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Doctors: Major responsibility for cost control not ours
When it comes to reducing health costs, physicians believe burden of responsibility lies primarily with plaintiffs attorneys, followed by insurers, hospitals, drug and device makers, patients, and, lastly, themselves. Those conclusions are based on 2,438 responses from some 3,900 physicians randomly surveyed in 2012. Dr. Jon C. Tilburt of the Mayo Clinic, Rochester, Minn., and his colleagues reported their findings in JAMA.
When asked whether individual physicians should have a major responsibility in reducing health costs, 36% of respondents said yes. Sixty percent said that trial lawyers bore the major burden, with health insurers coming in a close second.
More than half said that drug and device companies, hospitals and health systems, and patients also should have major responsibility for cost containment. A total of 44% said the government had that responsibility (JAMA 2013;310:380-8 [doi:10.1001/jama.2013.8278]).
Physicians also were asked about their enthusiasm for various cost-control strategies and to examine their own role in cost containment by assessing their knowledge of prices of procedures and tests and their desire to personally curb costs in their practice. The authors asked about and analyzed potential barriers to physicians becoming more cost conscious, as well.
Doctors were very enthusiastic about improving the quality and efficiency of care, primarily through promoting continuity of care and going after fraud and abuse. Expanding access to preventive care was also warmly received. Physicians were enthusiastic about limiting access to expensive treatments that had shown little benefit, using cost-effectiveness data to choose a therapy, and promoting head-to-head trials of competing therapies.
Just over half of respondents said that cutting pay for the highest-paid specialists should be embraced.
Eliminating fee for service altogether was rejected by 70% of respondents. Ninety percent said that they weren?t enthusiastic about letting the Medicare Sustainable Growth Rate cuts take effect. Two-thirds said that bundled pay and penalties for readmissions ? both cost-control keystones advanced by the Obama administration ? were not attractive.
Not surprisingly, increasing use of electronic health records also got a strong negative response, with 29% saying they were "not enthusiastic."
When it came to their own practice, 76% said they were aware of the costs of treatments or tests they recommended, and 84% said that cost is important whether a patient pays out of pocket or not. When it comes to individual physicians? responsibility for reducing health costs, the responses were very mixed.
The survey participants largely agreed that "trying to contain costs is the responsibility of every physician" (85%) and that physicians should take a more prominent role in eliminating unnecessary tests (89%). But by almost the same percentages, physicians also said that they should be devoted to their individual patients, even if a test or therapy was expensive, and that they should not deny services to their patients because someone else might need it more.
"This apparent inconsistency may reflect inherent tensions in professional roles to serve patients individually and society as a whole," Dr. Tilburt and colleagues wrote.
Finally, physicians overwhelmingly said that fear of malpractice had substantially decreased their enjoyment of practicing medicine. The authors rated that fear as a barrier to cost-conscious practice. They also found that 43% of physicians admitted they ordered more tests when they did not know the patient as well. Half said that being more cost conscious was the right thing to do, but large numbers said that it might not make a difference or could make things worse. A total of 40% said it would not limit unreasonable patient demands, and 28% said it could erode patients? trust.
Dr. Tilburt and his colleagues pointed out that the findings should be viewed with caution in part because it could not fully reflect the opinions of all American physicians. Further, opinions could be in flux, given how much has changed since even a year ago.
They suggested that policy makers move slowly when it comes to changing payment models, and instead target areas where doctors seem to be enthusiastic, including improving quality of care and using comparative effectiveness data.
The study was funded by the Greenwall Foundation and the Mayo Clinic. The authors reported having no financial conflicts.
In an accompanying editorial, Dr. Ezekiel J. Emanuel, an ethicist at the University of Pennsylvania, Philadelphia, said that, "if there were ever an ?all-hands-on-deck? moment in the history of health care, that moment is now. The findings of this study suggest that physician do not yet have the mentality this historical moment demands. Indeed, this survey suggests that in the face of this new and uncertain moment in the reform of the health care system, physicians are lapsing into the well-known, cautious, instinctual approaches humans adopt whenever confronted by uncertainty: Blame others and persevere with "business as usual,"" (JAMA 2013;310:374-5).
Physicians have moved beyond denying that health care costs are a problem, he added. "Yet, they are not quite willing to accept physicians? primary responsibility and take action. The study findings suggest that physicians are ambivalent; they reject transformative solutions, such as eliminating fee-for-service or bundled payments, which address the seriousness of the cost problem.
"This study by Tilburt et al. indicates that the medical profession is not there yet ? that many physicians would prefer to sit on the sidelines while other actors in the health care system do the real work of reform.
This could marginalize and demote physicians, he concluded.
Dr. Emanuel had no conflicts.
Upon reading the JAMA manuscript (JAMA 2013;310:380-8 [doi:10.1001/jama.2013.8278), and more specifically, this summary article with commentary, I am reminded of the story about the defendant who takes the stand in court and is asked by the prosecution, "Sir, what year did you begin to beat your wife...". The defendant, of course, has never beaten his wife, but he now faces an up-hill battle with a now-biased jury.
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| Dr. Mark Morasch |
If asked, for which would you be most enthusiastic when it comes to controlling health care costs ? pursuing tort-reform (amongst other choices) or accepting salary reduction ? it is quite obvious which option the majority would choose. I am quite sure, if asked a similar question, the lion?s share of any profession would answer in kind. Furthermore, given the choice between looking after a patient?s best interest or, the alternative, reducing expense, it shouldn?t be hard to predict that a high percentage of respondents would choose the former. It is all about what questions are asked and how individuals may subjectively interpret the aggregate responses. The authors of the original article conclude that U.S. physicians agree that they do have some responsibility when it comes to addressing health care costs in their practices. Physicians also agree that efforts to improve quality and efficiency of care while increasing transparency with regards to cost information should be paramount. Their responses seem measured and reasonable to me.
In his accompanying commentary, Dr. Emanuel, an ethicist, has taken a significant leap when he interprets the data through his own prism and concludes that physicians choose to "Blame others and persevere with ?business as usual?" and that we "are not willing to accept...primary responsibility and take action." This attack seems to have been prompted by a reluctance, on the part of practicing physicians, to overwhelmingly support replacement of established fee-for-service paradigms. I am sorry, Dr. Emanuel, but completely eliminating fee-for-service and replacing it with a one-size-fits-all solution is simply not tenable at this time. Yes, we all must take responsibility when it comes to controlling the significant costs of health care and it is true that we risk marginalization if we fail, as a group, to be a part of the solution. But Dr. Emanuel seems to be trying his best to offend the one group who, arguably, best understands the problem and who holds, as our most important credo, to do whatever it takes to help the population we serve. To vilify physicians won?t help fix the problem.
Dr. Mark D. Morasch is a vascular surgeon at St. Vincent Healthcare Heart and Vascular, Billings, Mon., and an associate medical editor for Vascular Specialist.
Upon reading the JAMA manuscript (JAMA 2013;310:380-8 [doi:10.1001/jama.2013.8278), and more specifically, this summary article with commentary, I am reminded of the story about the defendant who takes the stand in court and is asked by the prosecution, "Sir, what year did you begin to beat your wife...". The defendant, of course, has never beaten his wife, but he now faces an up-hill battle with a now-biased jury.
|
| |
| Dr. Mark Morasch |
If asked, for which would you be most enthusiastic when it comes to controlling health care costs ? pursuing tort-reform (amongst other choices) or accepting salary reduction ? it is quite obvious which option the majority would choose. I am quite sure, if asked a similar question, the lion?s share of any profession would answer in kind. Furthermore, given the choice between looking after a patient?s best interest or, the alternative, reducing expense, it shouldn?t be hard to predict that a high percentage of respondents would choose the former. It is all about what questions are asked and how individuals may subjectively interpret the aggregate responses. The authors of the original article conclude that U.S. physicians agree that they do have some responsibility when it comes to addressing health care costs in their practices. Physicians also agree that efforts to improve quality and efficiency of care while increasing transparency with regards to cost information should be paramount. Their responses seem measured and reasonable to me.
In his accompanying commentary, Dr. Emanuel, an ethicist, has taken a significant leap when he interprets the data through his own prism and concludes that physicians choose to "Blame others and persevere with ?business as usual?" and that we "are not willing to accept...primary responsibility and take action." This attack seems to have been prompted by a reluctance, on the part of practicing physicians, to overwhelmingly support replacement of established fee-for-service paradigms. I am sorry, Dr. Emanuel, but completely eliminating fee-for-service and replacing it with a one-size-fits-all solution is simply not tenable at this time. Yes, we all must take responsibility when it comes to controlling the significant costs of health care and it is true that we risk marginalization if we fail, as a group, to be a part of the solution. But Dr. Emanuel seems to be trying his best to offend the one group who, arguably, best understands the problem and who holds, as our most important credo, to do whatever it takes to help the population we serve. To vilify physicians won?t help fix the problem.
Dr. Mark D. Morasch is a vascular surgeon at St. Vincent Healthcare Heart and Vascular, Billings, Mon., and an associate medical editor for Vascular Specialist.
Upon reading the JAMA manuscript (JAMA 2013;310:380-8 [doi:10.1001/jama.2013.8278), and more specifically, this summary article with commentary, I am reminded of the story about the defendant who takes the stand in court and is asked by the prosecution, "Sir, what year did you begin to beat your wife...". The defendant, of course, has never beaten his wife, but he now faces an up-hill battle with a now-biased jury.
|
| |
| Dr. Mark Morasch |
If asked, for which would you be most enthusiastic when it comes to controlling health care costs ? pursuing tort-reform (amongst other choices) or accepting salary reduction ? it is quite obvious which option the majority would choose. I am quite sure, if asked a similar question, the lion?s share of any profession would answer in kind. Furthermore, given the choice between looking after a patient?s best interest or, the alternative, reducing expense, it shouldn?t be hard to predict that a high percentage of respondents would choose the former. It is all about what questions are asked and how individuals may subjectively interpret the aggregate responses. The authors of the original article conclude that U.S. physicians agree that they do have some responsibility when it comes to addressing health care costs in their practices. Physicians also agree that efforts to improve quality and efficiency of care while increasing transparency with regards to cost information should be paramount. Their responses seem measured and reasonable to me.
In his accompanying commentary, Dr. Emanuel, an ethicist, has taken a significant leap when he interprets the data through his own prism and concludes that physicians choose to "Blame others and persevere with ?business as usual?" and that we "are not willing to accept...primary responsibility and take action." This attack seems to have been prompted by a reluctance, on the part of practicing physicians, to overwhelmingly support replacement of established fee-for-service paradigms. I am sorry, Dr. Emanuel, but completely eliminating fee-for-service and replacing it with a one-size-fits-all solution is simply not tenable at this time. Yes, we all must take responsibility when it comes to controlling the significant costs of health care and it is true that we risk marginalization if we fail, as a group, to be a part of the solution. But Dr. Emanuel seems to be trying his best to offend the one group who, arguably, best understands the problem and who holds, as our most important credo, to do whatever it takes to help the population we serve. To vilify physicians won?t help fix the problem.
Dr. Mark D. Morasch is a vascular surgeon at St. Vincent Healthcare Heart and Vascular, Billings, Mon., and an associate medical editor for Vascular Specialist.
When it comes to reducing health costs, physicians believe burden of responsibility lies primarily with plaintiffs attorneys, followed by insurers, hospitals, drug and device makers, patients, and, lastly, themselves. Those conclusions are based on 2,438 responses from some 3,900 physicians randomly surveyed in 2012. Dr. Jon C. Tilburt of the Mayo Clinic, Rochester, Minn., and his colleagues reported their findings in JAMA.
When asked whether individual physicians should have a major responsibility in reducing health costs, 36% of respondents said yes. Sixty percent said that trial lawyers bore the major burden, with health insurers coming in a close second.
More than half said that drug and device companies, hospitals and health systems, and patients also should have major responsibility for cost containment. A total of 44% said the government had that responsibility (JAMA 2013;310:380-8 [doi:10.1001/jama.2013.8278]).
Physicians also were asked about their enthusiasm for various cost-control strategies and to examine their own role in cost containment by assessing their knowledge of prices of procedures and tests and their desire to personally curb costs in their practice. The authors asked about and analyzed potential barriers to physicians becoming more cost conscious, as well.
Doctors were very enthusiastic about improving the quality and efficiency of care, primarily through promoting continuity of care and going after fraud and abuse. Expanding access to preventive care was also warmly received. Physicians were enthusiastic about limiting access to expensive treatments that had shown little benefit, using cost-effectiveness data to choose a therapy, and promoting head-to-head trials of competing therapies.
Just over half of respondents said that cutting pay for the highest-paid specialists should be embraced.
Eliminating fee for service altogether was rejected by 70% of respondents. Ninety percent said that they weren?t enthusiastic about letting the Medicare Sustainable Growth Rate cuts take effect. Two-thirds said that bundled pay and penalties for readmissions ? both cost-control keystones advanced by the Obama administration ? were not attractive.
Not surprisingly, increasing use of electronic health records also got a strong negative response, with 29% saying they were "not enthusiastic."
When it came to their own practice, 76% said they were aware of the costs of treatments or tests they recommended, and 84% said that cost is important whether a patient pays out of pocket or not. When it comes to individual physicians? responsibility for reducing health costs, the responses were very mixed.
The survey participants largely agreed that "trying to contain costs is the responsibility of every physician" (85%) and that physicians should take a more prominent role in eliminating unnecessary tests (89%). But by almost the same percentages, physicians also said that they should be devoted to their individual patients, even if a test or therapy was expensive, and that they should not deny services to their patients because someone else might need it more.
"This apparent inconsistency may reflect inherent tensions in professional roles to serve patients individually and society as a whole," Dr. Tilburt and colleagues wrote.
Finally, physicians overwhelmingly said that fear of malpractice had substantially decreased their enjoyment of practicing medicine. The authors rated that fear as a barrier to cost-conscious practice. They also found that 43% of physicians admitted they ordered more tests when they did not know the patient as well. Half said that being more cost conscious was the right thing to do, but large numbers said that it might not make a difference or could make things worse. A total of 40% said it would not limit unreasonable patient demands, and 28% said it could erode patients? trust.
Dr. Tilburt and his colleagues pointed out that the findings should be viewed with caution in part because it could not fully reflect the opinions of all American physicians. Further, opinions could be in flux, given how much has changed since even a year ago.
They suggested that policy makers move slowly when it comes to changing payment models, and instead target areas where doctors seem to be enthusiastic, including improving quality of care and using comparative effectiveness data.
The study was funded by the Greenwall Foundation and the Mayo Clinic. The authors reported having no financial conflicts.
In an accompanying editorial, Dr. Ezekiel J. Emanuel, an ethicist at the University of Pennsylvania, Philadelphia, said that, "if there were ever an ?all-hands-on-deck? moment in the history of health care, that moment is now. The findings of this study suggest that physician do not yet have the mentality this historical moment demands. Indeed, this survey suggests that in the face of this new and uncertain moment in the reform of the health care system, physicians are lapsing into the well-known, cautious, instinctual approaches humans adopt whenever confronted by uncertainty: Blame others and persevere with "business as usual,"" (JAMA 2013;310:374-5).
Physicians have moved beyond denying that health care costs are a problem, he added. "Yet, they are not quite willing to accept physicians? primary responsibility and take action. The study findings suggest that physicians are ambivalent; they reject transformative solutions, such as eliminating fee-for-service or bundled payments, which address the seriousness of the cost problem.
"This study by Tilburt et al. indicates that the medical profession is not there yet ? that many physicians would prefer to sit on the sidelines while other actors in the health care system do the real work of reform.
This could marginalize and demote physicians, he concluded.
Dr. Emanuel had no conflicts.
When it comes to reducing health costs, physicians believe burden of responsibility lies primarily with plaintiffs attorneys, followed by insurers, hospitals, drug and device makers, patients, and, lastly, themselves. Those conclusions are based on 2,438 responses from some 3,900 physicians randomly surveyed in 2012. Dr. Jon C. Tilburt of the Mayo Clinic, Rochester, Minn., and his colleagues reported their findings in JAMA.
When asked whether individual physicians should have a major responsibility in reducing health costs, 36% of respondents said yes. Sixty percent said that trial lawyers bore the major burden, with health insurers coming in a close second.
More than half said that drug and device companies, hospitals and health systems, and patients also should have major responsibility for cost containment. A total of 44% said the government had that responsibility (JAMA 2013;310:380-8 [doi:10.1001/jama.2013.8278]).
Physicians also were asked about their enthusiasm for various cost-control strategies and to examine their own role in cost containment by assessing their knowledge of prices of procedures and tests and their desire to personally curb costs in their practice. The authors asked about and analyzed potential barriers to physicians becoming more cost conscious, as well.
Doctors were very enthusiastic about improving the quality and efficiency of care, primarily through promoting continuity of care and going after fraud and abuse. Expanding access to preventive care was also warmly received. Physicians were enthusiastic about limiting access to expensive treatments that had shown little benefit, using cost-effectiveness data to choose a therapy, and promoting head-to-head trials of competing therapies.
Just over half of respondents said that cutting pay for the highest-paid specialists should be embraced.
Eliminating fee for service altogether was rejected by 70% of respondents. Ninety percent said that they weren?t enthusiastic about letting the Medicare Sustainable Growth Rate cuts take effect. Two-thirds said that bundled pay and penalties for readmissions ? both cost-control keystones advanced by the Obama administration ? were not attractive.
Not surprisingly, increasing use of electronic health records also got a strong negative response, with 29% saying they were "not enthusiastic."
When it came to their own practice, 76% said they were aware of the costs of treatments or tests they recommended, and 84% said that cost is important whether a patient pays out of pocket or not. When it comes to individual physicians? responsibility for reducing health costs, the responses were very mixed.
The survey participants largely agreed that "trying to contain costs is the responsibility of every physician" (85%) and that physicians should take a more prominent role in eliminating unnecessary tests (89%). But by almost the same percentages, physicians also said that they should be devoted to their individual patients, even if a test or therapy was expensive, and that they should not deny services to their patients because someone else might need it more.
"This apparent inconsistency may reflect inherent tensions in professional roles to serve patients individually and society as a whole," Dr. Tilburt and colleagues wrote.
Finally, physicians overwhelmingly said that fear of malpractice had substantially decreased their enjoyment of practicing medicine. The authors rated that fear as a barrier to cost-conscious practice. They also found that 43% of physicians admitted they ordered more tests when they did not know the patient as well. Half said that being more cost conscious was the right thing to do, but large numbers said that it might not make a difference or could make things worse. A total of 40% said it would not limit unreasonable patient demands, and 28% said it could erode patients? trust.
Dr. Tilburt and his colleagues pointed out that the findings should be viewed with caution in part because it could not fully reflect the opinions of all American physicians. Further, opinions could be in flux, given how much has changed since even a year ago.
They suggested that policy makers move slowly when it comes to changing payment models, and instead target areas where doctors seem to be enthusiastic, including improving quality of care and using comparative effectiveness data.
The study was funded by the Greenwall Foundation and the Mayo Clinic. The authors reported having no financial conflicts.
In an accompanying editorial, Dr. Ezekiel J. Emanuel, an ethicist at the University of Pennsylvania, Philadelphia, said that, "if there were ever an ?all-hands-on-deck? moment in the history of health care, that moment is now. The findings of this study suggest that physician do not yet have the mentality this historical moment demands. Indeed, this survey suggests that in the face of this new and uncertain moment in the reform of the health care system, physicians are lapsing into the well-known, cautious, instinctual approaches humans adopt whenever confronted by uncertainty: Blame others and persevere with "business as usual,"" (JAMA 2013;310:374-5).
Physicians have moved beyond denying that health care costs are a problem, he added. "Yet, they are not quite willing to accept physicians? primary responsibility and take action. The study findings suggest that physicians are ambivalent; they reject transformative solutions, such as eliminating fee-for-service or bundled payments, which address the seriousness of the cost problem.
"This study by Tilburt et al. indicates that the medical profession is not there yet ? that many physicians would prefer to sit on the sidelines while other actors in the health care system do the real work of reform.
This could marginalize and demote physicians, he concluded.
Dr. Emanuel had no conflicts.
Major finding: Sixty percent of responding physicians believe that trial attorneys bear major responsibility for reducing health costs.
Data source: A random survey of 3,900 physicians.
Disclosures: The study was funded by the Greenwall Foundation and the Mayo Clinic. The authors reported having no financial conflicts.
More Hospitals Learning to Share; Expanding Research Into PTSD and TBI; ED Visits for CNS Stimulant Abuse on the Rise; Talking About Suicide Matters; Decline in Childhood Obesity
New Rules for Value-Based Purchasing, Readmission Penalties, Admissions
The View from
Looking for more information to formulate a plan of attack? SHM offers a variety of HVBP resources to orient hospitalists and hospital leaders. The “What Every Hospitalist Should Know About Hospital Value-Based Purchasing” webinar and SHM’s free resource library (www.hospitalmedicine.org/hvbp) offer basic orientation on what to expect on pay-for-performance-related issues. The HVBP resource center also provides multiple case studies from various hospitals across the country, with success stories related to reducing readmissions, increasing evidence-based care focus, and enhancing performance on core measures.
In order to proactively address CMS’ new 30-day readmissions criteria for COPD, SHM’s COPD Resource Center (www.hospitalmedicine.org/copd) provides hospitalists with the most up-to-date guidelines, reviews, and peer-reviewed clinical trials that define evidence-based practice for the care of the COPD patient.
Hospitalists not only are under pressure to help improve hospital-level performance, but also will need to begin reporting physician-level measures. Beginning in 2015, CMS’s Physician Quality Reporting System (PQRS) will apply a penalty to all physicians who do not satisfactorily report data on quality measures for covered professional services.
The time to act is now. Reporting during the 2013 PQRS program year will be used to determine whether a 1.5% penalty applies in 2015. SHM has partnered with CECity to offer discounted access to PQRIwizard, a tool that facilitates PQRS reporting through SHM’s Learning Portal (www.shmlearningportal.org).
October is the beginning of a new year—in this case, fiscal-year 2014 for the Centers for Medicare & Medicaid Services (CMS). It’s a time when the new rules kick in. This month, we’ll look at some highlights, focusing on the new developments affecting your practice. Because you are held accountable for hospital-side performance on programs such as hospital value-based purchasing (HVBP) and the Readmissions Reduction Program, a working knowledge of the 2014 edition of the programs is crucial.
Close the Loop on HVBP
How will your hospital get paid under the 2014 version of HVBP? This past July, your hospital received a report outlining how its Medicare payments will be affected based on your hospital’s performance on process of care (heart failure, pneumonia, myocardial infarction, and surgery), patient experience (HCAHPS), and outcomes (30-day mortality for heart failure, pneumonia, and myocardial infarction).
Here are two hypothetical hospitals and how their performance in the program affects their 2014 payment. As background, in 2014, all hospitals have their base diagnosis related group (DRG) payments reduced by 1.25% for HVBP. They can earn back some, all, or an amount in excess of the 1.25% based on their performance. Payment is based on performance during the April 1 to Dec. 31, 2012, period. Under HVBP, CMS incentive payments occur at the level of individual patients, each of which is assigned a DRG.
Let’s look at two examples:
Hospital 1
- Base DRG payment reduction: 1.25% (all hospitals).
- Portion of base DRG earned back based on performance (process/patient experience/outcome metrics): 1.48%.
- Net change in base DRG payment: +0.23%.
Hospital 2
- Base DRG payment reduction: 1.25% (all hospitals).
- Portion of base DRG earned back based on performance (process/patient experience/outcome metrics): 1.08%.
- Net change in base DRG payment: -0.17%.
Hospital 1 performed relatively well, getting a bump of 0.23% in its base DRG rate. Hospital 2 did not perform so well, so it took a 0.17% hit on its base DRG rate.
In order to determine total dollars made or lost for your hospital, one multiplies the total number of eligible Medicare inpatients for 2014 times the base DRG payment times the percent change in base DRG payment. If Hospital 1 has 10,000 eligible patients in 2014 and a base DRG payment of $5,000, the value is 10,000 x $5,000 x 0.0023 (0.23%) = $115,000 gained. Hospital 2, with the same number of patients and base DRG payment, loses (10,000 x $5,000 x 0.0017 = $85,000).
Readmissions and Penalties
For 2014, CMS is adding 30-day readmissions for COPD to readmissions for heart failure, pneumonia, and myocardial infarction for its penalty program. CMS added COPD because it is the fourth-leading cause of readmissions, according to a recent Medicare Payment Advisory Commission report, and because there is wide variation in the rates (from 18% to 25%) of COPD hospital readmissions.
For 2014, CMS raises the ceiling on readmission penalties to a maximum of 2% of reimbursement for all of a hospital’s Medicare inpatients. (The maximum hit during the first round of readmission penalties, which began in October 2012, was 1%.) More than 2,200 U.S. hospitals will face some financial penalty for excess 30-day readmissions.
Disappointingly, CMS did not add a risk adjustment for socioeconomic status despite being under pressure to do so. There is growing evidence that these factors have a major impact on readmission rates.1,2
New Definition of an Admission
Amidst confusion from many and major blowback from beneficiaries saddled with large out-of-pocket expenses for observation stays and subsequent skilled-nursing-facility stays, CMS is clarifying the definition of an inpatient admission. The agency will define an admission as a hospital stay that spans at least two midnights. If a patient is in the hospital for a shorter period of time, CMS will deem the patient to be on observation status, unless medical record documentation supports a physician’s expectation “that the beneficiary would need care spanning at least two midnights” but unanticipated events led to a shorter stay.
Plan of Attack
For HVBP, make contact with your director of quality to understand your hospital’s performance and payment for 2014. If you have incentive compensation riding on HVBP, make sure you understand how your employer or contracted hospital is calculating the payout (because, for example, the performance period was in 2012!) and that your hospitalist group understands the payout calculation.
For COPD readmissions prevention, ensure patients have a home management plan; appropriate specialist follow-up and that they understand medication use, including inhalers and supplemental oxygen; and that you consider early referral for pulmonary rehabilitation for eligible patients.
For the new definition of inpatient admission, work with your hospital’s physician advisor and case management to ensure your group is getting appropriate guidance on documentation requirements. You are probably being held accountable for your hospital’s total number of observation hours, so remember to track these metrics following implementation of the new rule, as they (hopefully) should decrease. If they do, take some of the credit!
References
- Joynt KE, Orav EJ, Jha AK. Thirty-day readmission rates for Medicare beneficiaries by race and site of care. JAMA. 2011;305(7):675-681.
- Lindenauer PK, Lagu T, Rothberg MB, et al. Income inequality and 30 day outcomes after acute myocardial infarction, heart failure, and pneumonia: retrospective cohort study. BMJ. 2013;346:f521.
Dr. Whitcomb is medical director of healthcare quality at Baystate Medical Center in Springfield, Mass. He is co-founder and past president of SHM. Email him at [email protected].
The View from
Looking for more information to formulate a plan of attack? SHM offers a variety of HVBP resources to orient hospitalists and hospital leaders. The “What Every Hospitalist Should Know About Hospital Value-Based Purchasing” webinar and SHM’s free resource library (www.hospitalmedicine.org/hvbp) offer basic orientation on what to expect on pay-for-performance-related issues. The HVBP resource center also provides multiple case studies from various hospitals across the country, with success stories related to reducing readmissions, increasing evidence-based care focus, and enhancing performance on core measures.
In order to proactively address CMS’ new 30-day readmissions criteria for COPD, SHM’s COPD Resource Center (www.hospitalmedicine.org/copd) provides hospitalists with the most up-to-date guidelines, reviews, and peer-reviewed clinical trials that define evidence-based practice for the care of the COPD patient.
Hospitalists not only are under pressure to help improve hospital-level performance, but also will need to begin reporting physician-level measures. Beginning in 2015, CMS’s Physician Quality Reporting System (PQRS) will apply a penalty to all physicians who do not satisfactorily report data on quality measures for covered professional services.
The time to act is now. Reporting during the 2013 PQRS program year will be used to determine whether a 1.5% penalty applies in 2015. SHM has partnered with CECity to offer discounted access to PQRIwizard, a tool that facilitates PQRS reporting through SHM’s Learning Portal (www.shmlearningportal.org).
October is the beginning of a new year—in this case, fiscal-year 2014 for the Centers for Medicare & Medicaid Services (CMS). It’s a time when the new rules kick in. This month, we’ll look at some highlights, focusing on the new developments affecting your practice. Because you are held accountable for hospital-side performance on programs such as hospital value-based purchasing (HVBP) and the Readmissions Reduction Program, a working knowledge of the 2014 edition of the programs is crucial.
Close the Loop on HVBP
How will your hospital get paid under the 2014 version of HVBP? This past July, your hospital received a report outlining how its Medicare payments will be affected based on your hospital’s performance on process of care (heart failure, pneumonia, myocardial infarction, and surgery), patient experience (HCAHPS), and outcomes (30-day mortality for heart failure, pneumonia, and myocardial infarction).
Here are two hypothetical hospitals and how their performance in the program affects their 2014 payment. As background, in 2014, all hospitals have their base diagnosis related group (DRG) payments reduced by 1.25% for HVBP. They can earn back some, all, or an amount in excess of the 1.25% based on their performance. Payment is based on performance during the April 1 to Dec. 31, 2012, period. Under HVBP, CMS incentive payments occur at the level of individual patients, each of which is assigned a DRG.
Let’s look at two examples:
Hospital 1
- Base DRG payment reduction: 1.25% (all hospitals).
- Portion of base DRG earned back based on performance (process/patient experience/outcome metrics): 1.48%.
- Net change in base DRG payment: +0.23%.
Hospital 2
- Base DRG payment reduction: 1.25% (all hospitals).
- Portion of base DRG earned back based on performance (process/patient experience/outcome metrics): 1.08%.
- Net change in base DRG payment: -0.17%.
Hospital 1 performed relatively well, getting a bump of 0.23% in its base DRG rate. Hospital 2 did not perform so well, so it took a 0.17% hit on its base DRG rate.
In order to determine total dollars made or lost for your hospital, one multiplies the total number of eligible Medicare inpatients for 2014 times the base DRG payment times the percent change in base DRG payment. If Hospital 1 has 10,000 eligible patients in 2014 and a base DRG payment of $5,000, the value is 10,000 x $5,000 x 0.0023 (0.23%) = $115,000 gained. Hospital 2, with the same number of patients and base DRG payment, loses (10,000 x $5,000 x 0.0017 = $85,000).
Readmissions and Penalties
For 2014, CMS is adding 30-day readmissions for COPD to readmissions for heart failure, pneumonia, and myocardial infarction for its penalty program. CMS added COPD because it is the fourth-leading cause of readmissions, according to a recent Medicare Payment Advisory Commission report, and because there is wide variation in the rates (from 18% to 25%) of COPD hospital readmissions.
For 2014, CMS raises the ceiling on readmission penalties to a maximum of 2% of reimbursement for all of a hospital’s Medicare inpatients. (The maximum hit during the first round of readmission penalties, which began in October 2012, was 1%.) More than 2,200 U.S. hospitals will face some financial penalty for excess 30-day readmissions.
Disappointingly, CMS did not add a risk adjustment for socioeconomic status despite being under pressure to do so. There is growing evidence that these factors have a major impact on readmission rates.1,2
New Definition of an Admission
Amidst confusion from many and major blowback from beneficiaries saddled with large out-of-pocket expenses for observation stays and subsequent skilled-nursing-facility stays, CMS is clarifying the definition of an inpatient admission. The agency will define an admission as a hospital stay that spans at least two midnights. If a patient is in the hospital for a shorter period of time, CMS will deem the patient to be on observation status, unless medical record documentation supports a physician’s expectation “that the beneficiary would need care spanning at least two midnights” but unanticipated events led to a shorter stay.
Plan of Attack
For HVBP, make contact with your director of quality to understand your hospital’s performance and payment for 2014. If you have incentive compensation riding on HVBP, make sure you understand how your employer or contracted hospital is calculating the payout (because, for example, the performance period was in 2012!) and that your hospitalist group understands the payout calculation.
For COPD readmissions prevention, ensure patients have a home management plan; appropriate specialist follow-up and that they understand medication use, including inhalers and supplemental oxygen; and that you consider early referral for pulmonary rehabilitation for eligible patients.
For the new definition of inpatient admission, work with your hospital’s physician advisor and case management to ensure your group is getting appropriate guidance on documentation requirements. You are probably being held accountable for your hospital’s total number of observation hours, so remember to track these metrics following implementation of the new rule, as they (hopefully) should decrease. If they do, take some of the credit!
References
- Joynt KE, Orav EJ, Jha AK. Thirty-day readmission rates for Medicare beneficiaries by race and site of care. JAMA. 2011;305(7):675-681.
- Lindenauer PK, Lagu T, Rothberg MB, et al. Income inequality and 30 day outcomes after acute myocardial infarction, heart failure, and pneumonia: retrospective cohort study. BMJ. 2013;346:f521.
Dr. Whitcomb is medical director of healthcare quality at Baystate Medical Center in Springfield, Mass. He is co-founder and past president of SHM. Email him at [email protected].
The View from
Looking for more information to formulate a plan of attack? SHM offers a variety of HVBP resources to orient hospitalists and hospital leaders. The “What Every Hospitalist Should Know About Hospital Value-Based Purchasing” webinar and SHM’s free resource library (www.hospitalmedicine.org/hvbp) offer basic orientation on what to expect on pay-for-performance-related issues. The HVBP resource center also provides multiple case studies from various hospitals across the country, with success stories related to reducing readmissions, increasing evidence-based care focus, and enhancing performance on core measures.
In order to proactively address CMS’ new 30-day readmissions criteria for COPD, SHM’s COPD Resource Center (www.hospitalmedicine.org/copd) provides hospitalists with the most up-to-date guidelines, reviews, and peer-reviewed clinical trials that define evidence-based practice for the care of the COPD patient.
Hospitalists not only are under pressure to help improve hospital-level performance, but also will need to begin reporting physician-level measures. Beginning in 2015, CMS’s Physician Quality Reporting System (PQRS) will apply a penalty to all physicians who do not satisfactorily report data on quality measures for covered professional services.
The time to act is now. Reporting during the 2013 PQRS program year will be used to determine whether a 1.5% penalty applies in 2015. SHM has partnered with CECity to offer discounted access to PQRIwizard, a tool that facilitates PQRS reporting through SHM’s Learning Portal (www.shmlearningportal.org).
October is the beginning of a new year—in this case, fiscal-year 2014 for the Centers for Medicare & Medicaid Services (CMS). It’s a time when the new rules kick in. This month, we’ll look at some highlights, focusing on the new developments affecting your practice. Because you are held accountable for hospital-side performance on programs such as hospital value-based purchasing (HVBP) and the Readmissions Reduction Program, a working knowledge of the 2014 edition of the programs is crucial.
Close the Loop on HVBP
How will your hospital get paid under the 2014 version of HVBP? This past July, your hospital received a report outlining how its Medicare payments will be affected based on your hospital’s performance on process of care (heart failure, pneumonia, myocardial infarction, and surgery), patient experience (HCAHPS), and outcomes (30-day mortality for heart failure, pneumonia, and myocardial infarction).
Here are two hypothetical hospitals and how their performance in the program affects their 2014 payment. As background, in 2014, all hospitals have their base diagnosis related group (DRG) payments reduced by 1.25% for HVBP. They can earn back some, all, or an amount in excess of the 1.25% based on their performance. Payment is based on performance during the April 1 to Dec. 31, 2012, period. Under HVBP, CMS incentive payments occur at the level of individual patients, each of which is assigned a DRG.
Let’s look at two examples:
Hospital 1
- Base DRG payment reduction: 1.25% (all hospitals).
- Portion of base DRG earned back based on performance (process/patient experience/outcome metrics): 1.48%.
- Net change in base DRG payment: +0.23%.
Hospital 2
- Base DRG payment reduction: 1.25% (all hospitals).
- Portion of base DRG earned back based on performance (process/patient experience/outcome metrics): 1.08%.
- Net change in base DRG payment: -0.17%.
Hospital 1 performed relatively well, getting a bump of 0.23% in its base DRG rate. Hospital 2 did not perform so well, so it took a 0.17% hit on its base DRG rate.
In order to determine total dollars made or lost for your hospital, one multiplies the total number of eligible Medicare inpatients for 2014 times the base DRG payment times the percent change in base DRG payment. If Hospital 1 has 10,000 eligible patients in 2014 and a base DRG payment of $5,000, the value is 10,000 x $5,000 x 0.0023 (0.23%) = $115,000 gained. Hospital 2, with the same number of patients and base DRG payment, loses (10,000 x $5,000 x 0.0017 = $85,000).
Readmissions and Penalties
For 2014, CMS is adding 30-day readmissions for COPD to readmissions for heart failure, pneumonia, and myocardial infarction for its penalty program. CMS added COPD because it is the fourth-leading cause of readmissions, according to a recent Medicare Payment Advisory Commission report, and because there is wide variation in the rates (from 18% to 25%) of COPD hospital readmissions.
For 2014, CMS raises the ceiling on readmission penalties to a maximum of 2% of reimbursement for all of a hospital’s Medicare inpatients. (The maximum hit during the first round of readmission penalties, which began in October 2012, was 1%.) More than 2,200 U.S. hospitals will face some financial penalty for excess 30-day readmissions.
Disappointingly, CMS did not add a risk adjustment for socioeconomic status despite being under pressure to do so. There is growing evidence that these factors have a major impact on readmission rates.1,2
New Definition of an Admission
Amidst confusion from many and major blowback from beneficiaries saddled with large out-of-pocket expenses for observation stays and subsequent skilled-nursing-facility stays, CMS is clarifying the definition of an inpatient admission. The agency will define an admission as a hospital stay that spans at least two midnights. If a patient is in the hospital for a shorter period of time, CMS will deem the patient to be on observation status, unless medical record documentation supports a physician’s expectation “that the beneficiary would need care spanning at least two midnights” but unanticipated events led to a shorter stay.
Plan of Attack
For HVBP, make contact with your director of quality to understand your hospital’s performance and payment for 2014. If you have incentive compensation riding on HVBP, make sure you understand how your employer or contracted hospital is calculating the payout (because, for example, the performance period was in 2012!) and that your hospitalist group understands the payout calculation.
For COPD readmissions prevention, ensure patients have a home management plan; appropriate specialist follow-up and that they understand medication use, including inhalers and supplemental oxygen; and that you consider early referral for pulmonary rehabilitation for eligible patients.
For the new definition of inpatient admission, work with your hospital’s physician advisor and case management to ensure your group is getting appropriate guidance on documentation requirements. You are probably being held accountable for your hospital’s total number of observation hours, so remember to track these metrics following implementation of the new rule, as they (hopefully) should decrease. If they do, take some of the credit!
References
- Joynt KE, Orav EJ, Jha AK. Thirty-day readmission rates for Medicare beneficiaries by race and site of care. JAMA. 2011;305(7):675-681.
- Lindenauer PK, Lagu T, Rothberg MB, et al. Income inequality and 30 day outcomes after acute myocardial infarction, heart failure, and pneumonia: retrospective cohort study. BMJ. 2013;346:f521.
Dr. Whitcomb is medical director of healthcare quality at Baystate Medical Center in Springfield, Mass. He is co-founder and past president of SHM. Email him at [email protected].
SHM Introduces Discounted PQRS Through New Learning Portal
First, SHM’s new Learning Portal was the one-stop shop for free and discounted continuing medical education (CME) credits online. Now, the Learning Portal can help hospitalists report into the physician quality reporting system (PQRS) at a discounted individual rate.
And the time to start reporting measures in PQRS is now.
The PQRS was developed by the Centers for Medicare & Medicaid Services (CMS) in 2007 as a voluntary reporting program that provides a financial incentive to physicians and other eligible professionals who report data on quality measures for covered services furnished to Medicare beneficiaries. Starting in 2013, reporting in PQRS becomes mandatory for all eligible professionals.
SHM has encouraged its members to participate in the PQRS since the system’s inception in 2007. With the exciting launch of the SHM Learning Portal, it is easier than ever to get started. If you or your group are not currently reporting, there are still incentive payments available in 2013 and 2014. Beginning in 2015, there will be a penalty for not reporting quality measures based on 2013 performance.
Access the PQRIwizard through the SHM Learning Portal
SHM has secured a significant discount for members to report PQRS through the PQRIwizard. Located within the SHM Learning Portal, this online tool is a fast, convenient, and cost-effective solution to help collect and report quality measures data for the PQRS program. Similar to online tax-preparation software, the PQRIwizard guides you through a few easy steps to help rapidly collect, validate, report, and submit your results to CMS. The tool is powered by the CECity Registry, a CMS-qualified registry for PQRS reporting.
What Measures Are Available?
The SHM PQRIwizard features six individual quality measures in the areas of stroke and stroke rehabilitation, including measures on screening for dysphagia and thrombolytic therapy. To report on any of these measures, simply select three measures and report on 80 percent of your Medicare Part B fee-for-services patients who apply to the measures you selected.
PQRIwizard has a built-in progress monitor that validates your report by checking for missing data. The monitor also tracks your data to provide you with continuous feedback regarding valid patients. The system even calculates your measures and provides a printable report of your measure results in real time.
First, SHM’s new Learning Portal was the one-stop shop for free and discounted continuing medical education (CME) credits online. Now, the Learning Portal can help hospitalists report into the physician quality reporting system (PQRS) at a discounted individual rate.
And the time to start reporting measures in PQRS is now.
The PQRS was developed by the Centers for Medicare & Medicaid Services (CMS) in 2007 as a voluntary reporting program that provides a financial incentive to physicians and other eligible professionals who report data on quality measures for covered services furnished to Medicare beneficiaries. Starting in 2013, reporting in PQRS becomes mandatory for all eligible professionals.
SHM has encouraged its members to participate in the PQRS since the system’s inception in 2007. With the exciting launch of the SHM Learning Portal, it is easier than ever to get started. If you or your group are not currently reporting, there are still incentive payments available in 2013 and 2014. Beginning in 2015, there will be a penalty for not reporting quality measures based on 2013 performance.
Access the PQRIwizard through the SHM Learning Portal
SHM has secured a significant discount for members to report PQRS through the PQRIwizard. Located within the SHM Learning Portal, this online tool is a fast, convenient, and cost-effective solution to help collect and report quality measures data for the PQRS program. Similar to online tax-preparation software, the PQRIwizard guides you through a few easy steps to help rapidly collect, validate, report, and submit your results to CMS. The tool is powered by the CECity Registry, a CMS-qualified registry for PQRS reporting.
What Measures Are Available?
The SHM PQRIwizard features six individual quality measures in the areas of stroke and stroke rehabilitation, including measures on screening for dysphagia and thrombolytic therapy. To report on any of these measures, simply select three measures and report on 80 percent of your Medicare Part B fee-for-services patients who apply to the measures you selected.
PQRIwizard has a built-in progress monitor that validates your report by checking for missing data. The monitor also tracks your data to provide you with continuous feedback regarding valid patients. The system even calculates your measures and provides a printable report of your measure results in real time.
First, SHM’s new Learning Portal was the one-stop shop for free and discounted continuing medical education (CME) credits online. Now, the Learning Portal can help hospitalists report into the physician quality reporting system (PQRS) at a discounted individual rate.
And the time to start reporting measures in PQRS is now.
The PQRS was developed by the Centers for Medicare & Medicaid Services (CMS) in 2007 as a voluntary reporting program that provides a financial incentive to physicians and other eligible professionals who report data on quality measures for covered services furnished to Medicare beneficiaries. Starting in 2013, reporting in PQRS becomes mandatory for all eligible professionals.
SHM has encouraged its members to participate in the PQRS since the system’s inception in 2007. With the exciting launch of the SHM Learning Portal, it is easier than ever to get started. If you or your group are not currently reporting, there are still incentive payments available in 2013 and 2014. Beginning in 2015, there will be a penalty for not reporting quality measures based on 2013 performance.
Access the PQRIwizard through the SHM Learning Portal
SHM has secured a significant discount for members to report PQRS through the PQRIwizard. Located within the SHM Learning Portal, this online tool is a fast, convenient, and cost-effective solution to help collect and report quality measures data for the PQRS program. Similar to online tax-preparation software, the PQRIwizard guides you through a few easy steps to help rapidly collect, validate, report, and submit your results to CMS. The tool is powered by the CECity Registry, a CMS-qualified registry for PQRS reporting.
What Measures Are Available?
The SHM PQRIwizard features six individual quality measures in the areas of stroke and stroke rehabilitation, including measures on screening for dysphagia and thrombolytic therapy. To report on any of these measures, simply select three measures and report on 80 percent of your Medicare Part B fee-for-services patients who apply to the measures you selected.
PQRIwizard has a built-in progress monitor that validates your report by checking for missing data. The monitor also tracks your data to provide you with continuous feedback regarding valid patients. The system even calculates your measures and provides a printable report of your measure results in real time.
Another Whack at the Backlog; Leveling the Health Care Playing Field; Clearing Up Confusion About the Affordable Care Act; VA Health System Makes the Most Wired List
Docs: Major responsibility for cost control not ours
When it comes to reducing health costs, physicians believe burden of responsibility lies primarily with plaintiffs attorneys, followed by insurers, hospitals, drug and device makers, patients, and, lastly, themselves. Those conclusions are based on 2,438 responses from some 3,900 physicians randomly surveyed in 2012. Dr. Jon C. Tilburt of the Mayo Clinic, Rochester, Minn., and his colleagues reported their findings.
When asked whether individual physicians should have a major responsibility in reducing health costs, 36% of respondents said yes. Sixty percent said that trial lawyers bore the major burden, with health insurers coming in a close second.
More than half said that drug and device companies, hospitals and health systems, and patients also should have major responsibility for cost containment. A total of 44% said the government had that responsibility (JAMA 2013;310:380-8).
Physicians also were asked about their enthusiasm for various cost-control strategies and to examine their own role in cost containment by assessing their knowledge of prices of procedures and tests and their desire to personally curb costs in their practice. The authors asked about and analyzed potential barriers to physicians becoming more cost conscious, as well.
Doctors were very enthusiastic about improving the quality and efficiency of care, primarily through promoting continuity of care and going after fraud and abuse. Expanding access to preventive care was also warmly received. Physicians were also enthusiastic about limiting access to expensive treatments that had shown little benefit, using cost-effectiveness data to choose a therapy, and promoting head-to-head trials of competing therapies.
Just over half of respondents said that cutting pay for the highest-paid specialists should be embraced.
Eliminating fee for service altogether was rejected by 70% of respondents. Ninety percent said that they weren’t enthusiastic about letting the Medicare Sustainable Growth Rate cuts take effect. Two-thirds said that bundled pay and penalties for readmissions – both cost-control keystones advanced by the Obama administration – were not attractive.
Not surprisingly, increasing use of electronic health records also got a strong negative response, with 29% saying they were "not enthusiastic."
When it came to their own practice, 76% said they were aware of the costs of treatments or tests they recommended, and 84% said that cost is important whether a patient pays out of pocket or not.
When it comes to individual physicians’ responsibility for reducing health costs, the responses were very mixed. The survey participants largely agreed that "trying to contain costs is the responsibility of every physician" (85%) and that physicians should take a more prominent role in eliminating unnecessary tests (89%). But by almost the same percentages, physicians also said that they should be devoted to their individual patients, even if a test or therapy was expensive, and that they should not deny services to their patients because someone else might need it more.
"This apparent inconsistency may reflect inherent tensions in professional roles to serve patients individually and society as a whole," Dr. Tilburt and colleagues wrote.
Finally, physicians overwhelmingly said that fear of malpractice had substantially decreased their enjoyment of practicing medicine. The authors rated that fear as a barrier to cost-conscious practice.
They also found that 43% of physicians admitted they ordered more tests when they did not know the patient as well. Half said that being more cost conscious was the right thing to do, but large numbers said that it might not make a difference or could make things worse. A total of 40% said it would not limit unreasonable patient demands, and 28% said it could erode patients’ trust.
Dr. Tilburt and his colleagues pointed out that the findings should be viewed with caution in part because it could not fully reflect the opinions of all American physicians. Further, opinions could be in flux, given how much things are changing.
The study was funded by the Greenwall Foundation and the Mayo Clinic. The authors reported having no financial conflicts.
If there were ever an "all-hands-on-deck" moment in the history of health care, that moment is now. The findings of this study suggest that physician do not yet have the mentality this historical moment demands. Indeed, this survey suggests that in the face of this new and uncertain moment in the reform of the health care system, physicians are lapsing into the well-known, cautious, instinctual approaches humans adopt whenever confronted by uncertainty: Blame others and persevere with "business as usual."
Physicians have moved beyond denying that health care costs are a problem. Yet, they are not quite willing to accept physicians’ primary responsibility and take action. The study findings suggest that physicians are ambivalent; they reject transformative solutions, such as eliminating fee-for-service or bundled payments, which address the seriousness of the cost problem.
This study by Tilburt et al. indicates that the medical profession is not there yet – that many physicians would prefer to sit on the sidelines while other actors in the health care system do the real work of reform.
This could marginalize and demote physicians.
Dr. Ezekiel J. Emanuel is an ethicist at the University of Pennsylvania, Philadelphia. He reported no related conflicts. These remarks were taken from an editorial accompanying Dr. Tilburt’s study (JAMA 2013;310:374-5).
If there were ever an "all-hands-on-deck" moment in the history of health care, that moment is now. The findings of this study suggest that physician do not yet have the mentality this historical moment demands. Indeed, this survey suggests that in the face of this new and uncertain moment in the reform of the health care system, physicians are lapsing into the well-known, cautious, instinctual approaches humans adopt whenever confronted by uncertainty: Blame others and persevere with "business as usual."
Physicians have moved beyond denying that health care costs are a problem. Yet, they are not quite willing to accept physicians’ primary responsibility and take action. The study findings suggest that physicians are ambivalent; they reject transformative solutions, such as eliminating fee-for-service or bundled payments, which address the seriousness of the cost problem.
This study by Tilburt et al. indicates that the medical profession is not there yet – that many physicians would prefer to sit on the sidelines while other actors in the health care system do the real work of reform.
This could marginalize and demote physicians.
Dr. Ezekiel J. Emanuel is an ethicist at the University of Pennsylvania, Philadelphia. He reported no related conflicts. These remarks were taken from an editorial accompanying Dr. Tilburt’s study (JAMA 2013;310:374-5).
If there were ever an "all-hands-on-deck" moment in the history of health care, that moment is now. The findings of this study suggest that physician do not yet have the mentality this historical moment demands. Indeed, this survey suggests that in the face of this new and uncertain moment in the reform of the health care system, physicians are lapsing into the well-known, cautious, instinctual approaches humans adopt whenever confronted by uncertainty: Blame others and persevere with "business as usual."
Physicians have moved beyond denying that health care costs are a problem. Yet, they are not quite willing to accept physicians’ primary responsibility and take action. The study findings suggest that physicians are ambivalent; they reject transformative solutions, such as eliminating fee-for-service or bundled payments, which address the seriousness of the cost problem.
This study by Tilburt et al. indicates that the medical profession is not there yet – that many physicians would prefer to sit on the sidelines while other actors in the health care system do the real work of reform.
This could marginalize and demote physicians.
Dr. Ezekiel J. Emanuel is an ethicist at the University of Pennsylvania, Philadelphia. He reported no related conflicts. These remarks were taken from an editorial accompanying Dr. Tilburt’s study (JAMA 2013;310:374-5).
When it comes to reducing health costs, physicians believe burden of responsibility lies primarily with plaintiffs attorneys, followed by insurers, hospitals, drug and device makers, patients, and, lastly, themselves. Those conclusions are based on 2,438 responses from some 3,900 physicians randomly surveyed in 2012. Dr. Jon C. Tilburt of the Mayo Clinic, Rochester, Minn., and his colleagues reported their findings.
When asked whether individual physicians should have a major responsibility in reducing health costs, 36% of respondents said yes. Sixty percent said that trial lawyers bore the major burden, with health insurers coming in a close second.
More than half said that drug and device companies, hospitals and health systems, and patients also should have major responsibility for cost containment. A total of 44% said the government had that responsibility (JAMA 2013;310:380-8).
Physicians also were asked about their enthusiasm for various cost-control strategies and to examine their own role in cost containment by assessing their knowledge of prices of procedures and tests and their desire to personally curb costs in their practice. The authors asked about and analyzed potential barriers to physicians becoming more cost conscious, as well.
Doctors were very enthusiastic about improving the quality and efficiency of care, primarily through promoting continuity of care and going after fraud and abuse. Expanding access to preventive care was also warmly received. Physicians were also enthusiastic about limiting access to expensive treatments that had shown little benefit, using cost-effectiveness data to choose a therapy, and promoting head-to-head trials of competing therapies.
Just over half of respondents said that cutting pay for the highest-paid specialists should be embraced.
Eliminating fee for service altogether was rejected by 70% of respondents. Ninety percent said that they weren’t enthusiastic about letting the Medicare Sustainable Growth Rate cuts take effect. Two-thirds said that bundled pay and penalties for readmissions – both cost-control keystones advanced by the Obama administration – were not attractive.
Not surprisingly, increasing use of electronic health records also got a strong negative response, with 29% saying they were "not enthusiastic."
When it came to their own practice, 76% said they were aware of the costs of treatments or tests they recommended, and 84% said that cost is important whether a patient pays out of pocket or not.
When it comes to individual physicians’ responsibility for reducing health costs, the responses were very mixed. The survey participants largely agreed that "trying to contain costs is the responsibility of every physician" (85%) and that physicians should take a more prominent role in eliminating unnecessary tests (89%). But by almost the same percentages, physicians also said that they should be devoted to their individual patients, even if a test or therapy was expensive, and that they should not deny services to their patients because someone else might need it more.
"This apparent inconsistency may reflect inherent tensions in professional roles to serve patients individually and society as a whole," Dr. Tilburt and colleagues wrote.
Finally, physicians overwhelmingly said that fear of malpractice had substantially decreased their enjoyment of practicing medicine. The authors rated that fear as a barrier to cost-conscious practice.
They also found that 43% of physicians admitted they ordered more tests when they did not know the patient as well. Half said that being more cost conscious was the right thing to do, but large numbers said that it might not make a difference or could make things worse. A total of 40% said it would not limit unreasonable patient demands, and 28% said it could erode patients’ trust.
Dr. Tilburt and his colleagues pointed out that the findings should be viewed with caution in part because it could not fully reflect the opinions of all American physicians. Further, opinions could be in flux, given how much things are changing.
The study was funded by the Greenwall Foundation and the Mayo Clinic. The authors reported having no financial conflicts.
When it comes to reducing health costs, physicians believe burden of responsibility lies primarily with plaintiffs attorneys, followed by insurers, hospitals, drug and device makers, patients, and, lastly, themselves. Those conclusions are based on 2,438 responses from some 3,900 physicians randomly surveyed in 2012. Dr. Jon C. Tilburt of the Mayo Clinic, Rochester, Minn., and his colleagues reported their findings.
When asked whether individual physicians should have a major responsibility in reducing health costs, 36% of respondents said yes. Sixty percent said that trial lawyers bore the major burden, with health insurers coming in a close second.
More than half said that drug and device companies, hospitals and health systems, and patients also should have major responsibility for cost containment. A total of 44% said the government had that responsibility (JAMA 2013;310:380-8).
Physicians also were asked about their enthusiasm for various cost-control strategies and to examine their own role in cost containment by assessing their knowledge of prices of procedures and tests and their desire to personally curb costs in their practice. The authors asked about and analyzed potential barriers to physicians becoming more cost conscious, as well.
Doctors were very enthusiastic about improving the quality and efficiency of care, primarily through promoting continuity of care and going after fraud and abuse. Expanding access to preventive care was also warmly received. Physicians were also enthusiastic about limiting access to expensive treatments that had shown little benefit, using cost-effectiveness data to choose a therapy, and promoting head-to-head trials of competing therapies.
Just over half of respondents said that cutting pay for the highest-paid specialists should be embraced.
Eliminating fee for service altogether was rejected by 70% of respondents. Ninety percent said that they weren’t enthusiastic about letting the Medicare Sustainable Growth Rate cuts take effect. Two-thirds said that bundled pay and penalties for readmissions – both cost-control keystones advanced by the Obama administration – were not attractive.
Not surprisingly, increasing use of electronic health records also got a strong negative response, with 29% saying they were "not enthusiastic."
When it came to their own practice, 76% said they were aware of the costs of treatments or tests they recommended, and 84% said that cost is important whether a patient pays out of pocket or not.
When it comes to individual physicians’ responsibility for reducing health costs, the responses were very mixed. The survey participants largely agreed that "trying to contain costs is the responsibility of every physician" (85%) and that physicians should take a more prominent role in eliminating unnecessary tests (89%). But by almost the same percentages, physicians also said that they should be devoted to their individual patients, even if a test or therapy was expensive, and that they should not deny services to their patients because someone else might need it more.
"This apparent inconsistency may reflect inherent tensions in professional roles to serve patients individually and society as a whole," Dr. Tilburt and colleagues wrote.
Finally, physicians overwhelmingly said that fear of malpractice had substantially decreased their enjoyment of practicing medicine. The authors rated that fear as a barrier to cost-conscious practice.
They also found that 43% of physicians admitted they ordered more tests when they did not know the patient as well. Half said that being more cost conscious was the right thing to do, but large numbers said that it might not make a difference or could make things worse. A total of 40% said it would not limit unreasonable patient demands, and 28% said it could erode patients’ trust.
Dr. Tilburt and his colleagues pointed out that the findings should be viewed with caution in part because it could not fully reflect the opinions of all American physicians. Further, opinions could be in flux, given how much things are changing.
The study was funded by the Greenwall Foundation and the Mayo Clinic. The authors reported having no financial conflicts.
Medicare ups readmission penalties, changes rules
Beginning in October 2013, Medicare will double the penalties for preventable hospital readmissions and will change the rules for determining when to admit patients or to place them in observation status.
Under the fiscal year 2014 Hospital Inpatient Prospective Payment System rule, Medicare is raising the maximum penalties for preventable, unplanned hospital readmissions from 1% of base operating payments to 2%, starting in October 2013. Details of the payment hike, which is mandated by the Affordable Care Act, were announced Aug. 2 and were published Aug. 19 in the Federal Register.
The changes impact the Hospital Readmissions Reduction program, which was originally launched in October 2012.
That program penalizes hospitals with excess 30-day Medicare readmissions for acute myocardial infarction, heart failure, and pneumonia.
The new payment rule exempts more types of planned readmissions from the program. It also expands the program to include total hip and knee arthroplasty and acute chronic obstructive pulmonary disease, starting in October 2014.
In response to concerns from hospitals and patients, the hospital inpatient payment rule also provides greater guidance about which patients are appropriate for admission to the hospital and thus covered under Part A, and which patients should be considered for observation status, which is covered under Medicare Part B.
The criteria now will be based on the amount of time the physician expects the patient to spend as an inpatient.
Starting in October 2013, Medicare contractors will assume that a hospital stay is eligible for Part A payment if the physician expects the patient to stay as an inpatient in the hospital for at least 2 midnights. The inpatient stay is not triggered until the physician formally admits the patient.
However, officials at the Centers for Medicare and Medicaid Services said physicians may consider the patient’s time in observation, the emergency department, the operating room, and other in-hospital treatment areas when deciding if it is appropriate to expect the patient to stay for at least 2 midnights.
"This rule helps improve hospital care and establishes clearer guidance to hospitals for when we will consider inpatient care to be appropriate so the system works better for patients and providers," CMS Administrator Marilyn Tavenner said in a statement.
The CMS estimates that the policy change will increase spending by approximately $220 million because of increases in inpatient admissions, so the agency is reducing hospital payments accordingly.
Medicare’s changed admission policy is already drawing some critics.
The new criteria will do nothing to protect hospitals from "burdensome" audits and appeals, and it will require physicians to have a "sixth sense and predict the future treatment needs for patients," warned Blair Childs, senior vice president of public affairs for Premier, an alliance of hospitals and other health facilities.
"Moreover, these changes add insult to injury, imposing an associated 0.2% payment reduction to offset what CMS believes will be an increased inpatient volume," Mr. Childs said in a statement.
"We expect that this will result in even more confusion around what constitutes an appropriate inpatient hospital admission, all while cutting payments for following CMS’s rules."
Beginning in October 2013, Medicare will double the penalties for preventable hospital readmissions and will change the rules for determining when to admit patients or to place them in observation status.
Under the fiscal year 2014 Hospital Inpatient Prospective Payment System rule, Medicare is raising the maximum penalties for preventable, unplanned hospital readmissions from 1% of base operating payments to 2%, starting in October 2013. Details of the payment hike, which is mandated by the Affordable Care Act, were announced Aug. 2 and were published Aug. 19 in the Federal Register.
The changes impact the Hospital Readmissions Reduction program, which was originally launched in October 2012.
That program penalizes hospitals with excess 30-day Medicare readmissions for acute myocardial infarction, heart failure, and pneumonia.
The new payment rule exempts more types of planned readmissions from the program. It also expands the program to include total hip and knee arthroplasty and acute chronic obstructive pulmonary disease, starting in October 2014.
In response to concerns from hospitals and patients, the hospital inpatient payment rule also provides greater guidance about which patients are appropriate for admission to the hospital and thus covered under Part A, and which patients should be considered for observation status, which is covered under Medicare Part B.
The criteria now will be based on the amount of time the physician expects the patient to spend as an inpatient.
Starting in October 2013, Medicare contractors will assume that a hospital stay is eligible for Part A payment if the physician expects the patient to stay as an inpatient in the hospital for at least 2 midnights. The inpatient stay is not triggered until the physician formally admits the patient.
However, officials at the Centers for Medicare and Medicaid Services said physicians may consider the patient’s time in observation, the emergency department, the operating room, and other in-hospital treatment areas when deciding if it is appropriate to expect the patient to stay for at least 2 midnights.
"This rule helps improve hospital care and establishes clearer guidance to hospitals for when we will consider inpatient care to be appropriate so the system works better for patients and providers," CMS Administrator Marilyn Tavenner said in a statement.
The CMS estimates that the policy change will increase spending by approximately $220 million because of increases in inpatient admissions, so the agency is reducing hospital payments accordingly.
Medicare’s changed admission policy is already drawing some critics.
The new criteria will do nothing to protect hospitals from "burdensome" audits and appeals, and it will require physicians to have a "sixth sense and predict the future treatment needs for patients," warned Blair Childs, senior vice president of public affairs for Premier, an alliance of hospitals and other health facilities.
"Moreover, these changes add insult to injury, imposing an associated 0.2% payment reduction to offset what CMS believes will be an increased inpatient volume," Mr. Childs said in a statement.
"We expect that this will result in even more confusion around what constitutes an appropriate inpatient hospital admission, all while cutting payments for following CMS’s rules."
Beginning in October 2013, Medicare will double the penalties for preventable hospital readmissions and will change the rules for determining when to admit patients or to place them in observation status.
Under the fiscal year 2014 Hospital Inpatient Prospective Payment System rule, Medicare is raising the maximum penalties for preventable, unplanned hospital readmissions from 1% of base operating payments to 2%, starting in October 2013. Details of the payment hike, which is mandated by the Affordable Care Act, were announced Aug. 2 and were published Aug. 19 in the Federal Register.
The changes impact the Hospital Readmissions Reduction program, which was originally launched in October 2012.
That program penalizes hospitals with excess 30-day Medicare readmissions for acute myocardial infarction, heart failure, and pneumonia.
The new payment rule exempts more types of planned readmissions from the program. It also expands the program to include total hip and knee arthroplasty and acute chronic obstructive pulmonary disease, starting in October 2014.
In response to concerns from hospitals and patients, the hospital inpatient payment rule also provides greater guidance about which patients are appropriate for admission to the hospital and thus covered under Part A, and which patients should be considered for observation status, which is covered under Medicare Part B.
The criteria now will be based on the amount of time the physician expects the patient to spend as an inpatient.
Starting in October 2013, Medicare contractors will assume that a hospital stay is eligible for Part A payment if the physician expects the patient to stay as an inpatient in the hospital for at least 2 midnights. The inpatient stay is not triggered until the physician formally admits the patient.
However, officials at the Centers for Medicare and Medicaid Services said physicians may consider the patient’s time in observation, the emergency department, the operating room, and other in-hospital treatment areas when deciding if it is appropriate to expect the patient to stay for at least 2 midnights.
"This rule helps improve hospital care and establishes clearer guidance to hospitals for when we will consider inpatient care to be appropriate so the system works better for patients and providers," CMS Administrator Marilyn Tavenner said in a statement.
The CMS estimates that the policy change will increase spending by approximately $220 million because of increases in inpatient admissions, so the agency is reducing hospital payments accordingly.
Medicare’s changed admission policy is already drawing some critics.
The new criteria will do nothing to protect hospitals from "burdensome" audits and appeals, and it will require physicians to have a "sixth sense and predict the future treatment needs for patients," warned Blair Childs, senior vice president of public affairs for Premier, an alliance of hospitals and other health facilities.
"Moreover, these changes add insult to injury, imposing an associated 0.2% payment reduction to offset what CMS believes will be an increased inpatient volume," Mr. Childs said in a statement.
"We expect that this will result in even more confusion around what constitutes an appropriate inpatient hospital admission, all while cutting payments for following CMS’s rules."
Study Finds Decline in Suicide Among Veterans; Sequestration and the NIH; Improving Cancer Care for African Americans; Grants Extend the Reach of Health Care for Veterans
Sunshine apps track industry payments
Two new smartphone apps aim to help log drug, device, and diagnostic manufacturer payments to doctors and health care providers, as called for by the Affordable Care Act.
To promote transparency in relationships between providers and industry, the ACA requires that manufacturers track and report payments for consulting, honoraria, and more.
Originally known as the Sunshine Act, the effort is now called the Open Payments Program by the Centers for Medicare and Medicaid Services (CMS).
While physicians are not required to inventory anything of value they receive from manufacturers, CMS and many medical professional societies advise that they do so.
The app for physicians – Open Payments for Physicians – is designed to help doctors keep tabs on all their transactions in real time. Users can manually enter all the information regarding a particular transaction, for example, the receipt of a grant payment or a gift that’s worth more than $10.
The app is free and can be downloaded from the iTunes App Store or from Google Play.
CMS also created an app for industry representatives to use (Open Payments for Industry).
Industry users and physician users can exchange information with their apps. By using a built-in QR (quick response) code reader, the manufacturer can transfer a record of a transaction to the physician for review, according to the agency.
In a blog post, CMS Program Integrity Director Dr. Peter Budetti said the agency’s "foray into mobile technology is about providing user-friendly tools for doctors, manufacturers, and others in the health care industry to use in working with us to implement the law in a smart way."
The idea is that physicians can use the records contained in the app to compare what’s reported by manufacturers to CMS. There is a 45-day lag between when the data are reported to CMS and posted publicly. Physicians have that window to challenge the reports before they are posted on the Open Payments website. Corrections can be made later, but the erroneous data will likely stay public for awhile.
The first year of the program will be a little bit more forgiving. Data collected beginning Aug. 1 won’t be publicly reported until September 2014.
The apps can’t be used to directly transfer data to CMS, said the agency, which added that although it developed the apps, it will not "validate the accuracy of data stored in the apps, nor will it be responsible for protecting data stored in the apps."
[email protected]
On Twitter @aliciaault
Two new smartphone apps aim to help log drug, device, and diagnostic manufacturer payments to doctors and health care providers, as called for by the Affordable Care Act.
To promote transparency in relationships between providers and industry, the ACA requires that manufacturers track and report payments for consulting, honoraria, and more.
Originally known as the Sunshine Act, the effort is now called the Open Payments Program by the Centers for Medicare and Medicaid Services (CMS).
While physicians are not required to inventory anything of value they receive from manufacturers, CMS and many medical professional societies advise that they do so.
The app for physicians – Open Payments for Physicians – is designed to help doctors keep tabs on all their transactions in real time. Users can manually enter all the information regarding a particular transaction, for example, the receipt of a grant payment or a gift that’s worth more than $10.
The app is free and can be downloaded from the iTunes App Store or from Google Play.
CMS also created an app for industry representatives to use (Open Payments for Industry).
Industry users and physician users can exchange information with their apps. By using a built-in QR (quick response) code reader, the manufacturer can transfer a record of a transaction to the physician for review, according to the agency.
In a blog post, CMS Program Integrity Director Dr. Peter Budetti said the agency’s "foray into mobile technology is about providing user-friendly tools for doctors, manufacturers, and others in the health care industry to use in working with us to implement the law in a smart way."
The idea is that physicians can use the records contained in the app to compare what’s reported by manufacturers to CMS. There is a 45-day lag between when the data are reported to CMS and posted publicly. Physicians have that window to challenge the reports before they are posted on the Open Payments website. Corrections can be made later, but the erroneous data will likely stay public for awhile.
The first year of the program will be a little bit more forgiving. Data collected beginning Aug. 1 won’t be publicly reported until September 2014.
The apps can’t be used to directly transfer data to CMS, said the agency, which added that although it developed the apps, it will not "validate the accuracy of data stored in the apps, nor will it be responsible for protecting data stored in the apps."
[email protected]
On Twitter @aliciaault
Two new smartphone apps aim to help log drug, device, and diagnostic manufacturer payments to doctors and health care providers, as called for by the Affordable Care Act.
To promote transparency in relationships between providers and industry, the ACA requires that manufacturers track and report payments for consulting, honoraria, and more.
Originally known as the Sunshine Act, the effort is now called the Open Payments Program by the Centers for Medicare and Medicaid Services (CMS).
While physicians are not required to inventory anything of value they receive from manufacturers, CMS and many medical professional societies advise that they do so.
The app for physicians – Open Payments for Physicians – is designed to help doctors keep tabs on all their transactions in real time. Users can manually enter all the information regarding a particular transaction, for example, the receipt of a grant payment or a gift that’s worth more than $10.
The app is free and can be downloaded from the iTunes App Store or from Google Play.
CMS also created an app for industry representatives to use (Open Payments for Industry).
Industry users and physician users can exchange information with their apps. By using a built-in QR (quick response) code reader, the manufacturer can transfer a record of a transaction to the physician for review, according to the agency.
In a blog post, CMS Program Integrity Director Dr. Peter Budetti said the agency’s "foray into mobile technology is about providing user-friendly tools for doctors, manufacturers, and others in the health care industry to use in working with us to implement the law in a smart way."
The idea is that physicians can use the records contained in the app to compare what’s reported by manufacturers to CMS. There is a 45-day lag between when the data are reported to CMS and posted publicly. Physicians have that window to challenge the reports before they are posted on the Open Payments website. Corrections can be made later, but the erroneous data will likely stay public for awhile.
The first year of the program will be a little bit more forgiving. Data collected beginning Aug. 1 won’t be publicly reported until September 2014.
The apps can’t be used to directly transfer data to CMS, said the agency, which added that although it developed the apps, it will not "validate the accuracy of data stored in the apps, nor will it be responsible for protecting data stored in the apps."
[email protected]
On Twitter @aliciaault
The Pros and Cons of Electronic Health Records
An electronic health record (EHR)—sometimes called an electronic medical record (EMR)—allows health-care providers to record patient information electronically instead of using paper records.1 It also has the capability to perform various tasks that can assist in health-care delivery while maintaining standards of practice. The Health Information Technology for Economic and Clinical Health (HITECH) Act, enacted under the American Recovery and Reinvestment Act of 2009 (Recovery Act), established a provision for incentive payments for eligible professionals (EPs), critical-access hospitals (CAHs), and eligible hospitals if they can demonstrate meaningful use of certified EHR technology:2
- The use of a certified EHR in a meaningful manner (e.g. e-prescribing);
- The use of certified EHR technology for electronic exchange of health information to improve quality of health care; and
- The use of certified EHR technology to submit clinical quality and other measures.
Eligible professionals must satisfy 20 of 25 meaningful-use objectives (15 required core objectives and five objectives chosen from a list of 10 menu-set objectives).3 Eligible hospitals and CAHs must achieve 19 of 24 objectives (14 required core objectives and five objectives chosen from a list of 10 menu-set objectives).3
It seems that any program implementation with the potential to generate new or additional payment also has the potential to generate new or additional scrutiny of its application to ensure the generated payment is appropriate.5 Issues with EHR that recently have been highlighted include copy-and-paste, pulling notes forward, and upcoding based on volume instead of necessity.
Consider the Case
A patient is admitted to the hospital for pain, warmth, and swelling in the left lower extremity; r/o deep vein thrombosis (DVT) versus cellulitis. The patient’s history includes peripheral vascular disease (PVD), chronic renal insufficiency (CRI), and allergic rhinitis (AR). Testing confirms DVT, and the patient begins anticoagulation therapy. To achieve a therapeutic balance and prevent adverse reactions, the hospitalist orders INR monitoring.
On admission, the complexity of the patient’s condition may be considered high given the nature of the presenting problem.4 The hospitalist receives extensive credit for developing a care plan involving differential diagnoses with additional testing in anticipation of confirming a diagnosis. The patient’s presenting problem elevates the risk of morbidity/mortality, while the determined course of anticoagulation therapy places the patient at increased (i.e. “high”) risk for bleeding and requires intensive monitoring for toxicity. In this instance, 99223 may be warranted if the documentation requirements corresponding to this visit level have been satisfied.
As subsequent hospital days ensue, the complexity of the patient’s condition may not be as high. Even though the risk of anticoagulation remains high, the number of diagnoses and/or data ordered/reviewed may be less extensive than the initial encounter. Therefore, without any new or additional factors, the overall complexity of decision-making may be more appropriately categorized as moderate or low (e.g. 99232 or 99231, respectively).4
Do not fall victim to shortcuts that may falsely ease the workload of the overburdened physician. For example, the patient’s co-existing conditions of PVD, CRI, and AR likely were addressed during the initial encounter for DVT with inclusion in the plan of care. When using an electronic documentation system, it might be possible to copy the previously entered information from the initial encounter into the current encounter to save time. However, the previously entered information could include elements that do not need to be re-addressed during a subsequent encounter (e.g., AR) or yield information involving care for conditions that are being managed concurrently by another specialist (e.g. CRI being managed by the nephrologist).
Leaving the pasted information unaltered, without modification, can misrepresent the patient’s condition or the care provided by the hospitalist during the subsequent encounter.
Preventative Measures
Documentation should support the service provided on a given date, and the information included in the entry should reflect the content that was rendered and/or considered for assessment and management. Information that is pulled forward or copied and pasted from a previous entry should be modified to demonstrate updated content and nonoverlapping care with relevance for that date.
Do not use coding tools, or EHR “service calculators,” that override medical decision-making to determine the service level. Determining the service level for a particular CPT code category depends upon the key components of history, exam, and medical decision-making (MDM).4 For some code categories, each of the three key components must meet the documentation guidelines for the corresponding visit level (i.e. initial hospital care, initial observation care, and consultations). If all three components do not satisfy the requirements for a particular visit level, code selection is determined by the lowest component. For example, the physician must select 99221 when documenting a detailed history despite having also documented a comprehensive exam and high complexity decision-making. In other code categories, coding principles require that only two key components need to meet the documentation guidelines (i.e. subsequent hospital care and subsequent observation care) for code selection.
More specifically, code selection is determined by the second-lowest component. For example, the physician may appropriately select 99233 when only documenting a brief history after having also documented a detailed exam and high complexity decision-making. Based on this “two of three” stipulation, 99233 is acceptable. Service calculators that override MDM as one of the two supporting components in subsequent care services could generate 99233 for a service involving a detailed history and a detailed exam but only low complexity decision-making. Such coding practice can leave the hospitalist vulnerable to external inquiries involving medical necessity and upcoding. Despite this “two component” technicality with subsequent services (99231-99233 and 99224-99226), MDM always should be one of the two key components considered during subsequent visit level selection as it most clearly conveys the medical necessity of the encounter.
References
- Centers for Medicare & Medicaid Services. The official web site for the Medicare and Medicaid electronic health records (EHR) incentive programs. Centers for Medicare & Medicaid Services website. Available at: http://www.cms.gov/Regulations-and-Guidance/Legislation/EHRIncentivePrograms/index.html?redirect=/ehrincentiveprograms/. Accessed March 10, 2013.
- Centers for Medicare & Medicaid Services. Frequently asked questions (FAQs). Centers for Medicare & Medicaid Services website. Available at: http://www.cms.gov/Regulations-and-Guidance/Legislation/EHRIncentivePrograms/FAQ.html. Accessed March 10, 2013.
- Centers for Medicare & Medicaid Services. Meaningful use. Centers for Medicare & Medicaid Services website. Available at: http://www.cms.gov/Regulations-and-Guidance/Legislation/EHRIncentivePrograms/Meaningful_Use.html. Accessed March 10, 2013.
- Abraham M, Ahlman J, Anderson C, Boudreau A, Connelly J. Current Procedural Terminology 2012 Professional Edition. Chicago: American Medical Association Press; 2011:13-17.
- U.S. Department of Health and Human Services. Office of Inspector General work plan fiscal year 2013. U.S. Department of Health and Human Services website. Available at: http://oig.hhs.gov/reports-and-publications/archives/workplan/2013/Work-Plan-2013.pdf. Accessed March 11, 2013.
An electronic health record (EHR)—sometimes called an electronic medical record (EMR)—allows health-care providers to record patient information electronically instead of using paper records.1 It also has the capability to perform various tasks that can assist in health-care delivery while maintaining standards of practice. The Health Information Technology for Economic and Clinical Health (HITECH) Act, enacted under the American Recovery and Reinvestment Act of 2009 (Recovery Act), established a provision for incentive payments for eligible professionals (EPs), critical-access hospitals (CAHs), and eligible hospitals if they can demonstrate meaningful use of certified EHR technology:2
- The use of a certified EHR in a meaningful manner (e.g. e-prescribing);
- The use of certified EHR technology for electronic exchange of health information to improve quality of health care; and
- The use of certified EHR technology to submit clinical quality and other measures.
Eligible professionals must satisfy 20 of 25 meaningful-use objectives (15 required core objectives and five objectives chosen from a list of 10 menu-set objectives).3 Eligible hospitals and CAHs must achieve 19 of 24 objectives (14 required core objectives and five objectives chosen from a list of 10 menu-set objectives).3
It seems that any program implementation with the potential to generate new or additional payment also has the potential to generate new or additional scrutiny of its application to ensure the generated payment is appropriate.5 Issues with EHR that recently have been highlighted include copy-and-paste, pulling notes forward, and upcoding based on volume instead of necessity.
Consider the Case
A patient is admitted to the hospital for pain, warmth, and swelling in the left lower extremity; r/o deep vein thrombosis (DVT) versus cellulitis. The patient’s history includes peripheral vascular disease (PVD), chronic renal insufficiency (CRI), and allergic rhinitis (AR). Testing confirms DVT, and the patient begins anticoagulation therapy. To achieve a therapeutic balance and prevent adverse reactions, the hospitalist orders INR monitoring.
On admission, the complexity of the patient’s condition may be considered high given the nature of the presenting problem.4 The hospitalist receives extensive credit for developing a care plan involving differential diagnoses with additional testing in anticipation of confirming a diagnosis. The patient’s presenting problem elevates the risk of morbidity/mortality, while the determined course of anticoagulation therapy places the patient at increased (i.e. “high”) risk for bleeding and requires intensive monitoring for toxicity. In this instance, 99223 may be warranted if the documentation requirements corresponding to this visit level have been satisfied.
As subsequent hospital days ensue, the complexity of the patient’s condition may not be as high. Even though the risk of anticoagulation remains high, the number of diagnoses and/or data ordered/reviewed may be less extensive than the initial encounter. Therefore, without any new or additional factors, the overall complexity of decision-making may be more appropriately categorized as moderate or low (e.g. 99232 or 99231, respectively).4
Do not fall victim to shortcuts that may falsely ease the workload of the overburdened physician. For example, the patient’s co-existing conditions of PVD, CRI, and AR likely were addressed during the initial encounter for DVT with inclusion in the plan of care. When using an electronic documentation system, it might be possible to copy the previously entered information from the initial encounter into the current encounter to save time. However, the previously entered information could include elements that do not need to be re-addressed during a subsequent encounter (e.g., AR) or yield information involving care for conditions that are being managed concurrently by another specialist (e.g. CRI being managed by the nephrologist).
Leaving the pasted information unaltered, without modification, can misrepresent the patient’s condition or the care provided by the hospitalist during the subsequent encounter.
Preventative Measures
Documentation should support the service provided on a given date, and the information included in the entry should reflect the content that was rendered and/or considered for assessment and management. Information that is pulled forward or copied and pasted from a previous entry should be modified to demonstrate updated content and nonoverlapping care with relevance for that date.
Do not use coding tools, or EHR “service calculators,” that override medical decision-making to determine the service level. Determining the service level for a particular CPT code category depends upon the key components of history, exam, and medical decision-making (MDM).4 For some code categories, each of the three key components must meet the documentation guidelines for the corresponding visit level (i.e. initial hospital care, initial observation care, and consultations). If all three components do not satisfy the requirements for a particular visit level, code selection is determined by the lowest component. For example, the physician must select 99221 when documenting a detailed history despite having also documented a comprehensive exam and high complexity decision-making. In other code categories, coding principles require that only two key components need to meet the documentation guidelines (i.e. subsequent hospital care and subsequent observation care) for code selection.
More specifically, code selection is determined by the second-lowest component. For example, the physician may appropriately select 99233 when only documenting a brief history after having also documented a detailed exam and high complexity decision-making. Based on this “two of three” stipulation, 99233 is acceptable. Service calculators that override MDM as one of the two supporting components in subsequent care services could generate 99233 for a service involving a detailed history and a detailed exam but only low complexity decision-making. Such coding practice can leave the hospitalist vulnerable to external inquiries involving medical necessity and upcoding. Despite this “two component” technicality with subsequent services (99231-99233 and 99224-99226), MDM always should be one of the two key components considered during subsequent visit level selection as it most clearly conveys the medical necessity of the encounter.
References
- Centers for Medicare & Medicaid Services. The official web site for the Medicare and Medicaid electronic health records (EHR) incentive programs. Centers for Medicare & Medicaid Services website. Available at: http://www.cms.gov/Regulations-and-Guidance/Legislation/EHRIncentivePrograms/index.html?redirect=/ehrincentiveprograms/. Accessed March 10, 2013.
- Centers for Medicare & Medicaid Services. Frequently asked questions (FAQs). Centers for Medicare & Medicaid Services website. Available at: http://www.cms.gov/Regulations-and-Guidance/Legislation/EHRIncentivePrograms/FAQ.html. Accessed March 10, 2013.
- Centers for Medicare & Medicaid Services. Meaningful use. Centers for Medicare & Medicaid Services website. Available at: http://www.cms.gov/Regulations-and-Guidance/Legislation/EHRIncentivePrograms/Meaningful_Use.html. Accessed March 10, 2013.
- Abraham M, Ahlman J, Anderson C, Boudreau A, Connelly J. Current Procedural Terminology 2012 Professional Edition. Chicago: American Medical Association Press; 2011:13-17.
- U.S. Department of Health and Human Services. Office of Inspector General work plan fiscal year 2013. U.S. Department of Health and Human Services website. Available at: http://oig.hhs.gov/reports-and-publications/archives/workplan/2013/Work-Plan-2013.pdf. Accessed March 11, 2013.
An electronic health record (EHR)—sometimes called an electronic medical record (EMR)—allows health-care providers to record patient information electronically instead of using paper records.1 It also has the capability to perform various tasks that can assist in health-care delivery while maintaining standards of practice. The Health Information Technology for Economic and Clinical Health (HITECH) Act, enacted under the American Recovery and Reinvestment Act of 2009 (Recovery Act), established a provision for incentive payments for eligible professionals (EPs), critical-access hospitals (CAHs), and eligible hospitals if they can demonstrate meaningful use of certified EHR technology:2
- The use of a certified EHR in a meaningful manner (e.g. e-prescribing);
- The use of certified EHR technology for electronic exchange of health information to improve quality of health care; and
- The use of certified EHR technology to submit clinical quality and other measures.
Eligible professionals must satisfy 20 of 25 meaningful-use objectives (15 required core objectives and five objectives chosen from a list of 10 menu-set objectives).3 Eligible hospitals and CAHs must achieve 19 of 24 objectives (14 required core objectives and five objectives chosen from a list of 10 menu-set objectives).3
It seems that any program implementation with the potential to generate new or additional payment also has the potential to generate new or additional scrutiny of its application to ensure the generated payment is appropriate.5 Issues with EHR that recently have been highlighted include copy-and-paste, pulling notes forward, and upcoding based on volume instead of necessity.
Consider the Case
A patient is admitted to the hospital for pain, warmth, and swelling in the left lower extremity; r/o deep vein thrombosis (DVT) versus cellulitis. The patient’s history includes peripheral vascular disease (PVD), chronic renal insufficiency (CRI), and allergic rhinitis (AR). Testing confirms DVT, and the patient begins anticoagulation therapy. To achieve a therapeutic balance and prevent adverse reactions, the hospitalist orders INR monitoring.
On admission, the complexity of the patient’s condition may be considered high given the nature of the presenting problem.4 The hospitalist receives extensive credit for developing a care plan involving differential diagnoses with additional testing in anticipation of confirming a diagnosis. The patient’s presenting problem elevates the risk of morbidity/mortality, while the determined course of anticoagulation therapy places the patient at increased (i.e. “high”) risk for bleeding and requires intensive monitoring for toxicity. In this instance, 99223 may be warranted if the documentation requirements corresponding to this visit level have been satisfied.
As subsequent hospital days ensue, the complexity of the patient’s condition may not be as high. Even though the risk of anticoagulation remains high, the number of diagnoses and/or data ordered/reviewed may be less extensive than the initial encounter. Therefore, without any new or additional factors, the overall complexity of decision-making may be more appropriately categorized as moderate or low (e.g. 99232 or 99231, respectively).4
Do not fall victim to shortcuts that may falsely ease the workload of the overburdened physician. For example, the patient’s co-existing conditions of PVD, CRI, and AR likely were addressed during the initial encounter for DVT with inclusion in the plan of care. When using an electronic documentation system, it might be possible to copy the previously entered information from the initial encounter into the current encounter to save time. However, the previously entered information could include elements that do not need to be re-addressed during a subsequent encounter (e.g., AR) or yield information involving care for conditions that are being managed concurrently by another specialist (e.g. CRI being managed by the nephrologist).
Leaving the pasted information unaltered, without modification, can misrepresent the patient’s condition or the care provided by the hospitalist during the subsequent encounter.
Preventative Measures
Documentation should support the service provided on a given date, and the information included in the entry should reflect the content that was rendered and/or considered for assessment and management. Information that is pulled forward or copied and pasted from a previous entry should be modified to demonstrate updated content and nonoverlapping care with relevance for that date.
Do not use coding tools, or EHR “service calculators,” that override medical decision-making to determine the service level. Determining the service level for a particular CPT code category depends upon the key components of history, exam, and medical decision-making (MDM).4 For some code categories, each of the three key components must meet the documentation guidelines for the corresponding visit level (i.e. initial hospital care, initial observation care, and consultations). If all three components do not satisfy the requirements for a particular visit level, code selection is determined by the lowest component. For example, the physician must select 99221 when documenting a detailed history despite having also documented a comprehensive exam and high complexity decision-making. In other code categories, coding principles require that only two key components need to meet the documentation guidelines (i.e. subsequent hospital care and subsequent observation care) for code selection.
More specifically, code selection is determined by the second-lowest component. For example, the physician may appropriately select 99233 when only documenting a brief history after having also documented a detailed exam and high complexity decision-making. Based on this “two of three” stipulation, 99233 is acceptable. Service calculators that override MDM as one of the two supporting components in subsequent care services could generate 99233 for a service involving a detailed history and a detailed exam but only low complexity decision-making. Such coding practice can leave the hospitalist vulnerable to external inquiries involving medical necessity and upcoding. Despite this “two component” technicality with subsequent services (99231-99233 and 99224-99226), MDM always should be one of the two key components considered during subsequent visit level selection as it most clearly conveys the medical necessity of the encounter.
References
- Centers for Medicare & Medicaid Services. The official web site for the Medicare and Medicaid electronic health records (EHR) incentive programs. Centers for Medicare & Medicaid Services website. Available at: http://www.cms.gov/Regulations-and-Guidance/Legislation/EHRIncentivePrograms/index.html?redirect=/ehrincentiveprograms/. Accessed March 10, 2013.
- Centers for Medicare & Medicaid Services. Frequently asked questions (FAQs). Centers for Medicare & Medicaid Services website. Available at: http://www.cms.gov/Regulations-and-Guidance/Legislation/EHRIncentivePrograms/FAQ.html. Accessed March 10, 2013.
- Centers for Medicare & Medicaid Services. Meaningful use. Centers for Medicare & Medicaid Services website. Available at: http://www.cms.gov/Regulations-and-Guidance/Legislation/EHRIncentivePrograms/Meaningful_Use.html. Accessed March 10, 2013.
- Abraham M, Ahlman J, Anderson C, Boudreau A, Connelly J. Current Procedural Terminology 2012 Professional Edition. Chicago: American Medical Association Press; 2011:13-17.
- U.S. Department of Health and Human Services. Office of Inspector General work plan fiscal year 2013. U.S. Department of Health and Human Services website. Available at: http://oig.hhs.gov/reports-and-publications/archives/workplan/2013/Work-Plan-2013.pdf. Accessed March 11, 2013.