As many hospitalists are probably acutely aware, the Centers for Medicare & Medicaid Services (CMS) is putting a new rule into effect that will greatly impact how inpatient admission decisions are made. The rule, known as the “two-midnight rule,” states that if the admitting practitioner admits a Medicare beneficiary as an inpatient with the reasonable expectation that the beneficiary will require care that “crosses two midnights” and this decision is justified in the medical record, Medicare Part A payment is “generally appropriate.”

While there are multiple caveats, exceptions, and details, this rule can be simply articulated: If the admitting physician feels a patient will be in the hospital for a period longer than two midnights and the medical record supports this determination, the patient is an inpatient. Stays expected to be shorter than two midnights should be under observation status.

This new policy is an attempt to respond both to hospital calls for more guidance about when a beneficiary is appropriately treated as an inpatient—and paid by Medicare—and concerns about increasingly long hospital stays under observation status. Most hospitalists wrestle with status determination issues on a daily basis.

SHM is aware of the struggle and has been advocating on behalf of hospitalists to help shape observation status and the two-midnight rule. When the rule was first proposed, SHM voiced serious concerns about its utility and how it was unlikely to solve the overall confusion surrounding inpatient status determinations. Nevertheless, CMS finalized the rule as an attempt to begin addressing the problem.

Faced with an increasingly loud chorus of providers and hospitals concerned about the implementation of the new policy, CMS agreed to delay full enforcement from the original date of Oct. 1, 2013, until March 31, 2014.

During the delayed enforcement period, hospitals will be expected to begin implementing the two-midnight rule, and auditors will be giving hospitals non-punitive feedback on their application of the policy. To accomplish this, CMS is instructing Medicare Administrative Contractors (MACs) to review a sample of 10 to 25 inpatient hospital claims spanning less than two midnights after admission for each hospital. This probe sample will be used to assist hospitals with implementing the new requirements correctly. To give an additional level of comfort during this adjustment period, CMS has announced that it will not conduct post-payment patient status reviews for claims with dates of admission Oct. 1, 2013, through March 31, 2014.

Unfortunately, beyond the vague guidance CMS has offered thus far, there is no foolproof guide to establishing new hospital admissions policies that comply with the rule. As a result, there likely will be wide variation among hospitals.

To assist in sorting out the confusion, SHM will be hosting a webinar this month with case studies from several hospitals. The focus will be on the internal processes each hospital is using to implement the rule and how they were developed. Sharing and learning from national implementation experiences is a valuable way for hospitalists to gain new perspectives and to bring those experiences to their home institutions when considering their own roles in meeting the new admissions criteria head on.

For more information about the webinar and to register, visit www.hospitalmedicine.org today.

Josh Boswell is SHM’s senior manager of government relations.

As many hospitalists are probably acutely aware, the Centers for Medicare & Medicaid Services (CMS) is putting a new rule into effect that will greatly impact how inpatient admission decisions are made. The rule, known as the “two-midnight rule,” states that if the admitting practitioner admits a Medicare beneficiary as an inpatient with the reasonable expectation that the beneficiary will require care that “crosses two midnights” and this decision is justified in the medical record, Medicare Part A payment is “generally appropriate.”

While there are multiple caveats, exceptions, and details, this rule can be simply articulated: If the admitting physician feels a patient will be in the hospital for a period longer than two midnights and the medical record supports this determination, the patient is an inpatient. Stays expected to be shorter than two midnights should be under observation status.

This new policy is an attempt to respond both to hospital calls for more guidance about when a beneficiary is appropriately treated as an inpatient—and paid by Medicare—and concerns about increasingly long hospital stays under observation status. Most hospitalists wrestle with status determination issues on a daily basis.

SHM is aware of the struggle and has been advocating on behalf of hospitalists to help shape observation status and the two-midnight rule. When the rule was first proposed, SHM voiced serious concerns about its utility and how it was unlikely to solve the overall confusion surrounding inpatient status determinations. Nevertheless, CMS finalized the rule as an attempt to begin addressing the problem.

Faced with an increasingly loud chorus of providers and hospitals concerned about the implementation of the new policy, CMS agreed to delay full enforcement from the original date of Oct. 1, 2013, until March 31, 2014.

During the delayed enforcement period, hospitals will be expected to begin implementing the two-midnight rule, and auditors will be giving hospitals non-punitive feedback on their application of the policy. To accomplish this, CMS is instructing Medicare Administrative Contractors (MACs) to review a sample of 10 to 25 inpatient hospital claims spanning less than two midnights after admission for each hospital. This probe sample will be used to assist hospitals with implementing the new requirements correctly. To give an additional level of comfort during this adjustment period, CMS has announced that it will not conduct post-payment patient status reviews for claims with dates of admission Oct. 1, 2013, through March 31, 2014.

Unfortunately, beyond the vague guidance CMS has offered thus far, there is no foolproof guide to establishing new hospital admissions policies that comply with the rule. As a result, there likely will be wide variation among hospitals.

To assist in sorting out the confusion, SHM will be hosting a webinar this month with case studies from several hospitals. The focus will be on the internal processes each hospital is using to implement the rule and how they were developed. Sharing and learning from national implementation experiences is a valuable way for hospitalists to gain new perspectives and to bring those experiences to their home institutions when considering their own roles in meeting the new admissions criteria head on.

For more information about the webinar and to register, visit www.hospitalmedicine.org today.

Josh Boswell is SHM’s senior manager of government relations.

As many hospitalists are probably acutely aware, the Centers for Medicare & Medicaid Services (CMS) is putting a new rule into effect that will greatly impact how inpatient admission decisions are made. The rule, known as the “two-midnight rule,” states that if the admitting practitioner admits a Medicare beneficiary as an inpatient with the reasonable expectation that the beneficiary will require care that “crosses two midnights” and this decision is justified in the medical record, Medicare Part A payment is “generally appropriate.”

While there are multiple caveats, exceptions, and details, this rule can be simply articulated: If the admitting physician feels a patient will be in the hospital for a period longer than two midnights and the medical record supports this determination, the patient is an inpatient. Stays expected to be shorter than two midnights should be under observation status.

This new policy is an attempt to respond both to hospital calls for more guidance about when a beneficiary is appropriately treated as an inpatient—and paid by Medicare—and concerns about increasingly long hospital stays under observation status. Most hospitalists wrestle with status determination issues on a daily basis.

SHM is aware of the struggle and has been advocating on behalf of hospitalists to help shape observation status and the two-midnight rule. When the rule was first proposed, SHM voiced serious concerns about its utility and how it was unlikely to solve the overall confusion surrounding inpatient status determinations. Nevertheless, CMS finalized the rule as an attempt to begin addressing the problem.

Faced with an increasingly loud chorus of providers and hospitals concerned about the implementation of the new policy, CMS agreed to delay full enforcement from the original date of Oct. 1, 2013, until March 31, 2014.

During the delayed enforcement period, hospitals will be expected to begin implementing the two-midnight rule, and auditors will be giving hospitals non-punitive feedback on their application of the policy. To accomplish this, CMS is instructing Medicare Administrative Contractors (MACs) to review a sample of 10 to 25 inpatient hospital claims spanning less than two midnights after admission for each hospital. This probe sample will be used to assist hospitals with implementing the new requirements correctly. To give an additional level of comfort during this adjustment period, CMS has announced that it will not conduct post-payment patient status reviews for claims with dates of admission Oct. 1, 2013, through March 31, 2014.

Unfortunately, beyond the vague guidance CMS has offered thus far, there is no foolproof guide to establishing new hospital admissions policies that comply with the rule. As a result, there likely will be wide variation among hospitals.

To assist in sorting out the confusion, SHM will be hosting a webinar this month with case studies from several hospitals. The focus will be on the internal processes each hospital is using to implement the rule and how they were developed. Sharing and learning from national implementation experiences is a valuable way for hospitalists to gain new perspectives and to bring those experiences to their home institutions when considering their own roles in meeting the new admissions criteria head on.

For more information about the webinar and to register, visit www.hospitalmedicine.org today.

Josh Boswell is SHM’s senior manager of government relations.

A new feature installed on HMX, LinkedIn Connect, makes it easier for you to fill out your member profile by pulling pieces of your LinkedIn profile into HMX. How does it work exactly?

Login at www.hmxchange.org and click “My Profile.” Midway down the page, you will see a section that reads, “Grab Profile Info from LinkedIn.” Click the link and follow the onscreen instructions. HMX will connect with your LinkedIn profile, pulling information like your photo, bio, education, and job history information.

It makes filling out your profile just a little bit easier.

A new feature installed on HMX, LinkedIn Connect, makes it easier for you to fill out your member profile by pulling pieces of your LinkedIn profile into HMX. How does it work exactly?

Login at www.hmxchange.org and click “My Profile.” Midway down the page, you will see a section that reads, “Grab Profile Info from LinkedIn.” Click the link and follow the onscreen instructions. HMX will connect with your LinkedIn profile, pulling information like your photo, bio, education, and job history information.

It makes filling out your profile just a little bit easier.

A new feature installed on HMX, LinkedIn Connect, makes it easier for you to fill out your member profile by pulling pieces of your LinkedIn profile into HMX. How does it work exactly?

Login at www.hmxchange.org and click “My Profile.” Midway down the page, you will see a section that reads, “Grab Profile Info from LinkedIn.” Click the link and follow the onscreen instructions. HMX will connect with your LinkedIn profile, pulling information like your photo, bio, education, and job history information.

It makes filling out your profile just a little bit easier.

Here are three simple steps to register for the FPHM MOC, according to the ABIM.

1. Click “Physician Login” at www.abim.org and enter your ABIM ID and your password. The default password is your six-digit date of birth (MMDDYY).
2. Under “My Maintenance of Certification Program,” click on “Enter Focused Practice in Hospital Medicine MOC Program.”
3. There you will begin the entry process, which requires you to complete a Web-based self-attestation, as well as the submission of the Senior Hospital Officer attestation to your eligibility. The attestations must be submitted and approved prior to entry into the program.

You can track your status in this process via the “View Status of Entry into Focused Practice in Hospital Medicine MOC Program” on your home page.

Here are three simple steps to register for the FPHM MOC, according to the ABIM.

1. Click “Physician Login” at www.abim.org and enter your ABIM ID and your password. The default password is your six-digit date of birth (MMDDYY).
2. Under “My Maintenance of Certification Program,” click on “Enter Focused Practice in Hospital Medicine MOC Program.”
3. There you will begin the entry process, which requires you to complete a Web-based self-attestation, as well as the submission of the Senior Hospital Officer attestation to your eligibility. The attestations must be submitted and approved prior to entry into the program.

You can track your status in this process via the “View Status of Entry into Focused Practice in Hospital Medicine MOC Program” on your home page.

Here are three simple steps to register for the FPHM MOC, according to the ABIM.

1. Click “Physician Login” at www.abim.org and enter your ABIM ID and your password. The default password is your six-digit date of birth (MMDDYY).
2. Under “My Maintenance of Certification Program,” click on “Enter Focused Practice in Hospital Medicine MOC Program.”
3. There you will begin the entry process, which requires you to complete a Web-based self-attestation, as well as the submission of the Senior Hospital Officer attestation to your eligibility. The attestations must be submitted and approved prior to entry into the program.

You can track your status in this process via the “View Status of Entry into Focused Practice in Hospital Medicine MOC Program” on your home page.

The Hospital Medicine MOC secure exams are offered every spring and fall. Although the dates might seem far off now, hospitalists interested in taking the Hospital Medicine MOC exam must complete the entry process for the FPHM program at least two weeks before the exam registration deadline. For the spring MOC exam, this means hospitalists must complete the FPHM program entry process by Feb. 14, 2014, for the Spring 2014 exam, and Aug. 1, 2014, for the Fall 2014 exam.

To complete the entry process, hospitalists must:

• Be licensed and in good standing.
• Hold current or previous ABIM certification in Internal Medicine and current Advanced Cardiac Life Support (ACLS) certification.
• Complete at least three years of unsupervised hospital medicine practice experience prior to entry into the Focused Practice in Hospital Medicine MOC program. Formal fellowship training in a hospital medicine fellowship program can be counted toward the three-year practice experience criteria.
• Electronically submit a self-attestation and an attestation from a Senior Hospital Officer (SHO) that they meet the patient encounter thresholds for internal medicine practice in the hospital setting.

Once enrolled, hospitalists will be eligible to schedule a seat for the Hospital Medicine MOC exam during the registration period; however, the ABIM stipulates that hospitalists must be entered into the program at least two weeks prior to the exam date.

At the same time, hospitalists must have completed 100 points of self-evaluation within the last 10 years. Twenty of the points in Self-Evaluation of Medical Knowledge and 40 points in Self-Evaluation of Practice Performance must have been completed in the last three years.

The Hospital Medicine MOC secure exams are offered every spring and fall. Although the dates might seem far off now, hospitalists interested in taking the Hospital Medicine MOC exam must complete the entry process for the FPHM program at least two weeks before the exam registration deadline. For the spring MOC exam, this means hospitalists must complete the FPHM program entry process by Feb. 14, 2014, for the Spring 2014 exam, and Aug. 1, 2014, for the Fall 2014 exam.

To complete the entry process, hospitalists must:

• Be licensed and in good standing.
• Hold current or previous ABIM certification in Internal Medicine and current Advanced Cardiac Life Support (ACLS) certification.
• Complete at least three years of unsupervised hospital medicine practice experience prior to entry into the Focused Practice in Hospital Medicine MOC program. Formal fellowship training in a hospital medicine fellowship program can be counted toward the three-year practice experience criteria.
• Electronically submit a self-attestation and an attestation from a Senior Hospital Officer (SHO) that they meet the patient encounter thresholds for internal medicine practice in the hospital setting.

Once enrolled, hospitalists will be eligible to schedule a seat for the Hospital Medicine MOC exam during the registration period; however, the ABIM stipulates that hospitalists must be entered into the program at least two weeks prior to the exam date.

At the same time, hospitalists must have completed 100 points of self-evaluation within the last 10 years. Twenty of the points in Self-Evaluation of Medical Knowledge and 40 points in Self-Evaluation of Practice Performance must have been completed in the last three years.

The Hospital Medicine MOC secure exams are offered every spring and fall. Although the dates might seem far off now, hospitalists interested in taking the Hospital Medicine MOC exam must complete the entry process for the FPHM program at least two weeks before the exam registration deadline. For the spring MOC exam, this means hospitalists must complete the FPHM program entry process by Feb. 14, 2014, for the Spring 2014 exam, and Aug. 1, 2014, for the Fall 2014 exam.

To complete the entry process, hospitalists must:

• Be licensed and in good standing.
• Hold current or previous ABIM certification in Internal Medicine and current Advanced Cardiac Life Support (ACLS) certification.
• Complete at least three years of unsupervised hospital medicine practice experience prior to entry into the Focused Practice in Hospital Medicine MOC program. Formal fellowship training in a hospital medicine fellowship program can be counted toward the three-year practice experience criteria.
• Electronically submit a self-attestation and an attestation from a Senior Hospital Officer (SHO) that they meet the patient encounter thresholds for internal medicine practice in the hospital setting.

Once enrolled, hospitalists will be eligible to schedule a seat for the Hospital Medicine MOC exam during the registration period; however, the ABIM stipulates that hospitalists must be entered into the program at least two weeks prior to the exam date.

At the same time, hospitalists must have completed 100 points of self-evaluation within the last 10 years. Twenty of the points in Self-Evaluation of Medical Knowledge and 40 points in Self-Evaluation of Practice Performance must have been completed in the last three years.

While the program is just a few years old, changes to the Focused Practice in Hospital Medicine (FPHM) Maintenance of Certification (MOC) from the American Board of Internal Medicine (ABIM) make it more attractive to hospitalists, bringing it in line with other MOC programs. And now is the time to act for 2014.

Not only do the changes to the FPHM MOC streamline the process, it remains the only ABIM certification designed exclusively for the growing ranks of hospitalists, according to hospitalists who have already earned the new certification. The hospitalist-centric program makes their board certification more applicable to their everyday practice and emphasizes their expertise in the specialty.

The alignment with the hospital medicine specialty has both practical and ideological benefits for hospitalists. On the practical side, the hospital medicine focused medical knowledge modules and preparation for the Hospital Medicine MOC exam are more focused, as the content better matches the day-to-day life of a hospitalist.

“From a content perspective, both for studying and the updates, it allows the hospitalist to focus on content that’s most relevant to their practice,” says hospitalist Jennifer Myers, MD, associate professor of clinical medicine and associate designated institutional official for graduate medical education at the Hospital of the University of Pennsylvania in Philadelphia.

Dr. Myers earned the FPHM certification in 2011. Compared to the internal medicine MOC, she says “the standard questions focused on ambulatory medicine do not always apply,” and the likelihood that hospitalists kept up on those topics was slim. Rather, “hospitalists will be better prepared to take the Focused Practice in Hospital Medicine. And as they’re updating and studying, they can focus on relevant topics for their practice,” she says.

For hospitalist and former SHM president Jeffrey Wiese, MD, MHM, the FPHM MOC program helps define his work in ways other than just the physical space of the hospital.

“If I am to have public accountability as a hospitalist, it has to be more than just geography. Intrinsic to a true hospitalist is systems architecture…improving the quality and patient safety delivered by the hospital system,” says Dr. Wiese, professor of medicine and senior associate dean of graduate medical education at Tulane University in New Orleans.

Dr. Wiese is intimately familiar with the process: He served on the ABIM’s Hospital Medicine MOC Exam Writing ABIM test writing committee for the FPHM pathway MOC program. He now serves on the new ABIM Council.

“This is a way to distinguish the ideals of the specialty,” he says. “What hospitalists do is more than just deliver inpatient care. … It’s about advancing the quality and safety of the system, and the FPHM MOC track ensures fidelity to that standard.”

FPHM’s ability to differentiate hospitalists resonates with Daniel Brotman, MD, director of the hospitalist program at Johns Hopkins Hospital in Baltimore and chair of SHM’s Annual Meeting Committee and Education Committee. And that differentiation extends from the individual hospitalist to the movement as a whole.

“If you’re a hospitalist and you’re invested in the field, this is an important statement to make on behalf of your specialty,” he says. “It can give you some added respect within your institution when people ask you about specialized training in hospital medicine.”

Even if hospitalists didn’t have specialized training, the FPHM MOC demonstrates that they “did have to pass a specialized certification process that gives different credentials,” Dr. Brotman says. “This is the best way to do that.”

He also sees it as an individual benefit for hospitalists—both for their career advancement and their peace of mind—knowing that they are more up to date with their clinical practice.

“You practice hospital medicine. If you want an exam that hits the ball to your forehand, this is it,” he says. “If you’re nervous about the board exam, I’d be more nervous about taking a generalized exam.”

Brendon Shank is SHM’s associate vice president of communications.

While the program is just a few years old, changes to the Focused Practice in Hospital Medicine (FPHM) Maintenance of Certification (MOC) from the American Board of Internal Medicine (ABIM) make it more attractive to hospitalists, bringing it in line with other MOC programs. And now is the time to act for 2014.

Not only do the changes to the FPHM MOC streamline the process, it remains the only ABIM certification designed exclusively for the growing ranks of hospitalists, according to hospitalists who have already earned the new certification. The hospitalist-centric program makes their board certification more applicable to their everyday practice and emphasizes their expertise in the specialty.

The alignment with the hospital medicine specialty has both practical and ideological benefits for hospitalists. On the practical side, the hospital medicine focused medical knowledge modules and preparation for the Hospital Medicine MOC exam are more focused, as the content better matches the day-to-day life of a hospitalist.

“From a content perspective, both for studying and the updates, it allows the hospitalist to focus on content that’s most relevant to their practice,” says hospitalist Jennifer Myers, MD, associate professor of clinical medicine and associate designated institutional official for graduate medical education at the Hospital of the University of Pennsylvania in Philadelphia.

Dr. Myers earned the FPHM certification in 2011. Compared to the internal medicine MOC, she says “the standard questions focused on ambulatory medicine do not always apply,” and the likelihood that hospitalists kept up on those topics was slim. Rather, “hospitalists will be better prepared to take the Focused Practice in Hospital Medicine. And as they’re updating and studying, they can focus on relevant topics for their practice,” she says.

For hospitalist and former SHM president Jeffrey Wiese, MD, MHM, the FPHM MOC program helps define his work in ways other than just the physical space of the hospital.

“If I am to have public accountability as a hospitalist, it has to be more than just geography. Intrinsic to a true hospitalist is systems architecture…improving the quality and patient safety delivered by the hospital system,” says Dr. Wiese, professor of medicine and senior associate dean of graduate medical education at Tulane University in New Orleans.

Dr. Wiese is intimately familiar with the process: He served on the ABIM’s Hospital Medicine MOC Exam Writing ABIM test writing committee for the FPHM pathway MOC program. He now serves on the new ABIM Council.

“This is a way to distinguish the ideals of the specialty,” he says. “What hospitalists do is more than just deliver inpatient care. … It’s about advancing the quality and safety of the system, and the FPHM MOC track ensures fidelity to that standard.”

FPHM’s ability to differentiate hospitalists resonates with Daniel Brotman, MD, director of the hospitalist program at Johns Hopkins Hospital in Baltimore and chair of SHM’s Annual Meeting Committee and Education Committee. And that differentiation extends from the individual hospitalist to the movement as a whole.

“If you’re a hospitalist and you’re invested in the field, this is an important statement to make on behalf of your specialty,” he says. “It can give you some added respect within your institution when people ask you about specialized training in hospital medicine.”

Even if hospitalists didn’t have specialized training, the FPHM MOC demonstrates that they “did have to pass a specialized certification process that gives different credentials,” Dr. Brotman says. “This is the best way to do that.”

He also sees it as an individual benefit for hospitalists—both for their career advancement and their peace of mind—knowing that they are more up to date with their clinical practice.

“You practice hospital medicine. If you want an exam that hits the ball to your forehand, this is it,” he says. “If you’re nervous about the board exam, I’d be more nervous about taking a generalized exam.”

Brendon Shank is SHM’s associate vice president of communications.

While the program is just a few years old, changes to the Focused Practice in Hospital Medicine (FPHM) Maintenance of Certification (MOC) from the American Board of Internal Medicine (ABIM) make it more attractive to hospitalists, bringing it in line with other MOC programs. And now is the time to act for 2014.

Not only do the changes to the FPHM MOC streamline the process, it remains the only ABIM certification designed exclusively for the growing ranks of hospitalists, according to hospitalists who have already earned the new certification. The hospitalist-centric program makes their board certification more applicable to their everyday practice and emphasizes their expertise in the specialty.

The alignment with the hospital medicine specialty has both practical and ideological benefits for hospitalists. On the practical side, the hospital medicine focused medical knowledge modules and preparation for the Hospital Medicine MOC exam are more focused, as the content better matches the day-to-day life of a hospitalist.

“From a content perspective, both for studying and the updates, it allows the hospitalist to focus on content that’s most relevant to their practice,” says hospitalist Jennifer Myers, MD, associate professor of clinical medicine and associate designated institutional official for graduate medical education at the Hospital of the University of Pennsylvania in Philadelphia.

Dr. Myers earned the FPHM certification in 2011. Compared to the internal medicine MOC, she says “the standard questions focused on ambulatory medicine do not always apply,” and the likelihood that hospitalists kept up on those topics was slim. Rather, “hospitalists will be better prepared to take the Focused Practice in Hospital Medicine. And as they’re updating and studying, they can focus on relevant topics for their practice,” she says.

For hospitalist and former SHM president Jeffrey Wiese, MD, MHM, the FPHM MOC program helps define his work in ways other than just the physical space of the hospital.

“If I am to have public accountability as a hospitalist, it has to be more than just geography. Intrinsic to a true hospitalist is systems architecture…improving the quality and patient safety delivered by the hospital system,” says Dr. Wiese, professor of medicine and senior associate dean of graduate medical education at Tulane University in New Orleans.

Dr. Wiese is intimately familiar with the process: He served on the ABIM’s Hospital Medicine MOC Exam Writing ABIM test writing committee for the FPHM pathway MOC program. He now serves on the new ABIM Council.

“This is a way to distinguish the ideals of the specialty,” he says. “What hospitalists do is more than just deliver inpatient care. … It’s about advancing the quality and safety of the system, and the FPHM MOC track ensures fidelity to that standard.”

FPHM’s ability to differentiate hospitalists resonates with Daniel Brotman, MD, director of the hospitalist program at Johns Hopkins Hospital in Baltimore and chair of SHM’s Annual Meeting Committee and Education Committee. And that differentiation extends from the individual hospitalist to the movement as a whole.

“If you’re a hospitalist and you’re invested in the field, this is an important statement to make on behalf of your specialty,” he says. “It can give you some added respect within your institution when people ask you about specialized training in hospital medicine.”

Even if hospitalists didn’t have specialized training, the FPHM MOC demonstrates that they “did have to pass a specialized certification process that gives different credentials,” Dr. Brotman says. “This is the best way to do that.”

He also sees it as an individual benefit for hospitalists—both for their career advancement and their peace of mind—knowing that they are more up to date with their clinical practice.

“You practice hospital medicine. If you want an exam that hits the ball to your forehand, this is it,” he says. “If you’re nervous about the board exam, I’d be more nervous about taking a generalized exam.”

Brendon Shank is SHM’s associate vice president of communications.

Initial Efforts

1965

• President Lyndon B. Johnson signs the Social Security Act, which authorizes both Medicare and Medicaid; the law is widely labeled the biggest healthcare reform of the past century.

1993

• President Bill Clinton attempts to craft universal healthcare legislation that includes both individual and employer mandates. He appoints his wife, Hillary Rodham Clinton, as chair of the White House Task Force on Health Reform. The President’s Health Security Act ultimately fails in Congress.

1997

• State Children’s Health Insurance Program (S-CHIP) authorized by Congress, covering low-income children in families above Medicaid eligibility levels.

2006

• Massachusetts (followed by Vermont in 2011) passes legislation that expands healthcare coverage to nearly all state residents; the Massachusetts law is later deemed a template for the Patient Protection and Affordable Care Act of 2010.

The Patient Protection and Affordable Care Act (ACA)

March 23, 2010

• President Obama signs the ACA into law. Among the law’s early provisions: Medicare beneficiaries who reach the Part D drug coverage gap begin receiving $250 rebates, and the IRS begins allowing tax credits to small employers that offer health insurance to their employees.

July 1, 2010

• Federal government begins enrolling patients with pre-existing conditions in a temporary Pre-Existing Condition Insurance Plan (PCIP).

• Healthcare.gov website debuts.

• IRS begins assessing 10% tax on indoor tanning.

Sep. 23, 2010

• Patient-Centered Outcomes Research Institute (PCORI) launches with 21-member board of directors.

• For new insurance plans or those renewed on or after this date, parents are allowed to keep adult children on their health policies until they turn 26 (many private plans voluntarily offered this option earlier).

• HHS bans insurers from imposing lifetime coverage limits and from denying health coverage to children with pre-existing conditions or excluding specific conditions from coverage.

• HHS requires new and renewing health plans to eliminate cost sharing for certain preventive services recommended by U.S. Preventive Services Task Force.

Sep. 30, 2010

• U.S. Comptroller General appoints 15 members to National Health Care Workforce Commission (commission does not secure funding).

December 30, 2010

• Medicare debuts first phase of Physician Compare website.

Jan. 1, 2011

• CMS begins closing Medicare Part D drug coverage gap.

• Medicare begins paying 10% bonus for primary care services (funded through 2015).

• Center for Medicare and Medicaid Innovation debuts, with a focus on testing new payment and care delivery systems.

March 23, 2011

• HHS begins providing grants to individual states to help set up health insurance exchanges.

July 1, 2011

• CMS stops paying for Medicaid services related to specific hospital-acquired infections.

Oct. 1, 2011

• Fifteen-member Independent Payment Advisory Board is formally established (but no members are nominated). The IPAB is charged with issuing legislative recommendations to lower Medicare spending growth, but only if projected costs exceed a certain threshold.

Jan. 1, 2012

• CMS launches Medicaid bundled-payment demonstration and Accountable Care Organization (ACO) incentive program.

• CMS reduces Medicare Advantage rebates but offers bonuses to high-quality plans.

Aug. 1, 2012

• HHS requires most new and renewing health plans to eliminate cost sharing for women’s preventive health services, including contraception.

Oct. 1, 2012

• CMS begins its Value-Based Purchasing (VBP) Program in Medicare, starting with a 1% withholding in FY2013.

• CMS begins reducing Medicare payments based on excess hospital readmissions, starting with a 1% penalty in FY2013.

Jan. 1, 2013

• CMS starts five-year bundled payment pilot program for Medicare, covering 10 conditions.

• CMS increases Medicaid payments for primary care services to 100% of Medicare’s rate (funded for two years).

• IRS increases Medicare tax rate to 2.35% on individuals earning more than $200,000 and on married couples earning more than $250,000; also imposes 3.8% tax on unearned income among high-income taxpayers.

• IRS begins assessing excise tax of 2.3% on sale of taxable medical devices.

Jan. 2, 2013

• Sequestration results in across-the-board cuts of 2% in Medicare reimbursements.

July 1, 2013

• DHS officially launches Consumer Operated and Oriented Plan (CO-OP) to encourage growth of nonprofit health insurers (roughly $2 billion in loans given to co-ops in 23 states by end of 2012).

Oct. 1, 2013

• Open enrollment begins for state- and federal government-run health insurance exchanges and expanded Medicaid; the rollout is marred by multiple computer glitches.

• CMS lowers Medicare Disproportionate Share Hospital (DSH) payments by 75%, starting in FY2014 but plans to supplement these payments based on each hospital’s share of uncompensated care.

• CMS lowers Medicaid DSH payments by $22 billion over 10 years, beginning with $500 million reduction in FY2014.

Jan. 1, 2014

• Coverage begins through health insurance exchanges. Individuals and families with incomes between 100% and 400% of the federal poverty level can receive subsidies to help pay for premiums.

• Voluntary Medicaid expansions expected to take place in roughly half of all states, for individuals up to 138% of the federal poverty level.

• Insurers banned from imposing annual limits on coverage, from restricting coverage due to pre-existing conditions, and from basing premiums on gender.

• Insurers required to cover 10 “essential health benefits,” including medication and maternity care.

March 31, 2014

• Open enrollment closes for health insurance exchanges; under the “individual mandate,” people who qualify but don’t buy insurance by this date will be penalized up to 1% of income (penalty increases in subsequent years).

Oct. 1, 2014

• CMS imposes 1% reduction in payments to hospitals with excess hospital-acquired conditions (FY2015).

• CMS imposes penalties on hospitals that haven’t met electronic health record (EHR) meaningful use requirements.

Jan. 1, 2015

• Employer Shared Responsibility Payment, or the “employer mandate,” begins (delayed from Jan. 1, 2014). With a few exceptions, employers with more than 50 employees must offer coverage or pay a fine.

• CMS begins imposing fines based on doctors who didn’t meet Physician Quality Reporting System requirements during 2013, with an initial 1.5% penalty that rises to 2% in 2016.

Jan. 1, 2018

• High-cost, or so-called “Cadillac,” insurance plans—those with premiums over $10,200 for individuals or $27,500 for family coverage—will be assessed an excise tax.

Sources: Healthcare.gov, Commonwealth Fund, Kaiser Family Foundation, American Medical Association, Greater New York Hospital Association.

Initial Efforts

1965

• President Lyndon B. Johnson signs the Social Security Act, which authorizes both Medicare and Medicaid; the law is widely labeled the biggest healthcare reform of the past century.

1993

• President Bill Clinton attempts to craft universal healthcare legislation that includes both individual and employer mandates. He appoints his wife, Hillary Rodham Clinton, as chair of the White House Task Force on Health Reform. The President’s Health Security Act ultimately fails in Congress.

1997

• State Children’s Health Insurance Program (S-CHIP) authorized by Congress, covering low-income children in families above Medicaid eligibility levels.

2006

• Massachusetts (followed by Vermont in 2011) passes legislation that expands healthcare coverage to nearly all state residents; the Massachusetts law is later deemed a template for the Patient Protection and Affordable Care Act of 2010.

The Patient Protection and Affordable Care Act (ACA)

March 23, 2010

• President Obama signs the ACA into law. Among the law’s early provisions: Medicare beneficiaries who reach the Part D drug coverage gap begin receiving $250 rebates, and the IRS begins allowing tax credits to small employers that offer health insurance to their employees.

July 1, 2010

• Federal government begins enrolling patients with pre-existing conditions in a temporary Pre-Existing Condition Insurance Plan (PCIP).

• Healthcare.gov website debuts.

• IRS begins assessing 10% tax on indoor tanning.

Sep. 23, 2010

• Patient-Centered Outcomes Research Institute (PCORI) launches with 21-member board of directors.

• For new insurance plans or those renewed on or after this date, parents are allowed to keep adult children on their health policies until they turn 26 (many private plans voluntarily offered this option earlier).

• HHS bans insurers from imposing lifetime coverage limits and from denying health coverage to children with pre-existing conditions or excluding specific conditions from coverage.

• HHS requires new and renewing health plans to eliminate cost sharing for certain preventive services recommended by U.S. Preventive Services Task Force.

Sep. 30, 2010

• U.S. Comptroller General appoints 15 members to National Health Care Workforce Commission (commission does not secure funding).

December 30, 2010

• Medicare debuts first phase of Physician Compare website.

Jan. 1, 2011

• CMS begins closing Medicare Part D drug coverage gap.

• Medicare begins paying 10% bonus for primary care services (funded through 2015).

• Center for Medicare and Medicaid Innovation debuts, with a focus on testing new payment and care delivery systems.

March 23, 2011

• HHS begins providing grants to individual states to help set up health insurance exchanges.

July 1, 2011

• CMS stops paying for Medicaid services related to specific hospital-acquired infections.

Oct. 1, 2011

• Fifteen-member Independent Payment Advisory Board is formally established (but no members are nominated). The IPAB is charged with issuing legislative recommendations to lower Medicare spending growth, but only if projected costs exceed a certain threshold.

Jan. 1, 2012

• CMS launches Medicaid bundled-payment demonstration and Accountable Care Organization (ACO) incentive program.

• CMS reduces Medicare Advantage rebates but offers bonuses to high-quality plans.

Aug. 1, 2012

• HHS requires most new and renewing health plans to eliminate cost sharing for women’s preventive health services, including contraception.

Oct. 1, 2012

• CMS begins its Value-Based Purchasing (VBP) Program in Medicare, starting with a 1% withholding in FY2013.

• CMS begins reducing Medicare payments based on excess hospital readmissions, starting with a 1% penalty in FY2013.

Jan. 1, 2013

• CMS starts five-year bundled payment pilot program for Medicare, covering 10 conditions.

• CMS increases Medicaid payments for primary care services to 100% of Medicare’s rate (funded for two years).

• IRS increases Medicare tax rate to 2.35% on individuals earning more than $200,000 and on married couples earning more than $250,000; also imposes 3.8% tax on unearned income among high-income taxpayers.

• IRS begins assessing excise tax of 2.3% on sale of taxable medical devices.

Jan. 2, 2013

• Sequestration results in across-the-board cuts of 2% in Medicare reimbursements.

July 1, 2013

• DHS officially launches Consumer Operated and Oriented Plan (CO-OP) to encourage growth of nonprofit health insurers (roughly $2 billion in loans given to co-ops in 23 states by end of 2012).

Oct. 1, 2013

• Open enrollment begins for state- and federal government-run health insurance exchanges and expanded Medicaid; the rollout is marred by multiple computer glitches.

• CMS lowers Medicare Disproportionate Share Hospital (DSH) payments by 75%, starting in FY2014 but plans to supplement these payments based on each hospital’s share of uncompensated care.

• CMS lowers Medicaid DSH payments by $22 billion over 10 years, beginning with $500 million reduction in FY2014.

Jan. 1, 2014

• Coverage begins through health insurance exchanges. Individuals and families with incomes between 100% and 400% of the federal poverty level can receive subsidies to help pay for premiums.

• Voluntary Medicaid expansions expected to take place in roughly half of all states, for individuals up to 138% of the federal poverty level.

• Insurers banned from imposing annual limits on coverage, from restricting coverage due to pre-existing conditions, and from basing premiums on gender.

• Insurers required to cover 10 “essential health benefits,” including medication and maternity care.

March 31, 2014

• Open enrollment closes for health insurance exchanges; under the “individual mandate,” people who qualify but don’t buy insurance by this date will be penalized up to 1% of income (penalty increases in subsequent years).

Oct. 1, 2014

• CMS imposes 1% reduction in payments to hospitals with excess hospital-acquired conditions (FY2015).

• CMS imposes penalties on hospitals that haven’t met electronic health record (EHR) meaningful use requirements.

Jan. 1, 2015

• Employer Shared Responsibility Payment, or the “employer mandate,” begins (delayed from Jan. 1, 2014). With a few exceptions, employers with more than 50 employees must offer coverage or pay a fine.

• CMS begins imposing fines based on doctors who didn’t meet Physician Quality Reporting System requirements during 2013, with an initial 1.5% penalty that rises to 2% in 2016.

Jan. 1, 2018

• High-cost, or so-called “Cadillac,” insurance plans—those with premiums over $10,200 for individuals or $27,500 for family coverage—will be assessed an excise tax.

Sources: Healthcare.gov, Commonwealth Fund, Kaiser Family Foundation, American Medical Association, Greater New York Hospital Association.

Initial Efforts

1965

• President Lyndon B. Johnson signs the Social Security Act, which authorizes both Medicare and Medicaid; the law is widely labeled the biggest healthcare reform of the past century.

1993

• President Bill Clinton attempts to craft universal healthcare legislation that includes both individual and employer mandates. He appoints his wife, Hillary Rodham Clinton, as chair of the White House Task Force on Health Reform. The President’s Health Security Act ultimately fails in Congress.

1997

• State Children’s Health Insurance Program (S-CHIP) authorized by Congress, covering low-income children in families above Medicaid eligibility levels.

2006

• Massachusetts (followed by Vermont in 2011) passes legislation that expands healthcare coverage to nearly all state residents; the Massachusetts law is later deemed a template for the Patient Protection and Affordable Care Act of 2010.

The Patient Protection and Affordable Care Act (ACA)

March 23, 2010

• President Obama signs the ACA into law. Among the law’s early provisions: Medicare beneficiaries who reach the Part D drug coverage gap begin receiving $250 rebates, and the IRS begins allowing tax credits to small employers that offer health insurance to their employees.

July 1, 2010

• Federal government begins enrolling patients with pre-existing conditions in a temporary Pre-Existing Condition Insurance Plan (PCIP).

• Healthcare.gov website debuts.

• IRS begins assessing 10% tax on indoor tanning.

Sep. 23, 2010

• Patient-Centered Outcomes Research Institute (PCORI) launches with 21-member board of directors.

• For new insurance plans or those renewed on or after this date, parents are allowed to keep adult children on their health policies until they turn 26 (many private plans voluntarily offered this option earlier).

• HHS bans insurers from imposing lifetime coverage limits and from denying health coverage to children with pre-existing conditions or excluding specific conditions from coverage.

• HHS requires new and renewing health plans to eliminate cost sharing for certain preventive services recommended by U.S. Preventive Services Task Force.

Sep. 30, 2010

• U.S. Comptroller General appoints 15 members to National Health Care Workforce Commission (commission does not secure funding).

December 30, 2010

• Medicare debuts first phase of Physician Compare website.

Jan. 1, 2011

• CMS begins closing Medicare Part D drug coverage gap.

• Medicare begins paying 10% bonus for primary care services (funded through 2015).

• Center for Medicare and Medicaid Innovation debuts, with a focus on testing new payment and care delivery systems.

March 23, 2011

• HHS begins providing grants to individual states to help set up health insurance exchanges.

July 1, 2011

• CMS stops paying for Medicaid services related to specific hospital-acquired infections.

Oct. 1, 2011

• Fifteen-member Independent Payment Advisory Board is formally established (but no members are nominated). The IPAB is charged with issuing legislative recommendations to lower Medicare spending growth, but only if projected costs exceed a certain threshold.

Jan. 1, 2012

• CMS launches Medicaid bundled-payment demonstration and Accountable Care Organization (ACO) incentive program.

• CMS reduces Medicare Advantage rebates but offers bonuses to high-quality plans.

Aug. 1, 2012

• HHS requires most new and renewing health plans to eliminate cost sharing for women’s preventive health services, including contraception.

Oct. 1, 2012

• CMS begins its Value-Based Purchasing (VBP) Program in Medicare, starting with a 1% withholding in FY2013.

• CMS begins reducing Medicare payments based on excess hospital readmissions, starting with a 1% penalty in FY2013.

Jan. 1, 2013

• CMS starts five-year bundled payment pilot program for Medicare, covering 10 conditions.

• CMS increases Medicaid payments for primary care services to 100% of Medicare’s rate (funded for two years).

• IRS increases Medicare tax rate to 2.35% on individuals earning more than $200,000 and on married couples earning more than $250,000; also imposes 3.8% tax on unearned income among high-income taxpayers.

• IRS begins assessing excise tax of 2.3% on sale of taxable medical devices.

Jan. 2, 2013

• Sequestration results in across-the-board cuts of 2% in Medicare reimbursements.

July 1, 2013

• DHS officially launches Consumer Operated and Oriented Plan (CO-OP) to encourage growth of nonprofit health insurers (roughly $2 billion in loans given to co-ops in 23 states by end of 2012).

Oct. 1, 2013

• Open enrollment begins for state- and federal government-run health insurance exchanges and expanded Medicaid; the rollout is marred by multiple computer glitches.

• CMS lowers Medicare Disproportionate Share Hospital (DSH) payments by 75%, starting in FY2014 but plans to supplement these payments based on each hospital’s share of uncompensated care.

• CMS lowers Medicaid DSH payments by $22 billion over 10 years, beginning with $500 million reduction in FY2014.

Jan. 1, 2014

• Coverage begins through health insurance exchanges. Individuals and families with incomes between 100% and 400% of the federal poverty level can receive subsidies to help pay for premiums.

• Voluntary Medicaid expansions expected to take place in roughly half of all states, for individuals up to 138% of the federal poverty level.

• Insurers banned from imposing annual limits on coverage, from restricting coverage due to pre-existing conditions, and from basing premiums on gender.

• Insurers required to cover 10 “essential health benefits,” including medication and maternity care.

March 31, 2014

• Open enrollment closes for health insurance exchanges; under the “individual mandate,” people who qualify but don’t buy insurance by this date will be penalized up to 1% of income (penalty increases in subsequent years).

Oct. 1, 2014

• CMS imposes 1% reduction in payments to hospitals with excess hospital-acquired conditions (FY2015).

• CMS imposes penalties on hospitals that haven’t met electronic health record (EHR) meaningful use requirements.

Jan. 1, 2015

• Employer Shared Responsibility Payment, or the “employer mandate,” begins (delayed from Jan. 1, 2014). With a few exceptions, employers with more than 50 employees must offer coverage or pay a fine.

• CMS begins imposing fines based on doctors who didn’t meet Physician Quality Reporting System requirements during 2013, with an initial 1.5% penalty that rises to 2% in 2016.

Jan. 1, 2018

• High-cost, or so-called “Cadillac,” insurance plans—those with premiums over $10,200 for individuals or $27,500 for family coverage—will be assessed an excise tax.

Sources: Healthcare.gov, Commonwealth Fund, Kaiser Family Foundation, American Medical Association, Greater New York Hospital Association.

Sometimes, numbers do tell a story. The Affordable Care Act has no shortage of them, and amid the densely packed provisions, regulations, pilots, demonstrations, fines, and other elements, a few numbers provide a glimpse of the intense wrangling that created both winners and losers in the healthcare reform effort.

One of the biggest numbers is also the mostly hotly contested: whether Obamacare will blow a hole in the nation’s deficit or lead to a trillion dollars or more in savings over the first two decades. In March 2010, the Congressional Budget Office predicted the latter, with savings of $143 billion through 2019 and a hazier guess of savings equivalent to 0.5% of gross domestic product—equal to $1 trillion or more—through the 2020s.

The problem? “That calculation reflects an assumption that the provisions of the legislation are enacted and remain unchanged throughout the next two decades, which is often not the case for major legislation,” the CBO wrote at the time. That prediction, at least, was spot on.

Amid the ongoing political back and forth, one point is often overlooked: Although still unsustainably high, per capita healthcare spending is now increasing at the lowest rate in decades. Robert Berenson, MD, an Institute Fellow at the Washington, D.C.-based Urban Institute, a nonpartisan think tank focused on social and economic policy, notes that the trend (starting in 2006) predated the recession. Likewise, it is occurring in Medicare, where most beneficiaries have first-dollar coverage. Instead of being a side effect of the sluggish economy, Dr. Berenson believes fundamental change is occurring on the provider side, and that the additional focus on reform may be making a difference.

Some analysts, he says, believe that providers are responding to the anticipation of change in the system and are beginning to change their own behavior accordingly.

“That means we have more time to get it right, in terms of wholesale change in how healthcare is delivered, and, for me, that’s a good thing,” he says.

A few other numbers of note:

$1.075 trillion

The state- and federal-run healthcare exchanges are expected to cost $1.075 trillion through 2023, according to the CBO. That eye-popping number includes spending for “high-risk pools, premium review activities, loans to consumer-operated and -oriented plans, and grants to states for the establishment of exchanges.”

The big question, of course, is whether that investment will pay off, and a big part of the answer will rest with a well-balanced risk pool. In other words, long-term financial stability means getting as many young and healthy people into the exchanges as possible.

$2 billion

The ACA sought to increase competition by supporting the creation of consumer co-ops, despite opposition from the insurance industry. By the end of last year, HHS had doled out roughly $2 billion in loans to nonprofit co-ops in 23 states, as part of its Consumer Operated and Oriented Plan (CO-OP). Backers of these co-ops had initially sought $10 billion, however, based on estimates of what would be required to ensure a higher likelihood of success.

Although preliminary evidence suggests that these newcomers may be helping to drive down costs in some states, a lack of additional funding has prevented other potential co-ops from receiving startup loans. The co-ops also are barred from using any federal money for marketing, cannot jointly negotiate contracts with doctors, and have limited access to the large employer insurance market—casting doubt on their continued viability.

$0

On Sep. 30, 2010, the U.S. comptroller general appointed 15 members to the National Health Care Workforce Commission, an acknowledgment that the country needs more guidance in how to address existing shortages—expected to widen—in doctors and other healthcare providers. The commission, authorized by the ACA, has never met, however. The act didn’t appropriate any money for it, and Congress has yet to approve any funding either, meaning that the commission’s members are legally barred from conducting any work.

—Bryn Nelson, PhD

Sometimes, numbers do tell a story. The Affordable Care Act has no shortage of them, and amid the densely packed provisions, regulations, pilots, demonstrations, fines, and other elements, a few numbers provide a glimpse of the intense wrangling that created both winners and losers in the healthcare reform effort.

One of the biggest numbers is also the mostly hotly contested: whether Obamacare will blow a hole in the nation’s deficit or lead to a trillion dollars or more in savings over the first two decades. In March 2010, the Congressional Budget Office predicted the latter, with savings of $143 billion through 2019 and a hazier guess of savings equivalent to 0.5% of gross domestic product—equal to $1 trillion or more—through the 2020s.

The problem? “That calculation reflects an assumption that the provisions of the legislation are enacted and remain unchanged throughout the next two decades, which is often not the case for major legislation,” the CBO wrote at the time. That prediction, at least, was spot on.

Amid the ongoing political back and forth, one point is often overlooked: Although still unsustainably high, per capita healthcare spending is now increasing at the lowest rate in decades. Robert Berenson, MD, an Institute Fellow at the Washington, D.C.-based Urban Institute, a nonpartisan think tank focused on social and economic policy, notes that the trend (starting in 2006) predated the recession. Likewise, it is occurring in Medicare, where most beneficiaries have first-dollar coverage. Instead of being a side effect of the sluggish economy, Dr. Berenson believes fundamental change is occurring on the provider side, and that the additional focus on reform may be making a difference.

Some analysts, he says, believe that providers are responding to the anticipation of change in the system and are beginning to change their own behavior accordingly.

“That means we have more time to get it right, in terms of wholesale change in how healthcare is delivered, and, for me, that’s a good thing,” he says.

A few other numbers of note:

$1.075 trillion

The state- and federal-run healthcare exchanges are expected to cost $1.075 trillion through 2023, according to the CBO. That eye-popping number includes spending for “high-risk pools, premium review activities, loans to consumer-operated and -oriented plans, and grants to states for the establishment of exchanges.”

The big question, of course, is whether that investment will pay off, and a big part of the answer will rest with a well-balanced risk pool. In other words, long-term financial stability means getting as many young and healthy people into the exchanges as possible.

$2 billion

The ACA sought to increase competition by supporting the creation of consumer co-ops, despite opposition from the insurance industry. By the end of last year, HHS had doled out roughly $2 billion in loans to nonprofit co-ops in 23 states, as part of its Consumer Operated and Oriented Plan (CO-OP). Backers of these co-ops had initially sought $10 billion, however, based on estimates of what would be required to ensure a higher likelihood of success.

Although preliminary evidence suggests that these newcomers may be helping to drive down costs in some states, a lack of additional funding has prevented other potential co-ops from receiving startup loans. The co-ops also are barred from using any federal money for marketing, cannot jointly negotiate contracts with doctors, and have limited access to the large employer insurance market—casting doubt on their continued viability.

$0

On Sep. 30, 2010, the U.S. comptroller general appointed 15 members to the National Health Care Workforce Commission, an acknowledgment that the country needs more guidance in how to address existing shortages—expected to widen—in doctors and other healthcare providers. The commission, authorized by the ACA, has never met, however. The act didn’t appropriate any money for it, and Congress has yet to approve any funding either, meaning that the commission’s members are legally barred from conducting any work.

—Bryn Nelson, PhD

Sometimes, numbers do tell a story. The Affordable Care Act has no shortage of them, and amid the densely packed provisions, regulations, pilots, demonstrations, fines, and other elements, a few numbers provide a glimpse of the intense wrangling that created both winners and losers in the healthcare reform effort.

One of the biggest numbers is also the mostly hotly contested: whether Obamacare will blow a hole in the nation’s deficit or lead to a trillion dollars or more in savings over the first two decades. In March 2010, the Congressional Budget Office predicted the latter, with savings of $143 billion through 2019 and a hazier guess of savings equivalent to 0.5% of gross domestic product—equal to $1 trillion or more—through the 2020s.

The problem? “That calculation reflects an assumption that the provisions of the legislation are enacted and remain unchanged throughout the next two decades, which is often not the case for major legislation,” the CBO wrote at the time. That prediction, at least, was spot on.

Amid the ongoing political back and forth, one point is often overlooked: Although still unsustainably high, per capita healthcare spending is now increasing at the lowest rate in decades. Robert Berenson, MD, an Institute Fellow at the Washington, D.C.-based Urban Institute, a nonpartisan think tank focused on social and economic policy, notes that the trend (starting in 2006) predated the recession. Likewise, it is occurring in Medicare, where most beneficiaries have first-dollar coverage. Instead of being a side effect of the sluggish economy, Dr. Berenson believes fundamental change is occurring on the provider side, and that the additional focus on reform may be making a difference.

Some analysts, he says, believe that providers are responding to the anticipation of change in the system and are beginning to change their own behavior accordingly.

“That means we have more time to get it right, in terms of wholesale change in how healthcare is delivered, and, for me, that’s a good thing,” he says.

A few other numbers of note:

$1.075 trillion

The state- and federal-run healthcare exchanges are expected to cost $1.075 trillion through 2023, according to the CBO. That eye-popping number includes spending for “high-risk pools, premium review activities, loans to consumer-operated and -oriented plans, and grants to states for the establishment of exchanges.”

The big question, of course, is whether that investment will pay off, and a big part of the answer will rest with a well-balanced risk pool. In other words, long-term financial stability means getting as many young and healthy people into the exchanges as possible.

$2 billion

The ACA sought to increase competition by supporting the creation of consumer co-ops, despite opposition from the insurance industry. By the end of last year, HHS had doled out roughly $2 billion in loans to nonprofit co-ops in 23 states, as part of its Consumer Operated and Oriented Plan (CO-OP). Backers of these co-ops had initially sought $10 billion, however, based on estimates of what would be required to ensure a higher likelihood of success.

Although preliminary evidence suggests that these newcomers may be helping to drive down costs in some states, a lack of additional funding has prevented other potential co-ops from receiving startup loans. The co-ops also are barred from using any federal money for marketing, cannot jointly negotiate contracts with doctors, and have limited access to the large employer insurance market—casting doubt on their continued viability.

$0

On Sep. 30, 2010, the U.S. comptroller general appointed 15 members to the National Health Care Workforce Commission, an acknowledgment that the country needs more guidance in how to address existing shortages—expected to widen—in doctors and other healthcare providers. The commission, authorized by the ACA, has never met, however. The act didn’t appropriate any money for it, and Congress has yet to approve any funding either, meaning that the commission’s members are legally barred from conducting any work.

—Bryn Nelson, PhD

Many of the buzzwords being bandied about in discussions of the Affordable Care Act, or ACA, already are familiar to hospitalists. HM providers regularly operate in an interdisciplinary environment and have been leading the charge in quality improvement initiatives over the past few years. But as the ACA kicks into high gear, hospitalists say it will ramp up the emphasis on tighter cost controls (especially identifying and eliminating waste), greater efficiency, and smoother transitions of care.

Supporters of the law have advanced the moral and ethical argument that everyone deserves at least basic healthcare.

“Money is not going to magically appear to pay for that,”

Dr. Hilger says. “So we’re all responsible for looking at what we do and where’s the waste in the system to help improve the care for the most at-risk patients.”

Some fundamentals of the work environment haven’t changed dramatically.

“Even before the ACA, there were core measures and coding and documentation requirements,” Dr. Hilger says. What’s different now, he says, is an added sense of urgency in scrutinizing quality and cost. That expectation may be especially acute for HM providers. “I think there’s a lot of pressure on hospitalists because organizations and hospitals are expecting us to be the primary care doctors in the hospital and to eliminate waste,” he says. That mandate dovetails with campaigns like Choosing Wisely that ask doctors to ponder the necessity of often overused or misused tests and procedures.

There’s going to be two steps forward, one step back, but the simple question is: Was it ever OK to have tens of millions of patients who had no insurance or were underinsured and were using the emergency room as their primary care? I think, no matter what your political affiliation, that, in general, the answer is no.

—Rick Hilger, MD, SFHM,medical director for care management, Regions Hospital, St. Paul, Minn., hospitalist, HealthPartners, member, SHM Public Policy Committee.

Another area of added emphasis is transitioning patients out of the hospital in a high-quality, low-cost way.

“That’s something we should have been doing 10 years ago,” Dr. Hilger says. “So that’s definitely a trend in the right direction that the ACA is helping to further.”

In effect, the heightened profile of ACOs, the rise of quality-based metrics, and the shift toward pay-for-performance models are extending the expectations around what happens to patients before, during, and after a hospital stay.

“We’re expected to not only provide excellent care to the patient while they’re in the hospital, but we’re expected to make sure that there is a good transition plan at discharge,” Dr. Hilger explains. “We’re expected to make sure that the patient has appropriate appointments lined up, that they’re getting appropriate services either at home or that we try to get them appropriately to a skilled nursing facility.”

Dr. Lenchus says a major objective of healthcare reform—at least in principle—is to devote more energy to preventive care to help ward off more expensive acute care.

“If we assume the hypothesis that the ACA really tries to keep people out of the hospital, that makes their time in the hospital that much more focused and concentrated, to the point where quality, cost control, and efficiency are really going to come into play,” he says.

And, at least initially, patients who have chronic conditions or were excluded from the healthcare system due to pre-existing illnesses or an inability to pay are likely to be clamoring for access the most. Consequently, those who do end up in the hospital will require more complex care.

“With respect to the workload, I believe we’ll see patients who are farther along in their disease process, in more acute, more dire need for healthcare,” Dr. Lenchus says.

Providers already accustomed to working in teams to improve quality and to communicating with a hospital’s chief medical officer and other C-suite executives over matters of cost will have a clear advantage.

“The ACA is not perfect, and it’s going to take time to figure out what works and what doesn’t, but what we have control over on a daily basis is to really focus on high-quality, low-cost, standardized best practices,” Dr. Hilger says.

What does that mean in practice? “Really work on perfecting or maximizing your transitions of care,” he says. “Really work with care management and social workers, and work with your hospital to try to develop relationships—if you haven’t already—with the primary care systems in your community.”

Bryn Nelson is a freelance medical writer in Seattle.

Many of the buzzwords being bandied about in discussions of the Affordable Care Act, or ACA, already are familiar to hospitalists. HM providers regularly operate in an interdisciplinary environment and have been leading the charge in quality improvement initiatives over the past few years. But as the ACA kicks into high gear, hospitalists say it will ramp up the emphasis on tighter cost controls (especially identifying and eliminating waste), greater efficiency, and smoother transitions of care.

Supporters of the law have advanced the moral and ethical argument that everyone deserves at least basic healthcare.

“Money is not going to magically appear to pay for that,”

Dr. Hilger says. “So we’re all responsible for looking at what we do and where’s the waste in the system to help improve the care for the most at-risk patients.”

Some fundamentals of the work environment haven’t changed dramatically.

“Even before the ACA, there were core measures and coding and documentation requirements,” Dr. Hilger says. What’s different now, he says, is an added sense of urgency in scrutinizing quality and cost. That expectation may be especially acute for HM providers. “I think there’s a lot of pressure on hospitalists because organizations and hospitals are expecting us to be the primary care doctors in the hospital and to eliminate waste,” he says. That mandate dovetails with campaigns like Choosing Wisely that ask doctors to ponder the necessity of often overused or misused tests and procedures.

There’s going to be two steps forward, one step back, but the simple question is: Was it ever OK to have tens of millions of patients who had no insurance or were underinsured and were using the emergency room as their primary care? I think, no matter what your political affiliation, that, in general, the answer is no.

—Rick Hilger, MD, SFHM,medical director for care management, Regions Hospital, St. Paul, Minn., hospitalist, HealthPartners, member, SHM Public Policy Committee.

Another area of added emphasis is transitioning patients out of the hospital in a high-quality, low-cost way.

“That’s something we should have been doing 10 years ago,” Dr. Hilger says. “So that’s definitely a trend in the right direction that the ACA is helping to further.”

In effect, the heightened profile of ACOs, the rise of quality-based metrics, and the shift toward pay-for-performance models are extending the expectations around what happens to patients before, during, and after a hospital stay.

“We’re expected to not only provide excellent care to the patient while they’re in the hospital, but we’re expected to make sure that there is a good transition plan at discharge,” Dr. Hilger explains. “We’re expected to make sure that the patient has appropriate appointments lined up, that they’re getting appropriate services either at home or that we try to get them appropriately to a skilled nursing facility.”

Dr. Lenchus says a major objective of healthcare reform—at least in principle—is to devote more energy to preventive care to help ward off more expensive acute care.

“If we assume the hypothesis that the ACA really tries to keep people out of the hospital, that makes their time in the hospital that much more focused and concentrated, to the point where quality, cost control, and efficiency are really going to come into play,” he says.

And, at least initially, patients who have chronic conditions or were excluded from the healthcare system due to pre-existing illnesses or an inability to pay are likely to be clamoring for access the most. Consequently, those who do end up in the hospital will require more complex care.

“With respect to the workload, I believe we’ll see patients who are farther along in their disease process, in more acute, more dire need for healthcare,” Dr. Lenchus says.

Providers already accustomed to working in teams to improve quality and to communicating with a hospital’s chief medical officer and other C-suite executives over matters of cost will have a clear advantage.

“The ACA is not perfect, and it’s going to take time to figure out what works and what doesn’t, but what we have control over on a daily basis is to really focus on high-quality, low-cost, standardized best practices,” Dr. Hilger says.

What does that mean in practice? “Really work on perfecting or maximizing your transitions of care,” he says. “Really work with care management and social workers, and work with your hospital to try to develop relationships—if you haven’t already—with the primary care systems in your community.”

Bryn Nelson is a freelance medical writer in Seattle.

Many of the buzzwords being bandied about in discussions of the Affordable Care Act, or ACA, already are familiar to hospitalists. HM providers regularly operate in an interdisciplinary environment and have been leading the charge in quality improvement initiatives over the past few years. But as the ACA kicks into high gear, hospitalists say it will ramp up the emphasis on tighter cost controls (especially identifying and eliminating waste), greater efficiency, and smoother transitions of care.

Supporters of the law have advanced the moral and ethical argument that everyone deserves at least basic healthcare.

“Money is not going to magically appear to pay for that,”

Dr. Hilger says. “So we’re all responsible for looking at what we do and where’s the waste in the system to help improve the care for the most at-risk patients.”

Some fundamentals of the work environment haven’t changed dramatically.

“Even before the ACA, there were core measures and coding and documentation requirements,” Dr. Hilger says. What’s different now, he says, is an added sense of urgency in scrutinizing quality and cost. That expectation may be especially acute for HM providers. “I think there’s a lot of pressure on hospitalists because organizations and hospitals are expecting us to be the primary care doctors in the hospital and to eliminate waste,” he says. That mandate dovetails with campaigns like Choosing Wisely that ask doctors to ponder the necessity of often overused or misused tests and procedures.

There’s going to be two steps forward, one step back, but the simple question is: Was it ever OK to have tens of millions of patients who had no insurance or were underinsured and were using the emergency room as their primary care? I think, no matter what your political affiliation, that, in general, the answer is no.

—Rick Hilger, MD, SFHM,medical director for care management, Regions Hospital, St. Paul, Minn., hospitalist, HealthPartners, member, SHM Public Policy Committee.

Another area of added emphasis is transitioning patients out of the hospital in a high-quality, low-cost way.

“That’s something we should have been doing 10 years ago,” Dr. Hilger says. “So that’s definitely a trend in the right direction that the ACA is helping to further.”

In effect, the heightened profile of ACOs, the rise of quality-based metrics, and the shift toward pay-for-performance models are extending the expectations around what happens to patients before, during, and after a hospital stay.

“We’re expected to not only provide excellent care to the patient while they’re in the hospital, but we’re expected to make sure that there is a good transition plan at discharge,” Dr. Hilger explains. “We’re expected to make sure that the patient has appropriate appointments lined up, that they’re getting appropriate services either at home or that we try to get them appropriately to a skilled nursing facility.”

Dr. Lenchus says a major objective of healthcare reform—at least in principle—is to devote more energy to preventive care to help ward off more expensive acute care.

“If we assume the hypothesis that the ACA really tries to keep people out of the hospital, that makes their time in the hospital that much more focused and concentrated, to the point where quality, cost control, and efficiency are really going to come into play,” he says.

And, at least initially, patients who have chronic conditions or were excluded from the healthcare system due to pre-existing illnesses or an inability to pay are likely to be clamoring for access the most. Consequently, those who do end up in the hospital will require more complex care.

“With respect to the workload, I believe we’ll see patients who are farther along in their disease process, in more acute, more dire need for healthcare,” Dr. Lenchus says.

Providers already accustomed to working in teams to improve quality and to communicating with a hospital’s chief medical officer and other C-suite executives over matters of cost will have a clear advantage.

“The ACA is not perfect, and it’s going to take time to figure out what works and what doesn’t, but what we have control over on a daily basis is to really focus on high-quality, low-cost, standardized best practices,” Dr. Hilger says.

What does that mean in practice? “Really work on perfecting or maximizing your transitions of care,” he says. “Really work with care management and social workers, and work with your hospital to try to develop relationships—if you haven’t already—with the primary care systems in your community.”

Bryn Nelson is a freelance medical writer in Seattle.

Dr. O’Malley

It has survived a bitterly divided Congress and a polarized public, a narrow Supreme Court ruling, and a 16-day government shutdown triggered by an effort to defund or repeal it. Hailed by some as the most significant healthcare reform in a half-century, it is also roundly scorned by others as an ill-advised debacle.

With some of its most hotly contested provisions now taking effect, the Affordable Care Act—or Obamacare, as both backers and detractors now call it—has been the object of admiration and animosity, of optimism and consternation. Its supporters have pointed to the promise of unprecedented access to healthcare for millions, while its critics have pointed to the trickle of consumers able to access the main web portal during an error-plagued rollout.

Beyond the heated rhetoric, however, what will the complicated and quickly evolving elements of Obamacare actually mean for hospitalists and for healthcare access, affordability, capacity, and delivery? In the short term, analysts say so much change is happening all at once that it’s nearly impossible to predict how it might turn out.

“Everyone’s kind of holding their breath to see what happens,” says Ann O’Malley, MD, MPH, a senior fellow at the Washington, D.C.-based Center for Studying Health System Change.

One thing is certain: more reliance on hospital-based providers.

Dr. O’Malley

“I think there are a lot of things on a hospitalist’s plate right now. And hospitals, because of the cost pressures, are definitely looking to us to lead the way through this uncertain time,” says Rick Hilger, MD, SFHM, medical director for care management at Regions Hospital in St. Paul, Minn., and a hospitalist for HealthPartners.

Amid the upheaval, experts are seeing the signs of a few major trends. In the short term, one emerging theme is considerable geographical variation in consumer access and costs, and in pressure on providers.

“How this is going to feel will depend, to a great extent, on where you live,” says Leighton Ku, PhD, MPH, director of the Center for Health Policy Research at George Washington University School of Public Health and Health Services in Washington, D.C.

Dr. Ku

Analysts also have seen hints of more universal changes, including an accelerated trend toward the consolidation of provider groups, an added emphasis on team-based care, and significant momentum toward a pay-for-performance delivery model.

An Uneven Exchange

One of the law’s most visible and controversial elements, the health insurance exchange or marketplace, got off to a rocky start Oct. 1, 2013, when computer glitches hobbled the main healthcare.gov portal for 36 state exchanges and plagued many state-run sites as well.

While some state-run exchanges have generally earned high marks, others have struggled. Analysts are most worried about the balkiness of the main web-based portal, through which the majority of enrollees will have to pass. While older and sicker patients are generally more motivated to keep trying, the same isn’t necessarily true for younger and healthier people whose participation will be vital to help balance each state’s risk pool. Analysts sometimes call these people, “young invincibles.” Because they generally seek out care far less often than older consumers, their lower medical costs can help compensate for higher expenditures elsewhere.

If too few sign up, however, a state’s risk pool may be imbalanced toward costlier patients, causing insurance premiums to rise and creating a vicious cycle that destabilizes the market and makes more expensive insurance less attractive to younger people. Economists say the carrot-and-stick approach—offering subsidies to help lower-income people pay for premiums and gradually increasing financial penalties for those who choose not to buy any coverage—is likely to help. Nevertheless, supporters are nervous that malfunctioning exchange sites could cause would-be enrollees to delay or drop out, and, at the end of 2013, a worried Obama administration was scrambling to address the cascade of glitches.

Because the health insurance exchanges were highly controversial already, says Dr. Ku, who sits on the board of the Washington, D.C. Health Benefits Exchange Authority, every problem is likely to be magnified by critics. Although he doesn’t expect “huge changes” in physician payment rates from plans in the exchanges, he says varying degrees of competition could drive down insurers’ prices in some markets.

Doctors also are likely to encounter plenty of confusion among the newly insured, and Dr. Ku hopes educational sessions will help healthcare professionals take more of a leading role in helping patients navigate an often bewildering system.

“One of the most important things that a hospital can do to help in the beginning is to help on the enrollment end of things,” he says. “Help patients who don’t quite understand how to get in, how to use these systems.”

It’s too early to say whether the exchanges can still meet the Congressional Budget Office’s prediction of 7 million enrollees by the end of the 2014 enrollment period (and 13 million by 2015). But analysts say the composition of the risk pool—something that should be clearer this spring—may provide a glimpse into the ACA’s long-term financial viability.

Instead of a consistent pattern across the country, the exchanges will be shaped by local market forces, such as the number of competitors and the extent to which cheaper plans will try to limit access to providers. To minimize their costs, some exchange-based plans are promising in-network hospitals higher patient volumes in exchange for discounted reimbursements. Other hospitals now find themselves excluded from most private plans in favor of cheaper options.

In exchange for lower premiums, some of these insurers are offering “skinny networks” that give consumers more limited provider options.

“A primary objective in the marketplace is to offer the cheapest plan possible, and to do that the insurers are going to look at who are the least expensive providers,” says Christiane Mitchell, director of federal affairs for the Association of American Medical Colleges. Not surprisingly, some of the costliest providers tend to take care of sicker or higher-risk patients.

“It’s a very, very strong concern, and it’s one that we have been very vocal on since the enactment of the Affordable Care Act,” Mitchell says. The association also has expressed concern that lower-income patients buying into the cheapest plans may not have access to the specialty services they need the most. That possibility, she says, increases the importance of navigators helping the newly insured pick out the best plans.

A Question of Access

Another big question is how the healthcare system will accommodate the influx of newly insured. Because hospitals already have been the safety net for many patients lacking access to preventive and primary care, urgent and specialty care may go through a bigger adjustment period, says Dr. Hilger, who sits on SHM’s Public Policy Committee.

The growing provider shortage certainly won’t help. By 2015, the AAMC predicts a shortfall of 63,000 doctors, almost evenly split between primary and specialty care. By 2025, that number is expected to more than double.

Mitchell says the gap between supply and demand is worsening due to the sheer number of baby boomers entering Medicare. At the same time, she says, one in three doctors in the U.S. is now over the age of 60 and nearing retirement age. Whether through Medicaid or the marketplace, the ACA’s coverage expansion will exacerbate the shortages. “It’s not to the level of the boomers entering Medicare, but it certainly is having a major impact on access issues and exacerbating the shortage, again, across specialties,” she says.

Other analysts say the extent of the capacity problem will depend in large part on location.

“The truth is that the extent to which there are enough doctors or enough hospital beds is largely a function of geography,” Dr. Ku says. “So, if you’re in an urban area with lots of teaching hospitals, you probably have enough doctors and you probably have enough hospital beds. If, on the other hand, you’re in a poor, rural area, chances are you don’t.”

As both insurance and demand for healthcare expand, those areas that were having problems already “are going to be stretched even more,” Dr. Ku says.

Meeting demand also means training more doctors, and Mitchell worries about a pipeline that already is underfunded. Although medical school enrollment is at a record high, federal support for residency training has been frozen since 1997, meaning that the funded residency slots may not be sufficient to accommodate future graduates. Further declines in the clinical income that subsidizes training would place additional pressure on the educational mission of teaching hospitals, Mitchell says.

Joshua Lenchus, DO, RPh, FACP, SFHM, associate professor of clinical medicine in the division of hospital medicine at the University of Miami, says existing doctor deficits, the ACA’s new demands, and the growing medical training gap could swirl into a “perfect storm” of access problems. Longer delays in accessing primary and specialty care, in turn, could prevent timely interventions earlier during the course of a disease or condition.

“What it’s going to mean for hospitalists is that we’re going to see—over the short-term, maybe even the next three to five years—a real impact on when patients present, in terms of the acuity of their disease,” Dr. Lenchus says. That means sicker patients in the hospital.

Given the massive changes, observers like Mitchell and Dr. Hilger acknowledge that ironing out the rough spots will take time.

“There’s going to be two steps forward, one step back, but the simple question is: Was it ever OK to have tens of millions of patients who had no insurance or were underinsured and were using the emergency room as their primary care?” Dr. Hilger says. “I think, no matter what your political affiliation, that, in general, the answer is no.”

What it’s going to mean for hospitalists is that we’re going to see—over the short-term, maybe even the next three to five years—a real impact on when patients present, in terms of the acuity of their disease. That means sicker patients in the hospital.

—Joshua Lenchus, DO, RPh, FACP, SFHM, associate professor of clinical medicine, division of hospital medicine, University of Miami, member, SHM Public Policy Committee.

Costs All Over the Map

One of the plan’s biggest goals and part of its name—affordability for those patients—also seems to vary considerably by geography. A recent analysis by The New York Times, for example, found that 58% of all counties served by the federal-run exchanges offer plans from only one or two insurance carriers. The relative lack of competition in many markets has created some huge cost disparities in premiums between neighboring states, and even neighboring counties.

With so many factors influencing costs, both proponents and opponents have found fodder to bolster their case that the law is either making insurance more affordable or sharply increasing premiums. One important consideration, Dr. Ku says, is that all plans must now include 10 “essential health benefits,” such as maternity care and medications, for example, and cannot allow gender to be a rating factor. As a result, he says, the cheapest plans for a relatively healthy young man may cost more now, while costs for a woman or an older person with a chronic condition like diabetes may go down.

Although the new mandates were designed to improve insurance standards, they sparked another firestorm when millions of Americans began receiving policy cancellation notices in 2013. Because many private insurance plans sold to individuals no longer met the ACA’s minimum requirements, insurers began dropping those plans or requiring enrollees to switch to other, often more expensive, ones. In November, in an effort to stem the mass cancellations, President Barack Obama bowed to mounting political pressure and announced a reprieve that allows insurance companies to renew existing policies for another year. That attempted fix has not been so straightforward, however. Many insurers were reluctant to reissue cancelled policies, and multiple states, which have the authority to regulate insurance sold within their borders, declined the administration’s request.

If, in fact, the exchanges offer good insurance products that the public begins to accept and find that they have good information to make choices, it could affect the prevalence of employer-based insurance.

—Robert Berenson, MD, senior fellow, Urban Institute, Washington, D.C.

The Long View

Despite the intense focus on the first few months of health insurance enrollment, it may take several years before the markets begin to settle and other insurers waiting on the sidelines decide whether to participate. If they eventually succeed, the ACA exchanges could have several long-term consequences.

“If, in fact, the exchanges offer good insurance products that the public begins to accept and find that they have good information to make choices, it could affect the prevalence of employer-based insurance,” says Robert Berenson, MD, a senior fellow at the Washington, D.C.-based Urban Institute, a nonpartisan think tank focused on social and economic policy. Over many years, employers could begin moving their employees into exchanges rather than providing direct healthcare benefits.

If they prove viable, the exchanges also may help accelerate the trend toward more consolidation of physician practices or increase pressure to align with larger entities. Despite concerns over skinnier networks, for example, the more tightly controlled access to providers under certain plans dovetails with the ACA’s heightened emphasis on more integrated accountable care organizations (ACOs).

In fact, ACOs and other lower-profile provisions that enjoy more bipartisan support could ultimately play key roles in reshaping how healthcare is delivered in the U.S. Many of these reform efforts have been launched as pilots or demonstration projects. Salt Lake City-based healthcare consulting firm Leavitt Partners tallied nearly 500 ACOs through the end of July 2013, more than double the total in June 2012.

Other Obamacare provisions are levying fines based on excessive hospital-acquired conditions or readmissions and adjusting reimbursements based on e-prescribing, the Physician Quality Reporting System (PQRS), value-based purchasing, meaningful use of electronic health records, and other mandates.

“The overall theme is that the ACA is speeding up the move away from fee-for-service payment toward new payment methodologies that are going to be increasingly based on quality measures,” Dr. O’Malley says. “All of these are basically efforts to shift incentives away from rewarding volume of services toward value and quality of care for patients. And the crux of all of them is to try to get physicians to work together, not only with other specialists and their primary care colleagues, but also with other inter-professional members of their team.”

For hospitalists, it means relying more on nurses, physician assistants, and other support staff.

“In a collaborative agreement, where it’s a physician-led healthcare team, I think non-physician healthcare providers could help to support the physician hospitalists,” Dr. Lenchus says.

That extra help may be essential.

“I do think the workload will increase, and not just because we’ll have more people clamoring for healthcare and more patients who are sicker—remember, there are no more pre-existing conditions,” Dr. Lenchus says. “The other piece to this that goes outside the patient-physician interaction is that there’s a lot of additional regulations and administrative burdens, if you will, as individual hospitalists and as hospitals on the whole.”

The need to share resources to cut down on doctors’ workloads, Dr. O’Malley says, may be yet another factor in the accelerated rate of practice consolidation.

“There’s pressure among docs not just to function as teams but to consolidate among themselves either through physicians’ organizations like IPAs [independent practice associations] or becoming employees of hospitals,” she says. “That’s where you get economies of scale and shared infrastructure to do a lot of the things that the ACA is requiring of them.”

Consolidation or not, she sees plenty of potential for increased efficiency. Some medical groups may need to hire more support staff, whereas others may simply require more coordination and delegation among existing personnel to lighten the load and focus on priorities. The trick, Dr. Hilger says, is finding the right balance amid the dramatic change.

“Bottom line, it goes back to the triple aim that hospitalists should be aiming for: high quality, low-cost, patient-centered care,” he says. “I think the challenge over the next 10 years is how to find the sweet spot between all of those.”

Bryn Nelson is a freelance medical writer in Seattle.

Dr. O’Malley

It has survived a bitterly divided Congress and a polarized public, a narrow Supreme Court ruling, and a 16-day government shutdown triggered by an effort to defund or repeal it. Hailed by some as the most significant healthcare reform in a half-century, it is also roundly scorned by others as an ill-advised debacle.

With some of its most hotly contested provisions now taking effect, the Affordable Care Act—or Obamacare, as both backers and detractors now call it—has been the object of admiration and animosity, of optimism and consternation. Its supporters have pointed to the promise of unprecedented access to healthcare for millions, while its critics have pointed to the trickle of consumers able to access the main web portal during an error-plagued rollout.

Beyond the heated rhetoric, however, what will the complicated and quickly evolving elements of Obamacare actually mean for hospitalists and for healthcare access, affordability, capacity, and delivery? In the short term, analysts say so much change is happening all at once that it’s nearly impossible to predict how it might turn out.

“Everyone’s kind of holding their breath to see what happens,” says Ann O’Malley, MD, MPH, a senior fellow at the Washington, D.C.-based Center for Studying Health System Change.

One thing is certain: more reliance on hospital-based providers.

Dr. O’Malley

“I think there are a lot of things on a hospitalist’s plate right now. And hospitals, because of the cost pressures, are definitely looking to us to lead the way through this uncertain time,” says Rick Hilger, MD, SFHM, medical director for care management at Regions Hospital in St. Paul, Minn., and a hospitalist for HealthPartners.

Amid the upheaval, experts are seeing the signs of a few major trends. In the short term, one emerging theme is considerable geographical variation in consumer access and costs, and in pressure on providers.

“How this is going to feel will depend, to a great extent, on where you live,” says Leighton Ku, PhD, MPH, director of the Center for Health Policy Research at George Washington University School of Public Health and Health Services in Washington, D.C.

Dr. Ku

Analysts also have seen hints of more universal changes, including an accelerated trend toward the consolidation of provider groups, an added emphasis on team-based care, and significant momentum toward a pay-for-performance delivery model.

An Uneven Exchange

One of the law’s most visible and controversial elements, the health insurance exchange or marketplace, got off to a rocky start Oct. 1, 2013, when computer glitches hobbled the main healthcare.gov portal for 36 state exchanges and plagued many state-run sites as well.

While some state-run exchanges have generally earned high marks, others have struggled. Analysts are most worried about the balkiness of the main web-based portal, through which the majority of enrollees will have to pass. While older and sicker patients are generally more motivated to keep trying, the same isn’t necessarily true for younger and healthier people whose participation will be vital to help balance each state’s risk pool. Analysts sometimes call these people, “young invincibles.” Because they generally seek out care far less often than older consumers, their lower medical costs can help compensate for higher expenditures elsewhere.

If too few sign up, however, a state’s risk pool may be imbalanced toward costlier patients, causing insurance premiums to rise and creating a vicious cycle that destabilizes the market and makes more expensive insurance less attractive to younger people. Economists say the carrot-and-stick approach—offering subsidies to help lower-income people pay for premiums and gradually increasing financial penalties for those who choose not to buy any coverage—is likely to help. Nevertheless, supporters are nervous that malfunctioning exchange sites could cause would-be enrollees to delay or drop out, and, at the end of 2013, a worried Obama administration was scrambling to address the cascade of glitches.

Because the health insurance exchanges were highly controversial already, says Dr. Ku, who sits on the board of the Washington, D.C. Health Benefits Exchange Authority, every problem is likely to be magnified by critics. Although he doesn’t expect “huge changes” in physician payment rates from plans in the exchanges, he says varying degrees of competition could drive down insurers’ prices in some markets.

Doctors also are likely to encounter plenty of confusion among the newly insured, and Dr. Ku hopes educational sessions will help healthcare professionals take more of a leading role in helping patients navigate an often bewildering system.

“One of the most important things that a hospital can do to help in the beginning is to help on the enrollment end of things,” he says. “Help patients who don’t quite understand how to get in, how to use these systems.”

It’s too early to say whether the exchanges can still meet the Congressional Budget Office’s prediction of 7 million enrollees by the end of the 2014 enrollment period (and 13 million by 2015). But analysts say the composition of the risk pool—something that should be clearer this spring—may provide a glimpse into the ACA’s long-term financial viability.

Instead of a consistent pattern across the country, the exchanges will be shaped by local market forces, such as the number of competitors and the extent to which cheaper plans will try to limit access to providers. To minimize their costs, some exchange-based plans are promising in-network hospitals higher patient volumes in exchange for discounted reimbursements. Other hospitals now find themselves excluded from most private plans in favor of cheaper options.

In exchange for lower premiums, some of these insurers are offering “skinny networks” that give consumers more limited provider options.

“A primary objective in the marketplace is to offer the cheapest plan possible, and to do that the insurers are going to look at who are the least expensive providers,” says Christiane Mitchell, director of federal affairs for the Association of American Medical Colleges. Not surprisingly, some of the costliest providers tend to take care of sicker or higher-risk patients.

“It’s a very, very strong concern, and it’s one that we have been very vocal on since the enactment of the Affordable Care Act,” Mitchell says. The association also has expressed concern that lower-income patients buying into the cheapest plans may not have access to the specialty services they need the most. That possibility, she says, increases the importance of navigators helping the newly insured pick out the best plans.

A Question of Access

Another big question is how the healthcare system will accommodate the influx of newly insured. Because hospitals already have been the safety net for many patients lacking access to preventive and primary care, urgent and specialty care may go through a bigger adjustment period, says Dr. Hilger, who sits on SHM’s Public Policy Committee.

The growing provider shortage certainly won’t help. By 2015, the AAMC predicts a shortfall of 63,000 doctors, almost evenly split between primary and specialty care. By 2025, that number is expected to more than double.

Mitchell says the gap between supply and demand is worsening due to the sheer number of baby boomers entering Medicare. At the same time, she says, one in three doctors in the U.S. is now over the age of 60 and nearing retirement age. Whether through Medicaid or the marketplace, the ACA’s coverage expansion will exacerbate the shortages. “It’s not to the level of the boomers entering Medicare, but it certainly is having a major impact on access issues and exacerbating the shortage, again, across specialties,” she says.

Other analysts say the extent of the capacity problem will depend in large part on location.

“The truth is that the extent to which there are enough doctors or enough hospital beds is largely a function of geography,” Dr. Ku says. “So, if you’re in an urban area with lots of teaching hospitals, you probably have enough doctors and you probably have enough hospital beds. If, on the other hand, you’re in a poor, rural area, chances are you don’t.”

As both insurance and demand for healthcare expand, those areas that were having problems already “are going to be stretched even more,” Dr. Ku says.

Meeting demand also means training more doctors, and Mitchell worries about a pipeline that already is underfunded. Although medical school enrollment is at a record high, federal support for residency training has been frozen since 1997, meaning that the funded residency slots may not be sufficient to accommodate future graduates. Further declines in the clinical income that subsidizes training would place additional pressure on the educational mission of teaching hospitals, Mitchell says.

Joshua Lenchus, DO, RPh, FACP, SFHM, associate professor of clinical medicine in the division of hospital medicine at the University of Miami, says existing doctor deficits, the ACA’s new demands, and the growing medical training gap could swirl into a “perfect storm” of access problems. Longer delays in accessing primary and specialty care, in turn, could prevent timely interventions earlier during the course of a disease or condition.

“What it’s going to mean for hospitalists is that we’re going to see—over the short-term, maybe even the next three to five years—a real impact on when patients present, in terms of the acuity of their disease,” Dr. Lenchus says. That means sicker patients in the hospital.

Given the massive changes, observers like Mitchell and Dr. Hilger acknowledge that ironing out the rough spots will take time.

“There’s going to be two steps forward, one step back, but the simple question is: Was it ever OK to have tens of millions of patients who had no insurance or were underinsured and were using the emergency room as their primary care?” Dr. Hilger says. “I think, no matter what your political affiliation, that, in general, the answer is no.”

What it’s going to mean for hospitalists is that we’re going to see—over the short-term, maybe even the next three to five years—a real impact on when patients present, in terms of the acuity of their disease. That means sicker patients in the hospital.

—Joshua Lenchus, DO, RPh, FACP, SFHM, associate professor of clinical medicine, division of hospital medicine, University of Miami, member, SHM Public Policy Committee.

Costs All Over the Map

One of the plan’s biggest goals and part of its name—affordability for those patients—also seems to vary considerably by geography. A recent analysis by The New York Times, for example, found that 58% of all counties served by the federal-run exchanges offer plans from only one or two insurance carriers. The relative lack of competition in many markets has created some huge cost disparities in premiums between neighboring states, and even neighboring counties.

With so many factors influencing costs, both proponents and opponents have found fodder to bolster their case that the law is either making insurance more affordable or sharply increasing premiums. One important consideration, Dr. Ku says, is that all plans must now include 10 “essential health benefits,” such as maternity care and medications, for example, and cannot allow gender to be a rating factor. As a result, he says, the cheapest plans for a relatively healthy young man may cost more now, while costs for a woman or an older person with a chronic condition like diabetes may go down.

Although the new mandates were designed to improve insurance standards, they sparked another firestorm when millions of Americans began receiving policy cancellation notices in 2013. Because many private insurance plans sold to individuals no longer met the ACA’s minimum requirements, insurers began dropping those plans or requiring enrollees to switch to other, often more expensive, ones. In November, in an effort to stem the mass cancellations, President Barack Obama bowed to mounting political pressure and announced a reprieve that allows insurance companies to renew existing policies for another year. That attempted fix has not been so straightforward, however. Many insurers were reluctant to reissue cancelled policies, and multiple states, which have the authority to regulate insurance sold within their borders, declined the administration’s request.

If, in fact, the exchanges offer good insurance products that the public begins to accept and find that they have good information to make choices, it could affect the prevalence of employer-based insurance.

—Robert Berenson, MD, senior fellow, Urban Institute, Washington, D.C.

The Long View

Despite the intense focus on the first few months of health insurance enrollment, it may take several years before the markets begin to settle and other insurers waiting on the sidelines decide whether to participate. If they eventually succeed, the ACA exchanges could have several long-term consequences.

“If, in fact, the exchanges offer good insurance products that the public begins to accept and find that they have good information to make choices, it could affect the prevalence of employer-based insurance,” says Robert Berenson, MD, a senior fellow at the Washington, D.C.-based Urban Institute, a nonpartisan think tank focused on social and economic policy. Over many years, employers could begin moving their employees into exchanges rather than providing direct healthcare benefits.

If they prove viable, the exchanges also may help accelerate the trend toward more consolidation of physician practices or increase pressure to align with larger entities. Despite concerns over skinnier networks, for example, the more tightly controlled access to providers under certain plans dovetails with the ACA’s heightened emphasis on more integrated accountable care organizations (ACOs).

In fact, ACOs and other lower-profile provisions that enjoy more bipartisan support could ultimately play key roles in reshaping how healthcare is delivered in the U.S. Many of these reform efforts have been launched as pilots or demonstration projects. Salt Lake City-based healthcare consulting firm Leavitt Partners tallied nearly 500 ACOs through the end of July 2013, more than double the total in June 2012.

Other Obamacare provisions are levying fines based on excessive hospital-acquired conditions or readmissions and adjusting reimbursements based on e-prescribing, the Physician Quality Reporting System (PQRS), value-based purchasing, meaningful use of electronic health records, and other mandates.

“The overall theme is that the ACA is speeding up the move away from fee-for-service payment toward new payment methodologies that are going to be increasingly based on quality measures,” Dr. O’Malley says. “All of these are basically efforts to shift incentives away from rewarding volume of services toward value and quality of care for patients. And the crux of all of them is to try to get physicians to work together, not only with other specialists and their primary care colleagues, but also with other inter-professional members of their team.”

For hospitalists, it means relying more on nurses, physician assistants, and other support staff.

“In a collaborative agreement, where it’s a physician-led healthcare team, I think non-physician healthcare providers could help to support the physician hospitalists,” Dr. Lenchus says.

That extra help may be essential.

“I do think the workload will increase, and not just because we’ll have more people clamoring for healthcare and more patients who are sicker—remember, there are no more pre-existing conditions,” Dr. Lenchus says. “The other piece to this that goes outside the patient-physician interaction is that there’s a lot of additional regulations and administrative burdens, if you will, as individual hospitalists and as hospitals on the whole.”

The need to share resources to cut down on doctors’ workloads, Dr. O’Malley says, may be yet another factor in the accelerated rate of practice consolidation.

“There’s pressure among docs not just to function as teams but to consolidate among themselves either through physicians’ organizations like IPAs [independent practice associations] or becoming employees of hospitals,” she says. “That’s where you get economies of scale and shared infrastructure to do a lot of the things that the ACA is requiring of them.”

Consolidation or not, she sees plenty of potential for increased efficiency. Some medical groups may need to hire more support staff, whereas others may simply require more coordination and delegation among existing personnel to lighten the load and focus on priorities. The trick, Dr. Hilger says, is finding the right balance amid the dramatic change.

“Bottom line, it goes back to the triple aim that hospitalists should be aiming for: high quality, low-cost, patient-centered care,” he says. “I think the challenge over the next 10 years is how to find the sweet spot between all of those.”

Bryn Nelson is a freelance medical writer in Seattle.

Dr. O’Malley

It has survived a bitterly divided Congress and a polarized public, a narrow Supreme Court ruling, and a 16-day government shutdown triggered by an effort to defund or repeal it. Hailed by some as the most significant healthcare reform in a half-century, it is also roundly scorned by others as an ill-advised debacle.

With some of its most hotly contested provisions now taking effect, the Affordable Care Act—or Obamacare, as both backers and detractors now call it—has been the object of admiration and animosity, of optimism and consternation. Its supporters have pointed to the promise of unprecedented access to healthcare for millions, while its critics have pointed to the trickle of consumers able to access the main web portal during an error-plagued rollout.

Beyond the heated rhetoric, however, what will the complicated and quickly evolving elements of Obamacare actually mean for hospitalists and for healthcare access, affordability, capacity, and delivery? In the short term, analysts say so much change is happening all at once that it’s nearly impossible to predict how it might turn out.

“Everyone’s kind of holding their breath to see what happens,” says Ann O’Malley, MD, MPH, a senior fellow at the Washington, D.C.-based Center for Studying Health System Change.

One thing is certain: more reliance on hospital-based providers.

Dr. O’Malley

“I think there are a lot of things on a hospitalist’s plate right now. And hospitals, because of the cost pressures, are definitely looking to us to lead the way through this uncertain time,” says Rick Hilger, MD, SFHM, medical director for care management at Regions Hospital in St. Paul, Minn., and a hospitalist for HealthPartners.

Amid the upheaval, experts are seeing the signs of a few major trends. In the short term, one emerging theme is considerable geographical variation in consumer access and costs, and in pressure on providers.

“How this is going to feel will depend, to a great extent, on where you live,” says Leighton Ku, PhD, MPH, director of the Center for Health Policy Research at George Washington University School of Public Health and Health Services in Washington, D.C.

Dr. Ku

Analysts also have seen hints of more universal changes, including an accelerated trend toward the consolidation of provider groups, an added emphasis on team-based care, and significant momentum toward a pay-for-performance delivery model.

An Uneven Exchange

One of the law’s most visible and controversial elements, the health insurance exchange or marketplace, got off to a rocky start Oct. 1, 2013, when computer glitches hobbled the main healthcare.gov portal for 36 state exchanges and plagued many state-run sites as well.

While some state-run exchanges have generally earned high marks, others have struggled. Analysts are most worried about the balkiness of the main web-based portal, through which the majority of enrollees will have to pass. While older and sicker patients are generally more motivated to keep trying, the same isn’t necessarily true for younger and healthier people whose participation will be vital to help balance each state’s risk pool. Analysts sometimes call these people, “young invincibles.” Because they generally seek out care far less often than older consumers, their lower medical costs can help compensate for higher expenditures elsewhere.

If too few sign up, however, a state’s risk pool may be imbalanced toward costlier patients, causing insurance premiums to rise and creating a vicious cycle that destabilizes the market and makes more expensive insurance less attractive to younger people. Economists say the carrot-and-stick approach—offering subsidies to help lower-income people pay for premiums and gradually increasing financial penalties for those who choose not to buy any coverage—is likely to help. Nevertheless, supporters are nervous that malfunctioning exchange sites could cause would-be enrollees to delay or drop out, and, at the end of 2013, a worried Obama administration was scrambling to address the cascade of glitches.

Because the health insurance exchanges were highly controversial already, says Dr. Ku, who sits on the board of the Washington, D.C. Health Benefits Exchange Authority, every problem is likely to be magnified by critics. Although he doesn’t expect “huge changes” in physician payment rates from plans in the exchanges, he says varying degrees of competition could drive down insurers’ prices in some markets.

Doctors also are likely to encounter plenty of confusion among the newly insured, and Dr. Ku hopes educational sessions will help healthcare professionals take more of a leading role in helping patients navigate an often bewildering system.

“One of the most important things that a hospital can do to help in the beginning is to help on the enrollment end of things,” he says. “Help patients who don’t quite understand how to get in, how to use these systems.”

It’s too early to say whether the exchanges can still meet the Congressional Budget Office’s prediction of 7 million enrollees by the end of the 2014 enrollment period (and 13 million by 2015). But analysts say the composition of the risk pool—something that should be clearer this spring—may provide a glimpse into the ACA’s long-term financial viability.

Instead of a consistent pattern across the country, the exchanges will be shaped by local market forces, such as the number of competitors and the extent to which cheaper plans will try to limit access to providers. To minimize their costs, some exchange-based plans are promising in-network hospitals higher patient volumes in exchange for discounted reimbursements. Other hospitals now find themselves excluded from most private plans in favor of cheaper options.

In exchange for lower premiums, some of these insurers are offering “skinny networks” that give consumers more limited provider options.

“A primary objective in the marketplace is to offer the cheapest plan possible, and to do that the insurers are going to look at who are the least expensive providers,” says Christiane Mitchell, director of federal affairs for the Association of American Medical Colleges. Not surprisingly, some of the costliest providers tend to take care of sicker or higher-risk patients.

“It’s a very, very strong concern, and it’s one that we have been very vocal on since the enactment of the Affordable Care Act,” Mitchell says. The association also has expressed concern that lower-income patients buying into the cheapest plans may not have access to the specialty services they need the most. That possibility, she says, increases the importance of navigators helping the newly insured pick out the best plans.

A Question of Access

Another big question is how the healthcare system will accommodate the influx of newly insured. Because hospitals already have been the safety net for many patients lacking access to preventive and primary care, urgent and specialty care may go through a bigger adjustment period, says Dr. Hilger, who sits on SHM’s Public Policy Committee.

The growing provider shortage certainly won’t help. By 2015, the AAMC predicts a shortfall of 63,000 doctors, almost evenly split between primary and specialty care. By 2025, that number is expected to more than double.

Mitchell says the gap between supply and demand is worsening due to the sheer number of baby boomers entering Medicare. At the same time, she says, one in three doctors in the U.S. is now over the age of 60 and nearing retirement age. Whether through Medicaid or the marketplace, the ACA’s coverage expansion will exacerbate the shortages. “It’s not to the level of the boomers entering Medicare, but it certainly is having a major impact on access issues and exacerbating the shortage, again, across specialties,” she says.

Other analysts say the extent of the capacity problem will depend in large part on location.

“The truth is that the extent to which there are enough doctors or enough hospital beds is largely a function of geography,” Dr. Ku says. “So, if you’re in an urban area with lots of teaching hospitals, you probably have enough doctors and you probably have enough hospital beds. If, on the other hand, you’re in a poor, rural area, chances are you don’t.”

As both insurance and demand for healthcare expand, those areas that were having problems already “are going to be stretched even more,” Dr. Ku says.

Meeting demand also means training more doctors, and Mitchell worries about a pipeline that already is underfunded. Although medical school enrollment is at a record high, federal support for residency training has been frozen since 1997, meaning that the funded residency slots may not be sufficient to accommodate future graduates. Further declines in the clinical income that subsidizes training would place additional pressure on the educational mission of teaching hospitals, Mitchell says.

Joshua Lenchus, DO, RPh, FACP, SFHM, associate professor of clinical medicine in the division of hospital medicine at the University of Miami, says existing doctor deficits, the ACA’s new demands, and the growing medical training gap could swirl into a “perfect storm” of access problems. Longer delays in accessing primary and specialty care, in turn, could prevent timely interventions earlier during the course of a disease or condition.

“What it’s going to mean for hospitalists is that we’re going to see—over the short-term, maybe even the next three to five years—a real impact on when patients present, in terms of the acuity of their disease,” Dr. Lenchus says. That means sicker patients in the hospital.

Given the massive changes, observers like Mitchell and Dr. Hilger acknowledge that ironing out the rough spots will take time.

“There’s going to be two steps forward, one step back, but the simple question is: Was it ever OK to have tens of millions of patients who had no insurance or were underinsured and were using the emergency room as their primary care?” Dr. Hilger says. “I think, no matter what your political affiliation, that, in general, the answer is no.”

What it’s going to mean for hospitalists is that we’re going to see—over the short-term, maybe even the next three to five years—a real impact on when patients present, in terms of the acuity of their disease. That means sicker patients in the hospital.

—Joshua Lenchus, DO, RPh, FACP, SFHM, associate professor of clinical medicine, division of hospital medicine, University of Miami, member, SHM Public Policy Committee.

Costs All Over the Map

One of the plan’s biggest goals and part of its name—affordability for those patients—also seems to vary considerably by geography. A recent analysis by The New York Times, for example, found that 58% of all counties served by the federal-run exchanges offer plans from only one or two insurance carriers. The relative lack of competition in many markets has created some huge cost disparities in premiums between neighboring states, and even neighboring counties.

With so many factors influencing costs, both proponents and opponents have found fodder to bolster their case that the law is either making insurance more affordable or sharply increasing premiums. One important consideration, Dr. Ku says, is that all plans must now include 10 “essential health benefits,” such as maternity care and medications, for example, and cannot allow gender to be a rating factor. As a result, he says, the cheapest plans for a relatively healthy young man may cost more now, while costs for a woman or an older person with a chronic condition like diabetes may go down.

Although the new mandates were designed to improve insurance standards, they sparked another firestorm when millions of Americans began receiving policy cancellation notices in 2013. Because many private insurance plans sold to individuals no longer met the ACA’s minimum requirements, insurers began dropping those plans or requiring enrollees to switch to other, often more expensive, ones. In November, in an effort to stem the mass cancellations, President Barack Obama bowed to mounting political pressure and announced a reprieve that allows insurance companies to renew existing policies for another year. That attempted fix has not been so straightforward, however. Many insurers were reluctant to reissue cancelled policies, and multiple states, which have the authority to regulate insurance sold within their borders, declined the administration’s request.

If, in fact, the exchanges offer good insurance products that the public begins to accept and find that they have good information to make choices, it could affect the prevalence of employer-based insurance.

—Robert Berenson, MD, senior fellow, Urban Institute, Washington, D.C.

The Long View

Despite the intense focus on the first few months of health insurance enrollment, it may take several years before the markets begin to settle and other insurers waiting on the sidelines decide whether to participate. If they eventually succeed, the ACA exchanges could have several long-term consequences.

“If, in fact, the exchanges offer good insurance products that the public begins to accept and find that they have good information to make choices, it could affect the prevalence of employer-based insurance,” says Robert Berenson, MD, a senior fellow at the Washington, D.C.-based Urban Institute, a nonpartisan think tank focused on social and economic policy. Over many years, employers could begin moving their employees into exchanges rather than providing direct healthcare benefits.

If they prove viable, the exchanges also may help accelerate the trend toward more consolidation of physician practices or increase pressure to align with larger entities. Despite concerns over skinnier networks, for example, the more tightly controlled access to providers under certain plans dovetails with the ACA’s heightened emphasis on more integrated accountable care organizations (ACOs).

In fact, ACOs and other lower-profile provisions that enjoy more bipartisan support could ultimately play key roles in reshaping how healthcare is delivered in the U.S. Many of these reform efforts have been launched as pilots or demonstration projects. Salt Lake City-based healthcare consulting firm Leavitt Partners tallied nearly 500 ACOs through the end of July 2013, more than double the total in June 2012.

Other Obamacare provisions are levying fines based on excessive hospital-acquired conditions or readmissions and adjusting reimbursements based on e-prescribing, the Physician Quality Reporting System (PQRS), value-based purchasing, meaningful use of electronic health records, and other mandates.

“The overall theme is that the ACA is speeding up the move away from fee-for-service payment toward new payment methodologies that are going to be increasingly based on quality measures,” Dr. O’Malley says. “All of these are basically efforts to shift incentives away from rewarding volume of services toward value and quality of care for patients. And the crux of all of them is to try to get physicians to work together, not only with other specialists and their primary care colleagues, but also with other inter-professional members of their team.”

For hospitalists, it means relying more on nurses, physician assistants, and other support staff.

“In a collaborative agreement, where it’s a physician-led healthcare team, I think non-physician healthcare providers could help to support the physician hospitalists,” Dr. Lenchus says.

That extra help may be essential.

“I do think the workload will increase, and not just because we’ll have more people clamoring for healthcare and more patients who are sicker—remember, there are no more pre-existing conditions,” Dr. Lenchus says. “The other piece to this that goes outside the patient-physician interaction is that there’s a lot of additional regulations and administrative burdens, if you will, as individual hospitalists and as hospitals on the whole.”

The need to share resources to cut down on doctors’ workloads, Dr. O’Malley says, may be yet another factor in the accelerated rate of practice consolidation.

“There’s pressure among docs not just to function as teams but to consolidate among themselves either through physicians’ organizations like IPAs [independent practice associations] or becoming employees of hospitals,” she says. “That’s where you get economies of scale and shared infrastructure to do a lot of the things that the ACA is requiring of them.”

Consolidation or not, she sees plenty of potential for increased efficiency. Some medical groups may need to hire more support staff, whereas others may simply require more coordination and delegation among existing personnel to lighten the load and focus on priorities. The trick, Dr. Hilger says, is finding the right balance amid the dramatic change.

“Bottom line, it goes back to the triple aim that hospitalists should be aiming for: high quality, low-cost, patient-centered care,” he says. “I think the challenge over the next 10 years is how to find the sweet spot between all of those.”

Bryn Nelson is a freelance medical writer in Seattle.

Lung cancer found belatedly despite multiple chest radiographs

DURING AN ANNUAL PHYSICAL EXAMINATION by her primary care physician, a 68-year-old woman with a history of smoking for more than 30 years had an in-house chest x-ray. The physician didn’t have a radiologist read the radiograph or order follow-up imaging. The chest film was repeated the following year. A year after that, the patient developed pulmonary symptoms. A chest x-ray showed an abnormality. The doctor prescribed antibiotics for presumed bronchitis or pneumonia. When the antibiotics didn’t relieve her symptoms, he referred her to a radiologist, who reported a large lesion suggestive of advanced lung cancer. Subsequent films confirmed stage IIIB lung cancer. After 16 rounds of chemotherapy, the patient died at age 73.

PLAINTIFF'S CLAIM The doctor missed an obvious lung lesion on the first radiograph; missed the lesion, which had grown and metastasized, on the second x-ray; and misinterpreted late-stage metastatic cancer on the third radiograph as bronchitis or pneumonia. The chest radiographs should have been over-read, especially when they showed an abnormality. A cancer diagnosis at the time of the first chest radiograph would have allowed a 75% possibility of cure with surgery alone. By the time of the diagnosis 2 years later, a surgical cure wasn’t possible. 

THE DEFENSE The lesion could be seen only on retrospective review of the radiographs. The first and second radiographs were consistent with pulmonary hypertension and didn’t necessitate referral to a radiologist or additional imaging. The patient had many comorbid conditions, including obesity, hypertension, and stenosis of the carotid arteries. She also had a family history of heart disease and COPD.

VERDICT $2 million Virginia verdict.

COMMENT This case illustrates that a simple test, a chest x-ray in this instance, has the potential for litigation if it isn’t interpreted accurately and followed up. Failure to appropriately follow up on test results is one of the 2 major patient safety issues for family medicine; the other is medication errors/drug interactions.

Otitis media? Not likely

A 3-MONTH-OLD INFANT was taken to the emergency department with a fever of 103°F. The ED physician discharged her with a diagnosis of otitis media and a prescription for amoxicillin. He didn’t document which ear was infected or what he observed in the affected ear. The following day, the infant was pale, cool to the touch, and lethargic. She was brought to her pediatrician, then transferred immediately to a local medical center, where she was diagnosed with pneumococcal meningitis, hypoxic brain injury, and hydrocephalus and hospitalized for nearly a month. She was subsequently taken to the hospital 10 times and evaluated by several specialists. The child died of respiratory complications linked to the infection almost 2 years after her initial hospitalization.

PLAINTIFF'S CLAIM The ED physician should have ordered a blood count and urinalysis to rule out bacteremia and meningitis. He should have scheduled a follow-up within 24 to 48 hours of the ED visit.

THE DEFENSE The doctor wasn’t negligent; he couldn’t have anticipated the infant’s clinical course. The bacteremia and meningitis developed after the baby left the hospital, and the causative pneumococcal strain was resistant to amoxicillin.

VERDICT $1.72 million Pennsylvania verdict.

COMMENT Does otitis media ever cause a fever of 103°F in a 3-month-old? Although no definitive studies exist, I doubt it. Otitis media is a closed-space infection like an abscess, and abscesses rarely cause fever. Furthermore, the physical findings of otitis media, although not recorded in this case, are highly unreliable in a 3-month-old. Attributing a fever of 103°F in a 3-month-old to otitis media is always a bad idea.

Lung cancer found belatedly despite multiple chest radiographs

DURING AN ANNUAL PHYSICAL EXAMINATION by her primary care physician, a 68-year-old woman with a history of smoking for more than 30 years had an in-house chest x-ray. The physician didn’t have a radiologist read the radiograph or order follow-up imaging. The chest film was repeated the following year. A year after that, the patient developed pulmonary symptoms. A chest x-ray showed an abnormality. The doctor prescribed antibiotics for presumed bronchitis or pneumonia. When the antibiotics didn’t relieve her symptoms, he referred her to a radiologist, who reported a large lesion suggestive of advanced lung cancer. Subsequent films confirmed stage IIIB lung cancer. After 16 rounds of chemotherapy, the patient died at age 73.

PLAINTIFF'S CLAIM The doctor missed an obvious lung lesion on the first radiograph; missed the lesion, which had grown and metastasized, on the second x-ray; and misinterpreted late-stage metastatic cancer on the third radiograph as bronchitis or pneumonia. The chest radiographs should have been over-read, especially when they showed an abnormality. A cancer diagnosis at the time of the first chest radiograph would have allowed a 75% possibility of cure with surgery alone. By the time of the diagnosis 2 years later, a surgical cure wasn’t possible. 

THE DEFENSE The lesion could be seen only on retrospective review of the radiographs. The first and second radiographs were consistent with pulmonary hypertension and didn’t necessitate referral to a radiologist or additional imaging. The patient had many comorbid conditions, including obesity, hypertension, and stenosis of the carotid arteries. She also had a family history of heart disease and COPD.

VERDICT $2 million Virginia verdict.

COMMENT This case illustrates that a simple test, a chest x-ray in this instance, has the potential for litigation if it isn’t interpreted accurately and followed up. Failure to appropriately follow up on test results is one of the 2 major patient safety issues for family medicine; the other is medication errors/drug interactions.

Otitis media? Not likely

A 3-MONTH-OLD INFANT was taken to the emergency department with a fever of 103°F. The ED physician discharged her with a diagnosis of otitis media and a prescription for amoxicillin. He didn’t document which ear was infected or what he observed in the affected ear. The following day, the infant was pale, cool to the touch, and lethargic. She was brought to her pediatrician, then transferred immediately to a local medical center, where she was diagnosed with pneumococcal meningitis, hypoxic brain injury, and hydrocephalus and hospitalized for nearly a month. She was subsequently taken to the hospital 10 times and evaluated by several specialists. The child died of respiratory complications linked to the infection almost 2 years after her initial hospitalization.

PLAINTIFF'S CLAIM The ED physician should have ordered a blood count and urinalysis to rule out bacteremia and meningitis. He should have scheduled a follow-up within 24 to 48 hours of the ED visit.

THE DEFENSE The doctor wasn’t negligent; he couldn’t have anticipated the infant’s clinical course. The bacteremia and meningitis developed after the baby left the hospital, and the causative pneumococcal strain was resistant to amoxicillin.

VERDICT $1.72 million Pennsylvania verdict.

COMMENT Does otitis media ever cause a fever of 103°F in a 3-month-old? Although no definitive studies exist, I doubt it. Otitis media is a closed-space infection like an abscess, and abscesses rarely cause fever. Furthermore, the physical findings of otitis media, although not recorded in this case, are highly unreliable in a 3-month-old. Attributing a fever of 103°F in a 3-month-old to otitis media is always a bad idea.

Lung cancer found belatedly despite multiple chest radiographs

DURING AN ANNUAL PHYSICAL EXAMINATION by her primary care physician, a 68-year-old woman with a history of smoking for more than 30 years had an in-house chest x-ray. The physician didn’t have a radiologist read the radiograph or order follow-up imaging. The chest film was repeated the following year. A year after that, the patient developed pulmonary symptoms. A chest x-ray showed an abnormality. The doctor prescribed antibiotics for presumed bronchitis or pneumonia. When the antibiotics didn’t relieve her symptoms, he referred her to a radiologist, who reported a large lesion suggestive of advanced lung cancer. Subsequent films confirmed stage IIIB lung cancer. After 16 rounds of chemotherapy, the patient died at age 73.

PLAINTIFF'S CLAIM The doctor missed an obvious lung lesion on the first radiograph; missed the lesion, which had grown and metastasized, on the second x-ray; and misinterpreted late-stage metastatic cancer on the third radiograph as bronchitis or pneumonia. The chest radiographs should have been over-read, especially when they showed an abnormality. A cancer diagnosis at the time of the first chest radiograph would have allowed a 75% possibility of cure with surgery alone. By the time of the diagnosis 2 years later, a surgical cure wasn’t possible. 

THE DEFENSE The lesion could be seen only on retrospective review of the radiographs. The first and second radiographs were consistent with pulmonary hypertension and didn’t necessitate referral to a radiologist or additional imaging. The patient had many comorbid conditions, including obesity, hypertension, and stenosis of the carotid arteries. She also had a family history of heart disease and COPD.

VERDICT $2 million Virginia verdict.

COMMENT This case illustrates that a simple test, a chest x-ray in this instance, has the potential for litigation if it isn’t interpreted accurately and followed up. Failure to appropriately follow up on test results is one of the 2 major patient safety issues for family medicine; the other is medication errors/drug interactions.

Otitis media? Not likely

A 3-MONTH-OLD INFANT was taken to the emergency department with a fever of 103°F. The ED physician discharged her with a diagnosis of otitis media and a prescription for amoxicillin. He didn’t document which ear was infected or what he observed in the affected ear. The following day, the infant was pale, cool to the touch, and lethargic. She was brought to her pediatrician, then transferred immediately to a local medical center, where she was diagnosed with pneumococcal meningitis, hypoxic brain injury, and hydrocephalus and hospitalized for nearly a month. She was subsequently taken to the hospital 10 times and evaluated by several specialists. The child died of respiratory complications linked to the infection almost 2 years after her initial hospitalization.

PLAINTIFF'S CLAIM The ED physician should have ordered a blood count and urinalysis to rule out bacteremia and meningitis. He should have scheduled a follow-up within 24 to 48 hours of the ED visit.

THE DEFENSE The doctor wasn’t negligent; he couldn’t have anticipated the infant’s clinical course. The bacteremia and meningitis developed after the baby left the hospital, and the causative pneumococcal strain was resistant to amoxicillin.

VERDICT $1.72 million Pennsylvania verdict.

COMMENT Does otitis media ever cause a fever of 103°F in a 3-month-old? Although no definitive studies exist, I doubt it. Otitis media is a closed-space infection like an abscess, and abscesses rarely cause fever. Furthermore, the physical findings of otitis media, although not recorded in this case, are highly unreliable in a 3-month-old. Attributing a fever of 103°F in a 3-month-old to otitis media is always a bad idea.