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Editor’s Note: The Society of Hospital Medicine’s (SHM’s) Physician in Training Committee launched a scholarship program in 2015 for medical students to help transform healthcare and revolutionize patient care. The program has been expanded for the 2017-18 year, offering two options for students to receive funding and engage in scholarly work during their first, second and third years of medical school. As a part of the program, recipients are required to write about their experience on a biweekly basis.

As I walk the University of Chicago Hospital observing various health care practitioners, I am continually impressed with the businesslike approach and productivity of each individual. The hospital staff is composed of highly intelligent, experienced, and talented physicians, but I have come to understand that in this large system it can be difficult to maintain quality patient care with both increased census and increased handoffs.

The research project I am working on focuses on shared mental models between the MICU and the general floor on what the most important factor of care is while they are on the floor, and to identify how prominent it is for shared mental models to be present between the transferring and receiving teams. After reading various papers, I am beginning to understand the various complexities present in translating information when transferring patients from any department onto the floor.

When looking through the current data showing each individual’s responses on an interprofessional team, I start to recognize trends and see key phrases or words that represent whether the two groups are, or are not, in agreement with one another. When comparing agreement between teams, certain factors continually come up in regards to patient care, such as respiratory, hemodynamic, or infection management, and I start to see whether there is both inter-team and intra-team concordance.

I continue to discuss these topics with my mentors, Dr. Vineet Arora and Dr. Juan Rojas, in order to appropriately categorize all survey responses and identify whether there is concordance between teams. I am glad to be able to rely on their insight concerning methods of coding the data, as well as what type of medical care each responding individual receives, and remaining on track with my estimated timeline of completion.

Past research supports the idea that increased times, distractions, and workloads in regard to handoffs result in potential errors, decreasing the quality of patient care and potentially resulting in worse patient outcomes. MICU patients are at a particular risk, since ineffective communication could lead to readmission, which could result in worsened health outcomes.

I believe that this current research project is highly significant since it highlights whether effective communication is occurring in the first place, and whether teams are appropriately communicating patient plans for this group of higher-acuity patients. As I continue my research at the university, I hope to further identify whether effective communication is taking place for this at-risk group of floor patients.
 

Anton Garazha is a medical student at Chicago Medical School at Rosalind Franklin University in North Chicago. He received his bachelor of science degree in biology from Loyola University in Chicago in 2015 and his master of biomedical science degree from Rosalind Franklin University in 2016. Anton is very interested in community outreach and quality improvement, and in his spare time tutors students in science-based subjects.

 

Editor’s Note: The Society of Hospital Medicine’s (SHM’s) Physician in Training Committee launched a scholarship program in 2015 for medical students to help transform healthcare and revolutionize patient care. The program has been expanded for the 2017-18 year, offering two options for students to receive funding and engage in scholarly work during their first, second and third years of medical school. As a part of the program, recipients are required to write about their experience on a biweekly basis.

As I walk the University of Chicago Hospital observing various health care practitioners, I am continually impressed with the businesslike approach and productivity of each individual. The hospital staff is composed of highly intelligent, experienced, and talented physicians, but I have come to understand that in this large system it can be difficult to maintain quality patient care with both increased census and increased handoffs.

The research project I am working on focuses on shared mental models between the MICU and the general floor on what the most important factor of care is while they are on the floor, and to identify how prominent it is for shared mental models to be present between the transferring and receiving teams. After reading various papers, I am beginning to understand the various complexities present in translating information when transferring patients from any department onto the floor.

When looking through the current data showing each individual’s responses on an interprofessional team, I start to recognize trends and see key phrases or words that represent whether the two groups are, or are not, in agreement with one another. When comparing agreement between teams, certain factors continually come up in regards to patient care, such as respiratory, hemodynamic, or infection management, and I start to see whether there is both inter-team and intra-team concordance.

I continue to discuss these topics with my mentors, Dr. Vineet Arora and Dr. Juan Rojas, in order to appropriately categorize all survey responses and identify whether there is concordance between teams. I am glad to be able to rely on their insight concerning methods of coding the data, as well as what type of medical care each responding individual receives, and remaining on track with my estimated timeline of completion.

Past research supports the idea that increased times, distractions, and workloads in regard to handoffs result in potential errors, decreasing the quality of patient care and potentially resulting in worse patient outcomes. MICU patients are at a particular risk, since ineffective communication could lead to readmission, which could result in worsened health outcomes.

I believe that this current research project is highly significant since it highlights whether effective communication is occurring in the first place, and whether teams are appropriately communicating patient plans for this group of higher-acuity patients. As I continue my research at the university, I hope to further identify whether effective communication is taking place for this at-risk group of floor patients.
 

Anton Garazha is a medical student at Chicago Medical School at Rosalind Franklin University in North Chicago. He received his bachelor of science degree in biology from Loyola University in Chicago in 2015 and his master of biomedical science degree from Rosalind Franklin University in 2016. Anton is very interested in community outreach and quality improvement, and in his spare time tutors students in science-based subjects.

 

Editor’s Note: The Society of Hospital Medicine’s (SHM’s) Physician in Training Committee launched a scholarship program in 2015 for medical students to help transform healthcare and revolutionize patient care. The program has been expanded for the 2017-18 year, offering two options for students to receive funding and engage in scholarly work during their first, second and third years of medical school. As a part of the program, recipients are required to write about their experience on a biweekly basis.

As I walk the University of Chicago Hospital observing various health care practitioners, I am continually impressed with the businesslike approach and productivity of each individual. The hospital staff is composed of highly intelligent, experienced, and talented physicians, but I have come to understand that in this large system it can be difficult to maintain quality patient care with both increased census and increased handoffs.

The research project I am working on focuses on shared mental models between the MICU and the general floor on what the most important factor of care is while they are on the floor, and to identify how prominent it is for shared mental models to be present between the transferring and receiving teams. After reading various papers, I am beginning to understand the various complexities present in translating information when transferring patients from any department onto the floor.

When looking through the current data showing each individual’s responses on an interprofessional team, I start to recognize trends and see key phrases or words that represent whether the two groups are, or are not, in agreement with one another. When comparing agreement between teams, certain factors continually come up in regards to patient care, such as respiratory, hemodynamic, or infection management, and I start to see whether there is both inter-team and intra-team concordance.

I continue to discuss these topics with my mentors, Dr. Vineet Arora and Dr. Juan Rojas, in order to appropriately categorize all survey responses and identify whether there is concordance between teams. I am glad to be able to rely on their insight concerning methods of coding the data, as well as what type of medical care each responding individual receives, and remaining on track with my estimated timeline of completion.

Past research supports the idea that increased times, distractions, and workloads in regard to handoffs result in potential errors, decreasing the quality of patient care and potentially resulting in worse patient outcomes. MICU patients are at a particular risk, since ineffective communication could lead to readmission, which could result in worsened health outcomes.

I believe that this current research project is highly significant since it highlights whether effective communication is occurring in the first place, and whether teams are appropriately communicating patient plans for this group of higher-acuity patients. As I continue my research at the university, I hope to further identify whether effective communication is taking place for this at-risk group of floor patients.
 

Anton Garazha is a medical student at Chicago Medical School at Rosalind Franklin University in North Chicago. He received his bachelor of science degree in biology from Loyola University in Chicago in 2015 and his master of biomedical science degree from Rosalind Franklin University in 2016. Anton is very interested in community outreach and quality improvement, and in his spare time tutors students in science-based subjects.

 

Early decision for Fellows applications is Sept. 15. Apply now!

SHM’s Fellows designation is a prestigious way to differentiate yourself among your peers in hospital medicine. There are currently over 2,000 hospitalists who have earned the Fellow in Hospital Medicine (FHM) or Senior Fellow in Hospital Medicine (SFHM) designation by demonstrating core values of leadership, teamwork, and quality improvement.

“I was encouraged to consider SHM’s Fellow designation by other members of an SHM committee that I belonged to. Although reluctant at first, I realized that this was an opportunity to really confirm that I was a career hospitalist. The application process itself allowed me to objectively evaluate the work I had done to date and how it fit into my overall career plan. I believe that this FHM designation has fostered connections in the HM community and within my own institution that may not have been open to me before.” – Dr. Patricia Seymour, MD, FAAFP, FHM

Apply now and learn how you can join other hospitalists who have earned this exclusive designation and recognition at hospitalmedicine.org/fellows. Applications officially close on Nov. 30, 2017.
 

Got research? Get noticed at HM18!

Don’t miss your chance to present your research to a national audience. SHM’s scientific abstract and poster competition, known as Research, Innovations, and Clinical Vignettes (RIV), is one of the most popular events at SHM’s annual meeting, enabling hospitalists from across the country to discuss emerging scientific and clinical cases, share feedback, and make valuable professional connections.

Hospital Medicine 2018 (HM18) will be held April 8-11, 2018 at the Orlando World Center Marriott. Many cutting-edge abstracts first presented at SHM’s RIV sessions go on to be published in respected medical journals. Yours could be next.

For more details, visit hospitalmedicine2018.org.
 

Know someone with exceptional achievements in Hospital Medicine?

SHM’s prestigious Awards of Excellence recognize exceptional achievements in the field of hospital medicine in the following categories:

• Excellence in Research.

• Management Excellence in Hospital Medicine.

• Outstanding Service in Hospital Medicine.

• Excellence in Teaching.

• Clinical Excellence for Physicians.

• Clinical Excellence for Nurse Practitioners and Physician Assistants.

• Excellence in Humanitarian Services.

• Excellence in Teamwork.

Awards of Excellence nominations are due on Oct. 2, 2017. Nominate yourself or a colleague today at hospitalmedicine.org/awards.
 

Invest in your career with SPARK ONE

SPARK ONE, SHM’s premier online self-assessment created specifically for hospital medicine professionals, is the perfect tool to help you reach your goals. The activity contains 450+ vignette-style multiple-choice questions covering 100% of the American Board of Internal Medicine’s Focused Practice in Hospital Medicine (FPHM) exam blueprint.

This online tool is your complete resource for successfully preparing for the FPHM exam or assessing your general knowledge in hospital medicine. Used as a self-paced study guide, it engages learners through an open-book format, allowing users to review detailed learning objectives and discussion points, and define individual areas of strengths and weaknesses. Earn up to 23 AMA PRA Category 1 Credit™ and 23 MOC points.

Learn more at hospitalmedicine.org/sparkone.
 

Strengthen your knowledge & skills in practice administration

Get involved in the SHM Practice Administrators’ Committee 2018 Mentor/Mentee Program.

This program helps you create relationships and serves as an outlet for you to pose questions or ideas to a seasoned hospital medicine group administrator. There are two different ways you can participate: as a less experienced administrator looking for a mentor or as a more experienced administrator looking to be paired with a peer. This program is free to members only. Not a member? Join today at hospitalmedicine.org/join.

Learn more about the program and submit your application at hospitalmedicine.org/pamentor.
 

Obtain an extensive insight into Hospital Medicine groups configuration and operation

SHM’s State of Hospital Medicine Report includes data collected from 600 hospital medicine groups (HMGs) representing 9,000 providers to keep you current on hospitalist compensation and production, in addition to cutting-edge knowledge covering practice demographics, staffing levels, turnover, staff growth, compensation methods, and financial support for solid, evidence-based management decisions.

The 2016 State of Hospital Medicine Report is not only in print but also available in an enhanced, fully searchable digital version. Order your copy at hospitalmedicine.org/sohm.
 

Mr. Radler is marketing communications manager at the Society of Hospital Medicine.

 

Early decision for Fellows applications is Sept. 15. Apply now!

SHM’s Fellows designation is a prestigious way to differentiate yourself among your peers in hospital medicine. There are currently over 2,000 hospitalists who have earned the Fellow in Hospital Medicine (FHM) or Senior Fellow in Hospital Medicine (SFHM) designation by demonstrating core values of leadership, teamwork, and quality improvement.

“I was encouraged to consider SHM’s Fellow designation by other members of an SHM committee that I belonged to. Although reluctant at first, I realized that this was an opportunity to really confirm that I was a career hospitalist. The application process itself allowed me to objectively evaluate the work I had done to date and how it fit into my overall career plan. I believe that this FHM designation has fostered connections in the HM community and within my own institution that may not have been open to me before.” – Dr. Patricia Seymour, MD, FAAFP, FHM

Apply now and learn how you can join other hospitalists who have earned this exclusive designation and recognition at hospitalmedicine.org/fellows. Applications officially close on Nov. 30, 2017.
 

Got research? Get noticed at HM18!

Don’t miss your chance to present your research to a national audience. SHM’s scientific abstract and poster competition, known as Research, Innovations, and Clinical Vignettes (RIV), is one of the most popular events at SHM’s annual meeting, enabling hospitalists from across the country to discuss emerging scientific and clinical cases, share feedback, and make valuable professional connections.

Hospital Medicine 2018 (HM18) will be held April 8-11, 2018 at the Orlando World Center Marriott. Many cutting-edge abstracts first presented at SHM’s RIV sessions go on to be published in respected medical journals. Yours could be next.

For more details, visit hospitalmedicine2018.org.
 

Know someone with exceptional achievements in Hospital Medicine?

SHM’s prestigious Awards of Excellence recognize exceptional achievements in the field of hospital medicine in the following categories:

• Excellence in Research.

• Management Excellence in Hospital Medicine.

• Outstanding Service in Hospital Medicine.

• Excellence in Teaching.

• Clinical Excellence for Physicians.

• Clinical Excellence for Nurse Practitioners and Physician Assistants.

• Excellence in Humanitarian Services.

• Excellence in Teamwork.

Awards of Excellence nominations are due on Oct. 2, 2017. Nominate yourself or a colleague today at hospitalmedicine.org/awards.
 

Invest in your career with SPARK ONE

SPARK ONE, SHM’s premier online self-assessment created specifically for hospital medicine professionals, is the perfect tool to help you reach your goals. The activity contains 450+ vignette-style multiple-choice questions covering 100% of the American Board of Internal Medicine’s Focused Practice in Hospital Medicine (FPHM) exam blueprint.

This online tool is your complete resource for successfully preparing for the FPHM exam or assessing your general knowledge in hospital medicine. Used as a self-paced study guide, it engages learners through an open-book format, allowing users to review detailed learning objectives and discussion points, and define individual areas of strengths and weaknesses. Earn up to 23 AMA PRA Category 1 Credit™ and 23 MOC points.

Learn more at hospitalmedicine.org/sparkone.
 

Strengthen your knowledge & skills in practice administration

Get involved in the SHM Practice Administrators’ Committee 2018 Mentor/Mentee Program.

This program helps you create relationships and serves as an outlet for you to pose questions or ideas to a seasoned hospital medicine group administrator. There are two different ways you can participate: as a less experienced administrator looking for a mentor or as a more experienced administrator looking to be paired with a peer. This program is free to members only. Not a member? Join today at hospitalmedicine.org/join.

Learn more about the program and submit your application at hospitalmedicine.org/pamentor.
 

Obtain an extensive insight into Hospital Medicine groups configuration and operation

SHM’s State of Hospital Medicine Report includes data collected from 600 hospital medicine groups (HMGs) representing 9,000 providers to keep you current on hospitalist compensation and production, in addition to cutting-edge knowledge covering practice demographics, staffing levels, turnover, staff growth, compensation methods, and financial support for solid, evidence-based management decisions.

The 2016 State of Hospital Medicine Report is not only in print but also available in an enhanced, fully searchable digital version. Order your copy at hospitalmedicine.org/sohm.
 

Mr. Radler is marketing communications manager at the Society of Hospital Medicine.

 

Early decision for Fellows applications is Sept. 15. Apply now!

SHM’s Fellows designation is a prestigious way to differentiate yourself among your peers in hospital medicine. There are currently over 2,000 hospitalists who have earned the Fellow in Hospital Medicine (FHM) or Senior Fellow in Hospital Medicine (SFHM) designation by demonstrating core values of leadership, teamwork, and quality improvement.

“I was encouraged to consider SHM’s Fellow designation by other members of an SHM committee that I belonged to. Although reluctant at first, I realized that this was an opportunity to really confirm that I was a career hospitalist. The application process itself allowed me to objectively evaluate the work I had done to date and how it fit into my overall career plan. I believe that this FHM designation has fostered connections in the HM community and within my own institution that may not have been open to me before.” – Dr. Patricia Seymour, MD, FAAFP, FHM

Apply now and learn how you can join other hospitalists who have earned this exclusive designation and recognition at hospitalmedicine.org/fellows. Applications officially close on Nov. 30, 2017.
 

Got research? Get noticed at HM18!

Don’t miss your chance to present your research to a national audience. SHM’s scientific abstract and poster competition, known as Research, Innovations, and Clinical Vignettes (RIV), is one of the most popular events at SHM’s annual meeting, enabling hospitalists from across the country to discuss emerging scientific and clinical cases, share feedback, and make valuable professional connections.

Hospital Medicine 2018 (HM18) will be held April 8-11, 2018 at the Orlando World Center Marriott. Many cutting-edge abstracts first presented at SHM’s RIV sessions go on to be published in respected medical journals. Yours could be next.

For more details, visit hospitalmedicine2018.org.
 

Know someone with exceptional achievements in Hospital Medicine?

SHM’s prestigious Awards of Excellence recognize exceptional achievements in the field of hospital medicine in the following categories:

• Excellence in Research.

• Management Excellence in Hospital Medicine.

• Outstanding Service in Hospital Medicine.

• Excellence in Teaching.

• Clinical Excellence for Physicians.

• Clinical Excellence for Nurse Practitioners and Physician Assistants.

• Excellence in Humanitarian Services.

• Excellence in Teamwork.

Awards of Excellence nominations are due on Oct. 2, 2017. Nominate yourself or a colleague today at hospitalmedicine.org/awards.
 

Invest in your career with SPARK ONE

SPARK ONE, SHM’s premier online self-assessment created specifically for hospital medicine professionals, is the perfect tool to help you reach your goals. The activity contains 450+ vignette-style multiple-choice questions covering 100% of the American Board of Internal Medicine’s Focused Practice in Hospital Medicine (FPHM) exam blueprint.

This online tool is your complete resource for successfully preparing for the FPHM exam or assessing your general knowledge in hospital medicine. Used as a self-paced study guide, it engages learners through an open-book format, allowing users to review detailed learning objectives and discussion points, and define individual areas of strengths and weaknesses. Earn up to 23 AMA PRA Category 1 Credit™ and 23 MOC points.

Learn more at hospitalmedicine.org/sparkone.
 

Strengthen your knowledge & skills in practice administration

Get involved in the SHM Practice Administrators’ Committee 2018 Mentor/Mentee Program.

This program helps you create relationships and serves as an outlet for you to pose questions or ideas to a seasoned hospital medicine group administrator. There are two different ways you can participate: as a less experienced administrator looking for a mentor or as a more experienced administrator looking to be paired with a peer. This program is free to members only. Not a member? Join today at hospitalmedicine.org/join.

Learn more about the program and submit your application at hospitalmedicine.org/pamentor.
 

Obtain an extensive insight into Hospital Medicine groups configuration and operation

SHM’s State of Hospital Medicine Report includes data collected from 600 hospital medicine groups (HMGs) representing 9,000 providers to keep you current on hospitalist compensation and production, in addition to cutting-edge knowledge covering practice demographics, staffing levels, turnover, staff growth, compensation methods, and financial support for solid, evidence-based management decisions.

The 2016 State of Hospital Medicine Report is not only in print but also available in an enhanced, fully searchable digital version. Order your copy at hospitalmedicine.org/sohm.
 

Mr. Radler is marketing communications manager at the Society of Hospital Medicine.

 

Editor:

Dr. Nasim Afsar’s article of June 2, 2017 (“A case for building our leadership skills”) calls for the integration of leadership skills into medical training, and we at the University of Colorado wholeheartedly agree. There are several institutions around the country that are already addressing this problem head on, and we write this letter to highlight a few educational programs we’ve created that demonstrate the power of arming our trainees with this skill set. Furthermore, we wish to encourage collaboration between educators and institutions that are engaged in similar work in the hopes of moving this field forward.

Here at the University of Colorado, a team of Hospital Medicine faculty has created a number of programs to address the leadership education gap in learners at the undergraduate medical education,¹ graduate medical education,² and fellowship levels – creating a pipeline for developing leaders in hospital medicine. These programs include an immersive medical student elective, a dedicated leadership track in the Internal Medicine Residency Program, and a fellowship program in Hospital Medicine focused on Quality Improvement and Health Systems Leadership. Our goal in each of these programs to equip trainees across the spectrum of medical education with the knowledge, attitudes, and skills needed to lead high-functioning teams.

Critical leadership skills such as stakeholder engagement, change management, conflict management, and negotiation are taught through a variety of modalities including dedicated didactic sessions, personalized mentorship, and experiential work focused on practicing effective leadership behaviors. Ultimately, we hope to accelerate our graduates into positions of health care leadership by providing them with the core skills needed to successfully navigate a career in medicine, though we feel strongly that the development of leadership skills is imperative for all providers in the dynamic health care landscape, regardless of whether individual learners wish to pursue titled leadership positions in their organizations. Further, we agree with Dr. Afsar that leadership skills are important for all physicians, and would add that these skills are imperative regardless of motivations to hold a “titled leadership position.”

In our 5-year experience with our leadership training pipeline, we’ve learned a few important lessons. First, medical trainees are rarely exposed to the leadership skill set elsewhere in medical training, and are eager to learn new approaches to common problems that they encounter on a daily basis: How do I negotiate with a colleague? How can I motivate team members to change behavior to accomplish a goal? How can I use data to support requests for resources?

Secondly, trainees who are exposed to leadership concepts and who are given the opportunity to practice them through challenging project work in the live system routinely make meaningful changes to the health system. Our trainees have revamped our process of managing interhospital transfers, have decreased rates of inappropriate antibiotic usage, and have enhanced the patient experience in our stroke units. Further, our recent graduates have positioned themselves as leaders in health systems. Our graduates are leading a QI program at a major academic center, being promoted to educational leadership roles such as assistant program director within a residency training program, directing process improvement in a developing country, and leading the operations unit of a large physician group.

As Dr. Afsar highlights, there is much work to be done to better equip trainees with the skill set to lead. We strongly encourage other training programs to develop strategies to teach leadership and create forums for trainees to practice their burgeoning skill set. In addition to responding to Dr. Afsar’s call to develop programs, we should form collaborative working groups through our regional and national organizations to develop comprehensive leadership programs for medical trainees at all levels. Collaborating to empower the next generation of providers is critical to our future as hospitalists as we continue to take the lead in improving and shaping our health care systems.
 

Tyler Anstett, DO

Manuel Diaz, MD

Emily Gottenborg, MD

University of Colorado School of Medicine, Anschutz Medical Campus, Aurora, Colo.

References

1. Sweigart JR, Tad-Y D, Kneeland P, Williams MV, Glasheen JJ. Hospital Medicine Resident Training Tracks: Developing the Hospital Medicine Pipeline. J Hosp Med. 2017 Mar;12(3):173-176. doi: 10.12788/jhm.2703.

2. Tad-y D, Price L, Cumbler E, Levin D, Wald H, Glasheen J. An experiential quality improvement curriculum for the inpatient setting – part 1: design phase of a QI project. MedEdPORTAL Publications. 2014;10:9841. http://doi.org/10.15766/mep_2374-8265.9841.

 

Editor:

Dr. Nasim Afsar’s article of June 2, 2017 (“A case for building our leadership skills”) calls for the integration of leadership skills into medical training, and we at the University of Colorado wholeheartedly agree. There are several institutions around the country that are already addressing this problem head on, and we write this letter to highlight a few educational programs we’ve created that demonstrate the power of arming our trainees with this skill set. Furthermore, we wish to encourage collaboration between educators and institutions that are engaged in similar work in the hopes of moving this field forward.

Here at the University of Colorado, a team of Hospital Medicine faculty has created a number of programs to address the leadership education gap in learners at the undergraduate medical education,¹ graduate medical education,² and fellowship levels – creating a pipeline for developing leaders in hospital medicine. These programs include an immersive medical student elective, a dedicated leadership track in the Internal Medicine Residency Program, and a fellowship program in Hospital Medicine focused on Quality Improvement and Health Systems Leadership. Our goal in each of these programs to equip trainees across the spectrum of medical education with the knowledge, attitudes, and skills needed to lead high-functioning teams.

Critical leadership skills such as stakeholder engagement, change management, conflict management, and negotiation are taught through a variety of modalities including dedicated didactic sessions, personalized mentorship, and experiential work focused on practicing effective leadership behaviors. Ultimately, we hope to accelerate our graduates into positions of health care leadership by providing them with the core skills needed to successfully navigate a career in medicine, though we feel strongly that the development of leadership skills is imperative for all providers in the dynamic health care landscape, regardless of whether individual learners wish to pursue titled leadership positions in their organizations. Further, we agree with Dr. Afsar that leadership skills are important for all physicians, and would add that these skills are imperative regardless of motivations to hold a “titled leadership position.”

In our 5-year experience with our leadership training pipeline, we’ve learned a few important lessons. First, medical trainees are rarely exposed to the leadership skill set elsewhere in medical training, and are eager to learn new approaches to common problems that they encounter on a daily basis: How do I negotiate with a colleague? How can I motivate team members to change behavior to accomplish a goal? How can I use data to support requests for resources?

Secondly, trainees who are exposed to leadership concepts and who are given the opportunity to practice them through challenging project work in the live system routinely make meaningful changes to the health system. Our trainees have revamped our process of managing interhospital transfers, have decreased rates of inappropriate antibiotic usage, and have enhanced the patient experience in our stroke units. Further, our recent graduates have positioned themselves as leaders in health systems. Our graduates are leading a QI program at a major academic center, being promoted to educational leadership roles such as assistant program director within a residency training program, directing process improvement in a developing country, and leading the operations unit of a large physician group.

As Dr. Afsar highlights, there is much work to be done to better equip trainees with the skill set to lead. We strongly encourage other training programs to develop strategies to teach leadership and create forums for trainees to practice their burgeoning skill set. In addition to responding to Dr. Afsar’s call to develop programs, we should form collaborative working groups through our regional and national organizations to develop comprehensive leadership programs for medical trainees at all levels. Collaborating to empower the next generation of providers is critical to our future as hospitalists as we continue to take the lead in improving and shaping our health care systems.
 

Tyler Anstett, DO

Manuel Diaz, MD

Emily Gottenborg, MD

University of Colorado School of Medicine, Anschutz Medical Campus, Aurora, Colo.

References

1. Sweigart JR, Tad-Y D, Kneeland P, Williams MV, Glasheen JJ. Hospital Medicine Resident Training Tracks: Developing the Hospital Medicine Pipeline. J Hosp Med. 2017 Mar;12(3):173-176. doi: 10.12788/jhm.2703.

2. Tad-y D, Price L, Cumbler E, Levin D, Wald H, Glasheen J. An experiential quality improvement curriculum for the inpatient setting – part 1: design phase of a QI project. MedEdPORTAL Publications. 2014;10:9841. http://doi.org/10.15766/mep_2374-8265.9841.

 

Editor:

Dr. Nasim Afsar’s article of June 2, 2017 (“A case for building our leadership skills”) calls for the integration of leadership skills into medical training, and we at the University of Colorado wholeheartedly agree. There are several institutions around the country that are already addressing this problem head on, and we write this letter to highlight a few educational programs we’ve created that demonstrate the power of arming our trainees with this skill set. Furthermore, we wish to encourage collaboration between educators and institutions that are engaged in similar work in the hopes of moving this field forward.

Here at the University of Colorado, a team of Hospital Medicine faculty has created a number of programs to address the leadership education gap in learners at the undergraduate medical education,¹ graduate medical education,² and fellowship levels – creating a pipeline for developing leaders in hospital medicine. These programs include an immersive medical student elective, a dedicated leadership track in the Internal Medicine Residency Program, and a fellowship program in Hospital Medicine focused on Quality Improvement and Health Systems Leadership. Our goal in each of these programs to equip trainees across the spectrum of medical education with the knowledge, attitudes, and skills needed to lead high-functioning teams.

Critical leadership skills such as stakeholder engagement, change management, conflict management, and negotiation are taught through a variety of modalities including dedicated didactic sessions, personalized mentorship, and experiential work focused on practicing effective leadership behaviors. Ultimately, we hope to accelerate our graduates into positions of health care leadership by providing them with the core skills needed to successfully navigate a career in medicine, though we feel strongly that the development of leadership skills is imperative for all providers in the dynamic health care landscape, regardless of whether individual learners wish to pursue titled leadership positions in their organizations. Further, we agree with Dr. Afsar that leadership skills are important for all physicians, and would add that these skills are imperative regardless of motivations to hold a “titled leadership position.”

In our 5-year experience with our leadership training pipeline, we’ve learned a few important lessons. First, medical trainees are rarely exposed to the leadership skill set elsewhere in medical training, and are eager to learn new approaches to common problems that they encounter on a daily basis: How do I negotiate with a colleague? How can I motivate team members to change behavior to accomplish a goal? How can I use data to support requests for resources?

Secondly, trainees who are exposed to leadership concepts and who are given the opportunity to practice them through challenging project work in the live system routinely make meaningful changes to the health system. Our trainees have revamped our process of managing interhospital transfers, have decreased rates of inappropriate antibiotic usage, and have enhanced the patient experience in our stroke units. Further, our recent graduates have positioned themselves as leaders in health systems. Our graduates are leading a QI program at a major academic center, being promoted to educational leadership roles such as assistant program director within a residency training program, directing process improvement in a developing country, and leading the operations unit of a large physician group.

As Dr. Afsar highlights, there is much work to be done to better equip trainees with the skill set to lead. We strongly encourage other training programs to develop strategies to teach leadership and create forums for trainees to practice their burgeoning skill set. In addition to responding to Dr. Afsar’s call to develop programs, we should form collaborative working groups through our regional and national organizations to develop comprehensive leadership programs for medical trainees at all levels. Collaborating to empower the next generation of providers is critical to our future as hospitalists as we continue to take the lead in improving and shaping our health care systems.
 

Tyler Anstett, DO

Manuel Diaz, MD

Emily Gottenborg, MD

University of Colorado School of Medicine, Anschutz Medical Campus, Aurora, Colo.

References

1. Sweigart JR, Tad-Y D, Kneeland P, Williams MV, Glasheen JJ. Hospital Medicine Resident Training Tracks: Developing the Hospital Medicine Pipeline. J Hosp Med. 2017 Mar;12(3):173-176. doi: 10.12788/jhm.2703.

2. Tad-y D, Price L, Cumbler E, Levin D, Wald H, Glasheen J. An experiential quality improvement curriculum for the inpatient setting – part 1: design phase of a QI project. MedEdPORTAL Publications. 2014;10:9841. http://doi.org/10.15766/mep_2374-8265.9841.

 

In 2016, a series of studies showed the impact of Medicaid expansion on hospitals.¹ The news was good: Hospitals in states that accepted Medicaid expansion through the Affordable Care Act saw dramatic reductions in their uninsured patient populations, increases in their Medicaid stays, and reductions in uncompensated care costs.^1,2

In 2017, additional data continue to show that Medicaid expansion has been a boon to hospitals, including an April 2017 report published by the Urban Institute and a May 2017 analysis from The Commonwealth Fund.^3,4 Both show that some of the hospitals that need it most are reaping the greatest benefits of expansion.

“We found that small hospitals and hospitals in non-metro areas experienced larger gains in profit margins in states that expanded Medicaid compared to their counterparts in states that did not expand Medicaid,” said Fredric Blavin, PhD, senior research associate at the Urban Institute’s Health Policy Center. His report was an update to an October 2016 study he authored in the Journal of the American Medical Association.⁵ Notably, he said, these gains were among hospitals that are “financially vulnerable and prone to closures.”

At the same time, Craig Garthwaite, PhD, MPP, lead author of The Commonwealth Fund report, said Medicaid expansion “wiped out roughly half of the uncompensated care faced by hospitals, with relatively little or no decline in nonexpansion states.” To date, 19 states have not expanded Medicaid.

With Medicaid facing an uncertain future, Dr. Blavin said some experts are concerned about what could happen to vulnerable hospitals if Medicaid expansion is repealed or scaled back. Indeed, President Trump and Congressional Republicans have proposed significantly altering Medicaid by either transitioning it to block grants or by capping federal funding for the entitlement.^6,7

“We wanted to give people a sense of the stakes of what you’re talking about with repeal of the Affordable Care Act and go back to a system where patients are able to get emergency care at the hospital but not the complete care they get if they’re insured. We’re not going to be paying hospitals for that care, so the hospital has that coming out of their profit margin,” said Dr. Garthwaite, professor of strategy and codirector of the Health Enterprise Management Program in the Kellogg School of Management at Northwestern University, Evanston, Ill.

The Commonwealth Fund report used data from the Centers for Medicare & Medicaid Services (CMS) Hospital Cost Reports to examine 1,154 hospitals in expansion and nonexpansion states. It built on a Health Affairs study Dr. Garthwaite and his coauthors published in 2016.² The analysis found that between 2013 and 2014, uncompensated care costs declined dramatically in expansion states and continued into 2015, falling from 3.9% to 2.3% of operating costs. Meanwhile, hospitals in nonexpansion states saw uncompensated care costs drop just 0.3-0.4 percentage points. The largest reductions were seen by hospitals providing the highest proportion of care to low-income and uninsured patients and overall savings to hospitals in expansion states amounted to $6.2 billion.

“Any contraction of the Medicaid expansion will reduce overall health insurance coverage and could have important financial implications for hospitals,” Dr. Blavin said. “We are likely to see large increases in expenses attributable to uninsured patients, declines in Medicaid revenue, and increases in uncompensated care burdens that can be a significant financial strain to hospitals.”

As part of a project supported by the Robert Wood Johnson Foundation, the Urban Institute in May 2011 began to track and study the impact of health reform. The report Dr. Blavin authored is part of this endeavor and utilized data from the American Hospital Association Annual Survey and the CMS Health Care Cost Reports to update the 2016 JAMA study. It compared hospitals in expansion states to those in nonexpansion states between fiscal years 2011 and 2015, excluding hospitals in states that expanded before January 2014. It examined hospital-reported data on uncompensated care, uncompensated care as a percentage of total hospital expenses, Medicaid revenue, Medicaid as a percentage of total revenue, operating margins, and excess margins.

The analysis found that Medicaid expansion resulted in a $3.2 million reduction in uncompensated care and a $5.0 million increase in mean annual Medicaid revenue per hospital. Expansion-state hospitals also saw improvements in excess and operating margins relative to nonexpansion state hospitals.

However, Ajay Kumar, MD, FACP, SFHM, chief of medicine at Hartford (Conn.) Hospital, said his hospital has not observed these same trends. Connecticut expanded Medicaid in 2010. “We have seen some decline in uncompensated care; however, revenue has not improved,” Dr. Kumar said. “Medicaid expansion has not been economically favorable to us, not because of intent of the ACA, but due to state policies.”

In Connecticut, Medicaid reimbursement rates are among the lowest in the country.⁸ The state uses a provider tax to finance Medicaid but, facing a budget deficit, state leaders have dramatically reduced the amount of money returned to hospitals in recent years.⁹

“Our Medicaid patient volume has gone up but our margins have declined because the return on investment is so low,” added Dr. Kumar, a practicing hospitalist and member of the SHM Public Policy Committee. He is concerned about what happens if Medicaid is capped or transitioned to a block grant, since “block grants have not been favorable so far … It would further squeeze us.”

In Arizona, Steve Narang, MD, MHCM, a hospitalist and CEO of Banner–University Medical Center Phoenix (B-UMCP), already knows what it’s like when Medicaid funding expands and then contracts. In 2001, the state expanded Medicaid to 100% of the federal poverty level for childless adults but then in 2011, in the throes of recession, the state froze its match on federal dollars. Prior to the freeze, charity care and bad debt made up 9% of B-UMCP’s net revenue. After the state cut to Medicaid, the hospital’s uncompensated care doubled; charity care and bad debt spiked to 20% of net revenue. Once the freeze was lifted and the state expanded Medicaid through the ACA in 2014, bad debt and charity care plummeted to 7% of revenue and remains in the single digits, Dr. Narang said.

“You hear a lot, especially in debates, about Medicaid being bad coverage … From a hospital perspective, if you’re taking care of a patient who is uninsured versus a patient with Medicaid coverage, that hospital is likely better off financially treating the patient with Medicaid coverage,” said Dr. Blavin.

For Dr. Narang, who practiced as a pediatric hospitalist for more than a decade before becoming a hospital leader, the issue goes beyond the economics of his hospital.

“From a basic commitment to our fellow human beings, are we doing the right thing as a country?” he asked, noting that states and the federal government must address the economic realities of health care while also providing safety nets for patients. “We have to do both. But I have faith that the state and federal government will find a model and we will continue to focus on what we can control.”
 

 

References

1. Tyrrell K. Benefits of Medicaid Expansion for Hospitalists. The Hospitalist. 2016 March;2016(3). http://www.the-hospitalist.org/hospitalist/article/121832/benefits-medicaid-expansion-hospitalists. Accessed May 25, 2017.

2. Dranove D., Garthwaite C., Ody C. Uncompensated Care Decreased at Hospitals in Medicaid Expansion States but Not at Hospitals in Nonexpansion States. Health Affairs, Aug. 2016 35(8):1471-9. http://content.healthaffairs.org/content/35/8/1471.abstract. Accessed May 25, 2017.

3. Blavin F. How Has the ACA Changed Finances for Different Types of Hospitals? Updated Insights from 2015 Cost Report Data. Urban Institute. Published April 2017. Accessed May 25, 2017. http://www.urban.org/sites/default/files/publication/89446/2001215-how-has-the-aca-changed-finances-for-different-types-of-hospitals.pdf.

4. Dranove D., Garthwaite C., Ody C. The Impact of the ACA’s Medicaid Expansion on Hospitals’ Uncompensated Care Burden and the Potential Effects of Repeal. Published May 3, 2017. Accessed May 25, 2017. http://www.commonwealthfund.org/publications/issue-briefs/2017/may/aca-medicaid-expansion-hospital-uncompensated-care.

5. Blavin F. Association Between the 2014 Medicaid Expansion and US Hospital Finances. http://jamanetwork.com/journals/jama/fullarticle/2565750. JAMA 2016;316(14):1475-1483. doi:10.1001/jama.2016.14765

6. President Trump’s 2018 Budget Proposal Reduces Federal Funding for Coverage of Children in Medicaid and CHIP. Kaiser Family Foundation. Published March 23, 2017. Accessed May 25, 2017. http://kff.org/medicaid/fact-sheet/presidents-2018-budget-proposal-reduces-federal-funding-for-coverage-of-children-in-medicaid-and-chip/

7. Paradise J. Restructuring Medicaid in the American Health Care Act: Five Key Considerations. Kaiser Family Foundation. Published March 15, 2017. Accessed May 25, 2017. http://kff.org/medicaid/issue-brief/restructuring-medicaid-in-the-american-health-care-act-five-key-considerations/

8. Medicaid Hospital Payment: A comparison across states and to Medicare. MACPAC Issue Brief. Published April 2017.

9. Levin Becker A. Hospitals blast Malloy’s proposal to subject them to property taxes. Published Feb. 8, 2017. Accessed May 25, 2017. https://ctmirror.org/2017/02/08/hospitals-blast-malloys-proposal-to-subject-them-to-property-taxes/

 

In 2016, a series of studies showed the impact of Medicaid expansion on hospitals.¹ The news was good: Hospitals in states that accepted Medicaid expansion through the Affordable Care Act saw dramatic reductions in their uninsured patient populations, increases in their Medicaid stays, and reductions in uncompensated care costs.^1,2

In 2017, additional data continue to show that Medicaid expansion has been a boon to hospitals, including an April 2017 report published by the Urban Institute and a May 2017 analysis from The Commonwealth Fund.^3,4 Both show that some of the hospitals that need it most are reaping the greatest benefits of expansion.

“We found that small hospitals and hospitals in non-metro areas experienced larger gains in profit margins in states that expanded Medicaid compared to their counterparts in states that did not expand Medicaid,” said Fredric Blavin, PhD, senior research associate at the Urban Institute’s Health Policy Center. His report was an update to an October 2016 study he authored in the Journal of the American Medical Association.⁵ Notably, he said, these gains were among hospitals that are “financially vulnerable and prone to closures.”

At the same time, Craig Garthwaite, PhD, MPP, lead author of The Commonwealth Fund report, said Medicaid expansion “wiped out roughly half of the uncompensated care faced by hospitals, with relatively little or no decline in nonexpansion states.” To date, 19 states have not expanded Medicaid.

With Medicaid facing an uncertain future, Dr. Blavin said some experts are concerned about what could happen to vulnerable hospitals if Medicaid expansion is repealed or scaled back. Indeed, President Trump and Congressional Republicans have proposed significantly altering Medicaid by either transitioning it to block grants or by capping federal funding for the entitlement.^6,7

“We wanted to give people a sense of the stakes of what you’re talking about with repeal of the Affordable Care Act and go back to a system where patients are able to get emergency care at the hospital but not the complete care they get if they’re insured. We’re not going to be paying hospitals for that care, so the hospital has that coming out of their profit margin,” said Dr. Garthwaite, professor of strategy and codirector of the Health Enterprise Management Program in the Kellogg School of Management at Northwestern University, Evanston, Ill.

The Commonwealth Fund report used data from the Centers for Medicare & Medicaid Services (CMS) Hospital Cost Reports to examine 1,154 hospitals in expansion and nonexpansion states. It built on a Health Affairs study Dr. Garthwaite and his coauthors published in 2016.² The analysis found that between 2013 and 2014, uncompensated care costs declined dramatically in expansion states and continued into 2015, falling from 3.9% to 2.3% of operating costs. Meanwhile, hospitals in nonexpansion states saw uncompensated care costs drop just 0.3-0.4 percentage points. The largest reductions were seen by hospitals providing the highest proportion of care to low-income and uninsured patients and overall savings to hospitals in expansion states amounted to $6.2 billion.

“Any contraction of the Medicaid expansion will reduce overall health insurance coverage and could have important financial implications for hospitals,” Dr. Blavin said. “We are likely to see large increases in expenses attributable to uninsured patients, declines in Medicaid revenue, and increases in uncompensated care burdens that can be a significant financial strain to hospitals.”

As part of a project supported by the Robert Wood Johnson Foundation, the Urban Institute in May 2011 began to track and study the impact of health reform. The report Dr. Blavin authored is part of this endeavor and utilized data from the American Hospital Association Annual Survey and the CMS Health Care Cost Reports to update the 2016 JAMA study. It compared hospitals in expansion states to those in nonexpansion states between fiscal years 2011 and 2015, excluding hospitals in states that expanded before January 2014. It examined hospital-reported data on uncompensated care, uncompensated care as a percentage of total hospital expenses, Medicaid revenue, Medicaid as a percentage of total revenue, operating margins, and excess margins.

The analysis found that Medicaid expansion resulted in a $3.2 million reduction in uncompensated care and a $5.0 million increase in mean annual Medicaid revenue per hospital. Expansion-state hospitals also saw improvements in excess and operating margins relative to nonexpansion state hospitals.

However, Ajay Kumar, MD, FACP, SFHM, chief of medicine at Hartford (Conn.) Hospital, said his hospital has not observed these same trends. Connecticut expanded Medicaid in 2010. “We have seen some decline in uncompensated care; however, revenue has not improved,” Dr. Kumar said. “Medicaid expansion has not been economically favorable to us, not because of intent of the ACA, but due to state policies.”

In Connecticut, Medicaid reimbursement rates are among the lowest in the country.⁸ The state uses a provider tax to finance Medicaid but, facing a budget deficit, state leaders have dramatically reduced the amount of money returned to hospitals in recent years.⁹

“Our Medicaid patient volume has gone up but our margins have declined because the return on investment is so low,” added Dr. Kumar, a practicing hospitalist and member of the SHM Public Policy Committee. He is concerned about what happens if Medicaid is capped or transitioned to a block grant, since “block grants have not been favorable so far … It would further squeeze us.”

In Arizona, Steve Narang, MD, MHCM, a hospitalist and CEO of Banner–University Medical Center Phoenix (B-UMCP), already knows what it’s like when Medicaid funding expands and then contracts. In 2001, the state expanded Medicaid to 100% of the federal poverty level for childless adults but then in 2011, in the throes of recession, the state froze its match on federal dollars. Prior to the freeze, charity care and bad debt made up 9% of B-UMCP’s net revenue. After the state cut to Medicaid, the hospital’s uncompensated care doubled; charity care and bad debt spiked to 20% of net revenue. Once the freeze was lifted and the state expanded Medicaid through the ACA in 2014, bad debt and charity care plummeted to 7% of revenue and remains in the single digits, Dr. Narang said.

“You hear a lot, especially in debates, about Medicaid being bad coverage … From a hospital perspective, if you’re taking care of a patient who is uninsured versus a patient with Medicaid coverage, that hospital is likely better off financially treating the patient with Medicaid coverage,” said Dr. Blavin.

For Dr. Narang, who practiced as a pediatric hospitalist for more than a decade before becoming a hospital leader, the issue goes beyond the economics of his hospital.

“From a basic commitment to our fellow human beings, are we doing the right thing as a country?” he asked, noting that states and the federal government must address the economic realities of health care while also providing safety nets for patients. “We have to do both. But I have faith that the state and federal government will find a model and we will continue to focus on what we can control.”
 

 

References

1. Tyrrell K. Benefits of Medicaid Expansion for Hospitalists. The Hospitalist. 2016 March;2016(3). http://www.the-hospitalist.org/hospitalist/article/121832/benefits-medicaid-expansion-hospitalists. Accessed May 25, 2017.

2. Dranove D., Garthwaite C., Ody C. Uncompensated Care Decreased at Hospitals in Medicaid Expansion States but Not at Hospitals in Nonexpansion States. Health Affairs, Aug. 2016 35(8):1471-9. http://content.healthaffairs.org/content/35/8/1471.abstract. Accessed May 25, 2017.

3. Blavin F. How Has the ACA Changed Finances for Different Types of Hospitals? Updated Insights from 2015 Cost Report Data. Urban Institute. Published April 2017. Accessed May 25, 2017. http://www.urban.org/sites/default/files/publication/89446/2001215-how-has-the-aca-changed-finances-for-different-types-of-hospitals.pdf.

4. Dranove D., Garthwaite C., Ody C. The Impact of the ACA’s Medicaid Expansion on Hospitals’ Uncompensated Care Burden and the Potential Effects of Repeal. Published May 3, 2017. Accessed May 25, 2017. http://www.commonwealthfund.org/publications/issue-briefs/2017/may/aca-medicaid-expansion-hospital-uncompensated-care.

5. Blavin F. Association Between the 2014 Medicaid Expansion and US Hospital Finances. http://jamanetwork.com/journals/jama/fullarticle/2565750. JAMA 2016;316(14):1475-1483. doi:10.1001/jama.2016.14765

6. President Trump’s 2018 Budget Proposal Reduces Federal Funding for Coverage of Children in Medicaid and CHIP. Kaiser Family Foundation. Published March 23, 2017. Accessed May 25, 2017. http://kff.org/medicaid/fact-sheet/presidents-2018-budget-proposal-reduces-federal-funding-for-coverage-of-children-in-medicaid-and-chip/

7. Paradise J. Restructuring Medicaid in the American Health Care Act: Five Key Considerations. Kaiser Family Foundation. Published March 15, 2017. Accessed May 25, 2017. http://kff.org/medicaid/issue-brief/restructuring-medicaid-in-the-american-health-care-act-five-key-considerations/

8. Medicaid Hospital Payment: A comparison across states and to Medicare. MACPAC Issue Brief. Published April 2017.

9. Levin Becker A. Hospitals blast Malloy’s proposal to subject them to property taxes. Published Feb. 8, 2017. Accessed May 25, 2017. https://ctmirror.org/2017/02/08/hospitals-blast-malloys-proposal-to-subject-them-to-property-taxes/

 

In 2016, a series of studies showed the impact of Medicaid expansion on hospitals.¹ The news was good: Hospitals in states that accepted Medicaid expansion through the Affordable Care Act saw dramatic reductions in their uninsured patient populations, increases in their Medicaid stays, and reductions in uncompensated care costs.^1,2

In 2017, additional data continue to show that Medicaid expansion has been a boon to hospitals, including an April 2017 report published by the Urban Institute and a May 2017 analysis from The Commonwealth Fund.^3,4 Both show that some of the hospitals that need it most are reaping the greatest benefits of expansion.

“We found that small hospitals and hospitals in non-metro areas experienced larger gains in profit margins in states that expanded Medicaid compared to their counterparts in states that did not expand Medicaid,” said Fredric Blavin, PhD, senior research associate at the Urban Institute’s Health Policy Center. His report was an update to an October 2016 study he authored in the Journal of the American Medical Association.⁵ Notably, he said, these gains were among hospitals that are “financially vulnerable and prone to closures.”

At the same time, Craig Garthwaite, PhD, MPP, lead author of The Commonwealth Fund report, said Medicaid expansion “wiped out roughly half of the uncompensated care faced by hospitals, with relatively little or no decline in nonexpansion states.” To date, 19 states have not expanded Medicaid.

With Medicaid facing an uncertain future, Dr. Blavin said some experts are concerned about what could happen to vulnerable hospitals if Medicaid expansion is repealed or scaled back. Indeed, President Trump and Congressional Republicans have proposed significantly altering Medicaid by either transitioning it to block grants or by capping federal funding for the entitlement.^6,7

“We wanted to give people a sense of the stakes of what you’re talking about with repeal of the Affordable Care Act and go back to a system where patients are able to get emergency care at the hospital but not the complete care they get if they’re insured. We’re not going to be paying hospitals for that care, so the hospital has that coming out of their profit margin,” said Dr. Garthwaite, professor of strategy and codirector of the Health Enterprise Management Program in the Kellogg School of Management at Northwestern University, Evanston, Ill.

The Commonwealth Fund report used data from the Centers for Medicare & Medicaid Services (CMS) Hospital Cost Reports to examine 1,154 hospitals in expansion and nonexpansion states. It built on a Health Affairs study Dr. Garthwaite and his coauthors published in 2016.² The analysis found that between 2013 and 2014, uncompensated care costs declined dramatically in expansion states and continued into 2015, falling from 3.9% to 2.3% of operating costs. Meanwhile, hospitals in nonexpansion states saw uncompensated care costs drop just 0.3-0.4 percentage points. The largest reductions were seen by hospitals providing the highest proportion of care to low-income and uninsured patients and overall savings to hospitals in expansion states amounted to $6.2 billion.

“Any contraction of the Medicaid expansion will reduce overall health insurance coverage and could have important financial implications for hospitals,” Dr. Blavin said. “We are likely to see large increases in expenses attributable to uninsured patients, declines in Medicaid revenue, and increases in uncompensated care burdens that can be a significant financial strain to hospitals.”

As part of a project supported by the Robert Wood Johnson Foundation, the Urban Institute in May 2011 began to track and study the impact of health reform. The report Dr. Blavin authored is part of this endeavor and utilized data from the American Hospital Association Annual Survey and the CMS Health Care Cost Reports to update the 2016 JAMA study. It compared hospitals in expansion states to those in nonexpansion states between fiscal years 2011 and 2015, excluding hospitals in states that expanded before January 2014. It examined hospital-reported data on uncompensated care, uncompensated care as a percentage of total hospital expenses, Medicaid revenue, Medicaid as a percentage of total revenue, operating margins, and excess margins.

The analysis found that Medicaid expansion resulted in a $3.2 million reduction in uncompensated care and a $5.0 million increase in mean annual Medicaid revenue per hospital. Expansion-state hospitals also saw improvements in excess and operating margins relative to nonexpansion state hospitals.

However, Ajay Kumar, MD, FACP, SFHM, chief of medicine at Hartford (Conn.) Hospital, said his hospital has not observed these same trends. Connecticut expanded Medicaid in 2010. “We have seen some decline in uncompensated care; however, revenue has not improved,” Dr. Kumar said. “Medicaid expansion has not been economically favorable to us, not because of intent of the ACA, but due to state policies.”

In Connecticut, Medicaid reimbursement rates are among the lowest in the country.⁸ The state uses a provider tax to finance Medicaid but, facing a budget deficit, state leaders have dramatically reduced the amount of money returned to hospitals in recent years.⁹

“Our Medicaid patient volume has gone up but our margins have declined because the return on investment is so low,” added Dr. Kumar, a practicing hospitalist and member of the SHM Public Policy Committee. He is concerned about what happens if Medicaid is capped or transitioned to a block grant, since “block grants have not been favorable so far … It would further squeeze us.”

In Arizona, Steve Narang, MD, MHCM, a hospitalist and CEO of Banner–University Medical Center Phoenix (B-UMCP), already knows what it’s like when Medicaid funding expands and then contracts. In 2001, the state expanded Medicaid to 100% of the federal poverty level for childless adults but then in 2011, in the throes of recession, the state froze its match on federal dollars. Prior to the freeze, charity care and bad debt made up 9% of B-UMCP’s net revenue. After the state cut to Medicaid, the hospital’s uncompensated care doubled; charity care and bad debt spiked to 20% of net revenue. Once the freeze was lifted and the state expanded Medicaid through the ACA in 2014, bad debt and charity care plummeted to 7% of revenue and remains in the single digits, Dr. Narang said.

“You hear a lot, especially in debates, about Medicaid being bad coverage … From a hospital perspective, if you’re taking care of a patient who is uninsured versus a patient with Medicaid coverage, that hospital is likely better off financially treating the patient with Medicaid coverage,” said Dr. Blavin.

For Dr. Narang, who practiced as a pediatric hospitalist for more than a decade before becoming a hospital leader, the issue goes beyond the economics of his hospital.

“From a basic commitment to our fellow human beings, are we doing the right thing as a country?” he asked, noting that states and the federal government must address the economic realities of health care while also providing safety nets for patients. “We have to do both. But I have faith that the state and federal government will find a model and we will continue to focus on what we can control.”
 

 

References

1. Tyrrell K. Benefits of Medicaid Expansion for Hospitalists. The Hospitalist. 2016 March;2016(3). http://www.the-hospitalist.org/hospitalist/article/121832/benefits-medicaid-expansion-hospitalists. Accessed May 25, 2017.

2. Dranove D., Garthwaite C., Ody C. Uncompensated Care Decreased at Hospitals in Medicaid Expansion States but Not at Hospitals in Nonexpansion States. Health Affairs, Aug. 2016 35(8):1471-9. http://content.healthaffairs.org/content/35/8/1471.abstract. Accessed May 25, 2017.

3. Blavin F. How Has the ACA Changed Finances for Different Types of Hospitals? Updated Insights from 2015 Cost Report Data. Urban Institute. Published April 2017. Accessed May 25, 2017. http://www.urban.org/sites/default/files/publication/89446/2001215-how-has-the-aca-changed-finances-for-different-types-of-hospitals.pdf.

4. Dranove D., Garthwaite C., Ody C. The Impact of the ACA’s Medicaid Expansion on Hospitals’ Uncompensated Care Burden and the Potential Effects of Repeal. Published May 3, 2017. Accessed May 25, 2017. http://www.commonwealthfund.org/publications/issue-briefs/2017/may/aca-medicaid-expansion-hospital-uncompensated-care.

5. Blavin F. Association Between the 2014 Medicaid Expansion and US Hospital Finances. http://jamanetwork.com/journals/jama/fullarticle/2565750. JAMA 2016;316(14):1475-1483. doi:10.1001/jama.2016.14765

6. President Trump’s 2018 Budget Proposal Reduces Federal Funding for Coverage of Children in Medicaid and CHIP. Kaiser Family Foundation. Published March 23, 2017. Accessed May 25, 2017. http://kff.org/medicaid/fact-sheet/presidents-2018-budget-proposal-reduces-federal-funding-for-coverage-of-children-in-medicaid-and-chip/

7. Paradise J. Restructuring Medicaid in the American Health Care Act: Five Key Considerations. Kaiser Family Foundation. Published March 15, 2017. Accessed May 25, 2017. http://kff.org/medicaid/issue-brief/restructuring-medicaid-in-the-american-health-care-act-five-key-considerations/

8. Medicaid Hospital Payment: A comparison across states and to Medicare. MACPAC Issue Brief. Published April 2017.

9. Levin Becker A. Hospitals blast Malloy’s proposal to subject them to property taxes. Published Feb. 8, 2017. Accessed May 25, 2017. https://ctmirror.org/2017/02/08/hospitals-blast-malloys-proposal-to-subject-them-to-property-taxes/

 

Clostridium difficile infection (CDI) patients treated with bezlotoxumab were less likely to be readmitted for recurring symptoms within 30 days of discharge, according to a phase 3 trial funded by Merck.

Recurrent CDI is a burden on both patients and providers, increasing health risks with each recurrence and eating through hospital resources, according to Vimalanand S. Prabhu, PhD, associate principal scientist for Merck.

cjc2nd/Wikimedia Commons/CC ASA-3.0

“Approximately 25% of patients experience recurrent CDI. … After a first recurrence of CDI, the probability of a second recurrence is approximately 38%,” according to a study cited by Dr. Prabhu and colleagues (Clin Infect Dis. 2014 Aug 1;59[3]:345-54). “Recent model-based estimates place the 2014 economic cost of CDI at $5.4 billion in the United States, mostly attributable to hospitalization.”

In a randomized, double-blind, placebo-controlled, study of 1,050 CDI patients, a total of 27 (5%) of 530 of those given bezlotoxumab were re-hospitalized 30 days after discharge, compared with 58 (11%) of 520 patients in the placebo group (Clin Infect Dis. 2017 Aug 11. doi. 10.1093/cid/cix523).

Patients were gathered from 322 sites across 30 countries between November 2011 and May 2015.

When measuring CDI-related readmissions, the investigators found use of bezlotoxumab reduced rCDI hospitalizations by 6%, and by approximately 8% in high-risk patients, such as those over 65 years old or with severe CDI.

Bezlotoxumab works by binding to CDI toxin B, a primary cause of CDI symptoms, according to Dr. Prabhu and fellow investigators. The researchers suggested that bezlotoxumab could be a prevailing factor in fighting the rate of CDI infections, which accounted for 29,000 deaths in 2011 (N Engl J Med. 2015 Jun 11;372[24]:2368-9).

Investigators acknowledged that patients admitted for the study may be healthier than the real-world CDI population.

All investigators reported some financial involvement, whether being a full-time employee or acting as a consultant, for Merck, which funded the study. Individually, investigators reported financial ties to similar medical companies, such as Pfizer and AstraZeneca.

[email protected]

On Twitter @eaztweets

 

Clostridium difficile infection (CDI) patients treated with bezlotoxumab were less likely to be readmitted for recurring symptoms within 30 days of discharge, according to a phase 3 trial funded by Merck.

Recurrent CDI is a burden on both patients and providers, increasing health risks with each recurrence and eating through hospital resources, according to Vimalanand S. Prabhu, PhD, associate principal scientist for Merck.

cjc2nd/Wikimedia Commons/CC ASA-3.0

“Approximately 25% of patients experience recurrent CDI. … After a first recurrence of CDI, the probability of a second recurrence is approximately 38%,” according to a study cited by Dr. Prabhu and colleagues (Clin Infect Dis. 2014 Aug 1;59[3]:345-54). “Recent model-based estimates place the 2014 economic cost of CDI at $5.4 billion in the United States, mostly attributable to hospitalization.”

In a randomized, double-blind, placebo-controlled, study of 1,050 CDI patients, a total of 27 (5%) of 530 of those given bezlotoxumab were re-hospitalized 30 days after discharge, compared with 58 (11%) of 520 patients in the placebo group (Clin Infect Dis. 2017 Aug 11. doi. 10.1093/cid/cix523).

Patients were gathered from 322 sites across 30 countries between November 2011 and May 2015.

When measuring CDI-related readmissions, the investigators found use of bezlotoxumab reduced rCDI hospitalizations by 6%, and by approximately 8% in high-risk patients, such as those over 65 years old or with severe CDI.

Bezlotoxumab works by binding to CDI toxin B, a primary cause of CDI symptoms, according to Dr. Prabhu and fellow investigators. The researchers suggested that bezlotoxumab could be a prevailing factor in fighting the rate of CDI infections, which accounted for 29,000 deaths in 2011 (N Engl J Med. 2015 Jun 11;372[24]:2368-9).

Investigators acknowledged that patients admitted for the study may be healthier than the real-world CDI population.

All investigators reported some financial involvement, whether being a full-time employee or acting as a consultant, for Merck, which funded the study. Individually, investigators reported financial ties to similar medical companies, such as Pfizer and AstraZeneca.

[email protected]

On Twitter @eaztweets

 

Clostridium difficile infection (CDI) patients treated with bezlotoxumab were less likely to be readmitted for recurring symptoms within 30 days of discharge, according to a phase 3 trial funded by Merck.

Recurrent CDI is a burden on both patients and providers, increasing health risks with each recurrence and eating through hospital resources, according to Vimalanand S. Prabhu, PhD, associate principal scientist for Merck.

cjc2nd/Wikimedia Commons/CC ASA-3.0

“Approximately 25% of patients experience recurrent CDI. … After a first recurrence of CDI, the probability of a second recurrence is approximately 38%,” according to a study cited by Dr. Prabhu and colleagues (Clin Infect Dis. 2014 Aug 1;59[3]:345-54). “Recent model-based estimates place the 2014 economic cost of CDI at $5.4 billion in the United States, mostly attributable to hospitalization.”

In a randomized, double-blind, placebo-controlled, study of 1,050 CDI patients, a total of 27 (5%) of 530 of those given bezlotoxumab were re-hospitalized 30 days after discharge, compared with 58 (11%) of 520 patients in the placebo group (Clin Infect Dis. 2017 Aug 11. doi. 10.1093/cid/cix523).

Patients were gathered from 322 sites across 30 countries between November 2011 and May 2015.

When measuring CDI-related readmissions, the investigators found use of bezlotoxumab reduced rCDI hospitalizations by 6%, and by approximately 8% in high-risk patients, such as those over 65 years old or with severe CDI.

Bezlotoxumab works by binding to CDI toxin B, a primary cause of CDI symptoms, according to Dr. Prabhu and fellow investigators. The researchers suggested that bezlotoxumab could be a prevailing factor in fighting the rate of CDI infections, which accounted for 29,000 deaths in 2011 (N Engl J Med. 2015 Jun 11;372[24]:2368-9).

Investigators acknowledged that patients admitted for the study may be healthier than the real-world CDI population.

All investigators reported some financial involvement, whether being a full-time employee or acting as a consultant, for Merck, which funded the study. Individually, investigators reported financial ties to similar medical companies, such as Pfizer and AstraZeneca.

[email protected]

On Twitter @eaztweets

 

Over 70% of all hospitalist programs have nocturnists, according to the 2016 State of Hospital Medicine Report. For adult-only practices, this has increased to 72.3% from 46.1% in the 2012 State of Hospital Medicine Report.

While one can assert that most hospital medicine practices have nocturnists, not all nights are covered by nocturnists. Thirty-nine percent (39%) of adult practices report that nocturnists cover 100% of nights, and 9.2% report that less than 25% of nights are covered by nocturnists. So, there remains a great deal of variability in the widespread use of nocturnists for nighttime coverage.

Why is nocturnist presence continuing to increase?

Categorically, nocturnists are hospitalists who work primarily at night, providing in-house coverage for hospitalist admissions and coverage for patients cared for by the hospitalist group.

Other clinicians, such as nurses, patient care technicians, medical technologists, and radiology technologists, have worked night shifts for many, many years. The phenomenon of hospital-based physicians and advanced practice clinicians working only at night is reflective of the needs in an acute care environment.

There are many lifestyle benefits to being a nocturnist – raising a family during the day while working at night, working fewer hours for more pay, and being in high demand.

Nocturnists can also allow a hospitalist group to offer more flexible scheduling options and create career longevity within the group. Having a nocturnist can allow a group to offer other hospitalists a “day shift only” option and other flexible scheduling options that many seasoned hospitalists are looking for.
 

Demand

Because of the increasing demand, it’s becoming more difficult to find long-term nocturnists, and therefore permanent nocturnists are expensive to hire. As reported in the 2016 State of Hospital Medicine Report, groups with nocturnists may offer either a differential in the hours or shifts worked, or compensation, or a combination of both.

About half of nocturnists work fewer shifts, compared with non-nocturnists. Equally stated, about half of nocturnists work the same number of shifts as their day-only counterparts. Of those groups whose nocturnists work fewer shifts than their daytime counterparts, about 60% work 1%-20% fewer shifts.

Nearly 70% of groups with nocturnists pay nocturnists differently. The median pay differential is 15%. While this compensation differential is an increase since the 2014 report, it is on par with the 2012 report.

It should not be construed that every practice with hospitalists offers both fewer shifts and more compensation. In fact, there are many who may offer neither and develop other, more creative ways of recognizing the nocturnist differently, such as evaluating scheduled hours per shift (e.g., 8 vs. 10 vs. 12).
 

Responsibility

With more adaptation and remuneration for nocturnists comes more responsibility.

Working as a nocturnist can be grueling work. Many times nocturnists may be working alone, and with less support from consultants and fewer hospital resources at night. On the other hand, it’s quieter at night and there can be a strong camaraderie from the smaller team at the hospital at night.

Nocturnists, many times, must be comfortable working alone; they must have strong clinical skills, and may need to seek extra training. In fact, in some hospitals the nocturnists may be the primary, or only, physician covering in-house codes.

Nocturnists must also take responsibility to remain abreast of the quality initiatives of the hospitalist group and hospital, since many of the quality committee meetings and hospitalist group meetings typically occur during daytime hours. Nocturnists may need to make an extra effort to feel a part of the group by voluntarily participating in daytime group activities, so that they don’t feel like an outsider.

Nocturnists should take the lead in receiving hand-off each evening, and handing off each morning to the day shift. This will likely mean handing off valuable patient care information with more than a few of their hospitalist colleagues. This is so immensely important that national patient safety-focused organizations have emphasized it for many years.

Since four out of five hospitalist programs have a hospitalist on site at night, and the majority of those programs have at least some nocturnist coverage, designing hospitalist programs and staffing models that meet the patient care need of 24/7 in-house coverage is a necessity. Also, given the strong demand for nocturnists, more and more program leaders are being challenged to evaluate creative alternatives to provide sustainable hospitalist services.

Some examples of creative solutions for in-house night coverage are implementing telemedicine for admissions, cross cover, or both; expanding coverage by advanced practice clinicians; and staggering shifts to cover late evenings and early mornings.

Perhaps we’ll see more questions about how hospitalist groups are addressing this need in future surveys?
 

Amanda Trask, MBA, MHA, FACHE, CMPE, SFHM, is national vice president, Hospital Medicine Service Line, at Catholic Health Initiatives, Englewood, Colo.

 

Over 70% of all hospitalist programs have nocturnists, according to the 2016 State of Hospital Medicine Report. For adult-only practices, this has increased to 72.3% from 46.1% in the 2012 State of Hospital Medicine Report.

While one can assert that most hospital medicine practices have nocturnists, not all nights are covered by nocturnists. Thirty-nine percent (39%) of adult practices report that nocturnists cover 100% of nights, and 9.2% report that less than 25% of nights are covered by nocturnists. So, there remains a great deal of variability in the widespread use of nocturnists for nighttime coverage.

Why is nocturnist presence continuing to increase?

Categorically, nocturnists are hospitalists who work primarily at night, providing in-house coverage for hospitalist admissions and coverage for patients cared for by the hospitalist group.

Other clinicians, such as nurses, patient care technicians, medical technologists, and radiology technologists, have worked night shifts for many, many years. The phenomenon of hospital-based physicians and advanced practice clinicians working only at night is reflective of the needs in an acute care environment.

There are many lifestyle benefits to being a nocturnist – raising a family during the day while working at night, working fewer hours for more pay, and being in high demand.

Nocturnists can also allow a hospitalist group to offer more flexible scheduling options and create career longevity within the group. Having a nocturnist can allow a group to offer other hospitalists a “day shift only” option and other flexible scheduling options that many seasoned hospitalists are looking for.
 

Demand

Because of the increasing demand, it’s becoming more difficult to find long-term nocturnists, and therefore permanent nocturnists are expensive to hire. As reported in the 2016 State of Hospital Medicine Report, groups with nocturnists may offer either a differential in the hours or shifts worked, or compensation, or a combination of both.

About half of nocturnists work fewer shifts, compared with non-nocturnists. Equally stated, about half of nocturnists work the same number of shifts as their day-only counterparts. Of those groups whose nocturnists work fewer shifts than their daytime counterparts, about 60% work 1%-20% fewer shifts.

Nearly 70% of groups with nocturnists pay nocturnists differently. The median pay differential is 15%. While this compensation differential is an increase since the 2014 report, it is on par with the 2012 report.

It should not be construed that every practice with hospitalists offers both fewer shifts and more compensation. In fact, there are many who may offer neither and develop other, more creative ways of recognizing the nocturnist differently, such as evaluating scheduled hours per shift (e.g., 8 vs. 10 vs. 12).
 

Responsibility

With more adaptation and remuneration for nocturnists comes more responsibility.

Working as a nocturnist can be grueling work. Many times nocturnists may be working alone, and with less support from consultants and fewer hospital resources at night. On the other hand, it’s quieter at night and there can be a strong camaraderie from the smaller team at the hospital at night.

Nocturnists, many times, must be comfortable working alone; they must have strong clinical skills, and may need to seek extra training. In fact, in some hospitals the nocturnists may be the primary, or only, physician covering in-house codes.

Nocturnists must also take responsibility to remain abreast of the quality initiatives of the hospitalist group and hospital, since many of the quality committee meetings and hospitalist group meetings typically occur during daytime hours. Nocturnists may need to make an extra effort to feel a part of the group by voluntarily participating in daytime group activities, so that they don’t feel like an outsider.

Nocturnists should take the lead in receiving hand-off each evening, and handing off each morning to the day shift. This will likely mean handing off valuable patient care information with more than a few of their hospitalist colleagues. This is so immensely important that national patient safety-focused organizations have emphasized it for many years.

Since four out of five hospitalist programs have a hospitalist on site at night, and the majority of those programs have at least some nocturnist coverage, designing hospitalist programs and staffing models that meet the patient care need of 24/7 in-house coverage is a necessity. Also, given the strong demand for nocturnists, more and more program leaders are being challenged to evaluate creative alternatives to provide sustainable hospitalist services.

Some examples of creative solutions for in-house night coverage are implementing telemedicine for admissions, cross cover, or both; expanding coverage by advanced practice clinicians; and staggering shifts to cover late evenings and early mornings.

Perhaps we’ll see more questions about how hospitalist groups are addressing this need in future surveys?
 

Amanda Trask, MBA, MHA, FACHE, CMPE, SFHM, is national vice president, Hospital Medicine Service Line, at Catholic Health Initiatives, Englewood, Colo.

 

Over 70% of all hospitalist programs have nocturnists, according to the 2016 State of Hospital Medicine Report. For adult-only practices, this has increased to 72.3% from 46.1% in the 2012 State of Hospital Medicine Report.

While one can assert that most hospital medicine practices have nocturnists, not all nights are covered by nocturnists. Thirty-nine percent (39%) of adult practices report that nocturnists cover 100% of nights, and 9.2% report that less than 25% of nights are covered by nocturnists. So, there remains a great deal of variability in the widespread use of nocturnists for nighttime coverage.

Why is nocturnist presence continuing to increase?

Categorically, nocturnists are hospitalists who work primarily at night, providing in-house coverage for hospitalist admissions and coverage for patients cared for by the hospitalist group.

Other clinicians, such as nurses, patient care technicians, medical technologists, and radiology technologists, have worked night shifts for many, many years. The phenomenon of hospital-based physicians and advanced practice clinicians working only at night is reflective of the needs in an acute care environment.

There are many lifestyle benefits to being a nocturnist – raising a family during the day while working at night, working fewer hours for more pay, and being in high demand.

Nocturnists can also allow a hospitalist group to offer more flexible scheduling options and create career longevity within the group. Having a nocturnist can allow a group to offer other hospitalists a “day shift only” option and other flexible scheduling options that many seasoned hospitalists are looking for.
 

Demand

Because of the increasing demand, it’s becoming more difficult to find long-term nocturnists, and therefore permanent nocturnists are expensive to hire. As reported in the 2016 State of Hospital Medicine Report, groups with nocturnists may offer either a differential in the hours or shifts worked, or compensation, or a combination of both.

About half of nocturnists work fewer shifts, compared with non-nocturnists. Equally stated, about half of nocturnists work the same number of shifts as their day-only counterparts. Of those groups whose nocturnists work fewer shifts than their daytime counterparts, about 60% work 1%-20% fewer shifts.

Nearly 70% of groups with nocturnists pay nocturnists differently. The median pay differential is 15%. While this compensation differential is an increase since the 2014 report, it is on par with the 2012 report.

It should not be construed that every practice with hospitalists offers both fewer shifts and more compensation. In fact, there are many who may offer neither and develop other, more creative ways of recognizing the nocturnist differently, such as evaluating scheduled hours per shift (e.g., 8 vs. 10 vs. 12).
 

Responsibility

With more adaptation and remuneration for nocturnists comes more responsibility.

Working as a nocturnist can be grueling work. Many times nocturnists may be working alone, and with less support from consultants and fewer hospital resources at night. On the other hand, it’s quieter at night and there can be a strong camaraderie from the smaller team at the hospital at night.

Nocturnists, many times, must be comfortable working alone; they must have strong clinical skills, and may need to seek extra training. In fact, in some hospitals the nocturnists may be the primary, or only, physician covering in-house codes.

Nocturnists must also take responsibility to remain abreast of the quality initiatives of the hospitalist group and hospital, since many of the quality committee meetings and hospitalist group meetings typically occur during daytime hours. Nocturnists may need to make an extra effort to feel a part of the group by voluntarily participating in daytime group activities, so that they don’t feel like an outsider.

Nocturnists should take the lead in receiving hand-off each evening, and handing off each morning to the day shift. This will likely mean handing off valuable patient care information with more than a few of their hospitalist colleagues. This is so immensely important that national patient safety-focused organizations have emphasized it for many years.

Since four out of five hospitalist programs have a hospitalist on site at night, and the majority of those programs have at least some nocturnist coverage, designing hospitalist programs and staffing models that meet the patient care need of 24/7 in-house coverage is a necessity. Also, given the strong demand for nocturnists, more and more program leaders are being challenged to evaluate creative alternatives to provide sustainable hospitalist services.

Some examples of creative solutions for in-house night coverage are implementing telemedicine for admissions, cross cover, or both; expanding coverage by advanced practice clinicians; and staggering shifts to cover late evenings and early mornings.

Perhaps we’ll see more questions about how hospitalist groups are addressing this need in future surveys?
 

Amanda Trask, MBA, MHA, FACHE, CMPE, SFHM, is national vice president, Hospital Medicine Service Line, at Catholic Health Initiatives, Englewood, Colo.

 

Universal screening for alcohol misuse in acute medical admissions is feasible and can reduce readmissions for liver disease, according to a new study.

Detecting patients’ alcohol misuse early can help treat or prevent alcohol-related liver disease, such as cirrhosis; however, screening is not being used in a routine, effective way, according to Greta Westwood, PhD, head of Nursing, Midwifery, and AHP Research at Portsmouth (England) Hospitals and her fellow investigators.

“In primary care, screening is highly variable, and treatment rates are low, often focusing on patients who already have advanced psychiatric or physical illness,” Dr. Westwood and her colleagues wrote. “In addition, many patients with alcohol use disorders do not fully engage with primary care services for a variety of reasons, often leading to excessive use of the hospital ED as the first point of contact.”

Investigators conducted a retrospective, observational study of 53,165 patients who were admitted to the acute medical unit at Queen Alexandra Hospital, Portsmouth, England, between July 2011 and March 2014 (J Hepatol. 2017 Sep;67[3]:559-67).

Katarzyna Bialasiewicz/ThinkStockPhotos

More than half of patients were male (52%), the average patient age was 67 years, and the patients had an average of three previous hospital admissions.

Of the patients observed, 48,211 (90.68%) completed the screening test, while the remaining 4,934 (9.32%) did not.

Those who were not screened had a higher mortality rate than did those who were (8.30% vs 6.17%; P less than .001), were more likely to be discharged the same day (3.37% vs. 1.87%; P less than .001), and were more likely to discharge themselves (29.67% vs. 13.31%; P less than .001).

The screening process, an electronic modified version of the Paddington Alcohol Test, consisted of the nurses’ asking a series of questions about types of alcohol consumed, frequency and maximum daily amount, whether the admission was considered alcohol related, and they documented signs of alcohol withdrawal.

Patients were then given a score based on how the answers compared with the healthy level of alcohol consumption, with 0-2 points considered “low risk,” 3-5 points considered “increasing risk,” and 6-10 points considered “high risk.”

Those assigned a low-risk status were not referred to intervention, but doctors recommended increasing-risk patients attend a community alcohol intervention team for brief intervention, while high-risk patients were automatically referred to an Alcohol Specialist Nursing Service (ASNS).

Of those screened, there were 1,135 patients (2.33%) considered at increasing risk of alcohol misuse and 1,921 (3.98%) at high risk.

While 68.5% of patients with a high-risk score were referred to the ASNS, all those who were referred completed the medical detoxification course, according to investigators.

High-risk patients were found to have had, on average, more hospital visits than increasing- and low-risk patients – 4.74 visits, compared with 2.92 and 3.00, respectively; they also reported more ED trips – 7.68 visits, compared with 3.81 and 2.64, respectively.

Dr. Westwood and her colleagues found that, when using the screening tool, investigators were more likely to find signs of alcohol-related liver disease among those with higher scores.

Liver, pancreatic, and digestive disorders accounted for 22.1% of primary admission codes of high-risk patients, compared with 3.2% of low-risk patients.

Investigators wrote that this tool can help doctors identify at-risk patients early and attack the problem of alcohol misuse head on and in a timely manner.

“It is vital that patients with cirrhosis who continue to drink are identified and referred to dedicated hospital alcohol care teams,” Dr. Westwood and her colleagues wrote. “Screening can identify patients at an increased risk of alcohol-related harm whose range of diagnoses is not dissimilar to lower-risk patients and whose misuse of alcohol might otherwise have not been identified.”

Investigators did not account for decreased scores or testing effectiveness in patients readmitted and retested. Additionally, the long-term impact of ASNS care is still being studied.

Two investigators reported affiliations with the Learning Clinic, which created and licensed the analysis program that is part of the screening tool. All other investigators, including Dr. Westwood, reported no relevant financial disclosures.

[email protected]

On Twitter @eaztweets

 

Universal screening for alcohol misuse in acute medical admissions is feasible and can reduce readmissions for liver disease, according to a new study.

Detecting patients’ alcohol misuse early can help treat or prevent alcohol-related liver disease, such as cirrhosis; however, screening is not being used in a routine, effective way, according to Greta Westwood, PhD, head of Nursing, Midwifery, and AHP Research at Portsmouth (England) Hospitals and her fellow investigators.

“In primary care, screening is highly variable, and treatment rates are low, often focusing on patients who already have advanced psychiatric or physical illness,” Dr. Westwood and her colleagues wrote. “In addition, many patients with alcohol use disorders do not fully engage with primary care services for a variety of reasons, often leading to excessive use of the hospital ED as the first point of contact.”

Investigators conducted a retrospective, observational study of 53,165 patients who were admitted to the acute medical unit at Queen Alexandra Hospital, Portsmouth, England, between July 2011 and March 2014 (J Hepatol. 2017 Sep;67[3]:559-67).

Katarzyna Bialasiewicz/ThinkStockPhotos

More than half of patients were male (52%), the average patient age was 67 years, and the patients had an average of three previous hospital admissions.

Of the patients observed, 48,211 (90.68%) completed the screening test, while the remaining 4,934 (9.32%) did not.

Those who were not screened had a higher mortality rate than did those who were (8.30% vs 6.17%; P less than .001), were more likely to be discharged the same day (3.37% vs. 1.87%; P less than .001), and were more likely to discharge themselves (29.67% vs. 13.31%; P less than .001).

The screening process, an electronic modified version of the Paddington Alcohol Test, consisted of the nurses’ asking a series of questions about types of alcohol consumed, frequency and maximum daily amount, whether the admission was considered alcohol related, and they documented signs of alcohol withdrawal.

Patients were then given a score based on how the answers compared with the healthy level of alcohol consumption, with 0-2 points considered “low risk,” 3-5 points considered “increasing risk,” and 6-10 points considered “high risk.”

Those assigned a low-risk status were not referred to intervention, but doctors recommended increasing-risk patients attend a community alcohol intervention team for brief intervention, while high-risk patients were automatically referred to an Alcohol Specialist Nursing Service (ASNS).

Of those screened, there were 1,135 patients (2.33%) considered at increasing risk of alcohol misuse and 1,921 (3.98%) at high risk.

While 68.5% of patients with a high-risk score were referred to the ASNS, all those who were referred completed the medical detoxification course, according to investigators.

High-risk patients were found to have had, on average, more hospital visits than increasing- and low-risk patients – 4.74 visits, compared with 2.92 and 3.00, respectively; they also reported more ED trips – 7.68 visits, compared with 3.81 and 2.64, respectively.

Dr. Westwood and her colleagues found that, when using the screening tool, investigators were more likely to find signs of alcohol-related liver disease among those with higher scores.

Liver, pancreatic, and digestive disorders accounted for 22.1% of primary admission codes of high-risk patients, compared with 3.2% of low-risk patients.

Investigators wrote that this tool can help doctors identify at-risk patients early and attack the problem of alcohol misuse head on and in a timely manner.

“It is vital that patients with cirrhosis who continue to drink are identified and referred to dedicated hospital alcohol care teams,” Dr. Westwood and her colleagues wrote. “Screening can identify patients at an increased risk of alcohol-related harm whose range of diagnoses is not dissimilar to lower-risk patients and whose misuse of alcohol might otherwise have not been identified.”

Investigators did not account for decreased scores or testing effectiveness in patients readmitted and retested. Additionally, the long-term impact of ASNS care is still being studied.

Two investigators reported affiliations with the Learning Clinic, which created and licensed the analysis program that is part of the screening tool. All other investigators, including Dr. Westwood, reported no relevant financial disclosures.

[email protected]

On Twitter @eaztweets

 

Universal screening for alcohol misuse in acute medical admissions is feasible and can reduce readmissions for liver disease, according to a new study.

Detecting patients’ alcohol misuse early can help treat or prevent alcohol-related liver disease, such as cirrhosis; however, screening is not being used in a routine, effective way, according to Greta Westwood, PhD, head of Nursing, Midwifery, and AHP Research at Portsmouth (England) Hospitals and her fellow investigators.

“In primary care, screening is highly variable, and treatment rates are low, often focusing on patients who already have advanced psychiatric or physical illness,” Dr. Westwood and her colleagues wrote. “In addition, many patients with alcohol use disorders do not fully engage with primary care services for a variety of reasons, often leading to excessive use of the hospital ED as the first point of contact.”

Investigators conducted a retrospective, observational study of 53,165 patients who were admitted to the acute medical unit at Queen Alexandra Hospital, Portsmouth, England, between July 2011 and March 2014 (J Hepatol. 2017 Sep;67[3]:559-67).

Katarzyna Bialasiewicz/ThinkStockPhotos

More than half of patients were male (52%), the average patient age was 67 years, and the patients had an average of three previous hospital admissions.

Of the patients observed, 48,211 (90.68%) completed the screening test, while the remaining 4,934 (9.32%) did not.

Those who were not screened had a higher mortality rate than did those who were (8.30% vs 6.17%; P less than .001), were more likely to be discharged the same day (3.37% vs. 1.87%; P less than .001), and were more likely to discharge themselves (29.67% vs. 13.31%; P less than .001).

The screening process, an electronic modified version of the Paddington Alcohol Test, consisted of the nurses’ asking a series of questions about types of alcohol consumed, frequency and maximum daily amount, whether the admission was considered alcohol related, and they documented signs of alcohol withdrawal.

Patients were then given a score based on how the answers compared with the healthy level of alcohol consumption, with 0-2 points considered “low risk,” 3-5 points considered “increasing risk,” and 6-10 points considered “high risk.”

Those assigned a low-risk status were not referred to intervention, but doctors recommended increasing-risk patients attend a community alcohol intervention team for brief intervention, while high-risk patients were automatically referred to an Alcohol Specialist Nursing Service (ASNS).

Of those screened, there were 1,135 patients (2.33%) considered at increasing risk of alcohol misuse and 1,921 (3.98%) at high risk.

While 68.5% of patients with a high-risk score were referred to the ASNS, all those who were referred completed the medical detoxification course, according to investigators.

High-risk patients were found to have had, on average, more hospital visits than increasing- and low-risk patients – 4.74 visits, compared with 2.92 and 3.00, respectively; they also reported more ED trips – 7.68 visits, compared with 3.81 and 2.64, respectively.

Dr. Westwood and her colleagues found that, when using the screening tool, investigators were more likely to find signs of alcohol-related liver disease among those with higher scores.

Liver, pancreatic, and digestive disorders accounted for 22.1% of primary admission codes of high-risk patients, compared with 3.2% of low-risk patients.

Investigators wrote that this tool can help doctors identify at-risk patients early and attack the problem of alcohol misuse head on and in a timely manner.

“It is vital that patients with cirrhosis who continue to drink are identified and referred to dedicated hospital alcohol care teams,” Dr. Westwood and her colleagues wrote. “Screening can identify patients at an increased risk of alcohol-related harm whose range of diagnoses is not dissimilar to lower-risk patients and whose misuse of alcohol might otherwise have not been identified.”

Investigators did not account for decreased scores or testing effectiveness in patients readmitted and retested. Additionally, the long-term impact of ASNS care is still being studied.

Two investigators reported affiliations with the Learning Clinic, which created and licensed the analysis program that is part of the screening tool. All other investigators, including Dr. Westwood, reported no relevant financial disclosures.

[email protected]

On Twitter @eaztweets

Robert Harrington, MD, recently was tabbed as chief medical officer of SurveyVitals, a health care analytics company specializing in digital patient-experience surveys. Dr. Harrington has 20 years experience, including CMO roles with Reliant Post–Acute Care Solutions and Locum Leaders, a hospitalist staffing firm.

With SurveyVitals, Dr. Harrington will focus on client needs as the company seeks new ways to help patients provide feedback to providers. He also will support and direct the development of new features for SurveyVitals.

Dr. Harrington is a senior fellow in Hospital Medicine and is past president and member of the board of directors with the Society of Hospital Medicine.
 

David Northington, DO, has been named the new chief medical officer at Stone County Hospital in Wiggins, Miss. The former hospitalist comes to Stone County after working as chief of staff and chief medical information officer at Memorial Hospital in Gulfport, Miss., where he was also medical director of the hospitalist program.

In addition to his new role, Dr. Northington will serve as medical director of the Woodland Village Nursing Center in Diamondhead, Miss., and the Stone County Nursing and Rehabilitation Center in Wiggins.
 

Schuyler K. Geller, MD, has been recognized by Continental Who’s Who as a Pinnacle Lifetime Member in the medical field. Dr. Geller works as a full-time hospitalist and a principal consultant for The CopperRidge Group, which provides guidance to patients in health, wellness, and fitness services and products.

In addition to his work at the CopperRidge Group, Dr. Geller is a member of Civil Vision International’s board of directors. He has extensive civilian and military-based experience in the United States, Africa, the Middle East, and South Asia.

A physician leader in the U.S. Air Force, Dr. Geller earned White House Medical Unit commendations for planning and leading the surgical and intensive care unit teams to support President Clinton’s trips to Vietnam and Africa in 2000.
 

Nikhil Sharma, MD, recently was selected by the International Association of HealthCare Professionals to be part of the Leading Physicians of the World. Dr. Sharma is a hospitalist serving at the Ochsner Health System in New Orleans.

Dr. Sharma, a member of the Southern Hospital Association and the Louisiana Medical Association, began his medical career in 2009 with a residency and fellowship at Ochsner, where he has remained ever since. He specializes in internal medicine and transplants.
 

I. Carol Nwelue, MD, a longtime hospitalist and the medical director of the Sparrow Medical Group Adult Hospitalist Service, recently received the Sparrow Physician Leadership Award. The award goes to an emerging leader who provides outstanding work in areas such as safety, clinical or service excellence, research, teaching, publishing, teamwork, and innovation.

Dr. Nwelue completed the Sparrow Physician Leadership Academy program, earning recognition for innovation in leadership, as well as practice management.
 

Laura Jin, MD, recently was promoted to medical director for utilization management at the University of Maryland Shore Regional Health. In her new role, Dr. Jin will identify and facilitate the resolution of utilization issues; in so doing, she will serve as a consultant leader to the health care system, its physicians, its advance practice providers, and the care management team.

Dr. Jin will remain as a hospitalist at Digestive Health Associates while fulfilling the duties in her new position at Shore Regional. She will guide the center on issues such as compliance, level of care, length of stay, resource management, reimbursement, emergency department throughput, and more.
 

Business Moves

The Mount Sinai Health System and The New Jewish Home, both based in New York City, have extended their relationship to improve care of hospitalized patients who require specialized post-acute or long-term care at a skilled nursing facility. Through the Mount Sinai-New Jewish Home Hospitalist Program, Mount Sinai hospitalists will be charged with providing a seamless transition to The New Jewish Home for patients who need nursing care.

This model will buoy communication and ensure the sharing of vital information between the two venues, reducing the risk of rehospitalization.
 

Gryphon Investors, based in San Francisco, recently announced it will acquire OB Hospitalist Group, one of the nation’s leading providers of obstetric hospital medicine. The deal with OBHG’s current partner, Ares Management, was finalized in late July.

OBHG, based out of Mauldin, S.C., has a national network of more than 550 OB hospitalists, covering more than 120 hospitals in 28 states. OBHG’s hospitalist program features an obstetric emergency department, providing expectant mothers at partner hospitals with 24/7/365 access to medical care.
 

Envision Healthcare, based in Nashville, Tenn., and Greenwood Village, Colo., a provider of physician-led services and ambulatory surgery services, has acquired Milwaukee-based Infinity Healthcare. Infinity’s group-physician practice includes more than 340 physicians and providers delivering emergency and hospital medicine, anesthesia, and radiology services.

Robert Harrington, MD, recently was tabbed as chief medical officer of SurveyVitals, a health care analytics company specializing in digital patient-experience surveys. Dr. Harrington has 20 years experience, including CMO roles with Reliant Post–Acute Care Solutions and Locum Leaders, a hospitalist staffing firm.

With SurveyVitals, Dr. Harrington will focus on client needs as the company seeks new ways to help patients provide feedback to providers. He also will support and direct the development of new features for SurveyVitals.

Dr. Harrington is a senior fellow in Hospital Medicine and is past president and member of the board of directors with the Society of Hospital Medicine.
 

David Northington, DO, has been named the new chief medical officer at Stone County Hospital in Wiggins, Miss. The former hospitalist comes to Stone County after working as chief of staff and chief medical information officer at Memorial Hospital in Gulfport, Miss., where he was also medical director of the hospitalist program.

In addition to his new role, Dr. Northington will serve as medical director of the Woodland Village Nursing Center in Diamondhead, Miss., and the Stone County Nursing and Rehabilitation Center in Wiggins.
 

Schuyler K. Geller, MD, has been recognized by Continental Who’s Who as a Pinnacle Lifetime Member in the medical field. Dr. Geller works as a full-time hospitalist and a principal consultant for The CopperRidge Group, which provides guidance to patients in health, wellness, and fitness services and products.

In addition to his work at the CopperRidge Group, Dr. Geller is a member of Civil Vision International’s board of directors. He has extensive civilian and military-based experience in the United States, Africa, the Middle East, and South Asia.

A physician leader in the U.S. Air Force, Dr. Geller earned White House Medical Unit commendations for planning and leading the surgical and intensive care unit teams to support President Clinton’s trips to Vietnam and Africa in 2000.
 

Nikhil Sharma, MD, recently was selected by the International Association of HealthCare Professionals to be part of the Leading Physicians of the World. Dr. Sharma is a hospitalist serving at the Ochsner Health System in New Orleans.

Dr. Sharma, a member of the Southern Hospital Association and the Louisiana Medical Association, began his medical career in 2009 with a residency and fellowship at Ochsner, where he has remained ever since. He specializes in internal medicine and transplants.
 

I. Carol Nwelue, MD, a longtime hospitalist and the medical director of the Sparrow Medical Group Adult Hospitalist Service, recently received the Sparrow Physician Leadership Award. The award goes to an emerging leader who provides outstanding work in areas such as safety, clinical or service excellence, research, teaching, publishing, teamwork, and innovation.

Dr. Nwelue completed the Sparrow Physician Leadership Academy program, earning recognition for innovation in leadership, as well as practice management.
 

Laura Jin, MD, recently was promoted to medical director for utilization management at the University of Maryland Shore Regional Health. In her new role, Dr. Jin will identify and facilitate the resolution of utilization issues; in so doing, she will serve as a consultant leader to the health care system, its physicians, its advance practice providers, and the care management team.

Dr. Jin will remain as a hospitalist at Digestive Health Associates while fulfilling the duties in her new position at Shore Regional. She will guide the center on issues such as compliance, level of care, length of stay, resource management, reimbursement, emergency department throughput, and more.
 

Business Moves

The Mount Sinai Health System and The New Jewish Home, both based in New York City, have extended their relationship to improve care of hospitalized patients who require specialized post-acute or long-term care at a skilled nursing facility. Through the Mount Sinai-New Jewish Home Hospitalist Program, Mount Sinai hospitalists will be charged with providing a seamless transition to The New Jewish Home for patients who need nursing care.

This model will buoy communication and ensure the sharing of vital information between the two venues, reducing the risk of rehospitalization.
 

Gryphon Investors, based in San Francisco, recently announced it will acquire OB Hospitalist Group, one of the nation’s leading providers of obstetric hospital medicine. The deal with OBHG’s current partner, Ares Management, was finalized in late July.

OBHG, based out of Mauldin, S.C., has a national network of more than 550 OB hospitalists, covering more than 120 hospitals in 28 states. OBHG’s hospitalist program features an obstetric emergency department, providing expectant mothers at partner hospitals with 24/7/365 access to medical care.
 

Envision Healthcare, based in Nashville, Tenn., and Greenwood Village, Colo., a provider of physician-led services and ambulatory surgery services, has acquired Milwaukee-based Infinity Healthcare. Infinity’s group-physician practice includes more than 340 physicians and providers delivering emergency and hospital medicine, anesthesia, and radiology services.

Robert Harrington, MD, recently was tabbed as chief medical officer of SurveyVitals, a health care analytics company specializing in digital patient-experience surveys. Dr. Harrington has 20 years experience, including CMO roles with Reliant Post–Acute Care Solutions and Locum Leaders, a hospitalist staffing firm.

With SurveyVitals, Dr. Harrington will focus on client needs as the company seeks new ways to help patients provide feedback to providers. He also will support and direct the development of new features for SurveyVitals.

Dr. Harrington is a senior fellow in Hospital Medicine and is past president and member of the board of directors with the Society of Hospital Medicine.
 

David Northington, DO, has been named the new chief medical officer at Stone County Hospital in Wiggins, Miss. The former hospitalist comes to Stone County after working as chief of staff and chief medical information officer at Memorial Hospital in Gulfport, Miss., where he was also medical director of the hospitalist program.

In addition to his new role, Dr. Northington will serve as medical director of the Woodland Village Nursing Center in Diamondhead, Miss., and the Stone County Nursing and Rehabilitation Center in Wiggins.
 

Schuyler K. Geller, MD, has been recognized by Continental Who’s Who as a Pinnacle Lifetime Member in the medical field. Dr. Geller works as a full-time hospitalist and a principal consultant for The CopperRidge Group, which provides guidance to patients in health, wellness, and fitness services and products.

In addition to his work at the CopperRidge Group, Dr. Geller is a member of Civil Vision International’s board of directors. He has extensive civilian and military-based experience in the United States, Africa, the Middle East, and South Asia.

A physician leader in the U.S. Air Force, Dr. Geller earned White House Medical Unit commendations for planning and leading the surgical and intensive care unit teams to support President Clinton’s trips to Vietnam and Africa in 2000.
 

Nikhil Sharma, MD, recently was selected by the International Association of HealthCare Professionals to be part of the Leading Physicians of the World. Dr. Sharma is a hospitalist serving at the Ochsner Health System in New Orleans.

Dr. Sharma, a member of the Southern Hospital Association and the Louisiana Medical Association, began his medical career in 2009 with a residency and fellowship at Ochsner, where he has remained ever since. He specializes in internal medicine and transplants.
 

I. Carol Nwelue, MD, a longtime hospitalist and the medical director of the Sparrow Medical Group Adult Hospitalist Service, recently received the Sparrow Physician Leadership Award. The award goes to an emerging leader who provides outstanding work in areas such as safety, clinical or service excellence, research, teaching, publishing, teamwork, and innovation.

Dr. Nwelue completed the Sparrow Physician Leadership Academy program, earning recognition for innovation in leadership, as well as practice management.
 

Laura Jin, MD, recently was promoted to medical director for utilization management at the University of Maryland Shore Regional Health. In her new role, Dr. Jin will identify and facilitate the resolution of utilization issues; in so doing, she will serve as a consultant leader to the health care system, its physicians, its advance practice providers, and the care management team.

Dr. Jin will remain as a hospitalist at Digestive Health Associates while fulfilling the duties in her new position at Shore Regional. She will guide the center on issues such as compliance, level of care, length of stay, resource management, reimbursement, emergency department throughput, and more.
 

Business Moves

The Mount Sinai Health System and The New Jewish Home, both based in New York City, have extended their relationship to improve care of hospitalized patients who require specialized post-acute or long-term care at a skilled nursing facility. Through the Mount Sinai-New Jewish Home Hospitalist Program, Mount Sinai hospitalists will be charged with providing a seamless transition to The New Jewish Home for patients who need nursing care.

This model will buoy communication and ensure the sharing of vital information between the two venues, reducing the risk of rehospitalization.
 

Gryphon Investors, based in San Francisco, recently announced it will acquire OB Hospitalist Group, one of the nation’s leading providers of obstetric hospital medicine. The deal with OBHG’s current partner, Ares Management, was finalized in late July.

OBHG, based out of Mauldin, S.C., has a national network of more than 550 OB hospitalists, covering more than 120 hospitals in 28 states. OBHG’s hospitalist program features an obstetric emergency department, providing expectant mothers at partner hospitals with 24/7/365 access to medical care.
 

Envision Healthcare, based in Nashville, Tenn., and Greenwood Village, Colo., a provider of physician-led services and ambulatory surgery services, has acquired Milwaukee-based Infinity Healthcare. Infinity’s group-physician practice includes more than 340 physicians and providers delivering emergency and hospital medicine, anesthesia, and radiology services.

 

Hospital readmissions are frequent, harmful, and costly. Consider the fact that 18% of Medicare patients can expect to be readmitted within 30 days at a cost of more than $17 billion.¹ Recent changes in health care policy aimed at reducing readmission have substantially increased attention to this major health care issue.²

The Affordable Care Act has mandated that the Centers for Medicare & Medicaid Services reduce payment to hospitals with higher-than-expected 30-day readmissions, with its Hospital Readmissions Reduction Program. This has driven rapid growth in the study of patients rehospitalized within 30 days of discharge.³ So what are some strategies that have either been proven to reduce readmissions or show promise in doing so?

FY 2017 IPPS Final Rule HRRP Supplemental Data File. Courtesy of Advisory Board.

An ounce of prevention

In studying inpatient and outpatient physicians’ perspectives regarding factors contributing to readmission,⁴ Shoshana Herzig, MD, MPH, assistant professor of medicine, Harvard Medical School, and director of Hospital Medicine Research, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, and her colleagues identified some potential preventive strategies.

The most commonly endorsed strategy to prevent readmissions by both primary care physicians and hospitalists surveyed involved improving self-management plans at discharge. “This refers to actions such as providing patient-centered discharge instructions (that is, making sure they are written in language that patients can understand) or asking transition coaches to help facilitate a successful transition,” Dr. Herzig said. “This finding is consistent with the fact that the factor most commonly identified as contributing to readmissions was insufficient patient understanding or ability to self-manage. Combined, these findings suggest that strategies to enhance patient understanding of their illness, care plan, and what to expect after hospital discharge, are likely to be important components of successful readmission reduction programs.”

monkeybusinessimages/Thinkstock

Another commonly endorsed strategy to prevent readmission was greater engagement of home and community supports. This entails enlisting the help of social workers and community agencies to deliver meals, provide transportation to doctors’ appointments, and so forth. “Inadequate social support contributes to many readmissions,” Dr. Herzig said. “Hospitalists should request assistance from social workers in helping to secure assistance for patients who need these services.”

Provisioning of resources to patients to help them manage their care after discharge is also recommended. For example, engaging nurses or pharmacists who can help with issues that arise after discharge may help keep patients out of the hospital.

“Hospitalists should be aware of what resources are available to help patients manage their care,” Dr. Herzig said. For example, if a patient needs periodic blood pressure monitoring, the hospitalist can tell the patient about free blood pressure checkpoints or suggest a home-automated blood pressure monitor.

The study also showed that improved coordination of care between inpatient and outpatient providers, such as sharing medical records, could reduce readmission rates. “This allows for better inpatient care and increased ability for primary care physicians to react appropriately to issues arising after discharge,” Dr. Herzig said. “In the absence of a shared system, hospitalists should complete discharge summaries in a timely fashion and ensure that they’re promptly transmitted to primary care physicians.”

Finally, the researchers believe that multifaceted, broadly applied interventions may be more successful than those relying upon individual providers choosing specific services based on perceived risk factors. “This is because a prior study⁵ demonstrated that it is difficult to anticipate in advance which patients will be readmitted, and, in our study, physicians did not agree on the factors that contributed to a given readmission,” Dr. Herzig explained. “Because of these findings, it becomes hard to rely on physicians to identify patients at increased risk for readmission, and to direct services that correctly anticipate contributing factors. Instead, it seems that programs aimed at improving general processes for particular patient categories may be more successful at reducing readmissions.” For example, it might be better to use a transition coach for all patients over the age of 65, rather than relying on physicians to decide which patients are at high risk for readmission.

Dr. Herzig said it’s important to note that hospitalists and primary care physicians had different appraisals of reasons for readmission. Therefore, when designing readmission reduction programs or determining specific services to prevent a readmission for a given patient, it is important for hospitalists to obtain input from primary care physicians to ensure that they address all of the potential contributors to readmission for a given patient.

 

Interviewing patients regarding readmissions

After involved clinicians and independent physician reviewers performed extensive case reviews of more than 700 readmitted patients,⁶ Ashley Busuttil, MD, FHM, associate section chief, Hospital Medicine, University of California, Los Angeles Department of Medicine; and executive medical director, Medicine Services, UCLA Department of Medicine, and Erin Dowling, MD, assistant clinical professor, General Internal Medicine, Hospitalist Services, UCLA Medical Center, Santa Monica, Calif., and their colleagues were unable to identify which readmissions could have easily been prevented, and found that readmission causality varied extensively.

Given this, the researchers set out to identify a more nuanced understanding of why patients return to the hospital. They decided to do this by talking to patients directly, and specifically studied patient readiness from the patient perspective.

Through interviews with patients, the researchers determined that patients were more likely to think that their readmission was preventable if they felt unready for discharge during their initial hospitalization. This was despite the fact that patients met what clinicians would consider “ready” by objective, provider-centric criteria: they were medically stable, they had in-home support services, they had follow-up arranged, and so forth. As such, they wanted to put effort into educating and preparing patients for what home will look and feel like posthospitalization to address their feelings of unreadiness.

To that end, the researchers created an enhanced transition initiative that included showing an educational video near the time of admission and a patient-centered discharge checklist to help patients identify questions they might have after discharge. The discharge checklist asks patients to put themselves in the position of being at home and working through scenarios they may face so they will know how to deal with them. For example, if you have pain, who should you call? What should you do if you run out of medication?

Dr. Dowling believes that the hospitalist will, over time, become essential to assessing patient readiness. “As we learn more about how patients approach discharge, hospitalists’ understanding of patient needs beyond straightforward medical care will be crucial to having smoother transitions of care,” she said.

The researchers also explored pain control. As a health system, UCLA Medical Center has formed a multidisciplinary task force to optimize its approach to pain control. “If we can address comfort – for both patients at high risk of readmission and those that aren’t – we hope we can improve symptom control overall,” Dr. Busuttil said. “It’s not uncommon for patients to feel inadequate symptom control at discharge. While this is likely only one component of all the readmission pieces, a patient who feels that their symptoms are not controlled is likely to feel less ready for discharge. Increasing patient readiness, perhaps by increasing symptom control and improving communication regarding symptom management expectations, is a task that the hospitalist is well positioned to address.”

In addition, a focus group that included patient representatives was conducted to identify potential discharge paperwork enhancements. Patients were asked to identify opportunities for improvement in the health system’s discharge After Visit Summary (AVS). “We were surprised to learn that even though patients knew that they had follow-up appointments, they were unable to locate the follow-up appointment section on the AVS,” Dr. Busuttil said. “We also learned that the medication section was confusing. Efforts for an AVS revision are underway.”

The researchers also wanted to find out why patients may not use available outpatient resources, and assessed them for decisional conflict – a measure of certainty with decision making – when selecting from multiple options for accessing medical care if they were home postdischarge and began to feel ill again. “Patients with decisional conflict were more likely to state that they would go the emergency room rather than call their primary medical physician or visit an urgent care center,” Dr. Busuttil said.

The health system continues to screen patients for decisional conflict. “When positive, we provide bedside education on when to seek medical care through primary care, urgent care, or the emergency department,” Dr. Busuttil said. “We also provide patients with information on how to access each of these resources.”

While a prior discharge plan may have seemed ideal on paper, time and time again it’s not logistically possible for certain patients. “By having this knowledge gleaned from patient interviews, hospitalists are able to provide feedback to health systems regarding different options of outpatient care that may work for the different patient populations they serve,” Dr. Dowling said.

To understand why one particular patient population is being readmitted requires taking the time to understand that population, Dr. Dowling noted. “While many validated risk stratification tools are available, they may only serve as general guides,” she said. “To impact the population you serve, you must first understand the readmission process as it looks to them.”

 

Employing the HOSPITAL score

In another effort to reduce hospital readmissions, Jacques Donzé, MD, MSc, associate physician, Bern University Hospital, Switzerland, and research associate, Brigham and Women’s Hospital, Boston, and his colleagues used the HOSPITAL score to identify patients at high risk of 30-day potentially avoidable readmission.

To most efficiently reduce hospital readmissions, hospitals need to target complex and intensive discharge interventions for patients at high risk of potentially avoidable readmission who are more likely to benefit.² “However, prior research indicates that clinical health care providers are not able to accurately identify which patients are at high risk for readmission,” Dr. Donzé said.

In their large international multicenter external validation study, Dr. Donzé and his colleagues found that the HOSPITAL score accurately predicted the risk of 30-day potentially avoidable readmissions. The HOSPITAL score is easy to use and can be calculated before discharge, which makes it a practical tool for identifying patients at high risk for preventable readmission and the timely administration of high-intensity interventions designed to improve transitions of care.²

Dr. Donzé believes that several factors may influence the performance of a prediction model, such as the initial selection of the potential predictors, the quality of the derivation method, including readily available predictors commonly available, and including reliable factors that aren’t subject to subjective evaluation. “All of these factors can play a role in the performance and generalizability of the HOSPITAL score,” he said.

When a patient is identified as high risk to be readmitted, hospitalists can take certain actions to prevent readmission. “Interventions are more likely to be effective when they include several components,” Dr. Donzé said. “These include follow-up phone calls and/or home visits, review of the patient’s medication list, patient education, and sending a discharge summary to the patient’s primary care physician in a timely manner. For now, enough evidence for a specific effective multimodal intervention to be generalizable to the majority of patients is lacking.”

Currently, the HOSPITAL score has been validated in approximately 180,000 patients in 14 hospitals across five countries and three continents – always showing good performance and generalizability. The HOSPITAL score includes seven variables readily available before hospital discharge, is easy to use, and is the most widely validated prediction model for readmission, Dr. Donzé said.

Before being implemented into practice, a score should ideally reach the highest level of validation, that is, show its clinical impact. “We expect that the score will not only be able to accurately predict high-risk patients, but using the score will also impact patient care by reducing readmissions when coupled with an appropriate intervention,” Dr. Donzé said.

In summary, research has shown that a variety of methods can be used to reduce hospital readmissions, including studying inpatient and outpatient physicians’ perspectives regarding factors contributing to readmission; interviewing patients regarding readmissions; and identifying patients at high risk of readmission using the HOSPITAL score.

Many researchers are continuing their studies in these areas.

Karen Appold is a medical writer in Pennsylvania.

Using hospitalist reflections as a means to reduce readmissions

Readmission studies and the development of readmission scoring systems and prediction tools rely on data from a large number of patients, typically extracted from administrative databases.

To complement this data, Deanne Kashiwagi, MD, consultant, Hospital Internal Medicine, Mayo Clinic, Rochester, Minn., and her colleagues asked hospitalists to reflect upon the readmissions of patients for whom they cared to add insight into the culture of patient care transitions within the health system.

“We felt there was some value in considering these nuances of the local care environment, which may not be represented in studies drawing from large databases, as potential targets for readmission efforts,” she said.

Dr. Kashiwagi and her colleagues developed a chart review tool to guide hospitalists through reflection about their patients’ admissions and readmissions. “We included factors frequently cited in the literature as contributors to readmissions and added factors that our study group, after a chart review of 40 patients’ readmissions, identified as variables contributing to our own patients’ readmissions,” Dr. Kashiwagi said. “Some of these variables reflected our local care system, such as our staffing model, which led to some patients being cared for by more than two hospitalists during their admission. The study group considered such variables as potential contributors to our own group’s readmissions, but they were not necessarily common readmission risk factors identified in large-scale studies.”

Dr. Kashiwagi believes that including elements of local practice and culture was the strength of their work. “Groups interested in replicating this reflective process should consider including factors specific to their practices that may contribute to readmission,” she said.

Asking hospitalists to perform reviews has led to implementing changes. Physicians were prompted to schedule earlier follow-up appointments and nurse practitioners and physician assistants have worked to improve the quality of their discharge summaries. The exercise also engaged hospitalists to suggest system changes that might contribute to decreased readmissions, such as a geriatrician-run service (which was recently begun) to provide multidisciplinary acute geriatric care for hospitalized older adults.

“Although large-scale studies are clearly important, readmission review at a more granular level may have merit as well,” Dr. Kashiwagi said, noting that such reviews identify local practice factors that groups may quickly act upon to help decrease readmissions. “Hospitalists readily engaged in this reflective exercise, which yielded actionable information to decrease readmissions.”

In commenting on why a different similar study⁷ didn’t mimic the results of Mayo Clinic’s study, Dr. Kashiwagi said there were some differences in methodology that may explain the difference in readmission rates. “First, this group excluded patients on dialysis, which in our study was a common comorbidity of our readmitted patients,” she said. “It is also notable that the chart review tool was different. Perhaps there is less representation of local factors, unique to that hospitalist group and their practice culture, than on our review form. These investigators also discussed their readmissions at routine intervals. Additionally, their preintervention readmission rate was lower than Mayo Clinic’s group, and although the readmission rate trended downward postintervention, it did not reach statistical significance.”

 

References

1. Jencks SF, Williams MV, Coleman EA. Rehospitalizations among patients in the Medicare fee-for-service program. N Engl J Med. 2009;360(14):1418-28.

2. Donzé JD, Williams MV, Robinson EJ, et al. International validity of the HOSPITAL Score to predict 30-day potentially avoidable hospital readmissions. JAMA Intern Med. 2016 Apr;176(4):496-502.

3. Kashiwagi DT, Burton MC, Hakim FA, et al. Reflective practice: a tool for readmission reduction. Am J Med Qual. 2016 May;31(3):265-71.

4. Herzig SJ, Schnipper JL, Doctoroff L, et al. Physician perspectives on factors contributing to readmissions and potential prevention strategies: a multicenter survey. J Gen Intern Med. 2016 Nov;31(11):1287-93. Epub 2016 Jun 9.

5. Allaudeen N, Schnipper JL, Orav EJ, et al. Inability of providers to predict unplanned readmissions. J Gen Intern Med. 2011 Jul;26(7):771-6.

6. Busuttil A, Howard-Anderson J, Dowling EP, et al. Building a comprehensive patient-centered readmission reduction program [abstract]. J Hosp Med. 2016;11(suppl 1).

7. Rana V, Thapa B, Saini SC, et al. Self-reflection as a tool to increase hospitalist participation in readmission quality improvement. Qual Manag Health Care. 2016 Oct/Dec;25(4):219-24.

 

Hospital readmissions are frequent, harmful, and costly. Consider the fact that 18% of Medicare patients can expect to be readmitted within 30 days at a cost of more than $17 billion.¹ Recent changes in health care policy aimed at reducing readmission have substantially increased attention to this major health care issue.²

The Affordable Care Act has mandated that the Centers for Medicare & Medicaid Services reduce payment to hospitals with higher-than-expected 30-day readmissions, with its Hospital Readmissions Reduction Program. This has driven rapid growth in the study of patients rehospitalized within 30 days of discharge.³ So what are some strategies that have either been proven to reduce readmissions or show promise in doing so?

FY 2017 IPPS Final Rule HRRP Supplemental Data File. Courtesy of Advisory Board.

An ounce of prevention

In studying inpatient and outpatient physicians’ perspectives regarding factors contributing to readmission,⁴ Shoshana Herzig, MD, MPH, assistant professor of medicine, Harvard Medical School, and director of Hospital Medicine Research, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, and her colleagues identified some potential preventive strategies.

The most commonly endorsed strategy to prevent readmissions by both primary care physicians and hospitalists surveyed involved improving self-management plans at discharge. “This refers to actions such as providing patient-centered discharge instructions (that is, making sure they are written in language that patients can understand) or asking transition coaches to help facilitate a successful transition,” Dr. Herzig said. “This finding is consistent with the fact that the factor most commonly identified as contributing to readmissions was insufficient patient understanding or ability to self-manage. Combined, these findings suggest that strategies to enhance patient understanding of their illness, care plan, and what to expect after hospital discharge, are likely to be important components of successful readmission reduction programs.”

monkeybusinessimages/Thinkstock

Another commonly endorsed strategy to prevent readmission was greater engagement of home and community supports. This entails enlisting the help of social workers and community agencies to deliver meals, provide transportation to doctors’ appointments, and so forth. “Inadequate social support contributes to many readmissions,” Dr. Herzig said. “Hospitalists should request assistance from social workers in helping to secure assistance for patients who need these services.”

Provisioning of resources to patients to help them manage their care after discharge is also recommended. For example, engaging nurses or pharmacists who can help with issues that arise after discharge may help keep patients out of the hospital.

“Hospitalists should be aware of what resources are available to help patients manage their care,” Dr. Herzig said. For example, if a patient needs periodic blood pressure monitoring, the hospitalist can tell the patient about free blood pressure checkpoints or suggest a home-automated blood pressure monitor.

The study also showed that improved coordination of care between inpatient and outpatient providers, such as sharing medical records, could reduce readmission rates. “This allows for better inpatient care and increased ability for primary care physicians to react appropriately to issues arising after discharge,” Dr. Herzig said. “In the absence of a shared system, hospitalists should complete discharge summaries in a timely fashion and ensure that they’re promptly transmitted to primary care physicians.”

Finally, the researchers believe that multifaceted, broadly applied interventions may be more successful than those relying upon individual providers choosing specific services based on perceived risk factors. “This is because a prior study⁵ demonstrated that it is difficult to anticipate in advance which patients will be readmitted, and, in our study, physicians did not agree on the factors that contributed to a given readmission,” Dr. Herzig explained. “Because of these findings, it becomes hard to rely on physicians to identify patients at increased risk for readmission, and to direct services that correctly anticipate contributing factors. Instead, it seems that programs aimed at improving general processes for particular patient categories may be more successful at reducing readmissions.” For example, it might be better to use a transition coach for all patients over the age of 65, rather than relying on physicians to decide which patients are at high risk for readmission.

Dr. Herzig said it’s important to note that hospitalists and primary care physicians had different appraisals of reasons for readmission. Therefore, when designing readmission reduction programs or determining specific services to prevent a readmission for a given patient, it is important for hospitalists to obtain input from primary care physicians to ensure that they address all of the potential contributors to readmission for a given patient.

 

Interviewing patients regarding readmissions

After involved clinicians and independent physician reviewers performed extensive case reviews of more than 700 readmitted patients,⁶ Ashley Busuttil, MD, FHM, associate section chief, Hospital Medicine, University of California, Los Angeles Department of Medicine; and executive medical director, Medicine Services, UCLA Department of Medicine, and Erin Dowling, MD, assistant clinical professor, General Internal Medicine, Hospitalist Services, UCLA Medical Center, Santa Monica, Calif., and their colleagues were unable to identify which readmissions could have easily been prevented, and found that readmission causality varied extensively.

Given this, the researchers set out to identify a more nuanced understanding of why patients return to the hospital. They decided to do this by talking to patients directly, and specifically studied patient readiness from the patient perspective.

Through interviews with patients, the researchers determined that patients were more likely to think that their readmission was preventable if they felt unready for discharge during their initial hospitalization. This was despite the fact that patients met what clinicians would consider “ready” by objective, provider-centric criteria: they were medically stable, they had in-home support services, they had follow-up arranged, and so forth. As such, they wanted to put effort into educating and preparing patients for what home will look and feel like posthospitalization to address their feelings of unreadiness.

To that end, the researchers created an enhanced transition initiative that included showing an educational video near the time of admission and a patient-centered discharge checklist to help patients identify questions they might have after discharge. The discharge checklist asks patients to put themselves in the position of being at home and working through scenarios they may face so they will know how to deal with them. For example, if you have pain, who should you call? What should you do if you run out of medication?

Dr. Dowling believes that the hospitalist will, over time, become essential to assessing patient readiness. “As we learn more about how patients approach discharge, hospitalists’ understanding of patient needs beyond straightforward medical care will be crucial to having smoother transitions of care,” she said.

The researchers also explored pain control. As a health system, UCLA Medical Center has formed a multidisciplinary task force to optimize its approach to pain control. “If we can address comfort – for both patients at high risk of readmission and those that aren’t – we hope we can improve symptom control overall,” Dr. Busuttil said. “It’s not uncommon for patients to feel inadequate symptom control at discharge. While this is likely only one component of all the readmission pieces, a patient who feels that their symptoms are not controlled is likely to feel less ready for discharge. Increasing patient readiness, perhaps by increasing symptom control and improving communication regarding symptom management expectations, is a task that the hospitalist is well positioned to address.”

In addition, a focus group that included patient representatives was conducted to identify potential discharge paperwork enhancements. Patients were asked to identify opportunities for improvement in the health system’s discharge After Visit Summary (AVS). “We were surprised to learn that even though patients knew that they had follow-up appointments, they were unable to locate the follow-up appointment section on the AVS,” Dr. Busuttil said. “We also learned that the medication section was confusing. Efforts for an AVS revision are underway.”

The researchers also wanted to find out why patients may not use available outpatient resources, and assessed them for decisional conflict – a measure of certainty with decision making – when selecting from multiple options for accessing medical care if they were home postdischarge and began to feel ill again. “Patients with decisional conflict were more likely to state that they would go the emergency room rather than call their primary medical physician or visit an urgent care center,” Dr. Busuttil said.

The health system continues to screen patients for decisional conflict. “When positive, we provide bedside education on when to seek medical care through primary care, urgent care, or the emergency department,” Dr. Busuttil said. “We also provide patients with information on how to access each of these resources.”

While a prior discharge plan may have seemed ideal on paper, time and time again it’s not logistically possible for certain patients. “By having this knowledge gleaned from patient interviews, hospitalists are able to provide feedback to health systems regarding different options of outpatient care that may work for the different patient populations they serve,” Dr. Dowling said.

To understand why one particular patient population is being readmitted requires taking the time to understand that population, Dr. Dowling noted. “While many validated risk stratification tools are available, they may only serve as general guides,” she said. “To impact the population you serve, you must first understand the readmission process as it looks to them.”

 

Employing the HOSPITAL score

In another effort to reduce hospital readmissions, Jacques Donzé, MD, MSc, associate physician, Bern University Hospital, Switzerland, and research associate, Brigham and Women’s Hospital, Boston, and his colleagues used the HOSPITAL score to identify patients at high risk of 30-day potentially avoidable readmission.

To most efficiently reduce hospital readmissions, hospitals need to target complex and intensive discharge interventions for patients at high risk of potentially avoidable readmission who are more likely to benefit.² “However, prior research indicates that clinical health care providers are not able to accurately identify which patients are at high risk for readmission,” Dr. Donzé said.

In their large international multicenter external validation study, Dr. Donzé and his colleagues found that the HOSPITAL score accurately predicted the risk of 30-day potentially avoidable readmissions. The HOSPITAL score is easy to use and can be calculated before discharge, which makes it a practical tool for identifying patients at high risk for preventable readmission and the timely administration of high-intensity interventions designed to improve transitions of care.²

Dr. Donzé believes that several factors may influence the performance of a prediction model, such as the initial selection of the potential predictors, the quality of the derivation method, including readily available predictors commonly available, and including reliable factors that aren’t subject to subjective evaluation. “All of these factors can play a role in the performance and generalizability of the HOSPITAL score,” he said.

When a patient is identified as high risk to be readmitted, hospitalists can take certain actions to prevent readmission. “Interventions are more likely to be effective when they include several components,” Dr. Donzé said. “These include follow-up phone calls and/or home visits, review of the patient’s medication list, patient education, and sending a discharge summary to the patient’s primary care physician in a timely manner. For now, enough evidence for a specific effective multimodal intervention to be generalizable to the majority of patients is lacking.”

Currently, the HOSPITAL score has been validated in approximately 180,000 patients in 14 hospitals across five countries and three continents – always showing good performance and generalizability. The HOSPITAL score includes seven variables readily available before hospital discharge, is easy to use, and is the most widely validated prediction model for readmission, Dr. Donzé said.

Before being implemented into practice, a score should ideally reach the highest level of validation, that is, show its clinical impact. “We expect that the score will not only be able to accurately predict high-risk patients, but using the score will also impact patient care by reducing readmissions when coupled with an appropriate intervention,” Dr. Donzé said.

In summary, research has shown that a variety of methods can be used to reduce hospital readmissions, including studying inpatient and outpatient physicians’ perspectives regarding factors contributing to readmission; interviewing patients regarding readmissions; and identifying patients at high risk of readmission using the HOSPITAL score.

Many researchers are continuing their studies in these areas.

Karen Appold is a medical writer in Pennsylvania.

Using hospitalist reflections as a means to reduce readmissions

Readmission studies and the development of readmission scoring systems and prediction tools rely on data from a large number of patients, typically extracted from administrative databases.

To complement this data, Deanne Kashiwagi, MD, consultant, Hospital Internal Medicine, Mayo Clinic, Rochester, Minn., and her colleagues asked hospitalists to reflect upon the readmissions of patients for whom they cared to add insight into the culture of patient care transitions within the health system.

“We felt there was some value in considering these nuances of the local care environment, which may not be represented in studies drawing from large databases, as potential targets for readmission efforts,” she said.

Dr. Kashiwagi and her colleagues developed a chart review tool to guide hospitalists through reflection about their patients’ admissions and readmissions. “We included factors frequently cited in the literature as contributors to readmissions and added factors that our study group, after a chart review of 40 patients’ readmissions, identified as variables contributing to our own patients’ readmissions,” Dr. Kashiwagi said. “Some of these variables reflected our local care system, such as our staffing model, which led to some patients being cared for by more than two hospitalists during their admission. The study group considered such variables as potential contributors to our own group’s readmissions, but they were not necessarily common readmission risk factors identified in large-scale studies.”

Dr. Kashiwagi believes that including elements of local practice and culture was the strength of their work. “Groups interested in replicating this reflective process should consider including factors specific to their practices that may contribute to readmission,” she said.

Asking hospitalists to perform reviews has led to implementing changes. Physicians were prompted to schedule earlier follow-up appointments and nurse practitioners and physician assistants have worked to improve the quality of their discharge summaries. The exercise also engaged hospitalists to suggest system changes that might contribute to decreased readmissions, such as a geriatrician-run service (which was recently begun) to provide multidisciplinary acute geriatric care for hospitalized older adults.

“Although large-scale studies are clearly important, readmission review at a more granular level may have merit as well,” Dr. Kashiwagi said, noting that such reviews identify local practice factors that groups may quickly act upon to help decrease readmissions. “Hospitalists readily engaged in this reflective exercise, which yielded actionable information to decrease readmissions.”

In commenting on why a different similar study⁷ didn’t mimic the results of Mayo Clinic’s study, Dr. Kashiwagi said there were some differences in methodology that may explain the difference in readmission rates. “First, this group excluded patients on dialysis, which in our study was a common comorbidity of our readmitted patients,” she said. “It is also notable that the chart review tool was different. Perhaps there is less representation of local factors, unique to that hospitalist group and their practice culture, than on our review form. These investigators also discussed their readmissions at routine intervals. Additionally, their preintervention readmission rate was lower than Mayo Clinic’s group, and although the readmission rate trended downward postintervention, it did not reach statistical significance.”

 

References

1. Jencks SF, Williams MV, Coleman EA. Rehospitalizations among patients in the Medicare fee-for-service program. N Engl J Med. 2009;360(14):1418-28.

2. Donzé JD, Williams MV, Robinson EJ, et al. International validity of the HOSPITAL Score to predict 30-day potentially avoidable hospital readmissions. JAMA Intern Med. 2016 Apr;176(4):496-502.

3. Kashiwagi DT, Burton MC, Hakim FA, et al. Reflective practice: a tool for readmission reduction. Am J Med Qual. 2016 May;31(3):265-71.

4. Herzig SJ, Schnipper JL, Doctoroff L, et al. Physician perspectives on factors contributing to readmissions and potential prevention strategies: a multicenter survey. J Gen Intern Med. 2016 Nov;31(11):1287-93. Epub 2016 Jun 9.

5. Allaudeen N, Schnipper JL, Orav EJ, et al. Inability of providers to predict unplanned readmissions. J Gen Intern Med. 2011 Jul;26(7):771-6.

6. Busuttil A, Howard-Anderson J, Dowling EP, et al. Building a comprehensive patient-centered readmission reduction program [abstract]. J Hosp Med. 2016;11(suppl 1).

7. Rana V, Thapa B, Saini SC, et al. Self-reflection as a tool to increase hospitalist participation in readmission quality improvement. Qual Manag Health Care. 2016 Oct/Dec;25(4):219-24.

 

Hospital readmissions are frequent, harmful, and costly. Consider the fact that 18% of Medicare patients can expect to be readmitted within 30 days at a cost of more than $17 billion.¹ Recent changes in health care policy aimed at reducing readmission have substantially increased attention to this major health care issue.²

The Affordable Care Act has mandated that the Centers for Medicare & Medicaid Services reduce payment to hospitals with higher-than-expected 30-day readmissions, with its Hospital Readmissions Reduction Program. This has driven rapid growth in the study of patients rehospitalized within 30 days of discharge.³ So what are some strategies that have either been proven to reduce readmissions or show promise in doing so?

FY 2017 IPPS Final Rule HRRP Supplemental Data File. Courtesy of Advisory Board.

An ounce of prevention

In studying inpatient and outpatient physicians’ perspectives regarding factors contributing to readmission,⁴ Shoshana Herzig, MD, MPH, assistant professor of medicine, Harvard Medical School, and director of Hospital Medicine Research, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, and her colleagues identified some potential preventive strategies.

The most commonly endorsed strategy to prevent readmissions by both primary care physicians and hospitalists surveyed involved improving self-management plans at discharge. “This refers to actions such as providing patient-centered discharge instructions (that is, making sure they are written in language that patients can understand) or asking transition coaches to help facilitate a successful transition,” Dr. Herzig said. “This finding is consistent with the fact that the factor most commonly identified as contributing to readmissions was insufficient patient understanding or ability to self-manage. Combined, these findings suggest that strategies to enhance patient understanding of their illness, care plan, and what to expect after hospital discharge, are likely to be important components of successful readmission reduction programs.”

monkeybusinessimages/Thinkstock

Another commonly endorsed strategy to prevent readmission was greater engagement of home and community supports. This entails enlisting the help of social workers and community agencies to deliver meals, provide transportation to doctors’ appointments, and so forth. “Inadequate social support contributes to many readmissions,” Dr. Herzig said. “Hospitalists should request assistance from social workers in helping to secure assistance for patients who need these services.”

Provisioning of resources to patients to help them manage their care after discharge is also recommended. For example, engaging nurses or pharmacists who can help with issues that arise after discharge may help keep patients out of the hospital.

“Hospitalists should be aware of what resources are available to help patients manage their care,” Dr. Herzig said. For example, if a patient needs periodic blood pressure monitoring, the hospitalist can tell the patient about free blood pressure checkpoints or suggest a home-automated blood pressure monitor.

The study also showed that improved coordination of care between inpatient and outpatient providers, such as sharing medical records, could reduce readmission rates. “This allows for better inpatient care and increased ability for primary care physicians to react appropriately to issues arising after discharge,” Dr. Herzig said. “In the absence of a shared system, hospitalists should complete discharge summaries in a timely fashion and ensure that they’re promptly transmitted to primary care physicians.”

Finally, the researchers believe that multifaceted, broadly applied interventions may be more successful than those relying upon individual providers choosing specific services based on perceived risk factors. “This is because a prior study⁵ demonstrated that it is difficult to anticipate in advance which patients will be readmitted, and, in our study, physicians did not agree on the factors that contributed to a given readmission,” Dr. Herzig explained. “Because of these findings, it becomes hard to rely on physicians to identify patients at increased risk for readmission, and to direct services that correctly anticipate contributing factors. Instead, it seems that programs aimed at improving general processes for particular patient categories may be more successful at reducing readmissions.” For example, it might be better to use a transition coach for all patients over the age of 65, rather than relying on physicians to decide which patients are at high risk for readmission.

Dr. Herzig said it’s important to note that hospitalists and primary care physicians had different appraisals of reasons for readmission. Therefore, when designing readmission reduction programs or determining specific services to prevent a readmission for a given patient, it is important for hospitalists to obtain input from primary care physicians to ensure that they address all of the potential contributors to readmission for a given patient.

 

Interviewing patients regarding readmissions

After involved clinicians and independent physician reviewers performed extensive case reviews of more than 700 readmitted patients,⁶ Ashley Busuttil, MD, FHM, associate section chief, Hospital Medicine, University of California, Los Angeles Department of Medicine; and executive medical director, Medicine Services, UCLA Department of Medicine, and Erin Dowling, MD, assistant clinical professor, General Internal Medicine, Hospitalist Services, UCLA Medical Center, Santa Monica, Calif., and their colleagues were unable to identify which readmissions could have easily been prevented, and found that readmission causality varied extensively.

Given this, the researchers set out to identify a more nuanced understanding of why patients return to the hospital. They decided to do this by talking to patients directly, and specifically studied patient readiness from the patient perspective.

Through interviews with patients, the researchers determined that patients were more likely to think that their readmission was preventable if they felt unready for discharge during their initial hospitalization. This was despite the fact that patients met what clinicians would consider “ready” by objective, provider-centric criteria: they were medically stable, they had in-home support services, they had follow-up arranged, and so forth. As such, they wanted to put effort into educating and preparing patients for what home will look and feel like posthospitalization to address their feelings of unreadiness.

To that end, the researchers created an enhanced transition initiative that included showing an educational video near the time of admission and a patient-centered discharge checklist to help patients identify questions they might have after discharge. The discharge checklist asks patients to put themselves in the position of being at home and working through scenarios they may face so they will know how to deal with them. For example, if you have pain, who should you call? What should you do if you run out of medication?

Dr. Dowling believes that the hospitalist will, over time, become essential to assessing patient readiness. “As we learn more about how patients approach discharge, hospitalists’ understanding of patient needs beyond straightforward medical care will be crucial to having smoother transitions of care,” she said.

The researchers also explored pain control. As a health system, UCLA Medical Center has formed a multidisciplinary task force to optimize its approach to pain control. “If we can address comfort – for both patients at high risk of readmission and those that aren’t – we hope we can improve symptom control overall,” Dr. Busuttil said. “It’s not uncommon for patients to feel inadequate symptom control at discharge. While this is likely only one component of all the readmission pieces, a patient who feels that their symptoms are not controlled is likely to feel less ready for discharge. Increasing patient readiness, perhaps by increasing symptom control and improving communication regarding symptom management expectations, is a task that the hospitalist is well positioned to address.”

In addition, a focus group that included patient representatives was conducted to identify potential discharge paperwork enhancements. Patients were asked to identify opportunities for improvement in the health system’s discharge After Visit Summary (AVS). “We were surprised to learn that even though patients knew that they had follow-up appointments, they were unable to locate the follow-up appointment section on the AVS,” Dr. Busuttil said. “We also learned that the medication section was confusing. Efforts for an AVS revision are underway.”

The researchers also wanted to find out why patients may not use available outpatient resources, and assessed them for decisional conflict – a measure of certainty with decision making – when selecting from multiple options for accessing medical care if they were home postdischarge and began to feel ill again. “Patients with decisional conflict were more likely to state that they would go the emergency room rather than call their primary medical physician or visit an urgent care center,” Dr. Busuttil said.

The health system continues to screen patients for decisional conflict. “When positive, we provide bedside education on when to seek medical care through primary care, urgent care, or the emergency department,” Dr. Busuttil said. “We also provide patients with information on how to access each of these resources.”

While a prior discharge plan may have seemed ideal on paper, time and time again it’s not logistically possible for certain patients. “By having this knowledge gleaned from patient interviews, hospitalists are able to provide feedback to health systems regarding different options of outpatient care that may work for the different patient populations they serve,” Dr. Dowling said.

To understand why one particular patient population is being readmitted requires taking the time to understand that population, Dr. Dowling noted. “While many validated risk stratification tools are available, they may only serve as general guides,” she said. “To impact the population you serve, you must first understand the readmission process as it looks to them.”

 

Employing the HOSPITAL score

In another effort to reduce hospital readmissions, Jacques Donzé, MD, MSc, associate physician, Bern University Hospital, Switzerland, and research associate, Brigham and Women’s Hospital, Boston, and his colleagues used the HOSPITAL score to identify patients at high risk of 30-day potentially avoidable readmission.

To most efficiently reduce hospital readmissions, hospitals need to target complex and intensive discharge interventions for patients at high risk of potentially avoidable readmission who are more likely to benefit.² “However, prior research indicates that clinical health care providers are not able to accurately identify which patients are at high risk for readmission,” Dr. Donzé said.

In their large international multicenter external validation study, Dr. Donzé and his colleagues found that the HOSPITAL score accurately predicted the risk of 30-day potentially avoidable readmissions. The HOSPITAL score is easy to use and can be calculated before discharge, which makes it a practical tool for identifying patients at high risk for preventable readmission and the timely administration of high-intensity interventions designed to improve transitions of care.²

Dr. Donzé believes that several factors may influence the performance of a prediction model, such as the initial selection of the potential predictors, the quality of the derivation method, including readily available predictors commonly available, and including reliable factors that aren’t subject to subjective evaluation. “All of these factors can play a role in the performance and generalizability of the HOSPITAL score,” he said.

When a patient is identified as high risk to be readmitted, hospitalists can take certain actions to prevent readmission. “Interventions are more likely to be effective when they include several components,” Dr. Donzé said. “These include follow-up phone calls and/or home visits, review of the patient’s medication list, patient education, and sending a discharge summary to the patient’s primary care physician in a timely manner. For now, enough evidence for a specific effective multimodal intervention to be generalizable to the majority of patients is lacking.”

Currently, the HOSPITAL score has been validated in approximately 180,000 patients in 14 hospitals across five countries and three continents – always showing good performance and generalizability. The HOSPITAL score includes seven variables readily available before hospital discharge, is easy to use, and is the most widely validated prediction model for readmission, Dr. Donzé said.

Before being implemented into practice, a score should ideally reach the highest level of validation, that is, show its clinical impact. “We expect that the score will not only be able to accurately predict high-risk patients, but using the score will also impact patient care by reducing readmissions when coupled with an appropriate intervention,” Dr. Donzé said.

In summary, research has shown that a variety of methods can be used to reduce hospital readmissions, including studying inpatient and outpatient physicians’ perspectives regarding factors contributing to readmission; interviewing patients regarding readmissions; and identifying patients at high risk of readmission using the HOSPITAL score.

Many researchers are continuing their studies in these areas.

Karen Appold is a medical writer in Pennsylvania.

Using hospitalist reflections as a means to reduce readmissions

Readmission studies and the development of readmission scoring systems and prediction tools rely on data from a large number of patients, typically extracted from administrative databases.

To complement this data, Deanne Kashiwagi, MD, consultant, Hospital Internal Medicine, Mayo Clinic, Rochester, Minn., and her colleagues asked hospitalists to reflect upon the readmissions of patients for whom they cared to add insight into the culture of patient care transitions within the health system.

“We felt there was some value in considering these nuances of the local care environment, which may not be represented in studies drawing from large databases, as potential targets for readmission efforts,” she said.

Dr. Kashiwagi and her colleagues developed a chart review tool to guide hospitalists through reflection about their patients’ admissions and readmissions. “We included factors frequently cited in the literature as contributors to readmissions and added factors that our study group, after a chart review of 40 patients’ readmissions, identified as variables contributing to our own patients’ readmissions,” Dr. Kashiwagi said. “Some of these variables reflected our local care system, such as our staffing model, which led to some patients being cared for by more than two hospitalists during their admission. The study group considered such variables as potential contributors to our own group’s readmissions, but they were not necessarily common readmission risk factors identified in large-scale studies.”

Dr. Kashiwagi believes that including elements of local practice and culture was the strength of their work. “Groups interested in replicating this reflective process should consider including factors specific to their practices that may contribute to readmission,” she said.

Asking hospitalists to perform reviews has led to implementing changes. Physicians were prompted to schedule earlier follow-up appointments and nurse practitioners and physician assistants have worked to improve the quality of their discharge summaries. The exercise also engaged hospitalists to suggest system changes that might contribute to decreased readmissions, such as a geriatrician-run service (which was recently begun) to provide multidisciplinary acute geriatric care for hospitalized older adults.

“Although large-scale studies are clearly important, readmission review at a more granular level may have merit as well,” Dr. Kashiwagi said, noting that such reviews identify local practice factors that groups may quickly act upon to help decrease readmissions. “Hospitalists readily engaged in this reflective exercise, which yielded actionable information to decrease readmissions.”

In commenting on why a different similar study⁷ didn’t mimic the results of Mayo Clinic’s study, Dr. Kashiwagi said there were some differences in methodology that may explain the difference in readmission rates. “First, this group excluded patients on dialysis, which in our study was a common comorbidity of our readmitted patients,” she said. “It is also notable that the chart review tool was different. Perhaps there is less representation of local factors, unique to that hospitalist group and their practice culture, than on our review form. These investigators also discussed their readmissions at routine intervals. Additionally, their preintervention readmission rate was lower than Mayo Clinic’s group, and although the readmission rate trended downward postintervention, it did not reach statistical significance.”

 

References

1. Jencks SF, Williams MV, Coleman EA. Rehospitalizations among patients in the Medicare fee-for-service program. N Engl J Med. 2009;360(14):1418-28.

2. Donzé JD, Williams MV, Robinson EJ, et al. International validity of the HOSPITAL Score to predict 30-day potentially avoidable hospital readmissions. JAMA Intern Med. 2016 Apr;176(4):496-502.

3. Kashiwagi DT, Burton MC, Hakim FA, et al. Reflective practice: a tool for readmission reduction. Am J Med Qual. 2016 May;31(3):265-71.

4. Herzig SJ, Schnipper JL, Doctoroff L, et al. Physician perspectives on factors contributing to readmissions and potential prevention strategies: a multicenter survey. J Gen Intern Med. 2016 Nov;31(11):1287-93. Epub 2016 Jun 9.

5. Allaudeen N, Schnipper JL, Orav EJ, et al. Inability of providers to predict unplanned readmissions. J Gen Intern Med. 2011 Jul;26(7):771-6.

6. Busuttil A, Howard-Anderson J, Dowling EP, et al. Building a comprehensive patient-centered readmission reduction program [abstract]. J Hosp Med. 2016;11(suppl 1).

7. Rana V, Thapa B, Saini SC, et al. Self-reflection as a tool to increase hospitalist participation in readmission quality improvement. Qual Manag Health Care. 2016 Oct/Dec;25(4):219-24.

 

Over the last 5 years, I’ve periodically devoted this column to providing updates to the Hospital Value-Based Purchasing program. HVBP launched in 2013 as a 5-year mixed upside/downside incentive program with mandatory participation for all U.S. acute care hospitals (critical access, acute inpatient rehabilitation, and long-term acute care hospitals are exempt). The program initially included process and patient experience measures. It later added measures for mortality, efficiency, and patient safety.

For the 2017 version of HVBP, the measures are allocated as follows: eight for patient experience, seven for patient safety (1 of which is a roll up of 11 claims-based measures), three for process, and three for mortality. HVBP uses a budget-neutral funding approach with some winners and some losers but overall net zero spending on the program. It initially put hospitals at risk for 1% of their Medicare inpatient payments (in 2013), with a progressive increase to 2% by this year. HVBP has used a complex approach to determining incentives and penalties, rewarding either improvement or achievement, depending on the baseline performance of the hospital.

When HVBP was rolled out it seemed like a big deal. Hospitals devoted resources to it. I contended that hospitalists should pay attention to its measures and to work with their hospital quality department to promote high performance in the relevant measure domains. I emphasized that the program was good for hospitalists because it put dollars behind the quality improvement projects we had been working on for some time – projects to improve HCAHPS scores; lower mortality; improve heart failure, heart attack, or pneumonia processes; and decrease hospital-acquired infections. For some perspective on dollars at stake, by this year, a 700-bed hospital has about $3.4 million at risk in the program, and a 90-bed hospital has roughly $250,000 at risk.

Has HVBP improved quality? Two studies looking at the early period of HVBP failed to show improvements in process or patient experience measures and demonstrated no change in mortality for heart failure, pneumonia, or heart attack.^1,2 Now that the program is in its 5th and final year, thanks to a recent study by Ryan et al., we have an idea if HVBP is associated with longer-term improvements in quality.³

In the study, Ryan et al. compared hospitals participating in HVBP with critical access hospitals, which are exempt from the program. The study yielded some disappointing, if not surprising, results. Improvements in process and patient experience measures for HVBP hospitals were no greater than those for the control group. HVBP was not associated with a significant reduction in mortality for heart failure or heart attack, but was associated with a mortality reduction for pneumonia. In sum, HVBP was not associated with improvements in process or patient experience, and was not associated with lower mortality, except in pneumonia.

As a program designed to incentivize better quality, where did HVBP go wrong? I believe HVBP simply had too many measures for the cognitive bandwidth of an individual or a team looking to improve quality. The total measure count for 2017 is 21! I submit that a hospitalist working to improve quality can keep top-of-mind one or two measures, possibly three at most. While others have postulated that the amount of dollars at risk are too small, I don’t think that’s the problem. Instead, my sense is that hospitalists and other members of the hospital team have quality improvement in their DNA and, regardless of the size of the financial incentives, will work to improve it as long as they have the right tools. Chief among these are good performance data and the time to focus on a finite number of projects.

What lessons can inform better design in the future? As of January 2017, the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) – representing the biggest change in reimbursement in a generation – progressively exposes doctors and other professionals to upside/downside incentives for quality, resource utilization, use of a certified electronic health record (hospitalists are exempt as they already use the hospital’s EHR), and practice improvement activities.

It would be wise to learn from the shortcomings of HVBP. Namely, if MACRA keeps on its course to incentivize physicians using a complicated formula based on four domains and many more subdomains, it will repeat the mistakes of HVBP and – while creating more administrative burden – likely improve quality very little, if at all. Instead, MACRA should delineate a simple measure set representing improvement activities that physicians and teams can incorporate into their regular work flow without more time taken away from patient care.

The reality is that complicated pay-for-performance programs divert limited available resources away from meaningful improvement activities in order to comply with onerous reporting requirements. As we gain a more nuanced understanding of how these programs work, policy makers should pay attention to the elements of “low-value” and “high-value” incentive systems and apply the “less is more” ethos of high-value care to the next generation of pay-for-performance programs.
 

 

Dr. Whitcomb is chief medical officer at Remedy Partners in Darien, Conn., and a cofounder and past president of SHM.

References

1. Ryan AM, Burgess JF, Pesko MF, Borden WB, Dimick JB. “The early effects of Medicare’s mandatory hospital pay-for-performance program” Health Serv Res. 2015;50:81-97.

2. Figueroa JF, Tsugawa Y, Zheng J, Orav EJ, Jha AK. “Association between the Value-Based Purchasing pay for performance program and patient mortality in US hospitals: observational study” BMJ. 2016;353:i2214.

3. Ryan AM, Krinsky S, Maurer KA, Dimick JB. “Changes in Hospital Quality Associated with Hospital Value-Based Purchasing” N Engl J Med. 2017;376:2358-66.

 

Over the last 5 years, I’ve periodically devoted this column to providing updates to the Hospital Value-Based Purchasing program. HVBP launched in 2013 as a 5-year mixed upside/downside incentive program with mandatory participation for all U.S. acute care hospitals (critical access, acute inpatient rehabilitation, and long-term acute care hospitals are exempt). The program initially included process and patient experience measures. It later added measures for mortality, efficiency, and patient safety.

For the 2017 version of HVBP, the measures are allocated as follows: eight for patient experience, seven for patient safety (1 of which is a roll up of 11 claims-based measures), three for process, and three for mortality. HVBP uses a budget-neutral funding approach with some winners and some losers but overall net zero spending on the program. It initially put hospitals at risk for 1% of their Medicare inpatient payments (in 2013), with a progressive increase to 2% by this year. HVBP has used a complex approach to determining incentives and penalties, rewarding either improvement or achievement, depending on the baseline performance of the hospital.

When HVBP was rolled out it seemed like a big deal. Hospitals devoted resources to it. I contended that hospitalists should pay attention to its measures and to work with their hospital quality department to promote high performance in the relevant measure domains. I emphasized that the program was good for hospitalists because it put dollars behind the quality improvement projects we had been working on for some time – projects to improve HCAHPS scores; lower mortality; improve heart failure, heart attack, or pneumonia processes; and decrease hospital-acquired infections. For some perspective on dollars at stake, by this year, a 700-bed hospital has about $3.4 million at risk in the program, and a 90-bed hospital has roughly $250,000 at risk.

Has HVBP improved quality? Two studies looking at the early period of HVBP failed to show improvements in process or patient experience measures and demonstrated no change in mortality for heart failure, pneumonia, or heart attack.^1,2 Now that the program is in its 5th and final year, thanks to a recent study by Ryan et al., we have an idea if HVBP is associated with longer-term improvements in quality.³

In the study, Ryan et al. compared hospitals participating in HVBP with critical access hospitals, which are exempt from the program. The study yielded some disappointing, if not surprising, results. Improvements in process and patient experience measures for HVBP hospitals were no greater than those for the control group. HVBP was not associated with a significant reduction in mortality for heart failure or heart attack, but was associated with a mortality reduction for pneumonia. In sum, HVBP was not associated with improvements in process or patient experience, and was not associated with lower mortality, except in pneumonia.

As a program designed to incentivize better quality, where did HVBP go wrong? I believe HVBP simply had too many measures for the cognitive bandwidth of an individual or a team looking to improve quality. The total measure count for 2017 is 21! I submit that a hospitalist working to improve quality can keep top-of-mind one or two measures, possibly three at most. While others have postulated that the amount of dollars at risk are too small, I don’t think that’s the problem. Instead, my sense is that hospitalists and other members of the hospital team have quality improvement in their DNA and, regardless of the size of the financial incentives, will work to improve it as long as they have the right tools. Chief among these are good performance data and the time to focus on a finite number of projects.

What lessons can inform better design in the future? As of January 2017, the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) – representing the biggest change in reimbursement in a generation – progressively exposes doctors and other professionals to upside/downside incentives for quality, resource utilization, use of a certified electronic health record (hospitalists are exempt as they already use the hospital’s EHR), and practice improvement activities.

It would be wise to learn from the shortcomings of HVBP. Namely, if MACRA keeps on its course to incentivize physicians using a complicated formula based on four domains and many more subdomains, it will repeat the mistakes of HVBP and – while creating more administrative burden – likely improve quality very little, if at all. Instead, MACRA should delineate a simple measure set representing improvement activities that physicians and teams can incorporate into their regular work flow without more time taken away from patient care.

The reality is that complicated pay-for-performance programs divert limited available resources away from meaningful improvement activities in order to comply with onerous reporting requirements. As we gain a more nuanced understanding of how these programs work, policy makers should pay attention to the elements of “low-value” and “high-value” incentive systems and apply the “less is more” ethos of high-value care to the next generation of pay-for-performance programs.
 

 

Dr. Whitcomb is chief medical officer at Remedy Partners in Darien, Conn., and a cofounder and past president of SHM.

References

1. Ryan AM, Burgess JF, Pesko MF, Borden WB, Dimick JB. “The early effects of Medicare’s mandatory hospital pay-for-performance program” Health Serv Res. 2015;50:81-97.

2. Figueroa JF, Tsugawa Y, Zheng J, Orav EJ, Jha AK. “Association between the Value-Based Purchasing pay for performance program and patient mortality in US hospitals: observational study” BMJ. 2016;353:i2214.

3. Ryan AM, Krinsky S, Maurer KA, Dimick JB. “Changes in Hospital Quality Associated with Hospital Value-Based Purchasing” N Engl J Med. 2017;376:2358-66.

 

Over the last 5 years, I’ve periodically devoted this column to providing updates to the Hospital Value-Based Purchasing program. HVBP launched in 2013 as a 5-year mixed upside/downside incentive program with mandatory participation for all U.S. acute care hospitals (critical access, acute inpatient rehabilitation, and long-term acute care hospitals are exempt). The program initially included process and patient experience measures. It later added measures for mortality, efficiency, and patient safety.

For the 2017 version of HVBP, the measures are allocated as follows: eight for patient experience, seven for patient safety (1 of which is a roll up of 11 claims-based measures), three for process, and three for mortality. HVBP uses a budget-neutral funding approach with some winners and some losers but overall net zero spending on the program. It initially put hospitals at risk for 1% of their Medicare inpatient payments (in 2013), with a progressive increase to 2% by this year. HVBP has used a complex approach to determining incentives and penalties, rewarding either improvement or achievement, depending on the baseline performance of the hospital.

When HVBP was rolled out it seemed like a big deal. Hospitals devoted resources to it. I contended that hospitalists should pay attention to its measures and to work with their hospital quality department to promote high performance in the relevant measure domains. I emphasized that the program was good for hospitalists because it put dollars behind the quality improvement projects we had been working on for some time – projects to improve HCAHPS scores; lower mortality; improve heart failure, heart attack, or pneumonia processes; and decrease hospital-acquired infections. For some perspective on dollars at stake, by this year, a 700-bed hospital has about $3.4 million at risk in the program, and a 90-bed hospital has roughly $250,000 at risk.

Has HVBP improved quality? Two studies looking at the early period of HVBP failed to show improvements in process or patient experience measures and demonstrated no change in mortality for heart failure, pneumonia, or heart attack.^1,2 Now that the program is in its 5th and final year, thanks to a recent study by Ryan et al., we have an idea if HVBP is associated with longer-term improvements in quality.³

In the study, Ryan et al. compared hospitals participating in HVBP with critical access hospitals, which are exempt from the program. The study yielded some disappointing, if not surprising, results. Improvements in process and patient experience measures for HVBP hospitals were no greater than those for the control group. HVBP was not associated with a significant reduction in mortality for heart failure or heart attack, but was associated with a mortality reduction for pneumonia. In sum, HVBP was not associated with improvements in process or patient experience, and was not associated with lower mortality, except in pneumonia.

As a program designed to incentivize better quality, where did HVBP go wrong? I believe HVBP simply had too many measures for the cognitive bandwidth of an individual or a team looking to improve quality. The total measure count for 2017 is 21! I submit that a hospitalist working to improve quality can keep top-of-mind one or two measures, possibly three at most. While others have postulated that the amount of dollars at risk are too small, I don’t think that’s the problem. Instead, my sense is that hospitalists and other members of the hospital team have quality improvement in their DNA and, regardless of the size of the financial incentives, will work to improve it as long as they have the right tools. Chief among these are good performance data and the time to focus on a finite number of projects.

What lessons can inform better design in the future? As of January 2017, the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) – representing the biggest change in reimbursement in a generation – progressively exposes doctors and other professionals to upside/downside incentives for quality, resource utilization, use of a certified electronic health record (hospitalists are exempt as they already use the hospital’s EHR), and practice improvement activities.

It would be wise to learn from the shortcomings of HVBP. Namely, if MACRA keeps on its course to incentivize physicians using a complicated formula based on four domains and many more subdomains, it will repeat the mistakes of HVBP and – while creating more administrative burden – likely improve quality very little, if at all. Instead, MACRA should delineate a simple measure set representing improvement activities that physicians and teams can incorporate into their regular work flow without more time taken away from patient care.

The reality is that complicated pay-for-performance programs divert limited available resources away from meaningful improvement activities in order to comply with onerous reporting requirements. As we gain a more nuanced understanding of how these programs work, policy makers should pay attention to the elements of “low-value” and “high-value” incentive systems and apply the “less is more” ethos of high-value care to the next generation of pay-for-performance programs.
 

 

Dr. Whitcomb is chief medical officer at Remedy Partners in Darien, Conn., and a cofounder and past president of SHM.

References

1. Ryan AM, Burgess JF, Pesko MF, Borden WB, Dimick JB. “The early effects of Medicare’s mandatory hospital pay-for-performance program” Health Serv Res. 2015;50:81-97.

2. Figueroa JF, Tsugawa Y, Zheng J, Orav EJ, Jha AK. “Association between the Value-Based Purchasing pay for performance program and patient mortality in US hospitals: observational study” BMJ. 2016;353:i2214.

3. Ryan AM, Krinsky S, Maurer KA, Dimick JB. “Changes in Hospital Quality Associated with Hospital Value-Based Purchasing” N Engl J Med. 2017;376:2358-66.