcare system,” says Ron Greeno, MD, FCCP, MHM, an SHM board member, chair of SHM’s Public Policy Committee, and chief strategy officer at IPC Healthcare. “Ideally, there would be permanent parity.”

From a healthcare policy standpoint, it seems intellectually inconsistent, and from a public health standpoint, is it really justifiable? At the end of the day, the fundamental question is, do we really want to have two classes of access to American healthcare?

–Dr. Greeno

In February, Dan Polsky, PhD, the Robert D. Eilers professor in healthcare management and economics at the University of Pennsylvania Perelman School of Medicine in Philadelphia, and colleagues published a study in the New England Journal of Medicine that showed an increase in primary care appointments for new Medicaid patients correlating with the temporary increase in reimbursement.⁴

“We saw a 10% increase in the number of providers willing to see new Medicaid patients,” Dr. Polsky says. “It was an economic behavior test to see how physicians respond to changes in payment rates, because in a lot of states, policy makers are being asked to extend parity, and the typical comment was: ‘We don’t know if it works; it’s not cheap.’”

Indeed, the Congressional Budget Office estimated that the two-year pay increase would cost between $11 and $12 billion.¹

“We came up with evidence it works,” Dr. Polsky says.

However, further measures of the parity program’s success remain a challenge, according to the author of a Kaiser Family Foundation brief, because it’s difficult to separate it from other elements of the healthcare law. Studies have also conflicted with regard to the ability of payment boosts to improve access, and the reimbursement increase may not be compatible with a shift away from the fee-for-service model.¹

Yet, experts like Dr. Polsky say that to encourage greater participation in Medicaid, some type of parity is needed. “If we’re going to maintain better provider availability, I think you would need something like this,” he says.

For hospitalists, the two-year boost meant the ability to provide better care for hospitalized patients, Dr. Greeno says. Anecdotally, hospitalists reported that it was easier to discharge Medicaid patients to primary care follow-up in the community, he says, and better pay meant better staffing ratios were possible.

As of Jan. 1, 2015, 16 states and the District of Columbia reported that they will continue to reimburse Medicaid primary care services at Medicare levels.² Dr. Greeno says the disparity between states that reimburse at higher rates for Medicaid and those that won’t could start changing the macroeconomics of medical practice, similar to the situation that occurred when states differentially imposed caps on malpractice liability.

A May 2015 Health Affairs policy brief indicates that, despite the House and Senate bill, Congress is unlikely to act soon on increasing Medicaid reimbursement rates again. Dr. Greeno believes this a mistake.

“From a healthcare policy standpoint, it seems intellectually inconsistent, and from a public health standpoint, is it really justifiable?” he asks. “At the end of the day, the fundamental question is, do we really want to have two classes of access to American healthcare?”

Kelly April Tyrrell is a freelance writer in Madison, Wis.

References

1. Paradise J. Henry J. Kaiser Family Foundation. The Kaiser Commission on Medicaid and the Uninsured. Medicaid moving forward. March 9, 2015. Accessed July 7, 2015.
2. Tollen L. Medicaid primary care parity. May 11, 2015. Health Affairs online. Accessed July 7, 2015.
3. Medicaid and CHIP Payment and Access Commission (MACPAC). March 2015 report to Congress on Medicaid and CHIP, chapter 8: an update on the Medicaid primary care payment increase. Accessed July 7, 2015.
4. Polsky D, Richards M, Basseyn S, et al. Appointment availability after increases in Medicaid payments for primary care. N Engl J Med. 2015;372:537-545. doi: 10.1056/NEJMsa1413299.

On the last day of 2014, a provision of the Affordable Care Act (ACA) that increased payments to some physicians providing primary care services to the country’s poorest patients expired. The Medicaid payment parity program, under section 1202 of the ACA, increased to Medicare levels Medicaid reimbursement for primary care services rendered by internists, pediatricians, family medicine physicians, some subspecialists, and hospitalists in all states in 2013 and 2014.

A bill introduced in 2015, the Ensuring Access to Primary Care for Women and Children Act—sponsored by Sherrod Brown (D-Ohio) and Patty Murray, (D-W. Va.) in the Senate and Kathy Castor (D-Fla.) in the House—seeks to extend the parity program another two years and expand it to other providers, like obstetricians and nurse practitioners.

The parity program was intended to improve access to healthcare for the millions of Americans newly eligible for Medicaid under the ACA. Currently, one in five Americans is on Medicaid.

Fewer physicians in the U.S. participate in Medicaid than in Medicare or private insurance, and low reimbursement rates are sometimes cited as a cause.1,2 In 2012, fee-for-service Medicaid reimbursement for primary care averaged just 59% of Medicare fee levels nationally, but during the years of increased payment, eligible physicians saw a 73% boost in reimbursement for Medicaid primary care services.^1,2

The new bill is similar to one introduced unsuccessfully last year in the Senate, which sought to avoid a lapse in the program. Initially beset by delays, some experts say the program did not last long enough to gather sufficient data or to demonstrate its effectiveness. Others say the short duration of the program prevented new providers from accepting Medicaid patients.³

An extension “would give people the chance to get more data and show the payment increase resulted in a more cost-effective healthcare system,” says Ron Greeno, MD, FCCP, MHM, an SHM board member, chair of SHM’s Public Policy Committee, and chief strategy officer at IPC Healthcare. “Ideally, there would be permanent parity.”

From a healthcare policy standpoint, it seems intellectually inconsistent, and from a public health standpoint, is it really justifiable? At the end of the day, the fundamental question is, do we really want to have two classes of access to American healthcare?

–Dr. Greeno

In February, Dan Polsky, PhD, the Robert D. Eilers professor in healthcare management and economics at the University of Pennsylvania Perelman School of Medicine in Philadelphia, and colleagues published a study in the New England Journal of Medicine that showed an increase in primary care appointments for new Medicaid patients correlating with the temporary increase in reimbursement.⁴

“We saw a 10% increase in the number of providers willing to see new Medicaid patients,” Dr. Polsky says. “It was an economic behavior test to see how physicians respond to changes in payment rates, because in a lot of states, policy makers are being asked to extend parity, and the typical comment was: ‘We don’t know if it works; it’s not cheap.’”

Indeed, the Congressional Budget Office estimated that the two-year pay increase would cost between $11 and $12 billion.¹

“We came up with evidence it works,” Dr. Polsky says.

However, further measures of the parity program’s success remain a challenge, according to the author of a Kaiser Family Foundation brief, because it’s difficult to separate it from other elements of the healthcare law. Studies have also conflicted with regard to the ability of payment boosts to improve access, and the reimbursement increase may not be compatible with a shift away from the fee-for-service model.¹

Yet, experts like Dr. Polsky say that to encourage greater participation in Medicaid, some type of parity is needed. “If we’re going to maintain better provider availability, I think you would need something like this,” he says.

For hospitalists, the two-year boost meant the ability to provide better care for hospitalized patients, Dr. Greeno says. Anecdotally, hospitalists reported that it was easier to discharge Medicaid patients to primary care follow-up in the community, he says, and better pay meant better staffing ratios were possible.

As of Jan. 1, 2015, 16 states and the District of Columbia reported that they will continue to reimburse Medicaid primary care services at Medicare levels.² Dr. Greeno says the disparity between states that reimburse at higher rates for Medicaid and those that won’t could start changing the macroeconomics of medical practice, similar to the situation that occurred when states differentially imposed caps on malpractice liability.

A May 2015 Health Affairs policy brief indicates that, despite the House and Senate bill, Congress is unlikely to act soon on increasing Medicaid reimbursement rates again. Dr. Greeno believes this a mistake.

“From a healthcare policy standpoint, it seems intellectually inconsistent, and from a public health standpoint, is it really justifiable?” he asks. “At the end of the day, the fundamental question is, do we really want to have two classes of access to American healthcare?”

Kelly April Tyrrell is a freelance writer in Madison, Wis.

References

1. Paradise J. Henry J. Kaiser Family Foundation. The Kaiser Commission on Medicaid and the Uninsured. Medicaid moving forward. March 9, 2015. Accessed July 7, 2015.
2. Tollen L. Medicaid primary care parity. May 11, 2015. Health Affairs online. Accessed July 7, 2015.
3. Medicaid and CHIP Payment and Access Commission (MACPAC). March 2015 report to Congress on Medicaid and CHIP, chapter 8: an update on the Medicaid primary care payment increase. Accessed July 7, 2015.
4. Polsky D, Richards M, Basseyn S, et al. Appointment availability after increases in Medicaid payments for primary care. N Engl J Med. 2015;372:537-545. doi: 10.1056/NEJMsa1413299.

Society of Hospital Medicine members have a real impact.

A paper published in the Journal of Hospital Medicine in April by Ann Sheehy, MD, MS, and colleagues was recently cited in Sen. Ben Cardin’s (D-Md.) amendment to the Audit and Appeal Fairness, Integrity, and Reforms in Medicare Act of 2015.^1,2 The act aims to improve the accuracy and transparency of recovery audits (RA), which were the subject of testimony given by Dr. Sheehy—a hospitalist at the University of Wisconsin-Madison—by invitation before Congress twice in 2014.

Formally called recovery audit contractors, or RACS, RAs evaluate whether hospitals were overpaid for hospitalizations improperly deemed inpatient rather than outpatient via observation status. In the study cited before the Senate Finance Committee, Dr. Sheehy’s group found a three-fold increase in RA overpayment determinations from 2010 to 2013; concurrently, the number of decisions overturned in favor of cited hospitals, either in discussion or appeal, doubled, going from 36% in 2010 to nearly 70% in 2013.

RAs share a percentage of the money they recover for the Centers for Medicare and Medicaid Services, even when decisions are appealed and won by hospitals. As Dr. Sheehy testified last year: “Unfortunately, these contingency incentives favor aggressive auditing, without transparency, accountability, or repercussions for cases that should never have been audited.”

The bill passed the Senate on June 5, 2015.

References

1. Sheehy AM, Locke C, Engel JZ, et al. Recovery audit contractor audits and appeals at three academic medical centers. J Hosp Med. 2015;10(4):212-219. doi: 10.1002/jhm.2332.
2. United States Senate Committee on Finance. Master Amendments of the Audit and Appeal Fairness, Integrity, and Reforms in Medicare Act of 2015. Accessed July 7, 2015.

Society of Hospital Medicine members have a real impact.

A paper published in the Journal of Hospital Medicine in April by Ann Sheehy, MD, MS, and colleagues was recently cited in Sen. Ben Cardin’s (D-Md.) amendment to the Audit and Appeal Fairness, Integrity, and Reforms in Medicare Act of 2015.^1,2 The act aims to improve the accuracy and transparency of recovery audits (RA), which were the subject of testimony given by Dr. Sheehy—a hospitalist at the University of Wisconsin-Madison—by invitation before Congress twice in 2014.

Formally called recovery audit contractors, or RACS, RAs evaluate whether hospitals were overpaid for hospitalizations improperly deemed inpatient rather than outpatient via observation status. In the study cited before the Senate Finance Committee, Dr. Sheehy’s group found a three-fold increase in RA overpayment determinations from 2010 to 2013; concurrently, the number of decisions overturned in favor of cited hospitals, either in discussion or appeal, doubled, going from 36% in 2010 to nearly 70% in 2013.

RAs share a percentage of the money they recover for the Centers for Medicare and Medicaid Services, even when decisions are appealed and won by hospitals. As Dr. Sheehy testified last year: “Unfortunately, these contingency incentives favor aggressive auditing, without transparency, accountability, or repercussions for cases that should never have been audited.”

The bill passed the Senate on June 5, 2015.

References

1. Sheehy AM, Locke C, Engel JZ, et al. Recovery audit contractor audits and appeals at three academic medical centers. J Hosp Med. 2015;10(4):212-219. doi: 10.1002/jhm.2332.
2. United States Senate Committee on Finance. Master Amendments of the Audit and Appeal Fairness, Integrity, and Reforms in Medicare Act of 2015. Accessed July 7, 2015.

Society of Hospital Medicine members have a real impact.

A paper published in the Journal of Hospital Medicine in April by Ann Sheehy, MD, MS, and colleagues was recently cited in Sen. Ben Cardin’s (D-Md.) amendment to the Audit and Appeal Fairness, Integrity, and Reforms in Medicare Act of 2015.^1,2 The act aims to improve the accuracy and transparency of recovery audits (RA), which were the subject of testimony given by Dr. Sheehy—a hospitalist at the University of Wisconsin-Madison—by invitation before Congress twice in 2014.

Formally called recovery audit contractors, or RACS, RAs evaluate whether hospitals were overpaid for hospitalizations improperly deemed inpatient rather than outpatient via observation status. In the study cited before the Senate Finance Committee, Dr. Sheehy’s group found a three-fold increase in RA overpayment determinations from 2010 to 2013; concurrently, the number of decisions overturned in favor of cited hospitals, either in discussion or appeal, doubled, going from 36% in 2010 to nearly 70% in 2013.

RAs share a percentage of the money they recover for the Centers for Medicare and Medicaid Services, even when decisions are appealed and won by hospitals. As Dr. Sheehy testified last year: “Unfortunately, these contingency incentives favor aggressive auditing, without transparency, accountability, or repercussions for cases that should never have been audited.”

The bill passed the Senate on June 5, 2015.

References

1. Sheehy AM, Locke C, Engel JZ, et al. Recovery audit contractor audits and appeals at three academic medical centers. J Hosp Med. 2015;10(4):212-219. doi: 10.1002/jhm.2332.
2. United States Senate Committee on Finance. Master Amendments of the Audit and Appeal Fairness, Integrity, and Reforms in Medicare Act of 2015. Accessed July 7, 2015.

Editor’s note: This article is adapted from a June 2015 post on SHM’s official blog, “The Hospital Leader”.

When you see him on stage, it’s like he’s always been here. Bob Wachter, MD, one of the pioneers of the hospital medicine movement, has taken the podium at SHM’s annual meetings for more than a decade. Whether he’s uncovering important issues in electronic medical records or covering Elton John songs, he seems like a fixture in our world—and in healthcare.

The Unique Paths of Hospitalist Careers

But, rather than being a fixed, static thing, the life of any hospitalist—including the leaders of the movement—is a progression.

That progression starts in a different place for every hospitalist and is influenced by the people and events in their lives. Some hospitalists knew they wanted to be in medicine from a young age. Others found their calling much later in life.

Every one of those progressions is interspersed with moments of humor. For instance, this piece of hospitalist trivia: Dr. Wachter was the Penn Quaker mascot for the University of Pennsylvania the last time its men’s basketball team made it to the Final Four.

They also include the kinds of profound experiences that get to the very root of what it means to be a hospitalist. For Bob, it was being a resident in the ICU at the University of California San Francisco in the 1980s, just as AIDS was beginning to be diagnosed and understood.

That’s why I’m proud to introduce “Before the White Coat,” a new podcast from SHM, available on iTunes and other podcast apps. “Before the White Coat” is a 20-minute podcast, presented every two weeks.

Today, you can listen to full interviews between me and Bob Wachter, Ron Greeno of IPC Health, Jeff Wiese at Tulane University, SHM President Bob Harrington, CMS's Chief Medical Officer Patrick Conway and UCLA's Nasim Afsar. And later in September, Before the White Coat will present exclusive insights into the lives of Brian Harte of the Cleveland Clinic and Mark Williams at the University of Kentucky.

Today, you can listen to full interviews between me and Bob Wachter, Ron Greeno of IPC Health, Jeff Wiese at Tulane University, SHM President Bob Harrington, CMS's Chief Medical Officer Patrick Conway and UCLA’s Nasim Afsar. And later in September, Before the White Coat will present exclusive insights into the lives of Brian Harte of the Cleveland Clinic and Mark Williams at the University of Kentucky.

—Larry Wellikson, MD, MHM

Next, you’ll hear from Ron Greeno, MD, MHM, FCCP, now chief strategy officer at IPC Healthcare. After that, I’ll talk with many of the other leaders every two weeks, including Pat Conway, MD, MSc, at the Centers for Medicare and Medicaid Services, Mary Jo Gorman, MD, MBA, who founded Advanced ICU Care, and Nasim Afsar, MD, FSHM, at UCLA.

I’m looking forward to exploring the progression of their lives and careers with you. These personal conversations complement the wealth of clinical and practice management information that SHM already offers.

Podcast: A Format That Works for Hospitalists

Hospitalists are busy people. Whether at the hospital or at home, they are almost constantly on their feet. We wanted to present “Before the White Coat” as a podcast—something you can listen to while on the way to the hospital—or on the way home. Or maybe during an off hour in either place.

And we know that hospitalists are interested in podcasts; podcasts produced and distributed by The Hospitalist have been downloaded more than 40,000 times.

In fact, this podcast is modeled on some of the most successful podcasts out there: National Public Radio’s industry-leading podcasts, the new podcasts from Gimlet Media, and Adam Corolla’s “Take a Knee.”

Those podcasts have proven that the format works—and that people are catching on quickly. According to new research from the Pew Research Center, one in three Americans have listened to a podcast, and the number of people who have listened to a podcast in the last month has doubled since 2008.

How to Listen and Share

I hope you’ll join their ranks today. Here’s how:

• Visit the “Before the White Coat” website, www.beforethewhitecoat.org.
• iTunes users can subscribe by searching “Before the White Coat” in the podcast section of iTunes.
• And listeners using other podcast apps can either search for “Before the White Coat” or find details on the podcast website.

This is a new project for SHM, and I hope you’ll tell us what you think. You can tweet your reaction at @SHMLive—use the #B4theWC hashtag.

Finally, if you like it, I hope you’ll share it with friends, colleagues, and others in medicine.

As always, thank you for being an active part of the hospital medicine movement. I hope you’ll enjoy this newest piece of it.

Larry Wellikson is CEO of the Society of Hospital Medicine.

Editor’s note: This article is adapted from a June 2015 post on SHM’s official blog, “The Hospital Leader”.

When you see him on stage, it’s like he’s always been here. Bob Wachter, MD, one of the pioneers of the hospital medicine movement, has taken the podium at SHM’s annual meetings for more than a decade. Whether he’s uncovering important issues in electronic medical records or covering Elton John songs, he seems like a fixture in our world—and in healthcare.

The Unique Paths of Hospitalist Careers

But, rather than being a fixed, static thing, the life of any hospitalist—including the leaders of the movement—is a progression.

That progression starts in a different place for every hospitalist and is influenced by the people and events in their lives. Some hospitalists knew they wanted to be in medicine from a young age. Others found their calling much later in life.

Every one of those progressions is interspersed with moments of humor. For instance, this piece of hospitalist trivia: Dr. Wachter was the Penn Quaker mascot for the University of Pennsylvania the last time its men’s basketball team made it to the Final Four.

They also include the kinds of profound experiences that get to the very root of what it means to be a hospitalist. For Bob, it was being a resident in the ICU at the University of California San Francisco in the 1980s, just as AIDS was beginning to be diagnosed and understood.

That’s why I’m proud to introduce “Before the White Coat,” a new podcast from SHM, available on iTunes and other podcast apps. “Before the White Coat” is a 20-minute podcast, presented every two weeks.

Today, you can listen to full interviews between me and Bob Wachter, Ron Greeno of IPC Health, Jeff Wiese at Tulane University, SHM President Bob Harrington, CMS's Chief Medical Officer Patrick Conway and UCLA's Nasim Afsar. And later in September, Before the White Coat will present exclusive insights into the lives of Brian Harte of the Cleveland Clinic and Mark Williams at the University of Kentucky.

Today, you can listen to full interviews between me and Bob Wachter, Ron Greeno of IPC Health, Jeff Wiese at Tulane University, SHM President Bob Harrington, CMS's Chief Medical Officer Patrick Conway and UCLA’s Nasim Afsar. And later in September, Before the White Coat will present exclusive insights into the lives of Brian Harte of the Cleveland Clinic and Mark Williams at the University of Kentucky.

—Larry Wellikson, MD, MHM

Next, you’ll hear from Ron Greeno, MD, MHM, FCCP, now chief strategy officer at IPC Healthcare. After that, I’ll talk with many of the other leaders every two weeks, including Pat Conway, MD, MSc, at the Centers for Medicare and Medicaid Services, Mary Jo Gorman, MD, MBA, who founded Advanced ICU Care, and Nasim Afsar, MD, FSHM, at UCLA.

I’m looking forward to exploring the progression of their lives and careers with you. These personal conversations complement the wealth of clinical and practice management information that SHM already offers.

Podcast: A Format That Works for Hospitalists

Hospitalists are busy people. Whether at the hospital or at home, they are almost constantly on their feet. We wanted to present “Before the White Coat” as a podcast—something you can listen to while on the way to the hospital—or on the way home. Or maybe during an off hour in either place.

And we know that hospitalists are interested in podcasts; podcasts produced and distributed by The Hospitalist have been downloaded more than 40,000 times.

In fact, this podcast is modeled on some of the most successful podcasts out there: National Public Radio’s industry-leading podcasts, the new podcasts from Gimlet Media, and Adam Corolla’s “Take a Knee.”

Those podcasts have proven that the format works—and that people are catching on quickly. According to new research from the Pew Research Center, one in three Americans have listened to a podcast, and the number of people who have listened to a podcast in the last month has doubled since 2008.

How to Listen and Share

I hope you’ll join their ranks today. Here’s how:

• Visit the “Before the White Coat” website, www.beforethewhitecoat.org.
• iTunes users can subscribe by searching “Before the White Coat” in the podcast section of iTunes.
• And listeners using other podcast apps can either search for “Before the White Coat” or find details on the podcast website.

This is a new project for SHM, and I hope you’ll tell us what you think. You can tweet your reaction at @SHMLive—use the #B4theWC hashtag.

Finally, if you like it, I hope you’ll share it with friends, colleagues, and others in medicine.

As always, thank you for being an active part of the hospital medicine movement. I hope you’ll enjoy this newest piece of it.

Larry Wellikson is CEO of the Society of Hospital Medicine.

Editor’s note: This article is adapted from a June 2015 post on SHM’s official blog, “The Hospital Leader”.

When you see him on stage, it’s like he’s always been here. Bob Wachter, MD, one of the pioneers of the hospital medicine movement, has taken the podium at SHM’s annual meetings for more than a decade. Whether he’s uncovering important issues in electronic medical records or covering Elton John songs, he seems like a fixture in our world—and in healthcare.

The Unique Paths of Hospitalist Careers

But, rather than being a fixed, static thing, the life of any hospitalist—including the leaders of the movement—is a progression.

That progression starts in a different place for every hospitalist and is influenced by the people and events in their lives. Some hospitalists knew they wanted to be in medicine from a young age. Others found their calling much later in life.

Every one of those progressions is interspersed with moments of humor. For instance, this piece of hospitalist trivia: Dr. Wachter was the Penn Quaker mascot for the University of Pennsylvania the last time its men’s basketball team made it to the Final Four.

They also include the kinds of profound experiences that get to the very root of what it means to be a hospitalist. For Bob, it was being a resident in the ICU at the University of California San Francisco in the 1980s, just as AIDS was beginning to be diagnosed and understood.

That’s why I’m proud to introduce “Before the White Coat,” a new podcast from SHM, available on iTunes and other podcast apps. “Before the White Coat” is a 20-minute podcast, presented every two weeks.

Today, you can listen to full interviews between me and Bob Wachter, Ron Greeno of IPC Health, Jeff Wiese at Tulane University, SHM President Bob Harrington, CMS's Chief Medical Officer Patrick Conway and UCLA's Nasim Afsar. And later in September, Before the White Coat will present exclusive insights into the lives of Brian Harte of the Cleveland Clinic and Mark Williams at the University of Kentucky.

Today, you can listen to full interviews between me and Bob Wachter, Ron Greeno of IPC Health, Jeff Wiese at Tulane University, SHM President Bob Harrington, CMS's Chief Medical Officer Patrick Conway and UCLA’s Nasim Afsar. And later in September, Before the White Coat will present exclusive insights into the lives of Brian Harte of the Cleveland Clinic and Mark Williams at the University of Kentucky.

—Larry Wellikson, MD, MHM

Next, you’ll hear from Ron Greeno, MD, MHM, FCCP, now chief strategy officer at IPC Healthcare. After that, I’ll talk with many of the other leaders every two weeks, including Pat Conway, MD, MSc, at the Centers for Medicare and Medicaid Services, Mary Jo Gorman, MD, MBA, who founded Advanced ICU Care, and Nasim Afsar, MD, FSHM, at UCLA.

I’m looking forward to exploring the progression of their lives and careers with you. These personal conversations complement the wealth of clinical and practice management information that SHM already offers.

Podcast: A Format That Works for Hospitalists

Hospitalists are busy people. Whether at the hospital or at home, they are almost constantly on their feet. We wanted to present “Before the White Coat” as a podcast—something you can listen to while on the way to the hospital—or on the way home. Or maybe during an off hour in either place.

And we know that hospitalists are interested in podcasts; podcasts produced and distributed by The Hospitalist have been downloaded more than 40,000 times.

In fact, this podcast is modeled on some of the most successful podcasts out there: National Public Radio’s industry-leading podcasts, the new podcasts from Gimlet Media, and Adam Corolla’s “Take a Knee.”

Those podcasts have proven that the format works—and that people are catching on quickly. According to new research from the Pew Research Center, one in three Americans have listened to a podcast, and the number of people who have listened to a podcast in the last month has doubled since 2008.

How to Listen and Share

I hope you’ll join their ranks today. Here’s how:

• Visit the “Before the White Coat” website, www.beforethewhitecoat.org.
• iTunes users can subscribe by searching “Before the White Coat” in the podcast section of iTunes.
• And listeners using other podcast apps can either search for “Before the White Coat” or find details on the podcast website.

This is a new project for SHM, and I hope you’ll tell us what you think. You can tweet your reaction at @SHMLive—use the #B4theWC hashtag.

Finally, if you like it, I hope you’ll share it with friends, colleagues, and others in medicine.

As always, thank you for being an active part of the hospital medicine movement. I hope you’ll enjoy this newest piece of it.

Larry Wellikson is CEO of the Society of Hospital Medicine.

Nearly 20 years ago, Bob Wachter, MD, coined the term “hospitalist,” defining a new specialty caring for the hospitalized medical patient. Since that time, we’ve seen rapid growth in the numbers of physicians who identify themselves as hospitalists, dominated by training in internal medicine and, to a lesser extent, family practice and pediatrics.

But, what about other specialty hospitalists, trained in the medicine or surgical specialties? How much of a presence do they have in our institutions today and in which specialties? To help us better understand this, a new question in 2014 State of Hospital Medicine survey asked whether specialty hospitalists practice in your hospital or health system.

Much like our own field’s exponential growth, we are likely to see further expansion of specialty hospitalists over the next several years.

—Carolyn Sites, DO, FHM

Results show the top three specialty hospitalists to be critical care, at (35.4%), followed by general surgery/trauma (16.6%) and neurology (15.7%), based on the responses of survey participants representing hospital medicine groups (HMGs) that care for adults only. Other specialties included obstetrics (OB), psychiatry, GI, cardiology, and orthopedics (see Figure 1).

Perhaps not too surprising, the greatest number of specialty hospitalists are found in university and academic settings. These are our primary training centers, offering fellowship programs and further subspecialization programs. Much like in our own field of hospital medicine, some academic centers have created one-year fellowships for those interested in specific hospital specialty fields, such as OB hospitalist.

For reasons that are less clear, the survey also shows percentages are highest in the western U.S. and lowest in the East.

Critical care hospitalists, also known as intensivists, dominate the spectrum, being present in academic and nonacademic centers, regardless of the employment model of the medical hospitalists at those facilities. This is not unexpected, given the Leapfrog Group’s endorsement of ICU physician staffing with intensivists.

What’s driving the other specialty hospitalist fields? I suspect the reasons are similar to those of our own specialty. OB and neuro hospitalists at my health system cite the challenges of managing outpatient and inpatient practices, the higher inpatient acuity and focused skill set that are required, immediate availability demands, and work-life balance as key factors. Further drivers include external quality/safety governing agencies or groups, such as the Leapfrog example above, or The Joint Commission’s requirements for certification as a Comprehensive Stroke Center with neurointensive care units.

Much like our own field’s exponential growth, we are likely to see further expansion of specialty hospitalists over the next several years. It will be interesting to watch how much and how fast this occurs, and what impact and influence these groups will bring to the care of the hospitalized patient. I’m already looking forward to next year’s SOHM report to see those results.

Dr. Sites is regional medical director of hospital medicine at Providence Health Systems in Oregon and a member of the SHM Practice Analysis Committee.

Nearly 20 years ago, Bob Wachter, MD, coined the term “hospitalist,” defining a new specialty caring for the hospitalized medical patient. Since that time, we’ve seen rapid growth in the numbers of physicians who identify themselves as hospitalists, dominated by training in internal medicine and, to a lesser extent, family practice and pediatrics.

But, what about other specialty hospitalists, trained in the medicine or surgical specialties? How much of a presence do they have in our institutions today and in which specialties? To help us better understand this, a new question in 2014 State of Hospital Medicine survey asked whether specialty hospitalists practice in your hospital or health system.

Much like our own field’s exponential growth, we are likely to see further expansion of specialty hospitalists over the next several years.

—Carolyn Sites, DO, FHM

Results show the top three specialty hospitalists to be critical care, at (35.4%), followed by general surgery/trauma (16.6%) and neurology (15.7%), based on the responses of survey participants representing hospital medicine groups (HMGs) that care for adults only. Other specialties included obstetrics (OB), psychiatry, GI, cardiology, and orthopedics (see Figure 1).

Perhaps not too surprising, the greatest number of specialty hospitalists are found in university and academic settings. These are our primary training centers, offering fellowship programs and further subspecialization programs. Much like in our own field of hospital medicine, some academic centers have created one-year fellowships for those interested in specific hospital specialty fields, such as OB hospitalist.

For reasons that are less clear, the survey also shows percentages are highest in the western U.S. and lowest in the East.

Critical care hospitalists, also known as intensivists, dominate the spectrum, being present in academic and nonacademic centers, regardless of the employment model of the medical hospitalists at those facilities. This is not unexpected, given the Leapfrog Group’s endorsement of ICU physician staffing with intensivists.

What’s driving the other specialty hospitalist fields? I suspect the reasons are similar to those of our own specialty. OB and neuro hospitalists at my health system cite the challenges of managing outpatient and inpatient practices, the higher inpatient acuity and focused skill set that are required, immediate availability demands, and work-life balance as key factors. Further drivers include external quality/safety governing agencies or groups, such as the Leapfrog example above, or The Joint Commission’s requirements for certification as a Comprehensive Stroke Center with neurointensive care units.

Much like our own field’s exponential growth, we are likely to see further expansion of specialty hospitalists over the next several years. It will be interesting to watch how much and how fast this occurs, and what impact and influence these groups will bring to the care of the hospitalized patient. I’m already looking forward to next year’s SOHM report to see those results.

Dr. Sites is regional medical director of hospital medicine at Providence Health Systems in Oregon and a member of the SHM Practice Analysis Committee.

Nearly 20 years ago, Bob Wachter, MD, coined the term “hospitalist,” defining a new specialty caring for the hospitalized medical patient. Since that time, we’ve seen rapid growth in the numbers of physicians who identify themselves as hospitalists, dominated by training in internal medicine and, to a lesser extent, family practice and pediatrics.

But, what about other specialty hospitalists, trained in the medicine or surgical specialties? How much of a presence do they have in our institutions today and in which specialties? To help us better understand this, a new question in 2014 State of Hospital Medicine survey asked whether specialty hospitalists practice in your hospital or health system.

Much like our own field’s exponential growth, we are likely to see further expansion of specialty hospitalists over the next several years.

—Carolyn Sites, DO, FHM

Results show the top three specialty hospitalists to be critical care, at (35.4%), followed by general surgery/trauma (16.6%) and neurology (15.7%), based on the responses of survey participants representing hospital medicine groups (HMGs) that care for adults only. Other specialties included obstetrics (OB), psychiatry, GI, cardiology, and orthopedics (see Figure 1).

Perhaps not too surprising, the greatest number of specialty hospitalists are found in university and academic settings. These are our primary training centers, offering fellowship programs and further subspecialization programs. Much like in our own field of hospital medicine, some academic centers have created one-year fellowships for those interested in specific hospital specialty fields, such as OB hospitalist.

For reasons that are less clear, the survey also shows percentages are highest in the western U.S. and lowest in the East.

Critical care hospitalists, also known as intensivists, dominate the spectrum, being present in academic and nonacademic centers, regardless of the employment model of the medical hospitalists at those facilities. This is not unexpected, given the Leapfrog Group’s endorsement of ICU physician staffing with intensivists.

What’s driving the other specialty hospitalist fields? I suspect the reasons are similar to those of our own specialty. OB and neuro hospitalists at my health system cite the challenges of managing outpatient and inpatient practices, the higher inpatient acuity and focused skill set that are required, immediate availability demands, and work-life balance as key factors. Further drivers include external quality/safety governing agencies or groups, such as the Leapfrog example above, or The Joint Commission’s requirements for certification as a Comprehensive Stroke Center with neurointensive care units.

Much like our own field’s exponential growth, we are likely to see further expansion of specialty hospitalists over the next several years. It will be interesting to watch how much and how fast this occurs, and what impact and influence these groups will bring to the care of the hospitalized patient. I’m already looking forward to next year’s SOHM report to see those results.

Dr. Sites is regional medical director of hospital medicine at Providence Health Systems in Oregon and a member of the SHM Practice Analysis Committee.