Kenneth Donovan, MD, FHM

Sarada Sripada, MD, SFHM

Donald Quinn, MD, MBA, SFHM

Kenneth Donovan, MD, FHM and Sarada Sripada, MD, SFHM have been named the 2011 Hospitalists of the Year, and Donald Quinn, MD, MBA, SFHM was named the 2011 Post Acute Hospitalist of the Year by IPC: The Hospitalist Company Inc. Selected by IPC’s senior management team, the award includes an honorarium to each of the recipients. Additionally, IPC will make a $2,500 donation to the charity of their choice for each of the recipients.

Paul Fu Jr., MD, MPH, FAAP, recently was named chief medical informatics officer (CMIO) at Harbor-UCLA Medical Center in Los Angeles. He has served as chief of the division of pediatric hospital medicine since July 2011.

Anna-Gene O’Neal

Former Cogent HMG senior vice president in charge of quality initiatives Anna-Gene O’Neal has taken a CEO position with Alive Hospice, a Nashville, Tenn.-based end-of-life care and grief support company. As CEO, O’Neal will oversee hospice and palliative care, as well as grief-support programs in a service area of 12 Middle Tennessee counties.

Kasra Djalayer, MD, a hospitalist based in Franklin, N.H., has received the 2011 Patients’ Choice Award from Patients’ Choice, an organization that collects and analyzes rankings from various patient-feedback websites, such as Vitals.com. Dr. Djalayer was honored based on a top ranking among physicians across the nation.

Glenn Rosenbluth, MD

Hospitalist Glenn Rosenbluth, MD, has been appointed director of quality and safety programs for graduate medical education (GME) at University of California at San Francisco Medical Center. In his new role, Dr. Rosenbluth will lead multiple GME-related programs while still continuing his leadership as associated director of the pediatrics residency training program.

Business Moves

Cogent HMG has established a new critical-care program at Saint Francis Hospital in Brentwood, Tenn., which marks the hospitalist management company’s 11th full-service intensivist program. The new program will be operated by The Intensivist Group, recently acquired by Cogent HMG, and will include the development and implementation of literature-based ICU guidelines, a staff intensivist in the hospital seven days a week, and intensivist consultation and comanagement for all ICU patients.

IPC: The Hospitalist Company Inc. has acquired the facility-based practice of Asana Integrated Medical Group, a professional medical corporation that serves Southern California and Phoenix. Headquartered in Agoura Hills, Calif., the acquisition will add approximately 65,000 patient encounters annually to IPC.

IPC: The Hospitalist Company Inc. has entered into agreements to provide hospitalist services to four Methodist Healthcare System hospitals in San Antonio. The agreements are with Methodist Stone Oak Hospital, Methodist Specialty and Transplant Hospital, Northeast Methodist Hospital, and Metropolitan Methodist Hospital.

Apollo Medical Holdings Inc. has appointed Gary Augusta to its board of directors. Augusta brings more than 20 years of experience as an executive to the job.

University of Pittsburgh Medical Center has extended its hospitalist program to three additional Pennsylvania campuses, including the McKeesport, Greenville and Farrell hospitals.

Colquitt Regional Medical Center in Moultrie, Ga., has started a hospitalist program. The new team will be led by Marshall Tanner, MD, and will also include Alan Brown, MD, MBA, Frank Wilson, MD, and Ndubuisi Apu Ndukwe, MD.

—Alexandra Schultz

Kenneth Donovan, MD, FHM

Sarada Sripada, MD, SFHM

Donald Quinn, MD, MBA, SFHM

Kenneth Donovan, MD, FHM and Sarada Sripada, MD, SFHM have been named the 2011 Hospitalists of the Year, and Donald Quinn, MD, MBA, SFHM was named the 2011 Post Acute Hospitalist of the Year by IPC: The Hospitalist Company Inc. Selected by IPC’s senior management team, the award includes an honorarium to each of the recipients. Additionally, IPC will make a $2,500 donation to the charity of their choice for each of the recipients.

Paul Fu Jr., MD, MPH, FAAP, recently was named chief medical informatics officer (CMIO) at Harbor-UCLA Medical Center in Los Angeles. He has served as chief of the division of pediatric hospital medicine since July 2011.

Anna-Gene O’Neal

Former Cogent HMG senior vice president in charge of quality initiatives Anna-Gene O’Neal has taken a CEO position with Alive Hospice, a Nashville, Tenn.-based end-of-life care and grief support company. As CEO, O’Neal will oversee hospice and palliative care, as well as grief-support programs in a service area of 12 Middle Tennessee counties.

Kasra Djalayer, MD, a hospitalist based in Franklin, N.H., has received the 2011 Patients’ Choice Award from Patients’ Choice, an organization that collects and analyzes rankings from various patient-feedback websites, such as Vitals.com. Dr. Djalayer was honored based on a top ranking among physicians across the nation.

Glenn Rosenbluth, MD

Hospitalist Glenn Rosenbluth, MD, has been appointed director of quality and safety programs for graduate medical education (GME) at University of California at San Francisco Medical Center. In his new role, Dr. Rosenbluth will lead multiple GME-related programs while still continuing his leadership as associated director of the pediatrics residency training program.

Business Moves

Cogent HMG has established a new critical-care program at Saint Francis Hospital in Brentwood, Tenn., which marks the hospitalist management company’s 11th full-service intensivist program. The new program will be operated by The Intensivist Group, recently acquired by Cogent HMG, and will include the development and implementation of literature-based ICU guidelines, a staff intensivist in the hospital seven days a week, and intensivist consultation and comanagement for all ICU patients.

IPC: The Hospitalist Company Inc. has acquired the facility-based practice of Asana Integrated Medical Group, a professional medical corporation that serves Southern California and Phoenix. Headquartered in Agoura Hills, Calif., the acquisition will add approximately 65,000 patient encounters annually to IPC.

IPC: The Hospitalist Company Inc. has entered into agreements to provide hospitalist services to four Methodist Healthcare System hospitals in San Antonio. The agreements are with Methodist Stone Oak Hospital, Methodist Specialty and Transplant Hospital, Northeast Methodist Hospital, and Metropolitan Methodist Hospital.

Apollo Medical Holdings Inc. has appointed Gary Augusta to its board of directors. Augusta brings more than 20 years of experience as an executive to the job.

University of Pittsburgh Medical Center has extended its hospitalist program to three additional Pennsylvania campuses, including the McKeesport, Greenville and Farrell hospitals.

Colquitt Regional Medical Center in Moultrie, Ga., has started a hospitalist program. The new team will be led by Marshall Tanner, MD, and will also include Alan Brown, MD, MBA, Frank Wilson, MD, and Ndubuisi Apu Ndukwe, MD.

—Alexandra Schultz

Kenneth Donovan, MD, FHM

Sarada Sripada, MD, SFHM

Donald Quinn, MD, MBA, SFHM

Kenneth Donovan, MD, FHM and Sarada Sripada, MD, SFHM have been named the 2011 Hospitalists of the Year, and Donald Quinn, MD, MBA, SFHM was named the 2011 Post Acute Hospitalist of the Year by IPC: The Hospitalist Company Inc. Selected by IPC’s senior management team, the award includes an honorarium to each of the recipients. Additionally, IPC will make a $2,500 donation to the charity of their choice for each of the recipients.

Paul Fu Jr., MD, MPH, FAAP, recently was named chief medical informatics officer (CMIO) at Harbor-UCLA Medical Center in Los Angeles. He has served as chief of the division of pediatric hospital medicine since July 2011.

Anna-Gene O’Neal

Former Cogent HMG senior vice president in charge of quality initiatives Anna-Gene O’Neal has taken a CEO position with Alive Hospice, a Nashville, Tenn.-based end-of-life care and grief support company. As CEO, O’Neal will oversee hospice and palliative care, as well as grief-support programs in a service area of 12 Middle Tennessee counties.

Kasra Djalayer, MD, a hospitalist based in Franklin, N.H., has received the 2011 Patients’ Choice Award from Patients’ Choice, an organization that collects and analyzes rankings from various patient-feedback websites, such as Vitals.com. Dr. Djalayer was honored based on a top ranking among physicians across the nation.

Glenn Rosenbluth, MD

Hospitalist Glenn Rosenbluth, MD, has been appointed director of quality and safety programs for graduate medical education (GME) at University of California at San Francisco Medical Center. In his new role, Dr. Rosenbluth will lead multiple GME-related programs while still continuing his leadership as associated director of the pediatrics residency training program.

Business Moves

Cogent HMG has established a new critical-care program at Saint Francis Hospital in Brentwood, Tenn., which marks the hospitalist management company’s 11th full-service intensivist program. The new program will be operated by The Intensivist Group, recently acquired by Cogent HMG, and will include the development and implementation of literature-based ICU guidelines, a staff intensivist in the hospital seven days a week, and intensivist consultation and comanagement for all ICU patients.

IPC: The Hospitalist Company Inc. has acquired the facility-based practice of Asana Integrated Medical Group, a professional medical corporation that serves Southern California and Phoenix. Headquartered in Agoura Hills, Calif., the acquisition will add approximately 65,000 patient encounters annually to IPC.

IPC: The Hospitalist Company Inc. has entered into agreements to provide hospitalist services to four Methodist Healthcare System hospitals in San Antonio. The agreements are with Methodist Stone Oak Hospital, Methodist Specialty and Transplant Hospital, Northeast Methodist Hospital, and Metropolitan Methodist Hospital.

Apollo Medical Holdings Inc. has appointed Gary Augusta to its board of directors. Augusta brings more than 20 years of experience as an executive to the job.

University of Pittsburgh Medical Center has extended its hospitalist program to three additional Pennsylvania campuses, including the McKeesport, Greenville and Farrell hospitals.

Colquitt Regional Medical Center in Moultrie, Ga., has started a hospitalist program. The new team will be led by Marshall Tanner, MD, and will also include Alan Brown, MD, MBA, Frank Wilson, MD, and Ndubuisi Apu Ndukwe, MD.

—Alexandra Schultz

Physician assistants and other non-physician providers (NPPs) can stay up to date on the fastest-growing specialty in medicine through the Adult Hospital Medicine Boot Camp, Oct. 18-21 in New Orleans, with optional half-day pre-courses on Oct. 17.

Co-hosted by SHM and the American Academy of Physician Assistants, this annual boot-camp-style educational event will immerse clinicians who are practicing in HM or who are interested in an intensive internal-medicine review of commonly encountered diagnoses and diseases of the hospitalized adult patient.

In addition to educating those already practicing in the HM setting, the boot camp provides an ideal introduction for clinicians who plan to practice in HM soon.

The boot camp has been approved for a maximum of 29.5 AAPA Category I CME credits.

For more information, visit the link on the SHM “Events” page at www.hospitalmedicine.org/events.

Physician assistants and other non-physician providers (NPPs) can stay up to date on the fastest-growing specialty in medicine through the Adult Hospital Medicine Boot Camp, Oct. 18-21 in New Orleans, with optional half-day pre-courses on Oct. 17.

Co-hosted by SHM and the American Academy of Physician Assistants, this annual boot-camp-style educational event will immerse clinicians who are practicing in HM or who are interested in an intensive internal-medicine review of commonly encountered diagnoses and diseases of the hospitalized adult patient.

In addition to educating those already practicing in the HM setting, the boot camp provides an ideal introduction for clinicians who plan to practice in HM soon.

The boot camp has been approved for a maximum of 29.5 AAPA Category I CME credits.

For more information, visit the link on the SHM “Events” page at www.hospitalmedicine.org/events.

Physician assistants and other non-physician providers (NPPs) can stay up to date on the fastest-growing specialty in medicine through the Adult Hospital Medicine Boot Camp, Oct. 18-21 in New Orleans, with optional half-day pre-courses on Oct. 17.

Co-hosted by SHM and the American Academy of Physician Assistants, this annual boot-camp-style educational event will immerse clinicians who are practicing in HM or who are interested in an intensive internal-medicine review of commonly encountered diagnoses and diseases of the hospitalized adult patient.

In addition to educating those already practicing in the HM setting, the boot camp provides an ideal introduction for clinicians who plan to practice in HM soon.

The boot camp has been approved for a maximum of 29.5 AAPA Category I CME credits.

For more information, visit the link on the SHM “Events” page at www.hospitalmedicine.org/events.

A key engine of healthcare reform is poised to accelerate, with the potential to improve clinical decision-making and care quality, curtail inappropriate utilization of ineffective treatments, and lower costs. Comparative-effectiveness research (CER), until now, has received relatively meager funding and has occupied a relatively low profile among policymakers, clinicians, and the public.

With a $1.1 billion injection from the American Recovery and Reinvestment Act of 2009 (better known as the “stimulus”) and dedicated funding mandated by the Affordable Care Act, a new national center dedicated to CER—the Patient-Centered Outcomes Research Institute (PCORI)—has recently released a draft of its national priorities and is mobilizing a national research agenda for CER.¹

Demonized by critics as a prelude to coverage denials, healthcare rationing, and intrusion upon physicians’ clinical autonomy, CER is reconstituting its reputation as a non-coercive yet powerful tool to reduce uncertainty about which healthcare options work best for which patients, and to encourage adoption of care practices that are truly effective.

“I practice on weekends as a pediatric hospitalist, and it is still far too common to encounter a case for which we don’t have good, evidence-based guidance—such as whether surgery or medical management is best for a neurologically impaired child presenting with aspiration and gastroesophageal reflux disease,” says Patrick Conway, MD, MSc, SFHM, chief medical officer of the Center for Medicare & Medicaid Services (CMS) and director of its Office of Clinical Standards and Quality.

SHM strongly supported the creation of PCORI during the health reform debate, and hospitalists have important opportunities to be part of the nation’s CER agenda, as well as key beneficiaries of its results, according to Dr. Conway.

Efficacy vs. Effectiveness

While the traditional “gold standard” of clinical research is the randomized controlled trial, its focus on efficacy typically involves comparing some treatment to no treatment at all (a placebo), and requires highly controlled, ideal conditions, often with narrow patient-inclusion criteria. All of those requirements sacrifice generalizability to patients whom physicians encounter daily in clinical settings who often have multiple chronic conditions and comorbidities and might require multiple therapies, Dr. Conway says.

CER studies larger, more representative patient populations treated in real-world clinical circumstances, explains SHM Research Committee chairman David Meltzer, MD, PhD, FHM, who is a member of the PCORI’s Methodology Committee. “One of the big initial tasks of the PCORI is to produce a translation table of what research study designs—randomized controlled trials, head-to-head, observational studies, and others—can best answer which kinds of questions,” he says.

The PCORI’s ultimate goal, says Dr. Conway, is to enable better-informed decision-making between physicians and their patients by allowing for the “right treatments to the right patients at the right time.”

The Case for CER

The unrelenting reality of an unsustainable healthcare cost spiral that threatens to bankrupt the national economy might be changing the conversation about CER (see “PCORI: Built to Reject the Myth of Coercive Rationing,” at left). Add to that increasing gravitation by government and private insurers toward reimbursement models that reward providers for better outcomes, more efficient care, and evidence-based practices (and penalizes the opposite), and CER makes a lot of sense.

An estimated $158 billion to $226 billion in wasteful healthcare spending last year came from “subjecting patients to care that, according to sound science and the patients’ own preferences, cannot possibly help them—care rooted in outmoded habits, supply-driven behaviors, and ignoring science,” wrote former CMS administrator Donald Berwick, MD, MPP, and RAND researcher Andrew Hackbarth, MPhil.²

It appears as though physicians are becoming more receptive to their role as responsible stewards of finite healthcare resources, and are willing to abandon some common clinical practices that add little value to patient care when given credible evidence. In the recent Choosing Wisely campaign (www.ChoosingWisely.org), for example, nine medical specialty societies worked with the ABIM Foundation and Consumer Reports to publicize 45 tests and procedures—five from each society—that are commonly used in their field, but which evidence suggests might be unnecessary and inappropriate for many patients.

Physicians who in the past might have resisted traditional evidence-based guidelines as “cookie cutter” algorithms that “don’t apply to my particular patient” will find it harder to dismiss CER findings on that basis, Dr. Meltzer notes, because CER is designed at the outset to be relevant to specific subsets of patients in actual clinical settings.

Nevertheless, incentives will be required to drive rapid and widespread adoption of CER findings, Dr. Conway believes.

“Just creating evidence doesn’t create change,” he says. “Cycle time from research finding to implementation matters, and the typical 17 years [time lag from bench to bedside] is not going to cut it. We need to work with clinicians and patients to take new findings and implement them sooner.”

CMS already has selected some evidence-based process and outcome metrics for its value-based purchasing program. “As CER identifies new evidence-based process and outcome metrics, we could incorporate them,” Dr. Conway adds.

Private insurers could use CER findings when making coverage decisions for their health plans. By law, CMS is obligated to provide coverage to Medicare beneficiaries for healthcare services that are “reasonable and necessary,” and cannot exclude coverage based on the cost of services.

“CMS could use CER findings to make coverage determinations based on ineffectiveness, when there is compelling evidence that a service is ‘not reasonable and necessary,’” Dr. Conway states.

HM Opportunity

Dr. Conway says hospitalists are uniquely poised to seek funding for CER that builds upon several critically important topics, such as examining the best discharge planning processes and transition-of-care protocols for certain types of patients. Dr. Meltzer, who is chief of the section of hospital medicine at University of Chicago, says he is seeking funding for a study of alternative transfusion thresholds for older patients with anemia across different levels of patients’ functional status.

“That’s the type of patient-centered study that CER is especially equipped to handle,” Dr. Meltzer says.

CER promises to produce important evidence for clinical questions that hospitalists struggle with day to day, Dr. Conway says. “Hospitalists should take the lead in developing effective ways to disseminate those findings, to teach medical trainees about them, and to spearhead CER-based QI [quality improvement] implementation and tracking efforts at their institutions,” he adds.

Christopher Guadagnino is a freelance medical writer in Philadelphia.

References

1. Patient-Centered Outcome Research Institute. Draft National Priorities for Research and Research Agenda, Version 1. Patient-Centered Outcome Research Institute website. Available at: http://interactive.snm.org/docs/PCORI-Draft-National-Priorities-and-Research-Agenda2.pdf. Accessed April 15, 2012.
2. Berwick DM, Hackbarth AD. Eliminating waste in U.S. health care. Journal of the American Medical Association website. Available at: http://jama.ama-assn.org/content/307/14/1513.full. Accessed April 15, 2012.
3. Selby JV. The researcher-in-chief at the Patient-Centered Outcomes Research Institute. Inverview by Susan Dentzer. Health Aff (Millwood). 2011;30(12):2252-2258.

A key engine of healthcare reform is poised to accelerate, with the potential to improve clinical decision-making and care quality, curtail inappropriate utilization of ineffective treatments, and lower costs. Comparative-effectiveness research (CER), until now, has received relatively meager funding and has occupied a relatively low profile among policymakers, clinicians, and the public.

With a $1.1 billion injection from the American Recovery and Reinvestment Act of 2009 (better known as the “stimulus”) and dedicated funding mandated by the Affordable Care Act, a new national center dedicated to CER—the Patient-Centered Outcomes Research Institute (PCORI)—has recently released a draft of its national priorities and is mobilizing a national research agenda for CER.¹

Demonized by critics as a prelude to coverage denials, healthcare rationing, and intrusion upon physicians’ clinical autonomy, CER is reconstituting its reputation as a non-coercive yet powerful tool to reduce uncertainty about which healthcare options work best for which patients, and to encourage adoption of care practices that are truly effective.

“I practice on weekends as a pediatric hospitalist, and it is still far too common to encounter a case for which we don’t have good, evidence-based guidance—such as whether surgery or medical management is best for a neurologically impaired child presenting with aspiration and gastroesophageal reflux disease,” says Patrick Conway, MD, MSc, SFHM, chief medical officer of the Center for Medicare & Medicaid Services (CMS) and director of its Office of Clinical Standards and Quality.

SHM strongly supported the creation of PCORI during the health reform debate, and hospitalists have important opportunities to be part of the nation’s CER agenda, as well as key beneficiaries of its results, according to Dr. Conway.

Efficacy vs. Effectiveness

While the traditional “gold standard” of clinical research is the randomized controlled trial, its focus on efficacy typically involves comparing some treatment to no treatment at all (a placebo), and requires highly controlled, ideal conditions, often with narrow patient-inclusion criteria. All of those requirements sacrifice generalizability to patients whom physicians encounter daily in clinical settings who often have multiple chronic conditions and comorbidities and might require multiple therapies, Dr. Conway says.

CER studies larger, more representative patient populations treated in real-world clinical circumstances, explains SHM Research Committee chairman David Meltzer, MD, PhD, FHM, who is a member of the PCORI’s Methodology Committee. “One of the big initial tasks of the PCORI is to produce a translation table of what research study designs—randomized controlled trials, head-to-head, observational studies, and others—can best answer which kinds of questions,” he says.

The PCORI’s ultimate goal, says Dr. Conway, is to enable better-informed decision-making between physicians and their patients by allowing for the “right treatments to the right patients at the right time.”

The Case for CER

The unrelenting reality of an unsustainable healthcare cost spiral that threatens to bankrupt the national economy might be changing the conversation about CER (see “PCORI: Built to Reject the Myth of Coercive Rationing,” at left). Add to that increasing gravitation by government and private insurers toward reimbursement models that reward providers for better outcomes, more efficient care, and evidence-based practices (and penalizes the opposite), and CER makes a lot of sense.

An estimated $158 billion to $226 billion in wasteful healthcare spending last year came from “subjecting patients to care that, according to sound science and the patients’ own preferences, cannot possibly help them—care rooted in outmoded habits, supply-driven behaviors, and ignoring science,” wrote former CMS administrator Donald Berwick, MD, MPP, and RAND researcher Andrew Hackbarth, MPhil.²

It appears as though physicians are becoming more receptive to their role as responsible stewards of finite healthcare resources, and are willing to abandon some common clinical practices that add little value to patient care when given credible evidence. In the recent Choosing Wisely campaign (www.ChoosingWisely.org), for example, nine medical specialty societies worked with the ABIM Foundation and Consumer Reports to publicize 45 tests and procedures—five from each society—that are commonly used in their field, but which evidence suggests might be unnecessary and inappropriate for many patients.

Physicians who in the past might have resisted traditional evidence-based guidelines as “cookie cutter” algorithms that “don’t apply to my particular patient” will find it harder to dismiss CER findings on that basis, Dr. Meltzer notes, because CER is designed at the outset to be relevant to specific subsets of patients in actual clinical settings.

Nevertheless, incentives will be required to drive rapid and widespread adoption of CER findings, Dr. Conway believes.

“Just creating evidence doesn’t create change,” he says. “Cycle time from research finding to implementation matters, and the typical 17 years [time lag from bench to bedside] is not going to cut it. We need to work with clinicians and patients to take new findings and implement them sooner.”

CMS already has selected some evidence-based process and outcome metrics for its value-based purchasing program. “As CER identifies new evidence-based process and outcome metrics, we could incorporate them,” Dr. Conway adds.

Private insurers could use CER findings when making coverage decisions for their health plans. By law, CMS is obligated to provide coverage to Medicare beneficiaries for healthcare services that are “reasonable and necessary,” and cannot exclude coverage based on the cost of services.

“CMS could use CER findings to make coverage determinations based on ineffectiveness, when there is compelling evidence that a service is ‘not reasonable and necessary,’” Dr. Conway states.

HM Opportunity

Dr. Conway says hospitalists are uniquely poised to seek funding for CER that builds upon several critically important topics, such as examining the best discharge planning processes and transition-of-care protocols for certain types of patients. Dr. Meltzer, who is chief of the section of hospital medicine at University of Chicago, says he is seeking funding for a study of alternative transfusion thresholds for older patients with anemia across different levels of patients’ functional status.

“That’s the type of patient-centered study that CER is especially equipped to handle,” Dr. Meltzer says.

CER promises to produce important evidence for clinical questions that hospitalists struggle with day to day, Dr. Conway says. “Hospitalists should take the lead in developing effective ways to disseminate those findings, to teach medical trainees about them, and to spearhead CER-based QI [quality improvement] implementation and tracking efforts at their institutions,” he adds.

Christopher Guadagnino is a freelance medical writer in Philadelphia.

References

1. Patient-Centered Outcome Research Institute. Draft National Priorities for Research and Research Agenda, Version 1. Patient-Centered Outcome Research Institute website. Available at: http://interactive.snm.org/docs/PCORI-Draft-National-Priorities-and-Research-Agenda2.pdf. Accessed April 15, 2012.
2. Berwick DM, Hackbarth AD. Eliminating waste in U.S. health care. Journal of the American Medical Association website. Available at: http://jama.ama-assn.org/content/307/14/1513.full. Accessed April 15, 2012.
3. Selby JV. The researcher-in-chief at the Patient-Centered Outcomes Research Institute. Inverview by Susan Dentzer. Health Aff (Millwood). 2011;30(12):2252-2258.

A key engine of healthcare reform is poised to accelerate, with the potential to improve clinical decision-making and care quality, curtail inappropriate utilization of ineffective treatments, and lower costs. Comparative-effectiveness research (CER), until now, has received relatively meager funding and has occupied a relatively low profile among policymakers, clinicians, and the public.

With a $1.1 billion injection from the American Recovery and Reinvestment Act of 2009 (better known as the “stimulus”) and dedicated funding mandated by the Affordable Care Act, a new national center dedicated to CER—the Patient-Centered Outcomes Research Institute (PCORI)—has recently released a draft of its national priorities and is mobilizing a national research agenda for CER.¹

Demonized by critics as a prelude to coverage denials, healthcare rationing, and intrusion upon physicians’ clinical autonomy, CER is reconstituting its reputation as a non-coercive yet powerful tool to reduce uncertainty about which healthcare options work best for which patients, and to encourage adoption of care practices that are truly effective.

“I practice on weekends as a pediatric hospitalist, and it is still far too common to encounter a case for which we don’t have good, evidence-based guidance—such as whether surgery or medical management is best for a neurologically impaired child presenting with aspiration and gastroesophageal reflux disease,” says Patrick Conway, MD, MSc, SFHM, chief medical officer of the Center for Medicare & Medicaid Services (CMS) and director of its Office of Clinical Standards and Quality.

SHM strongly supported the creation of PCORI during the health reform debate, and hospitalists have important opportunities to be part of the nation’s CER agenda, as well as key beneficiaries of its results, according to Dr. Conway.

Efficacy vs. Effectiveness

While the traditional “gold standard” of clinical research is the randomized controlled trial, its focus on efficacy typically involves comparing some treatment to no treatment at all (a placebo), and requires highly controlled, ideal conditions, often with narrow patient-inclusion criteria. All of those requirements sacrifice generalizability to patients whom physicians encounter daily in clinical settings who often have multiple chronic conditions and comorbidities and might require multiple therapies, Dr. Conway says.

CER studies larger, more representative patient populations treated in real-world clinical circumstances, explains SHM Research Committee chairman David Meltzer, MD, PhD, FHM, who is a member of the PCORI’s Methodology Committee. “One of the big initial tasks of the PCORI is to produce a translation table of what research study designs—randomized controlled trials, head-to-head, observational studies, and others—can best answer which kinds of questions,” he says.

The PCORI’s ultimate goal, says Dr. Conway, is to enable better-informed decision-making between physicians and their patients by allowing for the “right treatments to the right patients at the right time.”

The Case for CER

The unrelenting reality of an unsustainable healthcare cost spiral that threatens to bankrupt the national economy might be changing the conversation about CER (see “PCORI: Built to Reject the Myth of Coercive Rationing,” at left). Add to that increasing gravitation by government and private insurers toward reimbursement models that reward providers for better outcomes, more efficient care, and evidence-based practices (and penalizes the opposite), and CER makes a lot of sense.

An estimated $158 billion to $226 billion in wasteful healthcare spending last year came from “subjecting patients to care that, according to sound science and the patients’ own preferences, cannot possibly help them—care rooted in outmoded habits, supply-driven behaviors, and ignoring science,” wrote former CMS administrator Donald Berwick, MD, MPP, and RAND researcher Andrew Hackbarth, MPhil.²

It appears as though physicians are becoming more receptive to their role as responsible stewards of finite healthcare resources, and are willing to abandon some common clinical practices that add little value to patient care when given credible evidence. In the recent Choosing Wisely campaign (www.ChoosingWisely.org), for example, nine medical specialty societies worked with the ABIM Foundation and Consumer Reports to publicize 45 tests and procedures—five from each society—that are commonly used in their field, but which evidence suggests might be unnecessary and inappropriate for many patients.

Physicians who in the past might have resisted traditional evidence-based guidelines as “cookie cutter” algorithms that “don’t apply to my particular patient” will find it harder to dismiss CER findings on that basis, Dr. Meltzer notes, because CER is designed at the outset to be relevant to specific subsets of patients in actual clinical settings.

Nevertheless, incentives will be required to drive rapid and widespread adoption of CER findings, Dr. Conway believes.

“Just creating evidence doesn’t create change,” he says. “Cycle time from research finding to implementation matters, and the typical 17 years [time lag from bench to bedside] is not going to cut it. We need to work with clinicians and patients to take new findings and implement them sooner.”

CMS already has selected some evidence-based process and outcome metrics for its value-based purchasing program. “As CER identifies new evidence-based process and outcome metrics, we could incorporate them,” Dr. Conway adds.

Private insurers could use CER findings when making coverage decisions for their health plans. By law, CMS is obligated to provide coverage to Medicare beneficiaries for healthcare services that are “reasonable and necessary,” and cannot exclude coverage based on the cost of services.

“CMS could use CER findings to make coverage determinations based on ineffectiveness, when there is compelling evidence that a service is ‘not reasonable and necessary,’” Dr. Conway states.

HM Opportunity

Dr. Conway says hospitalists are uniquely poised to seek funding for CER that builds upon several critically important topics, such as examining the best discharge planning processes and transition-of-care protocols for certain types of patients. Dr. Meltzer, who is chief of the section of hospital medicine at University of Chicago, says he is seeking funding for a study of alternative transfusion thresholds for older patients with anemia across different levels of patients’ functional status.

“That’s the type of patient-centered study that CER is especially equipped to handle,” Dr. Meltzer says.

CER promises to produce important evidence for clinical questions that hospitalists struggle with day to day, Dr. Conway says. “Hospitalists should take the lead in developing effective ways to disseminate those findings, to teach medical trainees about them, and to spearhead CER-based QI [quality improvement] implementation and tracking efforts at their institutions,” he adds.

Christopher Guadagnino is a freelance medical writer in Philadelphia.

References

1. Patient-Centered Outcome Research Institute. Draft National Priorities for Research and Research Agenda, Version 1. Patient-Centered Outcome Research Institute website. Available at: http://interactive.snm.org/docs/PCORI-Draft-National-Priorities-and-Research-Agenda2.pdf. Accessed April 15, 2012.
2. Berwick DM, Hackbarth AD. Eliminating waste in U.S. health care. Journal of the American Medical Association website. Available at: http://jama.ama-assn.org/content/307/14/1513.full. Accessed April 15, 2012.
3. Selby JV. The researcher-in-chief at the Patient-Centered Outcomes Research Institute. Inverview by Susan Dentzer. Health Aff (Millwood). 2011;30(12):2252-2258.

A recent study in the Journal of Hospital Medicine that found inpatients are similarly satisfied with the care provided by hospitalists and the care of primary-care physicians (PCPs) should be considered a positive for HM, says lead author Adrianne Seiler, MD, of the Division of Healthcare Quality at Baystate Medical Center in Springfield, Mass.¹

The results are drawn from scripted patient-satisfaction telephone interviews of 8,295 patients discharged from three Massachusetts hospitals from 2003 to 2009. Starting in 2007, questions were added from the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) federal quality reporting system. Multivariate-adjusted satisfaction scores for physician care quality were only slightly higher for PCPs (4.24 on a five-point scale) than for hospitalists (4.20), with no statistical difference for individual hospitals or for different hospitalist groups.

“What has been passed down as dogma is the discontinuity in care introduced by the hospitalist model,” Dr. Seiler says. But actual data on the effects of the hospitalist model on patient satisfaction are scant. “Our finding that patients essentially were equally satisfied with either model of medical care—that’s huge.”

HCAHPS scores have not been validated to evaluate patient satisfaction with individual hospitalist providers specifically, Dr. Seiler says, but they are standardized nationwide. “Is this the best way to measure patient experience?” she asks. “It’s the best tool we have at this time.”

Another wrinkle in patient satisfaction was presented as an oral research abstract at HM12. Researchers from the Veterans Administration and the University of Michigan examined the association between hospitalist staffing levels and patient satisfaction.² Hospitals with the highest hospitalist staffing had modestly higher patient satisfaction scores than those with the lowest hospitalist staffing. Overall satisfaction was 65.6 for hospitals in the highest tertile of hospitalist staffing versus 62.7 those in the lowest tertile.

References

1. Seiler A, Visintainer P, Brzostek R, et al. Patient satisfaction with hospital care provided by hospitalists and primary care physicians. J Hosp Med. 2012;7:131-136.
2. Chen L, Birkmeyer J, Saint S, Ashish J. Hospitalist staffing and patient satisfaction in the national Medicare population. Abstract presented at HM12, April 2, 2012, San Diego.

A recent study in the Journal of Hospital Medicine that found inpatients are similarly satisfied with the care provided by hospitalists and the care of primary-care physicians (PCPs) should be considered a positive for HM, says lead author Adrianne Seiler, MD, of the Division of Healthcare Quality at Baystate Medical Center in Springfield, Mass.¹

The results are drawn from scripted patient-satisfaction telephone interviews of 8,295 patients discharged from three Massachusetts hospitals from 2003 to 2009. Starting in 2007, questions were added from the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) federal quality reporting system. Multivariate-adjusted satisfaction scores for physician care quality were only slightly higher for PCPs (4.24 on a five-point scale) than for hospitalists (4.20), with no statistical difference for individual hospitals or for different hospitalist groups.

“What has been passed down as dogma is the discontinuity in care introduced by the hospitalist model,” Dr. Seiler says. But actual data on the effects of the hospitalist model on patient satisfaction are scant. “Our finding that patients essentially were equally satisfied with either model of medical care—that’s huge.”

HCAHPS scores have not been validated to evaluate patient satisfaction with individual hospitalist providers specifically, Dr. Seiler says, but they are standardized nationwide. “Is this the best way to measure patient experience?” she asks. “It’s the best tool we have at this time.”

Another wrinkle in patient satisfaction was presented as an oral research abstract at HM12. Researchers from the Veterans Administration and the University of Michigan examined the association between hospitalist staffing levels and patient satisfaction.² Hospitals with the highest hospitalist staffing had modestly higher patient satisfaction scores than those with the lowest hospitalist staffing. Overall satisfaction was 65.6 for hospitals in the highest tertile of hospitalist staffing versus 62.7 those in the lowest tertile.

References

1. Seiler A, Visintainer P, Brzostek R, et al. Patient satisfaction with hospital care provided by hospitalists and primary care physicians. J Hosp Med. 2012;7:131-136.
2. Chen L, Birkmeyer J, Saint S, Ashish J. Hospitalist staffing and patient satisfaction in the national Medicare population. Abstract presented at HM12, April 2, 2012, San Diego.

A recent study in the Journal of Hospital Medicine that found inpatients are similarly satisfied with the care provided by hospitalists and the care of primary-care physicians (PCPs) should be considered a positive for HM, says lead author Adrianne Seiler, MD, of the Division of Healthcare Quality at Baystate Medical Center in Springfield, Mass.¹

The results are drawn from scripted patient-satisfaction telephone interviews of 8,295 patients discharged from three Massachusetts hospitals from 2003 to 2009. Starting in 2007, questions were added from the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) federal quality reporting system. Multivariate-adjusted satisfaction scores for physician care quality were only slightly higher for PCPs (4.24 on a five-point scale) than for hospitalists (4.20), with no statistical difference for individual hospitals or for different hospitalist groups.

“What has been passed down as dogma is the discontinuity in care introduced by the hospitalist model,” Dr. Seiler says. But actual data on the effects of the hospitalist model on patient satisfaction are scant. “Our finding that patients essentially were equally satisfied with either model of medical care—that’s huge.”

HCAHPS scores have not been validated to evaluate patient satisfaction with individual hospitalist providers specifically, Dr. Seiler says, but they are standardized nationwide. “Is this the best way to measure patient experience?” she asks. “It’s the best tool we have at this time.”

Another wrinkle in patient satisfaction was presented as an oral research abstract at HM12. Researchers from the Veterans Administration and the University of Michigan examined the association between hospitalist staffing levels and patient satisfaction.² Hospitals with the highest hospitalist staffing had modestly higher patient satisfaction scores than those with the lowest hospitalist staffing. Overall satisfaction was 65.6 for hospitals in the highest tertile of hospitalist staffing versus 62.7 those in the lowest tertile.

References

1. Seiler A, Visintainer P, Brzostek R, et al. Patient satisfaction with hospital care provided by hospitalists and primary care physicians. J Hosp Med. 2012;7:131-136.
2. Chen L, Birkmeyer J, Saint S, Ashish J. Hospitalist staffing and patient satisfaction in the national Medicare population. Abstract presented at HM12, April 2, 2012, San Diego.

Average difference in length of stay (LOS) between hospitalist groups and non-hospitalist groups, according to a meta-analysis of 17 studies of outcomes from the hospitalist approach.¹ The authors, from Cooper University Hospital in Camden, N.J., and elsewhere, searched medical literature through February 2011 for studies comparing length of stay or cost outcomes of hospitalist groups with non-hospitalist “comparator groups.” In studies comparing non-resident hospitalist services with non-resident, non-hospitalist services, LOS was shorter by 0.69 days for the hospitalist model. A total of 137,561 patients were included in the meta-analysis. No significant difference was found in cost between the hospitalist and comparison groups.

Reference

1. Rachoin JS, Skaf J, Cerceo E et al. The impact of hospitalists on length of stay and costs: Systematic review and meta-analysis. Am J Manag Care. 2012;18(1):e23-e30.

Average difference in length of stay (LOS) between hospitalist groups and non-hospitalist groups, according to a meta-analysis of 17 studies of outcomes from the hospitalist approach.¹ The authors, from Cooper University Hospital in Camden, N.J., and elsewhere, searched medical literature through February 2011 for studies comparing length of stay or cost outcomes of hospitalist groups with non-hospitalist “comparator groups.” In studies comparing non-resident hospitalist services with non-resident, non-hospitalist services, LOS was shorter by 0.69 days for the hospitalist model. A total of 137,561 patients were included in the meta-analysis. No significant difference was found in cost between the hospitalist and comparison groups.

Reference

1. Rachoin JS, Skaf J, Cerceo E et al. The impact of hospitalists on length of stay and costs: Systematic review and meta-analysis. Am J Manag Care. 2012;18(1):e23-e30.

Average difference in length of stay (LOS) between hospitalist groups and non-hospitalist groups, according to a meta-analysis of 17 studies of outcomes from the hospitalist approach.¹ The authors, from Cooper University Hospital in Camden, N.J., and elsewhere, searched medical literature through February 2011 for studies comparing length of stay or cost outcomes of hospitalist groups with non-hospitalist “comparator groups.” In studies comparing non-resident hospitalist services with non-resident, non-hospitalist services, LOS was shorter by 0.69 days for the hospitalist model. A total of 137,561 patients were included in the meta-analysis. No significant difference was found in cost between the hospitalist and comparison groups.

Reference

1. Rachoin JS, Skaf J, Cerceo E et al. The impact of hospitalists on length of stay and costs: Systematic review and meta-analysis. Am J Manag Care. 2012;18(1):e23-e30.

U.S. Department of Health and Human Services Secretary Kathleen Sebelius recently announced that the proportion of U.S. hospitals using health information technology (HIT), such as electronic health records (EHRs), has doubled in the past two years, reaching 35% in 2011, up from 16% in 2009, based on data from an American Hospital Association survey.

Nearly 2,000 hospitals and 41,000 physicians have taken advantage of $3.12 billion in EHR incentive payments from Medicare and Medicaid for ensuring meaningful use of HIT. Fully 85% of hospitals now report that they intend by 2015 to take advantage of HIT incentive payments, which were funded under the HITECH Act provisions of the American Recovery and Reinvestment Act of 2009.

The government also has created a network of 62 regional extension centers to provide technical guidance and resources. Individual HIT training is available at more than 90 community colleges and universities nationwide. For more information on the incentives, visit www.cms.gov/EHRIncentivePrograms.

A recent study of the “connected health maturity index”—systematic leveraging of HIT applications and health information exchanges—in eight countries finds the U.S. leading in several aspects of HIT use and adoption.¹ The Reston, Va., consulting firm Accenture interviewed and surveyed health-policy makers, HIT experts, and physicians in the U.S., Australia, Canada, England, France, Germany, Singapore, and Spain.

The U.S. led the way in computerized physician order entry, and 65% of its primary-care physicians (PCPs) use e-prescribing versus 20% in the other surveyed countries. Sixty-two percent of U.S. medical specialists use electronic tools to improve administrative efficiency. However, the report notes, the eight surveyed countries continue to lag behind such acknowledged HIT leaders as Denmark, Sweden, and New Zealand.

Reference

1. Accenture. U.S. among leaders in healthcare IT use and adoption, Accenture eight-country study reports. Accenture website. Available at: http://newsroom.accenture.com/news/us-among-leaders-in-healthcare-it-use-and-adoption-accenture-eight-country-study-reports.htm. Accessed March 29, 2012.

U.S. Department of Health and Human Services Secretary Kathleen Sebelius recently announced that the proportion of U.S. hospitals using health information technology (HIT), such as electronic health records (EHRs), has doubled in the past two years, reaching 35% in 2011, up from 16% in 2009, based on data from an American Hospital Association survey.

Nearly 2,000 hospitals and 41,000 physicians have taken advantage of $3.12 billion in EHR incentive payments from Medicare and Medicaid for ensuring meaningful use of HIT. Fully 85% of hospitals now report that they intend by 2015 to take advantage of HIT incentive payments, which were funded under the HITECH Act provisions of the American Recovery and Reinvestment Act of 2009.

The government also has created a network of 62 regional extension centers to provide technical guidance and resources. Individual HIT training is available at more than 90 community colleges and universities nationwide. For more information on the incentives, visit www.cms.gov/EHRIncentivePrograms.

A recent study of the “connected health maturity index”—systematic leveraging of HIT applications and health information exchanges—in eight countries finds the U.S. leading in several aspects of HIT use and adoption.¹ The Reston, Va., consulting firm Accenture interviewed and surveyed health-policy makers, HIT experts, and physicians in the U.S., Australia, Canada, England, France, Germany, Singapore, and Spain.

The U.S. led the way in computerized physician order entry, and 65% of its primary-care physicians (PCPs) use e-prescribing versus 20% in the other surveyed countries. Sixty-two percent of U.S. medical specialists use electronic tools to improve administrative efficiency. However, the report notes, the eight surveyed countries continue to lag behind such acknowledged HIT leaders as Denmark, Sweden, and New Zealand.

Reference

1. Accenture. U.S. among leaders in healthcare IT use and adoption, Accenture eight-country study reports. Accenture website. Available at: http://newsroom.accenture.com/news/us-among-leaders-in-healthcare-it-use-and-adoption-accenture-eight-country-study-reports.htm. Accessed March 29, 2012.

U.S. Department of Health and Human Services Secretary Kathleen Sebelius recently announced that the proportion of U.S. hospitals using health information technology (HIT), such as electronic health records (EHRs), has doubled in the past two years, reaching 35% in 2011, up from 16% in 2009, based on data from an American Hospital Association survey.

Nearly 2,000 hospitals and 41,000 physicians have taken advantage of $3.12 billion in EHR incentive payments from Medicare and Medicaid for ensuring meaningful use of HIT. Fully 85% of hospitals now report that they intend by 2015 to take advantage of HIT incentive payments, which were funded under the HITECH Act provisions of the American Recovery and Reinvestment Act of 2009.

The government also has created a network of 62 regional extension centers to provide technical guidance and resources. Individual HIT training is available at more than 90 community colleges and universities nationwide. For more information on the incentives, visit www.cms.gov/EHRIncentivePrograms.

A recent study of the “connected health maturity index”—systematic leveraging of HIT applications and health information exchanges—in eight countries finds the U.S. leading in several aspects of HIT use and adoption.¹ The Reston, Va., consulting firm Accenture interviewed and surveyed health-policy makers, HIT experts, and physicians in the U.S., Australia, Canada, England, France, Germany, Singapore, and Spain.

The U.S. led the way in computerized physician order entry, and 65% of its primary-care physicians (PCPs) use e-prescribing versus 20% in the other surveyed countries. Sixty-two percent of U.S. medical specialists use electronic tools to improve administrative efficiency. However, the report notes, the eight surveyed countries continue to lag behind such acknowledged HIT leaders as Denmark, Sweden, and New Zealand.

Reference

1. Accenture. U.S. among leaders in healthcare IT use and adoption, Accenture eight-country study reports. Accenture website. Available at: http://newsroom.accenture.com/news/us-among-leaders-in-healthcare-it-use-and-adoption-accenture-eight-country-study-reports.htm. Accessed March 29, 2012.

Residents can play a lead role in a program aimed at teaching commitment to the highest standards of excellence in medicine, to the welfare of patients, and to the best interests of the larger society, according to an innovations poster presentation at HM12.¹

Professionalism is important to physicians and medical trainees, says Pablo Garcia, MD, a critical-care fellow at the University of New Mexico (UNM) School of Medicine in Albuquerque and one of the project investigators who presented the results in San Diego.

“It directly impacts on patient care and the patient experience,” Dr. Garcia says. “But if we don’t police ourselves as a profession and set our own high standards, we may find that others outside of medicine will take notice.”

Academic medical centers have a particular interest in teaching professionalism to their trainees, not only because the Accreditation Council for Graduate Medical Education (ACGME) requires it, but also because of the profound impact of positive or negative examples by teachers—the “hidden curriculum”— on trainees, Dr. Garcia says.

The UNM project began with a lecture on elements of and threats to professionalism. A nine-item survey was completed by about half of the 70-member internal-medicine residency program. The results showed some less-than-ideal standards by residents. A team then met to develop nine vignettes involving real-world ethical situations, and small groups of four to six participants came together to discuss the vignettes and how they should be handled.

In some cases, attending physicians observed the groups and posed questions but did not lead the discussions, Dr. Garcia says. Over 12 months, all of the ethical scenarios were discussed at least once. Dr. Garcia was invited to speak to two other residency programs at UNM, pediatrics and emergency medicine, both of which developed their own vignettes for small-group discussion.

Reference

1. Menon R, Garcia P, Rogers K. Plugging gaps in professionalism education: a resident-generated curriculum. Abstract presented at HM12, April 2, 2012, San Diego.

Residents can play a lead role in a program aimed at teaching commitment to the highest standards of excellence in medicine, to the welfare of patients, and to the best interests of the larger society, according to an innovations poster presentation at HM12.¹

Professionalism is important to physicians and medical trainees, says Pablo Garcia, MD, a critical-care fellow at the University of New Mexico (UNM) School of Medicine in Albuquerque and one of the project investigators who presented the results in San Diego.

“It directly impacts on patient care and the patient experience,” Dr. Garcia says. “But if we don’t police ourselves as a profession and set our own high standards, we may find that others outside of medicine will take notice.”

Academic medical centers have a particular interest in teaching professionalism to their trainees, not only because the Accreditation Council for Graduate Medical Education (ACGME) requires it, but also because of the profound impact of positive or negative examples by teachers—the “hidden curriculum”— on trainees, Dr. Garcia says.

The UNM project began with a lecture on elements of and threats to professionalism. A nine-item survey was completed by about half of the 70-member internal-medicine residency program. The results showed some less-than-ideal standards by residents. A team then met to develop nine vignettes involving real-world ethical situations, and small groups of four to six participants came together to discuss the vignettes and how they should be handled.

In some cases, attending physicians observed the groups and posed questions but did not lead the discussions, Dr. Garcia says. Over 12 months, all of the ethical scenarios were discussed at least once. Dr. Garcia was invited to speak to two other residency programs at UNM, pediatrics and emergency medicine, both of which developed their own vignettes for small-group discussion.

Reference

1. Menon R, Garcia P, Rogers K. Plugging gaps in professionalism education: a resident-generated curriculum. Abstract presented at HM12, April 2, 2012, San Diego.

Residents can play a lead role in a program aimed at teaching commitment to the highest standards of excellence in medicine, to the welfare of patients, and to the best interests of the larger society, according to an innovations poster presentation at HM12.¹

Professionalism is important to physicians and medical trainees, says Pablo Garcia, MD, a critical-care fellow at the University of New Mexico (UNM) School of Medicine in Albuquerque and one of the project investigators who presented the results in San Diego.

“It directly impacts on patient care and the patient experience,” Dr. Garcia says. “But if we don’t police ourselves as a profession and set our own high standards, we may find that others outside of medicine will take notice.”

Academic medical centers have a particular interest in teaching professionalism to their trainees, not only because the Accreditation Council for Graduate Medical Education (ACGME) requires it, but also because of the profound impact of positive or negative examples by teachers—the “hidden curriculum”— on trainees, Dr. Garcia says.

The UNM project began with a lecture on elements of and threats to professionalism. A nine-item survey was completed by about half of the 70-member internal-medicine residency program. The results showed some less-than-ideal standards by residents. A team then met to develop nine vignettes involving real-world ethical situations, and small groups of four to six participants came together to discuss the vignettes and how they should be handled.

In some cases, attending physicians observed the groups and posed questions but did not lead the discussions, Dr. Garcia says. Over 12 months, all of the ethical scenarios were discussed at least once. Dr. Garcia was invited to speak to two other residency programs at UNM, pediatrics and emergency medicine, both of which developed their own vignettes for small-group discussion.

Reference

1. Menon R, Garcia P, Rogers K. Plugging gaps in professionalism education: a resident-generated curriculum. Abstract presented at HM12, April 2, 2012, San Diego.

Engaging in advance-care-planning discussions with their physicians or having advance directives filed in their medical records resulted in no significant difference in survival time for patients at three Colorado hospitals, according to a report in the Journal of Hospital Medicine.¹

A total of 458 adult patients admitted to general IM services at the hospitals were asked whether they’d had discussions with their physicians about advance directives, which are legal documents allowing patients to spell out treatment preferences (including a desire for more aggressive treatment) in advance of situations in which they are no longer able to communicate them. Charts were reviewed for the presence of advance directives, and the patients were then stratified based on low, medium, or high risk of death within a year. The high-risk patients were excluded from the study, and those in the low- and medium-risk groups were followed from 2003 to 2009.

“In regard to the current national debate about the merits of advance-care planning, this study suggests that honoring patients’ wishes to engage in advance directive discussions and documentation does not lead to harm,” the study concludes.

Lead author Stacy Fischer, MD, of the University of Colorado Denver says that it is striking how few hospitalized patients have actually engaged in these conversations, even though the population is quite ill. “So often, the conversation happens too late,” she says, “and then not with the patient but with a surrogate.”

Dr. Fischer encourages hospitalists to view the hospital admission as an important opportunity to start conversations with patients about their future care preferences. When patients come into the hospital, they must be asked about advance directives, but that process tends to be cursory, she says. At a minimum, hospitalists should clarify who the surrogate decision maker is, who would speak for the patient at a time of incapacity.

What should the hospitalist’s role be in end-of-life discussions? “That’s a complicated question in the current environment, where nobody seems to think it’s their role,” Dr. Fischer says. “I believe we all need to help move the conversation along. If [advance directive] forms can be available on the floor and if patients express interest in them, then encouraging them would be important.”

Larry Beresford is a freelance writer in Oakland, Calif.

References

1. Fischer SM, Min SJ, Sauaia A, Kutner JS. “They’re going to unplug grandma”: Advance directive discussions and documentation do not decrease survival in patients at baseline lower risk of death. J Hosp Med. 2012;7:3-7.

Engaging in advance-care-planning discussions with their physicians or having advance directives filed in their medical records resulted in no significant difference in survival time for patients at three Colorado hospitals, according to a report in the Journal of Hospital Medicine.¹

A total of 458 adult patients admitted to general IM services at the hospitals were asked whether they’d had discussions with their physicians about advance directives, which are legal documents allowing patients to spell out treatment preferences (including a desire for more aggressive treatment) in advance of situations in which they are no longer able to communicate them. Charts were reviewed for the presence of advance directives, and the patients were then stratified based on low, medium, or high risk of death within a year. The high-risk patients were excluded from the study, and those in the low- and medium-risk groups were followed from 2003 to 2009.

“In regard to the current national debate about the merits of advance-care planning, this study suggests that honoring patients’ wishes to engage in advance directive discussions and documentation does not lead to harm,” the study concludes.

Lead author Stacy Fischer, MD, of the University of Colorado Denver says that it is striking how few hospitalized patients have actually engaged in these conversations, even though the population is quite ill. “So often, the conversation happens too late,” she says, “and then not with the patient but with a surrogate.”

Dr. Fischer encourages hospitalists to view the hospital admission as an important opportunity to start conversations with patients about their future care preferences. When patients come into the hospital, they must be asked about advance directives, but that process tends to be cursory, she says. At a minimum, hospitalists should clarify who the surrogate decision maker is, who would speak for the patient at a time of incapacity.

What should the hospitalist’s role be in end-of-life discussions? “That’s a complicated question in the current environment, where nobody seems to think it’s their role,” Dr. Fischer says. “I believe we all need to help move the conversation along. If [advance directive] forms can be available on the floor and if patients express interest in them, then encouraging them would be important.”

Larry Beresford is a freelance writer in Oakland, Calif.

References

1. Fischer SM, Min SJ, Sauaia A, Kutner JS. “They’re going to unplug grandma”: Advance directive discussions and documentation do not decrease survival in patients at baseline lower risk of death. J Hosp Med. 2012;7:3-7.

Engaging in advance-care-planning discussions with their physicians or having advance directives filed in their medical records resulted in no significant difference in survival time for patients at three Colorado hospitals, according to a report in the Journal of Hospital Medicine.¹

A total of 458 adult patients admitted to general IM services at the hospitals were asked whether they’d had discussions with their physicians about advance directives, which are legal documents allowing patients to spell out treatment preferences (including a desire for more aggressive treatment) in advance of situations in which they are no longer able to communicate them. Charts were reviewed for the presence of advance directives, and the patients were then stratified based on low, medium, or high risk of death within a year. The high-risk patients were excluded from the study, and those in the low- and medium-risk groups were followed from 2003 to 2009.

“In regard to the current national debate about the merits of advance-care planning, this study suggests that honoring patients’ wishes to engage in advance directive discussions and documentation does not lead to harm,” the study concludes.

Lead author Stacy Fischer, MD, of the University of Colorado Denver says that it is striking how few hospitalized patients have actually engaged in these conversations, even though the population is quite ill. “So often, the conversation happens too late,” she says, “and then not with the patient but with a surrogate.”

Dr. Fischer encourages hospitalists to view the hospital admission as an important opportunity to start conversations with patients about their future care preferences. When patients come into the hospital, they must be asked about advance directives, but that process tends to be cursory, she says. At a minimum, hospitalists should clarify who the surrogate decision maker is, who would speak for the patient at a time of incapacity.

What should the hospitalist’s role be in end-of-life discussions? “That’s a complicated question in the current environment, where nobody seems to think it’s their role,” Dr. Fischer says. “I believe we all need to help move the conversation along. If [advance directive] forms can be available on the floor and if patients express interest in them, then encouraging them would be important.”

Larry Beresford is a freelance writer in Oakland, Calif.

References

1. Fischer SM, Min SJ, Sauaia A, Kutner JS. “They’re going to unplug grandma”: Advance directive discussions and documentation do not decrease survival in patients at baseline lower risk of death. J Hosp Med. 2012;7:3-7.

Hospital medicine has never been bashful about stating its goal to be a financial steward of the most expensive place in our healthcare system—the hospital. At the first gathering of hospitalists in April 1997, the newly formed board of directors debated whether we should promote efficiency as a primary goal of the organization and, by extension, our field. We drafted as the first line of our mission: To promote the high-quality and cost-effective care of the hospitalized patient.

Now, as the cost of healthcare approaches 18% of our nation’s gross domestic product, the jobless rate remains high, and the economic recovery underwhelms us, the emphasis of many thought leaders has shifted to cost as the single biggest barrier to ideal healthcare in the U.S.:

• The ABIM Foundation’s Choosing Wisely campaign encourages doctors and patients to “talk about medical tests and procedures that might be unnecessary, and in some instances can cause harm.” Its Physician Charter contains “wise use of finite resources” as a key element.
• In April, the American College of Physicians (ACP) announced “5 Things Internists and Patients Should Question in Internal Medicine”.
• At the Institute for Healthcare Improvement’s national meeting in December, the organization’s spiritual leader, Don Berwick, MD, had just returned from 16 months as CMS administrator and pronounced in his keynote address: “I would go so far as to say that, for the next three to five years at least, the credibility and leverage of the quality movement will rise or fall on its success in reducing the cost of healthcare … while improving patient experience. ‘Value’ improvement won’t be enough. It will take cost reduction to capture the flag. Otherwise, cutting wins.”

Cost Is the New Quality

I agree with Don: Sure, the other dimensions of quality healthcare—that it be safe, timely, equitable, effective, and person-centered—are critical. But now, efficiency is king. Looking ahead, it will require singular focus.

The problem is, who can get excited about reducing costs? (Don’t all raise your hands at once.) Well-meaning clinicians, when asked by healthcare administrators to order fewer tests or use cheaper drugs, shrug their shoulders and assume it is a ploy for the hospital or health plan to bolster profits off their backs. Or we simply feel that we have better places to focus our efforts. After all, ours is a noble profession, not a bottom-line-focused guild.

Waste Is the New Cost

The thing we can get excited about is reducing waste. We see waste every day and have the genuine wish to eliminate it. As an example, the Lean practice—borrowed from manufacturing—is a widely used tool in healthcare. Its primary focus is the recognition and elimination of waste. Lean recognizes as many types of waste as Eskimos have words for snow.

Dr. Berwick went on to outline six areas of waste in healthcare, at least three of which fall squarely on the shoulders of hospitalists:¹

• Failures of care delivery, or lack of uniform adoption of best-care processes. Examples: use of a central-line insertion bundle; early, goal-directed therapy in severe sepsis.
• Failures of care coordination. Poor handoffs and follow-up cause readmissions and other harm. Example: failure to provide a reconciled medication list to patient and next provider of care after discharge.
• Overtreatment, or exposing patients to care interventions that offer no benefit and could cause harm. Examples: VTE prophylaxis in low-risk patients; endotracheal intubation in a patient who does not desire it; admitting a patient to the hospital because it is easier than arranging outpatient follow-up from the ED (see Table 1).

The other three (administrative complexity, pricing failures, and fraud and abuse) are for another day.

Go Forth and Slash

What can we do immediately to reduce waste? At a high level, HM should take on the waste challenge the same way it confronted quality and patient safety. We have had an implicit waste agenda, at least in terms of efficient hospital throughput. Now we need to make that agenda explicit, and be clear that our focus on length of stay, costs, and avoidance of overtreatment is what is needed for our patients and our system. We need a framework for moving forward, and we need leaders from our ranks to build it out.

In the meantime, let’s go to work tomorrow and implement change in the three areas Dr. Berwick mentions. He believes in us. So do I.

Dr. Whitcomb is medical director of healthcare quality at Baystate Medical Center in Springfield, Mass. He is a co-founder and past president of SHM. Email him at [email protected].

Reference

1. Berwick DM, Hackbarth AD. Eliminating waste in US health care. JAMA. 2012;37(14):1513-1516.

Hospital medicine has never been bashful about stating its goal to be a financial steward of the most expensive place in our healthcare system—the hospital. At the first gathering of hospitalists in April 1997, the newly formed board of directors debated whether we should promote efficiency as a primary goal of the organization and, by extension, our field. We drafted as the first line of our mission: To promote the high-quality and cost-effective care of the hospitalized patient.

Now, as the cost of healthcare approaches 18% of our nation’s gross domestic product, the jobless rate remains high, and the economic recovery underwhelms us, the emphasis of many thought leaders has shifted to cost as the single biggest barrier to ideal healthcare in the U.S.:

• The ABIM Foundation’s Choosing Wisely campaign encourages doctors and patients to “talk about medical tests and procedures that might be unnecessary, and in some instances can cause harm.” Its Physician Charter contains “wise use of finite resources” as a key element.
• In April, the American College of Physicians (ACP) announced “5 Things Internists and Patients Should Question in Internal Medicine”.
• At the Institute for Healthcare Improvement’s national meeting in December, the organization’s spiritual leader, Don Berwick, MD, had just returned from 16 months as CMS administrator and pronounced in his keynote address: “I would go so far as to say that, for the next three to five years at least, the credibility and leverage of the quality movement will rise or fall on its success in reducing the cost of healthcare … while improving patient experience. ‘Value’ improvement won’t be enough. It will take cost reduction to capture the flag. Otherwise, cutting wins.”

Cost Is the New Quality

I agree with Don: Sure, the other dimensions of quality healthcare—that it be safe, timely, equitable, effective, and person-centered—are critical. But now, efficiency is king. Looking ahead, it will require singular focus.

The problem is, who can get excited about reducing costs? (Don’t all raise your hands at once.) Well-meaning clinicians, when asked by healthcare administrators to order fewer tests or use cheaper drugs, shrug their shoulders and assume it is a ploy for the hospital or health plan to bolster profits off their backs. Or we simply feel that we have better places to focus our efforts. After all, ours is a noble profession, not a bottom-line-focused guild.

Waste Is the New Cost

The thing we can get excited about is reducing waste. We see waste every day and have the genuine wish to eliminate it. As an example, the Lean practice—borrowed from manufacturing—is a widely used tool in healthcare. Its primary focus is the recognition and elimination of waste. Lean recognizes as many types of waste as Eskimos have words for snow.

Dr. Berwick went on to outline six areas of waste in healthcare, at least three of which fall squarely on the shoulders of hospitalists:¹

• Failures of care delivery, or lack of uniform adoption of best-care processes. Examples: use of a central-line insertion bundle; early, goal-directed therapy in severe sepsis.
• Failures of care coordination. Poor handoffs and follow-up cause readmissions and other harm. Example: failure to provide a reconciled medication list to patient and next provider of care after discharge.
• Overtreatment, or exposing patients to care interventions that offer no benefit and could cause harm. Examples: VTE prophylaxis in low-risk patients; endotracheal intubation in a patient who does not desire it; admitting a patient to the hospital because it is easier than arranging outpatient follow-up from the ED (see Table 1).

The other three (administrative complexity, pricing failures, and fraud and abuse) are for another day.

Go Forth and Slash

What can we do immediately to reduce waste? At a high level, HM should take on the waste challenge the same way it confronted quality and patient safety. We have had an implicit waste agenda, at least in terms of efficient hospital throughput. Now we need to make that agenda explicit, and be clear that our focus on length of stay, costs, and avoidance of overtreatment is what is needed for our patients and our system. We need a framework for moving forward, and we need leaders from our ranks to build it out.

In the meantime, let’s go to work tomorrow and implement change in the three areas Dr. Berwick mentions. He believes in us. So do I.

Dr. Whitcomb is medical director of healthcare quality at Baystate Medical Center in Springfield, Mass. He is a co-founder and past president of SHM. Email him at [email protected].

Reference

1. Berwick DM, Hackbarth AD. Eliminating waste in US health care. JAMA. 2012;37(14):1513-1516.

Hospital medicine has never been bashful about stating its goal to be a financial steward of the most expensive place in our healthcare system—the hospital. At the first gathering of hospitalists in April 1997, the newly formed board of directors debated whether we should promote efficiency as a primary goal of the organization and, by extension, our field. We drafted as the first line of our mission: To promote the high-quality and cost-effective care of the hospitalized patient.

Now, as the cost of healthcare approaches 18% of our nation’s gross domestic product, the jobless rate remains high, and the economic recovery underwhelms us, the emphasis of many thought leaders has shifted to cost as the single biggest barrier to ideal healthcare in the U.S.:

• The ABIM Foundation’s Choosing Wisely campaign encourages doctors and patients to “talk about medical tests and procedures that might be unnecessary, and in some instances can cause harm.” Its Physician Charter contains “wise use of finite resources” as a key element.
• In April, the American College of Physicians (ACP) announced “5 Things Internists and Patients Should Question in Internal Medicine”.
• At the Institute for Healthcare Improvement’s national meeting in December, the organization’s spiritual leader, Don Berwick, MD, had just returned from 16 months as CMS administrator and pronounced in his keynote address: “I would go so far as to say that, for the next three to five years at least, the credibility and leverage of the quality movement will rise or fall on its success in reducing the cost of healthcare … while improving patient experience. ‘Value’ improvement won’t be enough. It will take cost reduction to capture the flag. Otherwise, cutting wins.”

Cost Is the New Quality

I agree with Don: Sure, the other dimensions of quality healthcare—that it be safe, timely, equitable, effective, and person-centered—are critical. But now, efficiency is king. Looking ahead, it will require singular focus.

The problem is, who can get excited about reducing costs? (Don’t all raise your hands at once.) Well-meaning clinicians, when asked by healthcare administrators to order fewer tests or use cheaper drugs, shrug their shoulders and assume it is a ploy for the hospital or health plan to bolster profits off their backs. Or we simply feel that we have better places to focus our efforts. After all, ours is a noble profession, not a bottom-line-focused guild.

Waste Is the New Cost

The thing we can get excited about is reducing waste. We see waste every day and have the genuine wish to eliminate it. As an example, the Lean practice—borrowed from manufacturing—is a widely used tool in healthcare. Its primary focus is the recognition and elimination of waste. Lean recognizes as many types of waste as Eskimos have words for snow.

Dr. Berwick went on to outline six areas of waste in healthcare, at least three of which fall squarely on the shoulders of hospitalists:¹

• Failures of care delivery, or lack of uniform adoption of best-care processes. Examples: use of a central-line insertion bundle; early, goal-directed therapy in severe sepsis.
• Failures of care coordination. Poor handoffs and follow-up cause readmissions and other harm. Example: failure to provide a reconciled medication list to patient and next provider of care after discharge.
• Overtreatment, or exposing patients to care interventions that offer no benefit and could cause harm. Examples: VTE prophylaxis in low-risk patients; endotracheal intubation in a patient who does not desire it; admitting a patient to the hospital because it is easier than arranging outpatient follow-up from the ED (see Table 1).

The other three (administrative complexity, pricing failures, and fraud and abuse) are for another day.

Go Forth and Slash

What can we do immediately to reduce waste? At a high level, HM should take on the waste challenge the same way it confronted quality and patient safety. We have had an implicit waste agenda, at least in terms of efficient hospital throughput. Now we need to make that agenda explicit, and be clear that our focus on length of stay, costs, and avoidance of overtreatment is what is needed for our patients and our system. We need a framework for moving forward, and we need leaders from our ranks to build it out.

In the meantime, let’s go to work tomorrow and implement change in the three areas Dr. Berwick mentions. He believes in us. So do I.

Dr. Whitcomb is medical director of healthcare quality at Baystate Medical Center in Springfield, Mass. He is a co-founder and past president of SHM. Email him at [email protected].

Reference

1. Berwick DM, Hackbarth AD. Eliminating waste in US health care. JAMA. 2012;37(14):1513-1516.

Under Section 1862(a)(1)(A) of the Social Security Act, the Medicare program may only pay for items and services that are “reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member,” unless there is another statutory authorization for payment (e.g. colorectal cancer screening).¹ Coverage limitations include:²

• Proven clinical efficacy. For example, Medicare deems acupuncture “experimental/investigational” in the diagnosis or treatment of illness or injury;
• Diagnoses. As an example, vitamin B-12 injections are covered, but only for such diagnoses as pernicious anemia and dementias secondary to vitamin B-12 deficiency; and
• Frequency/utilization parameters. For example, a screening colonoscopy (G0105) can be paid once every 24 months for beneficiaries who are at high risk for colorectal cancer; otherwise the service is limited to once every 10 years.

Beyond these factors, individual consideration might be granted. Supportive and unambiguous documentation (medical records, clinical studies, etc.) must be submitted when the clinical circumstances do not appear to support the medical necessity for the service.

Diagnoses Selection

Select the code that best represents the primary reason for the service or procedure on a given date. In the absence of a definitive diagnosis, the code may correspond to a sign or symptom. Physicians never should report a code that represents a probable, suspected, or “rule out” condition. Although facility billing might consider these unconfirmed circumstances (when necessary), physician billing prohibits this practice.

Reporting services for hospitalized patients is challenging when multiple services for the same patient are provided on the same date by the same or different physician, also known as concurrent care. Each physician manages a particular aspect while still considering the patient’s overall condition; each physician should report the corresponding diagnosis for that management. If billed correctly, each physician will have a different primary diagnosis code to justify their involvement, increasing their opportunity for payment.³

The non-primary diagnoses might also be listed on the claim if appropriately addressed in the documentation (i.e. “non-primary” conditions’ indirect role in the focused management of the primary condition). For example, a hospitalist, pulmonologist, and nephrologist manage a patient’s uncontrolled diabetes (250.02), COPD exacerbation (491.21), and CRI (585.9), respectively. Each may report subsequent hospital care (99231-99233) for medically necessary concurrent care:

• Hospitalist: 250.02, 491.21, 585.9;
• Pulmonologist: 491.21, 250.02, 585.9; and
• Nephrologist: 585.9, 492.21, 250.02.

Coverage Determinations

Code comparisons can be made after diagnosis code selection. Coverage determinations identify specific conditions (i.e. ICD-9-CM codes) for which services are considered medically necessary. They also outline the frequency interval at which services can be performed, when applicable.

For example, vascular studies (e.g. CPT 93971) are indicated for the preoperative examination (ICD-9-CM V72.83) of potential harvest vein grafts prior to bypass surgery.⁴ This is a covered service only when the results of the study are necessary to locate suitable graft vessels. The need for bypass surgery must be determined prior to performance of the test. V72.83 is “covered” only when reported for a unilateral study, not a bilateral study (CPT 93970). Frequency parameters allow for only one preoperative scan.⁴

Coverage determination can occur on two levels: national and local. The Centers for Medicare & Medicaid Services (CMS) develops national coverage determinations (NCDs) through an evidence-based process, with opportunities for public participation.⁵ All Medicare administrative contractors must abide by NCDs without imposing further limitations or guidelines. As example, the NCD “Consultations With a Beneficiary’s Family and Associates” permits a physician to provide counseling to family members. Family counseling services are covered only when the primary purpose of such counseling is the treatment of the patient’s condition.⁶

Non-Medicare payors do not have to follow federal guidelines unless the member participates in a Medicare managed-care plan.

In the absence of a national coverage policy, an item or service may be covered at the discretion of the Medicare contractors based on a local coverage determination (LCD).⁵ LCDs vary by state, creating an inconsistent approach to medical coverage. The vascular study guidelines listed above do not apply to all contractors. For example, Trailblazer Health Enterprises’ policy does not reference preoperative exams being limited to unilateral studies.⁷ (A listing of Medicare Contractor LCDs can be found at www.cms.hhs.gov/DeterminationProcess/04_LCDs.asp.)

Other Considerations

Investigate “medical necessity” denials. Do not take them at face value. Billing personnel often assume that the physician reported an incorrect diagnosis code. Consider the service when trying to formulate a response to the denial. Procedures (surgical or diagnostic services) may be denied for an invalid diagnosis. After reviewing the documentation to ensure that it supports the diagnosis, the claim may be resubmitted with a corrected diagnosis code, when applicable. Denials for frequency limitations can only be appealed with documentation that explicitly identifies the need for the service beyond the contractor-stated parameters.

If the “medical necessity” denial involves a covered evaluation and management (E/M) visit, it is less likely to be diagnosis-related. More likely, when dealing with Medicare contractors, the denial is the result of a failed response to a prepayment request for documentation. Medicare typically issues a request to review documentation prior to payment for the following inpatient E/M services: 99223, 99233, 99239, and 99292.

If the documentation is not provided to the Medicare prepayment review department within the designated time frame, the claim is automatically denied with a citation of “not deemed a medical necessity.” Acknowledge this remittance remark and do not assume that the physician assigned an incorrect diagnosis code. Although this is a possibility, it is more likely due to the failed request response. Appealing these claims requires submission of documentation to the Medicare appeals department. Reimbursement is provided once supportive documentation is received.

Carol Pohlig is a billing and coding expert with the University of Pennsylvania Medical Center, Philadelphia. She is faculty for SHM’s inpatient coding course.

References

1. Social Security Administration. Exclusions from coverage and Medicare as a secondary payer. Social Security Administration website. Available at: http://www.ssa.gov/OP_Home/ssact/title18/1862.htm. Accessed March 1, 2012.
2. Highmark Medicare Services. A/B Reference Manual: Chapter 6, Medical Coverage, Medical Necessity, and Medical Policy. Highmark Medicare Services website. Available at: http://www.highmarkmedicareservices.com/refman/chapter-6.html. Accessed March 1, 2012.
3. Pohlig C. Daily care conundrums. The Hospitalist. 2008;12(12):18.
4. Highmark Medicare Services. LCD L27506: Non-Invasive Peripheral Venous Studies. Highmark Medicare Services website. Available at: http://www.highmarkmedicareservices.com/policy/mac-ab/l27506-r10.html. Accessed March 1, 2012.
5. Centers for Medicare & Medicaid Services. Medicare Coverage Determination Process: Overview. Centers for Medicare & Medicaid Services website. Available at: http://www.cms.hhs.gov/DeterminationProcess/01_Overview.asp#TopOfPage. Accessed March 1, 2012.
6. Centers for Medicare & Medicaid Services. Medicare National Coverage Determination Manual: Chapter 1, Part 1, Section 70.1. Centers for Medicare & Medicaid Services website. Available at: http://www.cms.gov/manuals/downloads/ncd103c1_Part1.pdf. Accessed March 1, 2012.
7. Trailblazer Health Enterprises. LCD 2866: Non-Invasive Venous Studies. Trailblazer Health Enterprises website. Available at: http://www.trailblazerhealth.com/Tools/LCDs.aspx?ID=2866. Accessed March 1, 2012.

Under Section 1862(a)(1)(A) of the Social Security Act, the Medicare program may only pay for items and services that are “reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member,” unless there is another statutory authorization for payment (e.g. colorectal cancer screening).¹ Coverage limitations include:²

• Proven clinical efficacy. For example, Medicare deems acupuncture “experimental/investigational” in the diagnosis or treatment of illness or injury;
• Diagnoses. As an example, vitamin B-12 injections are covered, but only for such diagnoses as pernicious anemia and dementias secondary to vitamin B-12 deficiency; and
• Frequency/utilization parameters. For example, a screening colonoscopy (G0105) can be paid once every 24 months for beneficiaries who are at high risk for colorectal cancer; otherwise the service is limited to once every 10 years.

Beyond these factors, individual consideration might be granted. Supportive and unambiguous documentation (medical records, clinical studies, etc.) must be submitted when the clinical circumstances do not appear to support the medical necessity for the service.

Diagnoses Selection

Select the code that best represents the primary reason for the service or procedure on a given date. In the absence of a definitive diagnosis, the code may correspond to a sign or symptom. Physicians never should report a code that represents a probable, suspected, or “rule out” condition. Although facility billing might consider these unconfirmed circumstances (when necessary), physician billing prohibits this practice.

Reporting services for hospitalized patients is challenging when multiple services for the same patient are provided on the same date by the same or different physician, also known as concurrent care. Each physician manages a particular aspect while still considering the patient’s overall condition; each physician should report the corresponding diagnosis for that management. If billed correctly, each physician will have a different primary diagnosis code to justify their involvement, increasing their opportunity for payment.³

The non-primary diagnoses might also be listed on the claim if appropriately addressed in the documentation (i.e. “non-primary” conditions’ indirect role in the focused management of the primary condition). For example, a hospitalist, pulmonologist, and nephrologist manage a patient’s uncontrolled diabetes (250.02), COPD exacerbation (491.21), and CRI (585.9), respectively. Each may report subsequent hospital care (99231-99233) for medically necessary concurrent care:

• Hospitalist: 250.02, 491.21, 585.9;
• Pulmonologist: 491.21, 250.02, 585.9; and
• Nephrologist: 585.9, 492.21, 250.02.

Coverage Determinations

Code comparisons can be made after diagnosis code selection. Coverage determinations identify specific conditions (i.e. ICD-9-CM codes) for which services are considered medically necessary. They also outline the frequency interval at which services can be performed, when applicable.

For example, vascular studies (e.g. CPT 93971) are indicated for the preoperative examination (ICD-9-CM V72.83) of potential harvest vein grafts prior to bypass surgery.⁴ This is a covered service only when the results of the study are necessary to locate suitable graft vessels. The need for bypass surgery must be determined prior to performance of the test. V72.83 is “covered” only when reported for a unilateral study, not a bilateral study (CPT 93970). Frequency parameters allow for only one preoperative scan.⁴

Coverage determination can occur on two levels: national and local. The Centers for Medicare & Medicaid Services (CMS) develops national coverage determinations (NCDs) through an evidence-based process, with opportunities for public participation.⁵ All Medicare administrative contractors must abide by NCDs without imposing further limitations or guidelines. As example, the NCD “Consultations With a Beneficiary’s Family and Associates” permits a physician to provide counseling to family members. Family counseling services are covered only when the primary purpose of such counseling is the treatment of the patient’s condition.⁶

Non-Medicare payors do not have to follow federal guidelines unless the member participates in a Medicare managed-care plan.

In the absence of a national coverage policy, an item or service may be covered at the discretion of the Medicare contractors based on a local coverage determination (LCD).⁵ LCDs vary by state, creating an inconsistent approach to medical coverage. The vascular study guidelines listed above do not apply to all contractors. For example, Trailblazer Health Enterprises’ policy does not reference preoperative exams being limited to unilateral studies.⁷ (A listing of Medicare Contractor LCDs can be found at www.cms.hhs.gov/DeterminationProcess/04_LCDs.asp.)

Other Considerations

Investigate “medical necessity” denials. Do not take them at face value. Billing personnel often assume that the physician reported an incorrect diagnosis code. Consider the service when trying to formulate a response to the denial. Procedures (surgical or diagnostic services) may be denied for an invalid diagnosis. After reviewing the documentation to ensure that it supports the diagnosis, the claim may be resubmitted with a corrected diagnosis code, when applicable. Denials for frequency limitations can only be appealed with documentation that explicitly identifies the need for the service beyond the contractor-stated parameters.

If the “medical necessity” denial involves a covered evaluation and management (E/M) visit, it is less likely to be diagnosis-related. More likely, when dealing with Medicare contractors, the denial is the result of a failed response to a prepayment request for documentation. Medicare typically issues a request to review documentation prior to payment for the following inpatient E/M services: 99223, 99233, 99239, and 99292.

If the documentation is not provided to the Medicare prepayment review department within the designated time frame, the claim is automatically denied with a citation of “not deemed a medical necessity.” Acknowledge this remittance remark and do not assume that the physician assigned an incorrect diagnosis code. Although this is a possibility, it is more likely due to the failed request response. Appealing these claims requires submission of documentation to the Medicare appeals department. Reimbursement is provided once supportive documentation is received.

Carol Pohlig is a billing and coding expert with the University of Pennsylvania Medical Center, Philadelphia. She is faculty for SHM’s inpatient coding course.

References

1. Social Security Administration. Exclusions from coverage and Medicare as a secondary payer. Social Security Administration website. Available at: http://www.ssa.gov/OP_Home/ssact/title18/1862.htm. Accessed March 1, 2012.
2. Highmark Medicare Services. A/B Reference Manual: Chapter 6, Medical Coverage, Medical Necessity, and Medical Policy. Highmark Medicare Services website. Available at: http://www.highmarkmedicareservices.com/refman/chapter-6.html. Accessed March 1, 2012.
3. Pohlig C. Daily care conundrums. The Hospitalist. 2008;12(12):18.
4. Highmark Medicare Services. LCD L27506: Non-Invasive Peripheral Venous Studies. Highmark Medicare Services website. Available at: http://www.highmarkmedicareservices.com/policy/mac-ab/l27506-r10.html. Accessed March 1, 2012.
5. Centers for Medicare & Medicaid Services. Medicare Coverage Determination Process: Overview. Centers for Medicare & Medicaid Services website. Available at: http://www.cms.hhs.gov/DeterminationProcess/01_Overview.asp#TopOfPage. Accessed March 1, 2012.
6. Centers for Medicare & Medicaid Services. Medicare National Coverage Determination Manual: Chapter 1, Part 1, Section 70.1. Centers for Medicare & Medicaid Services website. Available at: http://www.cms.gov/manuals/downloads/ncd103c1_Part1.pdf. Accessed March 1, 2012.
7. Trailblazer Health Enterprises. LCD 2866: Non-Invasive Venous Studies. Trailblazer Health Enterprises website. Available at: http://www.trailblazerhealth.com/Tools/LCDs.aspx?ID=2866. Accessed March 1, 2012.

Under Section 1862(a)(1)(A) of the Social Security Act, the Medicare program may only pay for items and services that are “reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member,” unless there is another statutory authorization for payment (e.g. colorectal cancer screening).¹ Coverage limitations include:²

• Proven clinical efficacy. For example, Medicare deems acupuncture “experimental/investigational” in the diagnosis or treatment of illness or injury;
• Diagnoses. As an example, vitamin B-12 injections are covered, but only for such diagnoses as pernicious anemia and dementias secondary to vitamin B-12 deficiency; and
• Frequency/utilization parameters. For example, a screening colonoscopy (G0105) can be paid once every 24 months for beneficiaries who are at high risk for colorectal cancer; otherwise the service is limited to once every 10 years.

Beyond these factors, individual consideration might be granted. Supportive and unambiguous documentation (medical records, clinical studies, etc.) must be submitted when the clinical circumstances do not appear to support the medical necessity for the service.

Diagnoses Selection

Select the code that best represents the primary reason for the service or procedure on a given date. In the absence of a definitive diagnosis, the code may correspond to a sign or symptom. Physicians never should report a code that represents a probable, suspected, or “rule out” condition. Although facility billing might consider these unconfirmed circumstances (when necessary), physician billing prohibits this practice.

Reporting services for hospitalized patients is challenging when multiple services for the same patient are provided on the same date by the same or different physician, also known as concurrent care. Each physician manages a particular aspect while still considering the patient’s overall condition; each physician should report the corresponding diagnosis for that management. If billed correctly, each physician will have a different primary diagnosis code to justify their involvement, increasing their opportunity for payment.³

The non-primary diagnoses might also be listed on the claim if appropriately addressed in the documentation (i.e. “non-primary” conditions’ indirect role in the focused management of the primary condition). For example, a hospitalist, pulmonologist, and nephrologist manage a patient’s uncontrolled diabetes (250.02), COPD exacerbation (491.21), and CRI (585.9), respectively. Each may report subsequent hospital care (99231-99233) for medically necessary concurrent care:

• Hospitalist: 250.02, 491.21, 585.9;
• Pulmonologist: 491.21, 250.02, 585.9; and
• Nephrologist: 585.9, 492.21, 250.02.

Coverage Determinations

Code comparisons can be made after diagnosis code selection. Coverage determinations identify specific conditions (i.e. ICD-9-CM codes) for which services are considered medically necessary. They also outline the frequency interval at which services can be performed, when applicable.

For example, vascular studies (e.g. CPT 93971) are indicated for the preoperative examination (ICD-9-CM V72.83) of potential harvest vein grafts prior to bypass surgery.⁴ This is a covered service only when the results of the study are necessary to locate suitable graft vessels. The need for bypass surgery must be determined prior to performance of the test. V72.83 is “covered” only when reported for a unilateral study, not a bilateral study (CPT 93970). Frequency parameters allow for only one preoperative scan.⁴

Coverage determination can occur on two levels: national and local. The Centers for Medicare & Medicaid Services (CMS) develops national coverage determinations (NCDs) through an evidence-based process, with opportunities for public participation.⁵ All Medicare administrative contractors must abide by NCDs without imposing further limitations or guidelines. As example, the NCD “Consultations With a Beneficiary’s Family and Associates” permits a physician to provide counseling to family members. Family counseling services are covered only when the primary purpose of such counseling is the treatment of the patient’s condition.⁶

Non-Medicare payors do not have to follow federal guidelines unless the member participates in a Medicare managed-care plan.

In the absence of a national coverage policy, an item or service may be covered at the discretion of the Medicare contractors based on a local coverage determination (LCD).⁵ LCDs vary by state, creating an inconsistent approach to medical coverage. The vascular study guidelines listed above do not apply to all contractors. For example, Trailblazer Health Enterprises’ policy does not reference preoperative exams being limited to unilateral studies.⁷ (A listing of Medicare Contractor LCDs can be found at www.cms.hhs.gov/DeterminationProcess/04_LCDs.asp.)

Other Considerations

Investigate “medical necessity” denials. Do not take them at face value. Billing personnel often assume that the physician reported an incorrect diagnosis code. Consider the service when trying to formulate a response to the denial. Procedures (surgical or diagnostic services) may be denied for an invalid diagnosis. After reviewing the documentation to ensure that it supports the diagnosis, the claim may be resubmitted with a corrected diagnosis code, when applicable. Denials for frequency limitations can only be appealed with documentation that explicitly identifies the need for the service beyond the contractor-stated parameters.

If the “medical necessity” denial involves a covered evaluation and management (E/M) visit, it is less likely to be diagnosis-related. More likely, when dealing with Medicare contractors, the denial is the result of a failed response to a prepayment request for documentation. Medicare typically issues a request to review documentation prior to payment for the following inpatient E/M services: 99223, 99233, 99239, and 99292.

If the documentation is not provided to the Medicare prepayment review department within the designated time frame, the claim is automatically denied with a citation of “not deemed a medical necessity.” Acknowledge this remittance remark and do not assume that the physician assigned an incorrect diagnosis code. Although this is a possibility, it is more likely due to the failed request response. Appealing these claims requires submission of documentation to the Medicare appeals department. Reimbursement is provided once supportive documentation is received.

Carol Pohlig is a billing and coding expert with the University of Pennsylvania Medical Center, Philadelphia. She is faculty for SHM’s inpatient coding course.

References

1. Social Security Administration. Exclusions from coverage and Medicare as a secondary payer. Social Security Administration website. Available at: http://www.ssa.gov/OP_Home/ssact/title18/1862.htm. Accessed March 1, 2012.
2. Highmark Medicare Services. A/B Reference Manual: Chapter 6, Medical Coverage, Medical Necessity, and Medical Policy. Highmark Medicare Services website. Available at: http://www.highmarkmedicareservices.com/refman/chapter-6.html. Accessed March 1, 2012.
3. Pohlig C. Daily care conundrums. The Hospitalist. 2008;12(12):18.
4. Highmark Medicare Services. LCD L27506: Non-Invasive Peripheral Venous Studies. Highmark Medicare Services website. Available at: http://www.highmarkmedicareservices.com/policy/mac-ab/l27506-r10.html. Accessed March 1, 2012.
5. Centers for Medicare & Medicaid Services. Medicare Coverage Determination Process: Overview. Centers for Medicare & Medicaid Services website. Available at: http://www.cms.hhs.gov/DeterminationProcess/01_Overview.asp#TopOfPage. Accessed March 1, 2012.
6. Centers for Medicare & Medicaid Services. Medicare National Coverage Determination Manual: Chapter 1, Part 1, Section 70.1. Centers for Medicare & Medicaid Services website. Available at: http://www.cms.gov/manuals/downloads/ncd103c1_Part1.pdf. Accessed March 1, 2012.
7. Trailblazer Health Enterprises. LCD 2866: Non-Invasive Venous Studies. Trailblazer Health Enterprises website. Available at: http://www.trailblazerhealth.com/Tools/LCDs.aspx?ID=2866. Accessed March 1, 2012.