In the April 2015 issue, on page 214 in the article by Jin XW, McKenzie ML, Yen-Lieberman B, “Can the test for human papillomavirus DNA be used as a stand-alone, first-line screening test for cervical cancer?”, the source for the information on predictive values was not cited. The final bulleted item should have read as follows:

• HPV testing by itself performed better than Pap-HPV cotesting, with positive predictive values of 12.25% vs 11.04% and negative predictive values of 99.58% vs 99.52% (data presented to the FDA Medical Devices Advisory Committee, Microbiology Panel. March 12, 2014. FDA Executive Summary).

This oversight has been corrected in the online version of the article.

In the April 2015 issue, on page 214 in the article by Jin XW, McKenzie ML, Yen-Lieberman B, “Can the test for human papillomavirus DNA be used as a stand-alone, first-line screening test for cervical cancer?”, the source for the information on predictive values was not cited. The final bulleted item should have read as follows:

• HPV testing by itself performed better than Pap-HPV cotesting, with positive predictive values of 12.25% vs 11.04% and negative predictive values of 99.58% vs 99.52% (data presented to the FDA Medical Devices Advisory Committee, Microbiology Panel. March 12, 2014. FDA Executive Summary).

This oversight has been corrected in the online version of the article.

In the April 2015 issue, on page 214 in the article by Jin XW, McKenzie ML, Yen-Lieberman B, “Can the test for human papillomavirus DNA be used as a stand-alone, first-line screening test for cervical cancer?”, the source for the information on predictive values was not cited. The final bulleted item should have read as follows:

• HPV testing by itself performed better than Pap-HPV cotesting, with positive predictive values of 12.25% vs 11.04% and negative predictive values of 99.58% vs 99.52% (data presented to the FDA Medical Devices Advisory Committee, Microbiology Panel. March 12, 2014. FDA Executive Summary).

This oversight has been corrected in the online version of the article.

The Dartmouth Institute for Health Policy and Clinical Practice and other institutions have long tried to quantify the prevalence and geographic variation of low-value care. Researchers have roughly defined low-value care as tests and procedures for which the potential benefit does not outweigh the potential harm, though the calculus can change significantly from patient to patient.

William Schpero, a former health policy fellow at the Dartmouth Institute and now a PhD student in health policy and management at Yale University, says he and colleagues initially identified three theoretical reasons for the geographical variation. An increase in the use of low-value care, they reasoned, might be driven by patients demanding more intensive treatments, by financial incentives to providers, or by providers supplying more services.

After adjusting for differences in the health status of patient populations, however, the Dartmouth Institute’s work consistently revealed large unexplained geographical variations, a finding that also held true for patients in the last six months of life. These variations, Schpero says, suggest that patient demand is not a major driver. A collaborative Dartmouth and Harvard study, released by the National Bureau of Economic Research in 2013, instead pointed to a more likely rationale, at least during the last two years of a patient’s life.

By linking patient and physician surveys to Medicare claims data, the report examined how physician and patient preferences affected overall healthcare spending in different geographic regions. The paper identified “cowboys,” or physicians who used treatments that were more intensive than those recommended by guidelines, and “comforters,” or physicians who recommended more low-cost treatment protocols.

Older physicians and smaller practices, the study suggested, were more likely to recommend higher levels of follow-up care and fall into the “cowboys” category.

It was this difference in physician culture and beliefs about effective treatment, not patient preferences, that drove most of the variation in healthcare spending. Monetary incentives, meanwhile, had only a marginal effect. If all physicians were to follow professional guidelines for effective care and not exceed recommended treatments, the report suggested, Medicare spending for end-of-life care could be reduced by 36 percent, “which is a huge, huge number,” Schpero says.

The Dartmouth Institute for Health Policy and Clinical Practice and other institutions have long tried to quantify the prevalence and geographic variation of low-value care. Researchers have roughly defined low-value care as tests and procedures for which the potential benefit does not outweigh the potential harm, though the calculus can change significantly from patient to patient.

William Schpero, a former health policy fellow at the Dartmouth Institute and now a PhD student in health policy and management at Yale University, says he and colleagues initially identified three theoretical reasons for the geographical variation. An increase in the use of low-value care, they reasoned, might be driven by patients demanding more intensive treatments, by financial incentives to providers, or by providers supplying more services.

After adjusting for differences in the health status of patient populations, however, the Dartmouth Institute’s work consistently revealed large unexplained geographical variations, a finding that also held true for patients in the last six months of life. These variations, Schpero says, suggest that patient demand is not a major driver. A collaborative Dartmouth and Harvard study, released by the National Bureau of Economic Research in 2013, instead pointed to a more likely rationale, at least during the last two years of a patient’s life.

By linking patient and physician surveys to Medicare claims data, the report examined how physician and patient preferences affected overall healthcare spending in different geographic regions. The paper identified “cowboys,” or physicians who used treatments that were more intensive than those recommended by guidelines, and “comforters,” or physicians who recommended more low-cost treatment protocols.

Older physicians and smaller practices, the study suggested, were more likely to recommend higher levels of follow-up care and fall into the “cowboys” category.

It was this difference in physician culture and beliefs about effective treatment, not patient preferences, that drove most of the variation in healthcare spending. Monetary incentives, meanwhile, had only a marginal effect. If all physicians were to follow professional guidelines for effective care and not exceed recommended treatments, the report suggested, Medicare spending for end-of-life care could be reduced by 36 percent, “which is a huge, huge number,” Schpero says.

The Dartmouth Institute for Health Policy and Clinical Practice and other institutions have long tried to quantify the prevalence and geographic variation of low-value care. Researchers have roughly defined low-value care as tests and procedures for which the potential benefit does not outweigh the potential harm, though the calculus can change significantly from patient to patient.

William Schpero, a former health policy fellow at the Dartmouth Institute and now a PhD student in health policy and management at Yale University, says he and colleagues initially identified three theoretical reasons for the geographical variation. An increase in the use of low-value care, they reasoned, might be driven by patients demanding more intensive treatments, by financial incentives to providers, or by providers supplying more services.

After adjusting for differences in the health status of patient populations, however, the Dartmouth Institute’s work consistently revealed large unexplained geographical variations, a finding that also held true for patients in the last six months of life. These variations, Schpero says, suggest that patient demand is not a major driver. A collaborative Dartmouth and Harvard study, released by the National Bureau of Economic Research in 2013, instead pointed to a more likely rationale, at least during the last two years of a patient’s life.

By linking patient and physician surveys to Medicare claims data, the report examined how physician and patient preferences affected overall healthcare spending in different geographic regions. The paper identified “cowboys,” or physicians who used treatments that were more intensive than those recommended by guidelines, and “comforters,” or physicians who recommended more low-cost treatment protocols.

Older physicians and smaller practices, the study suggested, were more likely to recommend higher levels of follow-up care and fall into the “cowboys” category.

It was this difference in physician culture and beliefs about effective treatment, not patient preferences, that drove most of the variation in healthcare spending. Monetary incentives, meanwhile, had only a marginal effect. If all physicians were to follow professional guidelines for effective care and not exceed recommended treatments, the report suggested, Medicare spending for end-of-life care could be reduced by 36 percent, “which is a huge, huge number,” Schpero says.

Sometimes, simply knowing what a test costs can make all the difference.

Many physicians have sheepishly admitted that they know little about the price tags attached to the procedures and tests they order on a routine basis—or how that might impact their patients financially. In Medscape’s Physician Compensation Report for 2012, only 38% of surveyed doctors said they regularly discussed the cost of treatment with their patients. The following year, the rate had dropped to 30%.

One medical resident, Neel Shah, MD, MPP discovered how important those discussions can be.

After a woman admitted to the ED tested positive on a pregnancy test, a follow-up hormone test warned of potential trouble with her pregnancy, and Dr. Shah asked her to return to the hospital for an ultrasound.

“She refused to come in until I could tell her how much the ultrasound would cost,” he recalls. Other providers had told him that bringing up costs with patients would decrease their trust, because they didn’t want doctors to focus on anything but providing care. “With her, it was very clear that my inability to tell her what things cost actually eroded her trust in me and, in her mind, she was being reasonable,” he says.

“If you’re trying to tell doctors or clinicians in general that we ought to be doing things differently, as a young person, it’s not a great way to make friends.”

–Neel Shah, MD, MPP

Dr. Shah had already grown disillusioned in medical school, watching providers around him make clinical decisions without regard to the cost for patients, and he took a hiatus to study politics at Harvard’s Kennedy School of Government. When he and a collaborator subsequently launched the nonprofit organization Costs of Care to point out the downsides of that lack of transparency, however, they received a less-than-enthusiastic reception from some quarters.

“If you’re trying to tell doctors or clinicians in general that we ought to be doing things differently, as a young person, it’s not a great way to make friends,” says

Dr. Shah, who is now an assistant professor at Harvard Medical School in Boston.

The group gained traction as its cost-awareness manifesto began to resonate with the public, however, and the essays on its site have been picked up by multiple media groups. Dr. Shah’s own experience with his pregnant patient, however, made one of the strongest impressions on him.

Getting an answer to her about the cost of an ultrasound took nearly 24 hours, he recalls, “because nobody around me knew.” In the interim, he fretted that his patient might have an ectopic pregnancy and bleed to death. She didn’t, but the outcome could have been very different, he says.

“That really struck home for me, for sure,” he adds. “I think about that all the time.”

Sometimes, simply knowing what a test costs can make all the difference.

Many physicians have sheepishly admitted that they know little about the price tags attached to the procedures and tests they order on a routine basis—or how that might impact their patients financially. In Medscape’s Physician Compensation Report for 2012, only 38% of surveyed doctors said they regularly discussed the cost of treatment with their patients. The following year, the rate had dropped to 30%.

One medical resident, Neel Shah, MD, MPP discovered how important those discussions can be.

After a woman admitted to the ED tested positive on a pregnancy test, a follow-up hormone test warned of potential trouble with her pregnancy, and Dr. Shah asked her to return to the hospital for an ultrasound.

“She refused to come in until I could tell her how much the ultrasound would cost,” he recalls. Other providers had told him that bringing up costs with patients would decrease their trust, because they didn’t want doctors to focus on anything but providing care. “With her, it was very clear that my inability to tell her what things cost actually eroded her trust in me and, in her mind, she was being reasonable,” he says.

“If you’re trying to tell doctors or clinicians in general that we ought to be doing things differently, as a young person, it’s not a great way to make friends.”

–Neel Shah, MD, MPP

Dr. Shah had already grown disillusioned in medical school, watching providers around him make clinical decisions without regard to the cost for patients, and he took a hiatus to study politics at Harvard’s Kennedy School of Government. When he and a collaborator subsequently launched the nonprofit organization Costs of Care to point out the downsides of that lack of transparency, however, they received a less-than-enthusiastic reception from some quarters.

“If you’re trying to tell doctors or clinicians in general that we ought to be doing things differently, as a young person, it’s not a great way to make friends,” says

Dr. Shah, who is now an assistant professor at Harvard Medical School in Boston.

The group gained traction as its cost-awareness manifesto began to resonate with the public, however, and the essays on its site have been picked up by multiple media groups. Dr. Shah’s own experience with his pregnant patient, however, made one of the strongest impressions on him.

Getting an answer to her about the cost of an ultrasound took nearly 24 hours, he recalls, “because nobody around me knew.” In the interim, he fretted that his patient might have an ectopic pregnancy and bleed to death. She didn’t, but the outcome could have been very different, he says.

“That really struck home for me, for sure,” he adds. “I think about that all the time.”

Sometimes, simply knowing what a test costs can make all the difference.

Many physicians have sheepishly admitted that they know little about the price tags attached to the procedures and tests they order on a routine basis—or how that might impact their patients financially. In Medscape’s Physician Compensation Report for 2012, only 38% of surveyed doctors said they regularly discussed the cost of treatment with their patients. The following year, the rate had dropped to 30%.

One medical resident, Neel Shah, MD, MPP discovered how important those discussions can be.

After a woman admitted to the ED tested positive on a pregnancy test, a follow-up hormone test warned of potential trouble with her pregnancy, and Dr. Shah asked her to return to the hospital for an ultrasound.

“She refused to come in until I could tell her how much the ultrasound would cost,” he recalls. Other providers had told him that bringing up costs with patients would decrease their trust, because they didn’t want doctors to focus on anything but providing care. “With her, it was very clear that my inability to tell her what things cost actually eroded her trust in me and, in her mind, she was being reasonable,” he says.

“If you’re trying to tell doctors or clinicians in general that we ought to be doing things differently, as a young person, it’s not a great way to make friends.”

–Neel Shah, MD, MPP

Dr. Shah had already grown disillusioned in medical school, watching providers around him make clinical decisions without regard to the cost for patients, and he took a hiatus to study politics at Harvard’s Kennedy School of Government. When he and a collaborator subsequently launched the nonprofit organization Costs of Care to point out the downsides of that lack of transparency, however, they received a less-than-enthusiastic reception from some quarters.

“If you’re trying to tell doctors or clinicians in general that we ought to be doing things differently, as a young person, it’s not a great way to make friends,” says

Dr. Shah, who is now an assistant professor at Harvard Medical School in Boston.

The group gained traction as its cost-awareness manifesto began to resonate with the public, however, and the essays on its site have been picked up by multiple media groups. Dr. Shah’s own experience with his pregnant patient, however, made one of the strongest impressions on him.

Getting an answer to her about the cost of an ultrasound took nearly 24 hours, he recalls, “because nobody around me knew.” In the interim, he fretted that his patient might have an ectopic pregnancy and bleed to death. She didn’t, but the outcome could have been very different, he says.

“That really struck home for me, for sure,” he adds. “I think about that all the time.”

Reform advocates agree that a doctor’s time is a scarce resource that can contribute to waste when it is stretched too thin.

“It’s not just about overtreatment; it’s about getting the right treatment, and the right treatment depends on the right diagnosis, and the right diagnosis depends on really taking the time to think carefully with the patient about what’s going on,” says Vineet Arora, MD, MAPP, FHM, a hospitalist and researcher at the University of Chicago. A doctor “pulled in 10 different ways in the hospital” simply may not have the bandwidth to devote sufficient time to a complex patient; ordering a test can then seem like an enticing way to save some time.

Although electronic health records may have simplified the process for ordering CT scans and other tests, Dr. Arora says, they sometimes supersede important conversations that should take place with radiologists or other specialists about whether those tests are truly necessary. Meanwhile, providers face a proliferation of reporting duties. Recent surveys, in fact, suggest that doctors are “drowning” in paperwork and computer-based reporting requirements. Placing additional demands on a doctor’s time, Dr. Arora says, can limit his or her availability for other duties.

With hospitalists caring for increasingly complex patients with more complicated therapeutics, UCSF’s Christopher Moriates, MD, agrees that insufficient time can be an important barrier to change. It is not, however, insurmountable. If the ethos of medicine is “First, do no harm,” he says, it’s critical for doctors to remember that waste is harm.

“If we’re really going to stand by that,” he says, “then it rises to be something that we really need to take on.”

Reform advocates agree that a doctor’s time is a scarce resource that can contribute to waste when it is stretched too thin.

“It’s not just about overtreatment; it’s about getting the right treatment, and the right treatment depends on the right diagnosis, and the right diagnosis depends on really taking the time to think carefully with the patient about what’s going on,” says Vineet Arora, MD, MAPP, FHM, a hospitalist and researcher at the University of Chicago. A doctor “pulled in 10 different ways in the hospital” simply may not have the bandwidth to devote sufficient time to a complex patient; ordering a test can then seem like an enticing way to save some time.

Although electronic health records may have simplified the process for ordering CT scans and other tests, Dr. Arora says, they sometimes supersede important conversations that should take place with radiologists or other specialists about whether those tests are truly necessary. Meanwhile, providers face a proliferation of reporting duties. Recent surveys, in fact, suggest that doctors are “drowning” in paperwork and computer-based reporting requirements. Placing additional demands on a doctor’s time, Dr. Arora says, can limit his or her availability for other duties.

With hospitalists caring for increasingly complex patients with more complicated therapeutics, UCSF’s Christopher Moriates, MD, agrees that insufficient time can be an important barrier to change. It is not, however, insurmountable. If the ethos of medicine is “First, do no harm,” he says, it’s critical for doctors to remember that waste is harm.

“If we’re really going to stand by that,” he says, “then it rises to be something that we really need to take on.”

Reform advocates agree that a doctor’s time is a scarce resource that can contribute to waste when it is stretched too thin.

“It’s not just about overtreatment; it’s about getting the right treatment, and the right treatment depends on the right diagnosis, and the right diagnosis depends on really taking the time to think carefully with the patient about what’s going on,” says Vineet Arora, MD, MAPP, FHM, a hospitalist and researcher at the University of Chicago. A doctor “pulled in 10 different ways in the hospital” simply may not have the bandwidth to devote sufficient time to a complex patient; ordering a test can then seem like an enticing way to save some time.

Although electronic health records may have simplified the process for ordering CT scans and other tests, Dr. Arora says, they sometimes supersede important conversations that should take place with radiologists or other specialists about whether those tests are truly necessary. Meanwhile, providers face a proliferation of reporting duties. Recent surveys, in fact, suggest that doctors are “drowning” in paperwork and computer-based reporting requirements. Placing additional demands on a doctor’s time, Dr. Arora says, can limit his or her availability for other duties.

With hospitalists caring for increasingly complex patients with more complicated therapeutics, UCSF’s Christopher Moriates, MD, agrees that insufficient time can be an important barrier to change. It is not, however, insurmountable. If the ethos of medicine is “First, do no harm,” he says, it’s critical for doctors to remember that waste is harm.

“If we’re really going to stand by that,” he says, “then it rises to be something that we really need to take on.”

In April 2013, The Joint Commission issued a Sentinel Event Alert that provided hospitals with recommendations for assessing their individual circumstances and developing a systematic, coordinated approach regarding medical device alarms.

The recommendations correspond with those of the Association for the Advancement of Medical Instrumentation (AAMI) and ECRI Institute. Most of the information and guidance provided in these alerts is drawn from The Joint Commission’s Sentinel Event Database, a voluntary reporting system for serious adverse events in healthcare.

The recommendations include the following:

1. Create a process for safe alarm management and response in high-risk areas;
2. Inventory alarm-equipped medical devices used for high-risk areas and conditions, and identify default alarm settings;
3. Have guidelines for tailoring alarm settings and limits for individual patients; and
4. Inspect, check, and maintain alarm-equipped devices.

The Joint Commission alert also recommended training and education for all clinical care team members on safe alarm management and response in high-risk areas. Organizations should also consider ways to reduce nuisance alarm signals.

“Patient harm and death that is caused by factors related to alarm management has persisted as the top patient safety issue,” says Ronald Wyatt, MD, MHA, medical director of the division of healthcare improvement at The Joint Commission in Oakbrook Terrace, Ill.

In addition to the alert and existing accreditation standards regarding alarm safety, The Joint Commission issued 2014 National Patient Safety Goals to help healthcare organizations address this issue.

Beginning in January 2014, hospitals were required to identify the most important alarms to manage based on their own internal situations. In phase 2, beginning in January 2016, hospitals will be expected to develop and implement specific components of alarm policies and procedures that address such items as clinically appropriate settings, when settings can be changed, and who is allowed to make such changes. Requirements only apply to organizations accredited by The Joint Commission.

In April 2013, The Joint Commission issued a Sentinel Event Alert that provided hospitals with recommendations for assessing their individual circumstances and developing a systematic, coordinated approach regarding medical device alarms.

The recommendations correspond with those of the Association for the Advancement of Medical Instrumentation (AAMI) and ECRI Institute. Most of the information and guidance provided in these alerts is drawn from The Joint Commission’s Sentinel Event Database, a voluntary reporting system for serious adverse events in healthcare.

The recommendations include the following:

1. Create a process for safe alarm management and response in high-risk areas;
2. Inventory alarm-equipped medical devices used for high-risk areas and conditions, and identify default alarm settings;
3. Have guidelines for tailoring alarm settings and limits for individual patients; and
4. Inspect, check, and maintain alarm-equipped devices.

The Joint Commission alert also recommended training and education for all clinical care team members on safe alarm management and response in high-risk areas. Organizations should also consider ways to reduce nuisance alarm signals.

“Patient harm and death that is caused by factors related to alarm management has persisted as the top patient safety issue,” says Ronald Wyatt, MD, MHA, medical director of the division of healthcare improvement at The Joint Commission in Oakbrook Terrace, Ill.

In addition to the alert and existing accreditation standards regarding alarm safety, The Joint Commission issued 2014 National Patient Safety Goals to help healthcare organizations address this issue.

Beginning in January 2014, hospitals were required to identify the most important alarms to manage based on their own internal situations. In phase 2, beginning in January 2016, hospitals will be expected to develop and implement specific components of alarm policies and procedures that address such items as clinically appropriate settings, when settings can be changed, and who is allowed to make such changes. Requirements only apply to organizations accredited by The Joint Commission.

In April 2013, The Joint Commission issued a Sentinel Event Alert that provided hospitals with recommendations for assessing their individual circumstances and developing a systematic, coordinated approach regarding medical device alarms.

The recommendations correspond with those of the Association for the Advancement of Medical Instrumentation (AAMI) and ECRI Institute. Most of the information and guidance provided in these alerts is drawn from The Joint Commission’s Sentinel Event Database, a voluntary reporting system for serious adverse events in healthcare.

The recommendations include the following:

1. Create a process for safe alarm management and response in high-risk areas;
2. Inventory alarm-equipped medical devices used for high-risk areas and conditions, and identify default alarm settings;
3. Have guidelines for tailoring alarm settings and limits for individual patients; and
4. Inspect, check, and maintain alarm-equipped devices.

The Joint Commission alert also recommended training and education for all clinical care team members on safe alarm management and response in high-risk areas. Organizations should also consider ways to reduce nuisance alarm signals.

“Patient harm and death that is caused by factors related to alarm management has persisted as the top patient safety issue,” says Ronald Wyatt, MD, MHA, medical director of the division of healthcare improvement at The Joint Commission in Oakbrook Terrace, Ill.

In addition to the alert and existing accreditation standards regarding alarm safety, The Joint Commission issued 2014 National Patient Safety Goals to help healthcare organizations address this issue.

Beginning in January 2014, hospitals were required to identify the most important alarms to manage based on their own internal situations. In phase 2, beginning in January 2016, hospitals will be expected to develop and implement specific components of alarm policies and procedures that address such items as clinically appropriate settings, when settings can be changed, and who is allowed to make such changes. Requirements only apply to organizations accredited by The Joint Commission.

As you may have heard, H.R. 876, a bill unanimously passed in the House recently, requires a hospital to give adequate oral and written notification of a patient’s observation status. The bill has now moved to the Senate.

“Notice of Observation Treatment and Implication for Care Eligibility Act,” known as the NOTICE Act, was sponsored by Rep. Lloyd Doggett (D-Texas) and co-sponsored by Rep. Earl Blumenauer (D-Ore.), Rep. Charles Rangel (D-N.Y.), and Rep. Todd Young (R-Ind.), all known to be admirable patient care advocates.

The bill proposes requiring that any patient who has been classified as observation status for more than 24 hours be given oral and written notice within 36 hours of that classification. That notice must include the reason for and implications of that status, including lack of coverage for services and cost sharing under Medicare Part B, as well as the name and title of the hospital staff who gave the oral notification. Written notification must be signed by the patient or, if the patient refuses, by the staff who presented it.

Although it is essential that patients are aware of observation status and its implications, this bill would not solve the underlying problem and would only create divisions between patients and the staff caring for them. Two issues stand out:

1. Observation status is not currently a medical determination; and
2. Hospitalized medical patients should not be considered outpatients.

When a patient is admitted to the hospital, acute inpatient versus observation status is often assigned by a non-clinician in the form of a “verbal” order before the attending hospitalist meets or even hears of the patient. This order must be signed promptly by that hospitalist to prevent penalization for lack of medical record compliance. Increasingly, more of these orders are for observation status, as hospitals fear bounty-hunting recovery audit contractors (RACs) in pursuit of “Medicare fraud.”

Under H.R. 876, the situation is further intensified for both clinicians and patients. Picture yourself in the middle of a busy day at your hospital, admitting and discharging patients, stabilizing critically ill patients, and discussing goals of care with patients given life-altering diagnoses. Your pager goes off.

“Mrs. H. on 6th Floor East wants to talk to you right away,” the conversation starts. Mrs. H is in tears, and her family is angry. “We were just told that Grandma is observation status, not admitted to the hospital! This makes no sense!”

Forty-five minutes later, you have agreed, commiserated, and let them know you have absolutely no control over the designation. To you, Mrs. H. is medically ill enough to require hospitalization, and she and her family agree, but Medicare regulations and fear of RAC audits keep her on observation status. What have you accomplished during that time?

H.R. 876 is not the problem, and it is clearly well intentioned. I regularly inform patients when I’m aware of their observation status, because it’s a lousy situation for the patient. We should all be doing as much.

But H.R. 876 is not the solution, either, because it does not address the core problems with observation policy. Now is the time for us all to step forward, voicing our support of SHM as it works to change observation status as we now know it. It is not an easy task. The ultimate goal is to be able to consider all hospitalized medical patients what they really are: inpatients.

Dr. Johnson is clinical associate professor in the department of internal medicine at the University of Iowa Carver College of Medicine. She is a member of the SHM Public Policy Committee and was one of the authors of the SHM PPC white paper on observation status released in July 2014.

As you may have heard, H.R. 876, a bill unanimously passed in the House recently, requires a hospital to give adequate oral and written notification of a patient’s observation status. The bill has now moved to the Senate.

“Notice of Observation Treatment and Implication for Care Eligibility Act,” known as the NOTICE Act, was sponsored by Rep. Lloyd Doggett (D-Texas) and co-sponsored by Rep. Earl Blumenauer (D-Ore.), Rep. Charles Rangel (D-N.Y.), and Rep. Todd Young (R-Ind.), all known to be admirable patient care advocates.

The bill proposes requiring that any patient who has been classified as observation status for more than 24 hours be given oral and written notice within 36 hours of that classification. That notice must include the reason for and implications of that status, including lack of coverage for services and cost sharing under Medicare Part B, as well as the name and title of the hospital staff who gave the oral notification. Written notification must be signed by the patient or, if the patient refuses, by the staff who presented it.

Although it is essential that patients are aware of observation status and its implications, this bill would not solve the underlying problem and would only create divisions between patients and the staff caring for them. Two issues stand out:

1. Observation status is not currently a medical determination; and
2. Hospitalized medical patients should not be considered outpatients.

When a patient is admitted to the hospital, acute inpatient versus observation status is often assigned by a non-clinician in the form of a “verbal” order before the attending hospitalist meets or even hears of the patient. This order must be signed promptly by that hospitalist to prevent penalization for lack of medical record compliance. Increasingly, more of these orders are for observation status, as hospitals fear bounty-hunting recovery audit contractors (RACs) in pursuit of “Medicare fraud.”

Under H.R. 876, the situation is further intensified for both clinicians and patients. Picture yourself in the middle of a busy day at your hospital, admitting and discharging patients, stabilizing critically ill patients, and discussing goals of care with patients given life-altering diagnoses. Your pager goes off.

“Mrs. H. on 6th Floor East wants to talk to you right away,” the conversation starts. Mrs. H is in tears, and her family is angry. “We were just told that Grandma is observation status, not admitted to the hospital! This makes no sense!”

Forty-five minutes later, you have agreed, commiserated, and let them know you have absolutely no control over the designation. To you, Mrs. H. is medically ill enough to require hospitalization, and she and her family agree, but Medicare regulations and fear of RAC audits keep her on observation status. What have you accomplished during that time?

H.R. 876 is not the problem, and it is clearly well intentioned. I regularly inform patients when I’m aware of their observation status, because it’s a lousy situation for the patient. We should all be doing as much.

But H.R. 876 is not the solution, either, because it does not address the core problems with observation policy. Now is the time for us all to step forward, voicing our support of SHM as it works to change observation status as we now know it. It is not an easy task. The ultimate goal is to be able to consider all hospitalized medical patients what they really are: inpatients.

Dr. Johnson is clinical associate professor in the department of internal medicine at the University of Iowa Carver College of Medicine. She is a member of the SHM Public Policy Committee and was one of the authors of the SHM PPC white paper on observation status released in July 2014.

As you may have heard, H.R. 876, a bill unanimously passed in the House recently, requires a hospital to give adequate oral and written notification of a patient’s observation status. The bill has now moved to the Senate.

“Notice of Observation Treatment and Implication for Care Eligibility Act,” known as the NOTICE Act, was sponsored by Rep. Lloyd Doggett (D-Texas) and co-sponsored by Rep. Earl Blumenauer (D-Ore.), Rep. Charles Rangel (D-N.Y.), and Rep. Todd Young (R-Ind.), all known to be admirable patient care advocates.

The bill proposes requiring that any patient who has been classified as observation status for more than 24 hours be given oral and written notice within 36 hours of that classification. That notice must include the reason for and implications of that status, including lack of coverage for services and cost sharing under Medicare Part B, as well as the name and title of the hospital staff who gave the oral notification. Written notification must be signed by the patient or, if the patient refuses, by the staff who presented it.

Although it is essential that patients are aware of observation status and its implications, this bill would not solve the underlying problem and would only create divisions between patients and the staff caring for them. Two issues stand out:

1. Observation status is not currently a medical determination; and
2. Hospitalized medical patients should not be considered outpatients.

When a patient is admitted to the hospital, acute inpatient versus observation status is often assigned by a non-clinician in the form of a “verbal” order before the attending hospitalist meets or even hears of the patient. This order must be signed promptly by that hospitalist to prevent penalization for lack of medical record compliance. Increasingly, more of these orders are for observation status, as hospitals fear bounty-hunting recovery audit contractors (RACs) in pursuit of “Medicare fraud.”

Under H.R. 876, the situation is further intensified for both clinicians and patients. Picture yourself in the middle of a busy day at your hospital, admitting and discharging patients, stabilizing critically ill patients, and discussing goals of care with patients given life-altering diagnoses. Your pager goes off.

“Mrs. H. on 6th Floor East wants to talk to you right away,” the conversation starts. Mrs. H is in tears, and her family is angry. “We were just told that Grandma is observation status, not admitted to the hospital! This makes no sense!”

Forty-five minutes later, you have agreed, commiserated, and let them know you have absolutely no control over the designation. To you, Mrs. H. is medically ill enough to require hospitalization, and she and her family agree, but Medicare regulations and fear of RAC audits keep her on observation status. What have you accomplished during that time?

H.R. 876 is not the problem, and it is clearly well intentioned. I regularly inform patients when I’m aware of their observation status, because it’s a lousy situation for the patient. We should all be doing as much.

But H.R. 876 is not the solution, either, because it does not address the core problems with observation policy. Now is the time for us all to step forward, voicing our support of SHM as it works to change observation status as we now know it. It is not an easy task. The ultimate goal is to be able to consider all hospitalized medical patients what they really are: inpatients.

Dr. Johnson is clinical associate professor in the department of internal medicine at the University of Iowa Carver College of Medicine. She is a member of the SHM Public Policy Committee and was one of the authors of the SHM PPC white paper on observation status released in July 2014.

SHM’s new Engagement Benchmarking Service helps hospital medicine groups (HMGs) better understand how to engage their physicians for increased retention and performance. Now, SHM is offering the service free to SHM members as a way to build a database and familiarize HMGs with the value of the service. For details, visit www.hospitalmedicine.org/engage.

SHM’s new Engagement Benchmarking Service helps hospital medicine groups (HMGs) better understand how to engage their physicians for increased retention and performance. Now, SHM is offering the service free to SHM members as a way to build a database and familiarize HMGs with the value of the service. For details, visit www.hospitalmedicine.org/engage.

SHM’s new Engagement Benchmarking Service helps hospital medicine groups (HMGs) better understand how to engage their physicians for increased retention and performance. Now, SHM is offering the service free to SHM members as a way to build a database and familiarize HMGs with the value of the service. For details, visit www.hospitalmedicine.org/engage.

More than 7,000 hospitalists have logged in to HMX to ask questions and share successes. These are the top topics hospitalists are discussing on HMX:

• PICC Line in IV Drug Users;
• Hospitalists Who Do Procedures;
• Census Cap Policies;
• Case Logs for Treating Patients on the Floors; and
• Medication Reconciliation.

Join the discussion—or start your own—today at www.hmxchange.org.

More than 7,000 hospitalists have logged in to HMX to ask questions and share successes. These are the top topics hospitalists are discussing on HMX:

• PICC Line in IV Drug Users;
• Hospitalists Who Do Procedures;
• Census Cap Policies;
• Case Logs for Treating Patients on the Floors; and
• Medication Reconciliation.

Join the discussion—or start your own—today at www.hmxchange.org.

More than 7,000 hospitalists have logged in to HMX to ask questions and share successes. These are the top topics hospitalists are discussing on HMX:

• PICC Line in IV Drug Users;
• Hospitalists Who Do Procedures;
• Census Cap Policies;
• Case Logs for Treating Patients on the Floors; and
• Medication Reconciliation.

Join the discussion—or start your own—today at www.hmxchange.org.

New Patient Experience Community and Resources

SHM’s new Patient Experience Committee has begun convening resources and people to help hospitalists address the patient experience. In addition to new resources on the SHM website, SHM has set up an HMX community specifically dedicated to the many issues related to the experience of patients in the hospital. To get involved, visit www.hospitalmedicine.org/patientexperience.

Project BOOST On-Demand Webinar Available

It’s never too late—or too early—to think about improving processes to reduce readmissions. SHM’s Project BOOST now accepts program applications throughout the year, and the recent webinar with Project BOOST program leaders is now available for free online. www.hospitalmedicine.org/boost.

Glycemic Control Implementation Guide available in June.

Glycemic control and the management of diabetic patients can be challenging for hospitalists. That’s why SHM is presenting the new Glycemic Control Implementation Guide. Recent webinars are available, too, at www.hospitalmedicine.org/qi.

Free CME on Acute Coronary Syndrome

Approximately 1.7 million patients are hospitalized for acute coronary syndrome (ACS), and 600,000 die because of an acute myocardial infarction. Now, SHM is presenting a free self-directed web-based activity designed to help hospitalists evaluate practices and strategies to affect outcomes. For details, visit www.hospitalmedicine.org/qi.

This educational initiative is supported by an educational grant from AstraZeneca.

New Patient Experience Community and Resources

SHM’s new Patient Experience Committee has begun convening resources and people to help hospitalists address the patient experience. In addition to new resources on the SHM website, SHM has set up an HMX community specifically dedicated to the many issues related to the experience of patients in the hospital. To get involved, visit www.hospitalmedicine.org/patientexperience.

Project BOOST On-Demand Webinar Available

It’s never too late—or too early—to think about improving processes to reduce readmissions. SHM’s Project BOOST now accepts program applications throughout the year, and the recent webinar with Project BOOST program leaders is now available for free online. www.hospitalmedicine.org/boost.

Glycemic Control Implementation Guide available in June.

Glycemic control and the management of diabetic patients can be challenging for hospitalists. That’s why SHM is presenting the new Glycemic Control Implementation Guide. Recent webinars are available, too, at www.hospitalmedicine.org/qi.

Free CME on Acute Coronary Syndrome

Approximately 1.7 million patients are hospitalized for acute coronary syndrome (ACS), and 600,000 die because of an acute myocardial infarction. Now, SHM is presenting a free self-directed web-based activity designed to help hospitalists evaluate practices and strategies to affect outcomes. For details, visit www.hospitalmedicine.org/qi.

This educational initiative is supported by an educational grant from AstraZeneca.

New Patient Experience Community and Resources

SHM’s new Patient Experience Committee has begun convening resources and people to help hospitalists address the patient experience. In addition to new resources on the SHM website, SHM has set up an HMX community specifically dedicated to the many issues related to the experience of patients in the hospital. To get involved, visit www.hospitalmedicine.org/patientexperience.

Project BOOST On-Demand Webinar Available

It’s never too late—or too early—to think about improving processes to reduce readmissions. SHM’s Project BOOST now accepts program applications throughout the year, and the recent webinar with Project BOOST program leaders is now available for free online. www.hospitalmedicine.org/boost.

Glycemic Control Implementation Guide available in June.

Glycemic control and the management of diabetic patients can be challenging for hospitalists. That’s why SHM is presenting the new Glycemic Control Implementation Guide. Recent webinars are available, too, at www.hospitalmedicine.org/qi.

Free CME on Acute Coronary Syndrome

Approximately 1.7 million patients are hospitalized for acute coronary syndrome (ACS), and 600,000 die because of an acute myocardial infarction. Now, SHM is presenting a free self-directed web-based activity designed to help hospitalists evaluate practices and strategies to affect outcomes. For details, visit www.hospitalmedicine.org/qi.

This educational initiative is supported by an educational grant from AstraZeneca.

Pediatric Hospital Medicine

July 23-26, San Antonio

PHM 2015 will also feature a mobile conference app for online access to the agenda and many other features. To register, visit www.phmmeeting.org.

Academic Hospitalist Academy

Oct. 7-10, Englewood, Colo.

Adult Hospital Medicine Boot Camp for Physician Assistants and Nurse Practitioners

Oct. 14-18, Phoenix

Leadership Academy

Oct. 19-22, Austin

Pediatric Hospital Medicine

July 23-26, San Antonio

PHM 2015 will also feature a mobile conference app for online access to the agenda and many other features. To register, visit www.phmmeeting.org.

Academic Hospitalist Academy

Oct. 7-10, Englewood, Colo.

Adult Hospital Medicine Boot Camp for Physician Assistants and Nurse Practitioners

Oct. 14-18, Phoenix

Leadership Academy

Oct. 19-22, Austin

Pediatric Hospital Medicine

July 23-26, San Antonio

PHM 2015 will also feature a mobile conference app for online access to the agenda and many other features. To register, visit www.phmmeeting.org.

Academic Hospitalist Academy

Oct. 7-10, Englewood, Colo.

Adult Hospital Medicine Boot Camp for Physician Assistants and Nurse Practitioners

Oct. 14-18, Phoenix

Leadership Academy

Oct. 19-22, Austin