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Hospital Mortality Rates Improve, but Quality Gap Persists
Risk-adjusted mortality and complication rates have decreased nearly 11% from 2006 through 2008, according to the12th annual HealthGrades Quality in America Study. However, the report found a wide gap between the nation’s best hospitals and all others. To save thousands of lives, the authors suggested focused improvement in sepsis, pneumonia, heart failure, and respiratory failure.
The report showed patients at highly rated hospitals have a 52% lower chance of dying, compared with the U.S. hospital average, according to the study authors. The rankings used 40 million Medicare patient outcomes from 2006 to 2008, and analyzed more than 5,000 U.S. hospitals. The scoring was based on 30 common procedures and diagnoses.
Patrick Torcson, MD, FHM, chair of SHM’s Performance and Standards Committee, says hospitalists may be one reason highly rated hospitals did well. “We’re on-site to evaluate patients and facilitate transition of care,” Dr. Torcson says. “I think that’s where the biggest impact is going to be.”
At Christ Hospital in Cincinnati, one of the nation’s top performers, hospitalist Rajan Lakhia, DO, credits the “absolute attitude everyone around here has—a dedication to quality.”
Berc Gawne, MD, the hospital’s chief medical officer, agreed. “Hospitalists know the people, policies, and politics. They know the barriers and where to go to get things done,” he says. “It’s their hospital and they take ownership for the order sets, the critical pathways, and performance improvement.”
Scottsdale Healthcare in Arizona has improved its ratings in recent years. Perhaps not coincidentally, the facility hired a hospitalist group two years ago to improve the quality of care. According to hospitalist Barry Freeman, MD, each quarter, the hospital publishes quality measures, and goals are established as part of a scorecard. Results are regularly reviewed and improvement discussed. In taking care of almost all medical and surgical patients, the hospitalists “can further educate the nonhospitalist staff on quality efforts and initiatives under way,” Dr. Freeman explains.
Risk-adjusted mortality and complication rates have decreased nearly 11% from 2006 through 2008, according to the12th annual HealthGrades Quality in America Study. However, the report found a wide gap between the nation’s best hospitals and all others. To save thousands of lives, the authors suggested focused improvement in sepsis, pneumonia, heart failure, and respiratory failure.
The report showed patients at highly rated hospitals have a 52% lower chance of dying, compared with the U.S. hospital average, according to the study authors. The rankings used 40 million Medicare patient outcomes from 2006 to 2008, and analyzed more than 5,000 U.S. hospitals. The scoring was based on 30 common procedures and diagnoses.
Patrick Torcson, MD, FHM, chair of SHM’s Performance and Standards Committee, says hospitalists may be one reason highly rated hospitals did well. “We’re on-site to evaluate patients and facilitate transition of care,” Dr. Torcson says. “I think that’s where the biggest impact is going to be.”
At Christ Hospital in Cincinnati, one of the nation’s top performers, hospitalist Rajan Lakhia, DO, credits the “absolute attitude everyone around here has—a dedication to quality.”
Berc Gawne, MD, the hospital’s chief medical officer, agreed. “Hospitalists know the people, policies, and politics. They know the barriers and where to go to get things done,” he says. “It’s their hospital and they take ownership for the order sets, the critical pathways, and performance improvement.”
Scottsdale Healthcare in Arizona has improved its ratings in recent years. Perhaps not coincidentally, the facility hired a hospitalist group two years ago to improve the quality of care. According to hospitalist Barry Freeman, MD, each quarter, the hospital publishes quality measures, and goals are established as part of a scorecard. Results are regularly reviewed and improvement discussed. In taking care of almost all medical and surgical patients, the hospitalists “can further educate the nonhospitalist staff on quality efforts and initiatives under way,” Dr. Freeman explains.
Risk-adjusted mortality and complication rates have decreased nearly 11% from 2006 through 2008, according to the12th annual HealthGrades Quality in America Study. However, the report found a wide gap between the nation’s best hospitals and all others. To save thousands of lives, the authors suggested focused improvement in sepsis, pneumonia, heart failure, and respiratory failure.
The report showed patients at highly rated hospitals have a 52% lower chance of dying, compared with the U.S. hospital average, according to the study authors. The rankings used 40 million Medicare patient outcomes from 2006 to 2008, and analyzed more than 5,000 U.S. hospitals. The scoring was based on 30 common procedures and diagnoses.
Patrick Torcson, MD, FHM, chair of SHM’s Performance and Standards Committee, says hospitalists may be one reason highly rated hospitals did well. “We’re on-site to evaluate patients and facilitate transition of care,” Dr. Torcson says. “I think that’s where the biggest impact is going to be.”
At Christ Hospital in Cincinnati, one of the nation’s top performers, hospitalist Rajan Lakhia, DO, credits the “absolute attitude everyone around here has—a dedication to quality.”
Berc Gawne, MD, the hospital’s chief medical officer, agreed. “Hospitalists know the people, policies, and politics. They know the barriers and where to go to get things done,” he says. “It’s their hospital and they take ownership for the order sets, the critical pathways, and performance improvement.”
Scottsdale Healthcare in Arizona has improved its ratings in recent years. Perhaps not coincidentally, the facility hired a hospitalist group two years ago to improve the quality of care. According to hospitalist Barry Freeman, MD, each quarter, the hospital publishes quality measures, and goals are established as part of a scorecard. Results are regularly reviewed and improvement discussed. In taking care of almost all medical and surgical patients, the hospitalists “can further educate the nonhospitalist staff on quality efforts and initiatives under way,” Dr. Freeman explains.
Clinical Update: Challenges in the Management of Constipation and Other Gastrointestinal Disorders
A supplement to Internal Medicine News.
This Clinical Update is supported by Braintree Laboratories, Inc.
The articles are based on interviews with the faculty.
To view the supplement, click the image above.
Topic Highlights
Gastrointestinal Disorders: When to Refer?
Understanding the Anatomy and Physiology of Constipation
Lawrence R. Schiller, MD, FACP, FACG
Program Director, Gastroenterology Fellowship
Department of Gastroenterology
Baylor University Medical Center
Dallas, TX
Consultant: Braintree Laboratories, Inc. and Novartis Pharmaceuticals. He discusses the unlabeled use of tegaserod for constipation. He also discusses the investigational use of NT-3 for constipation.
Management of Constipation Begins With Attention to Clinical Details
Jack A. DiPalma, MD, FACP, FACG
Professor and Director
Division of Gastroenterology
University of South Alabama College of Medicine
Mobile, AL
Grant/Research Support and Consultant: Braintree Laboratories, Inc.
Recent Clinical Trials Provide Stronger Basis for Constipation Therapy
Lawrence R. Schiller, MD, FACP, FACG
Patients at Opposite Ends of the Age Spectrum Share Clinical Features of Constipation
Jack A. DiPalma, MD, FACP, FACG
Surgical Treatment for Chronic Constipation: Favorable Option in Selected Patients
David E. Beck, MD, FACS
Chairman, Department of Colon and Rectal Surgery
Ochsner Clinical Foundation
New Orleans, LA
Nothing to disclose.
Recent H. pylori Literature Explores New Questions
A supplement to Internal Medicine News.
This Clinical Update is supported by Braintree Laboratories, Inc.
The articles are based on interviews with the faculty.
To view the supplement, click the image above.
Topic Highlights
Gastrointestinal Disorders: When to Refer?
Understanding the Anatomy and Physiology of Constipation
Lawrence R. Schiller, MD, FACP, FACG
Program Director, Gastroenterology Fellowship
Department of Gastroenterology
Baylor University Medical Center
Dallas, TX
Consultant: Braintree Laboratories, Inc. and Novartis Pharmaceuticals. He discusses the unlabeled use of tegaserod for constipation. He also discusses the investigational use of NT-3 for constipation.
Management of Constipation Begins With Attention to Clinical Details
Jack A. DiPalma, MD, FACP, FACG
Professor and Director
Division of Gastroenterology
University of South Alabama College of Medicine
Mobile, AL
Grant/Research Support and Consultant: Braintree Laboratories, Inc.
Recent Clinical Trials Provide Stronger Basis for Constipation Therapy
Lawrence R. Schiller, MD, FACP, FACG
Patients at Opposite Ends of the Age Spectrum Share Clinical Features of Constipation
Jack A. DiPalma, MD, FACP, FACG
Surgical Treatment for Chronic Constipation: Favorable Option in Selected Patients
David E. Beck, MD, FACS
Chairman, Department of Colon and Rectal Surgery
Ochsner Clinical Foundation
New Orleans, LA
Nothing to disclose.
Recent H. pylori Literature Explores New Questions
A supplement to Internal Medicine News.
This Clinical Update is supported by Braintree Laboratories, Inc.
The articles are based on interviews with the faculty.
To view the supplement, click the image above.
Topic Highlights
Gastrointestinal Disorders: When to Refer?
Understanding the Anatomy and Physiology of Constipation
Lawrence R. Schiller, MD, FACP, FACG
Program Director, Gastroenterology Fellowship
Department of Gastroenterology
Baylor University Medical Center
Dallas, TX
Consultant: Braintree Laboratories, Inc. and Novartis Pharmaceuticals. He discusses the unlabeled use of tegaserod for constipation. He also discusses the investigational use of NT-3 for constipation.
Management of Constipation Begins With Attention to Clinical Details
Jack A. DiPalma, MD, FACP, FACG
Professor and Director
Division of Gastroenterology
University of South Alabama College of Medicine
Mobile, AL
Grant/Research Support and Consultant: Braintree Laboratories, Inc.
Recent Clinical Trials Provide Stronger Basis for Constipation Therapy
Lawrence R. Schiller, MD, FACP, FACG
Patients at Opposite Ends of the Age Spectrum Share Clinical Features of Constipation
Jack A. DiPalma, MD, FACP, FACG
Surgical Treatment for Chronic Constipation: Favorable Option in Selected Patients
David E. Beck, MD, FACS
Chairman, Department of Colon and Rectal Surgery
Ochsner Clinical Foundation
New Orleans, LA
Nothing to disclose.
Recent H. pylori Literature Explores New Questions
Abuse Potential of Sleeping Agents: Liability Varies Among Agents
A supplement to Internal Medicine News.
This CLINICAL UPDATE is supported by Takeda Pharmaceuticals North America, Inc.
•Introduction
•Topic Highlights
To view the supplement, click the image above.
Introduction
Introduction
Roland R. Griffiths, PhD
Professor of Behavioral Biology
Departments of Psychiatry and Neuroscience
Johns Hopkins University
School of Medicine
Baltimore, Md.
Dr. Griffiths has disclosed that he is Principal Investigator of two grants from the National Institute on Drug Abuse (NIDA) (R01 DA03889 and R01 DA03890) and co-investigator on a contract and several other grants from NIDA. During the past 5 years, on issues about drug abuse liability, he has been a consultant to or received grants from the following pharmaceutical companies: Abbott Laboratories, Forest Laboratories Inc., Merck & Co., Inc., Neurocrine Biosciences, Inc., Novartis Pharmaceuticals Corporation, Orphan Medical, Pharmacia Corporation, Pfizer Inc., Takeda Pharmaceuticals, TransOral Pharmaceucticals, Inc., Somaxon Pharmaceuticals Inc., and Wyeth Pharmaceuticals. He has disclosed that he will be discussing non-medical use (ie, abuse) of various hypnotic drugs.
Topic Highlights
• Abuse Potential of Sleeping Agents: Liability Varies Among Agents
Insomnia: A Brief Review
Effects of Insomnia
Pharmacologic Treatment of Insomnia
Patterns of Sedative/Hypnotic Abuse
• Abuse Potential of Hypnotic Agents: Study Evaluates Relative Abuse Liability
Defining Relative Abuse Liability and Toxicity
Relative Abuse Liability Table
Results of Analysis
A supplement to Internal Medicine News.
This CLINICAL UPDATE is supported by Takeda Pharmaceuticals North America, Inc.
•Introduction
•Topic Highlights
To view the supplement, click the image above.
Introduction
Introduction
Roland R. Griffiths, PhD
Professor of Behavioral Biology
Departments of Psychiatry and Neuroscience
Johns Hopkins University
School of Medicine
Baltimore, Md.
Dr. Griffiths has disclosed that he is Principal Investigator of two grants from the National Institute on Drug Abuse (NIDA) (R01 DA03889 and R01 DA03890) and co-investigator on a contract and several other grants from NIDA. During the past 5 years, on issues about drug abuse liability, he has been a consultant to or received grants from the following pharmaceutical companies: Abbott Laboratories, Forest Laboratories Inc., Merck & Co., Inc., Neurocrine Biosciences, Inc., Novartis Pharmaceuticals Corporation, Orphan Medical, Pharmacia Corporation, Pfizer Inc., Takeda Pharmaceuticals, TransOral Pharmaceucticals, Inc., Somaxon Pharmaceuticals Inc., and Wyeth Pharmaceuticals. He has disclosed that he will be discussing non-medical use (ie, abuse) of various hypnotic drugs.
Topic Highlights
• Abuse Potential of Sleeping Agents: Liability Varies Among Agents
Insomnia: A Brief Review
Effects of Insomnia
Pharmacologic Treatment of Insomnia
Patterns of Sedative/Hypnotic Abuse
• Abuse Potential of Hypnotic Agents: Study Evaluates Relative Abuse Liability
Defining Relative Abuse Liability and Toxicity
Relative Abuse Liability Table
Results of Analysis
A supplement to Internal Medicine News.
This CLINICAL UPDATE is supported by Takeda Pharmaceuticals North America, Inc.
•Introduction
•Topic Highlights
To view the supplement, click the image above.
Introduction
Introduction
Roland R. Griffiths, PhD
Professor of Behavioral Biology
Departments of Psychiatry and Neuroscience
Johns Hopkins University
School of Medicine
Baltimore, Md.
Dr. Griffiths has disclosed that he is Principal Investigator of two grants from the National Institute on Drug Abuse (NIDA) (R01 DA03889 and R01 DA03890) and co-investigator on a contract and several other grants from NIDA. During the past 5 years, on issues about drug abuse liability, he has been a consultant to or received grants from the following pharmaceutical companies: Abbott Laboratories, Forest Laboratories Inc., Merck & Co., Inc., Neurocrine Biosciences, Inc., Novartis Pharmaceuticals Corporation, Orphan Medical, Pharmacia Corporation, Pfizer Inc., Takeda Pharmaceuticals, TransOral Pharmaceucticals, Inc., Somaxon Pharmaceuticals Inc., and Wyeth Pharmaceuticals. He has disclosed that he will be discussing non-medical use (ie, abuse) of various hypnotic drugs.
Topic Highlights
• Abuse Potential of Sleeping Agents: Liability Varies Among Agents
Insomnia: A Brief Review
Effects of Insomnia
Pharmacologic Treatment of Insomnia
Patterns of Sedative/Hypnotic Abuse
• Abuse Potential of Hypnotic Agents: Study Evaluates Relative Abuse Liability
Defining Relative Abuse Liability and Toxicity
Relative Abuse Liability Table
Results of Analysis
New Benchmarks in Acid-Related Disorders: A Debate With the Experts
A supplement to Internal Medicine News supported by a restricted grant from TAP Pharmaceutical Products, Inc.
Symposium Highlights of articles based on presentations given at a continuing medical education symposium held on May 19, 2002, in San Francisco, Calif.
To view the supplement, click the image above.
A supplement to Internal Medicine News supported by a restricted grant from TAP Pharmaceutical Products, Inc.
Symposium Highlights of articles based on presentations given at a continuing medical education symposium held on May 19, 2002, in San Francisco, Calif.
To view the supplement, click the image above.
A supplement to Internal Medicine News supported by a restricted grant from TAP Pharmaceutical Products, Inc.
Symposium Highlights of articles based on presentations given at a continuing medical education symposium held on May 19, 2002, in San Francisco, Calif.
To view the supplement, click the image above.
Improving Survival From Sudden Cardiac Arrest: Is it Time for Home Defibrillators?
A supplement to Internal Medicine News, supported by an unrestricted educational grant from Philips.
Highlights developed from physician interviews and from a panel discussion held in Washington, D.C., on January 30, 2002.
To view the supplement, click the image above.
Richard A. Lazar, Esq.
President/CEO
Fios, Inc.
Portland, Ga.
Nothing to disclose.
A supplement to Internal Medicine News, supported by an unrestricted educational grant from Philips.
Highlights developed from physician interviews and from a panel discussion held in Washington, D.C., on January 30, 2002.
To view the supplement, click the image above.
Richard A. Lazar, Esq.
President/CEO
Fios, Inc.
Portland, Ga.
Nothing to disclose.
A supplement to Internal Medicine News, supported by an unrestricted educational grant from Philips.
Highlights developed from physician interviews and from a panel discussion held in Washington, D.C., on January 30, 2002.
To view the supplement, click the image above.
Richard A. Lazar, Esq.
President/CEO
Fios, Inc.
Portland, Ga.
Nothing to disclose.
Immune Response Modifier Therapy in Anogenital Warts and Actinic Keratoses
A supplement to Family Practice News and Internal Medicine News.
This Journal Scan is supported by 3M Pharmaceuticals.
•Introduction
•Topic Highlights
To view the supplement, click the image above.
Introduction
Introduction
Thomas J. Zuber, MD, MPH, MBA
Adjunct Associate Professor
Brody School of Medicine, East Carolina University
Private Practice, Mountain Family Medicine
Boone, North Carolina
Nothing to disclose.
Topic Highlights
• Condyloma Recurrence Rates Improve With Immune Response Modifier Treatment
• 3-Year Experience With Imiquimod in Vulvar Warts
• Placebo-Controlled Trial in External Anogenital Warts
• Phase III Trials of Imiquimod in Actinic Keratosis
• Observational Long-Term Study of Imiquimod in Actinic Keratosis
• Immune Response Modifier Mechanism of Action
A supplement to Family Practice News and Internal Medicine News.
This Journal Scan is supported by 3M Pharmaceuticals.
•Introduction
•Topic Highlights
To view the supplement, click the image above.
Introduction
Introduction
Thomas J. Zuber, MD, MPH, MBA
Adjunct Associate Professor
Brody School of Medicine, East Carolina University
Private Practice, Mountain Family Medicine
Boone, North Carolina
Nothing to disclose.
Topic Highlights
• Condyloma Recurrence Rates Improve With Immune Response Modifier Treatment
• 3-Year Experience With Imiquimod in Vulvar Warts
• Placebo-Controlled Trial in External Anogenital Warts
• Phase III Trials of Imiquimod in Actinic Keratosis
• Observational Long-Term Study of Imiquimod in Actinic Keratosis
• Immune Response Modifier Mechanism of Action
A supplement to Family Practice News and Internal Medicine News.
This Journal Scan is supported by 3M Pharmaceuticals.
•Introduction
•Topic Highlights
To view the supplement, click the image above.
Introduction
Introduction
Thomas J. Zuber, MD, MPH, MBA
Adjunct Associate Professor
Brody School of Medicine, East Carolina University
Private Practice, Mountain Family Medicine
Boone, North Carolina
Nothing to disclose.
Topic Highlights
• Condyloma Recurrence Rates Improve With Immune Response Modifier Treatment
• 3-Year Experience With Imiquimod in Vulvar Warts
• Placebo-Controlled Trial in External Anogenital Warts
• Phase III Trials of Imiquimod in Actinic Keratosis
• Observational Long-Term Study of Imiquimod in Actinic Keratosis
• Immune Response Modifier Mechanism of Action
Effective Communication Ensures Patient Safety
Effective Communication Ensures Patient Safety
Can you explain to me what is meant by SBAR? I heard this acronym mentioned during a session at HM09, but I did not understand the term.
S. East, MD
Pullman, Wash.
Dr. Hospitalist responds: SBAR (pronounced “ess-bar”) is a standardized method of communication that originated in the Navy’s nuclear submarine program. It stands for:
- Situation: What is happening presently?
- Background: What circumstances led to this situation?
- Assessment: What do I think is the problem?
- Recommendation: What should we do to correct the problem?
The SBAR system was developed to prevent simple communication errors that could lead to global disaster.
Kaiser Permanente of Colorado was among the first to adopt this model of communication among its staff and has since popularized its use in healthcare. Numerous hospitals and healthcare organizations have implemented SBAR as an approach to minimize communication errors between healthcare providers. The idea is that eliminating communication errors between healthcare providers improves patient safety. SBAR encourages all providers (doctors, nurses, pharmacists, etc.) to communicate with a shared mental model for information transfer.
SBAR requires providers to organize their thoughts, understand what it is they want to convey, and make requests in an organized fashion. Adherence to SBAR allows providers to transmit factual information in a concise manner.
Highly effective communication is essential to any hospitalist program. The SBAR approach should not be limited to nurse-doctor communication. I encourage you to implement this tool at your institution.
For more information, an SBAR toolkit is available at www.azhha.org/patient_safety/sbar.aspx. TH
Effective Communication Ensures Patient Safety
Can you explain to me what is meant by SBAR? I heard this acronym mentioned during a session at HM09, but I did not understand the term.
S. East, MD
Pullman, Wash.
Dr. Hospitalist responds: SBAR (pronounced “ess-bar”) is a standardized method of communication that originated in the Navy’s nuclear submarine program. It stands for:
- Situation: What is happening presently?
- Background: What circumstances led to this situation?
- Assessment: What do I think is the problem?
- Recommendation: What should we do to correct the problem?
The SBAR system was developed to prevent simple communication errors that could lead to global disaster.
Kaiser Permanente of Colorado was among the first to adopt this model of communication among its staff and has since popularized its use in healthcare. Numerous hospitals and healthcare organizations have implemented SBAR as an approach to minimize communication errors between healthcare providers. The idea is that eliminating communication errors between healthcare providers improves patient safety. SBAR encourages all providers (doctors, nurses, pharmacists, etc.) to communicate with a shared mental model for information transfer.
SBAR requires providers to organize their thoughts, understand what it is they want to convey, and make requests in an organized fashion. Adherence to SBAR allows providers to transmit factual information in a concise manner.
Highly effective communication is essential to any hospitalist program. The SBAR approach should not be limited to nurse-doctor communication. I encourage you to implement this tool at your institution.
For more information, an SBAR toolkit is available at www.azhha.org/patient_safety/sbar.aspx. TH
Effective Communication Ensures Patient Safety
Can you explain to me what is meant by SBAR? I heard this acronym mentioned during a session at HM09, but I did not understand the term.
S. East, MD
Pullman, Wash.
Dr. Hospitalist responds: SBAR (pronounced “ess-bar”) is a standardized method of communication that originated in the Navy’s nuclear submarine program. It stands for:
- Situation: What is happening presently?
- Background: What circumstances led to this situation?
- Assessment: What do I think is the problem?
- Recommendation: What should we do to correct the problem?
The SBAR system was developed to prevent simple communication errors that could lead to global disaster.
Kaiser Permanente of Colorado was among the first to adopt this model of communication among its staff and has since popularized its use in healthcare. Numerous hospitals and healthcare organizations have implemented SBAR as an approach to minimize communication errors between healthcare providers. The idea is that eliminating communication errors between healthcare providers improves patient safety. SBAR encourages all providers (doctors, nurses, pharmacists, etc.) to communicate with a shared mental model for information transfer.
SBAR requires providers to organize their thoughts, understand what it is they want to convey, and make requests in an organized fashion. Adherence to SBAR allows providers to transmit factual information in a concise manner.
Highly effective communication is essential to any hospitalist program. The SBAR approach should not be limited to nurse-doctor communication. I encourage you to implement this tool at your institution.
For more information, an SBAR toolkit is available at www.azhha.org/patient_safety/sbar.aspx. TH
Necessary Evil: Change
The amount and complexity of medical knowledge we need to keep up with is changing and growing at a remarkable rate. I was trained in an era in which it was taken as a given that congestive heart failure patients should not receive beta-blockers; now it is a big mistake if we don’t prescribe them in most cases. But even before starting medical school, most of us realize that things will change a lot, and many of us see that as a good thing. It keeps our work interesting. Just recently, our hospital had a guest speaker who talked about potential medical applications of nanotechnology. It was way over my head, but it sounded pretty cool.
While I was prepared for ongoing changes in medical knowledge, I failed to anticipate how quickly the business of medicine would change during my career. I think the need to keep up with ever-increasing financial and regulatory issues siphons a lot of time and energy that could be used to keep up with the medical knowledge base. I wasn’t prepared for this when I started my career.
Because it is the start of a new year, I thought I would highlight one issue related to CPT coding: Medicare stopped recognizing consult codes as of Jan. 1 (see “Consultation Elimination,” p. 31).
What It Means for Hospitalists
The good news is that we can just use initial hospital visit codes, inpatient or observation, for all new visits. For example, it won’t matter anymore whether I’m admitting and serving as attending for a patient, or whether a surgeon admitted the patient and asked me to consult for preoperative medical evaluation (“clearance”). I should use the same CPT code in either situation, simply appending a modifier if I’m the admitting physician. And for billing purposes, we won’t have to worry about documenting which doctor requested that we see the patient, though it is a good idea to document it as part of the clinical record anyway.
But it gets a little more complicated. The codes aren’t going away or being removed from the CPT “bible” published by the American Medical Association (AMA). Instead, Medicare simply won’t recognize them anymore. Other payors probably will follow suit within a few months, but that isn’t certain. So it is possible that when asked by a surgeon to provide a preoperative evaluation, you will need to bill an initial hospital (or office or nursing facility) care visit if the patient is on Medicare but bill a consult code if the patient has other insurance. You should check with your billers to ensure you’re doing this correctly.
Medicare-paid consults are at a slightly higher rate than the equivalent service billed as initial hospital care (e.g., when the hospitalist is attending). So a higher reimbursing code has been replaced with one that pays a little less. For example, a 99253 consultation code requires a detailed history, detailed examination, and medical decision-making of low complexity; last year, 99253 was reimbursed by Medicare at an average rate of $114.69. The equivalent admission code for a detailed history, detailed examination, and low-complexity medical decision-making is a 99221 code, for which Medicare pays about $99.90. This represents a difference of about 14%.
However, the net financial impact of this change probably will be positive for most HM groups because you probably bill very few initial consult codes, and instead were stuck billing a follow-up visit code when seeing co-management “consults” (i.e., a patient admitted by a surgeon who asks you to follow and manage diabetes and other medical issues). Now, at least in the case of Medicare, it is appropriate for us to bill an initial hospital visit code, which provides significantly higher reimbursement than follow-up codes.
In addition, there is a modest (about 0.3%) proposed increase in work relative value units attached to the initial hospital visit codes, which will benefit us not only when we’re consulting, but also when we admit and serve as a patient’s attending.
Some specialists may be less interested in consulting on our patients because the initial visit codes will reimburse a little less than similar consultation codes. I don’t anticipate this will be a significant problem for most of us, particularly since many specialists bill the highest level of consultation code (99255), which pays about the same as the equivalent admission code (99223).
Although I think elimination of the use of consultation codes seems like a reasonable step toward simplifying how hospitalists bill for our services, keeping up with these frequent coding changes requires a high level of diligence on our part, and on the part of our administrative and clerical staffs. And it consumes time and resources that I—and my team—could better spend keeping up with changes in clinical practice.
Perhaps when all the dust settles around the healthcare reform debate, we will begin to move toward new, more creative payment models that will allow us to focus on what we do best. TH
Dr. Nelson has been a practicing hospitalist since 1988 and is cofounder and past president of SHM. He is a principal in Nelson Flores Hospital Medicine Consultants, a national hospitalist practice management consulting firm (www.nelsonflores.com). He is also course co-director and faculty for SHM’s “Best Practices in Managing a Hospital Medicine Program” course. This column represents his views and is not intended to reflect an official position of SHM.
The amount and complexity of medical knowledge we need to keep up with is changing and growing at a remarkable rate. I was trained in an era in which it was taken as a given that congestive heart failure patients should not receive beta-blockers; now it is a big mistake if we don’t prescribe them in most cases. But even before starting medical school, most of us realize that things will change a lot, and many of us see that as a good thing. It keeps our work interesting. Just recently, our hospital had a guest speaker who talked about potential medical applications of nanotechnology. It was way over my head, but it sounded pretty cool.
While I was prepared for ongoing changes in medical knowledge, I failed to anticipate how quickly the business of medicine would change during my career. I think the need to keep up with ever-increasing financial and regulatory issues siphons a lot of time and energy that could be used to keep up with the medical knowledge base. I wasn’t prepared for this when I started my career.
Because it is the start of a new year, I thought I would highlight one issue related to CPT coding: Medicare stopped recognizing consult codes as of Jan. 1 (see “Consultation Elimination,” p. 31).
What It Means for Hospitalists
The good news is that we can just use initial hospital visit codes, inpatient or observation, for all new visits. For example, it won’t matter anymore whether I’m admitting and serving as attending for a patient, or whether a surgeon admitted the patient and asked me to consult for preoperative medical evaluation (“clearance”). I should use the same CPT code in either situation, simply appending a modifier if I’m the admitting physician. And for billing purposes, we won’t have to worry about documenting which doctor requested that we see the patient, though it is a good idea to document it as part of the clinical record anyway.
But it gets a little more complicated. The codes aren’t going away or being removed from the CPT “bible” published by the American Medical Association (AMA). Instead, Medicare simply won’t recognize them anymore. Other payors probably will follow suit within a few months, but that isn’t certain. So it is possible that when asked by a surgeon to provide a preoperative evaluation, you will need to bill an initial hospital (or office or nursing facility) care visit if the patient is on Medicare but bill a consult code if the patient has other insurance. You should check with your billers to ensure you’re doing this correctly.
Medicare-paid consults are at a slightly higher rate than the equivalent service billed as initial hospital care (e.g., when the hospitalist is attending). So a higher reimbursing code has been replaced with one that pays a little less. For example, a 99253 consultation code requires a detailed history, detailed examination, and medical decision-making of low complexity; last year, 99253 was reimbursed by Medicare at an average rate of $114.69. The equivalent admission code for a detailed history, detailed examination, and low-complexity medical decision-making is a 99221 code, for which Medicare pays about $99.90. This represents a difference of about 14%.
However, the net financial impact of this change probably will be positive for most HM groups because you probably bill very few initial consult codes, and instead were stuck billing a follow-up visit code when seeing co-management “consults” (i.e., a patient admitted by a surgeon who asks you to follow and manage diabetes and other medical issues). Now, at least in the case of Medicare, it is appropriate for us to bill an initial hospital visit code, which provides significantly higher reimbursement than follow-up codes.
In addition, there is a modest (about 0.3%) proposed increase in work relative value units attached to the initial hospital visit codes, which will benefit us not only when we’re consulting, but also when we admit and serve as a patient’s attending.
Some specialists may be less interested in consulting on our patients because the initial visit codes will reimburse a little less than similar consultation codes. I don’t anticipate this will be a significant problem for most of us, particularly since many specialists bill the highest level of consultation code (99255), which pays about the same as the equivalent admission code (99223).
Although I think elimination of the use of consultation codes seems like a reasonable step toward simplifying how hospitalists bill for our services, keeping up with these frequent coding changes requires a high level of diligence on our part, and on the part of our administrative and clerical staffs. And it consumes time and resources that I—and my team—could better spend keeping up with changes in clinical practice.
Perhaps when all the dust settles around the healthcare reform debate, we will begin to move toward new, more creative payment models that will allow us to focus on what we do best. TH
Dr. Nelson has been a practicing hospitalist since 1988 and is cofounder and past president of SHM. He is a principal in Nelson Flores Hospital Medicine Consultants, a national hospitalist practice management consulting firm (www.nelsonflores.com). He is also course co-director and faculty for SHM’s “Best Practices in Managing a Hospital Medicine Program” course. This column represents his views and is not intended to reflect an official position of SHM.
The amount and complexity of medical knowledge we need to keep up with is changing and growing at a remarkable rate. I was trained in an era in which it was taken as a given that congestive heart failure patients should not receive beta-blockers; now it is a big mistake if we don’t prescribe them in most cases. But even before starting medical school, most of us realize that things will change a lot, and many of us see that as a good thing. It keeps our work interesting. Just recently, our hospital had a guest speaker who talked about potential medical applications of nanotechnology. It was way over my head, but it sounded pretty cool.
While I was prepared for ongoing changes in medical knowledge, I failed to anticipate how quickly the business of medicine would change during my career. I think the need to keep up with ever-increasing financial and regulatory issues siphons a lot of time and energy that could be used to keep up with the medical knowledge base. I wasn’t prepared for this when I started my career.
Because it is the start of a new year, I thought I would highlight one issue related to CPT coding: Medicare stopped recognizing consult codes as of Jan. 1 (see “Consultation Elimination,” p. 31).
What It Means for Hospitalists
The good news is that we can just use initial hospital visit codes, inpatient or observation, for all new visits. For example, it won’t matter anymore whether I’m admitting and serving as attending for a patient, or whether a surgeon admitted the patient and asked me to consult for preoperative medical evaluation (“clearance”). I should use the same CPT code in either situation, simply appending a modifier if I’m the admitting physician. And for billing purposes, we won’t have to worry about documenting which doctor requested that we see the patient, though it is a good idea to document it as part of the clinical record anyway.
But it gets a little more complicated. The codes aren’t going away or being removed from the CPT “bible” published by the American Medical Association (AMA). Instead, Medicare simply won’t recognize them anymore. Other payors probably will follow suit within a few months, but that isn’t certain. So it is possible that when asked by a surgeon to provide a preoperative evaluation, you will need to bill an initial hospital (or office or nursing facility) care visit if the patient is on Medicare but bill a consult code if the patient has other insurance. You should check with your billers to ensure you’re doing this correctly.
Medicare-paid consults are at a slightly higher rate than the equivalent service billed as initial hospital care (e.g., when the hospitalist is attending). So a higher reimbursing code has been replaced with one that pays a little less. For example, a 99253 consultation code requires a detailed history, detailed examination, and medical decision-making of low complexity; last year, 99253 was reimbursed by Medicare at an average rate of $114.69. The equivalent admission code for a detailed history, detailed examination, and low-complexity medical decision-making is a 99221 code, for which Medicare pays about $99.90. This represents a difference of about 14%.
However, the net financial impact of this change probably will be positive for most HM groups because you probably bill very few initial consult codes, and instead were stuck billing a follow-up visit code when seeing co-management “consults” (i.e., a patient admitted by a surgeon who asks you to follow and manage diabetes and other medical issues). Now, at least in the case of Medicare, it is appropriate for us to bill an initial hospital visit code, which provides significantly higher reimbursement than follow-up codes.
In addition, there is a modest (about 0.3%) proposed increase in work relative value units attached to the initial hospital visit codes, which will benefit us not only when we’re consulting, but also when we admit and serve as a patient’s attending.
Some specialists may be less interested in consulting on our patients because the initial visit codes will reimburse a little less than similar consultation codes. I don’t anticipate this will be a significant problem for most of us, particularly since many specialists bill the highest level of consultation code (99255), which pays about the same as the equivalent admission code (99223).
Although I think elimination of the use of consultation codes seems like a reasonable step toward simplifying how hospitalists bill for our services, keeping up with these frequent coding changes requires a high level of diligence on our part, and on the part of our administrative and clerical staffs. And it consumes time and resources that I—and my team—could better spend keeping up with changes in clinical practice.
Perhaps when all the dust settles around the healthcare reform debate, we will begin to move toward new, more creative payment models that will allow us to focus on what we do best. TH
Dr. Nelson has been a practicing hospitalist since 1988 and is cofounder and past president of SHM. He is a principal in Nelson Flores Hospital Medicine Consultants, a national hospitalist practice management consulting firm (www.nelsonflores.com). He is also course co-director and faculty for SHM’s “Best Practices in Managing a Hospital Medicine Program” course. This column represents his views and is not intended to reflect an official position of SHM.
Standing Ovation
Is this really happening? That’s what I was thinking as my mind quickly ran a differential of the possible explanations for the 80 people before me, positioned erectly, hands audibly moving together and apart. This had never happened to me before. Was this some sort of group yoga stretch aimed at quelling DVT formation, perhaps a pre-determined signal alerting security to have me removed for hitting an unconscionable level of boredom, or, most likely, a synchronized form of mass exit (my talks are accustomed to a certain level of attrition)? Beyond these possibilities lies just one alternative: I actually was receiving a standing ovation.
First, let me dispense with one ever-important technicality. The ovation, coming at the close of the recent four-day Academic Hospitalist Academy held outside Atlanta, was more rightly intended for the efforts of the entire eight-member faculty than me alone. I just happened to be giving the closing session.
The fact of the matter is that as a faculty member for this program, which aimed to provide early-career development for junior academic hospitalists, I, too, was in awe at the tremendous, unparalleled work of the faculty: Drs. Brad Sharpe, Vikas Parekh, Andy Auerbach, Jeff Wiese, Shobi Chheda, Bob Centor, and Jen Myers.
Yet there I was, just moments after uttering a few closing comments, being showered with praise, each clap further pumping my chest fuller with pride. It was then, with a deflating wheeze, that I realized what was happening—they weren’t clapping for me, or even the rest of the faculty. It turns out the more obvious cause for their enthusiasm had been staring me in the face the whole time. Or, more to the point, the faces staring back at me were reflecting my numerous missteps that this course had ensured they’d never make. And that was very ovation-worthy.
Take-Home Points
Clapping excitedly at table No. 4 was a young first-year hospitalist from a major academic medical center. Looking at her, I could tell she would not, like I had, make the mistake of waiting too long to find a mentor. It wasn’t until my fourth year in academics that I found a mentor. That was four years of unproductive wandering, chasing dead ends, grabbing at wrong straws. So after multiple sessions covering the importance and means of finding mentors, as well as the role of mentees, it was clear that this young hospitalist would build her career foundation on more firm footing.
Applauding from table No. 7 was a second-year hospitalist from a community teaching hospital with aspirations of making a splash on the national hospitalist scene. Unlike my early fruitless attempts to get involved outside of my institution, the session on the importance of peer and national networking provided his quiver with several time-honored arrows that took me years to acquire.
The eyes of a hospitalist at table No. 8 foretold the story of a young faculty member who wouldn’t struggle with the process of promotion, as I had. After sitting through talks that lifted the veil on both the inner workings of an academic medical center and the mysteries by which said centers promote their members, she had a head start on ensuring her academic success.
Table No. 3 offered several hospitalists who wouldn’t make the errors I’ve made—repeatedly—with e-mail, phone conversations and running a meeting. A presentation on the basics of communications ensured that they wouldn’t send those irretrievable e-missives carrying unintentional messages or waste hours trying to cover in e-mail what would be better solved over the phone or in a face-to-face meeting.
A person at table one patted me on the shoulder, the glint in his eye signaling that the sessions on how to run a teaching team and be a more effective teacher at both the bedside and at the chalkboard would help him avoid the lower teaching scores that plagued my early academic years.
Focus on Fundamentals
I could go on, but the point is that while my fellow faculty and I reveled in the pleasure of a standing ovation, the truth is that the clapping had less to do with us or how we imparted information and more to do with the fact that we had shared with them the ingredients of their future success, something they actively longed for—a means to enhance their career success and satisfaction.
Mind you, none of these revelations were shocking; indeed, most are mundane and straightforward. However, the reality is that more often than not we just need help getting started—a little enzymatic push in the right direction. The fact that these needs were finally being met was evident in every heartfelt clap of the hands.
Lest you think these lessons are only important for us academic eggheads, I’d submit to you that the same, or at least similarly important, points are just as critical for young community hospitalists.
In fact, hospitalists and the field of HM are all very young; most of us are in desperate need of career guidance. And I’d go so far as to say the success of our field depends on meeting these needs as much or more than our ability to improve the quality of healthcare. The reality is that without sated, successful, career-oriented hospitalists, there can be no HM movement to improve the quality of care.
It’s tempting to feel that our residency training should prepare us for our jobs. However, the reality is that while residency prepares us reasonably well to practice clinic medicine, it does very little to prepare us for the wide-ranging rigors of medical practice. And while it’s easy to dismiss early-career development as touchy-feely nonsense, we do so at our own peril.
That message is written in the conflicts that abound within our HM groups and our hospitals, the burnout and low satisfaction that fuel our high turnover rate, and the unfulfilled careers that litter the HM landscape. It’s a message that threatens our beloved specialty—a message that all the clapping couldn’t drown out. TH
Dr. Glasheen is associate professor of medicine at the University of Colorado Denver, where he serves as director of the Hospital Medicine Program and the Hospitalist Training Program, and as associate program director of the Internal Medicine Residency Program.
Is this really happening? That’s what I was thinking as my mind quickly ran a differential of the possible explanations for the 80 people before me, positioned erectly, hands audibly moving together and apart. This had never happened to me before. Was this some sort of group yoga stretch aimed at quelling DVT formation, perhaps a pre-determined signal alerting security to have me removed for hitting an unconscionable level of boredom, or, most likely, a synchronized form of mass exit (my talks are accustomed to a certain level of attrition)? Beyond these possibilities lies just one alternative: I actually was receiving a standing ovation.
First, let me dispense with one ever-important technicality. The ovation, coming at the close of the recent four-day Academic Hospitalist Academy held outside Atlanta, was more rightly intended for the efforts of the entire eight-member faculty than me alone. I just happened to be giving the closing session.
The fact of the matter is that as a faculty member for this program, which aimed to provide early-career development for junior academic hospitalists, I, too, was in awe at the tremendous, unparalleled work of the faculty: Drs. Brad Sharpe, Vikas Parekh, Andy Auerbach, Jeff Wiese, Shobi Chheda, Bob Centor, and Jen Myers.
Yet there I was, just moments after uttering a few closing comments, being showered with praise, each clap further pumping my chest fuller with pride. It was then, with a deflating wheeze, that I realized what was happening—they weren’t clapping for me, or even the rest of the faculty. It turns out the more obvious cause for their enthusiasm had been staring me in the face the whole time. Or, more to the point, the faces staring back at me were reflecting my numerous missteps that this course had ensured they’d never make. And that was very ovation-worthy.
Take-Home Points
Clapping excitedly at table No. 4 was a young first-year hospitalist from a major academic medical center. Looking at her, I could tell she would not, like I had, make the mistake of waiting too long to find a mentor. It wasn’t until my fourth year in academics that I found a mentor. That was four years of unproductive wandering, chasing dead ends, grabbing at wrong straws. So after multiple sessions covering the importance and means of finding mentors, as well as the role of mentees, it was clear that this young hospitalist would build her career foundation on more firm footing.
Applauding from table No. 7 was a second-year hospitalist from a community teaching hospital with aspirations of making a splash on the national hospitalist scene. Unlike my early fruitless attempts to get involved outside of my institution, the session on the importance of peer and national networking provided his quiver with several time-honored arrows that took me years to acquire.
The eyes of a hospitalist at table No. 8 foretold the story of a young faculty member who wouldn’t struggle with the process of promotion, as I had. After sitting through talks that lifted the veil on both the inner workings of an academic medical center and the mysteries by which said centers promote their members, she had a head start on ensuring her academic success.
Table No. 3 offered several hospitalists who wouldn’t make the errors I’ve made—repeatedly—with e-mail, phone conversations and running a meeting. A presentation on the basics of communications ensured that they wouldn’t send those irretrievable e-missives carrying unintentional messages or waste hours trying to cover in e-mail what would be better solved over the phone or in a face-to-face meeting.
A person at table one patted me on the shoulder, the glint in his eye signaling that the sessions on how to run a teaching team and be a more effective teacher at both the bedside and at the chalkboard would help him avoid the lower teaching scores that plagued my early academic years.
Focus on Fundamentals
I could go on, but the point is that while my fellow faculty and I reveled in the pleasure of a standing ovation, the truth is that the clapping had less to do with us or how we imparted information and more to do with the fact that we had shared with them the ingredients of their future success, something they actively longed for—a means to enhance their career success and satisfaction.
Mind you, none of these revelations were shocking; indeed, most are mundane and straightforward. However, the reality is that more often than not we just need help getting started—a little enzymatic push in the right direction. The fact that these needs were finally being met was evident in every heartfelt clap of the hands.
Lest you think these lessons are only important for us academic eggheads, I’d submit to you that the same, or at least similarly important, points are just as critical for young community hospitalists.
In fact, hospitalists and the field of HM are all very young; most of us are in desperate need of career guidance. And I’d go so far as to say the success of our field depends on meeting these needs as much or more than our ability to improve the quality of healthcare. The reality is that without sated, successful, career-oriented hospitalists, there can be no HM movement to improve the quality of care.
It’s tempting to feel that our residency training should prepare us for our jobs. However, the reality is that while residency prepares us reasonably well to practice clinic medicine, it does very little to prepare us for the wide-ranging rigors of medical practice. And while it’s easy to dismiss early-career development as touchy-feely nonsense, we do so at our own peril.
That message is written in the conflicts that abound within our HM groups and our hospitals, the burnout and low satisfaction that fuel our high turnover rate, and the unfulfilled careers that litter the HM landscape. It’s a message that threatens our beloved specialty—a message that all the clapping couldn’t drown out. TH
Dr. Glasheen is associate professor of medicine at the University of Colorado Denver, where he serves as director of the Hospital Medicine Program and the Hospitalist Training Program, and as associate program director of the Internal Medicine Residency Program.
Is this really happening? That’s what I was thinking as my mind quickly ran a differential of the possible explanations for the 80 people before me, positioned erectly, hands audibly moving together and apart. This had never happened to me before. Was this some sort of group yoga stretch aimed at quelling DVT formation, perhaps a pre-determined signal alerting security to have me removed for hitting an unconscionable level of boredom, or, most likely, a synchronized form of mass exit (my talks are accustomed to a certain level of attrition)? Beyond these possibilities lies just one alternative: I actually was receiving a standing ovation.
First, let me dispense with one ever-important technicality. The ovation, coming at the close of the recent four-day Academic Hospitalist Academy held outside Atlanta, was more rightly intended for the efforts of the entire eight-member faculty than me alone. I just happened to be giving the closing session.
The fact of the matter is that as a faculty member for this program, which aimed to provide early-career development for junior academic hospitalists, I, too, was in awe at the tremendous, unparalleled work of the faculty: Drs. Brad Sharpe, Vikas Parekh, Andy Auerbach, Jeff Wiese, Shobi Chheda, Bob Centor, and Jen Myers.
Yet there I was, just moments after uttering a few closing comments, being showered with praise, each clap further pumping my chest fuller with pride. It was then, with a deflating wheeze, that I realized what was happening—they weren’t clapping for me, or even the rest of the faculty. It turns out the more obvious cause for their enthusiasm had been staring me in the face the whole time. Or, more to the point, the faces staring back at me were reflecting my numerous missteps that this course had ensured they’d never make. And that was very ovation-worthy.
Take-Home Points
Clapping excitedly at table No. 4 was a young first-year hospitalist from a major academic medical center. Looking at her, I could tell she would not, like I had, make the mistake of waiting too long to find a mentor. It wasn’t until my fourth year in academics that I found a mentor. That was four years of unproductive wandering, chasing dead ends, grabbing at wrong straws. So after multiple sessions covering the importance and means of finding mentors, as well as the role of mentees, it was clear that this young hospitalist would build her career foundation on more firm footing.
Applauding from table No. 7 was a second-year hospitalist from a community teaching hospital with aspirations of making a splash on the national hospitalist scene. Unlike my early fruitless attempts to get involved outside of my institution, the session on the importance of peer and national networking provided his quiver with several time-honored arrows that took me years to acquire.
The eyes of a hospitalist at table No. 8 foretold the story of a young faculty member who wouldn’t struggle with the process of promotion, as I had. After sitting through talks that lifted the veil on both the inner workings of an academic medical center and the mysteries by which said centers promote their members, she had a head start on ensuring her academic success.
Table No. 3 offered several hospitalists who wouldn’t make the errors I’ve made—repeatedly—with e-mail, phone conversations and running a meeting. A presentation on the basics of communications ensured that they wouldn’t send those irretrievable e-missives carrying unintentional messages or waste hours trying to cover in e-mail what would be better solved over the phone or in a face-to-face meeting.
A person at table one patted me on the shoulder, the glint in his eye signaling that the sessions on how to run a teaching team and be a more effective teacher at both the bedside and at the chalkboard would help him avoid the lower teaching scores that plagued my early academic years.
Focus on Fundamentals
I could go on, but the point is that while my fellow faculty and I reveled in the pleasure of a standing ovation, the truth is that the clapping had less to do with us or how we imparted information and more to do with the fact that we had shared with them the ingredients of their future success, something they actively longed for—a means to enhance their career success and satisfaction.
Mind you, none of these revelations were shocking; indeed, most are mundane and straightforward. However, the reality is that more often than not we just need help getting started—a little enzymatic push in the right direction. The fact that these needs were finally being met was evident in every heartfelt clap of the hands.
Lest you think these lessons are only important for us academic eggheads, I’d submit to you that the same, or at least similarly important, points are just as critical for young community hospitalists.
In fact, hospitalists and the field of HM are all very young; most of us are in desperate need of career guidance. And I’d go so far as to say the success of our field depends on meeting these needs as much or more than our ability to improve the quality of healthcare. The reality is that without sated, successful, career-oriented hospitalists, there can be no HM movement to improve the quality of care.
It’s tempting to feel that our residency training should prepare us for our jobs. However, the reality is that while residency prepares us reasonably well to practice clinic medicine, it does very little to prepare us for the wide-ranging rigors of medical practice. And while it’s easy to dismiss early-career development as touchy-feely nonsense, we do so at our own peril.
That message is written in the conflicts that abound within our HM groups and our hospitals, the burnout and low satisfaction that fuel our high turnover rate, and the unfulfilled careers that litter the HM landscape. It’s a message that threatens our beloved specialty—a message that all the clapping couldn’t drown out. TH
Dr. Glasheen is associate professor of medicine at the University of Colorado Denver, where he serves as director of the Hospital Medicine Program and the Hospitalist Training Program, and as associate program director of the Internal Medicine Residency Program.
An Imperfect Solution
There is no doubt we are getting healthcare reform, and in the end, Democrats will declare victory for the first meaningful progress since the 1960s, when Medicare and Medicaid were passed. Of course, in the interim, we have had legislation facilitating the development of HMOs under President Nixon and a senior pharmacy benefit under President George W. Bush, but many presidents have flailed at taking a crack at making major changes.
Republicans will declare victory, too, for stopping many bad ideas and trying to hold the line on costs. And everyone will complain about all the things that are not in the bill President Obama will sign this year.
And everyone will be right.
One Out of Three
To oversimplify things, all of the talk about healthcare reform has focused on three main areas:
- Increasing access for the uninsured and underinsured;
- Reigning in healthcare costs; and
- Designing a new system that rewards performance and safety.
At best, all we are getting is a down payment on access—and it will come with a substantial cost.
But what we are more likely beginning is an unraveling of business as usual and a reshuffling of the deck—and some key stakeholders won’t like the cards they will be dealt. The best way to think of what is happening in 2010 is that this is the first step toward having the healthcare system we will have in 2020.
Civic Obligation
It is a national embarrassment for the U.S. to be the only developed country that has not come up with a solution that offers most of its citizens access to healthcare. As a culture, we have decided that every child deserves a free education, that all families should have access to fire and police protection, and that we all should have access to due process and “an attorney who will be appointed to you if you cannot afford one.”
But right now in our country, about 47 million people live sicker and die quicker because of a healthcare system that doesn’t include them. A more sorry aspect is the “underinsured,” the constantly employed person with “good” insurance who is unfortunate enough to be diagnosed with cancer only to find out that their $1 million lifetime benefit runs out in year two or three. Those families face the tough choices between bankruptcy and foreclosure, or allowing Mom or Dad to give up another year or two or three of life. Is this the America we are living in?
Reform, Part I
To get this partial loaf of healthcare reform, Obama and Congressional leaders had to be creative. What has torpedoed previous efforts has been the vast power and reach of large, well-funded stakeholders who see any change as a threat and take a “what’s in it for me” approach. These industries have not been shy about using power and money to influence Congress and the White House, and even more insidiously have gone “direct” with advertisements and commentators who use “Harry and Louise” tactics to frighten an underinformed public about this complex process.
But this time, Obama promised the doctors, the insurance industry, the pharmaceutical companies, the hospitals, the device-makers, and just about anybody who would listen that “they” would not be hurt by these reforms. In fact, in the access discussion for many of these stakeholders, the initial result would be 47 million more customers paying for healthcare products and services. Is it any wonder that the price tag must go up, and by trillions of dollars?
It is the price of admission, at least to get the ball rolling. Now we all are in the box. With a price tag approaching $3 trillion a year, and an aging population and a taxpaying workforce shrinking relative to those they must support with entitlements (think Medicare and Social Security), the die is cast for “Healthcare Reform: The Sequel.”
Trust me—the next round of change will be more cataclysmic. In the aggregate, physicians will make less than the nearly $500 billion we make now. Sure, the primary-care physicians (PCPs) and lower-paid specialties might not be hit (and could even move up), but some physicians will see a marked change in their compensation.
Hospitals will need to adapt as well. They must become more efficient. We saw this in California, Washington, Oregon, Massachusetts, and elsewhere, as capitation and managed care ratcheted down on the old “cost-plus” payment method and moved the industry to reward value and efficiency. Those who are efficient and effective will do very well. Those who have lived by just doing more and more without demonstrating their performance or achieving standards will suffer and be dissatisfied.
More Reforms Possible
The future of the insurance industry will be very different as well, maybe because of government’s more intrusive role (think Medicare for most people) or by evolving to a model like Germany’s, where 200 nonprofit insurance companies compete for business. We will demand that insurance companies return $0.95 on the dollar for patient care, not $0.75 or less, as is common practice today.
Device-makers and Big Pharma might start to see a glimpse into the future as comparative-effectiveness research looks at the value of new, expensive technology and advances in treatments. As medications become “included” in the standard benefits bundle, just like physician fees and hospitalizations, we will see a relentless push downward on pricing. Drugs will become just one more line item to be budgeted for, especially if MedPAC and Congress are involved. We will get what we can afford, not everything that is possible or available.
Because this is 21st-century America, under the cacophony of Glenn Beck and Keith Olbermann and Rush Limbaugh and Rachel Maddow, the potential losers will be loud. They will trumpet any fact or pseudo-fact to alarm the populace. Phrases like “government takeover” and “you will lose the great healthcare you have,” and “death squads” and “illegal immigrants” and “back to 19th-century healthcare,” will bounce around the 24-hour news cycle. They will make real, positive change difficult.
But the beauty of what we are passing now, in 2010, is that the train is leaving the station. We are burning the boats. The healthcare system shakeup officially is under way. There is no turning back.
HM was not borne of a new law or mandate. We are an innovation of a system that must change and evolve. And while HM is not all it eventually will be, there are hints of what we can become. For a new healthcare system that offers greater access and is grounded in documented performance and efficiency, HM will be a solution for hospitals with hospitalist groups.
A lot of uncertainty remains out there, and the next decade promises to be even more turbulent, but hospitalists are as well positioned as any stakeholder in healthcare.
We are ready to be an active, contributing, and solution-oriented profession that will add value to our patients and our healthcare communities.
Stay tuned. TH
Dr. Wellikson is CEO of SHM.
There is no doubt we are getting healthcare reform, and in the end, Democrats will declare victory for the first meaningful progress since the 1960s, when Medicare and Medicaid were passed. Of course, in the interim, we have had legislation facilitating the development of HMOs under President Nixon and a senior pharmacy benefit under President George W. Bush, but many presidents have flailed at taking a crack at making major changes.
Republicans will declare victory, too, for stopping many bad ideas and trying to hold the line on costs. And everyone will complain about all the things that are not in the bill President Obama will sign this year.
And everyone will be right.
One Out of Three
To oversimplify things, all of the talk about healthcare reform has focused on three main areas:
- Increasing access for the uninsured and underinsured;
- Reigning in healthcare costs; and
- Designing a new system that rewards performance and safety.
At best, all we are getting is a down payment on access—and it will come with a substantial cost.
But what we are more likely beginning is an unraveling of business as usual and a reshuffling of the deck—and some key stakeholders won’t like the cards they will be dealt. The best way to think of what is happening in 2010 is that this is the first step toward having the healthcare system we will have in 2020.
Civic Obligation
It is a national embarrassment for the U.S. to be the only developed country that has not come up with a solution that offers most of its citizens access to healthcare. As a culture, we have decided that every child deserves a free education, that all families should have access to fire and police protection, and that we all should have access to due process and “an attorney who will be appointed to you if you cannot afford one.”
But right now in our country, about 47 million people live sicker and die quicker because of a healthcare system that doesn’t include them. A more sorry aspect is the “underinsured,” the constantly employed person with “good” insurance who is unfortunate enough to be diagnosed with cancer only to find out that their $1 million lifetime benefit runs out in year two or three. Those families face the tough choices between bankruptcy and foreclosure, or allowing Mom or Dad to give up another year or two or three of life. Is this the America we are living in?
Reform, Part I
To get this partial loaf of healthcare reform, Obama and Congressional leaders had to be creative. What has torpedoed previous efforts has been the vast power and reach of large, well-funded stakeholders who see any change as a threat and take a “what’s in it for me” approach. These industries have not been shy about using power and money to influence Congress and the White House, and even more insidiously have gone “direct” with advertisements and commentators who use “Harry and Louise” tactics to frighten an underinformed public about this complex process.
But this time, Obama promised the doctors, the insurance industry, the pharmaceutical companies, the hospitals, the device-makers, and just about anybody who would listen that “they” would not be hurt by these reforms. In fact, in the access discussion for many of these stakeholders, the initial result would be 47 million more customers paying for healthcare products and services. Is it any wonder that the price tag must go up, and by trillions of dollars?
It is the price of admission, at least to get the ball rolling. Now we all are in the box. With a price tag approaching $3 trillion a year, and an aging population and a taxpaying workforce shrinking relative to those they must support with entitlements (think Medicare and Social Security), the die is cast for “Healthcare Reform: The Sequel.”
Trust me—the next round of change will be more cataclysmic. In the aggregate, physicians will make less than the nearly $500 billion we make now. Sure, the primary-care physicians (PCPs) and lower-paid specialties might not be hit (and could even move up), but some physicians will see a marked change in their compensation.
Hospitals will need to adapt as well. They must become more efficient. We saw this in California, Washington, Oregon, Massachusetts, and elsewhere, as capitation and managed care ratcheted down on the old “cost-plus” payment method and moved the industry to reward value and efficiency. Those who are efficient and effective will do very well. Those who have lived by just doing more and more without demonstrating their performance or achieving standards will suffer and be dissatisfied.
More Reforms Possible
The future of the insurance industry will be very different as well, maybe because of government’s more intrusive role (think Medicare for most people) or by evolving to a model like Germany’s, where 200 nonprofit insurance companies compete for business. We will demand that insurance companies return $0.95 on the dollar for patient care, not $0.75 or less, as is common practice today.
Device-makers and Big Pharma might start to see a glimpse into the future as comparative-effectiveness research looks at the value of new, expensive technology and advances in treatments. As medications become “included” in the standard benefits bundle, just like physician fees and hospitalizations, we will see a relentless push downward on pricing. Drugs will become just one more line item to be budgeted for, especially if MedPAC and Congress are involved. We will get what we can afford, not everything that is possible or available.
Because this is 21st-century America, under the cacophony of Glenn Beck and Keith Olbermann and Rush Limbaugh and Rachel Maddow, the potential losers will be loud. They will trumpet any fact or pseudo-fact to alarm the populace. Phrases like “government takeover” and “you will lose the great healthcare you have,” and “death squads” and “illegal immigrants” and “back to 19th-century healthcare,” will bounce around the 24-hour news cycle. They will make real, positive change difficult.
But the beauty of what we are passing now, in 2010, is that the train is leaving the station. We are burning the boats. The healthcare system shakeup officially is under way. There is no turning back.
HM was not borne of a new law or mandate. We are an innovation of a system that must change and evolve. And while HM is not all it eventually will be, there are hints of what we can become. For a new healthcare system that offers greater access and is grounded in documented performance and efficiency, HM will be a solution for hospitals with hospitalist groups.
A lot of uncertainty remains out there, and the next decade promises to be even more turbulent, but hospitalists are as well positioned as any stakeholder in healthcare.
We are ready to be an active, contributing, and solution-oriented profession that will add value to our patients and our healthcare communities.
Stay tuned. TH
Dr. Wellikson is CEO of SHM.
There is no doubt we are getting healthcare reform, and in the end, Democrats will declare victory for the first meaningful progress since the 1960s, when Medicare and Medicaid were passed. Of course, in the interim, we have had legislation facilitating the development of HMOs under President Nixon and a senior pharmacy benefit under President George W. Bush, but many presidents have flailed at taking a crack at making major changes.
Republicans will declare victory, too, for stopping many bad ideas and trying to hold the line on costs. And everyone will complain about all the things that are not in the bill President Obama will sign this year.
And everyone will be right.
One Out of Three
To oversimplify things, all of the talk about healthcare reform has focused on three main areas:
- Increasing access for the uninsured and underinsured;
- Reigning in healthcare costs; and
- Designing a new system that rewards performance and safety.
At best, all we are getting is a down payment on access—and it will come with a substantial cost.
But what we are more likely beginning is an unraveling of business as usual and a reshuffling of the deck—and some key stakeholders won’t like the cards they will be dealt. The best way to think of what is happening in 2010 is that this is the first step toward having the healthcare system we will have in 2020.
Civic Obligation
It is a national embarrassment for the U.S. to be the only developed country that has not come up with a solution that offers most of its citizens access to healthcare. As a culture, we have decided that every child deserves a free education, that all families should have access to fire and police protection, and that we all should have access to due process and “an attorney who will be appointed to you if you cannot afford one.”
But right now in our country, about 47 million people live sicker and die quicker because of a healthcare system that doesn’t include them. A more sorry aspect is the “underinsured,” the constantly employed person with “good” insurance who is unfortunate enough to be diagnosed with cancer only to find out that their $1 million lifetime benefit runs out in year two or three. Those families face the tough choices between bankruptcy and foreclosure, or allowing Mom or Dad to give up another year or two or three of life. Is this the America we are living in?
Reform, Part I
To get this partial loaf of healthcare reform, Obama and Congressional leaders had to be creative. What has torpedoed previous efforts has been the vast power and reach of large, well-funded stakeholders who see any change as a threat and take a “what’s in it for me” approach. These industries have not been shy about using power and money to influence Congress and the White House, and even more insidiously have gone “direct” with advertisements and commentators who use “Harry and Louise” tactics to frighten an underinformed public about this complex process.
But this time, Obama promised the doctors, the insurance industry, the pharmaceutical companies, the hospitals, the device-makers, and just about anybody who would listen that “they” would not be hurt by these reforms. In fact, in the access discussion for many of these stakeholders, the initial result would be 47 million more customers paying for healthcare products and services. Is it any wonder that the price tag must go up, and by trillions of dollars?
It is the price of admission, at least to get the ball rolling. Now we all are in the box. With a price tag approaching $3 trillion a year, and an aging population and a taxpaying workforce shrinking relative to those they must support with entitlements (think Medicare and Social Security), the die is cast for “Healthcare Reform: The Sequel.”
Trust me—the next round of change will be more cataclysmic. In the aggregate, physicians will make less than the nearly $500 billion we make now. Sure, the primary-care physicians (PCPs) and lower-paid specialties might not be hit (and could even move up), but some physicians will see a marked change in their compensation.
Hospitals will need to adapt as well. They must become more efficient. We saw this in California, Washington, Oregon, Massachusetts, and elsewhere, as capitation and managed care ratcheted down on the old “cost-plus” payment method and moved the industry to reward value and efficiency. Those who are efficient and effective will do very well. Those who have lived by just doing more and more without demonstrating their performance or achieving standards will suffer and be dissatisfied.
More Reforms Possible
The future of the insurance industry will be very different as well, maybe because of government’s more intrusive role (think Medicare for most people) or by evolving to a model like Germany’s, where 200 nonprofit insurance companies compete for business. We will demand that insurance companies return $0.95 on the dollar for patient care, not $0.75 or less, as is common practice today.
Device-makers and Big Pharma might start to see a glimpse into the future as comparative-effectiveness research looks at the value of new, expensive technology and advances in treatments. As medications become “included” in the standard benefits bundle, just like physician fees and hospitalizations, we will see a relentless push downward on pricing. Drugs will become just one more line item to be budgeted for, especially if MedPAC and Congress are involved. We will get what we can afford, not everything that is possible or available.
Because this is 21st-century America, under the cacophony of Glenn Beck and Keith Olbermann and Rush Limbaugh and Rachel Maddow, the potential losers will be loud. They will trumpet any fact or pseudo-fact to alarm the populace. Phrases like “government takeover” and “you will lose the great healthcare you have,” and “death squads” and “illegal immigrants” and “back to 19th-century healthcare,” will bounce around the 24-hour news cycle. They will make real, positive change difficult.
But the beauty of what we are passing now, in 2010, is that the train is leaving the station. We are burning the boats. The healthcare system shakeup officially is under way. There is no turning back.
HM was not borne of a new law or mandate. We are an innovation of a system that must change and evolve. And while HM is not all it eventually will be, there are hints of what we can become. For a new healthcare system that offers greater access and is grounded in documented performance and efficiency, HM will be a solution for hospitals with hospitalist groups.
A lot of uncertainty remains out there, and the next decade promises to be even more turbulent, but hospitalists are as well positioned as any stakeholder in healthcare.
We are ready to be an active, contributing, and solution-oriented profession that will add value to our patients and our healthcare communities.
Stay tuned. TH
Dr. Wellikson is CEO of SHM.