Latest News for HOSP

A cornerstone of hospital medicine is the delivery of high-quality inpatient care by improving the performance of the systems and facilities in which hospitalists work. By extension, hospitalists are often held accountable, in varying ways, for improving the performance of facility metrics, such as those in the Hospital Value-Based Purchasing (HVBP), Inpatient Quality Reporting, and Hospital Readmissions Reduction programs.

Despite the work hospitalists were already doing to improve both efficiency and quality within their institutions, the 2010 Affordable Care Act introduced penalties for clinicians who did not submit qualifying provider-level data via the Physician Quality Reporting System program. Initially only an incentive program, PQRS was ultimately incorporated into the Physician Value-Based Payment (VBP) Modifier to make performance-based payment adjustments to Medicare physician payment. At this point, many hospitalists were not only accountable for helping to improve the metrics of their facilities, but also required to report individually or within their groups on provider-level measures, many of which were irrelevant to hospital medicine practice.

With this dual burden becoming evident, the Society of Hospital Medicine approached the Centers for Medicare & Medicaid Services with a possible solution. Could hospitalists elect to use their facilities’ metrics as a stand-in for the provider level metrics? Not only would this reduce the burden of reporting irrelevant metrics, but it would also help alleviate some of the disadvantages hospitalists face within Physician VBP.

The CMS was initially very supportive of the concept, but informed the SHM such alignment was not possible under existing law. In brief, the law required Physician VBP to remain completely within the Physician Fee Schedule and its related metrics; facility level metrics from a different payment system could not be used.

Undeterred, the SHM sought opportunities to change the law. As Congress was developing the Medicare Access and Chip Reauthorization Act (MACRA), the SHM worked closely with lawmakers to include language that would permit measures in “other payment systems” to be used for physician performance assessment. This language was retained in the final version of MACRA that was signed into law on April 16, 2015.

The SHM continued its advocacy, working closely with the CMS and its new authority to shape an option to align Medicare’s facility metrics and scores with provider reporting. Today that idea is a reality. Beginning this year, the CMS will have a new Merit-based Incentive Payment System (MIPS) reporting option available for hospitalists: facility-based measurement.

Facility-based measurement enables clinicians to receive a score for the Quality and Cost categories of the MIPS, without the need to collect and report on measures separately. Eligible providers would receive the MIPS score in those categories associated with the same percentile as their hospital’s score in HVBP. No more administrative work necessary to collect, clean and report on data for quality measures in the MIPS. If you are eligible, the CMS will automatically calculate a Quality and Cost score and combine this with your score from Improvement Activities and Promoting Interoperability (if you are not exempt) to give you a final MIPS score. If you decide to report on quality measures through the traditional MIPS pathway as well, the CMS will give you the higher of the scores.

There are certainly trade-offs associated with the facility-based measurement option. You do not have the burden of reporting measures on your own, but you do not get to pick what measures and what facility’s score you receive. Facility-level measures may be more difficult to improve performance, particularly as an individual, but the automatic application of facility-based measurement to eligible clinicians and groups serves as a backstop for MIPS reporting.

Aligning facility and clinician performance should encourage collaboration and innovation to meet these shared goals. As such, facility-based measurement represents a massive philosophical and practical shift in CMS measure reporting. As we enter these uncharted waters together, we hope to continue learning from your experiences and perspectives and working to refine facility-based measurement in the future.

For more information about facility-based reporting and the MIPS in general, visit www.macraforhm.org.

Mr. Lapps is government relations senior manager and Mr. Boswell is government relations director at the Society of Hospital Medicine.

Who is eligible for facility-based measurement?

• Individual providers who bill more than 75% of their Medicare Part B professional services in Place of Service 21 (Emergency Department), 22 (Hospital Outpatient), and 23 (Inpatient Hospital), billing at least one service in POS 21 or 23, and work in a hospital with an HVBP score.
• Groups who have at least 75% of their individual clinicians who meet the eligibility criteria.
• Nearly all hospitalists should qualify for facility-based measurement as individuals, while group eligibility depends on the demographics of their staff.

A cornerstone of hospital medicine is the delivery of high-quality inpatient care by improving the performance of the systems and facilities in which hospitalists work. By extension, hospitalists are often held accountable, in varying ways, for improving the performance of facility metrics, such as those in the Hospital Value-Based Purchasing (HVBP), Inpatient Quality Reporting, and Hospital Readmissions Reduction programs.

Despite the work hospitalists were already doing to improve both efficiency and quality within their institutions, the 2010 Affordable Care Act introduced penalties for clinicians who did not submit qualifying provider-level data via the Physician Quality Reporting System program. Initially only an incentive program, PQRS was ultimately incorporated into the Physician Value-Based Payment (VBP) Modifier to make performance-based payment adjustments to Medicare physician payment. At this point, many hospitalists were not only accountable for helping to improve the metrics of their facilities, but also required to report individually or within their groups on provider-level measures, many of which were irrelevant to hospital medicine practice.

With this dual burden becoming evident, the Society of Hospital Medicine approached the Centers for Medicare & Medicaid Services with a possible solution. Could hospitalists elect to use their facilities’ metrics as a stand-in for the provider level metrics? Not only would this reduce the burden of reporting irrelevant metrics, but it would also help alleviate some of the disadvantages hospitalists face within Physician VBP.

The CMS was initially very supportive of the concept, but informed the SHM such alignment was not possible under existing law. In brief, the law required Physician VBP to remain completely within the Physician Fee Schedule and its related metrics; facility level metrics from a different payment system could not be used.

Undeterred, the SHM sought opportunities to change the law. As Congress was developing the Medicare Access and Chip Reauthorization Act (MACRA), the SHM worked closely with lawmakers to include language that would permit measures in “other payment systems” to be used for physician performance assessment. This language was retained in the final version of MACRA that was signed into law on April 16, 2015.

The SHM continued its advocacy, working closely with the CMS and its new authority to shape an option to align Medicare’s facility metrics and scores with provider reporting. Today that idea is a reality. Beginning this year, the CMS will have a new Merit-based Incentive Payment System (MIPS) reporting option available for hospitalists: facility-based measurement.

Facility-based measurement enables clinicians to receive a score for the Quality and Cost categories of the MIPS, without the need to collect and report on measures separately. Eligible providers would receive the MIPS score in those categories associated with the same percentile as their hospital’s score in HVBP. No more administrative work necessary to collect, clean and report on data for quality measures in the MIPS. If you are eligible, the CMS will automatically calculate a Quality and Cost score and combine this with your score from Improvement Activities and Promoting Interoperability (if you are not exempt) to give you a final MIPS score. If you decide to report on quality measures through the traditional MIPS pathway as well, the CMS will give you the higher of the scores.

There are certainly trade-offs associated with the facility-based measurement option. You do not have the burden of reporting measures on your own, but you do not get to pick what measures and what facility’s score you receive. Facility-level measures may be more difficult to improve performance, particularly as an individual, but the automatic application of facility-based measurement to eligible clinicians and groups serves as a backstop for MIPS reporting.

Aligning facility and clinician performance should encourage collaboration and innovation to meet these shared goals. As such, facility-based measurement represents a massive philosophical and practical shift in CMS measure reporting. As we enter these uncharted waters together, we hope to continue learning from your experiences and perspectives and working to refine facility-based measurement in the future.

For more information about facility-based reporting and the MIPS in general, visit www.macraforhm.org.

Mr. Lapps is government relations senior manager and Mr. Boswell is government relations director at the Society of Hospital Medicine.

Who is eligible for facility-based measurement?

• Individual providers who bill more than 75% of their Medicare Part B professional services in Place of Service 21 (Emergency Department), 22 (Hospital Outpatient), and 23 (Inpatient Hospital), billing at least one service in POS 21 or 23, and work in a hospital with an HVBP score.
• Groups who have at least 75% of their individual clinicians who meet the eligibility criteria.
• Nearly all hospitalists should qualify for facility-based measurement as individuals, while group eligibility depends on the demographics of their staff.

A cornerstone of hospital medicine is the delivery of high-quality inpatient care by improving the performance of the systems and facilities in which hospitalists work. By extension, hospitalists are often held accountable, in varying ways, for improving the performance of facility metrics, such as those in the Hospital Value-Based Purchasing (HVBP), Inpatient Quality Reporting, and Hospital Readmissions Reduction programs.

Despite the work hospitalists were already doing to improve both efficiency and quality within their institutions, the 2010 Affordable Care Act introduced penalties for clinicians who did not submit qualifying provider-level data via the Physician Quality Reporting System program. Initially only an incentive program, PQRS was ultimately incorporated into the Physician Value-Based Payment (VBP) Modifier to make performance-based payment adjustments to Medicare physician payment. At this point, many hospitalists were not only accountable for helping to improve the metrics of their facilities, but also required to report individually or within their groups on provider-level measures, many of which were irrelevant to hospital medicine practice.

With this dual burden becoming evident, the Society of Hospital Medicine approached the Centers for Medicare & Medicaid Services with a possible solution. Could hospitalists elect to use their facilities’ metrics as a stand-in for the provider level metrics? Not only would this reduce the burden of reporting irrelevant metrics, but it would also help alleviate some of the disadvantages hospitalists face within Physician VBP.

The CMS was initially very supportive of the concept, but informed the SHM such alignment was not possible under existing law. In brief, the law required Physician VBP to remain completely within the Physician Fee Schedule and its related metrics; facility level metrics from a different payment system could not be used.

Undeterred, the SHM sought opportunities to change the law. As Congress was developing the Medicare Access and Chip Reauthorization Act (MACRA), the SHM worked closely with lawmakers to include language that would permit measures in “other payment systems” to be used for physician performance assessment. This language was retained in the final version of MACRA that was signed into law on April 16, 2015.

The SHM continued its advocacy, working closely with the CMS and its new authority to shape an option to align Medicare’s facility metrics and scores with provider reporting. Today that idea is a reality. Beginning this year, the CMS will have a new Merit-based Incentive Payment System (MIPS) reporting option available for hospitalists: facility-based measurement.

Facility-based measurement enables clinicians to receive a score for the Quality and Cost categories of the MIPS, without the need to collect and report on measures separately. Eligible providers would receive the MIPS score in those categories associated with the same percentile as their hospital’s score in HVBP. No more administrative work necessary to collect, clean and report on data for quality measures in the MIPS. If you are eligible, the CMS will automatically calculate a Quality and Cost score and combine this with your score from Improvement Activities and Promoting Interoperability (if you are not exempt) to give you a final MIPS score. If you decide to report on quality measures through the traditional MIPS pathway as well, the CMS will give you the higher of the scores.

There are certainly trade-offs associated with the facility-based measurement option. You do not have the burden of reporting measures on your own, but you do not get to pick what measures and what facility’s score you receive. Facility-level measures may be more difficult to improve performance, particularly as an individual, but the automatic application of facility-based measurement to eligible clinicians and groups serves as a backstop for MIPS reporting.

Aligning facility and clinician performance should encourage collaboration and innovation to meet these shared goals. As such, facility-based measurement represents a massive philosophical and practical shift in CMS measure reporting. As we enter these uncharted waters together, we hope to continue learning from your experiences and perspectives and working to refine facility-based measurement in the future.

For more information about facility-based reporting and the MIPS in general, visit www.macraforhm.org.

Mr. Lapps is government relations senior manager and Mr. Boswell is government relations director at the Society of Hospital Medicine.

Who is eligible for facility-based measurement?

• Individual providers who bill more than 75% of their Medicare Part B professional services in Place of Service 21 (Emergency Department), 22 (Hospital Outpatient), and 23 (Inpatient Hospital), billing at least one service in POS 21 or 23, and work in a hospital with an HVBP score.
• Groups who have at least 75% of their individual clinicians who meet the eligibility criteria.
• Nearly all hospitalists should qualify for facility-based measurement as individuals, while group eligibility depends on the demographics of their staff.

SAN DIEGO – Hospitals pay a price for bad behavior by staff in the workplace, results of a large multicenter study suggest.

Randy Dotinga/MDedge News

A work culture in which disruptive behavior is tolerated can have consequences. Research on this topic has linked disruptive behavior by staff in the health care setting to increased frequency of medical errors and lower quality of care (Am J Med Qual. 2011 Sep-Oct;26(5):372-9; J Caring Sci. 2016 Sep 1;5(3):241-9). This new study, based on a workplace culture survey of 7,923 health care workers and 325 work settings at 16 hospitals in a large West Coast health care system, found higher rates of depression and burnout among staff where disruptive behavior is prevalent, researchers found. The paper was presented by study lead Allison Hadley, MD, of Duke Children’s Hospital, Durham, N.C., at the Critical Care Congress sponsored by the Society of Critical Care Medicine.

The investigators developed a novel survey scale for evaluating disruptive behaviors in the health care setting. The objective was to look at the associations between disruptive behavior, teamwork, safety culture, burnout, and depression. Disruptive behaviors included turning backs or hanging up the phone before a conversation is over, bullying or trying to publicly humiliate other staff, making inappropriate comments (with sexual, racial, religious, or ethnic slurs), and physical aggression (such as throwing, hitting, and pushing).

San Francisco internist Alan H. Rosenstein, MD, who studies disruptive behavior in medicine, said in an interview that the findings confirm anecdotal experience of medical staff. “One of the downsides of disruptive behavior is very unsatisfied and unhappy people,” he said

The investigators used a t-test analysis to study the strength of the association between disruptive behavior and work culture in health care work settings. They found a statistically significant association between less disruptive behavior and lower levels of burnout and depression among staff (t = 6.4 and t = 4.1, respectively, P less than .001) and higher levels of teamwork, safety culture, and work-life balance (t = 10.2, t = 9.5 and t = 5.8, respectively, P less than .001). Settings in which disruptive behaviors were more common were more likely to have poor teamwork culture (P less than .001) and safety climate (P less than .001), and higher rates of depression (P less than .001). Settings in which disruptive behaviors were more common were more likely to have poor teamwork culture (P less than .001) and safety climate (P less than .001), and higher rates of depression (P less than .001).

Bullying was reported at about 40% of workplaces with low teamwork levels, compared with nearly 20% in those with high teamwork levels.

Physical aggression was reported in nearly 20% of those workplaces with low teamwork levels, compared with 5% in workplaces with high teamwork levels (P less than .001).

Researchers also found that disruptive behaviors were least common during day shifts and more common among health care workers who care for both adults and children than among those who care for only adults. “Teamwork, safety culture, and work-life balance were highest in those [hospital] units with the least disruptive behaviors,” said Dr. Hadley.

Overall, the highest positive correlation was found between higher levels of teamwork and lower levels of disruptive behavior, Dr. Hadley said. If a hospital department is trying to address one issue to improve disruptive behavior, she’d suggest it “focus on teamwork first. I hope that would have the greatest impact.”

Dr. Rosenstein, who has conducted several studies on disruptive behavior, said the key to improving the workplace is to “build a culture based on the mission of providing patient care. It’s not to save a dollar, to make a dollar. The mission is patient care.”

What’s next? Dr. Hadley said her team is continuing to work on developing a scale to measure disruptive behavior in the workplace.

No study funding was reported. Dr. Hadley and Dr. Rosenstein reported no relevant disclosures.

SOURCE: Hadley A et al. CCC48, Abstract 114.
 

SAN DIEGO – Hospitals pay a price for bad behavior by staff in the workplace, results of a large multicenter study suggest.

Randy Dotinga/MDedge News

A work culture in which disruptive behavior is tolerated can have consequences. Research on this topic has linked disruptive behavior by staff in the health care setting to increased frequency of medical errors and lower quality of care (Am J Med Qual. 2011 Sep-Oct;26(5):372-9; J Caring Sci. 2016 Sep 1;5(3):241-9). This new study, based on a workplace culture survey of 7,923 health care workers and 325 work settings at 16 hospitals in a large West Coast health care system, found higher rates of depression and burnout among staff where disruptive behavior is prevalent, researchers found. The paper was presented by study lead Allison Hadley, MD, of Duke Children’s Hospital, Durham, N.C., at the Critical Care Congress sponsored by the Society of Critical Care Medicine.

The investigators developed a novel survey scale for evaluating disruptive behaviors in the health care setting. The objective was to look at the associations between disruptive behavior, teamwork, safety culture, burnout, and depression. Disruptive behaviors included turning backs or hanging up the phone before a conversation is over, bullying or trying to publicly humiliate other staff, making inappropriate comments (with sexual, racial, religious, or ethnic slurs), and physical aggression (such as throwing, hitting, and pushing).

San Francisco internist Alan H. Rosenstein, MD, who studies disruptive behavior in medicine, said in an interview that the findings confirm anecdotal experience of medical staff. “One of the downsides of disruptive behavior is very unsatisfied and unhappy people,” he said

The investigators used a t-test analysis to study the strength of the association between disruptive behavior and work culture in health care work settings. They found a statistically significant association between less disruptive behavior and lower levels of burnout and depression among staff (t = 6.4 and t = 4.1, respectively, P less than .001) and higher levels of teamwork, safety culture, and work-life balance (t = 10.2, t = 9.5 and t = 5.8, respectively, P less than .001). Settings in which disruptive behaviors were more common were more likely to have poor teamwork culture (P less than .001) and safety climate (P less than .001), and higher rates of depression (P less than .001). Settings in which disruptive behaviors were more common were more likely to have poor teamwork culture (P less than .001) and safety climate (P less than .001), and higher rates of depression (P less than .001).

Bullying was reported at about 40% of workplaces with low teamwork levels, compared with nearly 20% in those with high teamwork levels.

Physical aggression was reported in nearly 20% of those workplaces with low teamwork levels, compared with 5% in workplaces with high teamwork levels (P less than .001).

Researchers also found that disruptive behaviors were least common during day shifts and more common among health care workers who care for both adults and children than among those who care for only adults. “Teamwork, safety culture, and work-life balance were highest in those [hospital] units with the least disruptive behaviors,” said Dr. Hadley.

Overall, the highest positive correlation was found between higher levels of teamwork and lower levels of disruptive behavior, Dr. Hadley said. If a hospital department is trying to address one issue to improve disruptive behavior, she’d suggest it “focus on teamwork first. I hope that would have the greatest impact.”

Dr. Rosenstein, who has conducted several studies on disruptive behavior, said the key to improving the workplace is to “build a culture based on the mission of providing patient care. It’s not to save a dollar, to make a dollar. The mission is patient care.”

What’s next? Dr. Hadley said her team is continuing to work on developing a scale to measure disruptive behavior in the workplace.

No study funding was reported. Dr. Hadley and Dr. Rosenstein reported no relevant disclosures.

SOURCE: Hadley A et al. CCC48, Abstract 114.
 

SAN DIEGO – Hospitals pay a price for bad behavior by staff in the workplace, results of a large multicenter study suggest.

Randy Dotinga/MDedge News

A work culture in which disruptive behavior is tolerated can have consequences. Research on this topic has linked disruptive behavior by staff in the health care setting to increased frequency of medical errors and lower quality of care (Am J Med Qual. 2011 Sep-Oct;26(5):372-9; J Caring Sci. 2016 Sep 1;5(3):241-9). This new study, based on a workplace culture survey of 7,923 health care workers and 325 work settings at 16 hospitals in a large West Coast health care system, found higher rates of depression and burnout among staff where disruptive behavior is prevalent, researchers found. The paper was presented by study lead Allison Hadley, MD, of Duke Children’s Hospital, Durham, N.C., at the Critical Care Congress sponsored by the Society of Critical Care Medicine.

The investigators developed a novel survey scale for evaluating disruptive behaviors in the health care setting. The objective was to look at the associations between disruptive behavior, teamwork, safety culture, burnout, and depression. Disruptive behaviors included turning backs or hanging up the phone before a conversation is over, bullying or trying to publicly humiliate other staff, making inappropriate comments (with sexual, racial, religious, or ethnic slurs), and physical aggression (such as throwing, hitting, and pushing).

San Francisco internist Alan H. Rosenstein, MD, who studies disruptive behavior in medicine, said in an interview that the findings confirm anecdotal experience of medical staff. “One of the downsides of disruptive behavior is very unsatisfied and unhappy people,” he said

The investigators used a t-test analysis to study the strength of the association between disruptive behavior and work culture in health care work settings. They found a statistically significant association between less disruptive behavior and lower levels of burnout and depression among staff (t = 6.4 and t = 4.1, respectively, P less than .001) and higher levels of teamwork, safety culture, and work-life balance (t = 10.2, t = 9.5 and t = 5.8, respectively, P less than .001). Settings in which disruptive behaviors were more common were more likely to have poor teamwork culture (P less than .001) and safety climate (P less than .001), and higher rates of depression (P less than .001). Settings in which disruptive behaviors were more common were more likely to have poor teamwork culture (P less than .001) and safety climate (P less than .001), and higher rates of depression (P less than .001).

Bullying was reported at about 40% of workplaces with low teamwork levels, compared with nearly 20% in those with high teamwork levels.

Physical aggression was reported in nearly 20% of those workplaces with low teamwork levels, compared with 5% in workplaces with high teamwork levels (P less than .001).

Researchers also found that disruptive behaviors were least common during day shifts and more common among health care workers who care for both adults and children than among those who care for only adults. “Teamwork, safety culture, and work-life balance were highest in those [hospital] units with the least disruptive behaviors,” said Dr. Hadley.

Overall, the highest positive correlation was found between higher levels of teamwork and lower levels of disruptive behavior, Dr. Hadley said. If a hospital department is trying to address one issue to improve disruptive behavior, she’d suggest it “focus on teamwork first. I hope that would have the greatest impact.”

Dr. Rosenstein, who has conducted several studies on disruptive behavior, said the key to improving the workplace is to “build a culture based on the mission of providing patient care. It’s not to save a dollar, to make a dollar. The mission is patient care.”

What’s next? Dr. Hadley said her team is continuing to work on developing a scale to measure disruptive behavior in the workplace.

No study funding was reported. Dr. Hadley and Dr. Rosenstein reported no relevant disclosures.

SOURCE: Hadley A et al. CCC48, Abstract 114.
 

Therese Franco, MD, SFHM, a hospitalist at the Virginia Mason Medical Center in Seattle, is the current president of SHM’s Pacific Northwest chapter. 
The Hospitalist recently sat down with her to learn about her background and discuss some of the initiatives that the Pacific Northwest chapter has been working on.

Can you tell us about your education and training on the way to becoming a hospitalist?
My undergraduate degree is in engineering from Michigan State University. I then went to the University of Michigan in Ann Arbor and did one degree at the School of Public Health in environmental and industrial health, and another degree in the College of Engineering in industrial and operations engineering. In my work with the safety department at an automotive  company, I found I was spending a lot of time looking at data, and not talking to people. I got into a conversation with one of the occupational medicine physicians there, and he said, “You ought to try this.” I spoke with a good friend, who was a medical student, and she agreed.
So then I went to medical school thinking that I would practice occupational medicine. I went to medical school at Wayne State University in Detroit and did a couple of rotations in occupational medicine. I wasn’t sure that was the right fit, so I then went off to residency in internal medicine at the University of Connecticut and really enjoyed my wards experience. I liked the pace, I liked the variety, and just really liked all of hospital medicine. So that’s what I decided to do.

What are your areas of research interest?
This year I’m doing a research fellowship through the Center for Healthcare Improvement Science, at Virginia Mason. Through SHM’s mentored implementation program, I have done a lot of work on diabetes and glycemic control but never really published much of it. I think it is so important to share what you learn, so I’m working on publishing some of our results from the diabetes work. 
Another area of interest is advanced-practice providers in hospital medicine, which I think is very important, given all the issues that health care is facing. I think that medicine has gotten more complex and that we’re going to have to look at working in a collaborative, inter-professional, multidisciplinary way. I think that advanced practice can really improve the care of hospitalized patients, if we practice appropriate skill-task alignment, develop a culture of mutual respect, and find the best ways to deploy our advanced-practice providers and our physicians. 
That can be challenging. Some people, I think, are worried about losing their jobs, and some people feel like they want to “own” all of the patient, because it’s such a part of the culture of medicine. So it’s a really complicated issue, and I think that doctors are going to have to get used to delegating tasks that they used to perform.

So a collaborative practice requires both a professional and a cultural shift?
I think so. I was our inaugural program director for an advanced-practice fellowship in hospital medicine, and in that role, I attended conferences and learning events for program development. I think that many institutions are facing some of the same challenges. For the most part, I’m optimistic about things. I think we’re on the right track, and help is on the way – we just have to figure out how to use it.

Has your institution made any changes along these lines?
We’re primarily using the fellowship as a tool to recruit and retain some of the brightest and best. We’ve got three fellows that matriculated from our program and are currently working in the section of hospital medicine. Everyone’s been really flexible and open to the idea that the job description is emerging. I think my colleagues are very appreciative of our advanced-practice providers. We’ve got two nurse practitioners and one physician assistant who is also a PhD-trained pharmacist. They’ve been great additions to our team.

What are some of the other issues that the Pacific Northwest chapter members are concerned about?
One of our most successful meetings was around telemedicine. There’s a lot of interest in that, and it’s very financially and technically complex. Some hospitals in the area are really doing novel things. One of the most interesting things is an addiction medicine teleconsult.
That’s out of Swedish Medical Center, Seattle. Of course there’s telestroke, which I think is picking up in  popularity. We had speakers from Virginia Mason who presented on telestroke. Some institutions are even doing admissions this way. The University of Washington is doing some good antimicrobial stewardship work. They present cases and they teleconference and have an  infectious disease consultant. It’s not a program directed at revenue generation, but is focused instead on sharing and spreading expertise.
Our chapter also hosted a presentation on burnout that was pretty well attended. And then, unfortunately, we did lose a hospitalist to suicide over the summer. That was the inspiration for offering the screening of the movie, “Do No Harm: Exposing the Hippocratic Hoax.” 

What was the program that you put together around the screening? 
We had the filmmaker come for the screening, and we organized a panel discussion with a wellness officer from a local clinic and a psychiatrist who used to be on the board of the Physician Health Program. John Nelson, MD, MHM, one of SHM’s cofounders and a local hospitalist here, also participated as a  panelist. 
Overall, the event was well received. There were some things that I didn’t really expect. I’m not sure that the film resonated with too many people in the room. It is very much directed at the educational process – med students and residents – and at times the dialogue is a little inflammatory.
I learned a few important things from the film. I did not realize that the tragedy of physician suicide is not unique to the United States – it’s an international issue. And we sometimes use the term “pimping” to talk about questioning interns or residents on rounds. Apparently, that stands for “put in my place,” which is very condescending and unacceptable. I will not use the term again. 
I think future conversations need to come from thoughtful, rational, respectful leaders who are willing to work with regulatory agencies, hospitals, and administrators. If we want to move forward, physicians, administrators, and the public need to come together in the best interest of the patient and of public health. And I don’t know who leads that conversation.
 
Will your chapter have another event around that subject?
We will do what our membership wants and needs. We meet quarterly, and once a year we hold a people’s choice meeting and I solicit topics. If members want to keep the conversation moving, I’m going to do what I can to support them.

What are some other issues that stand out as important to your chapter? 
One key topic is the financial side of hospitalist practice, and dealing with issues that seem to create inefficiencies – regulatory issues, documentation issues, things that are important because we want to tell the story of what we’re doing. We certainly want to be reimbursed for the value-added work that we’re doing, but a lot of value-added work creates inefficiencies of practice, and I hear a lot of dissatisfaction around documentation, coding, billing, and other issues related to reimbursement. While people are concerned about these problems, nobody wants to talk about them. They just want somebody to fix it. So I’m not sure what to do with that, because I think if I had a meeting about coding and billing, I would have three attendees. 
But our annual poster meeting is always well attended. We always do it at the end of the year, to kick off the holiday season. It’s a nice opportunity to connect socially with colleagues because you mix and you mingle and look at the posters. We had some really great posters, and our top three prize winners were medical students, which is inspirational. They make you feel good about the future. 
Our chapter is trying to diversify geographically and clinically. We were fortunate to receive a development funds grant to use technology to do streaming meetings. Our hope is that we can host streaming meetings and eventually transition hosting to rotate around the state. Once there’s large enough attendance, the different delegates can develop their own leadership teams and, eventually, their own chapter. We’re hoping to grow the organization that way.
 
What else is on the horizon for hospitalists in the Pacific Northwest? 
I’d like to see more frequent meetings and a greater variety of meetings. I think there’s interest in adding some kind of service element to the chapter. Maybe we can do a blood pressure screening at a sporting event. 
I think we’ll also be focusing on students and residents and trying to create support for them. We held a student event around financial planning, and that was very well attended. I think we would like to do something around mentorship. Of course it’s hard to find mentors, because everybody is so busy. 
Our chapter really needs to leverage our technology if we want to have the reach that I’m talking about. I’m looking forward to piloting the streaming meeting concept, and I hope to do some live polling of our meeting attendees to get them engaged. I hope we continue to grow and keep the dialogue going about what matters in hospital medicine, and do our part to shape the future in the way we want it.

Therese Franco, MD, SFHM, a hospitalist at the Virginia Mason Medical Center in Seattle, is the current president of SHM’s Pacific Northwest chapter. 
The Hospitalist recently sat down with her to learn about her background and discuss some of the initiatives that the Pacific Northwest chapter has been working on.

Can you tell us about your education and training on the way to becoming a hospitalist?
My undergraduate degree is in engineering from Michigan State University. I then went to the University of Michigan in Ann Arbor and did one degree at the School of Public Health in environmental and industrial health, and another degree in the College of Engineering in industrial and operations engineering. In my work with the safety department at an automotive  company, I found I was spending a lot of time looking at data, and not talking to people. I got into a conversation with one of the occupational medicine physicians there, and he said, “You ought to try this.” I spoke with a good friend, who was a medical student, and she agreed.
So then I went to medical school thinking that I would practice occupational medicine. I went to medical school at Wayne State University in Detroit and did a couple of rotations in occupational medicine. I wasn’t sure that was the right fit, so I then went off to residency in internal medicine at the University of Connecticut and really enjoyed my wards experience. I liked the pace, I liked the variety, and just really liked all of hospital medicine. So that’s what I decided to do.

What are your areas of research interest?
This year I’m doing a research fellowship through the Center for Healthcare Improvement Science, at Virginia Mason. Through SHM’s mentored implementation program, I have done a lot of work on diabetes and glycemic control but never really published much of it. I think it is so important to share what you learn, so I’m working on publishing some of our results from the diabetes work. 
Another area of interest is advanced-practice providers in hospital medicine, which I think is very important, given all the issues that health care is facing. I think that medicine has gotten more complex and that we’re going to have to look at working in a collaborative, inter-professional, multidisciplinary way. I think that advanced practice can really improve the care of hospitalized patients, if we practice appropriate skill-task alignment, develop a culture of mutual respect, and find the best ways to deploy our advanced-practice providers and our physicians. 
That can be challenging. Some people, I think, are worried about losing their jobs, and some people feel like they want to “own” all of the patient, because it’s such a part of the culture of medicine. So it’s a really complicated issue, and I think that doctors are going to have to get used to delegating tasks that they used to perform.

So a collaborative practice requires both a professional and a cultural shift?
I think so. I was our inaugural program director for an advanced-practice fellowship in hospital medicine, and in that role, I attended conferences and learning events for program development. I think that many institutions are facing some of the same challenges. For the most part, I’m optimistic about things. I think we’re on the right track, and help is on the way – we just have to figure out how to use it.

Has your institution made any changes along these lines?
We’re primarily using the fellowship as a tool to recruit and retain some of the brightest and best. We’ve got three fellows that matriculated from our program and are currently working in the section of hospital medicine. Everyone’s been really flexible and open to the idea that the job description is emerging. I think my colleagues are very appreciative of our advanced-practice providers. We’ve got two nurse practitioners and one physician assistant who is also a PhD-trained pharmacist. They’ve been great additions to our team.

What are some of the other issues that the Pacific Northwest chapter members are concerned about?
One of our most successful meetings was around telemedicine. There’s a lot of interest in that, and it’s very financially and technically complex. Some hospitals in the area are really doing novel things. One of the most interesting things is an addiction medicine teleconsult.
That’s out of Swedish Medical Center, Seattle. Of course there’s telestroke, which I think is picking up in  popularity. We had speakers from Virginia Mason who presented on telestroke. Some institutions are even doing admissions this way. The University of Washington is doing some good antimicrobial stewardship work. They present cases and they teleconference and have an  infectious disease consultant. It’s not a program directed at revenue generation, but is focused instead on sharing and spreading expertise.
Our chapter also hosted a presentation on burnout that was pretty well attended. And then, unfortunately, we did lose a hospitalist to suicide over the summer. That was the inspiration for offering the screening of the movie, “Do No Harm: Exposing the Hippocratic Hoax.” 

What was the program that you put together around the screening? 
We had the filmmaker come for the screening, and we organized a panel discussion with a wellness officer from a local clinic and a psychiatrist who used to be on the board of the Physician Health Program. John Nelson, MD, MHM, one of SHM’s cofounders and a local hospitalist here, also participated as a  panelist. 
Overall, the event was well received. There were some things that I didn’t really expect. I’m not sure that the film resonated with too many people in the room. It is very much directed at the educational process – med students and residents – and at times the dialogue is a little inflammatory.
I learned a few important things from the film. I did not realize that the tragedy of physician suicide is not unique to the United States – it’s an international issue. And we sometimes use the term “pimping” to talk about questioning interns or residents on rounds. Apparently, that stands for “put in my place,” which is very condescending and unacceptable. I will not use the term again. 
I think future conversations need to come from thoughtful, rational, respectful leaders who are willing to work with regulatory agencies, hospitals, and administrators. If we want to move forward, physicians, administrators, and the public need to come together in the best interest of the patient and of public health. And I don’t know who leads that conversation.
 
Will your chapter have another event around that subject?
We will do what our membership wants and needs. We meet quarterly, and once a year we hold a people’s choice meeting and I solicit topics. If members want to keep the conversation moving, I’m going to do what I can to support them.

What are some other issues that stand out as important to your chapter? 
One key topic is the financial side of hospitalist practice, and dealing with issues that seem to create inefficiencies – regulatory issues, documentation issues, things that are important because we want to tell the story of what we’re doing. We certainly want to be reimbursed for the value-added work that we’re doing, but a lot of value-added work creates inefficiencies of practice, and I hear a lot of dissatisfaction around documentation, coding, billing, and other issues related to reimbursement. While people are concerned about these problems, nobody wants to talk about them. They just want somebody to fix it. So I’m not sure what to do with that, because I think if I had a meeting about coding and billing, I would have three attendees. 
But our annual poster meeting is always well attended. We always do it at the end of the year, to kick off the holiday season. It’s a nice opportunity to connect socially with colleagues because you mix and you mingle and look at the posters. We had some really great posters, and our top three prize winners were medical students, which is inspirational. They make you feel good about the future. 
Our chapter is trying to diversify geographically and clinically. We were fortunate to receive a development funds grant to use technology to do streaming meetings. Our hope is that we can host streaming meetings and eventually transition hosting to rotate around the state. Once there’s large enough attendance, the different delegates can develop their own leadership teams and, eventually, their own chapter. We’re hoping to grow the organization that way.
 
What else is on the horizon for hospitalists in the Pacific Northwest? 
I’d like to see more frequent meetings and a greater variety of meetings. I think there’s interest in adding some kind of service element to the chapter. Maybe we can do a blood pressure screening at a sporting event. 
I think we’ll also be focusing on students and residents and trying to create support for them. We held a student event around financial planning, and that was very well attended. I think we would like to do something around mentorship. Of course it’s hard to find mentors, because everybody is so busy. 
Our chapter really needs to leverage our technology if we want to have the reach that I’m talking about. I’m looking forward to piloting the streaming meeting concept, and I hope to do some live polling of our meeting attendees to get them engaged. I hope we continue to grow and keep the dialogue going about what matters in hospital medicine, and do our part to shape the future in the way we want it.

Therese Franco, MD, SFHM, a hospitalist at the Virginia Mason Medical Center in Seattle, is the current president of SHM’s Pacific Northwest chapter. 
The Hospitalist recently sat down with her to learn about her background and discuss some of the initiatives that the Pacific Northwest chapter has been working on.

Can you tell us about your education and training on the way to becoming a hospitalist?
My undergraduate degree is in engineering from Michigan State University. I then went to the University of Michigan in Ann Arbor and did one degree at the School of Public Health in environmental and industrial health, and another degree in the College of Engineering in industrial and operations engineering. In my work with the safety department at an automotive  company, I found I was spending a lot of time looking at data, and not talking to people. I got into a conversation with one of the occupational medicine physicians there, and he said, “You ought to try this.” I spoke with a good friend, who was a medical student, and she agreed.
So then I went to medical school thinking that I would practice occupational medicine. I went to medical school at Wayne State University in Detroit and did a couple of rotations in occupational medicine. I wasn’t sure that was the right fit, so I then went off to residency in internal medicine at the University of Connecticut and really enjoyed my wards experience. I liked the pace, I liked the variety, and just really liked all of hospital medicine. So that’s what I decided to do.

What are your areas of research interest?
This year I’m doing a research fellowship through the Center for Healthcare Improvement Science, at Virginia Mason. Through SHM’s mentored implementation program, I have done a lot of work on diabetes and glycemic control but never really published much of it. I think it is so important to share what you learn, so I’m working on publishing some of our results from the diabetes work. 
Another area of interest is advanced-practice providers in hospital medicine, which I think is very important, given all the issues that health care is facing. I think that medicine has gotten more complex and that we’re going to have to look at working in a collaborative, inter-professional, multidisciplinary way. I think that advanced practice can really improve the care of hospitalized patients, if we practice appropriate skill-task alignment, develop a culture of mutual respect, and find the best ways to deploy our advanced-practice providers and our physicians. 
That can be challenging. Some people, I think, are worried about losing their jobs, and some people feel like they want to “own” all of the patient, because it’s such a part of the culture of medicine. So it’s a really complicated issue, and I think that doctors are going to have to get used to delegating tasks that they used to perform.

So a collaborative practice requires both a professional and a cultural shift?
I think so. I was our inaugural program director for an advanced-practice fellowship in hospital medicine, and in that role, I attended conferences and learning events for program development. I think that many institutions are facing some of the same challenges. For the most part, I’m optimistic about things. I think we’re on the right track, and help is on the way – we just have to figure out how to use it.

Has your institution made any changes along these lines?
We’re primarily using the fellowship as a tool to recruit and retain some of the brightest and best. We’ve got three fellows that matriculated from our program and are currently working in the section of hospital medicine. Everyone’s been really flexible and open to the idea that the job description is emerging. I think my colleagues are very appreciative of our advanced-practice providers. We’ve got two nurse practitioners and one physician assistant who is also a PhD-trained pharmacist. They’ve been great additions to our team.

What are some of the other issues that the Pacific Northwest chapter members are concerned about?
One of our most successful meetings was around telemedicine. There’s a lot of interest in that, and it’s very financially and technically complex. Some hospitals in the area are really doing novel things. One of the most interesting things is an addiction medicine teleconsult.
That’s out of Swedish Medical Center, Seattle. Of course there’s telestroke, which I think is picking up in  popularity. We had speakers from Virginia Mason who presented on telestroke. Some institutions are even doing admissions this way. The University of Washington is doing some good antimicrobial stewardship work. They present cases and they teleconference and have an  infectious disease consultant. It’s not a program directed at revenue generation, but is focused instead on sharing and spreading expertise.
Our chapter also hosted a presentation on burnout that was pretty well attended. And then, unfortunately, we did lose a hospitalist to suicide over the summer. That was the inspiration for offering the screening of the movie, “Do No Harm: Exposing the Hippocratic Hoax.” 

What was the program that you put together around the screening? 
We had the filmmaker come for the screening, and we organized a panel discussion with a wellness officer from a local clinic and a psychiatrist who used to be on the board of the Physician Health Program. John Nelson, MD, MHM, one of SHM’s cofounders and a local hospitalist here, also participated as a  panelist. 
Overall, the event was well received. There were some things that I didn’t really expect. I’m not sure that the film resonated with too many people in the room. It is very much directed at the educational process – med students and residents – and at times the dialogue is a little inflammatory.
I learned a few important things from the film. I did not realize that the tragedy of physician suicide is not unique to the United States – it’s an international issue. And we sometimes use the term “pimping” to talk about questioning interns or residents on rounds. Apparently, that stands for “put in my place,” which is very condescending and unacceptable. I will not use the term again. 
I think future conversations need to come from thoughtful, rational, respectful leaders who are willing to work with regulatory agencies, hospitals, and administrators. If we want to move forward, physicians, administrators, and the public need to come together in the best interest of the patient and of public health. And I don’t know who leads that conversation.
 
Will your chapter have another event around that subject?
We will do what our membership wants and needs. We meet quarterly, and once a year we hold a people’s choice meeting and I solicit topics. If members want to keep the conversation moving, I’m going to do what I can to support them.

What are some other issues that stand out as important to your chapter? 
One key topic is the financial side of hospitalist practice, and dealing with issues that seem to create inefficiencies – regulatory issues, documentation issues, things that are important because we want to tell the story of what we’re doing. We certainly want to be reimbursed for the value-added work that we’re doing, but a lot of value-added work creates inefficiencies of practice, and I hear a lot of dissatisfaction around documentation, coding, billing, and other issues related to reimbursement. While people are concerned about these problems, nobody wants to talk about them. They just want somebody to fix it. So I’m not sure what to do with that, because I think if I had a meeting about coding and billing, I would have three attendees. 
But our annual poster meeting is always well attended. We always do it at the end of the year, to kick off the holiday season. It’s a nice opportunity to connect socially with colleagues because you mix and you mingle and look at the posters. We had some really great posters, and our top three prize winners were medical students, which is inspirational. They make you feel good about the future. 
Our chapter is trying to diversify geographically and clinically. We were fortunate to receive a development funds grant to use technology to do streaming meetings. Our hope is that we can host streaming meetings and eventually transition hosting to rotate around the state. Once there’s large enough attendance, the different delegates can develop their own leadership teams and, eventually, their own chapter. We’re hoping to grow the organization that way.
 
What else is on the horizon for hospitalists in the Pacific Northwest? 
I’d like to see more frequent meetings and a greater variety of meetings. I think there’s interest in adding some kind of service element to the chapter. Maybe we can do a blood pressure screening at a sporting event. 
I think we’ll also be focusing on students and residents and trying to create support for them. We held a student event around financial planning, and that was very well attended. I think we would like to do something around mentorship. Of course it’s hard to find mentors, because everybody is so busy. 
Our chapter really needs to leverage our technology if we want to have the reach that I’m talking about. I’m looking forward to piloting the streaming meeting concept, and I hope to do some live polling of our meeting attendees to get them engaged. I hope we continue to grow and keep the dialogue going about what matters in hospital medicine, and do our part to shape the future in the way we want it.

Like an unwelcome guest, the 2018-2019 flu season seems to be settling in for a lengthy stay as three more states have reached the highest level of influenza-like illness (ILI) activity, according to the Centers for Disease Control and Prevention.

There are now 21 states at level 10 on the CDC’s 1-10 scale, with the South showing up almost solidly red on the flu activity map for the week ending Feb. 9. Another five states are at levels 8 and 9, bringing the total in the high range to 26 for the week, compared with 24 the previous week, the CDC’s influenza division reported Feb. 15.

National activity, reflected in the proportion of outpatient visits involving ILI, took a step up from 4.3% the week before to 4.8% for the week ending Feb. 9. The national baseline rate is 2.2% for ILI, which the CDC defines “as fever (temperature of 100°F [37.8°C] or greater) and cough and/or sore throat.”

Two flu-related pediatric deaths occurred during the week ending Feb. 9, and another four were reported from earlier weeks, which brings the total for the 2018-2019 season to 34, the CDC said. At the same point in last year’s flu season, there had been 84 flu-related deaths in children.

In a separate report, the CDC said that, based on data collected from Nov. 23, 2018 to Feb. 2, 2019, “the influenza vaccine has been 47% effective in preventing medically attended acute respiratory virus infection across all age groups and specifically was 46% effective in preventing medical visits associated with influenza A(H1N1)pdm09.” The effectiveness of the vaccine was 61% for children aged 6 months to 17 years, the CDC said (MMWR. 2019 Feb 15;68[6];135-9).

Flu vaccination during the 2017-2018 season prevented 7.1 million illnesses, 3.7 million medical visits, 109,000 hospitalizations, and 8,000 flu-related deaths, the CDC said, adding that “vaccination has been found to reduce deaths, intensive care unit admissions and length of stay, and overall duration of hospitalization among hospitalized influenza patients.”

Forecasts for the rest of the 2018-2019 season “predict that elevated influenza activity in parts of the United States will continue for several more weeks,” the CDC said.

[email protected]

Like an unwelcome guest, the 2018-2019 flu season seems to be settling in for a lengthy stay as three more states have reached the highest level of influenza-like illness (ILI) activity, according to the Centers for Disease Control and Prevention.

There are now 21 states at level 10 on the CDC’s 1-10 scale, with the South showing up almost solidly red on the flu activity map for the week ending Feb. 9. Another five states are at levels 8 and 9, bringing the total in the high range to 26 for the week, compared with 24 the previous week, the CDC’s influenza division reported Feb. 15.

National activity, reflected in the proportion of outpatient visits involving ILI, took a step up from 4.3% the week before to 4.8% for the week ending Feb. 9. The national baseline rate is 2.2% for ILI, which the CDC defines “as fever (temperature of 100°F [37.8°C] or greater) and cough and/or sore throat.”

Two flu-related pediatric deaths occurred during the week ending Feb. 9, and another four were reported from earlier weeks, which brings the total for the 2018-2019 season to 34, the CDC said. At the same point in last year’s flu season, there had been 84 flu-related deaths in children.

In a separate report, the CDC said that, based on data collected from Nov. 23, 2018 to Feb. 2, 2019, “the influenza vaccine has been 47% effective in preventing medically attended acute respiratory virus infection across all age groups and specifically was 46% effective in preventing medical visits associated with influenza A(H1N1)pdm09.” The effectiveness of the vaccine was 61% for children aged 6 months to 17 years, the CDC said (MMWR. 2019 Feb 15;68[6];135-9).

Flu vaccination during the 2017-2018 season prevented 7.1 million illnesses, 3.7 million medical visits, 109,000 hospitalizations, and 8,000 flu-related deaths, the CDC said, adding that “vaccination has been found to reduce deaths, intensive care unit admissions and length of stay, and overall duration of hospitalization among hospitalized influenza patients.”

Forecasts for the rest of the 2018-2019 season “predict that elevated influenza activity in parts of the United States will continue for several more weeks,” the CDC said.

[email protected]

Like an unwelcome guest, the 2018-2019 flu season seems to be settling in for a lengthy stay as three more states have reached the highest level of influenza-like illness (ILI) activity, according to the Centers for Disease Control and Prevention.

There are now 21 states at level 10 on the CDC’s 1-10 scale, with the South showing up almost solidly red on the flu activity map for the week ending Feb. 9. Another five states are at levels 8 and 9, bringing the total in the high range to 26 for the week, compared with 24 the previous week, the CDC’s influenza division reported Feb. 15.

National activity, reflected in the proportion of outpatient visits involving ILI, took a step up from 4.3% the week before to 4.8% for the week ending Feb. 9. The national baseline rate is 2.2% for ILI, which the CDC defines “as fever (temperature of 100°F [37.8°C] or greater) and cough and/or sore throat.”

Two flu-related pediatric deaths occurred during the week ending Feb. 9, and another four were reported from earlier weeks, which brings the total for the 2018-2019 season to 34, the CDC said. At the same point in last year’s flu season, there had been 84 flu-related deaths in children.

In a separate report, the CDC said that, based on data collected from Nov. 23, 2018 to Feb. 2, 2019, “the influenza vaccine has been 47% effective in preventing medically attended acute respiratory virus infection across all age groups and specifically was 46% effective in preventing medical visits associated with influenza A(H1N1)pdm09.” The effectiveness of the vaccine was 61% for children aged 6 months to 17 years, the CDC said (MMWR. 2019 Feb 15;68[6];135-9).

Flu vaccination during the 2017-2018 season prevented 7.1 million illnesses, 3.7 million medical visits, 109,000 hospitalizations, and 8,000 flu-related deaths, the CDC said, adding that “vaccination has been found to reduce deaths, intensive care unit admissions and length of stay, and overall duration of hospitalization among hospitalized influenza patients.”

Forecasts for the rest of the 2018-2019 season “predict that elevated influenza activity in parts of the United States will continue for several more weeks,” the CDC said.

[email protected]

Stories are told of the first meeting, 20 years ago, where a hat was passed to collect donations to develop a fledgling organization of inpatient physicians. Today, 90% of hospitals with 200+ beds operate with a hospitalist model. Today, we are the Society of Hospital Medicine.

In the early 1900s, health care in many ways was simple. It was a doctor with a shingle hung. It was house calls. Remedies were limited. In the 1940s, companies developed insurance benefits to lure workers during World War II; this third party, the payer, added complexity. Meanwhile, treatment options began to diversify. Then, in the 1960s, Medicare was passed, and the government came into the mix, further increasing this complexity. Diagnostic and treatment options continued to diversify, seemingly exponentially. Some would say it took 30 years for our country to recognize that it had created the most advanced and expensive, as well as one of the least quality-controlled, health systems in the world. Thus, as hospital medicine was conceived in the 1990s, our national health system was awakening to the need – the creative niche – that hospitalists would fill.

When I began my career, I was unaware that I was a hospitalist. The title didn’t exist. Yes, I was working solely in the hospital. I was developing programs to improve care delivery. I was rounding, teaching, collaborating, connecting – everything that we now call hospital medicine. That first job has evolved into my career, one that I find both honorable and enjoyable.

As health care changes with the passing years, being a hospitalist continues to be about serving people, connecting, and improving care. Being a hospitalist is being innovative, willing, and even daring. Dare to try, dare to fail, dare to redesign and try again. Hospital medicine is thinking outside of the box while knowing how to color between the lines. In the coming decades, health care will continue to evolve, and hospital medicine will too. We now encompass surgical comanagement and perioperative care, palliative care, postacute care, and transitions of care services. In corners, hospital medicine is already experimenting with telecare, virtual health, and hospital at home. Our hospital medicine workforce is innovative, diverse, tech savvy and poised for leading.

We are ready and willing to face the pressures affecting health care in the United States today: the recognition of an overwhelming expense to society, the relative underperformance with regard to quality, the increasing complexity of illness and treatment options, the worsening health of the average American citizen, the aging population, the role of medical error in patient harm, the increasing engagement of people in their own care, and the desire to make care better. What our country is facing is actually a phenomenal opportunity, no matter what side of the political aisle you live on. Being in hospital medicine today is being at the center front of this evolutionary stage.

Since joining the SHM board of directors, I continue to find examples of the stellar work of our staff and our members across the country. Having the privilege as a board member to join several Chapter meetings, I have witnessed firsthand the camaraderie, the compassion, the team that makes our Society work. From Houston to San Francisco and from St. Louis to Seattle, I have been honored to work with SHM members that create and nurture local and regional networks with the support of SHM’s Chapters program – a program that now houses more than 50 chapters and has launched regional districts to further support networking and growth. SHM’s chapter venues allow our larger hospital medicine team – yes, the national one – to connect and collaborate.

Take the Pacific Northwest Chapter. In its early years hospitalists from various and competing health systems would convene at a restaurant and just talk. They spoke of how to staff, how to pay, and how to negotiate with hospital leadership. As I have joined chapter meetings in recent years, meetings continue to be the place to share ideas – how to develop new programs; what is the most recent approach to glycemic control, sepsis care, or antibiotic stewardship; how best to approach diagnosis without “anchoring”; and even how to care for each other in the time of loss of a colleague to suicide. It is here in our community that we share experiences, knowledge, new ideas – and this sharing makes us all stronger.

Our hospital medicine community also comes together through areas of shared interest. There are 18 Special Interest Groups (SIGs), focused on specific topic areas. I have been privileged as a board member to work with our Perioperative/Comanagement SIG as it launched in 2017 and has grown rapidly. Currently, the community hosts a “case of the month” hospital medicine discussion as well as a regular journal club webinar that allows participants to review recent literature and interact directly with the authors. As this SIG has grown, shared resources and ideas have allowed for diffusion of knowledge, providing our nation with infrastructure for improving perioperative care. It is networks like this that support our national hospital medicine team to build strength through sharing.

It is our society, our people, that have taken us from the passing of a hat to developing our national community and network. This March, we get to celebrate our field in a new way – Thursday, March 7, 2019, marks the inaugural National Hospitalist Day. Then, March 24-27, our annual conference, Hospital Medicine 2019, will bring thousands of our national team to National Harbor, Maryland. Join your colleagues. Find your niche and your community. Be a part of the change you want to see. While you are there, come introduce yourself to me and let me thank you for the amazing work you are doing.

We are all a part of this movement transforming patient care both on a local and national level. As we move to the future, our innovative, diverse, and connected network of hospital medicine will continue to create and guide health care advances in our country.

Dr. Thompson is professor and chief of the section of hospital medicine at University of Nebraska Medical Center, and medical director of clinical care transitions at Nebraska Medicine, Omaha.

Stories are told of the first meeting, 20 years ago, where a hat was passed to collect donations to develop a fledgling organization of inpatient physicians. Today, 90% of hospitals with 200+ beds operate with a hospitalist model. Today, we are the Society of Hospital Medicine.

In the early 1900s, health care in many ways was simple. It was a doctor with a shingle hung. It was house calls. Remedies were limited. In the 1940s, companies developed insurance benefits to lure workers during World War II; this third party, the payer, added complexity. Meanwhile, treatment options began to diversify. Then, in the 1960s, Medicare was passed, and the government came into the mix, further increasing this complexity. Diagnostic and treatment options continued to diversify, seemingly exponentially. Some would say it took 30 years for our country to recognize that it had created the most advanced and expensive, as well as one of the least quality-controlled, health systems in the world. Thus, as hospital medicine was conceived in the 1990s, our national health system was awakening to the need – the creative niche – that hospitalists would fill.

When I began my career, I was unaware that I was a hospitalist. The title didn’t exist. Yes, I was working solely in the hospital. I was developing programs to improve care delivery. I was rounding, teaching, collaborating, connecting – everything that we now call hospital medicine. That first job has evolved into my career, one that I find both honorable and enjoyable.

As health care changes with the passing years, being a hospitalist continues to be about serving people, connecting, and improving care. Being a hospitalist is being innovative, willing, and even daring. Dare to try, dare to fail, dare to redesign and try again. Hospital medicine is thinking outside of the box while knowing how to color between the lines. In the coming decades, health care will continue to evolve, and hospital medicine will too. We now encompass surgical comanagement and perioperative care, palliative care, postacute care, and transitions of care services. In corners, hospital medicine is already experimenting with telecare, virtual health, and hospital at home. Our hospital medicine workforce is innovative, diverse, tech savvy and poised for leading.

We are ready and willing to face the pressures affecting health care in the United States today: the recognition of an overwhelming expense to society, the relative underperformance with regard to quality, the increasing complexity of illness and treatment options, the worsening health of the average American citizen, the aging population, the role of medical error in patient harm, the increasing engagement of people in their own care, and the desire to make care better. What our country is facing is actually a phenomenal opportunity, no matter what side of the political aisle you live on. Being in hospital medicine today is being at the center front of this evolutionary stage.

Since joining the SHM board of directors, I continue to find examples of the stellar work of our staff and our members across the country. Having the privilege as a board member to join several Chapter meetings, I have witnessed firsthand the camaraderie, the compassion, the team that makes our Society work. From Houston to San Francisco and from St. Louis to Seattle, I have been honored to work with SHM members that create and nurture local and regional networks with the support of SHM’s Chapters program – a program that now houses more than 50 chapters and has launched regional districts to further support networking and growth. SHM’s chapter venues allow our larger hospital medicine team – yes, the national one – to connect and collaborate.

Take the Pacific Northwest Chapter. In its early years hospitalists from various and competing health systems would convene at a restaurant and just talk. They spoke of how to staff, how to pay, and how to negotiate with hospital leadership. As I have joined chapter meetings in recent years, meetings continue to be the place to share ideas – how to develop new programs; what is the most recent approach to glycemic control, sepsis care, or antibiotic stewardship; how best to approach diagnosis without “anchoring”; and even how to care for each other in the time of loss of a colleague to suicide. It is here in our community that we share experiences, knowledge, new ideas – and this sharing makes us all stronger.

Our hospital medicine community also comes together through areas of shared interest. There are 18 Special Interest Groups (SIGs), focused on specific topic areas. I have been privileged as a board member to work with our Perioperative/Comanagement SIG as it launched in 2017 and has grown rapidly. Currently, the community hosts a “case of the month” hospital medicine discussion as well as a regular journal club webinar that allows participants to review recent literature and interact directly with the authors. As this SIG has grown, shared resources and ideas have allowed for diffusion of knowledge, providing our nation with infrastructure for improving perioperative care. It is networks like this that support our national hospital medicine team to build strength through sharing.

It is our society, our people, that have taken us from the passing of a hat to developing our national community and network. This March, we get to celebrate our field in a new way – Thursday, March 7, 2019, marks the inaugural National Hospitalist Day. Then, March 24-27, our annual conference, Hospital Medicine 2019, will bring thousands of our national team to National Harbor, Maryland. Join your colleagues. Find your niche and your community. Be a part of the change you want to see. While you are there, come introduce yourself to me and let me thank you for the amazing work you are doing.

We are all a part of this movement transforming patient care both on a local and national level. As we move to the future, our innovative, diverse, and connected network of hospital medicine will continue to create and guide health care advances in our country.

Dr. Thompson is professor and chief of the section of hospital medicine at University of Nebraska Medical Center, and medical director of clinical care transitions at Nebraska Medicine, Omaha.

Stories are told of the first meeting, 20 years ago, where a hat was passed to collect donations to develop a fledgling organization of inpatient physicians. Today, 90% of hospitals with 200+ beds operate with a hospitalist model. Today, we are the Society of Hospital Medicine.

In the early 1900s, health care in many ways was simple. It was a doctor with a shingle hung. It was house calls. Remedies were limited. In the 1940s, companies developed insurance benefits to lure workers during World War II; this third party, the payer, added complexity. Meanwhile, treatment options began to diversify. Then, in the 1960s, Medicare was passed, and the government came into the mix, further increasing this complexity. Diagnostic and treatment options continued to diversify, seemingly exponentially. Some would say it took 30 years for our country to recognize that it had created the most advanced and expensive, as well as one of the least quality-controlled, health systems in the world. Thus, as hospital medicine was conceived in the 1990s, our national health system was awakening to the need – the creative niche – that hospitalists would fill.

When I began my career, I was unaware that I was a hospitalist. The title didn’t exist. Yes, I was working solely in the hospital. I was developing programs to improve care delivery. I was rounding, teaching, collaborating, connecting – everything that we now call hospital medicine. That first job has evolved into my career, one that I find both honorable and enjoyable.

As health care changes with the passing years, being a hospitalist continues to be about serving people, connecting, and improving care. Being a hospitalist is being innovative, willing, and even daring. Dare to try, dare to fail, dare to redesign and try again. Hospital medicine is thinking outside of the box while knowing how to color between the lines. In the coming decades, health care will continue to evolve, and hospital medicine will too. We now encompass surgical comanagement and perioperative care, palliative care, postacute care, and transitions of care services. In corners, hospital medicine is already experimenting with telecare, virtual health, and hospital at home. Our hospital medicine workforce is innovative, diverse, tech savvy and poised for leading.

We are ready and willing to face the pressures affecting health care in the United States today: the recognition of an overwhelming expense to society, the relative underperformance with regard to quality, the increasing complexity of illness and treatment options, the worsening health of the average American citizen, the aging population, the role of medical error in patient harm, the increasing engagement of people in their own care, and the desire to make care better. What our country is facing is actually a phenomenal opportunity, no matter what side of the political aisle you live on. Being in hospital medicine today is being at the center front of this evolutionary stage.

Since joining the SHM board of directors, I continue to find examples of the stellar work of our staff and our members across the country. Having the privilege as a board member to join several Chapter meetings, I have witnessed firsthand the camaraderie, the compassion, the team that makes our Society work. From Houston to San Francisco and from St. Louis to Seattle, I have been honored to work with SHM members that create and nurture local and regional networks with the support of SHM’s Chapters program – a program that now houses more than 50 chapters and has launched regional districts to further support networking and growth. SHM’s chapter venues allow our larger hospital medicine team – yes, the national one – to connect and collaborate.

Take the Pacific Northwest Chapter. In its early years hospitalists from various and competing health systems would convene at a restaurant and just talk. They spoke of how to staff, how to pay, and how to negotiate with hospital leadership. As I have joined chapter meetings in recent years, meetings continue to be the place to share ideas – how to develop new programs; what is the most recent approach to glycemic control, sepsis care, or antibiotic stewardship; how best to approach diagnosis without “anchoring”; and even how to care for each other in the time of loss of a colleague to suicide. It is here in our community that we share experiences, knowledge, new ideas – and this sharing makes us all stronger.

Our hospital medicine community also comes together through areas of shared interest. There are 18 Special Interest Groups (SIGs), focused on specific topic areas. I have been privileged as a board member to work with our Perioperative/Comanagement SIG as it launched in 2017 and has grown rapidly. Currently, the community hosts a “case of the month” hospital medicine discussion as well as a regular journal club webinar that allows participants to review recent literature and interact directly with the authors. As this SIG has grown, shared resources and ideas have allowed for diffusion of knowledge, providing our nation with infrastructure for improving perioperative care. It is networks like this that support our national hospital medicine team to build strength through sharing.

It is our society, our people, that have taken us from the passing of a hat to developing our national community and network. This March, we get to celebrate our field in a new way – Thursday, March 7, 2019, marks the inaugural National Hospitalist Day. Then, March 24-27, our annual conference, Hospital Medicine 2019, will bring thousands of our national team to National Harbor, Maryland. Join your colleagues. Find your niche and your community. Be a part of the change you want to see. While you are there, come introduce yourself to me and let me thank you for the amazing work you are doing.

We are all a part of this movement transforming patient care both on a local and national level. As we move to the future, our innovative, diverse, and connected network of hospital medicine will continue to create and guide health care advances in our country.

Dr. Thompson is professor and chief of the section of hospital medicine at University of Nebraska Medical Center, and medical director of clinical care transitions at Nebraska Medicine, Omaha.

I have to admit that I am not sure I am a legacy in hospital medicine, and the term legacy throws me off a bit. I came to medical school after working at McKinsey & Co. consulting, and I chose pediatrics because of my love of working with children and families, as well as a vague notion that I wanted to work on “system” issues, and therefore, more generalist-type training seemed applicable.

I met Chris Landrigan, MD, MPH, and Vinny Chiang, MD, and learned what a hospitalist was, as an intern in 2002. We had a research elective and I was able to publish a couple of papers in Pediatrics on pediatric hospital medicine with Chris and Raj Srivastava, MD, MPH. In 2004, I went to my first Society of Hospital Medicine meeting and met Larry Wellikson, MD, MHM, and others. From there, I went to the Robert Wood Johnson Clinical Scholars Program, with Ron Keren, MD, MPH, and others, and along with faculty from the Cincinnati Children’s in hospital medicine.

In 2007, I applied for a White House Fellowship and told my wife that I didn’t think there was a chance that I would get it, so we should keep building our new home in Cincinnati. We were both surprised when I was selected. I served Michael Leavitt, the then-Secretary of the Department of Health & Human Services, as his White House fellow during the Bush administration, and then served as his chief medical officer. Exposure to health policy and leadership at that level was career shaping. Cincinnati Children’s was searching for a leader for the conversion of pediatric hospital medicine into a full division in 2009. So I returned to Cincinnati to take on leading pediatric hospital medicine, and a role leading quality measurement and improvement efforts for the entire health system. I loved the work and thought I would remain in that role, and our family would be in Cincinnati for a long time. Best laid plans …

In early 2011, Don Berwick, MD, who was then the administrator of the Centers for Medicare & Medicaid Services called and asked whether I “would come talk with him in D.C.” That talk quickly became a series of interviews, and he offered me the opportunity to be chief medical officer of CMS. He said “this platform is like no other to drive change.” He was right. I have been fortunate to have a few step-change opportunities in my life, and that was one.

On my first day at CMS, I looked around the table of senior executives reporting to me and realized they had more than 200 years of CMS experience. I was a bit scared. Together, we led the implementation of Hospital Value-Based Purchasing, the Compare websites, and numerous quality measurement and improvement programs. Partnership for Patients works on patient safety and was associated with preventing more than 3 million infections and adverse events, over 125,000 lives saved, and more than $26 billion in savings.

In early 2013, I was asked to lead the CMS Innovation Center (CMMI). The goal was to launch new payment and service delivery models to improve quality and lower costs. We launched Accountable Care Organizations, Bundled Payment programs, primary care medical homes, state-based innovation, and so much more. Medicare went from zero dollars in alternative payment models, where providers are accountable for quality and total cost of care, to more than 30% of Medicare payments, representing over $200 billion through agreements with more than 200,000 providers in these alternative payment models. It was the biggest shift in U.S. history in how CMS paid for care. Later, I became principal deputy administrator and acting administrator of CMS, leading an agency that spends over $1 trillion per year, or more than $2.5 billion per day and insures over 130 million Americans. We also improved from being bottom quintile in employee engagement and satisfaction across the federal government to No. 2.

I had assumed that, after working at CMS, I would return to a hospital/health system leadership role. But then, a recruiter called about the CEO role at Blue Cross Blue Shield of North Carolina. It is one of the largest not-for-profit health plans in the country and insures most of the people in North Carolina, many for most of their lives. I met a 75-year-old woman the other day that we have insured every day of her life. I am almost a year into the role and it is a mission-driven organization that drives positive change. I love it so far.

We are going to partner with providers, so that more than half of our payments will be in advanced alternative payment models. No payer in the United States has done that yet. This allows us to innovate and decrease friction in the system (e.g., turn off prior authorization) and be jointly accountable with providers for quality and total cost of care. We insure people through the ACA [Affordable Care Act], commercial, and Medicare markets, and are competing to serve Medicaid as well. We have invested more than $50 million to address social determinants of health across the state. We are making major investments in primary care, and mental and behavioral health. Our goal is to be a Model Blue – or a Model of Health Transformation for our state and nation – and achieve better health outcomes, lower costs, and best-in-class experience for all people we serve. I have learned that no physician leads a health plan of this size, and apparently, no practicing physician has ever led a health plan of this size.

What are some lessons learned over my career? I have had five criteria for all my career decisions: 1) family; 2) impact – better care and outcomes, lower costs, and exceptional experience for populations of patients; 3) people – mentors and colleagues; 4) learning; and 5) joy in work. If someone gives you a chance to lead people in your career as a physician, jump at the chance. We do a relatively poor job of providing this type of opportunity to those early in their careers in medicine, and learning how to manage people and money allows you to progress as a leader and manager.

Don’t listen to the people who say “you must do X before Y” or “you must take this path.” They are usually wrong. Take chances. I applied for many roles for which I was a long shot, and I didn’t always succeed. That’s life and learning. Hospital medicine is a great career. I worked in the hospital on a recent weekend and was able to help families through everything from palliative care decisions and new diagnoses, to recovering from illness. It is an honor to serve and help families in their time of need. Hospitalists have been – and should continue to be – primary drivers of the shift in our health system to value-based care.

As I look back on my career (and I hope I am only halfway done), I could not have predicted more than 90% of it. I was blessed with many opportunities, mentors, and teachers along the way. I try to pass this on by mentoring and teaching others. How did my career happen? I am not sure, but it has been a fun ride! And hopefully I have helped improve the health system some, along the way.
 

Dr. Conway is president and CEO of Blue Cross and Blue Shield of North Carolina. He is a hospitalist and former deputy administrator for innovation and quality at the Centers for Medicare and Medicaid Services.

I have to admit that I am not sure I am a legacy in hospital medicine, and the term legacy throws me off a bit. I came to medical school after working at McKinsey & Co. consulting, and I chose pediatrics because of my love of working with children and families, as well as a vague notion that I wanted to work on “system” issues, and therefore, more generalist-type training seemed applicable.

I met Chris Landrigan, MD, MPH, and Vinny Chiang, MD, and learned what a hospitalist was, as an intern in 2002. We had a research elective and I was able to publish a couple of papers in Pediatrics on pediatric hospital medicine with Chris and Raj Srivastava, MD, MPH. In 2004, I went to my first Society of Hospital Medicine meeting and met Larry Wellikson, MD, MHM, and others. From there, I went to the Robert Wood Johnson Clinical Scholars Program, with Ron Keren, MD, MPH, and others, and along with faculty from the Cincinnati Children’s in hospital medicine.

In 2007, I applied for a White House Fellowship and told my wife that I didn’t think there was a chance that I would get it, so we should keep building our new home in Cincinnati. We were both surprised when I was selected. I served Michael Leavitt, the then-Secretary of the Department of Health & Human Services, as his White House fellow during the Bush administration, and then served as his chief medical officer. Exposure to health policy and leadership at that level was career shaping. Cincinnati Children’s was searching for a leader for the conversion of pediatric hospital medicine into a full division in 2009. So I returned to Cincinnati to take on leading pediatric hospital medicine, and a role leading quality measurement and improvement efforts for the entire health system. I loved the work and thought I would remain in that role, and our family would be in Cincinnati for a long time. Best laid plans …

In early 2011, Don Berwick, MD, who was then the administrator of the Centers for Medicare & Medicaid Services called and asked whether I “would come talk with him in D.C.” That talk quickly became a series of interviews, and he offered me the opportunity to be chief medical officer of CMS. He said “this platform is like no other to drive change.” He was right. I have been fortunate to have a few step-change opportunities in my life, and that was one.

On my first day at CMS, I looked around the table of senior executives reporting to me and realized they had more than 200 years of CMS experience. I was a bit scared. Together, we led the implementation of Hospital Value-Based Purchasing, the Compare websites, and numerous quality measurement and improvement programs. Partnership for Patients works on patient safety and was associated with preventing more than 3 million infections and adverse events, over 125,000 lives saved, and more than $26 billion in savings.

In early 2013, I was asked to lead the CMS Innovation Center (CMMI). The goal was to launch new payment and service delivery models to improve quality and lower costs. We launched Accountable Care Organizations, Bundled Payment programs, primary care medical homes, state-based innovation, and so much more. Medicare went from zero dollars in alternative payment models, where providers are accountable for quality and total cost of care, to more than 30% of Medicare payments, representing over $200 billion through agreements with more than 200,000 providers in these alternative payment models. It was the biggest shift in U.S. history in how CMS paid for care. Later, I became principal deputy administrator and acting administrator of CMS, leading an agency that spends over $1 trillion per year, or more than $2.5 billion per day and insures over 130 million Americans. We also improved from being bottom quintile in employee engagement and satisfaction across the federal government to No. 2.

I had assumed that, after working at CMS, I would return to a hospital/health system leadership role. But then, a recruiter called about the CEO role at Blue Cross Blue Shield of North Carolina. It is one of the largest not-for-profit health plans in the country and insures most of the people in North Carolina, many for most of their lives. I met a 75-year-old woman the other day that we have insured every day of her life. I am almost a year into the role and it is a mission-driven organization that drives positive change. I love it so far.

We are going to partner with providers, so that more than half of our payments will be in advanced alternative payment models. No payer in the United States has done that yet. This allows us to innovate and decrease friction in the system (e.g., turn off prior authorization) and be jointly accountable with providers for quality and total cost of care. We insure people through the ACA [Affordable Care Act], commercial, and Medicare markets, and are competing to serve Medicaid as well. We have invested more than $50 million to address social determinants of health across the state. We are making major investments in primary care, and mental and behavioral health. Our goal is to be a Model Blue – or a Model of Health Transformation for our state and nation – and achieve better health outcomes, lower costs, and best-in-class experience for all people we serve. I have learned that no physician leads a health plan of this size, and apparently, no practicing physician has ever led a health plan of this size.

What are some lessons learned over my career? I have had five criteria for all my career decisions: 1) family; 2) impact – better care and outcomes, lower costs, and exceptional experience for populations of patients; 3) people – mentors and colleagues; 4) learning; and 5) joy in work. If someone gives you a chance to lead people in your career as a physician, jump at the chance. We do a relatively poor job of providing this type of opportunity to those early in their careers in medicine, and learning how to manage people and money allows you to progress as a leader and manager.

Don’t listen to the people who say “you must do X before Y” or “you must take this path.” They are usually wrong. Take chances. I applied for many roles for which I was a long shot, and I didn’t always succeed. That’s life and learning. Hospital medicine is a great career. I worked in the hospital on a recent weekend and was able to help families through everything from palliative care decisions and new diagnoses, to recovering from illness. It is an honor to serve and help families in their time of need. Hospitalists have been – and should continue to be – primary drivers of the shift in our health system to value-based care.

As I look back on my career (and I hope I am only halfway done), I could not have predicted more than 90% of it. I was blessed with many opportunities, mentors, and teachers along the way. I try to pass this on by mentoring and teaching others. How did my career happen? I am not sure, but it has been a fun ride! And hopefully I have helped improve the health system some, along the way.
 

Dr. Conway is president and CEO of Blue Cross and Blue Shield of North Carolina. He is a hospitalist and former deputy administrator for innovation and quality at the Centers for Medicare and Medicaid Services.

I have to admit that I am not sure I am a legacy in hospital medicine, and the term legacy throws me off a bit. I came to medical school after working at McKinsey & Co. consulting, and I chose pediatrics because of my love of working with children and families, as well as a vague notion that I wanted to work on “system” issues, and therefore, more generalist-type training seemed applicable.

I met Chris Landrigan, MD, MPH, and Vinny Chiang, MD, and learned what a hospitalist was, as an intern in 2002. We had a research elective and I was able to publish a couple of papers in Pediatrics on pediatric hospital medicine with Chris and Raj Srivastava, MD, MPH. In 2004, I went to my first Society of Hospital Medicine meeting and met Larry Wellikson, MD, MHM, and others. From there, I went to the Robert Wood Johnson Clinical Scholars Program, with Ron Keren, MD, MPH, and others, and along with faculty from the Cincinnati Children’s in hospital medicine.

In 2007, I applied for a White House Fellowship and told my wife that I didn’t think there was a chance that I would get it, so we should keep building our new home in Cincinnati. We were both surprised when I was selected. I served Michael Leavitt, the then-Secretary of the Department of Health & Human Services, as his White House fellow during the Bush administration, and then served as his chief medical officer. Exposure to health policy and leadership at that level was career shaping. Cincinnati Children’s was searching for a leader for the conversion of pediatric hospital medicine into a full division in 2009. So I returned to Cincinnati to take on leading pediatric hospital medicine, and a role leading quality measurement and improvement efforts for the entire health system. I loved the work and thought I would remain in that role, and our family would be in Cincinnati for a long time. Best laid plans …

In early 2011, Don Berwick, MD, who was then the administrator of the Centers for Medicare & Medicaid Services called and asked whether I “would come talk with him in D.C.” That talk quickly became a series of interviews, and he offered me the opportunity to be chief medical officer of CMS. He said “this platform is like no other to drive change.” He was right. I have been fortunate to have a few step-change opportunities in my life, and that was one.

On my first day at CMS, I looked around the table of senior executives reporting to me and realized they had more than 200 years of CMS experience. I was a bit scared. Together, we led the implementation of Hospital Value-Based Purchasing, the Compare websites, and numerous quality measurement and improvement programs. Partnership for Patients works on patient safety and was associated with preventing more than 3 million infections and adverse events, over 125,000 lives saved, and more than $26 billion in savings.

In early 2013, I was asked to lead the CMS Innovation Center (CMMI). The goal was to launch new payment and service delivery models to improve quality and lower costs. We launched Accountable Care Organizations, Bundled Payment programs, primary care medical homes, state-based innovation, and so much more. Medicare went from zero dollars in alternative payment models, where providers are accountable for quality and total cost of care, to more than 30% of Medicare payments, representing over $200 billion through agreements with more than 200,000 providers in these alternative payment models. It was the biggest shift in U.S. history in how CMS paid for care. Later, I became principal deputy administrator and acting administrator of CMS, leading an agency that spends over $1 trillion per year, or more than $2.5 billion per day and insures over 130 million Americans. We also improved from being bottom quintile in employee engagement and satisfaction across the federal government to No. 2.

I had assumed that, after working at CMS, I would return to a hospital/health system leadership role. But then, a recruiter called about the CEO role at Blue Cross Blue Shield of North Carolina. It is one of the largest not-for-profit health plans in the country and insures most of the people in North Carolina, many for most of their lives. I met a 75-year-old woman the other day that we have insured every day of her life. I am almost a year into the role and it is a mission-driven organization that drives positive change. I love it so far.

We are going to partner with providers, so that more than half of our payments will be in advanced alternative payment models. No payer in the United States has done that yet. This allows us to innovate and decrease friction in the system (e.g., turn off prior authorization) and be jointly accountable with providers for quality and total cost of care. We insure people through the ACA [Affordable Care Act], commercial, and Medicare markets, and are competing to serve Medicaid as well. We have invested more than $50 million to address social determinants of health across the state. We are making major investments in primary care, and mental and behavioral health. Our goal is to be a Model Blue – or a Model of Health Transformation for our state and nation – and achieve better health outcomes, lower costs, and best-in-class experience for all people we serve. I have learned that no physician leads a health plan of this size, and apparently, no practicing physician has ever led a health plan of this size.

What are some lessons learned over my career? I have had five criteria for all my career decisions: 1) family; 2) impact – better care and outcomes, lower costs, and exceptional experience for populations of patients; 3) people – mentors and colleagues; 4) learning; and 5) joy in work. If someone gives you a chance to lead people in your career as a physician, jump at the chance. We do a relatively poor job of providing this type of opportunity to those early in their careers in medicine, and learning how to manage people and money allows you to progress as a leader and manager.

Don’t listen to the people who say “you must do X before Y” or “you must take this path.” They are usually wrong. Take chances. I applied for many roles for which I was a long shot, and I didn’t always succeed. That’s life and learning. Hospital medicine is a great career. I worked in the hospital on a recent weekend and was able to help families through everything from palliative care decisions and new diagnoses, to recovering from illness. It is an honor to serve and help families in their time of need. Hospitalists have been – and should continue to be – primary drivers of the shift in our health system to value-based care.

As I look back on my career (and I hope I am only halfway done), I could not have predicted more than 90% of it. I was blessed with many opportunities, mentors, and teachers along the way. I try to pass this on by mentoring and teaching others. How did my career happen? I am not sure, but it has been a fun ride! And hopefully I have helped improve the health system some, along the way.
 

Dr. Conway is president and CEO of Blue Cross and Blue Shield of North Carolina. He is a hospitalist and former deputy administrator for innovation and quality at the Centers for Medicare and Medicaid Services.

Are residents generally prepared for fellowship interviews? Applications to the Fellowship Match through the National Residency Matching Program (NRMP) Specialties Matching Service (SMS) are at an all-time high, but there is limited data regarding the preparedness of residents who go through the fellowship interview process, said Kelvin Wong, MD, a coauthor of research describing a new approach to fellowship interview preparation, which may be generalizable to hospitalists in applying for other positions.

“Applicants receive little to no feedback after their interviews and are thus likely to repeat the same mistakes throughout the process. Verbal feedback from our own fellowship directors indicated that residents as a whole are unprepared to interview,” according to an abstract written by Dr. Wong and his colleagues.

Dr. Wong wanted to investigate the effects of a standardized fellowship interview preparation course on resident preparedness. He and his coauthors developed a formal preparation course for the applicants in the summer of 2017.

Precourse surveys showed that only 17.65% of residents felt prepared to go on interviews; postcourse surveys showed a rise in this number to 82.35%. Immediately after their mock interview, only 27.78% of residents rated their overall interview skills as “very good” or “excellent,” whereas 87.5% of interviewers and 70.59% of observers rated their skills to be “very good” or “excellent.”

A final survey will be given to the applicants and the fellowship program directors once the applicants have completed all of their actual interviews.

“This demonstrates the potential positive impact that mock interviews and standardized interview preparation courses can have, which may be generalizable to hospitalists applying for other positions,” Dr. Wong said. “Specifically for teaching hospitalists in teaching hospitals, the institution of such fellowship interview preparation courses may improve resident preparedness for the fellowship application process.”
 

Reference

1. Wong K et al. A novel approach to improve fellowship interview skills [abstract]. https://www.shmabstracts.com/abstract/a-novel-approach-to-improve-fellowship-interview-skills/.

Are residents generally prepared for fellowship interviews? Applications to the Fellowship Match through the National Residency Matching Program (NRMP) Specialties Matching Service (SMS) are at an all-time high, but there is limited data regarding the preparedness of residents who go through the fellowship interview process, said Kelvin Wong, MD, a coauthor of research describing a new approach to fellowship interview preparation, which may be generalizable to hospitalists in applying for other positions.

“Applicants receive little to no feedback after their interviews and are thus likely to repeat the same mistakes throughout the process. Verbal feedback from our own fellowship directors indicated that residents as a whole are unprepared to interview,” according to an abstract written by Dr. Wong and his colleagues.

Dr. Wong wanted to investigate the effects of a standardized fellowship interview preparation course on resident preparedness. He and his coauthors developed a formal preparation course for the applicants in the summer of 2017.

Precourse surveys showed that only 17.65% of residents felt prepared to go on interviews; postcourse surveys showed a rise in this number to 82.35%. Immediately after their mock interview, only 27.78% of residents rated their overall interview skills as “very good” or “excellent,” whereas 87.5% of interviewers and 70.59% of observers rated their skills to be “very good” or “excellent.”

A final survey will be given to the applicants and the fellowship program directors once the applicants have completed all of their actual interviews.

“This demonstrates the potential positive impact that mock interviews and standardized interview preparation courses can have, which may be generalizable to hospitalists applying for other positions,” Dr. Wong said. “Specifically for teaching hospitalists in teaching hospitals, the institution of such fellowship interview preparation courses may improve resident preparedness for the fellowship application process.”
 

Reference

1. Wong K et al. A novel approach to improve fellowship interview skills [abstract]. https://www.shmabstracts.com/abstract/a-novel-approach-to-improve-fellowship-interview-skills/.

Are residents generally prepared for fellowship interviews? Applications to the Fellowship Match through the National Residency Matching Program (NRMP) Specialties Matching Service (SMS) are at an all-time high, but there is limited data regarding the preparedness of residents who go through the fellowship interview process, said Kelvin Wong, MD, a coauthor of research describing a new approach to fellowship interview preparation, which may be generalizable to hospitalists in applying for other positions.

“Applicants receive little to no feedback after their interviews and are thus likely to repeat the same mistakes throughout the process. Verbal feedback from our own fellowship directors indicated that residents as a whole are unprepared to interview,” according to an abstract written by Dr. Wong and his colleagues.

Dr. Wong wanted to investigate the effects of a standardized fellowship interview preparation course on resident preparedness. He and his coauthors developed a formal preparation course for the applicants in the summer of 2017.

Precourse surveys showed that only 17.65% of residents felt prepared to go on interviews; postcourse surveys showed a rise in this number to 82.35%. Immediately after their mock interview, only 27.78% of residents rated their overall interview skills as “very good” or “excellent,” whereas 87.5% of interviewers and 70.59% of observers rated their skills to be “very good” or “excellent.”

A final survey will be given to the applicants and the fellowship program directors once the applicants have completed all of their actual interviews.

“This demonstrates the potential positive impact that mock interviews and standardized interview preparation courses can have, which may be generalizable to hospitalists applying for other positions,” Dr. Wong said. “Specifically for teaching hospitalists in teaching hospitals, the institution of such fellowship interview preparation courses may improve resident preparedness for the fellowship application process.”
 

Reference

1. Wong K et al. A novel approach to improve fellowship interview skills [abstract]. https://www.shmabstracts.com/abstract/a-novel-approach-to-improve-fellowship-interview-skills/.

A start-up operating out of MIT in Cambridge, Mass., called Portal Instruments has developed a needleless injection system.

The device, called PRIME, delivers medication into the bloodstream in a high-pressure stream that travels at Mach 0.7 – the speed of a jet. The makers signed a commercial deal in December 2017, and the device is expected to be available soon.

Reference

1. Kerrigan S. The 16 Most Remarkable Healthcare Innovations, Events, and Discoveries of 2018 For World Health Day. https://interestingengineering.com/the-16-most-remarkable-healthcare-innovations-events-and-discoveries-of-2018-for-world-health-day. April 7, 2018. Accessed June 4, 2018.

A start-up operating out of MIT in Cambridge, Mass., called Portal Instruments has developed a needleless injection system.

The device, called PRIME, delivers medication into the bloodstream in a high-pressure stream that travels at Mach 0.7 – the speed of a jet. The makers signed a commercial deal in December 2017, and the device is expected to be available soon.

Reference

1. Kerrigan S. The 16 Most Remarkable Healthcare Innovations, Events, and Discoveries of 2018 For World Health Day. https://interestingengineering.com/the-16-most-remarkable-healthcare-innovations-events-and-discoveries-of-2018-for-world-health-day. April 7, 2018. Accessed June 4, 2018.

A start-up operating out of MIT in Cambridge, Mass., called Portal Instruments has developed a needleless injection system.

The device, called PRIME, delivers medication into the bloodstream in a high-pressure stream that travels at Mach 0.7 – the speed of a jet. The makers signed a commercial deal in December 2017, and the device is expected to be available soon.

Reference

1. Kerrigan S. The 16 Most Remarkable Healthcare Innovations, Events, and Discoveries of 2018 For World Health Day. https://interestingengineering.com/the-16-most-remarkable-healthcare-innovations-events-and-discoveries-of-2018-for-world-health-day. April 7, 2018. Accessed June 4, 2018.

Health care experts have long known of a link between patient outcomes and a hospital’s organizational culture, according to an article in the New York Times by Pauline W. Chen, MD.

“Heart attack patients who are treated at hospitals where nurses feel powerless and senior management is only sporadically involved in patient care tend to fare more poorly than patients hospitalized at institutions where nurses are asked regularly for their input and chief executives hold regular meetings with clinicians to review patient results,” she wrote.

But there is hope for change, Dr. Chen noted, and it’s demonstrable, citing a group of researchers that has written about strategies targeting hospital organizational culture called “Leadership Saves Lives.” The researchers showed hospitals could create significant cultural changes, which could impact patient outcomes, in just 2 years.

“Leadership Saves Lives requires that each hospital create a ‘Guiding Coalition,’ a group of staff members from across the entire institution. The coalition members participate in regular workshops, discussions, and national forums on ways hospitals might improve, then help their respective hospital translate newfound ideas and information into clinical practice,” she wrote.

The researchers monitored heart attack patients to assess the effect of Leadership Saves Lives in 10 hospitals that had below average patient outcomes. Over 2 years, all 10 hospitals changed significantly, but 6 hospitals experienced particularly profound cultural transformations.

“The staff of these hospitals spoke of an institutional shift from ‘because I said so’ to ‘focusing on the why’s,’ ” Dr. Chen wrote. “Instead of accepting that every heart attack patient had to undergo certain testing or take specific drugs because the chief of the department or administrator had previously established such clinical protocols, for example, it became more important to provide the data that proved such rituals were actually helpful. Staff members in these hospitals also said they received, and appreciated, increased support from senior management and a newfound freedom to voice opinions in ‘more of an equal role, no matter what position you are.’ ”

The degree of an institution’s cultural change was directly linked to patient outcomes, the researchers found. Indeed, hospitals that made more substantial changes in their work culture realized larger and more sustained drops in heart attack mortality rates.

References

1. Chen PW. A More Egalitarian Hospital Culture Is Better for Everyone. New York Times. https://www.nytimes.com/2018/05/31/well/live/doctors-patients-hospital-culture-better-health.html. Published May 31, 2018. Accessed June 1, 2018.

2. Curry LA et al. Organizational culture change in U.S. hospitals: A mixed methods longitudinal intervention study. Implementation Science. 2015 Mar 7. doi: 10.1186/s13012-015-0218-0. Accessed June 18, 2018.

Health care experts have long known of a link between patient outcomes and a hospital’s organizational culture, according to an article in the New York Times by Pauline W. Chen, MD.

“Heart attack patients who are treated at hospitals where nurses feel powerless and senior management is only sporadically involved in patient care tend to fare more poorly than patients hospitalized at institutions where nurses are asked regularly for their input and chief executives hold regular meetings with clinicians to review patient results,” she wrote.

But there is hope for change, Dr. Chen noted, and it’s demonstrable, citing a group of researchers that has written about strategies targeting hospital organizational culture called “Leadership Saves Lives.” The researchers showed hospitals could create significant cultural changes, which could impact patient outcomes, in just 2 years.

“Leadership Saves Lives requires that each hospital create a ‘Guiding Coalition,’ a group of staff members from across the entire institution. The coalition members participate in regular workshops, discussions, and national forums on ways hospitals might improve, then help their respective hospital translate newfound ideas and information into clinical practice,” she wrote.

The researchers monitored heart attack patients to assess the effect of Leadership Saves Lives in 10 hospitals that had below average patient outcomes. Over 2 years, all 10 hospitals changed significantly, but 6 hospitals experienced particularly profound cultural transformations.

“The staff of these hospitals spoke of an institutional shift from ‘because I said so’ to ‘focusing on the why’s,’ ” Dr. Chen wrote. “Instead of accepting that every heart attack patient had to undergo certain testing or take specific drugs because the chief of the department or administrator had previously established such clinical protocols, for example, it became more important to provide the data that proved such rituals were actually helpful. Staff members in these hospitals also said they received, and appreciated, increased support from senior management and a newfound freedom to voice opinions in ‘more of an equal role, no matter what position you are.’ ”

The degree of an institution’s cultural change was directly linked to patient outcomes, the researchers found. Indeed, hospitals that made more substantial changes in their work culture realized larger and more sustained drops in heart attack mortality rates.

References

1. Chen PW. A More Egalitarian Hospital Culture Is Better for Everyone. New York Times. https://www.nytimes.com/2018/05/31/well/live/doctors-patients-hospital-culture-better-health.html. Published May 31, 2018. Accessed June 1, 2018.

2. Curry LA et al. Organizational culture change in U.S. hospitals: A mixed methods longitudinal intervention study. Implementation Science. 2015 Mar 7. doi: 10.1186/s13012-015-0218-0. Accessed June 18, 2018.

Health care experts have long known of a link between patient outcomes and a hospital’s organizational culture, according to an article in the New York Times by Pauline W. Chen, MD.

“Heart attack patients who are treated at hospitals where nurses feel powerless and senior management is only sporadically involved in patient care tend to fare more poorly than patients hospitalized at institutions where nurses are asked regularly for their input and chief executives hold regular meetings with clinicians to review patient results,” she wrote.

But there is hope for change, Dr. Chen noted, and it’s demonstrable, citing a group of researchers that has written about strategies targeting hospital organizational culture called “Leadership Saves Lives.” The researchers showed hospitals could create significant cultural changes, which could impact patient outcomes, in just 2 years.

“Leadership Saves Lives requires that each hospital create a ‘Guiding Coalition,’ a group of staff members from across the entire institution. The coalition members participate in regular workshops, discussions, and national forums on ways hospitals might improve, then help their respective hospital translate newfound ideas and information into clinical practice,” she wrote.

The researchers monitored heart attack patients to assess the effect of Leadership Saves Lives in 10 hospitals that had below average patient outcomes. Over 2 years, all 10 hospitals changed significantly, but 6 hospitals experienced particularly profound cultural transformations.

“The staff of these hospitals spoke of an institutional shift from ‘because I said so’ to ‘focusing on the why’s,’ ” Dr. Chen wrote. “Instead of accepting that every heart attack patient had to undergo certain testing or take specific drugs because the chief of the department or administrator had previously established such clinical protocols, for example, it became more important to provide the data that proved such rituals were actually helpful. Staff members in these hospitals also said they received, and appreciated, increased support from senior management and a newfound freedom to voice opinions in ‘more of an equal role, no matter what position you are.’ ”

The degree of an institution’s cultural change was directly linked to patient outcomes, the researchers found. Indeed, hospitals that made more substantial changes in their work culture realized larger and more sustained drops in heart attack mortality rates.

References

1. Chen PW. A More Egalitarian Hospital Culture Is Better for Everyone. New York Times. https://www.nytimes.com/2018/05/31/well/live/doctors-patients-hospital-culture-better-health.html. Published May 31, 2018. Accessed June 1, 2018.

2. Curry LA et al. Organizational culture change in U.S. hospitals: A mixed methods longitudinal intervention study. Implementation Science. 2015 Mar 7. doi: 10.1186/s13012-015-0218-0. Accessed June 18, 2018.

Background: Medicaid and the Children’s Health Insurance Program (CHIP) provide health care to over 30 million children in the United States.^1,2 As a result, low-income children have had increased access to health care, of all forms, which has increased the utilization of primary care and decreased unnecessary ED visits and hospitalizations. However, this comes at a high cost, both at the state and national level. Medicaid currently subsidizes more than 50% of every state’s public insurance program, spending about $100 billion/year in health care payments for children.³ Given this hefty price tag, there have been myriad strategies proposed to help decrease these costs. One such strategy, includes decreasing enrollment in public insurance through decreasing income eligibility thresholds. As a result, many children from low-income families would lose their public insurance and be eligible for commercial insurance only. Consequently, this would place an undue financial burden on these families and the health care systems that care for them. Furthermore, it is anticipated that poor health care outcomes would increase in these vulnerable populations.

Study design: Retrospective cohort study using 2014 State Inpatient Databases.

Setting: Pediatric hospitalizations (aged less than 18 years) from 14 states during 2014 with public insurance listed as the primary payer. This encompassed about 30% of family households in the United States in 2014.

Synopsis: Simulations were done at three different thresholds of the federal poverty level (FPL), including less than 100%, less than 200% and less than 300%. Of the families included, 43% lived below 300%, 27% below 200% and 11% below 100% of the FPL. Of note, public insurance FPL eligibility limits tended to be lower in states with a greater percentage of the population being below 300% of the FPL. The results, of these reductions, were as follows:

• If reduced to less than 300% of the FPL, about 155,000 hospitalizations became ineligible for reimbursement. The median per-hospitalization estimated costs ranged from approximately $6,000 to approximately $10,000, accumulating $1.2 billion in estimated costs.
• If reduced to less than 200% of the FPL, about 440,000 hospitalizations became ineligible for reimbursement. The median per-hospitalization estimated costs ranged from approximately $2,000 to approximately $10,000, accumulating $3.1 billion in estimated costs.
• If reduced to less than 100% of the FPL, about 650,000 hospitalizations became ineligible for reimbursement. The median per-hospitalization estimated costs ranged from approximately $2,000 to approximately $10,000, accumulating $4.4 billion in estimated costs.

If these reductions occurred, healthy newborns would be disproportionately affected by them, which is important to note because newborn hospitalization is one of the fastest-rising costs in pediatric care. In fact, it can range from approximately $700 to approximately $2,000 per hospitalization, which may represent a huge financial strain for families that are unable to secure commercial insurance. Furthermore, with the average hospitalization of non-newborns ranging from $3,000 to $10,000, it is likely that this cost would constitute a fairly large percentage of a low income family’s annual income, which may represent an untenable financial burden.

Thus, if these families are unable to obtain commercial insurance and/or pay these debts, the financial burden will shift to the institutions that care for these vulnerable populations.

Bottom line: If public insurance eligibility thresholds were decreased, a large number of pediatric hospitalizations would become ineligible for coverage, which would shift the costs to families and institutions that are already financially strained and likely result in poor health care outcomes for some of our most vulnerable pediatric patients.

Citation: Bettenhausen JL et al. The effect of lowering public insurance income limits on hospitalizations for low-income children. Pediatrics. 2018 Aug. doi: 10.1542/peds.2017-3486.

Dr. Darden is a pediatric hospitalist at Phoenix Children’s Hospital and clinical assistant professor, University of Arizona, Phoenix.

References

1. The Henry J. Kaiser Family Foundation. Total Medicaid Spending. 2016. Available at: http://kff.org/medicaid/state-indicator/total-medicaid-spending/.

2. Medicaid and CHIP Payment and Access Commission. Trends in Medicaid Spending. 2016. Available at https://www.macpac.gov/wp-content/uploads/2016/06/Trends-in-Medicaid-Spending.pdf.

3. Medicaid and CHIP Payment and Access Commission. Medicaid’s share of state budgets. 2017. Available at: https://www.macpac.gov/subtopic/medicaids-share-of-state-budgets/.

Background: Medicaid and the Children’s Health Insurance Program (CHIP) provide health care to over 30 million children in the United States.^1,2 As a result, low-income children have had increased access to health care, of all forms, which has increased the utilization of primary care and decreased unnecessary ED visits and hospitalizations. However, this comes at a high cost, both at the state and national level. Medicaid currently subsidizes more than 50% of every state’s public insurance program, spending about $100 billion/year in health care payments for children.³ Given this hefty price tag, there have been myriad strategies proposed to help decrease these costs. One such strategy, includes decreasing enrollment in public insurance through decreasing income eligibility thresholds. As a result, many children from low-income families would lose their public insurance and be eligible for commercial insurance only. Consequently, this would place an undue financial burden on these families and the health care systems that care for them. Furthermore, it is anticipated that poor health care outcomes would increase in these vulnerable populations.

Study design: Retrospective cohort study using 2014 State Inpatient Databases.

Setting: Pediatric hospitalizations (aged less than 18 years) from 14 states during 2014 with public insurance listed as the primary payer. This encompassed about 30% of family households in the United States in 2014.

Synopsis: Simulations were done at three different thresholds of the federal poverty level (FPL), including less than 100%, less than 200% and less than 300%. Of the families included, 43% lived below 300%, 27% below 200% and 11% below 100% of the FPL. Of note, public insurance FPL eligibility limits tended to be lower in states with a greater percentage of the population being below 300% of the FPL. The results, of these reductions, were as follows:

• If reduced to less than 300% of the FPL, about 155,000 hospitalizations became ineligible for reimbursement. The median per-hospitalization estimated costs ranged from approximately $6,000 to approximately $10,000, accumulating $1.2 billion in estimated costs.
• If reduced to less than 200% of the FPL, about 440,000 hospitalizations became ineligible for reimbursement. The median per-hospitalization estimated costs ranged from approximately $2,000 to approximately $10,000, accumulating $3.1 billion in estimated costs.
• If reduced to less than 100% of the FPL, about 650,000 hospitalizations became ineligible for reimbursement. The median per-hospitalization estimated costs ranged from approximately $2,000 to approximately $10,000, accumulating $4.4 billion in estimated costs.

If these reductions occurred, healthy newborns would be disproportionately affected by them, which is important to note because newborn hospitalization is one of the fastest-rising costs in pediatric care. In fact, it can range from approximately $700 to approximately $2,000 per hospitalization, which may represent a huge financial strain for families that are unable to secure commercial insurance. Furthermore, with the average hospitalization of non-newborns ranging from $3,000 to $10,000, it is likely that this cost would constitute a fairly large percentage of a low income family’s annual income, which may represent an untenable financial burden.

Thus, if these families are unable to obtain commercial insurance and/or pay these debts, the financial burden will shift to the institutions that care for these vulnerable populations.

Bottom line: If public insurance eligibility thresholds were decreased, a large number of pediatric hospitalizations would become ineligible for coverage, which would shift the costs to families and institutions that are already financially strained and likely result in poor health care outcomes for some of our most vulnerable pediatric patients.

Citation: Bettenhausen JL et al. The effect of lowering public insurance income limits on hospitalizations for low-income children. Pediatrics. 2018 Aug. doi: 10.1542/peds.2017-3486.

Dr. Darden is a pediatric hospitalist at Phoenix Children’s Hospital and clinical assistant professor, University of Arizona, Phoenix.

References

1. The Henry J. Kaiser Family Foundation. Total Medicaid Spending. 2016. Available at: http://kff.org/medicaid/state-indicator/total-medicaid-spending/.

2. Medicaid and CHIP Payment and Access Commission. Trends in Medicaid Spending. 2016. Available at https://www.macpac.gov/wp-content/uploads/2016/06/Trends-in-Medicaid-Spending.pdf.

3. Medicaid and CHIP Payment and Access Commission. Medicaid’s share of state budgets. 2017. Available at: https://www.macpac.gov/subtopic/medicaids-share-of-state-budgets/.

Background: Medicaid and the Children’s Health Insurance Program (CHIP) provide health care to over 30 million children in the United States.^1,2 As a result, low-income children have had increased access to health care, of all forms, which has increased the utilization of primary care and decreased unnecessary ED visits and hospitalizations. However, this comes at a high cost, both at the state and national level. Medicaid currently subsidizes more than 50% of every state’s public insurance program, spending about $100 billion/year in health care payments for children.³ Given this hefty price tag, there have been myriad strategies proposed to help decrease these costs. One such strategy, includes decreasing enrollment in public insurance through decreasing income eligibility thresholds. As a result, many children from low-income families would lose their public insurance and be eligible for commercial insurance only. Consequently, this would place an undue financial burden on these families and the health care systems that care for them. Furthermore, it is anticipated that poor health care outcomes would increase in these vulnerable populations.

Study design: Retrospective cohort study using 2014 State Inpatient Databases.

Setting: Pediatric hospitalizations (aged less than 18 years) from 14 states during 2014 with public insurance listed as the primary payer. This encompassed about 30% of family households in the United States in 2014.

Synopsis: Simulations were done at three different thresholds of the federal poverty level (FPL), including less than 100%, less than 200% and less than 300%. Of the families included, 43% lived below 300%, 27% below 200% and 11% below 100% of the FPL. Of note, public insurance FPL eligibility limits tended to be lower in states with a greater percentage of the population being below 300% of the FPL. The results, of these reductions, were as follows:

• If reduced to less than 300% of the FPL, about 155,000 hospitalizations became ineligible for reimbursement. The median per-hospitalization estimated costs ranged from approximately $6,000 to approximately $10,000, accumulating $1.2 billion in estimated costs.
• If reduced to less than 200% of the FPL, about 440,000 hospitalizations became ineligible for reimbursement. The median per-hospitalization estimated costs ranged from approximately $2,000 to approximately $10,000, accumulating $3.1 billion in estimated costs.
• If reduced to less than 100% of the FPL, about 650,000 hospitalizations became ineligible for reimbursement. The median per-hospitalization estimated costs ranged from approximately $2,000 to approximately $10,000, accumulating $4.4 billion in estimated costs.

If these reductions occurred, healthy newborns would be disproportionately affected by them, which is important to note because newborn hospitalization is one of the fastest-rising costs in pediatric care. In fact, it can range from approximately $700 to approximately $2,000 per hospitalization, which may represent a huge financial strain for families that are unable to secure commercial insurance. Furthermore, with the average hospitalization of non-newborns ranging from $3,000 to $10,000, it is likely that this cost would constitute a fairly large percentage of a low income family’s annual income, which may represent an untenable financial burden.

Thus, if these families are unable to obtain commercial insurance and/or pay these debts, the financial burden will shift to the institutions that care for these vulnerable populations.

Bottom line: If public insurance eligibility thresholds were decreased, a large number of pediatric hospitalizations would become ineligible for coverage, which would shift the costs to families and institutions that are already financially strained and likely result in poor health care outcomes for some of our most vulnerable pediatric patients.

Citation: Bettenhausen JL et al. The effect of lowering public insurance income limits on hospitalizations for low-income children. Pediatrics. 2018 Aug. doi: 10.1542/peds.2017-3486.

Dr. Darden is a pediatric hospitalist at Phoenix Children’s Hospital and clinical assistant professor, University of Arizona, Phoenix.

References

1. The Henry J. Kaiser Family Foundation. Total Medicaid Spending. 2016. Available at: http://kff.org/medicaid/state-indicator/total-medicaid-spending/.

2. Medicaid and CHIP Payment and Access Commission. Trends in Medicaid Spending. 2016. Available at https://www.macpac.gov/wp-content/uploads/2016/06/Trends-in-Medicaid-Spending.pdf.

3. Medicaid and CHIP Payment and Access Commission. Medicaid’s share of state budgets. 2017. Available at: https://www.macpac.gov/subtopic/medicaids-share-of-state-budgets/.