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Hm15 Presenters: Chuck Ainsworth, MD, MCC,; Dan Virnich, MD, MBA; Roberta Himebaugh, MBA, SFHM; Robert Hickling, MHA; Sendil Krishnan, MD

Summation: The presenters, a group of physicians and administrators for hospital medicine groups, explored three dyad models. These three models were:

1. Office of the Executive, where there is one senior executive and a junior executive;
2. Coordinated Co-Leadership, where each of the two co-leaders has separate direct reports; and
3. Integrated Co-Leadership, where there are two co-leaders and the staff report to the co-leader team.

The discussion ensued to outline the benefit of a dyad leadership model, which can lead to growth and success in advancing the commitment to patient care. The group also emphasized the importance of providing leadership training and education to optimize the dyad leadership model. Bringing together physician and administrator dyads enables an organization to have complimentary expertise to advance hospital medicine programs into the next era.

Hm15 Presenters: Chuck Ainsworth, MD, MCC,; Dan Virnich, MD, MBA; Roberta Himebaugh, MBA, SFHM; Robert Hickling, MHA; Sendil Krishnan, MD

Summation: The presenters, a group of physicians and administrators for hospital medicine groups, explored three dyad models. These three models were:

1. Office of the Executive, where there is one senior executive and a junior executive;
2. Coordinated Co-Leadership, where each of the two co-leaders has separate direct reports; and
3. Integrated Co-Leadership, where there are two co-leaders and the staff report to the co-leader team.

The discussion ensued to outline the benefit of a dyad leadership model, which can lead to growth and success in advancing the commitment to patient care. The group also emphasized the importance of providing leadership training and education to optimize the dyad leadership model. Bringing together physician and administrator dyads enables an organization to have complimentary expertise to advance hospital medicine programs into the next era.

Hm15 Presenters: Chuck Ainsworth, MD, MCC,; Dan Virnich, MD, MBA; Roberta Himebaugh, MBA, SFHM; Robert Hickling, MHA; Sendil Krishnan, MD

Summation: The presenters, a group of physicians and administrators for hospital medicine groups, explored three dyad models. These three models were:

1. Office of the Executive, where there is one senior executive and a junior executive;
2. Coordinated Co-Leadership, where each of the two co-leaders has separate direct reports; and
3. Integrated Co-Leadership, where there are two co-leaders and the staff report to the co-leader team.

The discussion ensued to outline the benefit of a dyad leadership model, which can lead to growth and success in advancing the commitment to patient care. The group also emphasized the importance of providing leadership training and education to optimize the dyad leadership model. Bringing together physician and administrator dyads enables an organization to have complimentary expertise to advance hospital medicine programs into the next era.

HM15  Presenters: John Nelson, MD, MHM; Daniel Hanson, MD, FHM; Darren Thomas, MD

Summation: The presenters, from three entirely different geographic regions across the U.S., walked the audience through several different innovative hospitalist staffing models, from staffing in a multi-hospital system to integrating of advanced practice clinicians to deploying staggered staffing techniques to match the patient demand and enhance continuity of care.

Many multi-hospital systems are challenged to consider creative solutions on how to meet individual hospital staffing needs, while also creating staffing efficiencies across the system, such as cross coverage at night and back-up staffing solutions for increased patient volumes and unexpected staffing vacancies.

Examples to enhance patient continuity were presented throughout, such as pairing together a hospitalist from one week to a hospitalist from an alternate week to care for the same patients.

Similarly, the experts provided a compelling case to consider pairing hospitalist providers with patients, and referring physicians longitudinally across multiple admissions.

Key Takeaways:

1. Patients Come First - consider patient alignment, or continuity, in determing provider scheduling options.

2. Multi-hospital Systems - establish the onboarding parameters needed for providers to be successful in covering more than one hospital and how to build into your scheduling model.

3. Integrate the Care Team - ensure the roles of the integrated provider team (e.g., physicians and advanced practice clinicians) are clearly understood when developing the schedule.

4. Know Your Numbers - clearly understand the workload demands to properly balance the scheduling needs before establishing the schedule.

5. Regular Review - regularly review all of these areas and revise your schedule based on the changing landscape of demands on your hospital medicine group.

HM15  Presenters: John Nelson, MD, MHM; Daniel Hanson, MD, FHM; Darren Thomas, MD

Summation: The presenters, from three entirely different geographic regions across the U.S., walked the audience through several different innovative hospitalist staffing models, from staffing in a multi-hospital system to integrating of advanced practice clinicians to deploying staggered staffing techniques to match the patient demand and enhance continuity of care.

Many multi-hospital systems are challenged to consider creative solutions on how to meet individual hospital staffing needs, while also creating staffing efficiencies across the system, such as cross coverage at night and back-up staffing solutions for increased patient volumes and unexpected staffing vacancies.

Examples to enhance patient continuity were presented throughout, such as pairing together a hospitalist from one week to a hospitalist from an alternate week to care for the same patients.

Similarly, the experts provided a compelling case to consider pairing hospitalist providers with patients, and referring physicians longitudinally across multiple admissions.

Key Takeaways:

1. Patients Come First - consider patient alignment, or continuity, in determing provider scheduling options.

2. Multi-hospital Systems - establish the onboarding parameters needed for providers to be successful in covering more than one hospital and how to build into your scheduling model.

3. Integrate the Care Team - ensure the roles of the integrated provider team (e.g., physicians and advanced practice clinicians) are clearly understood when developing the schedule.

4. Know Your Numbers - clearly understand the workload demands to properly balance the scheduling needs before establishing the schedule.

5. Regular Review - regularly review all of these areas and revise your schedule based on the changing landscape of demands on your hospital medicine group.

HM15  Presenters: John Nelson, MD, MHM; Daniel Hanson, MD, FHM; Darren Thomas, MD

Summation: The presenters, from three entirely different geographic regions across the U.S., walked the audience through several different innovative hospitalist staffing models, from staffing in a multi-hospital system to integrating of advanced practice clinicians to deploying staggered staffing techniques to match the patient demand and enhance continuity of care.

Many multi-hospital systems are challenged to consider creative solutions on how to meet individual hospital staffing needs, while also creating staffing efficiencies across the system, such as cross coverage at night and back-up staffing solutions for increased patient volumes and unexpected staffing vacancies.

Examples to enhance patient continuity were presented throughout, such as pairing together a hospitalist from one week to a hospitalist from an alternate week to care for the same patients.

Similarly, the experts provided a compelling case to consider pairing hospitalist providers with patients, and referring physicians longitudinally across multiple admissions.

Key Takeaways:

1. Patients Come First - consider patient alignment, or continuity, in determing provider scheduling options.

2. Multi-hospital Systems - establish the onboarding parameters needed for providers to be successful in covering more than one hospital and how to build into your scheduling model.

3. Integrate the Care Team - ensure the roles of the integrated provider team (e.g., physicians and advanced practice clinicians) are clearly understood when developing the schedule.

4. Know Your Numbers - clearly understand the workload demands to properly balance the scheduling needs before establishing the schedule.

5. Regular Review - regularly review all of these areas and revise your schedule based on the changing landscape of demands on your hospital medicine group.

4/8/15

Session: Last-Minute Heroics and Palliative Care – Do They Meet in the Middle?

HM15 Presenter: Tammie Quest, MD

Summation: Heroics- a set of medical actions that attempt to prolong life with a low likelihood of success.

Palliative care- an approach of care provided to patients and families suffering from serious and/or life limiting illness; focus on physical, spiritual, psychological and social aspects of distress.

Hospice care- intense palliative care provided when the patient has terminal illness with a prognosis of 6 months or less if the disease runs its usual course.

We underutilize Palliative and Hospice care in the US. Here in the US fewer than 50% of all persons receive hospice care at EOL, of those who receive hospice care more than half receive care for less than 20 days, and 1 in 5 patients die in an ICU. Palliative Care can/should co-exist with life prolonging care following the diagnosis of serious illness.

Common therapies/interventions to be contemplated and discussed with patient at end of life: cpr, mechanical ventilation, central venous/arterial access, renal replacement therapy, surgical procedures, valve therapies, ventricular assist devices, continuous infusions, IV fluids, supplemental oxygen, artificial nutrition, antimicrobials, blood products, cancer directed therapy, antithrombotics, anticoagulation.

Practical Elements of Palliative Care: pain and symptom management, advance care planning, communication/goals of care, truth-telling, social support, spiritual support, psychological support, risk/burden assessment of treatments.

Key Points/HM Takeaways:

1-Palliative Care Bedside Talking Points-

• Cardiac arrest is the moment of death, very few people survive an attempt at reversing death
• If you are one of the few who survive to discharge, you may do well but few will survive to discharge
• Antibiotics DO improve survival, antibiotics DO NOT improve comfort
• No evidence to show that dying from pneumonia, or other infection, is painful
• Allowing natural death includes permitting the body to shut itself down through natural mechanisms, including infection
• Dialysis may extend life, but there will be progressive functional decline

2-Goals of Care define what therapies are indicated. Balance prolongation of life with illness experience.

Julianna Lindsey is a hospitalist and physician leader based in the Dallas-Fort Worth Metroplex. Her focus is patient safety/quality and physician leadership. She is a member of TeamHospitalist.

 

 

4/8/15

Session: Last-Minute Heroics and Palliative Care – Do They Meet in the Middle?

HM15 Presenter: Tammie Quest, MD

Summation: Heroics- a set of medical actions that attempt to prolong life with a low likelihood of success.

Palliative care- an approach of care provided to patients and families suffering from serious and/or life limiting illness; focus on physical, spiritual, psychological and social aspects of distress.

Hospice care- intense palliative care provided when the patient has terminal illness with a prognosis of 6 months or less if the disease runs its usual course.

We underutilize Palliative and Hospice care in the US. Here in the US fewer than 50% of all persons receive hospice care at EOL, of those who receive hospice care more than half receive care for less than 20 days, and 1 in 5 patients die in an ICU. Palliative Care can/should co-exist with life prolonging care following the diagnosis of serious illness.

Common therapies/interventions to be contemplated and discussed with patient at end of life: cpr, mechanical ventilation, central venous/arterial access, renal replacement therapy, surgical procedures, valve therapies, ventricular assist devices, continuous infusions, IV fluids, supplemental oxygen, artificial nutrition, antimicrobials, blood products, cancer directed therapy, antithrombotics, anticoagulation.

Practical Elements of Palliative Care: pain and symptom management, advance care planning, communication/goals of care, truth-telling, social support, spiritual support, psychological support, risk/burden assessment of treatments.

Key Points/HM Takeaways:

1-Palliative Care Bedside Talking Points-

• Cardiac arrest is the moment of death, very few people survive an attempt at reversing death
• If you are one of the few who survive to discharge, you may do well but few will survive to discharge
• Antibiotics DO improve survival, antibiotics DO NOT improve comfort
• No evidence to show that dying from pneumonia, or other infection, is painful
• Allowing natural death includes permitting the body to shut itself down through natural mechanisms, including infection
• Dialysis may extend life, but there will be progressive functional decline

2-Goals of Care define what therapies are indicated. Balance prolongation of life with illness experience.

Julianna Lindsey is a hospitalist and physician leader based in the Dallas-Fort Worth Metroplex. Her focus is patient safety/quality and physician leadership. She is a member of TeamHospitalist.

 

 

4/8/15

Session: Last-Minute Heroics and Palliative Care – Do They Meet in the Middle?

HM15 Presenter: Tammie Quest, MD

Summation: Heroics- a set of medical actions that attempt to prolong life with a low likelihood of success.

Palliative care- an approach of care provided to patients and families suffering from serious and/or life limiting illness; focus on physical, spiritual, psychological and social aspects of distress.

Hospice care- intense palliative care provided when the patient has terminal illness with a prognosis of 6 months or less if the disease runs its usual course.

We underutilize Palliative and Hospice care in the US. Here in the US fewer than 50% of all persons receive hospice care at EOL, of those who receive hospice care more than half receive care for less than 20 days, and 1 in 5 patients die in an ICU. Palliative Care can/should co-exist with life prolonging care following the diagnosis of serious illness.

Common therapies/interventions to be contemplated and discussed with patient at end of life: cpr, mechanical ventilation, central venous/arterial access, renal replacement therapy, surgical procedures, valve therapies, ventricular assist devices, continuous infusions, IV fluids, supplemental oxygen, artificial nutrition, antimicrobials, blood products, cancer directed therapy, antithrombotics, anticoagulation.

Practical Elements of Palliative Care: pain and symptom management, advance care planning, communication/goals of care, truth-telling, social support, spiritual support, psychological support, risk/burden assessment of treatments.

Key Points/HM Takeaways:

1-Palliative Care Bedside Talking Points-

• Cardiac arrest is the moment of death, very few people survive an attempt at reversing death
• If you are one of the few who survive to discharge, you may do well but few will survive to discharge
• Antibiotics DO improve survival, antibiotics DO NOT improve comfort
• No evidence to show that dying from pneumonia, or other infection, is painful
• Allowing natural death includes permitting the body to shut itself down through natural mechanisms, including infection
• Dialysis may extend life, but there will be progressive functional decline

2-Goals of Care define what therapies are indicated. Balance prolongation of life with illness experience.

Julianna Lindsey is a hospitalist and physician leader based in the Dallas-Fort Worth Metroplex. Her focus is patient safety/quality and physician leadership. She is a member of TeamHospitalist.

 

 

HM15 Session: Putting Your Nickel Down: The What, Why, and How of Implementing Physician Value-Based Purchasing in Your Practice

Presenters: Stephen Besch, Simone Karp RPh, Patrick Torcson MD MMM SFHM, Gregory Seymann MD SFHM

Summation: HHS has set a goal of tying increasing percentages of Medicare payments to quality or value through alternative payment models, such as Accountable Care Organizations (ACOs) or bundled payment arrangements. By the end of 2018 the goal is for 50% of Medicare payments to be tied to these alternative payment models.   For the remaining traditional Medicare payment arrangements, 90% of those will be tied to quality/value incentives by 2018.

Medicare is transforming itself from a “passive payer” to an “active purchaser” of high quality, efficient healthcare. As such- active participation by physicians, physician groups, and hospitals is required for payment eligibility.

At the physician/group level, hospitalists should be reporting PQRS measures. Incentive payments for PQRS ended in 2014, Medicare is now making “negative payment adjustments.” Penalties are equal to a percentage of all Medicare Part B FFS (Fee-for-Service) charges and there is a 2-year delay between reporting or performance failure and penalization.

Physician Value-Based Purchasing (P-VBP) affects all Eligible Providers (EPs) in 2015. P4P (Pay for Performance) assesses both quality and cost. Aim is for budget neutrality via “quality tiering” which rewards “high quality/low cost” practices with penalties from “low quality/high cost” practices. As of now (2015) ACPs and therapists can be penalized under P-VBP.

Key Points/HM Takeaways:

• Hospitalists should be reporting PQRS measures- penalty phase has begun
• Key PQRS Changes for 2015:

  • 6 measures applicable to inpatient billing removed
  • no useful inpatient measures added
  • penalty avoidance requires 9 measures at 50% or higher rates, covering at least 3 of the 6 NQS (National Quality Strategy) domains- including 1 cross-cutting measure
  • all 2015 PQRS data will be posted to Physician Compare website in 2016
  • 3 Examples of hospitalist applicable “cross-cutting measures” are

    • 47-advance care plan
    • 130-documentation of current medications
    • 317-preventative care: bp screening

  • PQRS data must be reported with respect to MAV clusters (Measure Applicability Validation)- reporting only measure that have no MAV cluster is a safe strategy so long as one of the measures is “cross-cutting”
  • Maximum P-VBP penalties automatically apply if group does not report enough PQRS data
  • visit CMS website for more information

HM15 Session: Putting Your Nickel Down: The What, Why, and How of Implementing Physician Value-Based Purchasing in Your Practice

Presenters: Stephen Besch, Simone Karp RPh, Patrick Torcson MD MMM SFHM, Gregory Seymann MD SFHM

Summation: HHS has set a goal of tying increasing percentages of Medicare payments to quality or value through alternative payment models, such as Accountable Care Organizations (ACOs) or bundled payment arrangements. By the end of 2018 the goal is for 50% of Medicare payments to be tied to these alternative payment models.   For the remaining traditional Medicare payment arrangements, 90% of those will be tied to quality/value incentives by 2018.

Medicare is transforming itself from a “passive payer” to an “active purchaser” of high quality, efficient healthcare. As such- active participation by physicians, physician groups, and hospitals is required for payment eligibility.

At the physician/group level, hospitalists should be reporting PQRS measures. Incentive payments for PQRS ended in 2014, Medicare is now making “negative payment adjustments.” Penalties are equal to a percentage of all Medicare Part B FFS (Fee-for-Service) charges and there is a 2-year delay between reporting or performance failure and penalization.

Physician Value-Based Purchasing (P-VBP) affects all Eligible Providers (EPs) in 2015. P4P (Pay for Performance) assesses both quality and cost. Aim is for budget neutrality via “quality tiering” which rewards “high quality/low cost” practices with penalties from “low quality/high cost” practices. As of now (2015) ACPs and therapists can be penalized under P-VBP.

Key Points/HM Takeaways:

• Hospitalists should be reporting PQRS measures- penalty phase has begun
• Key PQRS Changes for 2015:

  • 6 measures applicable to inpatient billing removed
  • no useful inpatient measures added
  • penalty avoidance requires 9 measures at 50% or higher rates, covering at least 3 of the 6 NQS (National Quality Strategy) domains- including 1 cross-cutting measure
  • all 2015 PQRS data will be posted to Physician Compare website in 2016
  • 3 Examples of hospitalist applicable “cross-cutting measures” are

    • 47-advance care plan
    • 130-documentation of current medications
    • 317-preventative care: bp screening

  • PQRS data must be reported with respect to MAV clusters (Measure Applicability Validation)- reporting only measure that have no MAV cluster is a safe strategy so long as one of the measures is “cross-cutting”
  • Maximum P-VBP penalties automatically apply if group does not report enough PQRS data
  • visit CMS website for more information

HM15 Session: Putting Your Nickel Down: The What, Why, and How of Implementing Physician Value-Based Purchasing in Your Practice

Presenters: Stephen Besch, Simone Karp RPh, Patrick Torcson MD MMM SFHM, Gregory Seymann MD SFHM

Summation: HHS has set a goal of tying increasing percentages of Medicare payments to quality or value through alternative payment models, such as Accountable Care Organizations (ACOs) or bundled payment arrangements. By the end of 2018 the goal is for 50% of Medicare payments to be tied to these alternative payment models.   For the remaining traditional Medicare payment arrangements, 90% of those will be tied to quality/value incentives by 2018.

Medicare is transforming itself from a “passive payer” to an “active purchaser” of high quality, efficient healthcare. As such- active participation by physicians, physician groups, and hospitals is required for payment eligibility.

At the physician/group level, hospitalists should be reporting PQRS measures. Incentive payments for PQRS ended in 2014, Medicare is now making “negative payment adjustments.” Penalties are equal to a percentage of all Medicare Part B FFS (Fee-for-Service) charges and there is a 2-year delay between reporting or performance failure and penalization.

Physician Value-Based Purchasing (P-VBP) affects all Eligible Providers (EPs) in 2015. P4P (Pay for Performance) assesses both quality and cost. Aim is for budget neutrality via “quality tiering” which rewards “high quality/low cost” practices with penalties from “low quality/high cost” practices. As of now (2015) ACPs and therapists can be penalized under P-VBP.

Key Points/HM Takeaways:

• Hospitalists should be reporting PQRS measures- penalty phase has begun
• Key PQRS Changes for 2015:

  • 6 measures applicable to inpatient billing removed
  • no useful inpatient measures added
  • penalty avoidance requires 9 measures at 50% or higher rates, covering at least 3 of the 6 NQS (National Quality Strategy) domains- including 1 cross-cutting measure
  • all 2015 PQRS data will be posted to Physician Compare website in 2016
  • 3 Examples of hospitalist applicable “cross-cutting measures” are

    • 47-advance care plan
    • 130-documentation of current medications
    • 317-preventative care: bp screening

  • PQRS data must be reported with respect to MAV clusters (Measure Applicability Validation)- reporting only measure that have no MAV cluster is a safe strategy so long as one of the measures is “cross-cutting”
  • Maximum P-VBP penalties automatically apply if group does not report enough PQRS data
  • visit CMS website for more information

HM15 Session  RAPID FIRE PANEL: Hot Topics in Practice Management Updates on Key Issues, Including the Key Characteristics of an Effective HMG

HM15 Presenters: Roy Sittig MD SFHM, Jeffrey Frank MD MBA, Jodi Braun

Summation: Speakers covered timely topics regarding the Accountable Care Act, namely Medicaid Expansion and Bundled Payment arrangements; and reviewed the seminal paper on “Key Principals and Characteristics of an Effective Hospitalist Medicine Group” and lessons learned in implementing those 10 Key Principles.

Medicaid Expansion: EDs serving the 29 Medicaid expansion states are reporting higher volumes, likely due to 11.4million new lives now insured under the ACA. While the ACA does provide for higher Medicaid payment rates thus far, only 34% of providers accept Medicaid, a 21% drop since the ACA went into effect.

Bundled Payment Arrangements:

• Bundled Payment Care Initiative (BPCI) lexicon:

  • Model 2-Episode Anchor (anchor admission) AND 90days post d/c; Medicare pays 98% of usual cost
  • Model 3-90days post d/c AFTER anchor admission; Medicare pays 97% of usual cost
  • Convener-entity that brings providers together and enters into CMS agreement to bear risk for bundles
  • Awardee (entity having agreement with Medicare to assume risk and receive payment via BPCI) and Convener own the Bundle
  • Episode initiator (EI) triggers “bundle period”
  • Bundles based on DRG

10-Key Principles of an Effective Hospitalist Medicine Group:

1. Effective Leadership
2. Engaged Hospitalists
3. Adequate Resources
4. Planning and Management Infrastructure
5. Alignment with Hospital/Health System
6. Care Coordination Across Settings
7. Leadership in Key Clinical Issues in the Hospital/Health System
8. Thoughtful Approach to Scope of Activity
9. Patient/Family-Centered, Team-Based Care; Effective Communication
10. Recruiting/Retaining Qualified Clinicians

Key Points/HM Takeaways:

Medicaid Expansion- many of the 11.4M newly insured lives under the ACA have moved into Medicaid. Only about 1/3 of providers now accept Medicaid- 1 in 5 covered persons now have Medicaid, nearly 20% increase since 2013.

Bundled Payments- Majority of savings opportunity lies in Post-Acute Care. Awardee and Convener make profit is total cost is less than 98% of Target Price. In gainsharing agreements individuals can be reimbursed up to 150% usual Medicare rate. Pay occurs in usual Medicare fashion but is reconciled 60-90 days after end of bundle. For more information: http://innovation.cms.gov/initiatives/bundled-payments/

Effective HM Groups- Three important areas for focus when beginning to address group performance are: engaged hospitalists, planning and management infrastructure, care coordination across settings. These three topics have broad reaching implications into the hospitalist practice and patient care. [Cawley P, et al. Journal of Hospital Medicine 2014; 9(2):123-128]

HM15 Session  RAPID FIRE PANEL: Hot Topics in Practice Management Updates on Key Issues, Including the Key Characteristics of an Effective HMG

HM15 Presenters: Roy Sittig MD SFHM, Jeffrey Frank MD MBA, Jodi Braun

Summation: Speakers covered timely topics regarding the Accountable Care Act, namely Medicaid Expansion and Bundled Payment arrangements; and reviewed the seminal paper on “Key Principals and Characteristics of an Effective Hospitalist Medicine Group” and lessons learned in implementing those 10 Key Principles.

Medicaid Expansion: EDs serving the 29 Medicaid expansion states are reporting higher volumes, likely due to 11.4million new lives now insured under the ACA. While the ACA does provide for higher Medicaid payment rates thus far, only 34% of providers accept Medicaid, a 21% drop since the ACA went into effect.

Bundled Payment Arrangements:

• Bundled Payment Care Initiative (BPCI) lexicon:

  • Model 2-Episode Anchor (anchor admission) AND 90days post d/c; Medicare pays 98% of usual cost
  • Model 3-90days post d/c AFTER anchor admission; Medicare pays 97% of usual cost
  • Convener-entity that brings providers together and enters into CMS agreement to bear risk for bundles
  • Awardee (entity having agreement with Medicare to assume risk and receive payment via BPCI) and Convener own the Bundle
  • Episode initiator (EI) triggers “bundle period”
  • Bundles based on DRG

10-Key Principles of an Effective Hospitalist Medicine Group:

1. Effective Leadership
2. Engaged Hospitalists
3. Adequate Resources
4. Planning and Management Infrastructure
5. Alignment with Hospital/Health System
6. Care Coordination Across Settings
7. Leadership in Key Clinical Issues in the Hospital/Health System
8. Thoughtful Approach to Scope of Activity
9. Patient/Family-Centered, Team-Based Care; Effective Communication
10. Recruiting/Retaining Qualified Clinicians

Key Points/HM Takeaways:

Medicaid Expansion- many of the 11.4M newly insured lives under the ACA have moved into Medicaid. Only about 1/3 of providers now accept Medicaid- 1 in 5 covered persons now have Medicaid, nearly 20% increase since 2013.

Bundled Payments- Majority of savings opportunity lies in Post-Acute Care. Awardee and Convener make profit is total cost is less than 98% of Target Price. In gainsharing agreements individuals can be reimbursed up to 150% usual Medicare rate. Pay occurs in usual Medicare fashion but is reconciled 60-90 days after end of bundle. For more information: http://innovation.cms.gov/initiatives/bundled-payments/

Effective HM Groups- Three important areas for focus when beginning to address group performance are: engaged hospitalists, planning and management infrastructure, care coordination across settings. These three topics have broad reaching implications into the hospitalist practice and patient care. [Cawley P, et al. Journal of Hospital Medicine 2014; 9(2):123-128]

HM15 Session  RAPID FIRE PANEL: Hot Topics in Practice Management Updates on Key Issues, Including the Key Characteristics of an Effective HMG

HM15 Presenters: Roy Sittig MD SFHM, Jeffrey Frank MD MBA, Jodi Braun

Summation: Speakers covered timely topics regarding the Accountable Care Act, namely Medicaid Expansion and Bundled Payment arrangements; and reviewed the seminal paper on “Key Principals and Characteristics of an Effective Hospitalist Medicine Group” and lessons learned in implementing those 10 Key Principles.

Medicaid Expansion: EDs serving the 29 Medicaid expansion states are reporting higher volumes, likely due to 11.4million new lives now insured under the ACA. While the ACA does provide for higher Medicaid payment rates thus far, only 34% of providers accept Medicaid, a 21% drop since the ACA went into effect.

Bundled Payment Arrangements:

• Bundled Payment Care Initiative (BPCI) lexicon:

  • Model 2-Episode Anchor (anchor admission) AND 90days post d/c; Medicare pays 98% of usual cost
  • Model 3-90days post d/c AFTER anchor admission; Medicare pays 97% of usual cost
  • Convener-entity that brings providers together and enters into CMS agreement to bear risk for bundles
  • Awardee (entity having agreement with Medicare to assume risk and receive payment via BPCI) and Convener own the Bundle
  • Episode initiator (EI) triggers “bundle period”
  • Bundles based on DRG

10-Key Principles of an Effective Hospitalist Medicine Group:

1. Effective Leadership
2. Engaged Hospitalists
3. Adequate Resources
4. Planning and Management Infrastructure
5. Alignment with Hospital/Health System
6. Care Coordination Across Settings
7. Leadership in Key Clinical Issues in the Hospital/Health System
8. Thoughtful Approach to Scope of Activity
9. Patient/Family-Centered, Team-Based Care; Effective Communication
10. Recruiting/Retaining Qualified Clinicians

Key Points/HM Takeaways:

Medicaid Expansion- many of the 11.4M newly insured lives under the ACA have moved into Medicaid. Only about 1/3 of providers now accept Medicaid- 1 in 5 covered persons now have Medicaid, nearly 20% increase since 2013.

Bundled Payments- Majority of savings opportunity lies in Post-Acute Care. Awardee and Convener make profit is total cost is less than 98% of Target Price. In gainsharing agreements individuals can be reimbursed up to 150% usual Medicare rate. Pay occurs in usual Medicare fashion but is reconciled 60-90 days after end of bundle. For more information: http://innovation.cms.gov/initiatives/bundled-payments/

Effective HM Groups- Three important areas for focus when beginning to address group performance are: engaged hospitalists, planning and management infrastructure, care coordination across settings. These three topics have broad reaching implications into the hospitalist practice and patient care. [Cawley P, et al. Journal of Hospital Medicine 2014; 9(2):123-128]

In a presentation on guidelines for ALTE, Jack Percelay, SHM representative to the AAP Subcommittee, provided further insight to the work that has been done for the clinical entity known as apparent life-threatening events (ALTE) since a consensus statement was put forward by the NIH in 1986. The original statement emphasized 4 possible features to constitute ALTE: apnea, color change, change in tone or gagging. The imprecise nature of the definition, along with both provider and caretaker anxiety related to the diagnosis, have lead to a cascade of diagnostic testing and treatments for what is a symptom complex, not a disease.

Subsequent work in the field has clarified that an ALTE is not a risk factor for SIDS. Of the myriad of etiologies that can cause an ALTE, many will have a readily identifiable etiology that a good history and physical exam will diagnose. Most other diseases, if not diagnosed at initial presentation, will become apparent subsequently without any significant consequences (for example epilepsy). Two diagnoses, which if missed, may have significant consequences include child abuse and a cardiac arrhythmia.

In an effort to synthesize new data along with expert opinion, the American Academy of Pediatrics has convened a Subcommittee on the Guideline for ALTE, lead by Joel Tieder, to develop a new practice guideline. This guideline is still in development with certain areas not ready for broad dissemination. The highlight of the new guideline will be a proposal for a name change for ALTEs. Dr Percelay reports the proposed new name would be BRUE (pronounced “brew”), Brief Resolved Unexplained Event. He anticipates further information to be published that will offer a framework to specify which infants to consider at low risk of recurrence versus higher risk for significant pathology. For those infants identified as low risk, the guideline will offer specific evaluation and treatment recommendations. An anticipated key point of the new guideline will be that a careful history and physical is the cornerstone of the initial evaluation and that in the absence of specific historical or exam findings, diagnostic testing of well-appearing infants is of low value.

In a presentation on guidelines for ALTE, Jack Percelay, SHM representative to the AAP Subcommittee, provided further insight to the work that has been done for the clinical entity known as apparent life-threatening events (ALTE) since a consensus statement was put forward by the NIH in 1986. The original statement emphasized 4 possible features to constitute ALTE: apnea, color change, change in tone or gagging. The imprecise nature of the definition, along with both provider and caretaker anxiety related to the diagnosis, have lead to a cascade of diagnostic testing and treatments for what is a symptom complex, not a disease.

Subsequent work in the field has clarified that an ALTE is not a risk factor for SIDS. Of the myriad of etiologies that can cause an ALTE, many will have a readily identifiable etiology that a good history and physical exam will diagnose. Most other diseases, if not diagnosed at initial presentation, will become apparent subsequently without any significant consequences (for example epilepsy). Two diagnoses, which if missed, may have significant consequences include child abuse and a cardiac arrhythmia.

In an effort to synthesize new data along with expert opinion, the American Academy of Pediatrics has convened a Subcommittee on the Guideline for ALTE, lead by Joel Tieder, to develop a new practice guideline. This guideline is still in development with certain areas not ready for broad dissemination. The highlight of the new guideline will be a proposal for a name change for ALTEs. Dr Percelay reports the proposed new name would be BRUE (pronounced “brew”), Brief Resolved Unexplained Event. He anticipates further information to be published that will offer a framework to specify which infants to consider at low risk of recurrence versus higher risk for significant pathology. For those infants identified as low risk, the guideline will offer specific evaluation and treatment recommendations. An anticipated key point of the new guideline will be that a careful history and physical is the cornerstone of the initial evaluation and that in the absence of specific historical or exam findings, diagnostic testing of well-appearing infants is of low value.

In a presentation on guidelines for ALTE, Jack Percelay, SHM representative to the AAP Subcommittee, provided further insight to the work that has been done for the clinical entity known as apparent life-threatening events (ALTE) since a consensus statement was put forward by the NIH in 1986. The original statement emphasized 4 possible features to constitute ALTE: apnea, color change, change in tone or gagging. The imprecise nature of the definition, along with both provider and caretaker anxiety related to the diagnosis, have lead to a cascade of diagnostic testing and treatments for what is a symptom complex, not a disease.

Subsequent work in the field has clarified that an ALTE is not a risk factor for SIDS. Of the myriad of etiologies that can cause an ALTE, many will have a readily identifiable etiology that a good history and physical exam will diagnose. Most other diseases, if not diagnosed at initial presentation, will become apparent subsequently without any significant consequences (for example epilepsy). Two diagnoses, which if missed, may have significant consequences include child abuse and a cardiac arrhythmia.

In an effort to synthesize new data along with expert opinion, the American Academy of Pediatrics has convened a Subcommittee on the Guideline for ALTE, lead by Joel Tieder, to develop a new practice guideline. This guideline is still in development with certain areas not ready for broad dissemination. The highlight of the new guideline will be a proposal for a name change for ALTEs. Dr Percelay reports the proposed new name would be BRUE (pronounced “brew”), Brief Resolved Unexplained Event. He anticipates further information to be published that will offer a framework to specify which infants to consider at low risk of recurrence versus higher risk for significant pathology. For those infants identified as low risk, the guideline will offer specific evaluation and treatment recommendations. An anticipated key point of the new guideline will be that a careful history and physical is the cornerstone of the initial evaluation and that in the absence of specific historical or exam findings, diagnostic testing of well-appearing infants is of low value.

Hospitalists practicing in post–acute-care facilities have a new resource via an SHM partnership.

The society and IPC Healthcare of North Hollywood, Calif., debuted at the "Primer for Hospitalists on Skilled Nursing Facilities" at 2015 annual meeting.

The educational program, housed at SHM's Learning Portal, has 32 lessons meant to differentiate the traditional acute-care hospital from post–acute-care facilities. Lessons are grouped into five sections and two modules, with a focus on skilled-nursing facilities (SNFs), the most common post–acute-care settings.

"The types of resources that are available are different, and that's not only in terms of staff, but the availability of specialists, the availability of testing capabilities," says Joseph Miller, SHM's senior vice president for practice management.

"If you need to work with a cardiologist for a particular patient…how do you engage them?" Miller adds. "You're not going to be able to have them come and see that patient frequently. How do you communicate with them to get the feedback you need as the attending physician?"

Miller says that some 30% of hospitalist groups are practicing in post-acute settings, with the number only expected to rise. That's why SHM partnered with IPC to adapt and supplement that firm's post–acute-care program.

In addition, the rise of bundled payments and other reimbursement plans that include the post-discharge period also make now the right time for SHM to help provide educational resources, he adds.

Miller compared hospitalists to football quarterbacks, coordinating patient care as part of a team. Historically their focus has only been on care within the four walls of the hospital. But this is changing.

“Discharging a patient is like throwing a football pass," Miller says. “Today you don’t pay much attention to the receiver—whether he catches the ball or not. In the future, hospitalists will need to be concerned with completing the pass and scoring a touchdown.”

Visit our website for more on post-acute care.

Hospitalists practicing in post–acute-care facilities have a new resource via an SHM partnership.

The society and IPC Healthcare of North Hollywood, Calif., debuted at the "Primer for Hospitalists on Skilled Nursing Facilities" at 2015 annual meeting.

The educational program, housed at SHM's Learning Portal, has 32 lessons meant to differentiate the traditional acute-care hospital from post–acute-care facilities. Lessons are grouped into five sections and two modules, with a focus on skilled-nursing facilities (SNFs), the most common post–acute-care settings.

"The types of resources that are available are different, and that's not only in terms of staff, but the availability of specialists, the availability of testing capabilities," says Joseph Miller, SHM's senior vice president for practice management.

"If you need to work with a cardiologist for a particular patient…how do you engage them?" Miller adds. "You're not going to be able to have them come and see that patient frequently. How do you communicate with them to get the feedback you need as the attending physician?"

Miller says that some 30% of hospitalist groups are practicing in post-acute settings, with the number only expected to rise. That's why SHM partnered with IPC to adapt and supplement that firm's post–acute-care program.

In addition, the rise of bundled payments and other reimbursement plans that include the post-discharge period also make now the right time for SHM to help provide educational resources, he adds.

Miller compared hospitalists to football quarterbacks, coordinating patient care as part of a team. Historically their focus has only been on care within the four walls of the hospital. But this is changing.

“Discharging a patient is like throwing a football pass," Miller says. “Today you don’t pay much attention to the receiver—whether he catches the ball or not. In the future, hospitalists will need to be concerned with completing the pass and scoring a touchdown.”

Visit our website for more on post-acute care.

Hospitalists practicing in post–acute-care facilities have a new resource via an SHM partnership.

The society and IPC Healthcare of North Hollywood, Calif., debuted at the "Primer for Hospitalists on Skilled Nursing Facilities" at 2015 annual meeting.

The educational program, housed at SHM's Learning Portal, has 32 lessons meant to differentiate the traditional acute-care hospital from post–acute-care facilities. Lessons are grouped into five sections and two modules, with a focus on skilled-nursing facilities (SNFs), the most common post–acute-care settings.

"The types of resources that are available are different, and that's not only in terms of staff, but the availability of specialists, the availability of testing capabilities," says Joseph Miller, SHM's senior vice president for practice management.

"If you need to work with a cardiologist for a particular patient…how do you engage them?" Miller adds. "You're not going to be able to have them come and see that patient frequently. How do you communicate with them to get the feedback you need as the attending physician?"

Miller says that some 30% of hospitalist groups are practicing in post-acute settings, with the number only expected to rise. That's why SHM partnered with IPC to adapt and supplement that firm's post–acute-care program.

In addition, the rise of bundled payments and other reimbursement plans that include the post-discharge period also make now the right time for SHM to help provide educational resources, he adds.

Miller compared hospitalists to football quarterbacks, coordinating patient care as part of a team. Historically their focus has only been on care within the four walls of the hospital. But this is changing.

“Discharging a patient is like throwing a football pass," Miller says. “Today you don’t pay much attention to the receiver—whether he catches the ball or not. In the future, hospitalists will need to be concerned with completing the pass and scoring a touchdown.”

Visit our website for more on post-acute care.

A recent study found different approaches used by four popular hospital ratings systems resulted in disagreement about the ranking of many U.S. hospitals.

"Only 10% of hospitals that were rated as a high performer on one of the systems were rated as a high performer on another rating system," says lead author John Matthew Austin, MS, PhD, assistant professor of anesthesiology and critical care medicine at Johns Hopkins University School of Medicine in Baltimore. "There was no one hospital that was rated as a high performer on all four."

The study, which appeared in Health Affairs, looked at the hospital ratings systems of U.S. News, Healthgrades, The Leapfrog Group, and Consumer Reports, and found none took the same approach to assessing hospital quality. Of the 83 hospitals rated by all four systems, none were universally recognized as either a high performer or a low performer.

"I think the impact, or the influence, on consumers is that these conflicting ratings could generate confusion," Dr. Austin says. "Depending on which rating system you look at, it may give you a different answer on which hospital or where you should seek care. If you look at these four rating systems in a community, you may actually wind up being directed to four different hospitals."

David Pressel, MD, PhD, medical director of inpatient care at Alfred I. duPont Hospital for Children in Wilmington, Del., emphasized the difficulty of defining quality.

"Measuring quality is really difficult and hard, and people, physicians, and hospitals struggle with this," he explains. "I think it's very important that people recognize in rating systems there’s always going to be a top 10% or top 50% and a bottom 10% or 50%, and what's really important is not if you're in the top or bottom but what the scatter of the data is. If the scatter of the data is very narrow, they may not be providing much worse care than the top hospitals. I think that is lost on the public."

Dr. Austin's study identified varying missions and methodologies for each ratings system.

"U.S. News' Best Hospitals is actually intending to identify the best medical centers for the most complicated cases," Dr. Austin says. "The Leapfrog Hospital Safety Score has a very laser focus on patient safety, so freedom from harm, things like errors, infections."

Dr. Austin also noticed that some rating systems were more descriptive about their methods than others.

"Some of the ratings are much more transparent in what they share, in terms of how hospitals are rated, and others are less clear," he notes. "Healthgrades lists the top 100 hospitals. They're supposedly looking at hospital outcomes, but they don't publicly make their methodology available in terms of their risk-adjustment levels."

The rating systems also communicated their ratings differently. Leapfrog issues letter grades A–F; Consumer Reports and U.S. News issue scores from 0–100; and Healthgrades identifies the top 50 and top 100 hospitals but doesn’t rank hospitals, and hospitals that are not in the top 100 are not rated at all.

The study authors outlined possible improvements to eliminate some of these disparities, including reaching out to the sponsoring organizations and encouraging them to be more transparent about their ratings to allow for easier patient interpretation.

"Patients should understand what's being measured," Dr. Austin says. "Hospitals should be able to duplicate their ratings, so full transparency of the measures themselves, of the methodologies, is really important. We feel like these are a great start, but we definitely have some issues that still need to be resolved around measurements. We need better standardized measures."

 

Visit our website for more information on hospital ratings.

A recent study found different approaches used by four popular hospital ratings systems resulted in disagreement about the ranking of many U.S. hospitals.

"Only 10% of hospitals that were rated as a high performer on one of the systems were rated as a high performer on another rating system," says lead author John Matthew Austin, MS, PhD, assistant professor of anesthesiology and critical care medicine at Johns Hopkins University School of Medicine in Baltimore. "There was no one hospital that was rated as a high performer on all four."

The study, which appeared in Health Affairs, looked at the hospital ratings systems of U.S. News, Healthgrades, The Leapfrog Group, and Consumer Reports, and found none took the same approach to assessing hospital quality. Of the 83 hospitals rated by all four systems, none were universally recognized as either a high performer or a low performer.

"I think the impact, or the influence, on consumers is that these conflicting ratings could generate confusion," Dr. Austin says. "Depending on which rating system you look at, it may give you a different answer on which hospital or where you should seek care. If you look at these four rating systems in a community, you may actually wind up being directed to four different hospitals."

David Pressel, MD, PhD, medical director of inpatient care at Alfred I. duPont Hospital for Children in Wilmington, Del., emphasized the difficulty of defining quality.

"Measuring quality is really difficult and hard, and people, physicians, and hospitals struggle with this," he explains. "I think it's very important that people recognize in rating systems there’s always going to be a top 10% or top 50% and a bottom 10% or 50%, and what's really important is not if you're in the top or bottom but what the scatter of the data is. If the scatter of the data is very narrow, they may not be providing much worse care than the top hospitals. I think that is lost on the public."

Dr. Austin's study identified varying missions and methodologies for each ratings system.

"U.S. News' Best Hospitals is actually intending to identify the best medical centers for the most complicated cases," Dr. Austin says. "The Leapfrog Hospital Safety Score has a very laser focus on patient safety, so freedom from harm, things like errors, infections."

Dr. Austin also noticed that some rating systems were more descriptive about their methods than others.

"Some of the ratings are much more transparent in what they share, in terms of how hospitals are rated, and others are less clear," he notes. "Healthgrades lists the top 100 hospitals. They're supposedly looking at hospital outcomes, but they don't publicly make their methodology available in terms of their risk-adjustment levels."

The rating systems also communicated their ratings differently. Leapfrog issues letter grades A–F; Consumer Reports and U.S. News issue scores from 0–100; and Healthgrades identifies the top 50 and top 100 hospitals but doesn’t rank hospitals, and hospitals that are not in the top 100 are not rated at all.

The study authors outlined possible improvements to eliminate some of these disparities, including reaching out to the sponsoring organizations and encouraging them to be more transparent about their ratings to allow for easier patient interpretation.

"Patients should understand what's being measured," Dr. Austin says. "Hospitals should be able to duplicate their ratings, so full transparency of the measures themselves, of the methodologies, is really important. We feel like these are a great start, but we definitely have some issues that still need to be resolved around measurements. We need better standardized measures."

 

Visit our website for more information on hospital ratings.

A recent study found different approaches used by four popular hospital ratings systems resulted in disagreement about the ranking of many U.S. hospitals.

"Only 10% of hospitals that were rated as a high performer on one of the systems were rated as a high performer on another rating system," says lead author John Matthew Austin, MS, PhD, assistant professor of anesthesiology and critical care medicine at Johns Hopkins University School of Medicine in Baltimore. "There was no one hospital that was rated as a high performer on all four."

The study, which appeared in Health Affairs, looked at the hospital ratings systems of U.S. News, Healthgrades, The Leapfrog Group, and Consumer Reports, and found none took the same approach to assessing hospital quality. Of the 83 hospitals rated by all four systems, none were universally recognized as either a high performer or a low performer.

"I think the impact, or the influence, on consumers is that these conflicting ratings could generate confusion," Dr. Austin says. "Depending on which rating system you look at, it may give you a different answer on which hospital or where you should seek care. If you look at these four rating systems in a community, you may actually wind up being directed to four different hospitals."

David Pressel, MD, PhD, medical director of inpatient care at Alfred I. duPont Hospital for Children in Wilmington, Del., emphasized the difficulty of defining quality.

"Measuring quality is really difficult and hard, and people, physicians, and hospitals struggle with this," he explains. "I think it's very important that people recognize in rating systems there’s always going to be a top 10% or top 50% and a bottom 10% or 50%, and what's really important is not if you're in the top or bottom but what the scatter of the data is. If the scatter of the data is very narrow, they may not be providing much worse care than the top hospitals. I think that is lost on the public."

Dr. Austin's study identified varying missions and methodologies for each ratings system.

"U.S. News' Best Hospitals is actually intending to identify the best medical centers for the most complicated cases," Dr. Austin says. "The Leapfrog Hospital Safety Score has a very laser focus on patient safety, so freedom from harm, things like errors, infections."

Dr. Austin also noticed that some rating systems were more descriptive about their methods than others.

"Some of the ratings are much more transparent in what they share, in terms of how hospitals are rated, and others are less clear," he notes. "Healthgrades lists the top 100 hospitals. They're supposedly looking at hospital outcomes, but they don't publicly make their methodology available in terms of their risk-adjustment levels."

The rating systems also communicated their ratings differently. Leapfrog issues letter grades A–F; Consumer Reports and U.S. News issue scores from 0–100; and Healthgrades identifies the top 50 and top 100 hospitals but doesn’t rank hospitals, and hospitals that are not in the top 100 are not rated at all.

The study authors outlined possible improvements to eliminate some of these disparities, including reaching out to the sponsoring organizations and encouraging them to be more transparent about their ratings to allow for easier patient interpretation.

"Patients should understand what's being measured," Dr. Austin says. "Hospitals should be able to duplicate their ratings, so full transparency of the measures themselves, of the methodologies, is really important. We feel like these are a great start, but we definitely have some issues that still need to be resolved around measurements. We need better standardized measures."

 

Visit our website for more information on hospital ratings.

In the article “Common Coding Mistakes Hospitalists Should Avoid” in the August 2014 issue of The Hospitalist, the author states:

“For inpatient care, an established problem is defined as one in which a care plan has been generated by the physician (or same specialty group practice member) during the current hospitalization.”

This definition contradicts what I have been told in other coding courses regarding new vs. established problems relative to the examiner. It has been my understanding that when [I am] rotating on service and I have not seen that particular patient during the current admission, all of the current problems are new to me, even if previously identified by another member of my group. This [situation] results in a higher complexity of medical decision-making, which is reflective of the increased time spent learning a new patient when coming on service. I would appreciate clarification from the author.

–Matt George, MD,

medical director, MBHS Hospitalists

Billing and coding expert Carol Pohlig, BSN, RN, CPC, ACS, explains:

Be mindful when attending coding courses that are not contractor sponsored, as they may not validate the geographical interpretations of the rules for providers. There are several factors to consider when crediting the physician with “new” or “established” problems.

CMS documentation guidelines state: “Decision making with respect to a diagnosed problem is easier than that for an identified but undiagnosed problem.¹

• For a presenting problem with an established diagnosis, the record should reflect whether the problem is:

  • Improved, well-controlled, resolving, or resolved or
  • Inadequately controlled, worsening, or failing to change as expected.

• For a presenting problem without an established diagnosis, the assessment or clinical impression may be stated in the form of differential diagnoses or as a “possible,” “probable,” or “rule out” diagnosis.

Although Medicare contractors utilize the Marshfield Clinic Scoring Tool when reviewing evaluation and management (E/M) services, a tool that historically refers to the “examiner” when considering the patient’s diagnoses, not all accept this tool-inspired standard, particularly in the advent of electronic health record accessibility and the idea that same-specialty physicians in a group practice are viewed as an individual physician.^2,3

Reviewing information and familiarization of patients is often considered pre-service work and factored into the payment for E/M services. More importantly, the feasibility of an auditor being able to distinguish new vs. established problems at the level of the “examiner” is decreased when auditing a single date of service. Non-Medicare payers who audit E/M services do not necessarily follow contractor-specific guidelines but, rather, general CMS guidelines.

Therefore, without knowing the insurer or their interpretation at the time of service or visit level selection, the CMS-developed standard is the most practical application when considering the complexity of the encounter.

References

1. Centers for Medicare and Medicaid Services. Department of Health and Human Services. Evaluation and management services guide. Available at: http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/downloads//eval_mgmt_serv_guide-ICN006764.pdf. Accessed November 13, 2014.
2. National Government Services. Evaluation and management documentation training too. Available at: http://www.ngsmedicare.com/ngs/wcm/connect/3632a905-b697-4266-8fc0-2aa2a84fedb2/1074_0514_EM_Documentation_Training_Tool_508.pdf?MOD=AJPERES. Accessed November 13, 2014.
3. Centers for Medicare and Medicaid Services. Medicare Claims Processing Manual. Chapter 12 – Physicians/nonphysician practitioners. Available at: http://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/clm104c12.pdf. Accessed November 13, 2014.

In the article “Common Coding Mistakes Hospitalists Should Avoid” in the August 2014 issue of The Hospitalist, the author states:

“For inpatient care, an established problem is defined as one in which a care plan has been generated by the physician (or same specialty group practice member) during the current hospitalization.”

This definition contradicts what I have been told in other coding courses regarding new vs. established problems relative to the examiner. It has been my understanding that when [I am] rotating on service and I have not seen that particular patient during the current admission, all of the current problems are new to me, even if previously identified by another member of my group. This [situation] results in a higher complexity of medical decision-making, which is reflective of the increased time spent learning a new patient when coming on service. I would appreciate clarification from the author.

–Matt George, MD,

medical director, MBHS Hospitalists

Billing and coding expert Carol Pohlig, BSN, RN, CPC, ACS, explains:

Be mindful when attending coding courses that are not contractor sponsored, as they may not validate the geographical interpretations of the rules for providers. There are several factors to consider when crediting the physician with “new” or “established” problems.

CMS documentation guidelines state: “Decision making with respect to a diagnosed problem is easier than that for an identified but undiagnosed problem.¹

• For a presenting problem with an established diagnosis, the record should reflect whether the problem is:

  • Improved, well-controlled, resolving, or resolved or
  • Inadequately controlled, worsening, or failing to change as expected.

• For a presenting problem without an established diagnosis, the assessment or clinical impression may be stated in the form of differential diagnoses or as a “possible,” “probable,” or “rule out” diagnosis.

Although Medicare contractors utilize the Marshfield Clinic Scoring Tool when reviewing evaluation and management (E/M) services, a tool that historically refers to the “examiner” when considering the patient’s diagnoses, not all accept this tool-inspired standard, particularly in the advent of electronic health record accessibility and the idea that same-specialty physicians in a group practice are viewed as an individual physician.^2,3

Reviewing information and familiarization of patients is often considered pre-service work and factored into the payment for E/M services. More importantly, the feasibility of an auditor being able to distinguish new vs. established problems at the level of the “examiner” is decreased when auditing a single date of service. Non-Medicare payers who audit E/M services do not necessarily follow contractor-specific guidelines but, rather, general CMS guidelines.

Therefore, without knowing the insurer or their interpretation at the time of service or visit level selection, the CMS-developed standard is the most practical application when considering the complexity of the encounter.

References

1. Centers for Medicare and Medicaid Services. Department of Health and Human Services. Evaluation and management services guide. Available at: http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/downloads//eval_mgmt_serv_guide-ICN006764.pdf. Accessed November 13, 2014.
2. National Government Services. Evaluation and management documentation training too. Available at: http://www.ngsmedicare.com/ngs/wcm/connect/3632a905-b697-4266-8fc0-2aa2a84fedb2/1074_0514_EM_Documentation_Training_Tool_508.pdf?MOD=AJPERES. Accessed November 13, 2014.
3. Centers for Medicare and Medicaid Services. Medicare Claims Processing Manual. Chapter 12 – Physicians/nonphysician practitioners. Available at: http://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/clm104c12.pdf. Accessed November 13, 2014.

In the article “Common Coding Mistakes Hospitalists Should Avoid” in the August 2014 issue of The Hospitalist, the author states:

“For inpatient care, an established problem is defined as one in which a care plan has been generated by the physician (or same specialty group practice member) during the current hospitalization.”

This definition contradicts what I have been told in other coding courses regarding new vs. established problems relative to the examiner. It has been my understanding that when [I am] rotating on service and I have not seen that particular patient during the current admission, all of the current problems are new to me, even if previously identified by another member of my group. This [situation] results in a higher complexity of medical decision-making, which is reflective of the increased time spent learning a new patient when coming on service. I would appreciate clarification from the author.

–Matt George, MD,

medical director, MBHS Hospitalists

Billing and coding expert Carol Pohlig, BSN, RN, CPC, ACS, explains:

Be mindful when attending coding courses that are not contractor sponsored, as they may not validate the geographical interpretations of the rules for providers. There are several factors to consider when crediting the physician with “new” or “established” problems.

CMS documentation guidelines state: “Decision making with respect to a diagnosed problem is easier than that for an identified but undiagnosed problem.¹

• For a presenting problem with an established diagnosis, the record should reflect whether the problem is:

  • Improved, well-controlled, resolving, or resolved or
  • Inadequately controlled, worsening, or failing to change as expected.

• For a presenting problem without an established diagnosis, the assessment or clinical impression may be stated in the form of differential diagnoses or as a “possible,” “probable,” or “rule out” diagnosis.

Although Medicare contractors utilize the Marshfield Clinic Scoring Tool when reviewing evaluation and management (E/M) services, a tool that historically refers to the “examiner” when considering the patient’s diagnoses, not all accept this tool-inspired standard, particularly in the advent of electronic health record accessibility and the idea that same-specialty physicians in a group practice are viewed as an individual physician.^2,3

Reviewing information and familiarization of patients is often considered pre-service work and factored into the payment for E/M services. More importantly, the feasibility of an auditor being able to distinguish new vs. established problems at the level of the “examiner” is decreased when auditing a single date of service. Non-Medicare payers who audit E/M services do not necessarily follow contractor-specific guidelines but, rather, general CMS guidelines.

Therefore, without knowing the insurer or their interpretation at the time of service or visit level selection, the CMS-developed standard is the most practical application when considering the complexity of the encounter.

References

1. Centers for Medicare and Medicaid Services. Department of Health and Human Services. Evaluation and management services guide. Available at: http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/downloads//eval_mgmt_serv_guide-ICN006764.pdf. Accessed November 13, 2014.
2. National Government Services. Evaluation and management documentation training too. Available at: http://www.ngsmedicare.com/ngs/wcm/connect/3632a905-b697-4266-8fc0-2aa2a84fedb2/1074_0514_EM_Documentation_Training_Tool_508.pdf?MOD=AJPERES. Accessed November 13, 2014.
3. Centers for Medicare and Medicaid Services. Medicare Claims Processing Manual. Chapter 12 – Physicians/nonphysician practitioners. Available at: http://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/clm104c12.pdf. Accessed November 13, 2014.