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HM17 On Demand now available

Couldn’t make it to Las Vegas for SHM’s annual meeting, Hospital Medicine 2017? HM17 On Demand gives you access to over 80 online audio and slide recordings from the hottest tracks, including clinical updates, rapid fire, pediatrics, comanagement, quality, and high-value care.

Additionally, you can earn up to 70 American Medical Association Physician Recognition Award Category 1 Credit(s) and up to 30 American Board of Internal Medicine Maintenance of Certification credits. HM17 attendees can also benefit by earning additional credits on the sessions you missed out on.

To easily access content through SHM’s Learning Portal, visit shmlearningportal.org/hm17-demand to learn more.
 

Chapter Excellence Awards

SHM is proud to recognize outstanding chapters for the fourth annual Chapter Excellence Awards. Each year, chapters strive to demonstrate growth, sustenance, and innovation within their chapter activities.

View more at www.hospitalmedicine.org/chapterexcellence. Please join SHM in congratulating the following chapters on their success!

Silver Chapters

Boston Association of Academic Hospital Medicine (BAAHM)

Charlotte Metro Area

Houston

Kentucky

Los Angeles

Minnesota

North Jersey

Pacific Northwest

Philadelphia Tri-State

Rocky Mountain

San Francisco Bay

South Central PA

Gold Chapters

New Mexico

Wiregrass

Platinum Chapters

IowaMaryland

Michigan

NYC/Westchester

St. Louis

Outstanding Chapter of the Year

Michigan

Rising Star Chapter

Wiregrass
 

Student Hospitalist Scholar grant winners

SHM’s Student Hospitalist Scholar Grant provides funds with which medical students can conduct mentored scholarly projects related to quality improvement and patient safety in the field of hospital medicine. The program offers a summer and a longitudinal option.

Congratulations to the 2017-2018 Student Hospitalist Scholar Grant recipients:Summer Program

Anton Garazha

Rosalind Franklin University of Medicine and Science

“Effectiveness of Communication During ICU to Ward Transfer and Association with Medical ICU Readmission”

Cole Hirschfeld

Weill Cornell Medical College

“The Role of Diagnostic Bone Biopsies in the Management of Osteomyelitis”

Farah Hussain

University of Cincinnati College of Medicine

“Better Understanding Clinical Deterioration in a Children’s Hospital”

Longitudinal Program

Monisha Bhatia

Vanderbilt University School of Medicine

“Using Electronic Medical Record Phenotypic Data to Predict Discharge Destination”

Victor Ekuta

University of California, San Diego School of Medicine

“Reducing CAUTI with Noninvasive UC Alternatives and Measure-vention”

Yun Li

Geisel School of Medicine at Dartmouth

“Developing and implementing clinical pathway(s) for hospitalized injection drug users due to injection-related infection sequelae”

Learn more about the Student Hospitalist Scholar Grant at hospitalmedicine.org/scholargrant.

SPARK ONE: A tool to teach residents

SPARK ONE is a comprehensive, online self-assessment tool created specifically for hospital medicine professionals. 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 can be utilized as a training mechanism for resident education on hospital medicine.

As a benefit of SHM membership, residents will receive a free subscription. SPARK ONE provides in-depth review of the following content areas:

• Cardiology
• Pulmonary Disease and Critical Care Medicine
• Gastroenterology and Hepatology
• Nephrology and Urology
• Endocrinology
• Hematology and Oncology
• Neurology
• Allergy, Immunology, Dermatology, Rheumatology and Transitions in Care
• Palliative Care, Medical Ethics and Decision-making
• Perioperative Medicine and Consultative Co-management
• Patient Safety
• Quality, Cost and Clinical Reasoning

“SPARK ONE provides a unique platform for academic institutions, engaging learners in directed learning sessions, reinforcing teaching points as we encounter specific conditions.” – Rachel E. Thompson, MD, MPH, SFHM

Visit hospitalmedicine.org/sparkone to learn more.
 

Sharpen your coding with the updated CODE-H

SHM’s Coding Optimally by Documenting Effectively for Hospitalists (CODE-H) has launched an updated program with all new content. It will now include eight recorded webinar sessions presented by expert faculty, downloadable resources, and an interactive discussion forum through the Hospital Medicine Exchange (HMX), enabling participants to ask questions and learn the most relevant best practices.

Following each webinar, learners will have the opportunity to complete an evaluation to redeem continuing medical education credits.

Webinars in the series include:
 

• E/M Basics Part I
• E/M Basics Part II
• Utilizing Other Providers in Your Practice
• EMR and Mitigating Risk
• Putting Time into Critical Care Documentation
• Time Based Services
• Navigating the Rules for Hospitalist Visits
• Challenges of Concurrent Care

To purchase CODE-H, visit hospitalmedicine.org/CODEH. If you have questions about the new program, please contact [email protected].
 

Set yourself apart as a Fellow in Hospital Medicine

The Fellow in Hospital Medicine (FHM) designation signals your commitment to the hospital medicine specialty and dedication to quality improvement and patient safety. This designation is available for hospital medicine practitioners, including practice administrators, nurse practitioners, and physician assistants. If you meet the prerequisites and complete the requirements, which are rooted in the Core Competencies in Hospital Medicine, you can apply for this prestigious designation and join more than 1,100 FHMs who are dedicated to the field of hospital medicine. Learn more and apply at hospitalmedicine.org/fellow.

New guide & modules on multimodal pain strategies for postoperative pain management

Pain management can pose multiple challenges in the acute care setting for hospitalists and front-line prescribers. While their first priority is to optimally manage pain in their patients, they also face the challenges of treating diverse patient populations, managing patient expectations, and considering how pain control and perceptions affect Hospital Consumer Assessment of Healthcare Providers and Systems scores. Furthermore, because of the ongoing opioid epidemic, prescribers must ensure that pain is managed responsibly and ethically.

To address these issues, SHM developed a guide to address how to work in an interdisciplinary team, identify impediments to implementation, and provide examples of appropriate pain management. In accompaniment with this Multimodal Pain Strategies Guide for Postoperative Pain Management, there are three modules presented by the authors which supplement the electronic guide.

To download the guide or view the modules, visit hospitalmedicine.org/pain.
 

Proven excellence through a unique education style: Academic Hospitalist Academy

Don’t miss the eighth annual Academic Hospitalist Academy (AHA), Sept. 25-28, 2017, at the Lakeway Resort and Spa in Austin, Texas. AHA attendees experience an energizing, interactive learning environment featuring didactics, small-group exercise and skill-building breakout sessions. Each full day of learning is facilitated by leading clinician-educators, hospitalist researchers, and clinical administrators in a 1 to 10 faculty to student ratio.

The Principal Goals of the Academy are to:

• Develop junior academic hospitalists as the premier teachers and educational leaders at their institutions
• Help academic hospitalists develop scholarly work and increase scholarly output
• Enhance awareness of the value of quality improvement and patient safety work
• Support academic promotion of all attendees

Don’t miss out on this unique, hands-on experience. Register before July 18, 2017, to receive the early-bird rates. Visit academichospitalist.org to learn more.
 

Choosing Wisely Case Study compendium now available

The Choosing Wisely Case Study Competition, hosted by SHM, sought submissions from hospitalists on innovative improvement initiatives implemented in their respective institutions. These initiatives reflect and promote movement toward reducing unnecessary medical tests and procedures and changing a culture that dictates, “More care is better care.”

Submissions were judged by the Choosing Wisely Subcommittee, a panel of SHM members, under adult and pediatric categories. One grand prize winner and three honorable mentions were selected from these categories. The compendium includes these case studies along with additional exemplary submissions.

View the Choosing Wisely Case Study Compendium at hospitalmedicine.org/choosingwisely.
 

Strengthen your interactions with the 5 Rs of Cultural Humility

Look inside this issue for your 5 Rs of Cultural Humility pocket card. It can be easily referenced on rounds and shared with colleagues. We hope to achieve heightened awareness of effective interactions. In addition to the definitions of each of the Rs, the card features questions to ask yourself before, during, and after every interaction to aid in attaining cultural humility.

For more information, visit hospitalmedicine.org/5Rs.

Brett Radler is communications specialist at the Society of Hospital Medicine.

HM17 On Demand now available

Couldn’t make it to Las Vegas for SHM’s annual meeting, Hospital Medicine 2017? HM17 On Demand gives you access to over 80 online audio and slide recordings from the hottest tracks, including clinical updates, rapid fire, pediatrics, comanagement, quality, and high-value care.

Additionally, you can earn up to 70 American Medical Association Physician Recognition Award Category 1 Credit(s) and up to 30 American Board of Internal Medicine Maintenance of Certification credits. HM17 attendees can also benefit by earning additional credits on the sessions you missed out on.

To easily access content through SHM’s Learning Portal, visit shmlearningportal.org/hm17-demand to learn more.
 

Chapter Excellence Awards

SHM is proud to recognize outstanding chapters for the fourth annual Chapter Excellence Awards. Each year, chapters strive to demonstrate growth, sustenance, and innovation within their chapter activities.

View more at www.hospitalmedicine.org/chapterexcellence. Please join SHM in congratulating the following chapters on their success!

Silver Chapters

Boston Association of Academic Hospital Medicine (BAAHM)

Charlotte Metro Area

Houston

Kentucky

Los Angeles

Minnesota

North Jersey

Pacific Northwest

Philadelphia Tri-State

Rocky Mountain

San Francisco Bay

South Central PA

Gold Chapters

New Mexico

Wiregrass

Platinum Chapters

IowaMaryland

Michigan

NYC/Westchester

St. Louis

Outstanding Chapter of the Year

Michigan

Rising Star Chapter

Wiregrass
 

Student Hospitalist Scholar grant winners

SHM’s Student Hospitalist Scholar Grant provides funds with which medical students can conduct mentored scholarly projects related to quality improvement and patient safety in the field of hospital medicine. The program offers a summer and a longitudinal option.

Congratulations to the 2017-2018 Student Hospitalist Scholar Grant recipients:Summer Program

Anton Garazha

Rosalind Franklin University of Medicine and Science

“Effectiveness of Communication During ICU to Ward Transfer and Association with Medical ICU Readmission”

Cole Hirschfeld

Weill Cornell Medical College

“The Role of Diagnostic Bone Biopsies in the Management of Osteomyelitis”

Farah Hussain

University of Cincinnati College of Medicine

“Better Understanding Clinical Deterioration in a Children’s Hospital”

Longitudinal Program

Monisha Bhatia

Vanderbilt University School of Medicine

“Using Electronic Medical Record Phenotypic Data to Predict Discharge Destination”

Victor Ekuta

University of California, San Diego School of Medicine

“Reducing CAUTI with Noninvasive UC Alternatives and Measure-vention”

Yun Li

Geisel School of Medicine at Dartmouth

“Developing and implementing clinical pathway(s) for hospitalized injection drug users due to injection-related infection sequelae”

Learn more about the Student Hospitalist Scholar Grant at hospitalmedicine.org/scholargrant.

SPARK ONE: A tool to teach residents

SPARK ONE is a comprehensive, online self-assessment tool created specifically for hospital medicine professionals. 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 can be utilized as a training mechanism for resident education on hospital medicine.

As a benefit of SHM membership, residents will receive a free subscription. SPARK ONE provides in-depth review of the following content areas:

• Cardiology
• Pulmonary Disease and Critical Care Medicine
• Gastroenterology and Hepatology
• Nephrology and Urology
• Endocrinology
• Hematology and Oncology
• Neurology
• Allergy, Immunology, Dermatology, Rheumatology and Transitions in Care
• Palliative Care, Medical Ethics and Decision-making
• Perioperative Medicine and Consultative Co-management
• Patient Safety
• Quality, Cost and Clinical Reasoning

“SPARK ONE provides a unique platform for academic institutions, engaging learners in directed learning sessions, reinforcing teaching points as we encounter specific conditions.” – Rachel E. Thompson, MD, MPH, SFHM

Visit hospitalmedicine.org/sparkone to learn more.
 

Sharpen your coding with the updated CODE-H

SHM’s Coding Optimally by Documenting Effectively for Hospitalists (CODE-H) has launched an updated program with all new content. It will now include eight recorded webinar sessions presented by expert faculty, downloadable resources, and an interactive discussion forum through the Hospital Medicine Exchange (HMX), enabling participants to ask questions and learn the most relevant best practices.

Following each webinar, learners will have the opportunity to complete an evaluation to redeem continuing medical education credits.

Webinars in the series include:
 

• E/M Basics Part I
• E/M Basics Part II
• Utilizing Other Providers in Your Practice
• EMR and Mitigating Risk
• Putting Time into Critical Care Documentation
• Time Based Services
• Navigating the Rules for Hospitalist Visits
• Challenges of Concurrent Care

To purchase CODE-H, visit hospitalmedicine.org/CODEH. If you have questions about the new program, please contact [email protected].
 

Set yourself apart as a Fellow in Hospital Medicine

The Fellow in Hospital Medicine (FHM) designation signals your commitment to the hospital medicine specialty and dedication to quality improvement and patient safety. This designation is available for hospital medicine practitioners, including practice administrators, nurse practitioners, and physician assistants. If you meet the prerequisites and complete the requirements, which are rooted in the Core Competencies in Hospital Medicine, you can apply for this prestigious designation and join more than 1,100 FHMs who are dedicated to the field of hospital medicine. Learn more and apply at hospitalmedicine.org/fellow.

New guide & modules on multimodal pain strategies for postoperative pain management

Pain management can pose multiple challenges in the acute care setting for hospitalists and front-line prescribers. While their first priority is to optimally manage pain in their patients, they also face the challenges of treating diverse patient populations, managing patient expectations, and considering how pain control and perceptions affect Hospital Consumer Assessment of Healthcare Providers and Systems scores. Furthermore, because of the ongoing opioid epidemic, prescribers must ensure that pain is managed responsibly and ethically.

To address these issues, SHM developed a guide to address how to work in an interdisciplinary team, identify impediments to implementation, and provide examples of appropriate pain management. In accompaniment with this Multimodal Pain Strategies Guide for Postoperative Pain Management, there are three modules presented by the authors which supplement the electronic guide.

To download the guide or view the modules, visit hospitalmedicine.org/pain.
 

Proven excellence through a unique education style: Academic Hospitalist Academy

Don’t miss the eighth annual Academic Hospitalist Academy (AHA), Sept. 25-28, 2017, at the Lakeway Resort and Spa in Austin, Texas. AHA attendees experience an energizing, interactive learning environment featuring didactics, small-group exercise and skill-building breakout sessions. Each full day of learning is facilitated by leading clinician-educators, hospitalist researchers, and clinical administrators in a 1 to 10 faculty to student ratio.

The Principal Goals of the Academy are to:

• Develop junior academic hospitalists as the premier teachers and educational leaders at their institutions
• Help academic hospitalists develop scholarly work and increase scholarly output
• Enhance awareness of the value of quality improvement and patient safety work
• Support academic promotion of all attendees

Don’t miss out on this unique, hands-on experience. Register before July 18, 2017, to receive the early-bird rates. Visit academichospitalist.org to learn more.
 

Choosing Wisely Case Study compendium now available

The Choosing Wisely Case Study Competition, hosted by SHM, sought submissions from hospitalists on innovative improvement initiatives implemented in their respective institutions. These initiatives reflect and promote movement toward reducing unnecessary medical tests and procedures and changing a culture that dictates, “More care is better care.”

Submissions were judged by the Choosing Wisely Subcommittee, a panel of SHM members, under adult and pediatric categories. One grand prize winner and three honorable mentions were selected from these categories. The compendium includes these case studies along with additional exemplary submissions.

View the Choosing Wisely Case Study Compendium at hospitalmedicine.org/choosingwisely.
 

Strengthen your interactions with the 5 Rs of Cultural Humility

Look inside this issue for your 5 Rs of Cultural Humility pocket card. It can be easily referenced on rounds and shared with colleagues. We hope to achieve heightened awareness of effective interactions. In addition to the definitions of each of the Rs, the card features questions to ask yourself before, during, and after every interaction to aid in attaining cultural humility.

For more information, visit hospitalmedicine.org/5Rs.

Brett Radler is communications specialist at the Society of Hospital Medicine.

HM17 On Demand now available

Couldn’t make it to Las Vegas for SHM’s annual meeting, Hospital Medicine 2017? HM17 On Demand gives you access to over 80 online audio and slide recordings from the hottest tracks, including clinical updates, rapid fire, pediatrics, comanagement, quality, and high-value care.

Additionally, you can earn up to 70 American Medical Association Physician Recognition Award Category 1 Credit(s) and up to 30 American Board of Internal Medicine Maintenance of Certification credits. HM17 attendees can also benefit by earning additional credits on the sessions you missed out on.

To easily access content through SHM’s Learning Portal, visit shmlearningportal.org/hm17-demand to learn more.
 

Chapter Excellence Awards

SHM is proud to recognize outstanding chapters for the fourth annual Chapter Excellence Awards. Each year, chapters strive to demonstrate growth, sustenance, and innovation within their chapter activities.

View more at www.hospitalmedicine.org/chapterexcellence. Please join SHM in congratulating the following chapters on their success!

Silver Chapters

Boston Association of Academic Hospital Medicine (BAAHM)

Charlotte Metro Area

Houston

Kentucky

Los Angeles

Minnesota

North Jersey

Pacific Northwest

Philadelphia Tri-State

Rocky Mountain

San Francisco Bay

South Central PA

Gold Chapters

New Mexico

Wiregrass

Platinum Chapters

IowaMaryland

Michigan

NYC/Westchester

St. Louis

Outstanding Chapter of the Year

Michigan

Rising Star Chapter

Wiregrass
 

Student Hospitalist Scholar grant winners

SHM’s Student Hospitalist Scholar Grant provides funds with which medical students can conduct mentored scholarly projects related to quality improvement and patient safety in the field of hospital medicine. The program offers a summer and a longitudinal option.

Congratulations to the 2017-2018 Student Hospitalist Scholar Grant recipients:Summer Program

Anton Garazha

Rosalind Franklin University of Medicine and Science

“Effectiveness of Communication During ICU to Ward Transfer and Association with Medical ICU Readmission”

Cole Hirschfeld

Weill Cornell Medical College

“The Role of Diagnostic Bone Biopsies in the Management of Osteomyelitis”

Farah Hussain

University of Cincinnati College of Medicine

“Better Understanding Clinical Deterioration in a Children’s Hospital”

Longitudinal Program

Monisha Bhatia

Vanderbilt University School of Medicine

“Using Electronic Medical Record Phenotypic Data to Predict Discharge Destination”

Victor Ekuta

University of California, San Diego School of Medicine

“Reducing CAUTI with Noninvasive UC Alternatives and Measure-vention”

Yun Li

Geisel School of Medicine at Dartmouth

“Developing and implementing clinical pathway(s) for hospitalized injection drug users due to injection-related infection sequelae”

Learn more about the Student Hospitalist Scholar Grant at hospitalmedicine.org/scholargrant.

SPARK ONE: A tool to teach residents

SPARK ONE is a comprehensive, online self-assessment tool created specifically for hospital medicine professionals. 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 can be utilized as a training mechanism for resident education on hospital medicine.

As a benefit of SHM membership, residents will receive a free subscription. SPARK ONE provides in-depth review of the following content areas:

• Cardiology
• Pulmonary Disease and Critical Care Medicine
• Gastroenterology and Hepatology
• Nephrology and Urology
• Endocrinology
• Hematology and Oncology
• Neurology
• Allergy, Immunology, Dermatology, Rheumatology and Transitions in Care
• Palliative Care, Medical Ethics and Decision-making
• Perioperative Medicine and Consultative Co-management
• Patient Safety
• Quality, Cost and Clinical Reasoning

“SPARK ONE provides a unique platform for academic institutions, engaging learners in directed learning sessions, reinforcing teaching points as we encounter specific conditions.” – Rachel E. Thompson, MD, MPH, SFHM

Visit hospitalmedicine.org/sparkone to learn more.
 

Sharpen your coding with the updated CODE-H

SHM’s Coding Optimally by Documenting Effectively for Hospitalists (CODE-H) has launched an updated program with all new content. It will now include eight recorded webinar sessions presented by expert faculty, downloadable resources, and an interactive discussion forum through the Hospital Medicine Exchange (HMX), enabling participants to ask questions and learn the most relevant best practices.

Following each webinar, learners will have the opportunity to complete an evaluation to redeem continuing medical education credits.

Webinars in the series include:
 

• E/M Basics Part I
• E/M Basics Part II
• Utilizing Other Providers in Your Practice
• EMR and Mitigating Risk
• Putting Time into Critical Care Documentation
• Time Based Services
• Navigating the Rules for Hospitalist Visits
• Challenges of Concurrent Care

To purchase CODE-H, visit hospitalmedicine.org/CODEH. If you have questions about the new program, please contact [email protected].
 

Set yourself apart as a Fellow in Hospital Medicine

The Fellow in Hospital Medicine (FHM) designation signals your commitment to the hospital medicine specialty and dedication to quality improvement and patient safety. This designation is available for hospital medicine practitioners, including practice administrators, nurse practitioners, and physician assistants. If you meet the prerequisites and complete the requirements, which are rooted in the Core Competencies in Hospital Medicine, you can apply for this prestigious designation and join more than 1,100 FHMs who are dedicated to the field of hospital medicine. Learn more and apply at hospitalmedicine.org/fellow.

New guide & modules on multimodal pain strategies for postoperative pain management

Pain management can pose multiple challenges in the acute care setting for hospitalists and front-line prescribers. While their first priority is to optimally manage pain in their patients, they also face the challenges of treating diverse patient populations, managing patient expectations, and considering how pain control and perceptions affect Hospital Consumer Assessment of Healthcare Providers and Systems scores. Furthermore, because of the ongoing opioid epidemic, prescribers must ensure that pain is managed responsibly and ethically.

To address these issues, SHM developed a guide to address how to work in an interdisciplinary team, identify impediments to implementation, and provide examples of appropriate pain management. In accompaniment with this Multimodal Pain Strategies Guide for Postoperative Pain Management, there are three modules presented by the authors which supplement the electronic guide.

To download the guide or view the modules, visit hospitalmedicine.org/pain.
 

Proven excellence through a unique education style: Academic Hospitalist Academy

Don’t miss the eighth annual Academic Hospitalist Academy (AHA), Sept. 25-28, 2017, at the Lakeway Resort and Spa in Austin, Texas. AHA attendees experience an energizing, interactive learning environment featuring didactics, small-group exercise and skill-building breakout sessions. Each full day of learning is facilitated by leading clinician-educators, hospitalist researchers, and clinical administrators in a 1 to 10 faculty to student ratio.

The Principal Goals of the Academy are to:

• Develop junior academic hospitalists as the premier teachers and educational leaders at their institutions
• Help academic hospitalists develop scholarly work and increase scholarly output
• Enhance awareness of the value of quality improvement and patient safety work
• Support academic promotion of all attendees

Don’t miss out on this unique, hands-on experience. Register before July 18, 2017, to receive the early-bird rates. Visit academichospitalist.org to learn more.
 

Choosing Wisely Case Study compendium now available

The Choosing Wisely Case Study Competition, hosted by SHM, sought submissions from hospitalists on innovative improvement initiatives implemented in their respective institutions. These initiatives reflect and promote movement toward reducing unnecessary medical tests and procedures and changing a culture that dictates, “More care is better care.”

Submissions were judged by the Choosing Wisely Subcommittee, a panel of SHM members, under adult and pediatric categories. One grand prize winner and three honorable mentions were selected from these categories. The compendium includes these case studies along with additional exemplary submissions.

View the Choosing Wisely Case Study Compendium at hospitalmedicine.org/choosingwisely.
 

Strengthen your interactions with the 5 Rs of Cultural Humility

Look inside this issue for your 5 Rs of Cultural Humility pocket card. It can be easily referenced on rounds and shared with colleagues. We hope to achieve heightened awareness of effective interactions. In addition to the definitions of each of the Rs, the card features questions to ask yourself before, during, and after every interaction to aid in attaining cultural humility.

For more information, visit hospitalmedicine.org/5Rs.

Brett Radler is communications specialist at the Society of Hospital Medicine.

Presenters

Tracy Cardin, ACNP, SFHM ; Emilie Thornhill, PA-C
 

Session summary

The Nurse Practitioner and Physician Assistant (NP/PA) special interest forum at HM17 drew more than 60 providers, including NPs, PAs, and physicians.

Emilie Thornhill, a certified PA and chair of the NP/PA Committee, and Tracy Cardin, SHM board member, updated the attendees regarding the work of the NP/PA committee over the last year. The committee has created a comprehensive “NP/PA Toolkit,” which was developed over the last 2 years in response to common inquiries about deployment and integration of NPs and PAs into Hospital Medicine practice groups.

• Benchmarking Surveys related to NP/PA burnout, including aspects of protected time, engagement, and workload; scheduling and deployment models; and NP/PA designation as faculty or staff.
• Increased utilization and engagement with HMX as a platform for sharing ideas and success stories to increase HM NP/PA visibility.
• Creation of a “Bizarre Bylaws Blog” to disseminate best practices and improve hospital bylaws through innovative storytelling of antiquated bylaws.
• Improved NP and PA participation and engagement with local chapters.

Key takeaways for HM

• An NP/PA Toolkit resource to be posted on the SHM website.
• The NP/PA committee will transition to a Special Interest Group over the next year.
• Hospital Medicine Exchange (HMX) engagement and participation are encouraged.
• An “Implementation and Optimization Project” to help improve workforce development is pending for the coming year.

Nicolas Houghton is an NP hospitalist in Cleveland and an editorial board member of The Hospitalist.

Presenters

Tracy Cardin, ACNP, SFHM ; Emilie Thornhill, PA-C
 

Session summary

The Nurse Practitioner and Physician Assistant (NP/PA) special interest forum at HM17 drew more than 60 providers, including NPs, PAs, and physicians.

Emilie Thornhill, a certified PA and chair of the NP/PA Committee, and Tracy Cardin, SHM board member, updated the attendees regarding the work of the NP/PA committee over the last year. The committee has created a comprehensive “NP/PA Toolkit,” which was developed over the last 2 years in response to common inquiries about deployment and integration of NPs and PAs into Hospital Medicine practice groups.

• Benchmarking Surveys related to NP/PA burnout, including aspects of protected time, engagement, and workload; scheduling and deployment models; and NP/PA designation as faculty or staff.
• Increased utilization and engagement with HMX as a platform for sharing ideas and success stories to increase HM NP/PA visibility.
• Creation of a “Bizarre Bylaws Blog” to disseminate best practices and improve hospital bylaws through innovative storytelling of antiquated bylaws.
• Improved NP and PA participation and engagement with local chapters.

Key takeaways for HM

• An NP/PA Toolkit resource to be posted on the SHM website.
• The NP/PA committee will transition to a Special Interest Group over the next year.
• Hospital Medicine Exchange (HMX) engagement and participation are encouraged.
• An “Implementation and Optimization Project” to help improve workforce development is pending for the coming year.

Nicolas Houghton is an NP hospitalist in Cleveland and an editorial board member of The Hospitalist.

Presenters

Tracy Cardin, ACNP, SFHM ; Emilie Thornhill, PA-C
 

Session summary

The Nurse Practitioner and Physician Assistant (NP/PA) special interest forum at HM17 drew more than 60 providers, including NPs, PAs, and physicians.

Emilie Thornhill, a certified PA and chair of the NP/PA Committee, and Tracy Cardin, SHM board member, updated the attendees regarding the work of the NP/PA committee over the last year. The committee has created a comprehensive “NP/PA Toolkit,” which was developed over the last 2 years in response to common inquiries about deployment and integration of NPs and PAs into Hospital Medicine practice groups.

• Benchmarking Surveys related to NP/PA burnout, including aspects of protected time, engagement, and workload; scheduling and deployment models; and NP/PA designation as faculty or staff.
• Increased utilization and engagement with HMX as a platform for sharing ideas and success stories to increase HM NP/PA visibility.
• Creation of a “Bizarre Bylaws Blog” to disseminate best practices and improve hospital bylaws through innovative storytelling of antiquated bylaws.
• Improved NP and PA participation and engagement with local chapters.

Key takeaways for HM

• An NP/PA Toolkit resource to be posted on the SHM website.
• The NP/PA committee will transition to a Special Interest Group over the next year.
• Hospital Medicine Exchange (HMX) engagement and participation are encouraged.
• An “Implementation and Optimization Project” to help improve workforce development is pending for the coming year.

Nicolas Houghton is an NP hospitalist in Cleveland and an editorial board member of The Hospitalist.

WASHINGTON – Researchers have devised a program that can predict severe sepsis or septic shock about 12-30 hours in advance of its onset in hospitalized patients, a feat they hope will allow them to apply early interventions to stave off impending sepsis.

“We’d love to see a change in sepsis mortality. Will earlier recognition and implementation of the sepsis bundle – fluids, antibiotics, etc. – improve outcomes?” wondered Heather M. Giannini, MD, in a video interview at an international conference of the American Thoracic Society.

The computer program works by monitoring all the data that enter a patient’s electronic health record during hospitalization. Researchers developed it and designed it specifically for inpatients who are not in the intensive care unit or emergency department.

Results from initial testing during October-December 2015 in 10,448 patients hospitalized at one of three participating Philadelphia hospitals showed the program predicted subsequent severe sepsis or septic shock with a sensitivity of 26% and a specificity of 98%, reported Dr. Giannini, a researcher in the Center for Evidence-Based Practice at the University of Pennsylvania in Philadelphia. Analysis also showed a positive likelihood ratio of 13 for severe sepsis or septic shock actually occurring following an alert generated by the computer program, a level indicating a “very strong” ability to predict sepsis, she said.

Dr. Giannini and her associates developed the prediction program using a technique called “computational machine learning,” an alternative to standard logistic regression modeling that is better suited to analyzing large data sets and can better integrate outlier data points. They took EHR data for all non-ICU, non-ED inpatients at three Philadelphia hospitals during a 3-year period during 2011-2014 and had the program focus particularly on EHR data gleaned from the nearly 1,000 patients who developed severe sepsis or septic shock during the 12 hours preceding the start of these sepsis events. The analysis identified patients as having developed severe sepsis or shock if they had a blood draw positive for infection at the same time as having a blood lactate level above 2.2 mmol/L or a systolic blood pressure below 90 mm Hg.

To create the algorithm the machine-learning device compared the EHR entries for patients who developed severe sepsis or septic shock with EHR data from patients who did not, a process that involved hundred of thousands of data points, Dr. Giannini said. This identified 587 individual types of relevant EHR data entries and ranked them from most important to least important. Important, novel determinants of impending severe sepsis identified this way included anion gap, blood urea nitrogen, and platelet count. The development process also confirmed an important role for many classic markers of septic shock, such as respiration rate, heart rate, and temperature.

The researchers designed the algorithm to have a moderate level of sensitivity to avoid “alert fatigue” from generating too many alarms for impending severe sepsis. Their goal was for clinicians to receive no more than about 10 alerts per day for each hospital.

“We are satisfied with the sensitivity. We felt it was better to have too few alerts rather than overwhelm clinicians. About 10 alerts a day is reasonable,” Dr. Giannini explained. During initial 2015 testing, the system generated a daily average of 11 alerts.

[email protected]

On Twitter @mitchelzoler

WASHINGTON – Researchers have devised a program that can predict severe sepsis or septic shock about 12-30 hours in advance of its onset in hospitalized patients, a feat they hope will allow them to apply early interventions to stave off impending sepsis.

“We’d love to see a change in sepsis mortality. Will earlier recognition and implementation of the sepsis bundle – fluids, antibiotics, etc. – improve outcomes?” wondered Heather M. Giannini, MD, in a video interview at an international conference of the American Thoracic Society.

The computer program works by monitoring all the data that enter a patient’s electronic health record during hospitalization. Researchers developed it and designed it specifically for inpatients who are not in the intensive care unit or emergency department.

Results from initial testing during October-December 2015 in 10,448 patients hospitalized at one of three participating Philadelphia hospitals showed the program predicted subsequent severe sepsis or septic shock with a sensitivity of 26% and a specificity of 98%, reported Dr. Giannini, a researcher in the Center for Evidence-Based Practice at the University of Pennsylvania in Philadelphia. Analysis also showed a positive likelihood ratio of 13 for severe sepsis or septic shock actually occurring following an alert generated by the computer program, a level indicating a “very strong” ability to predict sepsis, she said.

Dr. Giannini and her associates developed the prediction program using a technique called “computational machine learning,” an alternative to standard logistic regression modeling that is better suited to analyzing large data sets and can better integrate outlier data points. They took EHR data for all non-ICU, non-ED inpatients at three Philadelphia hospitals during a 3-year period during 2011-2014 and had the program focus particularly on EHR data gleaned from the nearly 1,000 patients who developed severe sepsis or septic shock during the 12 hours preceding the start of these sepsis events. The analysis identified patients as having developed severe sepsis or shock if they had a blood draw positive for infection at the same time as having a blood lactate level above 2.2 mmol/L or a systolic blood pressure below 90 mm Hg.

To create the algorithm the machine-learning device compared the EHR entries for patients who developed severe sepsis or septic shock with EHR data from patients who did not, a process that involved hundred of thousands of data points, Dr. Giannini said. This identified 587 individual types of relevant EHR data entries and ranked them from most important to least important. Important, novel determinants of impending severe sepsis identified this way included anion gap, blood urea nitrogen, and platelet count. The development process also confirmed an important role for many classic markers of septic shock, such as respiration rate, heart rate, and temperature.

The researchers designed the algorithm to have a moderate level of sensitivity to avoid “alert fatigue” from generating too many alarms for impending severe sepsis. Their goal was for clinicians to receive no more than about 10 alerts per day for each hospital.

“We are satisfied with the sensitivity. We felt it was better to have too few alerts rather than overwhelm clinicians. About 10 alerts a day is reasonable,” Dr. Giannini explained. During initial 2015 testing, the system generated a daily average of 11 alerts.

[email protected]

On Twitter @mitchelzoler

WASHINGTON – Researchers have devised a program that can predict severe sepsis or septic shock about 12-30 hours in advance of its onset in hospitalized patients, a feat they hope will allow them to apply early interventions to stave off impending sepsis.

“We’d love to see a change in sepsis mortality. Will earlier recognition and implementation of the sepsis bundle – fluids, antibiotics, etc. – improve outcomes?” wondered Heather M. Giannini, MD, in a video interview at an international conference of the American Thoracic Society.

The computer program works by monitoring all the data that enter a patient’s electronic health record during hospitalization. Researchers developed it and designed it specifically for inpatients who are not in the intensive care unit or emergency department.

Results from initial testing during October-December 2015 in 10,448 patients hospitalized at one of three participating Philadelphia hospitals showed the program predicted subsequent severe sepsis or septic shock with a sensitivity of 26% and a specificity of 98%, reported Dr. Giannini, a researcher in the Center for Evidence-Based Practice at the University of Pennsylvania in Philadelphia. Analysis also showed a positive likelihood ratio of 13 for severe sepsis or septic shock actually occurring following an alert generated by the computer program, a level indicating a “very strong” ability to predict sepsis, she said.

Dr. Giannini and her associates developed the prediction program using a technique called “computational machine learning,” an alternative to standard logistic regression modeling that is better suited to analyzing large data sets and can better integrate outlier data points. They took EHR data for all non-ICU, non-ED inpatients at three Philadelphia hospitals during a 3-year period during 2011-2014 and had the program focus particularly on EHR data gleaned from the nearly 1,000 patients who developed severe sepsis or septic shock during the 12 hours preceding the start of these sepsis events. The analysis identified patients as having developed severe sepsis or shock if they had a blood draw positive for infection at the same time as having a blood lactate level above 2.2 mmol/L or a systolic blood pressure below 90 mm Hg.

To create the algorithm the machine-learning device compared the EHR entries for patients who developed severe sepsis or septic shock with EHR data from patients who did not, a process that involved hundred of thousands of data points, Dr. Giannini said. This identified 587 individual types of relevant EHR data entries and ranked them from most important to least important. Important, novel determinants of impending severe sepsis identified this way included anion gap, blood urea nitrogen, and platelet count. The development process also confirmed an important role for many classic markers of septic shock, such as respiration rate, heart rate, and temperature.

The researchers designed the algorithm to have a moderate level of sensitivity to avoid “alert fatigue” from generating too many alarms for impending severe sepsis. Their goal was for clinicians to receive no more than about 10 alerts per day for each hospital.

“We are satisfied with the sensitivity. We felt it was better to have too few alerts rather than overwhelm clinicians. About 10 alerts a day is reasonable,” Dr. Giannini explained. During initial 2015 testing, the system generated a daily average of 11 alerts.

[email protected]

On Twitter @mitchelzoler

Presenter

Timothy Kasprzak, MD, MBA
 

Session summary

“What imaging study should I order for this patient?” is a question that comes up frequently in the hospital. Dr. Kasprzak, the director of abdominopelvic and oncologic imaging at Case Western MetroHealth, Cleveland, offered some practical advice for inpatient clinicians during a rapid-fire session at HM17.

Key takeaways for HM

• Utilize appropriate use criteria (such as offered by the ACR) for choosing the most worthwhile imaging study.

• Give relevant clinical history in your order to help the radiologist narrow the differential (and to help prevent the “clinically correlate” phrase as much as possible).

• Consider the risk/benefit of contrast use for all patients getting CT or MRI studies.

• Avoid the use of inpatient PET scans, except for very specific indications (such as obscure infections).

Dr. Sehgal is a hospitalist at the South Texas Veterans Health Care System in San Antonio, an associate professor of medicine at University of Texas Health-San Antonio, and a an editorial board member of The Hospitalist.

Presenter

Timothy Kasprzak, MD, MBA
 

Session summary

“What imaging study should I order for this patient?” is a question that comes up frequently in the hospital. Dr. Kasprzak, the director of abdominopelvic and oncologic imaging at Case Western MetroHealth, Cleveland, offered some practical advice for inpatient clinicians during a rapid-fire session at HM17.

Key takeaways for HM

• Utilize appropriate use criteria (such as offered by the ACR) for choosing the most worthwhile imaging study.

• Give relevant clinical history in your order to help the radiologist narrow the differential (and to help prevent the “clinically correlate” phrase as much as possible).

• Consider the risk/benefit of contrast use for all patients getting CT or MRI studies.

• Avoid the use of inpatient PET scans, except for very specific indications (such as obscure infections).

Dr. Sehgal is a hospitalist at the South Texas Veterans Health Care System in San Antonio, an associate professor of medicine at University of Texas Health-San Antonio, and a an editorial board member of The Hospitalist.

Presenter

Timothy Kasprzak, MD, MBA
 

Session summary

“What imaging study should I order for this patient?” is a question that comes up frequently in the hospital. Dr. Kasprzak, the director of abdominopelvic and oncologic imaging at Case Western MetroHealth, Cleveland, offered some practical advice for inpatient clinicians during a rapid-fire session at HM17.

Key takeaways for HM

• Utilize appropriate use criteria (such as offered by the ACR) for choosing the most worthwhile imaging study.

• Give relevant clinical history in your order to help the radiologist narrow the differential (and to help prevent the “clinically correlate” phrase as much as possible).

• Consider the risk/benefit of contrast use for all patients getting CT or MRI studies.

• Avoid the use of inpatient PET scans, except for very specific indications (such as obscure infections).

Dr. Sehgal is a hospitalist at the South Texas Veterans Health Care System in San Antonio, an associate professor of medicine at University of Texas Health-San Antonio, and a an editorial board member of The Hospitalist.

When it comes to developing, maintaining, and growing an effective hospital medicine team, James W. Levy, PA-C, SFHM, certified physician assistant and managing partner of iNDIGO Health Partners, credits much of the company’s success to a decision to purchase a group SHM membership for its hospital medicine team. Recognizing the value that membership brings, it was an easy decision to extend a group membership to iNDIGO’s hospital medicine team.

“As a company, we are strong supporters of SHM and its mission,” Mr. Levy said. “This seemed like the best way we could support SHM and allow all our providers access to all the personal and professional benefits of SHM membership.”

Brett Radler is SHM’s communications specialist.

When it comes to developing, maintaining, and growing an effective hospital medicine team, James W. Levy, PA-C, SFHM, certified physician assistant and managing partner of iNDIGO Health Partners, credits much of the company’s success to a decision to purchase a group SHM membership for its hospital medicine team. Recognizing the value that membership brings, it was an easy decision to extend a group membership to iNDIGO’s hospital medicine team.

“As a company, we are strong supporters of SHM and its mission,” Mr. Levy said. “This seemed like the best way we could support SHM and allow all our providers access to all the personal and professional benefits of SHM membership.”

Brett Radler is SHM’s communications specialist.

When it comes to developing, maintaining, and growing an effective hospital medicine team, James W. Levy, PA-C, SFHM, certified physician assistant and managing partner of iNDIGO Health Partners, credits much of the company’s success to a decision to purchase a group SHM membership for its hospital medicine team. Recognizing the value that membership brings, it was an easy decision to extend a group membership to iNDIGO’s hospital medicine team.

“As a company, we are strong supporters of SHM and its mission,” Mr. Levy said. “This seemed like the best way we could support SHM and allow all our providers access to all the personal and professional benefits of SHM membership.”

Brett Radler is SHM’s communications specialist.

PARIS – Just when the aldosterone receptor antagonists spironolactone and eplerenone received official recognition in the 2017 U.S. heart failure guidelines as the only drug class that benefits patients with heart failure with preserved ejection fraction (HFpEF), a new post-hoc analysis of the pivotal evidence suggests the benefit is mostly in women, with little benefit to men.

The new analysis used data collected from TOPCAT (Treatment of Preserved Cardiac Function Heart Failure with an Aldosterone Antagonist), which randomized patients with HFpEF to treatment with spironolactone or placebo. Results from the overall study were neutral for the primary outcome of cardiovascular death, aborted cardiac arrest, and heart failure hospitalization (N Engl J Med. 2014 April 10;370[15]:1383-92). However, a series of post-hoc analyses showed that a high percentage of patients enrolled at centers in Russia or Georgia did not match the expected HFpEF profile, and these patients had poor responses to spironolactone. In contrast, patients enrolled at centers in the Americas more frequently matched the study’s target HFpEF profile, and they showed significant improvement for the primary endpoint (Circulation. 2015 Jan 6;131[1]:34-42).

Mitchel L. Zoler/Frontline Medical News

[email protected]

On Twitter @mitchelzoler

PARIS – Just when the aldosterone receptor antagonists spironolactone and eplerenone received official recognition in the 2017 U.S. heart failure guidelines as the only drug class that benefits patients with heart failure with preserved ejection fraction (HFpEF), a new post-hoc analysis of the pivotal evidence suggests the benefit is mostly in women, with little benefit to men.

The new analysis used data collected from TOPCAT (Treatment of Preserved Cardiac Function Heart Failure with an Aldosterone Antagonist), which randomized patients with HFpEF to treatment with spironolactone or placebo. Results from the overall study were neutral for the primary outcome of cardiovascular death, aborted cardiac arrest, and heart failure hospitalization (N Engl J Med. 2014 April 10;370[15]:1383-92). However, a series of post-hoc analyses showed that a high percentage of patients enrolled at centers in Russia or Georgia did not match the expected HFpEF profile, and these patients had poor responses to spironolactone. In contrast, patients enrolled at centers in the Americas more frequently matched the study’s target HFpEF profile, and they showed significant improvement for the primary endpoint (Circulation. 2015 Jan 6;131[1]:34-42).

Mitchel L. Zoler/Frontline Medical News

[email protected]

On Twitter @mitchelzoler

PARIS – Just when the aldosterone receptor antagonists spironolactone and eplerenone received official recognition in the 2017 U.S. heart failure guidelines as the only drug class that benefits patients with heart failure with preserved ejection fraction (HFpEF), a new post-hoc analysis of the pivotal evidence suggests the benefit is mostly in women, with little benefit to men.

The new analysis used data collected from TOPCAT (Treatment of Preserved Cardiac Function Heart Failure with an Aldosterone Antagonist), which randomized patients with HFpEF to treatment with spironolactone or placebo. Results from the overall study were neutral for the primary outcome of cardiovascular death, aborted cardiac arrest, and heart failure hospitalization (N Engl J Med. 2014 April 10;370[15]:1383-92). However, a series of post-hoc analyses showed that a high percentage of patients enrolled at centers in Russia or Georgia did not match the expected HFpEF profile, and these patients had poor responses to spironolactone. In contrast, patients enrolled at centers in the Americas more frequently matched the study’s target HFpEF profile, and they showed significant improvement for the primary endpoint (Circulation. 2015 Jan 6;131[1]:34-42).

Mitchel L. Zoler/Frontline Medical News

[email protected]

On Twitter @mitchelzoler

Presenters

Shoshana J. Herzig, MD, MPH, and Hillary J. Mosher, MFA, MD, FHM

Summary

The growth in opiate prescribing and associated increases in adverse events has created unique challenges for hospitalists, including how best to assess pain and opiate use disorders and how to safely prescribe opiates during hospitalization and at discharge.

These challenges are compounded by patient and system factors and a paucity of evidence-based guidelines to help guide safe administration of opiates in hospitalized patients. This can mean frustration for hospitalists and harm for patients.

Key takeaways for HM

• When assessing patients’ pain, it is crucial to differentiate between acute and chronic pain (or both) and whether it is nociceptive or neuropathic. Misclassification of pain contributes to inappropriate exposure and escalation of opiate therapy during hospitalization.
• Always consider nonopioid analgesics such as NSAIDs first and pair them with opiates. Studies in a variety of conditions have demonstrated that these are equally, if not more, effective, even for severe pain, such as with renal colic. Reserve opiates for moderate to severe pain.
• Always assess whether the benefits of initiating or continuing opioid therapy outweigh the risks for individual patients. There is no validated tool to predict risk for adverse events and/or opioid abuse disorder but a careful review of patient history can identify established risk factors (such as a history of mental illness or substance abuse disorders, renal impairment, or other comorbidities). In addition, nearly all states now have Prescription Drug Monitoring Programs, and hospitalists should consult these routinely when prescribing opiates.
• Always clearly discuss expectations and risks of opioid therapy, including the potential for development of opioid use disorders with hospitalized patients prior to initiation. Emphasize pain reduction rather than elimination and focus on functional goals such as improved mobility. Also, set expectations for stepping down treatment up front.
• Use the lowest effective dose of immediate-release opioids (preferably oral route) for shortest duration possible. Long acting opiates are associated with increased risk of adverse events, and their initiation should generally be avoided in hospitalized patients with noncancer pain.
• Minimize risk by avoiding concurrent administration of other medications with sedative properties, especially benzodiazepines, which have been found to significantly increase the risk of adverse events, including overdose.
• Recognize that chronic opioid use often begins with treatment of acute pain during hospitalization. Adopt best practice for discharge, including prescribing shorter courses whenever possible, discussing initiation, and changes or modifications in opiate therapy with patients’ primary care provider, and ensure timely postdischarge follow-up. Also consider coprescription of naloxone at discharge for higher risk patients.

Dr. Stella is a hospitalist in Denver and an editorial board member of The Hospitalist.

Presenters

Shoshana J. Herzig, MD, MPH, and Hillary J. Mosher, MFA, MD, FHM

Summary

The growth in opiate prescribing and associated increases in adverse events has created unique challenges for hospitalists, including how best to assess pain and opiate use disorders and how to safely prescribe opiates during hospitalization and at discharge.

These challenges are compounded by patient and system factors and a paucity of evidence-based guidelines to help guide safe administration of opiates in hospitalized patients. This can mean frustration for hospitalists and harm for patients.

Key takeaways for HM

• When assessing patients’ pain, it is crucial to differentiate between acute and chronic pain (or both) and whether it is nociceptive or neuropathic. Misclassification of pain contributes to inappropriate exposure and escalation of opiate therapy during hospitalization.
• Always consider nonopioid analgesics such as NSAIDs first and pair them with opiates. Studies in a variety of conditions have demonstrated that these are equally, if not more, effective, even for severe pain, such as with renal colic. Reserve opiates for moderate to severe pain.
• Always assess whether the benefits of initiating or continuing opioid therapy outweigh the risks for individual patients. There is no validated tool to predict risk for adverse events and/or opioid abuse disorder but a careful review of patient history can identify established risk factors (such as a history of mental illness or substance abuse disorders, renal impairment, or other comorbidities). In addition, nearly all states now have Prescription Drug Monitoring Programs, and hospitalists should consult these routinely when prescribing opiates.
• Always clearly discuss expectations and risks of opioid therapy, including the potential for development of opioid use disorders with hospitalized patients prior to initiation. Emphasize pain reduction rather than elimination and focus on functional goals such as improved mobility. Also, set expectations for stepping down treatment up front.
• Use the lowest effective dose of immediate-release opioids (preferably oral route) for shortest duration possible. Long acting opiates are associated with increased risk of adverse events, and their initiation should generally be avoided in hospitalized patients with noncancer pain.
• Minimize risk by avoiding concurrent administration of other medications with sedative properties, especially benzodiazepines, which have been found to significantly increase the risk of adverse events, including overdose.
• Recognize that chronic opioid use often begins with treatment of acute pain during hospitalization. Adopt best practice for discharge, including prescribing shorter courses whenever possible, discussing initiation, and changes or modifications in opiate therapy with patients’ primary care provider, and ensure timely postdischarge follow-up. Also consider coprescription of naloxone at discharge for higher risk patients.

Dr. Stella is a hospitalist in Denver and an editorial board member of The Hospitalist.

Presenters

Shoshana J. Herzig, MD, MPH, and Hillary J. Mosher, MFA, MD, FHM

Summary

The growth in opiate prescribing and associated increases in adverse events has created unique challenges for hospitalists, including how best to assess pain and opiate use disorders and how to safely prescribe opiates during hospitalization and at discharge.

These challenges are compounded by patient and system factors and a paucity of evidence-based guidelines to help guide safe administration of opiates in hospitalized patients. This can mean frustration for hospitalists and harm for patients.

Key takeaways for HM

• When assessing patients’ pain, it is crucial to differentiate between acute and chronic pain (or both) and whether it is nociceptive or neuropathic. Misclassification of pain contributes to inappropriate exposure and escalation of opiate therapy during hospitalization.
• Always consider nonopioid analgesics such as NSAIDs first and pair them with opiates. Studies in a variety of conditions have demonstrated that these are equally, if not more, effective, even for severe pain, such as with renal colic. Reserve opiates for moderate to severe pain.
• Always assess whether the benefits of initiating or continuing opioid therapy outweigh the risks for individual patients. There is no validated tool to predict risk for adverse events and/or opioid abuse disorder but a careful review of patient history can identify established risk factors (such as a history of mental illness or substance abuse disorders, renal impairment, or other comorbidities). In addition, nearly all states now have Prescription Drug Monitoring Programs, and hospitalists should consult these routinely when prescribing opiates.
• Always clearly discuss expectations and risks of opioid therapy, including the potential for development of opioid use disorders with hospitalized patients prior to initiation. Emphasize pain reduction rather than elimination and focus on functional goals such as improved mobility. Also, set expectations for stepping down treatment up front.
• Use the lowest effective dose of immediate-release opioids (preferably oral route) for shortest duration possible. Long acting opiates are associated with increased risk of adverse events, and their initiation should generally be avoided in hospitalized patients with noncancer pain.
• Minimize risk by avoiding concurrent administration of other medications with sedative properties, especially benzodiazepines, which have been found to significantly increase the risk of adverse events, including overdose.
• Recognize that chronic opioid use often begins with treatment of acute pain during hospitalization. Adopt best practice for discharge, including prescribing shorter courses whenever possible, discussing initiation, and changes or modifications in opiate therapy with patients’ primary care provider, and ensure timely postdischarge follow-up. Also consider coprescription of naloxone at discharge for higher risk patients.

Dr. Stella is a hospitalist in Denver and an editorial board member of The Hospitalist.

A host of factors, some of them preventable or treatable, increase the risk of pregnancy-related stroke among women hospitalized for preeclampsia, according to findings from a case-control study of nearly 800 preeclamptic women in New York.

Women who experienced a stroke were roughly seven times more likely to have severe preeclampsia or eclampsia, and about three to four times more likely to have an infection, a prothrombotic state, a coagulopathy, or chronic hypertension, according to the findings (Stroke. 2017 May 25. doi: 10.1161/STROKEAHA.117.017374).

stockce/Thinkstock

A host of factors, some of them preventable or treatable, increase the risk of pregnancy-related stroke among women hospitalized for preeclampsia, according to findings from a case-control study of nearly 800 preeclamptic women in New York.

Women who experienced a stroke were roughly seven times more likely to have severe preeclampsia or eclampsia, and about three to four times more likely to have an infection, a prothrombotic state, a coagulopathy, or chronic hypertension, according to the findings (Stroke. 2017 May 25. doi: 10.1161/STROKEAHA.117.017374).

stockce/Thinkstock

A host of factors, some of them preventable or treatable, increase the risk of pregnancy-related stroke among women hospitalized for preeclampsia, according to findings from a case-control study of nearly 800 preeclamptic women in New York.

Women who experienced a stroke were roughly seven times more likely to have severe preeclampsia or eclampsia, and about three to four times more likely to have an infection, a prothrombotic state, a coagulopathy, or chronic hypertension, according to the findings (Stroke. 2017 May 25. doi: 10.1161/STROKEAHA.117.017374).

stockce/Thinkstock

LAS VEGAS – Alla Zilbering, MD, sat at attention for hours during HM17, jotting notes like a scribe about the myriad of federal rules that are pretty rapidly pushing hospitalists and health care as a whole away from fee-for-service payments to a world where doctors are paid for quality.

So, why did she do it? Why all that time on policy, instead of practice?

Because Dr. Zilbering felt compelled to get more involved. As a lead hospitalist at Cigna-HealthSpring, a Medicare Advantage program in Philadelphia, she’s already part of initiatives to improve transitions of care and reduce readmissions.

However, she said she wants to do more. “I’m feeling like, unless you actually address the policy, you can’t get that far in terms of what you can physically do with a patient.”

HM17 was the meeting for her, then. SHM, this year, unveiled its first Health Policy Mini Track, dedicated to updating attendees on the implementation of the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA), the Bundled Payments for Care Improvement initiative, and a host of other federal programs. Hospitalists were updated on a litany of advocacy efforts, including observation status, interoperability of electronic health records systems, and the recent launch of the first hospitalist billing code.

Two of the meeting’s three keynote speakers were Washington veterans who confirmed that, while nightly news reports may suggest that health care reforms contained in the Affordable Care Act are constantly in flux, the trajectory toward paying for higher quality care at lower costs shows no signs of abating.

LAS VEGAS – Alla Zilbering, MD, sat at attention for hours during HM17, jotting notes like a scribe about the myriad of federal rules that are pretty rapidly pushing hospitalists and health care as a whole away from fee-for-service payments to a world where doctors are paid for quality.

So, why did she do it? Why all that time on policy, instead of practice?

Because Dr. Zilbering felt compelled to get more involved. As a lead hospitalist at Cigna-HealthSpring, a Medicare Advantage program in Philadelphia, she’s already part of initiatives to improve transitions of care and reduce readmissions.

However, she said she wants to do more. “I’m feeling like, unless you actually address the policy, you can’t get that far in terms of what you can physically do with a patient.”

HM17 was the meeting for her, then. SHM, this year, unveiled its first Health Policy Mini Track, dedicated to updating attendees on the implementation of the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA), the Bundled Payments for Care Improvement initiative, and a host of other federal programs. Hospitalists were updated on a litany of advocacy efforts, including observation status, interoperability of electronic health records systems, and the recent launch of the first hospitalist billing code.

Two of the meeting’s three keynote speakers were Washington veterans who confirmed that, while nightly news reports may suggest that health care reforms contained in the Affordable Care Act are constantly in flux, the trajectory toward paying for higher quality care at lower costs shows no signs of abating.

LAS VEGAS – Alla Zilbering, MD, sat at attention for hours during HM17, jotting notes like a scribe about the myriad of federal rules that are pretty rapidly pushing hospitalists and health care as a whole away from fee-for-service payments to a world where doctors are paid for quality.

So, why did she do it? Why all that time on policy, instead of practice?

Because Dr. Zilbering felt compelled to get more involved. As a lead hospitalist at Cigna-HealthSpring, a Medicare Advantage program in Philadelphia, she’s already part of initiatives to improve transitions of care and reduce readmissions.

However, she said she wants to do more. “I’m feeling like, unless you actually address the policy, you can’t get that far in terms of what you can physically do with a patient.”

HM17 was the meeting for her, then. SHM, this year, unveiled its first Health Policy Mini Track, dedicated to updating attendees on the implementation of the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA), the Bundled Payments for Care Improvement initiative, and a host of other federal programs. Hospitalists were updated on a litany of advocacy efforts, including observation status, interoperability of electronic health records systems, and the recent launch of the first hospitalist billing code.

Two of the meeting’s three keynote speakers were Washington veterans who confirmed that, while nightly news reports may suggest that health care reforms contained in the Affordable Care Act are constantly in flux, the trajectory toward paying for higher quality care at lower costs shows no signs of abating.

Several months into 2017, physicians around the country are preparing for the first benchmark year of MACRA, the Medicare Access and CHIP Reauthorization Act. Passed in 2015, MACRA is the bipartisan health care law responsible for eliminating the Sustainable Growth Rate and it promises to continue to fundamentally alter the way providers are paid. This year determines reimbursement in 2019.

Under the law, physicians must report performance under one of two pathways: MIPS, the Merit-based Incentive Payment System, or participation in a qualified Advanced Alternative Payment Model, or Advanced APM. The first, MIPS, replaces the Physician Quality Reporting System, Meaningful Use and the Physician Value-Based Payment Modifier and is the track most providers can expect to follow, at least initially, because most will not meet the requirements for Advanced APMs.^1,2

This is especially true for hospitalists, most of whom are not yet participating in qualifying alternative payment models.²

The MIPS track is budget neutral, which means for every physician or physician group that receives a boost in reimbursement, another will receive a cut. Others will receive a neutral adjustment. All physicians see an annual 0.5% increase in payment between 2016 and 2019 and MIPS clinicians receive a 0.25% annual boost starting in 2026. Providers participating in Advanced APMs will also receive an annual 5% payment bonus between 2019 and 2024, and a 0.75% annual increase in payments beginning in 2026.¹

Both pathways are complex and will affect different clinicians in unique ways, particularly hospitalists.

MIPS

All providers who receive Medicare Physician Fee Schedule payments and do not participate in an Advanced APM will fall into MIPS, and reporting applies to all patients, not just Medicare beneficiaries.³ There are, however, exemptions: providers in their first year of Medicare, those billing Medicare Part B less than $30,000 annually, and those who see 100 or fewer Medicare patients.⁴

Under MIPS, physicians are scored on a scale of 1 to 100 based on performance across four weighted categories: Quality (60%), Advancing Care Information (25%), Improvement Activities (15%), and Cost (not included for 2017). Hospitalists who provide 75% or more of their services in hospital inpatient or outpatient settings, or in the emergency department, are exempt from Advancing Care Information, which replaced meaningful use. As a result, the Quality category will make up 85% of the overall score in 2017.

The CMS also announced added flexibility for 2017 with regard to reporting under MIPS, intended to give providers who need it extra time to prepare.⁵ Physicians and physician groups can report for a full year, starting January 1, 2017, or report for just 90 days, to be eligible for a positive payment adjustment. To avoid a negative adjustment, they can simply submit more than one quality measure, improvement activity, or advancing care information measure (for those not exempt). Or, providers can choose to report nothing and incur a negative 4% payment.

The approach to MIPS in 2017 will vary widely among SHM members, said Joshua Boswell, SHM’s director of government relations.

“Some are looking to do just the bare minimum, not because of their lack of readiness, but for at least this year, to avoid the time, resources, and cost associated with reporting.” he said. “Other groups are considering jumping in with both feet and fully reporting, their thinking being that they can’t lose, and if there is money on the table for high performers, they might as well go for it.”

For 2017, providers who score 70 or more points are eligible for a performance bonus, drawn from a $500 million pool set aside by CMS. The minimum point threshold defined by CMS is three, which a clinician can earn by submitting just one of the six required quality measures.⁴

Advanced APMs

Physicians who participate in Advanced APMs are exempt from MIPS. Advanced APMs must use Certified Electronic Health Record Technology (CEHRT) and take on a minimum amount of risk. For 2017 and 2018, providers must risk losing the lesser of 3% of their total Medicare expenditures or 8% of their revenue.⁹ They are paid based on the parameters of their particular model.

Additionally, for the 2019 payment year, 25% of a provider’s or group’s Medicare payments or 20% of their patients must be through the Advanced APM. This increases to 50% of payments and 35% of patients for 2021 and 2022, and in 2023, to 75% of payments and 50% of patients.

In 2017, APMs that meet the criteria for Advanced include: Comprehensive End-Stage Renal Disease Care, Comprehensive Primary Care Plus, Next Generation ACO Model, Shared Savings Program Tracks 2 and 3, Comprehensive Joint Replacement Payment Model Track 1, the Vermont Medicare ACO Initiative, and the Oncology Care Model. (APMs that do not qualify must report under MIPS.)⁵

The CMS also says that services provided at critical access hospitals, rural health clinics, and federally qualified health centers may qualify using patient counts, and medical home models and the Medicaid Medical Home Model may also be considered Advanced APMs using financial criteria.⁴

At this time, SHM is unable to quantify the number of hospitalists participating in Advanced APMs, and some, Dr. Greeno said, may not know whether they are part of an Advanced APM.

Currently, BPCI (Bundled Payments for Care Improvement) is the only alternative payment model in which hospitalists can directly take risk, Dr. Greeno says, but it does not yet qualify as an Advanced APM. However, that could change.

Prior to the passage of MACRA, Brandeis University worked with CMS to create the Episode Grouper for Medicare (EGM), software that converts claims data into episodes of care based on a patient’s condition or conditions or procedures. The American College of Surgeons (ACS) has since proposed an alternative payment model, called ACS-Brandeis, that would use the diagnostic grouper to take into account all of the work done by every provider on any episode admitted to the hospital and use algorithms to decide who affected a particular patient’s care.

“Anyone who takes care of the patient can take risk or gain share if the episode initiator allows them,” said Dr. Greeno.

For example, if a patient is admitted for surgery, but has an internist on their case because they have diabetes and heart failure, and they also have an anesthesiologist and an infectious disease specialist, everybody has an impact on their care and makes decisions about the resources used on the case. The risk associated with the case is effectively divided.

The ACS submitted the proposal to PTAC (the Physician-Focused Payment Model Technical Advisory Committee) in 2016 and SHM submitted a letter of support.

“In this model, everybody’s taking risk and everybody has the opportunity to gain share if the patient is managed well,” said Dr. Greeno. “It’s a very complicated, very complex model... Theoretically, everybody on that case should be optimally engaged – that’s the beauty of it – but we don’t know if it will work.”

The SHM got involved at the request of ACS, because it would not apply solely to surgical patients. Dr. Greeno says ACS asked SHM to look at common surgical diagnoses and review every medical scenario that could come to pass, from heart failure and pneumonia to infection.

“There’s bundles within bundles, medical bundles within surgical bundles,” he said. “It’s fascinating and it’s daunting but it is truly a big data approach to episodes of care. We’re thrilled to be invited and ACS was very enthusiastic about our involvement.”

Dr. Patel, who sits on PTAC, is heartened by the amount of physician-led innovation taking place. “Proposals are coming directly from doctors; they are telling us what they want,” she said.

For Dr. Greeno, this captures the intent of MACRA: “There is going to be a continual increase in the sophistication of models, and hopefully toward ones that are better and better and create the right incentives for everyone involved in the health care system.”


References

1. S. Findlay. Medicare’s new physician payment system. http://www.healthaffairs.org/healthpolicybriefs/brief.php?brief_id=156. Published April 21, 2016. Accessed March 6, 2017.

2. The Society of Hospital Medicine. Medicare physician payments are changing. http://www.macraforhm.org/. Accessed March 6, 2017.

3. A. Maciejowski. MACRA: What’s really in the final rule. http://blog.ncqa.org/macra-whats-really-in-the-final-rule/. Blog post published November 15, 2016. Accessed March 6, 2017.

4. Department of Health and Human Services, Centers for Medicare and Medicaid Services. Quality Payment Program executive summary. https://qpp.cms.gov/docs/QPP_Executive_Summary_of_Final_Rule.pdf. Published Oct. 14, 2016. Accessed March 6, 2017.

5. Department of Health and Human Services, Centers for Medicare and Medicaid Services. Quality Payment Program: Modernizing Medicare to provide better care and smarter spending for a healthier America. https://qpp.cms.gov/. Accessed March 6, 2017.

6. D. Barkholz. Potential MACRA byproduct: physician consolidation. http://www.modernhealthcare.com/article/20160630/NEWS/160639995. Published June 30, 2016. Accessed March 6, 2017.

7. United States Department of Health and Human Services. Better, smarter, healthier: In historic announcement, HHS sets clear goals and timeline for shifting Medicare reimbursement from volume to value. http://wayback.archive-it.org/3926/20170127185400/https://www.hhs.gov/about/news/2015/01/26/better-smarter-healthier-in-historic-announcement-hhs-sets-clear-goals-and-timeline-for-shifting-medicare-reimbursements-from-volume-to-value.html. Published January 26, 2015. Accessed March 6, 2017.

8. B. Wynne. MACRA Final Rule: CMS strikes a balance; will docs hang on? http://healthaffairs.org/blog/2016/10/17/macra-final-rule-cms-strikes-a-balance-will-docs-hang-on/. Published October 17, 2016. Accessed March 6, 2017.

9. United States Department of Health and Human Services, Office of the Assistant Secretary for Planning and Evaluation. Documents for Public Comment: Physician-Focused Payment Model Technical Advisory Committee. Proposal for a Physician-Focused Payment Model: CAS-Brandeis Advanced Alternative Payment Model, American College of Surgeons. https://aspe.hhs.gov/system/files/pdf/253406/TheACSBrandeisAdvancedAPM-ACS.pdf. Published December 13, 2016. Accessed March 6, 2017.

Several months into 2017, physicians around the country are preparing for the first benchmark year of MACRA, the Medicare Access and CHIP Reauthorization Act. Passed in 2015, MACRA is the bipartisan health care law responsible for eliminating the Sustainable Growth Rate and it promises to continue to fundamentally alter the way providers are paid. This year determines reimbursement in 2019.

Under the law, physicians must report performance under one of two pathways: MIPS, the Merit-based Incentive Payment System, or participation in a qualified Advanced Alternative Payment Model, or Advanced APM. The first, MIPS, replaces the Physician Quality Reporting System, Meaningful Use and the Physician Value-Based Payment Modifier and is the track most providers can expect to follow, at least initially, because most will not meet the requirements for Advanced APMs.^1,2

This is especially true for hospitalists, most of whom are not yet participating in qualifying alternative payment models.²

The MIPS track is budget neutral, which means for every physician or physician group that receives a boost in reimbursement, another will receive a cut. Others will receive a neutral adjustment. All physicians see an annual 0.5% increase in payment between 2016 and 2019 and MIPS clinicians receive a 0.25% annual boost starting in 2026. Providers participating in Advanced APMs will also receive an annual 5% payment bonus between 2019 and 2024, and a 0.75% annual increase in payments beginning in 2026.¹

Both pathways are complex and will affect different clinicians in unique ways, particularly hospitalists.

MIPS

All providers who receive Medicare Physician Fee Schedule payments and do not participate in an Advanced APM will fall into MIPS, and reporting applies to all patients, not just Medicare beneficiaries.³ There are, however, exemptions: providers in their first year of Medicare, those billing Medicare Part B less than $30,000 annually, and those who see 100 or fewer Medicare patients.⁴

Under MIPS, physicians are scored on a scale of 1 to 100 based on performance across four weighted categories: Quality (60%), Advancing Care Information (25%), Improvement Activities (15%), and Cost (not included for 2017). Hospitalists who provide 75% or more of their services in hospital inpatient or outpatient settings, or in the emergency department, are exempt from Advancing Care Information, which replaced meaningful use. As a result, the Quality category will make up 85% of the overall score in 2017.

The CMS also announced added flexibility for 2017 with regard to reporting under MIPS, intended to give providers who need it extra time to prepare.⁵ Physicians and physician groups can report for a full year, starting January 1, 2017, or report for just 90 days, to be eligible for a positive payment adjustment. To avoid a negative adjustment, they can simply submit more than one quality measure, improvement activity, or advancing care information measure (for those not exempt). Or, providers can choose to report nothing and incur a negative 4% payment.

The approach to MIPS in 2017 will vary widely among SHM members, said Joshua Boswell, SHM’s director of government relations.

“Some are looking to do just the bare minimum, not because of their lack of readiness, but for at least this year, to avoid the time, resources, and cost associated with reporting.” he said. “Other groups are considering jumping in with both feet and fully reporting, their thinking being that they can’t lose, and if there is money on the table for high performers, they might as well go for it.”

For 2017, providers who score 70 or more points are eligible for a performance bonus, drawn from a $500 million pool set aside by CMS. The minimum point threshold defined by CMS is three, which a clinician can earn by submitting just one of the six required quality measures.⁴

Advanced APMs

Physicians who participate in Advanced APMs are exempt from MIPS. Advanced APMs must use Certified Electronic Health Record Technology (CEHRT) and take on a minimum amount of risk. For 2017 and 2018, providers must risk losing the lesser of 3% of their total Medicare expenditures or 8% of their revenue.⁹ They are paid based on the parameters of their particular model.

Additionally, for the 2019 payment year, 25% of a provider’s or group’s Medicare payments or 20% of their patients must be through the Advanced APM. This increases to 50% of payments and 35% of patients for 2021 and 2022, and in 2023, to 75% of payments and 50% of patients.

In 2017, APMs that meet the criteria for Advanced include: Comprehensive End-Stage Renal Disease Care, Comprehensive Primary Care Plus, Next Generation ACO Model, Shared Savings Program Tracks 2 and 3, Comprehensive Joint Replacement Payment Model Track 1, the Vermont Medicare ACO Initiative, and the Oncology Care Model. (APMs that do not qualify must report under MIPS.)⁵

The CMS also says that services provided at critical access hospitals, rural health clinics, and federally qualified health centers may qualify using patient counts, and medical home models and the Medicaid Medical Home Model may also be considered Advanced APMs using financial criteria.⁴

At this time, SHM is unable to quantify the number of hospitalists participating in Advanced APMs, and some, Dr. Greeno said, may not know whether they are part of an Advanced APM.

Currently, BPCI (Bundled Payments for Care Improvement) is the only alternative payment model in which hospitalists can directly take risk, Dr. Greeno says, but it does not yet qualify as an Advanced APM. However, that could change.

Prior to the passage of MACRA, Brandeis University worked with CMS to create the Episode Grouper for Medicare (EGM), software that converts claims data into episodes of care based on a patient’s condition or conditions or procedures. The American College of Surgeons (ACS) has since proposed an alternative payment model, called ACS-Brandeis, that would use the diagnostic grouper to take into account all of the work done by every provider on any episode admitted to the hospital and use algorithms to decide who affected a particular patient’s care.

“Anyone who takes care of the patient can take risk or gain share if the episode initiator allows them,” said Dr. Greeno.

For example, if a patient is admitted for surgery, but has an internist on their case because they have diabetes and heart failure, and they also have an anesthesiologist and an infectious disease specialist, everybody has an impact on their care and makes decisions about the resources used on the case. The risk associated with the case is effectively divided.

The ACS submitted the proposal to PTAC (the Physician-Focused Payment Model Technical Advisory Committee) in 2016 and SHM submitted a letter of support.

“In this model, everybody’s taking risk and everybody has the opportunity to gain share if the patient is managed well,” said Dr. Greeno. “It’s a very complicated, very complex model... Theoretically, everybody on that case should be optimally engaged – that’s the beauty of it – but we don’t know if it will work.”

The SHM got involved at the request of ACS, because it would not apply solely to surgical patients. Dr. Greeno says ACS asked SHM to look at common surgical diagnoses and review every medical scenario that could come to pass, from heart failure and pneumonia to infection.

“There’s bundles within bundles, medical bundles within surgical bundles,” he said. “It’s fascinating and it’s daunting but it is truly a big data approach to episodes of care. We’re thrilled to be invited and ACS was very enthusiastic about our involvement.”

Dr. Patel, who sits on PTAC, is heartened by the amount of physician-led innovation taking place. “Proposals are coming directly from doctors; they are telling us what they want,” she said.

For Dr. Greeno, this captures the intent of MACRA: “There is going to be a continual increase in the sophistication of models, and hopefully toward ones that are better and better and create the right incentives for everyone involved in the health care system.”


References

1. S. Findlay. Medicare’s new physician payment system. http://www.healthaffairs.org/healthpolicybriefs/brief.php?brief_id=156. Published April 21, 2016. Accessed March 6, 2017.

2. The Society of Hospital Medicine. Medicare physician payments are changing. http://www.macraforhm.org/. Accessed March 6, 2017.

3. A. Maciejowski. MACRA: What’s really in the final rule. http://blog.ncqa.org/macra-whats-really-in-the-final-rule/. Blog post published November 15, 2016. Accessed March 6, 2017.

4. Department of Health and Human Services, Centers for Medicare and Medicaid Services. Quality Payment Program executive summary. https://qpp.cms.gov/docs/QPP_Executive_Summary_of_Final_Rule.pdf. Published Oct. 14, 2016. Accessed March 6, 2017.

5. Department of Health and Human Services, Centers for Medicare and Medicaid Services. Quality Payment Program: Modernizing Medicare to provide better care and smarter spending for a healthier America. https://qpp.cms.gov/. Accessed March 6, 2017.

6. D. Barkholz. Potential MACRA byproduct: physician consolidation. http://www.modernhealthcare.com/article/20160630/NEWS/160639995. Published June 30, 2016. Accessed March 6, 2017.

7. United States Department of Health and Human Services. Better, smarter, healthier: In historic announcement, HHS sets clear goals and timeline for shifting Medicare reimbursement from volume to value. http://wayback.archive-it.org/3926/20170127185400/https://www.hhs.gov/about/news/2015/01/26/better-smarter-healthier-in-historic-announcement-hhs-sets-clear-goals-and-timeline-for-shifting-medicare-reimbursements-from-volume-to-value.html. Published January 26, 2015. Accessed March 6, 2017.

8. B. Wynne. MACRA Final Rule: CMS strikes a balance; will docs hang on? http://healthaffairs.org/blog/2016/10/17/macra-final-rule-cms-strikes-a-balance-will-docs-hang-on/. Published October 17, 2016. Accessed March 6, 2017.

9. United States Department of Health and Human Services, Office of the Assistant Secretary for Planning and Evaluation. Documents for Public Comment: Physician-Focused Payment Model Technical Advisory Committee. Proposal for a Physician-Focused Payment Model: CAS-Brandeis Advanced Alternative Payment Model, American College of Surgeons. https://aspe.hhs.gov/system/files/pdf/253406/TheACSBrandeisAdvancedAPM-ACS.pdf. Published December 13, 2016. Accessed March 6, 2017.

Several months into 2017, physicians around the country are preparing for the first benchmark year of MACRA, the Medicare Access and CHIP Reauthorization Act. Passed in 2015, MACRA is the bipartisan health care law responsible for eliminating the Sustainable Growth Rate and it promises to continue to fundamentally alter the way providers are paid. This year determines reimbursement in 2019.

Under the law, physicians must report performance under one of two pathways: MIPS, the Merit-based Incentive Payment System, or participation in a qualified Advanced Alternative Payment Model, or Advanced APM. The first, MIPS, replaces the Physician Quality Reporting System, Meaningful Use and the Physician Value-Based Payment Modifier and is the track most providers can expect to follow, at least initially, because most will not meet the requirements for Advanced APMs.^1,2

This is especially true for hospitalists, most of whom are not yet participating in qualifying alternative payment models.²

The MIPS track is budget neutral, which means for every physician or physician group that receives a boost in reimbursement, another will receive a cut. Others will receive a neutral adjustment. All physicians see an annual 0.5% increase in payment between 2016 and 2019 and MIPS clinicians receive a 0.25% annual boost starting in 2026. Providers participating in Advanced APMs will also receive an annual 5% payment bonus between 2019 and 2024, and a 0.75% annual increase in payments beginning in 2026.¹

Both pathways are complex and will affect different clinicians in unique ways, particularly hospitalists.

MIPS

All providers who receive Medicare Physician Fee Schedule payments and do not participate in an Advanced APM will fall into MIPS, and reporting applies to all patients, not just Medicare beneficiaries.³ There are, however, exemptions: providers in their first year of Medicare, those billing Medicare Part B less than $30,000 annually, and those who see 100 or fewer Medicare patients.⁴

Under MIPS, physicians are scored on a scale of 1 to 100 based on performance across four weighted categories: Quality (60%), Advancing Care Information (25%), Improvement Activities (15%), and Cost (not included for 2017). Hospitalists who provide 75% or more of their services in hospital inpatient or outpatient settings, or in the emergency department, are exempt from Advancing Care Information, which replaced meaningful use. As a result, the Quality category will make up 85% of the overall score in 2017.

The CMS also announced added flexibility for 2017 with regard to reporting under MIPS, intended to give providers who need it extra time to prepare.⁵ Physicians and physician groups can report for a full year, starting January 1, 2017, or report for just 90 days, to be eligible for a positive payment adjustment. To avoid a negative adjustment, they can simply submit more than one quality measure, improvement activity, or advancing care information measure (for those not exempt). Or, providers can choose to report nothing and incur a negative 4% payment.

The approach to MIPS in 2017 will vary widely among SHM members, said Joshua Boswell, SHM’s director of government relations.

“Some are looking to do just the bare minimum, not because of their lack of readiness, but for at least this year, to avoid the time, resources, and cost associated with reporting.” he said. “Other groups are considering jumping in with both feet and fully reporting, their thinking being that they can’t lose, and if there is money on the table for high performers, they might as well go for it.”

For 2017, providers who score 70 or more points are eligible for a performance bonus, drawn from a $500 million pool set aside by CMS. The minimum point threshold defined by CMS is three, which a clinician can earn by submitting just one of the six required quality measures.⁴

Advanced APMs

Physicians who participate in Advanced APMs are exempt from MIPS. Advanced APMs must use Certified Electronic Health Record Technology (CEHRT) and take on a minimum amount of risk. For 2017 and 2018, providers must risk losing the lesser of 3% of their total Medicare expenditures or 8% of their revenue.⁹ They are paid based on the parameters of their particular model.

Additionally, for the 2019 payment year, 25% of a provider’s or group’s Medicare payments or 20% of their patients must be through the Advanced APM. This increases to 50% of payments and 35% of patients for 2021 and 2022, and in 2023, to 75% of payments and 50% of patients.

In 2017, APMs that meet the criteria for Advanced include: Comprehensive End-Stage Renal Disease Care, Comprehensive Primary Care Plus, Next Generation ACO Model, Shared Savings Program Tracks 2 and 3, Comprehensive Joint Replacement Payment Model Track 1, the Vermont Medicare ACO Initiative, and the Oncology Care Model. (APMs that do not qualify must report under MIPS.)⁵

The CMS also says that services provided at critical access hospitals, rural health clinics, and federally qualified health centers may qualify using patient counts, and medical home models and the Medicaid Medical Home Model may also be considered Advanced APMs using financial criteria.⁴

At this time, SHM is unable to quantify the number of hospitalists participating in Advanced APMs, and some, Dr. Greeno said, may not know whether they are part of an Advanced APM.

Currently, BPCI (Bundled Payments for Care Improvement) is the only alternative payment model in which hospitalists can directly take risk, Dr. Greeno says, but it does not yet qualify as an Advanced APM. However, that could change.

Prior to the passage of MACRA, Brandeis University worked with CMS to create the Episode Grouper for Medicare (EGM), software that converts claims data into episodes of care based on a patient’s condition or conditions or procedures. The American College of Surgeons (ACS) has since proposed an alternative payment model, called ACS-Brandeis, that would use the diagnostic grouper to take into account all of the work done by every provider on any episode admitted to the hospital and use algorithms to decide who affected a particular patient’s care.

“Anyone who takes care of the patient can take risk or gain share if the episode initiator allows them,” said Dr. Greeno.

For example, if a patient is admitted for surgery, but has an internist on their case because they have diabetes and heart failure, and they also have an anesthesiologist and an infectious disease specialist, everybody has an impact on their care and makes decisions about the resources used on the case. The risk associated with the case is effectively divided.

The ACS submitted the proposal to PTAC (the Physician-Focused Payment Model Technical Advisory Committee) in 2016 and SHM submitted a letter of support.

“In this model, everybody’s taking risk and everybody has the opportunity to gain share if the patient is managed well,” said Dr. Greeno. “It’s a very complicated, very complex model... Theoretically, everybody on that case should be optimally engaged – that’s the beauty of it – but we don’t know if it will work.”

The SHM got involved at the request of ACS, because it would not apply solely to surgical patients. Dr. Greeno says ACS asked SHM to look at common surgical diagnoses and review every medical scenario that could come to pass, from heart failure and pneumonia to infection.

“There’s bundles within bundles, medical bundles within surgical bundles,” he said. “It’s fascinating and it’s daunting but it is truly a big data approach to episodes of care. We’re thrilled to be invited and ACS was very enthusiastic about our involvement.”

Dr. Patel, who sits on PTAC, is heartened by the amount of physician-led innovation taking place. “Proposals are coming directly from doctors; they are telling us what they want,” she said.

For Dr. Greeno, this captures the intent of MACRA: “There is going to be a continual increase in the sophistication of models, and hopefully toward ones that are better and better and create the right incentives for everyone involved in the health care system.”


References

1. S. Findlay. Medicare’s new physician payment system. http://www.healthaffairs.org/healthpolicybriefs/brief.php?brief_id=156. Published April 21, 2016. Accessed March 6, 2017.

2. The Society of Hospital Medicine. Medicare physician payments are changing. http://www.macraforhm.org/. Accessed March 6, 2017.

3. A. Maciejowski. MACRA: What’s really in the final rule. http://blog.ncqa.org/macra-whats-really-in-the-final-rule/. Blog post published November 15, 2016. Accessed March 6, 2017.

4. Department of Health and Human Services, Centers for Medicare and Medicaid Services. Quality Payment Program executive summary. https://qpp.cms.gov/docs/QPP_Executive_Summary_of_Final_Rule.pdf. Published Oct. 14, 2016. Accessed March 6, 2017.

5. Department of Health and Human Services, Centers for Medicare and Medicaid Services. Quality Payment Program: Modernizing Medicare to provide better care and smarter spending for a healthier America. https://qpp.cms.gov/. Accessed March 6, 2017.

6. D. Barkholz. Potential MACRA byproduct: physician consolidation. http://www.modernhealthcare.com/article/20160630/NEWS/160639995. Published June 30, 2016. Accessed March 6, 2017.

7. United States Department of Health and Human Services. Better, smarter, healthier: In historic announcement, HHS sets clear goals and timeline for shifting Medicare reimbursement from volume to value. http://wayback.archive-it.org/3926/20170127185400/https://www.hhs.gov/about/news/2015/01/26/better-smarter-healthier-in-historic-announcement-hhs-sets-clear-goals-and-timeline-for-shifting-medicare-reimbursements-from-volume-to-value.html. Published January 26, 2015. Accessed March 6, 2017.

8. B. Wynne. MACRA Final Rule: CMS strikes a balance; will docs hang on? http://healthaffairs.org/blog/2016/10/17/macra-final-rule-cms-strikes-a-balance-will-docs-hang-on/. Published October 17, 2016. Accessed March 6, 2017.

9. United States Department of Health and Human Services, Office of the Assistant Secretary for Planning and Evaluation. Documents for Public Comment: Physician-Focused Payment Model Technical Advisory Committee. Proposal for a Physician-Focused Payment Model: CAS-Brandeis Advanced Alternative Payment Model, American College of Surgeons. https://aspe.hhs.gov/system/files/pdf/253406/TheACSBrandeisAdvancedAPM-ACS.pdf. Published December 13, 2016. Accessed March 6, 2017.