Blood smear showing

Plasmodium vivax infection

Image by Mae Melvin

Researchers say they have developed a human-chimeric mouse model that can advance the study of the malaria parasite Plasmodium vivax.

The model is engineered to grow human livers that can be infected with P vivax and used for investigations into parasite development, dormancy, and activation, as well as the effect certain drugs have on each aspect of the infection.

The researchers described this model in Cell Host & Microbe.

Stefan Kappe, PhD, of Seattle Biomedical Research Institute in Washington, and his colleagues noted that P vivax malaria parasites are more resistant to control and elimination than other malaria parasites because, after infection, they fall dormant within the liver for months to years.

When these dormant parasites eventually become activated, they replicate, infect the bloodstream, and cause relapsing malaria.

The lack of tractable P vivax animal models has made it difficult to examine P vivax liver-stage infection, but Dr Kappe and his colleagues found a solution in a model known as FRG KO huHep.

To create the FRG KO huHep model, the team transplanted human hepatocytes in the severely immunocompromised FRG KO mouse, which has deletions in fumarylacetoacetate hydrolase (FAH), recombinationactivating gene 2 (Rag2), and interleukin-2 receptor subunit gamma (Il2rg).

The researchers found that FRG KO huHep mice support P vivax sporozoite infection, liver-stage development, and the formation and persistence of dormant liver-stage parasites.

In addition, experiments with this model revealed that the antimalarial drug primaquine could prevent and eliminate liver-stage infection.

The researchers therefore concluded that P vivax-infected FRG KO huHep mice are a suitable model for studying liver-stage development and dormancy and may facilitate the discovery of drugs targeting relapsing malaria.

“This model is a real game-changer,” said Ivo Mueller, PhD, a malaria expert at the Walter and Eliza Hall Institute in Melbourne, Victoria, Australia, who was not involved in this research.

“For the first time, we now have a realistic opportunity that not only allows us to directly study this normally hidden P vivax life-stage, but also to test new drugs and vaccines. This new model is an essential resource in our quest to develop the new anti-vivax interventions that we will need to eliminate P vivax malaria.”

Blood smear showing

Plasmodium vivax infection

Image by Mae Melvin

Researchers say they have developed a human-chimeric mouse model that can advance the study of the malaria parasite Plasmodium vivax.

The model is engineered to grow human livers that can be infected with P vivax and used for investigations into parasite development, dormancy, and activation, as well as the effect certain drugs have on each aspect of the infection.

The researchers described this model in Cell Host & Microbe.

Stefan Kappe, PhD, of Seattle Biomedical Research Institute in Washington, and his colleagues noted that P vivax malaria parasites are more resistant to control and elimination than other malaria parasites because, after infection, they fall dormant within the liver for months to years.

When these dormant parasites eventually become activated, they replicate, infect the bloodstream, and cause relapsing malaria.

The lack of tractable P vivax animal models has made it difficult to examine P vivax liver-stage infection, but Dr Kappe and his colleagues found a solution in a model known as FRG KO huHep.

To create the FRG KO huHep model, the team transplanted human hepatocytes in the severely immunocompromised FRG KO mouse, which has deletions in fumarylacetoacetate hydrolase (FAH), recombinationactivating gene 2 (Rag2), and interleukin-2 receptor subunit gamma (Il2rg).

The researchers found that FRG KO huHep mice support P vivax sporozoite infection, liver-stage development, and the formation and persistence of dormant liver-stage parasites.

In addition, experiments with this model revealed that the antimalarial drug primaquine could prevent and eliminate liver-stage infection.

The researchers therefore concluded that P vivax-infected FRG KO huHep mice are a suitable model for studying liver-stage development and dormancy and may facilitate the discovery of drugs targeting relapsing malaria.

“This model is a real game-changer,” said Ivo Mueller, PhD, a malaria expert at the Walter and Eliza Hall Institute in Melbourne, Victoria, Australia, who was not involved in this research.

“For the first time, we now have a realistic opportunity that not only allows us to directly study this normally hidden P vivax life-stage, but also to test new drugs and vaccines. This new model is an essential resource in our quest to develop the new anti-vivax interventions that we will need to eliminate P vivax malaria.”

Blood smear showing

Plasmodium vivax infection

Image by Mae Melvin

Researchers say they have developed a human-chimeric mouse model that can advance the study of the malaria parasite Plasmodium vivax.

The model is engineered to grow human livers that can be infected with P vivax and used for investigations into parasite development, dormancy, and activation, as well as the effect certain drugs have on each aspect of the infection.

The researchers described this model in Cell Host & Microbe.

Stefan Kappe, PhD, of Seattle Biomedical Research Institute in Washington, and his colleagues noted that P vivax malaria parasites are more resistant to control and elimination than other malaria parasites because, after infection, they fall dormant within the liver for months to years.

When these dormant parasites eventually become activated, they replicate, infect the bloodstream, and cause relapsing malaria.

The lack of tractable P vivax animal models has made it difficult to examine P vivax liver-stage infection, but Dr Kappe and his colleagues found a solution in a model known as FRG KO huHep.

To create the FRG KO huHep model, the team transplanted human hepatocytes in the severely immunocompromised FRG KO mouse, which has deletions in fumarylacetoacetate hydrolase (FAH), recombinationactivating gene 2 (Rag2), and interleukin-2 receptor subunit gamma (Il2rg).

The researchers found that FRG KO huHep mice support P vivax sporozoite infection, liver-stage development, and the formation and persistence of dormant liver-stage parasites.

In addition, experiments with this model revealed that the antimalarial drug primaquine could prevent and eliminate liver-stage infection.

The researchers therefore concluded that P vivax-infected FRG KO huHep mice are a suitable model for studying liver-stage development and dormancy and may facilitate the discovery of drugs targeting relapsing malaria.

“This model is a real game-changer,” said Ivo Mueller, PhD, a malaria expert at the Walter and Eliza Hall Institute in Melbourne, Victoria, Australia, who was not involved in this research.

“For the first time, we now have a realistic opportunity that not only allows us to directly study this normally hidden P vivax life-stage, but also to test new drugs and vaccines. This new model is an essential resource in our quest to develop the new anti-vivax interventions that we will need to eliminate P vivax malaria.”

In the article “Common Coding Mistakes Hospitalists Should Avoid” in the August 2014 issue of The Hospitalist, the author states:

“For inpatient care, an established problem is defined as one in which a care plan has been generated by the physician (or same specialty group practice member) during the current hospitalization.”

This definition contradicts what I have been told in other coding courses regarding new vs. established problems relative to the examiner. It has been my understanding that when [I am] rotating on service and I have not seen that particular patient during the current admission, all of the current problems are new to me, even if previously identified by another member of my group. This [situation] results in a higher complexity of medical decision-making, which is reflective of the increased time spent learning a new patient when coming on service. I would appreciate clarification from the author.

–Matt George, MD,

medical director, MBHS Hospitalists

Billing and coding expert Carol Pohlig, BSN, RN, CPC, ACS, explains:

Be mindful when attending coding courses that are not contractor sponsored, as they may not validate the geographical interpretations of the rules for providers. There are several factors to consider when crediting the physician with “new” or “established” problems.

CMS documentation guidelines state: “Decision making with respect to a diagnosed problem is easier than that for an identified but undiagnosed problem.¹

• For a presenting problem with an established diagnosis, the record should reflect whether the problem is:

  • Improved, well-controlled, resolving, or resolved or
  • Inadequately controlled, worsening, or failing to change as expected.

• For a presenting problem without an established diagnosis, the assessment or clinical impression may be stated in the form of differential diagnoses or as a “possible,” “probable,” or “rule out” diagnosis.

Although Medicare contractors utilize the Marshfield Clinic Scoring Tool when reviewing evaluation and management (E/M) services, a tool that historically refers to the “examiner” when considering the patient’s diagnoses, not all accept this tool-inspired standard, particularly in the advent of electronic health record accessibility and the idea that same-specialty physicians in a group practice are viewed as an individual physician.^2,3

Reviewing information and familiarization of patients is often considered pre-service work and factored into the payment for E/M services. More importantly, the feasibility of an auditor being able to distinguish new vs. established problems at the level of the “examiner” is decreased when auditing a single date of service. Non-Medicare payers who audit E/M services do not necessarily follow contractor-specific guidelines but, rather, general CMS guidelines.

Therefore, without knowing the insurer or their interpretation at the time of service or visit level selection, the CMS-developed standard is the most practical application when considering the complexity of the encounter.

References

1. Centers for Medicare and Medicaid Services. Department of Health and Human Services. Evaluation and management services guide. Available at: http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/downloads//eval_mgmt_serv_guide-ICN006764.pdf. Accessed November 13, 2014.
2. National Government Services. Evaluation and management documentation training too. Available at: http://www.ngsmedicare.com/ngs/wcm/connect/3632a905-b697-4266-8fc0-2aa2a84fedb2/1074_0514_EM_Documentation_Training_Tool_508.pdf?MOD=AJPERES. Accessed November 13, 2014.
3. Centers for Medicare and Medicaid Services. Medicare Claims Processing Manual. Chapter 12 – Physicians/nonphysician practitioners. Available at: http://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/clm104c12.pdf. Accessed November 13, 2014.

In the article “Common Coding Mistakes Hospitalists Should Avoid” in the August 2014 issue of The Hospitalist, the author states:

“For inpatient care, an established problem is defined as one in which a care plan has been generated by the physician (or same specialty group practice member) during the current hospitalization.”

This definition contradicts what I have been told in other coding courses regarding new vs. established problems relative to the examiner. It has been my understanding that when [I am] rotating on service and I have not seen that particular patient during the current admission, all of the current problems are new to me, even if previously identified by another member of my group. This [situation] results in a higher complexity of medical decision-making, which is reflective of the increased time spent learning a new patient when coming on service. I would appreciate clarification from the author.

–Matt George, MD,

medical director, MBHS Hospitalists

Billing and coding expert Carol Pohlig, BSN, RN, CPC, ACS, explains:

Be mindful when attending coding courses that are not contractor sponsored, as they may not validate the geographical interpretations of the rules for providers. There are several factors to consider when crediting the physician with “new” or “established” problems.

CMS documentation guidelines state: “Decision making with respect to a diagnosed problem is easier than that for an identified but undiagnosed problem.¹

• For a presenting problem with an established diagnosis, the record should reflect whether the problem is:

  • Improved, well-controlled, resolving, or resolved or
  • Inadequately controlled, worsening, or failing to change as expected.

• For a presenting problem without an established diagnosis, the assessment or clinical impression may be stated in the form of differential diagnoses or as a “possible,” “probable,” or “rule out” diagnosis.

Although Medicare contractors utilize the Marshfield Clinic Scoring Tool when reviewing evaluation and management (E/M) services, a tool that historically refers to the “examiner” when considering the patient’s diagnoses, not all accept this tool-inspired standard, particularly in the advent of electronic health record accessibility and the idea that same-specialty physicians in a group practice are viewed as an individual physician.^2,3

Reviewing information and familiarization of patients is often considered pre-service work and factored into the payment for E/M services. More importantly, the feasibility of an auditor being able to distinguish new vs. established problems at the level of the “examiner” is decreased when auditing a single date of service. Non-Medicare payers who audit E/M services do not necessarily follow contractor-specific guidelines but, rather, general CMS guidelines.

Therefore, without knowing the insurer or their interpretation at the time of service or visit level selection, the CMS-developed standard is the most practical application when considering the complexity of the encounter.

References

1. Centers for Medicare and Medicaid Services. Department of Health and Human Services. Evaluation and management services guide. Available at: http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/downloads//eval_mgmt_serv_guide-ICN006764.pdf. Accessed November 13, 2014.
2. National Government Services. Evaluation and management documentation training too. Available at: http://www.ngsmedicare.com/ngs/wcm/connect/3632a905-b697-4266-8fc0-2aa2a84fedb2/1074_0514_EM_Documentation_Training_Tool_508.pdf?MOD=AJPERES. Accessed November 13, 2014.
3. Centers for Medicare and Medicaid Services. Medicare Claims Processing Manual. Chapter 12 – Physicians/nonphysician practitioners. Available at: http://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/clm104c12.pdf. Accessed November 13, 2014.

In the article “Common Coding Mistakes Hospitalists Should Avoid” in the August 2014 issue of The Hospitalist, the author states:

“For inpatient care, an established problem is defined as one in which a care plan has been generated by the physician (or same specialty group practice member) during the current hospitalization.”

This definition contradicts what I have been told in other coding courses regarding new vs. established problems relative to the examiner. It has been my understanding that when [I am] rotating on service and I have not seen that particular patient during the current admission, all of the current problems are new to me, even if previously identified by another member of my group. This [situation] results in a higher complexity of medical decision-making, which is reflective of the increased time spent learning a new patient when coming on service. I would appreciate clarification from the author.

–Matt George, MD,

medical director, MBHS Hospitalists

Billing and coding expert Carol Pohlig, BSN, RN, CPC, ACS, explains:

Be mindful when attending coding courses that are not contractor sponsored, as they may not validate the geographical interpretations of the rules for providers. There are several factors to consider when crediting the physician with “new” or “established” problems.

CMS documentation guidelines state: “Decision making with respect to a diagnosed problem is easier than that for an identified but undiagnosed problem.¹

• For a presenting problem with an established diagnosis, the record should reflect whether the problem is:

  • Improved, well-controlled, resolving, or resolved or
  • Inadequately controlled, worsening, or failing to change as expected.

• For a presenting problem without an established diagnosis, the assessment or clinical impression may be stated in the form of differential diagnoses or as a “possible,” “probable,” or “rule out” diagnosis.

Although Medicare contractors utilize the Marshfield Clinic Scoring Tool when reviewing evaluation and management (E/M) services, a tool that historically refers to the “examiner” when considering the patient’s diagnoses, not all accept this tool-inspired standard, particularly in the advent of electronic health record accessibility and the idea that same-specialty physicians in a group practice are viewed as an individual physician.^2,3

Reviewing information and familiarization of patients is often considered pre-service work and factored into the payment for E/M services. More importantly, the feasibility of an auditor being able to distinguish new vs. established problems at the level of the “examiner” is decreased when auditing a single date of service. Non-Medicare payers who audit E/M services do not necessarily follow contractor-specific guidelines but, rather, general CMS guidelines.

Therefore, without knowing the insurer or their interpretation at the time of service or visit level selection, the CMS-developed standard is the most practical application when considering the complexity of the encounter.

References

1. Centers for Medicare and Medicaid Services. Department of Health and Human Services. Evaluation and management services guide. Available at: http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/downloads//eval_mgmt_serv_guide-ICN006764.pdf. Accessed November 13, 2014.
2. National Government Services. Evaluation and management documentation training too. Available at: http://www.ngsmedicare.com/ngs/wcm/connect/3632a905-b697-4266-8fc0-2aa2a84fedb2/1074_0514_EM_Documentation_Training_Tool_508.pdf?MOD=AJPERES. Accessed November 13, 2014.
3. Centers for Medicare and Medicaid Services. Medicare Claims Processing Manual. Chapter 12 – Physicians/nonphysician practitioners. Available at: http://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/clm104c12.pdf. Accessed November 13, 2014.

Listen to Daniel Hunt, MD, chief of the hospital medicine unit at Massachusetts General Hospital, Boston, discuss his recent article titled “Perspectives” in the New England Journal of Medicine on consultation visits by primary care providers.

Listen to Daniel Hunt, MD, chief of the hospital medicine unit at Massachusetts General Hospital, Boston, discuss his recent article titled “Perspectives” in the New England Journal of Medicine on consultation visits by primary care providers.

Listen to Daniel Hunt, MD, chief of the hospital medicine unit at Massachusetts General Hospital, Boston, discuss his recent article titled “Perspectives” in the New England Journal of Medicine on consultation visits by primary care providers.

Jasen Gundersen, MD, MBA, SFHM, talks about mentors and assessing your personal qualities to be a good leader.

Jasen Gundersen, MD, MBA, SFHM, talks about mentors and assessing your personal qualities to be a good leader.

Jasen Gundersen, MD, MBA, SFHM, talks about mentors and assessing your personal qualities to be a good leader.

Listen to more of our interview with Bob Wachter, MD, MHM, on the gains, losses, and consequences resulting from healthcare IT.

Listen to more of our interview with Bob Wachter, MD, MHM, on the gains, losses, and consequences resulting from healthcare IT.

Listen to more of our interview with Bob Wachter, MD, MHM, on the gains, losses, and consequences resulting from healthcare IT.

Jeffrey Greenwald, MD, a hospitalist at Massacusetts General Hospital with 15 years of experience in hospital medicine, discusses his view of the spectrum of endocrine disorders and how hospitalists should approach the question of when to call in an endocrine specialist.

Jeffrey Greenwald, MD, a hospitalist at Massacusetts General Hospital with 15 years of experience in hospital medicine, discusses his view of the spectrum of endocrine disorders and how hospitalists should approach the question of when to call in an endocrine specialist.

Jeffrey Greenwald, MD, a hospitalist at Massacusetts General Hospital with 15 years of experience in hospital medicine, discusses his view of the spectrum of endocrine disorders and how hospitalists should approach the question of when to call in an endocrine specialist.

Amy Boutwell, MD, MPP, a hospitalist and founder of Collaborative Healthcare Strategies, talks about what clinicians can do to help improve care transitions based on her experience directing IHI’s STAAR Initiative (State-Action on Avoidable Re-hospitalizations).

Amy Boutwell, MD, MPP, a hospitalist and founder of Collaborative Healthcare Strategies, talks about what clinicians can do to help improve care transitions based on her experience directing IHI’s STAAR Initiative (State-Action on Avoidable Re-hospitalizations).

Amy Boutwell, MD, MPP, a hospitalist and founder of Collaborative Healthcare Strategies, talks about what clinicians can do to help improve care transitions based on her experience directing IHI’s STAAR Initiative (State-Action on Avoidable Re-hospitalizations).

Johns Hopkins hospitalist Eric Howell, MD, SFHM, discusses connections between SHM, hospitalist practices, handoffs, and successful care transitions.

Johns Hopkins hospitalist Eric Howell, MD, SFHM, discusses connections between SHM, hospitalist practices, handoffs, and successful care transitions.

Johns Hopkins hospitalist Eric Howell, MD, SFHM, discusses connections between SHM, hospitalist practices, handoffs, and successful care transitions.

Editor’s note: First of a two-part series examining bundled payments and hospital medicine. Additionally, Dr. Whitcomb works for a company that is an Awardee Convener in the CMS Bundled Payments for Care Improvement (BPCI) Initiative.

The Centers for Medicare and Medicaid Services’ (CMS) bundled payment initiative was announced in August 2011 and has been “live” since October 2013, when a handful of healthcare systems launched bundled payment programs. In 2014, the CMS initiative grew substantially as a result of large-scale interest on the part of hospitals, physician groups, skilled nursing facilities (SNFs), and others in testing the model, which can be described as a single payment for an episode of care.

The BPCI initiative will be a large-scale program by July 1; it starts with an April 1 cohort launch and will result in the program’s presence in all 50 states, with hundreds of physician practices and hospitals participating. The 2015 cohort will involve a large number of hospitalist practices, participating as “episode initiators” that bear clinical and economic responsibility for the bundle, or as “gainsharers” who are eligible to receive incentive payments if they can reduce costs while maintaining measurable quality for an episode of care.

How Does Bundled Payment Work?

The BPCI initiative is a large-scale, three- to five-year demonstration to test bundled payment in patients with fee-for-service Medicare. The most common model, referred to as Model 2, involves an inpatient hospitalization for one of 48 defined episodes, which include both medical and surgical conditions, followed by a recovery period lasting 30, 60, or 90 days.

Each hospital or physician practice that is considering entering the BPCI program receives prices for all 48 episodes based on a 2009-2012 historical average of Medicare part A and B claims associated with that hospital or physician group. After analyzing those prices, the hospital or physician practice may elect to choose the bundles that have a good chance of being successful—where actual spending comes in under the historical target price—based on care improvement expectations in their local system. In Model 2, CMS takes 2% off the target price for 90-day episodes and 3% off the target price for 30- and 60-day episodes, making it all the more important to choose bundles that demonstrate a high likelihood of success.

The revenue cycle for hospitals and physicians in the program does not change. They submit claims for their services and receive reimbursement as they always have; however, after the end of each quarter, when the majority of part A and B claims have been processed, a “look back” at actual spending for all participating episodes is reconciled against the baseline price derived from 2009-2012. If there is a net savings compared to the baseline, monies can be distributed to the participating providers—the hospital or physician practice—and those providers may further share some of the savings with other physicians/providers who have signed a gainsharing contract.

Hospitalists and BPCI

Hospitalist practices participate in the CMS program either as episode initiators or gainsharers. As episode initiators, they “own” the bundle, which means they bear economic risk for the program. In this capacity, overall savings will mean the hospitalist practice has a new revenue stream, which could be substantial; however, the practice is also responsible for any losses.

Other hospitalist practices have become gainsharers in the program, which means they have signed an agreement enabling them to receive payments in addition to professional fee revenues for activities that reduce costs while maintaining or improving quality. Such activities are referred to as “care redesign” in the program. Gainsharers do not bear financial risk.

Where Will Savings Come From?

Perhaps ironically for hospitalists, the main source of savings in the BPCI program comes from post-acute care and readmissions. For example, for common conditions like heart failure, COPD, and pneumonia, Medicare spends almost as much on post-acute care and readmissions in the first 30 days after discharge as it does on the index hospitalization.¹ As a result, the BPCI program adds further emphasis on preventing readmissions when added to existing pressures, and there is a new premium placed on “right-sizing” the usage of SNF and other post-acute facilities, such as inpatient rehabilitation and long-term acute care hospitals. For hospitalists, this means that new rigor is needed to connect to the post-acute setting, such as determining why a patient is being discharged to a skilled facility.

Another savings pool, called “internal cost savings,” is available to reward decreasing inpatient utilization from, for example, testing, imaging, and implantable devices.

Conclusion

Bundled payment might be the biggest thing to come along for hospitalists since the patient safety movement launched some 16 years ago. Why? Although accountable care organizations have largely focused on ambulatory practice, bundled payment has a major focus on hospital care and on the post-acute care decisions that are made during the hospitalization. If bundled payment proves to be an effective way to pay for—and organize—care, hospitalists will play a central role in the success of this innovation.

In part two of this series, I will explore specific roles hospitalists play in successful bundled payment programs.

Reference

1. Mechanic R. Post-acute care: the next frontier for controlling Medicare spending. N Engl J Med. 2014;370(8):692-694.

Editor’s note: First of a two-part series examining bundled payments and hospital medicine. Additionally, Dr. Whitcomb works for a company that is an Awardee Convener in the CMS Bundled Payments for Care Improvement (BPCI) Initiative.

The Centers for Medicare and Medicaid Services’ (CMS) bundled payment initiative was announced in August 2011 and has been “live” since October 2013, when a handful of healthcare systems launched bundled payment programs. In 2014, the CMS initiative grew substantially as a result of large-scale interest on the part of hospitals, physician groups, skilled nursing facilities (SNFs), and others in testing the model, which can be described as a single payment for an episode of care.

The BPCI initiative will be a large-scale program by July 1; it starts with an April 1 cohort launch and will result in the program’s presence in all 50 states, with hundreds of physician practices and hospitals participating. The 2015 cohort will involve a large number of hospitalist practices, participating as “episode initiators” that bear clinical and economic responsibility for the bundle, or as “gainsharers” who are eligible to receive incentive payments if they can reduce costs while maintaining measurable quality for an episode of care.

How Does Bundled Payment Work?

The BPCI initiative is a large-scale, three- to five-year demonstration to test bundled payment in patients with fee-for-service Medicare. The most common model, referred to as Model 2, involves an inpatient hospitalization for one of 48 defined episodes, which include both medical and surgical conditions, followed by a recovery period lasting 30, 60, or 90 days.

Each hospital or physician practice that is considering entering the BPCI program receives prices for all 48 episodes based on a 2009-2012 historical average of Medicare part A and B claims associated with that hospital or physician group. After analyzing those prices, the hospital or physician practice may elect to choose the bundles that have a good chance of being successful—where actual spending comes in under the historical target price—based on care improvement expectations in their local system. In Model 2, CMS takes 2% off the target price for 90-day episodes and 3% off the target price for 30- and 60-day episodes, making it all the more important to choose bundles that demonstrate a high likelihood of success.

The revenue cycle for hospitals and physicians in the program does not change. They submit claims for their services and receive reimbursement as they always have; however, after the end of each quarter, when the majority of part A and B claims have been processed, a “look back” at actual spending for all participating episodes is reconciled against the baseline price derived from 2009-2012. If there is a net savings compared to the baseline, monies can be distributed to the participating providers—the hospital or physician practice—and those providers may further share some of the savings with other physicians/providers who have signed a gainsharing contract.

Hospitalists and BPCI

Hospitalist practices participate in the CMS program either as episode initiators or gainsharers. As episode initiators, they “own” the bundle, which means they bear economic risk for the program. In this capacity, overall savings will mean the hospitalist practice has a new revenue stream, which could be substantial; however, the practice is also responsible for any losses.

Other hospitalist practices have become gainsharers in the program, which means they have signed an agreement enabling them to receive payments in addition to professional fee revenues for activities that reduce costs while maintaining or improving quality. Such activities are referred to as “care redesign” in the program. Gainsharers do not bear financial risk.

Where Will Savings Come From?

Perhaps ironically for hospitalists, the main source of savings in the BPCI program comes from post-acute care and readmissions. For example, for common conditions like heart failure, COPD, and pneumonia, Medicare spends almost as much on post-acute care and readmissions in the first 30 days after discharge as it does on the index hospitalization.¹ As a result, the BPCI program adds further emphasis on preventing readmissions when added to existing pressures, and there is a new premium placed on “right-sizing” the usage of SNF and other post-acute facilities, such as inpatient rehabilitation and long-term acute care hospitals. For hospitalists, this means that new rigor is needed to connect to the post-acute setting, such as determining why a patient is being discharged to a skilled facility.

Another savings pool, called “internal cost savings,” is available to reward decreasing inpatient utilization from, for example, testing, imaging, and implantable devices.

Conclusion

Bundled payment might be the biggest thing to come along for hospitalists since the patient safety movement launched some 16 years ago. Why? Although accountable care organizations have largely focused on ambulatory practice, bundled payment has a major focus on hospital care and on the post-acute care decisions that are made during the hospitalization. If bundled payment proves to be an effective way to pay for—and organize—care, hospitalists will play a central role in the success of this innovation.

In part two of this series, I will explore specific roles hospitalists play in successful bundled payment programs.

Reference

1. Mechanic R. Post-acute care: the next frontier for controlling Medicare spending. N Engl J Med. 2014;370(8):692-694.

Editor’s note: First of a two-part series examining bundled payments and hospital medicine. Additionally, Dr. Whitcomb works for a company that is an Awardee Convener in the CMS Bundled Payments for Care Improvement (BPCI) Initiative.

The Centers for Medicare and Medicaid Services’ (CMS) bundled payment initiative was announced in August 2011 and has been “live” since October 2013, when a handful of healthcare systems launched bundled payment programs. In 2014, the CMS initiative grew substantially as a result of large-scale interest on the part of hospitals, physician groups, skilled nursing facilities (SNFs), and others in testing the model, which can be described as a single payment for an episode of care.

The BPCI initiative will be a large-scale program by July 1; it starts with an April 1 cohort launch and will result in the program’s presence in all 50 states, with hundreds of physician practices and hospitals participating. The 2015 cohort will involve a large number of hospitalist practices, participating as “episode initiators” that bear clinical and economic responsibility for the bundle, or as “gainsharers” who are eligible to receive incentive payments if they can reduce costs while maintaining measurable quality for an episode of care.

How Does Bundled Payment Work?

The BPCI initiative is a large-scale, three- to five-year demonstration to test bundled payment in patients with fee-for-service Medicare. The most common model, referred to as Model 2, involves an inpatient hospitalization for one of 48 defined episodes, which include both medical and surgical conditions, followed by a recovery period lasting 30, 60, or 90 days.

Each hospital or physician practice that is considering entering the BPCI program receives prices for all 48 episodes based on a 2009-2012 historical average of Medicare part A and B claims associated with that hospital or physician group. After analyzing those prices, the hospital or physician practice may elect to choose the bundles that have a good chance of being successful—where actual spending comes in under the historical target price—based on care improvement expectations in their local system. In Model 2, CMS takes 2% off the target price for 90-day episodes and 3% off the target price for 30- and 60-day episodes, making it all the more important to choose bundles that demonstrate a high likelihood of success.

The revenue cycle for hospitals and physicians in the program does not change. They submit claims for their services and receive reimbursement as they always have; however, after the end of each quarter, when the majority of part A and B claims have been processed, a “look back” at actual spending for all participating episodes is reconciled against the baseline price derived from 2009-2012. If there is a net savings compared to the baseline, monies can be distributed to the participating providers—the hospital or physician practice—and those providers may further share some of the savings with other physicians/providers who have signed a gainsharing contract.

Hospitalists and BPCI

Hospitalist practices participate in the CMS program either as episode initiators or gainsharers. As episode initiators, they “own” the bundle, which means they bear economic risk for the program. In this capacity, overall savings will mean the hospitalist practice has a new revenue stream, which could be substantial; however, the practice is also responsible for any losses.

Other hospitalist practices have become gainsharers in the program, which means they have signed an agreement enabling them to receive payments in addition to professional fee revenues for activities that reduce costs while maintaining or improving quality. Such activities are referred to as “care redesign” in the program. Gainsharers do not bear financial risk.

Where Will Savings Come From?

Perhaps ironically for hospitalists, the main source of savings in the BPCI program comes from post-acute care and readmissions. For example, for common conditions like heart failure, COPD, and pneumonia, Medicare spends almost as much on post-acute care and readmissions in the first 30 days after discharge as it does on the index hospitalization.¹ As a result, the BPCI program adds further emphasis on preventing readmissions when added to existing pressures, and there is a new premium placed on “right-sizing” the usage of SNF and other post-acute facilities, such as inpatient rehabilitation and long-term acute care hospitals. For hospitalists, this means that new rigor is needed to connect to the post-acute setting, such as determining why a patient is being discharged to a skilled facility.

Another savings pool, called “internal cost savings,” is available to reward decreasing inpatient utilization from, for example, testing, imaging, and implantable devices.

Conclusion

Bundled payment might be the biggest thing to come along for hospitalists since the patient safety movement launched some 16 years ago. Why? Although accountable care organizations have largely focused on ambulatory practice, bundled payment has a major focus on hospital care and on the post-acute care decisions that are made during the hospitalization. If bundled payment proves to be an effective way to pay for—and organize—care, hospitalists will play a central role in the success of this innovation.

In part two of this series, I will explore specific roles hospitalists play in successful bundled payment programs.

Reference

1. Mechanic R. Post-acute care: the next frontier for controlling Medicare spending. N Engl J Med. 2014;370(8):692-694.

Ticagrelor tablets

Photo courtesy of AstraZeneca

The US Food and Drug Administration (FDA) has approved a new administration option for the antiplatelet agent ticagrelor (Brilinta).

The agency has decided that, for patients with acute coronary syndrome (ACS) who cannot swallow ticagrelor tablets whole, the pills may be crushed and administered in water by swallowing or via nasogastric tube.

Ticagrelor is the only P2Y12 inhibitor that is FDA-approved to be administered in this way.

“We know that some patients who experience a heart attack are unable to swallow medications whole, yet it is important for these patients to receive and continue their oral antiplatelet therapy,” said Steven Zelenkofske, DO, Vice President of US Medical Affairs, Cardiovascular, at AstraZeneca, the company developing ticagrelor.

Survey data have shown that 40% of adults in the general population experience problems swallowing pills, and this difficulty may increase with age. Moreover, some patients who experience a heart attack have difficulty swallowing medications in the emergency setting.

So the new administration option for ticagrelor is intended to give healthcare professionals flexibility in treating their ACS patients.

Ticagrelor is a direct-acting P2Y12 receptor antagonist that works by inhibiting platelet activation. The drug is available in 90 mg tablets, to be administered with a single 180 mg oral loading dose (two 90 mg tablets) followed by a twice daily, 90 mg maintenance dose.

Following an initial loading dose of aspirin, ticagrelor should be used with a maintenance dose of aspirin at 75 mg to 100 mg once daily (an 81 mg dose in the US).

Results of the PLATO trial showed that, in ACS patients, ticagrelor can reduce the rate of a combined endpoint of cardiovascular death, myocardial infarction, and stroke, when compared to clopidogrel. The difference between treatments was driven by cardiovascular death and myocardial infarction, with no difference in the rate of stroke.

For more information on ticagrelor, see the full prescribing information.

Ticagrelor tablets

Photo courtesy of AstraZeneca

The US Food and Drug Administration (FDA) has approved a new administration option for the antiplatelet agent ticagrelor (Brilinta).

The agency has decided that, for patients with acute coronary syndrome (ACS) who cannot swallow ticagrelor tablets whole, the pills may be crushed and administered in water by swallowing or via nasogastric tube.

Ticagrelor is the only P2Y12 inhibitor that is FDA-approved to be administered in this way.

“We know that some patients who experience a heart attack are unable to swallow medications whole, yet it is important for these patients to receive and continue their oral antiplatelet therapy,” said Steven Zelenkofske, DO, Vice President of US Medical Affairs, Cardiovascular, at AstraZeneca, the company developing ticagrelor.

Survey data have shown that 40% of adults in the general population experience problems swallowing pills, and this difficulty may increase with age. Moreover, some patients who experience a heart attack have difficulty swallowing medications in the emergency setting.

So the new administration option for ticagrelor is intended to give healthcare professionals flexibility in treating their ACS patients.

Ticagrelor is a direct-acting P2Y12 receptor antagonist that works by inhibiting platelet activation. The drug is available in 90 mg tablets, to be administered with a single 180 mg oral loading dose (two 90 mg tablets) followed by a twice daily, 90 mg maintenance dose.

Following an initial loading dose of aspirin, ticagrelor should be used with a maintenance dose of aspirin at 75 mg to 100 mg once daily (an 81 mg dose in the US).

Results of the PLATO trial showed that, in ACS patients, ticagrelor can reduce the rate of a combined endpoint of cardiovascular death, myocardial infarction, and stroke, when compared to clopidogrel. The difference between treatments was driven by cardiovascular death and myocardial infarction, with no difference in the rate of stroke.

For more information on ticagrelor, see the full prescribing information.

Ticagrelor tablets

Photo courtesy of AstraZeneca

The US Food and Drug Administration (FDA) has approved a new administration option for the antiplatelet agent ticagrelor (Brilinta).

The agency has decided that, for patients with acute coronary syndrome (ACS) who cannot swallow ticagrelor tablets whole, the pills may be crushed and administered in water by swallowing or via nasogastric tube.

Ticagrelor is the only P2Y12 inhibitor that is FDA-approved to be administered in this way.

“We know that some patients who experience a heart attack are unable to swallow medications whole, yet it is important for these patients to receive and continue their oral antiplatelet therapy,” said Steven Zelenkofske, DO, Vice President of US Medical Affairs, Cardiovascular, at AstraZeneca, the company developing ticagrelor.

Survey data have shown that 40% of adults in the general population experience problems swallowing pills, and this difficulty may increase with age. Moreover, some patients who experience a heart attack have difficulty swallowing medications in the emergency setting.

So the new administration option for ticagrelor is intended to give healthcare professionals flexibility in treating their ACS patients.

Ticagrelor is a direct-acting P2Y12 receptor antagonist that works by inhibiting platelet activation. The drug is available in 90 mg tablets, to be administered with a single 180 mg oral loading dose (two 90 mg tablets) followed by a twice daily, 90 mg maintenance dose.

Following an initial loading dose of aspirin, ticagrelor should be used with a maintenance dose of aspirin at 75 mg to 100 mg once daily (an 81 mg dose in the US).

Results of the PLATO trial showed that, in ACS patients, ticagrelor can reduce the rate of a combined endpoint of cardiovascular death, myocardial infarction, and stroke, when compared to clopidogrel. The difference between treatments was driven by cardiovascular death and myocardial infarction, with no difference in the rate of stroke.

For more information on ticagrelor, see the full prescribing information.