Practice Economics

Heart failure patients who had early follow-up (within seven days of discharge) with general medicine or cardiology providers had a lower risk of being readmitted to the hospital within 30 days, according to a study from Kaiser Permanente published in the journal Medical Care.

“We found that follow-up within the first seven days post-discharge—mostly done through in-person clinic visits—was independently associated with a 19% lower chance of readmission, whereas initial follow-up after seven days was not significantly associated with readmission,” says lead researcher Keane K. Lee, MD, MS, a cardiologist and research scientist with Kaiser Permanente. “Perhaps as important, we also observed that telephone visits, mostly done by non-physician providers, within seven days after hospital discharge were associated with a non-statistically significant trend toward lower 30-day readmission rates, even after carefully accounting for potential differences between patients.

“This finding that telephone visits could reduce readmissions has never been reported and has potentially important implications. Contact by telephone with non-physicians may be more convenient for patients and family members and be more practical and cost-effective when implemented on a large scale.”

Dr. Lee suggests hospitalists have a role in creating a system to reliably arrange this follow-up.

“Hospitalists serve as a key part of the process to help patients transition successfully from the hospital back home,” Dr. Lee says.

Reference

1. Lee KK, Yang J, Hernandez AF, Steimle AE, Go S. Post-discharge follow-up characteristics associated with 30-day readmission after heart failure hospitalization. Med Care. 2016;54(4):365-372.

Heart failure patients who had early follow-up (within seven days of discharge) with general medicine or cardiology providers had a lower risk of being readmitted to the hospital within 30 days, according to a study from Kaiser Permanente published in the journal Medical Care.

“We found that follow-up within the first seven days post-discharge—mostly done through in-person clinic visits—was independently associated with a 19% lower chance of readmission, whereas initial follow-up after seven days was not significantly associated with readmission,” says lead researcher Keane K. Lee, MD, MS, a cardiologist and research scientist with Kaiser Permanente. “Perhaps as important, we also observed that telephone visits, mostly done by non-physician providers, within seven days after hospital discharge were associated with a non-statistically significant trend toward lower 30-day readmission rates, even after carefully accounting for potential differences between patients.

“This finding that telephone visits could reduce readmissions has never been reported and has potentially important implications. Contact by telephone with non-physicians may be more convenient for patients and family members and be more practical and cost-effective when implemented on a large scale.”

Dr. Lee suggests hospitalists have a role in creating a system to reliably arrange this follow-up.

“Hospitalists serve as a key part of the process to help patients transition successfully from the hospital back home,” Dr. Lee says.

Reference

1. Lee KK, Yang J, Hernandez AF, Steimle AE, Go S. Post-discharge follow-up characteristics associated with 30-day readmission after heart failure hospitalization. Med Care. 2016;54(4):365-372.

Heart failure patients who had early follow-up (within seven days of discharge) with general medicine or cardiology providers had a lower risk of being readmitted to the hospital within 30 days, according to a study from Kaiser Permanente published in the journal Medical Care.

“We found that follow-up within the first seven days post-discharge—mostly done through in-person clinic visits—was independently associated with a 19% lower chance of readmission, whereas initial follow-up after seven days was not significantly associated with readmission,” says lead researcher Keane K. Lee, MD, MS, a cardiologist and research scientist with Kaiser Permanente. “Perhaps as important, we also observed that telephone visits, mostly done by non-physician providers, within seven days after hospital discharge were associated with a non-statistically significant trend toward lower 30-day readmission rates, even after carefully accounting for potential differences between patients.

“This finding that telephone visits could reduce readmissions has never been reported and has potentially important implications. Contact by telephone with non-physicians may be more convenient for patients and family members and be more practical and cost-effective when implemented on a large scale.”

Dr. Lee suggests hospitalists have a role in creating a system to reliably arrange this follow-up.

“Hospitalists serve as a key part of the process to help patients transition successfully from the hospital back home,” Dr. Lee says.

Reference

1. Lee KK, Yang J, Hernandez AF, Steimle AE, Go S. Post-discharge follow-up characteristics associated with 30-day readmission after heart failure hospitalization. Med Care. 2016;54(4):365-372.

Dear Dr. Hospitalist:

I am a seasoned hospitalist at a large academic medical center in the Northeast and have recently become more bothered by how our group is being coerced to aggressively bill for our services. It seems the current reimbursement environment has pushed some of our leaders to demand more aggressive billing from our hospitalists. How should I respond?

Sincerely,

A Seasoned Hospitalist

Dr. Hospitalist responds:

As another “seasoned” hospitalist, I, too, have seen the wide pendulum swing from when internist inpatient billing was an afterthought and done by others to the current system of billing classes, RVU enticement, and reminders of how to construct the note. Enter the electronic health record, and now instead of clinical notes being used as a form of communication among clinicians, it does seem today to be created more for billing purposes.

How did we get here?

Physicians have to accept some of the blame. I can recall when I was an orderly at our local hospital in the mid 1970s and some physician “rounds” consisted of standing in a patient’s doorway and calling out, “How are you doing today, Mrs. Smith?” I must admit to having no idea how these docs were billing, but I do know that Medicare allowed for twice-daily billing for hospital visits back then. I also recall some of the paltry progress notes that consisted of one-liners like “pt doing well today.”

Like most corrective actions, the response has overshot the intended mark and made the daily progress note more ritualistic than informative. When the first attempts by the American Medical Association and the Centers for Medicare & Medicaid Services were released in the early 1990s, I’m sure most docs had no idea it would morph into its current level of significance for reimbursement—and that one day docs would be asked to implement, keep up with changes and modifications (think ICD-10), and use daily. Don’t get me wrong: I, like most hospitalists, recognize the clinical utility of a concise and well-written note. But when an otherwise complete H&P gets down-coded from a level 99223 to a 99221 because I leave off the family history of a 95-year-old man, of course I believe something is wrong with the system.

Also, human nature being what it is, I have always felt that if you incentivize people to increase production of an item, whether it’s a widget or an RVU, you will have some who will learn to game the system, consciously or subconsciously. With healthcare spending in the U.S. approaching 20% of gross domestic product, we as physicians should not be placed in positions of increased financial gain at the expense of our country’s economic health and viability. After all, we’re citizens first and physicians second.

You should recognize the need for proper coding and billing as inherent to the hospital’s financial viability, and if done correctly, it should not create an ethical or legal conflict for you. In the vast majority of cases, a well-written note can be properly billed and coded without creating angst.

Good luck! TH

Dear Dr. Hospitalist:

I am a seasoned hospitalist at a large academic medical center in the Northeast and have recently become more bothered by how our group is being coerced to aggressively bill for our services. It seems the current reimbursement environment has pushed some of our leaders to demand more aggressive billing from our hospitalists. How should I respond?

Sincerely,

A Seasoned Hospitalist

Dr. Hospitalist responds:

As another “seasoned” hospitalist, I, too, have seen the wide pendulum swing from when internist inpatient billing was an afterthought and done by others to the current system of billing classes, RVU enticement, and reminders of how to construct the note. Enter the electronic health record, and now instead of clinical notes being used as a form of communication among clinicians, it does seem today to be created more for billing purposes.

How did we get here?

Physicians have to accept some of the blame. I can recall when I was an orderly at our local hospital in the mid 1970s and some physician “rounds” consisted of standing in a patient’s doorway and calling out, “How are you doing today, Mrs. Smith?” I must admit to having no idea how these docs were billing, but I do know that Medicare allowed for twice-daily billing for hospital visits back then. I also recall some of the paltry progress notes that consisted of one-liners like “pt doing well today.”

Like most corrective actions, the response has overshot the intended mark and made the daily progress note more ritualistic than informative. When the first attempts by the American Medical Association and the Centers for Medicare & Medicaid Services were released in the early 1990s, I’m sure most docs had no idea it would morph into its current level of significance for reimbursement—and that one day docs would be asked to implement, keep up with changes and modifications (think ICD-10), and use daily. Don’t get me wrong: I, like most hospitalists, recognize the clinical utility of a concise and well-written note. But when an otherwise complete H&P gets down-coded from a level 99223 to a 99221 because I leave off the family history of a 95-year-old man, of course I believe something is wrong with the system.

Also, human nature being what it is, I have always felt that if you incentivize people to increase production of an item, whether it’s a widget or an RVU, you will have some who will learn to game the system, consciously or subconsciously. With healthcare spending in the U.S. approaching 20% of gross domestic product, we as physicians should not be placed in positions of increased financial gain at the expense of our country’s economic health and viability. After all, we’re citizens first and physicians second.

You should recognize the need for proper coding and billing as inherent to the hospital’s financial viability, and if done correctly, it should not create an ethical or legal conflict for you. In the vast majority of cases, a well-written note can be properly billed and coded without creating angst.

Good luck! TH

Dear Dr. Hospitalist:

I am a seasoned hospitalist at a large academic medical center in the Northeast and have recently become more bothered by how our group is being coerced to aggressively bill for our services. It seems the current reimbursement environment has pushed some of our leaders to demand more aggressive billing from our hospitalists. How should I respond?

Sincerely,

A Seasoned Hospitalist

Dr. Hospitalist responds:

As another “seasoned” hospitalist, I, too, have seen the wide pendulum swing from when internist inpatient billing was an afterthought and done by others to the current system of billing classes, RVU enticement, and reminders of how to construct the note. Enter the electronic health record, and now instead of clinical notes being used as a form of communication among clinicians, it does seem today to be created more for billing purposes.

How did we get here?

Physicians have to accept some of the blame. I can recall when I was an orderly at our local hospital in the mid 1970s and some physician “rounds” consisted of standing in a patient’s doorway and calling out, “How are you doing today, Mrs. Smith?” I must admit to having no idea how these docs were billing, but I do know that Medicare allowed for twice-daily billing for hospital visits back then. I also recall some of the paltry progress notes that consisted of one-liners like “pt doing well today.”

Like most corrective actions, the response has overshot the intended mark and made the daily progress note more ritualistic than informative. When the first attempts by the American Medical Association and the Centers for Medicare & Medicaid Services were released in the early 1990s, I’m sure most docs had no idea it would morph into its current level of significance for reimbursement—and that one day docs would be asked to implement, keep up with changes and modifications (think ICD-10), and use daily. Don’t get me wrong: I, like most hospitalists, recognize the clinical utility of a concise and well-written note. But when an otherwise complete H&P gets down-coded from a level 99223 to a 99221 because I leave off the family history of a 95-year-old man, of course I believe something is wrong with the system.

Also, human nature being what it is, I have always felt that if you incentivize people to increase production of an item, whether it’s a widget or an RVU, you will have some who will learn to game the system, consciously or subconsciously. With healthcare spending in the U.S. approaching 20% of gross domestic product, we as physicians should not be placed in positions of increased financial gain at the expense of our country’s economic health and viability. After all, we’re citizens first and physicians second.

You should recognize the need for proper coding and billing as inherent to the hospital’s financial viability, and if done correctly, it should not create an ethical or legal conflict for you. In the vast majority of cases, a well-written note can be properly billed and coded without creating angst.

Good luck! TH

As MACRA makes quality-based care the law of the land, don’t just glide under the new expectations, thrive. That advice comes from accountable care experts who are seeing firsthand the tools leading to success in the new payment landscape.

Rule No. 1: Step up to the plate, said Julian D. “Bo” Bobbitt, a Raleigh, N.C.–based health law attorney and accountable care organization (ACO) specialist.

“MACRA changes everything,” he said in an interview. “This is massive. Indecision will not stop your placement in the value-based payment system. Why not control your destiny to achieve your professional and financial goals?”

On May 9, the Centers for Medicare & Medicaid Services published a proposed final rule that outlines key payment provisions of the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA). The proposal establishes parameters for the new Quality Payment Program, which includes the Merit-based Incentive Payment System (MIPS) and advanced Alternative Payment Models (APMs). Once final, the rule will consolidate three Medicare quality programs into MIPS: the Physician Quality Reporting System, the Value-Based Modifier Program; and the Meaningful Use program. CMS also proposes an APM pathway in which eligible clinicians can earn incentives.

The MACRA basics go as follows: From 2019 through 2024, well-performing physicians will be eligible for a bonus payment of up to 10% from a $500 million pool, according to CMS guidance released April 27. Poorly performing clinicians will see a pay cut of up to 4% in 2019, which increases to a max of 9% in 2022.

Taking small steps that focus on value now is key to excelling under MACRA, according to Jeb Dunkelberger, vice president for accountable care services at McKesson. “As an organization, ask: How can I get myself into a situation where I can maintain one foot on the boat and one foot on the dock, and be successful in the fee-for-service world, while starting to expose myself to fee-for-value?”

Starting a Medicare Shared Savings ACO is one way to accomplish this, Mr. Dunkelberger said in an interview. Track 1 of that program provides doctors with the potential for shared savings, while protecting them from financial risk. In his experience, practices have become successful after starting such ACOs, combined with a chronic care management initiative. Under this option, providers receive a fee-for-service payment, but they are also reaching out to patients and delivering preventive care, he said.

“You still have a traditional fee-for-service mechanism,” he said. “Your revenue cycle doesn’t change. Your coding doesn’t change. But at the same time, you’re simultaneously developing a competency that will be perceived as high-value in a futuristic world where we shift the location of care delivery and incentivize wellness and prevention more so than ever before.”

Joining an ACO sooner, rather than later, makes sense on many levels, Mr. Bobbitt added.

“Accountable care organizations seem to be an ideal vehicle to increase your value contribution and your reimbursement,” he said. “The law gives a 5% bump if you are in a qualifying ACO. There’s work involved and there’s infrastructure cost, but you can get into the plus side under MACRA and avoid the negative side, and you’re still open to the upside of the rewards for high performance.”

Transitioning early from volume to value has paid off for Dr. Grace E. Terrell and her large multispecialty group based in High Point, N.C. The group began adding components of value-based care in 2011 and is now part of an ACO with multiple payers and partners.

“We did this by changing the way we were providing care in specific care models and also investing substantially in information integration as well as changing our contracts so we were being paid based upon our outcomes, quality, and cost-effectiveness, rather than just fee-for-service,” said Dr. Terrell, the group’s president and CEO.

Since making the changes, the group has improved quality of care while reducing cost, said Dr. Terrell, who serves on the federal advisory committee for MACRA, officially known as the Physician-Focused Payment Model Technical Advisory Committee. Dr. Terrell said that her practice group had the sixth-highest quality score and the fourth-lowest cost among providers in the 2014 Medicare Shared Savings Program. The group has also launched a population health management company in collaboration with an academic medical center and a testing laboratory.

Maintaining a patient-focused viewpoint is essential to switching from volume to value, Dr. Terrell said. For example, her group focused on patients with severe chronic obstructive pulmonary disease and teamed them with a respiratory therapist, particularly after hospitalizations. Their efforts reduced 30-day hospital readmissions from 12% to 6%. They also created clinics for patients who have five or more chronic conditions; physicians are linked with nurse navigators, social workers, and other professionals to offer a more holistic approach.

“All of these different models focused foremost on patients,” Dr. Terrell said. “They also focused on teamwork. Even though physicians were leading the team, it involved integrated medicine. It also involved integration across the spectrum of care so we had to work very carefully with our hospital partners.”

Collaboration is a critical piece to quality-based success, Mr. Dunkelberger said, but he advises taking the time and effort to find the right partners. Thoroughly vet potential partners, he said. Ask for case studies and overall impact of work. Be wary of flashy flowcharts and “too good to be true” promises.

“Look for a partner and not [necessarily] a vendor,” Mr. Dunkelberger said. “Make sure their incentives align with yours.”

Take stock of readiness to participate in alternative payment models, advised Edith Coakley Stowe, a health care attorney in Washington. The ability to meet electronic health record expectations, a category under MACRA now called Advancing Care Information, is extremely important, she said. Equally important – especially in primary care – are strategies for managing patients between visits. Decide whether your practice should build, buy, or enter into a joint venture to achieve these goals.

“The good news is that what gets tested in alternative payment models generally finds its way into policies and programs applicable across the Medicare program,” Ms. Stowe said in an interview. “That means that participants in alternative payment models get a head start. Despite the blind corners and complexity of options facing physician groups right now, having a mentality of testing, trying, and continuously evaluating is going to stand them in the best stead.”

[email protected]

On Twitter @legal_med

As MACRA makes quality-based care the law of the land, don’t just glide under the new expectations, thrive. That advice comes from accountable care experts who are seeing firsthand the tools leading to success in the new payment landscape.

Rule No. 1: Step up to the plate, said Julian D. “Bo” Bobbitt, a Raleigh, N.C.–based health law attorney and accountable care organization (ACO) specialist.

“MACRA changes everything,” he said in an interview. “This is massive. Indecision will not stop your placement in the value-based payment system. Why not control your destiny to achieve your professional and financial goals?”

On May 9, the Centers for Medicare & Medicaid Services published a proposed final rule that outlines key payment provisions of the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA). The proposal establishes parameters for the new Quality Payment Program, which includes the Merit-based Incentive Payment System (MIPS) and advanced Alternative Payment Models (APMs). Once final, the rule will consolidate three Medicare quality programs into MIPS: the Physician Quality Reporting System, the Value-Based Modifier Program; and the Meaningful Use program. CMS also proposes an APM pathway in which eligible clinicians can earn incentives.

The MACRA basics go as follows: From 2019 through 2024, well-performing physicians will be eligible for a bonus payment of up to 10% from a $500 million pool, according to CMS guidance released April 27. Poorly performing clinicians will see a pay cut of up to 4% in 2019, which increases to a max of 9% in 2022.

Taking small steps that focus on value now is key to excelling under MACRA, according to Jeb Dunkelberger, vice president for accountable care services at McKesson. “As an organization, ask: How can I get myself into a situation where I can maintain one foot on the boat and one foot on the dock, and be successful in the fee-for-service world, while starting to expose myself to fee-for-value?”

Starting a Medicare Shared Savings ACO is one way to accomplish this, Mr. Dunkelberger said in an interview. Track 1 of that program provides doctors with the potential for shared savings, while protecting them from financial risk. In his experience, practices have become successful after starting such ACOs, combined with a chronic care management initiative. Under this option, providers receive a fee-for-service payment, but they are also reaching out to patients and delivering preventive care, he said.

“You still have a traditional fee-for-service mechanism,” he said. “Your revenue cycle doesn’t change. Your coding doesn’t change. But at the same time, you’re simultaneously developing a competency that will be perceived as high-value in a futuristic world where we shift the location of care delivery and incentivize wellness and prevention more so than ever before.”

Joining an ACO sooner, rather than later, makes sense on many levels, Mr. Bobbitt added.

“Accountable care organizations seem to be an ideal vehicle to increase your value contribution and your reimbursement,” he said. “The law gives a 5% bump if you are in a qualifying ACO. There’s work involved and there’s infrastructure cost, but you can get into the plus side under MACRA and avoid the negative side, and you’re still open to the upside of the rewards for high performance.”

Transitioning early from volume to value has paid off for Dr. Grace E. Terrell and her large multispecialty group based in High Point, N.C. The group began adding components of value-based care in 2011 and is now part of an ACO with multiple payers and partners.

“We did this by changing the way we were providing care in specific care models and also investing substantially in information integration as well as changing our contracts so we were being paid based upon our outcomes, quality, and cost-effectiveness, rather than just fee-for-service,” said Dr. Terrell, the group’s president and CEO.

Since making the changes, the group has improved quality of care while reducing cost, said Dr. Terrell, who serves on the federal advisory committee for MACRA, officially known as the Physician-Focused Payment Model Technical Advisory Committee. Dr. Terrell said that her practice group had the sixth-highest quality score and the fourth-lowest cost among providers in the 2014 Medicare Shared Savings Program. The group has also launched a population health management company in collaboration with an academic medical center and a testing laboratory.

Maintaining a patient-focused viewpoint is essential to switching from volume to value, Dr. Terrell said. For example, her group focused on patients with severe chronic obstructive pulmonary disease and teamed them with a respiratory therapist, particularly after hospitalizations. Their efforts reduced 30-day hospital readmissions from 12% to 6%. They also created clinics for patients who have five or more chronic conditions; physicians are linked with nurse navigators, social workers, and other professionals to offer a more holistic approach.

“All of these different models focused foremost on patients,” Dr. Terrell said. “They also focused on teamwork. Even though physicians were leading the team, it involved integrated medicine. It also involved integration across the spectrum of care so we had to work very carefully with our hospital partners.”

Collaboration is a critical piece to quality-based success, Mr. Dunkelberger said, but he advises taking the time and effort to find the right partners. Thoroughly vet potential partners, he said. Ask for case studies and overall impact of work. Be wary of flashy flowcharts and “too good to be true” promises.

“Look for a partner and not [necessarily] a vendor,” Mr. Dunkelberger said. “Make sure their incentives align with yours.”

Take stock of readiness to participate in alternative payment models, advised Edith Coakley Stowe, a health care attorney in Washington. The ability to meet electronic health record expectations, a category under MACRA now called Advancing Care Information, is extremely important, she said. Equally important – especially in primary care – are strategies for managing patients between visits. Decide whether your practice should build, buy, or enter into a joint venture to achieve these goals.

“The good news is that what gets tested in alternative payment models generally finds its way into policies and programs applicable across the Medicare program,” Ms. Stowe said in an interview. “That means that participants in alternative payment models get a head start. Despite the blind corners and complexity of options facing physician groups right now, having a mentality of testing, trying, and continuously evaluating is going to stand them in the best stead.”

[email protected]

On Twitter @legal_med

As MACRA makes quality-based care the law of the land, don’t just glide under the new expectations, thrive. That advice comes from accountable care experts who are seeing firsthand the tools leading to success in the new payment landscape.

Rule No. 1: Step up to the plate, said Julian D. “Bo” Bobbitt, a Raleigh, N.C.–based health law attorney and accountable care organization (ACO) specialist.

“MACRA changes everything,” he said in an interview. “This is massive. Indecision will not stop your placement in the value-based payment system. Why not control your destiny to achieve your professional and financial goals?”

On May 9, the Centers for Medicare & Medicaid Services published a proposed final rule that outlines key payment provisions of the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA). The proposal establishes parameters for the new Quality Payment Program, which includes the Merit-based Incentive Payment System (MIPS) and advanced Alternative Payment Models (APMs). Once final, the rule will consolidate three Medicare quality programs into MIPS: the Physician Quality Reporting System, the Value-Based Modifier Program; and the Meaningful Use program. CMS also proposes an APM pathway in which eligible clinicians can earn incentives.

The MACRA basics go as follows: From 2019 through 2024, well-performing physicians will be eligible for a bonus payment of up to 10% from a $500 million pool, according to CMS guidance released April 27. Poorly performing clinicians will see a pay cut of up to 4% in 2019, which increases to a max of 9% in 2022.

Taking small steps that focus on value now is key to excelling under MACRA, according to Jeb Dunkelberger, vice president for accountable care services at McKesson. “As an organization, ask: How can I get myself into a situation where I can maintain one foot on the boat and one foot on the dock, and be successful in the fee-for-service world, while starting to expose myself to fee-for-value?”

Starting a Medicare Shared Savings ACO is one way to accomplish this, Mr. Dunkelberger said in an interview. Track 1 of that program provides doctors with the potential for shared savings, while protecting them from financial risk. In his experience, practices have become successful after starting such ACOs, combined with a chronic care management initiative. Under this option, providers receive a fee-for-service payment, but they are also reaching out to patients and delivering preventive care, he said.

“You still have a traditional fee-for-service mechanism,” he said. “Your revenue cycle doesn’t change. Your coding doesn’t change. But at the same time, you’re simultaneously developing a competency that will be perceived as high-value in a futuristic world where we shift the location of care delivery and incentivize wellness and prevention more so than ever before.”

Joining an ACO sooner, rather than later, makes sense on many levels, Mr. Bobbitt added.

“Accountable care organizations seem to be an ideal vehicle to increase your value contribution and your reimbursement,” he said. “The law gives a 5% bump if you are in a qualifying ACO. There’s work involved and there’s infrastructure cost, but you can get into the plus side under MACRA and avoid the negative side, and you’re still open to the upside of the rewards for high performance.”

Transitioning early from volume to value has paid off for Dr. Grace E. Terrell and her large multispecialty group based in High Point, N.C. The group began adding components of value-based care in 2011 and is now part of an ACO with multiple payers and partners.

“We did this by changing the way we were providing care in specific care models and also investing substantially in information integration as well as changing our contracts so we were being paid based upon our outcomes, quality, and cost-effectiveness, rather than just fee-for-service,” said Dr. Terrell, the group’s president and CEO.

Since making the changes, the group has improved quality of care while reducing cost, said Dr. Terrell, who serves on the federal advisory committee for MACRA, officially known as the Physician-Focused Payment Model Technical Advisory Committee. Dr. Terrell said that her practice group had the sixth-highest quality score and the fourth-lowest cost among providers in the 2014 Medicare Shared Savings Program. The group has also launched a population health management company in collaboration with an academic medical center and a testing laboratory.

Maintaining a patient-focused viewpoint is essential to switching from volume to value, Dr. Terrell said. For example, her group focused on patients with severe chronic obstructive pulmonary disease and teamed them with a respiratory therapist, particularly after hospitalizations. Their efforts reduced 30-day hospital readmissions from 12% to 6%. They also created clinics for patients who have five or more chronic conditions; physicians are linked with nurse navigators, social workers, and other professionals to offer a more holistic approach.

“All of these different models focused foremost on patients,” Dr. Terrell said. “They also focused on teamwork. Even though physicians were leading the team, it involved integrated medicine. It also involved integration across the spectrum of care so we had to work very carefully with our hospital partners.”

Collaboration is a critical piece to quality-based success, Mr. Dunkelberger said, but he advises taking the time and effort to find the right partners. Thoroughly vet potential partners, he said. Ask for case studies and overall impact of work. Be wary of flashy flowcharts and “too good to be true” promises.

“Look for a partner and not [necessarily] a vendor,” Mr. Dunkelberger said. “Make sure their incentives align with yours.”

Take stock of readiness to participate in alternative payment models, advised Edith Coakley Stowe, a health care attorney in Washington. The ability to meet electronic health record expectations, a category under MACRA now called Advancing Care Information, is extremely important, she said. Equally important – especially in primary care – are strategies for managing patients between visits. Decide whether your practice should build, buy, or enter into a joint venture to achieve these goals.

“The good news is that what gets tested in alternative payment models generally finds its way into policies and programs applicable across the Medicare program,” Ms. Stowe said in an interview. “That means that participants in alternative payment models get a head start. Despite the blind corners and complexity of options facing physician groups right now, having a mentality of testing, trying, and continuously evaluating is going to stand them in the best stead.”

[email protected]

On Twitter @legal_med

Growing up, Denisse Rojas Marquez rarely visited the doctor. As undocumented immigrants from Mexico, her family viewed medical care as a luxury and sought it only in emergencies.

“I would always wait until it was very severe to see a doctor,” said Ms. Rojas Marquez, who came to the United States as a toddler. “That’s still a mentality I have to train myself out of. Growing up, going to the doctor meant very expensive bills and navigating through very complex systems.”

At 26, Ms. Rojas Marquez is determined to become a physician and help bridge the gap between undocumented immigrants and medical care. She is close to making that dream a reality because of a 2012 policy called the Deferred Action for Childhood Arrivals (DACA), which protects undocumented immigrants brought to the United States as children from deportation and offers access to work authorization. The policy enabled Ms. Rojas Marquez to become one of the first undocumented students to attend the Icahn School of Medicine at Mount Sinai in New York.

Photo provided by Denisse Rojas

But the fate of Ms. Rojas Marquez’s medical education is in flux as the U.S. Supreme Court considers protections for undocumented immigrants in the case of Texas v. United States. In dispute is the constitutionality of two of President Obama’s immigration policies: the Deferred Action for Parents of Americans and Lawful Permanent Residents (DAPA) and expanded DACA. The former protects undocumented immigrants who are parents of U.S. citizens from deportation, if they meet certain criteria. The second extends work authorization under the original DACA program from 2 years to 3 years and broadens age requirements.

Texas and 25 other states have sued over the programs, arguing the president does not have the authority to issue the new immigration policies, and that the programs violate the Constitution as well as the Administrative Procedure Act for notice-and-comment rule making. High court justices heard oral arguments April 18.

The ruling could impact the growing number of medical students with DACA status across the country, and jeopardize the funding invested in their training. Sixty-one medical schools now accept applications from DACA applicants, according to data from the Association of American Medical Colleges (AAMC). In 2015, 46 students with DACA status applied to U.S. medical schools and 20 were enrolled. In 2016, more than double (112) applied, although enrollment data will not be available until year’s end. Neither AAMC nor the National Resident Matching Program collect data on residents with DACA status.

A high court ruling in favor of the states could lead to DACA’s undoing, said Michael M. Hethmon, an attorney for the Immigration Reform Law Institute in Washington, D.C. The institute issued a brief to the Supreme Court in support of Texas.

If Texas prevails, “it’ll be a matter of weeks before a similar challenge will be levied against DACA and a number of other related programs,” Mr. Hethmon said in an interview. “There will be no more legal justification for those programs that exist.”

Saving talent or wasting money?

Loyola University in Chicago has accepted more students with DACA status than any other U.S. medical school. The reasons are simple, said Mark Kuczewski, Ph.D., chair of medical education at Loyola’s Stritch School of Medicine.

“We’re in the business of taking outstanding students,” Dr. Kuczewski said in an interview. “If the student is outstanding, we want them in our applicant pool. Second, being bilingual and bicultural is extremely important. We have patient populations out there that are diverse and underserved. We want to utilize this talent.”

In the fall of 2014, Stritch enrolled seven medical students with DACA status; in 2014, they doubled that enrollment. The students competed on the same playing field as other applicants and received no special treatment, Dr. Kuczewski said.

DACA students do pose funding challenges, he acknowledged. Although the students are protected from deportation and receive work authorization, they don’t qualify for federal student loans. Medical schools must find unique ways to help DACA students finance their education. A major Catholic health system provides student loan packages for several DACA students at Stritch, Dr. Kuczewski said. DACA students can also apply for financial assistance through an AAMC assistance program.

Abhinav Janghala

“Medical students use copious amounts of federal student loans,” he said. “Somehow the school has to make up that difference. We’ve found partners, but they don’t have infinite capacity, so we have to keep going back and finding new partners each year.”

The University of California, San Francisco, also has opened its doors to DACA students. Now in his third year, Jirayut New Latthivongskorn is UCSF’s first undocumented medical student. His education is financed by grants, private funding, and donations, said Mr. Latthivongskorn who came to the United States from Thailand when he was 9 years old. He is cofounder of Pre-Health Dreamers, a network of undocumented students who plan to pursue medical careers.

Before DACA granted his entry into UCSF, Mr. Latthivongskorn was accustomed to barriers because of his undocumented status, including having to turn down a nearly full-ride scholarship from the University of California, Davis, after high school.

“It was devastating,” Mr. Latthivongskorn said in an interview. “It was one of the very first times where I felt different and thought, ‘This is not going to work. You are undocumented.’”

Mr. Latthivongskorn and his family scraped together money for him to complete his undergraduate degree at the University of California, Berkeley. California has since passed the DREAM Act, a law that allows undocumented immigrants to receive private scholarships funded through public universities.

Not everyone believes undocumented immigrants should get the chance to become U.S. physicians. Dr. Jane M. Orient, executive director of the Association of American Physicians and Surgeons, argued that undocumented immigrants are not the answer to curbing the physician shortage.

“In a country that’s supposed to be ruled by law, it seems incomprehensible that people who are violating the law should be given privileges over people who are here legally,” she said in an interview. “We desperately do need more physicians, but we should not be blocking Americans from having this opportunity.”

Dr. Shirie Leng, a Boston anesthesiologist, said DACA is promising in theory, but falls short in practical application.

“There’s no particular reason why [undocumented students] wouldn’t make great doctors,” said Dr. Leng. “The problem is funding related. You can give kids all the opportunity you want, but if you can’t pay for it, that seems to me to be the biggest sticking point.”

Basing admission policies on programs that are vulnerable could end poorly for schools and students, Dr. Leng added.

If DACA is revoked, “it’s not just a waste of money for the school, but a waste of time for the kids,” she said.

Protections hinge on Supreme Court … and next president

During oral arguments earlier this month, justices appeared to disagree on whether DAPA and expanded DACA were properly executed.

Associate Justice Anthony M. Kennedy indicated that the normal order of government policy making had been “turned upside down,” by the creation of the programs. Associate Justice Sonia Sotomayor, meanwhile, noted that immigration policies with broader reaches have been similarly instituted in the past.

A ruling for the government would mean the president can use his executive power to enact policies that run contrary to immigration laws already in place, said Mr. Hethmon, the D.C. attorney. Current immigration laws trump informal agency discretion and do not allow for the government’s “arbitrary and capricious creation of a massive classification of nonstatus alien beneficiaries,” Mr. Hethmon wrote in his high court brief.

A decision that favors Texas would unravel opportunities for undocumented immigrants and prevent their ability to contribute to society, said Ignacia Rodriguez, a legal fellow at the National Immigration Law Center, which authored a brief in support of the government.

“What’s at stake is providing a stable environment for U.S. citizen children to grow, and providing people with the opportunity and tools to be able to contribute to the workforce [and] to the economy,” she said in an interview. “This is a payoff for everybody, not just those receiving the benefit.”

Regardless of what the Supreme Court decides, the next president could have the last word, according Ashley C. Parrish, a Washington D.C. attorney who cowrote a brief in support of the states. Mr. Parrish takes no position on the merits of the immigration programs, but rather, he is concerned with the administration’s failure to follow the Administrative Procedure Act’s requirements for notice-and-comment rule making.

“If the program were adopted as a legal rule after notice and comment, it could not be changed without going through a new notice-and-comment process,” he said. “If it is just a bare statement of policy, it can be changed at any time, without notice to anyone. The next administration could say, ‘Thank you for coming out of the shadows; we are now going to deport all of you.’ ”

Among the Democrats running for president, former Secretary of State Hillary Clinton has said she will defend DACA and Sen. Bernie Sanders (I-Vt.) has said he supports DACA and DAPA, and plans to expand them if elected.

Conversely, presumed Republican presidential nominee Donald Trump has indicated he would rescind DACA and related programs if elected.

After spending most of her life terrified of deportation, Ms. Rojas Marquez said she is not wasting time worrying about the Supreme Court’s decision or whether the next president will overturn the policy. She is keeping her studies foremost in her mind and the goal of becoming a doctor firmly in her heart.

“I have always lived with what-ifs,” she said. “This time around, I’m not going to be living in fear of the removing of DACA, because I wouldn’t have made it this far if I always lived in fear. My plan is no matter what happens, I’m going to finish medical school, and from there, I pray that I will be able to practice in the U.S.”

The Supreme Court is expected to issue its decision by June.

[email protected]

On Twitter @legal_med

Growing up, Denisse Rojas Marquez rarely visited the doctor. As undocumented immigrants from Mexico, her family viewed medical care as a luxury and sought it only in emergencies.

“I would always wait until it was very severe to see a doctor,” said Ms. Rojas Marquez, who came to the United States as a toddler. “That’s still a mentality I have to train myself out of. Growing up, going to the doctor meant very expensive bills and navigating through very complex systems.”

At 26, Ms. Rojas Marquez is determined to become a physician and help bridge the gap between undocumented immigrants and medical care. She is close to making that dream a reality because of a 2012 policy called the Deferred Action for Childhood Arrivals (DACA), which protects undocumented immigrants brought to the United States as children from deportation and offers access to work authorization. The policy enabled Ms. Rojas Marquez to become one of the first undocumented students to attend the Icahn School of Medicine at Mount Sinai in New York.

Photo provided by Denisse Rojas

But the fate of Ms. Rojas Marquez’s medical education is in flux as the U.S. Supreme Court considers protections for undocumented immigrants in the case of Texas v. United States. In dispute is the constitutionality of two of President Obama’s immigration policies: the Deferred Action for Parents of Americans and Lawful Permanent Residents (DAPA) and expanded DACA. The former protects undocumented immigrants who are parents of U.S. citizens from deportation, if they meet certain criteria. The second extends work authorization under the original DACA program from 2 years to 3 years and broadens age requirements.

Texas and 25 other states have sued over the programs, arguing the president does not have the authority to issue the new immigration policies, and that the programs violate the Constitution as well as the Administrative Procedure Act for notice-and-comment rule making. High court justices heard oral arguments April 18.

The ruling could impact the growing number of medical students with DACA status across the country, and jeopardize the funding invested in their training. Sixty-one medical schools now accept applications from DACA applicants, according to data from the Association of American Medical Colleges (AAMC). In 2015, 46 students with DACA status applied to U.S. medical schools and 20 were enrolled. In 2016, more than double (112) applied, although enrollment data will not be available until year’s end. Neither AAMC nor the National Resident Matching Program collect data on residents with DACA status.

A high court ruling in favor of the states could lead to DACA’s undoing, said Michael M. Hethmon, an attorney for the Immigration Reform Law Institute in Washington, D.C. The institute issued a brief to the Supreme Court in support of Texas.

If Texas prevails, “it’ll be a matter of weeks before a similar challenge will be levied against DACA and a number of other related programs,” Mr. Hethmon said in an interview. “There will be no more legal justification for those programs that exist.”

Saving talent or wasting money?

Loyola University in Chicago has accepted more students with DACA status than any other U.S. medical school. The reasons are simple, said Mark Kuczewski, Ph.D., chair of medical education at Loyola’s Stritch School of Medicine.

“We’re in the business of taking outstanding students,” Dr. Kuczewski said in an interview. “If the student is outstanding, we want them in our applicant pool. Second, being bilingual and bicultural is extremely important. We have patient populations out there that are diverse and underserved. We want to utilize this talent.”

In the fall of 2014, Stritch enrolled seven medical students with DACA status; in 2014, they doubled that enrollment. The students competed on the same playing field as other applicants and received no special treatment, Dr. Kuczewski said.

DACA students do pose funding challenges, he acknowledged. Although the students are protected from deportation and receive work authorization, they don’t qualify for federal student loans. Medical schools must find unique ways to help DACA students finance their education. A major Catholic health system provides student loan packages for several DACA students at Stritch, Dr. Kuczewski said. DACA students can also apply for financial assistance through an AAMC assistance program.

Abhinav Janghala

“Medical students use copious amounts of federal student loans,” he said. “Somehow the school has to make up that difference. We’ve found partners, but they don’t have infinite capacity, so we have to keep going back and finding new partners each year.”

The University of California, San Francisco, also has opened its doors to DACA students. Now in his third year, Jirayut New Latthivongskorn is UCSF’s first undocumented medical student. His education is financed by grants, private funding, and donations, said Mr. Latthivongskorn who came to the United States from Thailand when he was 9 years old. He is cofounder of Pre-Health Dreamers, a network of undocumented students who plan to pursue medical careers.

Before DACA granted his entry into UCSF, Mr. Latthivongskorn was accustomed to barriers because of his undocumented status, including having to turn down a nearly full-ride scholarship from the University of California, Davis, after high school.

“It was devastating,” Mr. Latthivongskorn said in an interview. “It was one of the very first times where I felt different and thought, ‘This is not going to work. You are undocumented.’”

Mr. Latthivongskorn and his family scraped together money for him to complete his undergraduate degree at the University of California, Berkeley. California has since passed the DREAM Act, a law that allows undocumented immigrants to receive private scholarships funded through public universities.

Not everyone believes undocumented immigrants should get the chance to become U.S. physicians. Dr. Jane M. Orient, executive director of the Association of American Physicians and Surgeons, argued that undocumented immigrants are not the answer to curbing the physician shortage.

“In a country that’s supposed to be ruled by law, it seems incomprehensible that people who are violating the law should be given privileges over people who are here legally,” she said in an interview. “We desperately do need more physicians, but we should not be blocking Americans from having this opportunity.”

Dr. Shirie Leng, a Boston anesthesiologist, said DACA is promising in theory, but falls short in practical application.

“There’s no particular reason why [undocumented students] wouldn’t make great doctors,” said Dr. Leng. “The problem is funding related. You can give kids all the opportunity you want, but if you can’t pay for it, that seems to me to be the biggest sticking point.”

Basing admission policies on programs that are vulnerable could end poorly for schools and students, Dr. Leng added.

If DACA is revoked, “it’s not just a waste of money for the school, but a waste of time for the kids,” she said.

Protections hinge on Supreme Court … and next president

During oral arguments earlier this month, justices appeared to disagree on whether DAPA and expanded DACA were properly executed.

Associate Justice Anthony M. Kennedy indicated that the normal order of government policy making had been “turned upside down,” by the creation of the programs. Associate Justice Sonia Sotomayor, meanwhile, noted that immigration policies with broader reaches have been similarly instituted in the past.

A ruling for the government would mean the president can use his executive power to enact policies that run contrary to immigration laws already in place, said Mr. Hethmon, the D.C. attorney. Current immigration laws trump informal agency discretion and do not allow for the government’s “arbitrary and capricious creation of a massive classification of nonstatus alien beneficiaries,” Mr. Hethmon wrote in his high court brief.

A decision that favors Texas would unravel opportunities for undocumented immigrants and prevent their ability to contribute to society, said Ignacia Rodriguez, a legal fellow at the National Immigration Law Center, which authored a brief in support of the government.

“What’s at stake is providing a stable environment for U.S. citizen children to grow, and providing people with the opportunity and tools to be able to contribute to the workforce [and] to the economy,” she said in an interview. “This is a payoff for everybody, not just those receiving the benefit.”

Regardless of what the Supreme Court decides, the next president could have the last word, according Ashley C. Parrish, a Washington D.C. attorney who cowrote a brief in support of the states. Mr. Parrish takes no position on the merits of the immigration programs, but rather, he is concerned with the administration’s failure to follow the Administrative Procedure Act’s requirements for notice-and-comment rule making.

“If the program were adopted as a legal rule after notice and comment, it could not be changed without going through a new notice-and-comment process,” he said. “If it is just a bare statement of policy, it can be changed at any time, without notice to anyone. The next administration could say, ‘Thank you for coming out of the shadows; we are now going to deport all of you.’ ”

Among the Democrats running for president, former Secretary of State Hillary Clinton has said she will defend DACA and Sen. Bernie Sanders (I-Vt.) has said he supports DACA and DAPA, and plans to expand them if elected.

Conversely, presumed Republican presidential nominee Donald Trump has indicated he would rescind DACA and related programs if elected.

After spending most of her life terrified of deportation, Ms. Rojas Marquez said she is not wasting time worrying about the Supreme Court’s decision or whether the next president will overturn the policy. She is keeping her studies foremost in her mind and the goal of becoming a doctor firmly in her heart.

“I have always lived with what-ifs,” she said. “This time around, I’m not going to be living in fear of the removing of DACA, because I wouldn’t have made it this far if I always lived in fear. My plan is no matter what happens, I’m going to finish medical school, and from there, I pray that I will be able to practice in the U.S.”

The Supreme Court is expected to issue its decision by June.

[email protected]

On Twitter @legal_med

Growing up, Denisse Rojas Marquez rarely visited the doctor. As undocumented immigrants from Mexico, her family viewed medical care as a luxury and sought it only in emergencies.

“I would always wait until it was very severe to see a doctor,” said Ms. Rojas Marquez, who came to the United States as a toddler. “That’s still a mentality I have to train myself out of. Growing up, going to the doctor meant very expensive bills and navigating through very complex systems.”

At 26, Ms. Rojas Marquez is determined to become a physician and help bridge the gap between undocumented immigrants and medical care. She is close to making that dream a reality because of a 2012 policy called the Deferred Action for Childhood Arrivals (DACA), which protects undocumented immigrants brought to the United States as children from deportation and offers access to work authorization. The policy enabled Ms. Rojas Marquez to become one of the first undocumented students to attend the Icahn School of Medicine at Mount Sinai in New York.

Photo provided by Denisse Rojas

But the fate of Ms. Rojas Marquez’s medical education is in flux as the U.S. Supreme Court considers protections for undocumented immigrants in the case of Texas v. United States. In dispute is the constitutionality of two of President Obama’s immigration policies: the Deferred Action for Parents of Americans and Lawful Permanent Residents (DAPA) and expanded DACA. The former protects undocumented immigrants who are parents of U.S. citizens from deportation, if they meet certain criteria. The second extends work authorization under the original DACA program from 2 years to 3 years and broadens age requirements.

Texas and 25 other states have sued over the programs, arguing the president does not have the authority to issue the new immigration policies, and that the programs violate the Constitution as well as the Administrative Procedure Act for notice-and-comment rule making. High court justices heard oral arguments April 18.

The ruling could impact the growing number of medical students with DACA status across the country, and jeopardize the funding invested in their training. Sixty-one medical schools now accept applications from DACA applicants, according to data from the Association of American Medical Colleges (AAMC). In 2015, 46 students with DACA status applied to U.S. medical schools and 20 were enrolled. In 2016, more than double (112) applied, although enrollment data will not be available until year’s end. Neither AAMC nor the National Resident Matching Program collect data on residents with DACA status.

A high court ruling in favor of the states could lead to DACA’s undoing, said Michael M. Hethmon, an attorney for the Immigration Reform Law Institute in Washington, D.C. The institute issued a brief to the Supreme Court in support of Texas.

If Texas prevails, “it’ll be a matter of weeks before a similar challenge will be levied against DACA and a number of other related programs,” Mr. Hethmon said in an interview. “There will be no more legal justification for those programs that exist.”

Saving talent or wasting money?

Loyola University in Chicago has accepted more students with DACA status than any other U.S. medical school. The reasons are simple, said Mark Kuczewski, Ph.D., chair of medical education at Loyola’s Stritch School of Medicine.

“We’re in the business of taking outstanding students,” Dr. Kuczewski said in an interview. “If the student is outstanding, we want them in our applicant pool. Second, being bilingual and bicultural is extremely important. We have patient populations out there that are diverse and underserved. We want to utilize this talent.”

In the fall of 2014, Stritch enrolled seven medical students with DACA status; in 2014, they doubled that enrollment. The students competed on the same playing field as other applicants and received no special treatment, Dr. Kuczewski said.

DACA students do pose funding challenges, he acknowledged. Although the students are protected from deportation and receive work authorization, they don’t qualify for federal student loans. Medical schools must find unique ways to help DACA students finance their education. A major Catholic health system provides student loan packages for several DACA students at Stritch, Dr. Kuczewski said. DACA students can also apply for financial assistance through an AAMC assistance program.

Abhinav Janghala

“Medical students use copious amounts of federal student loans,” he said. “Somehow the school has to make up that difference. We’ve found partners, but they don’t have infinite capacity, so we have to keep going back and finding new partners each year.”

The University of California, San Francisco, also has opened its doors to DACA students. Now in his third year, Jirayut New Latthivongskorn is UCSF’s first undocumented medical student. His education is financed by grants, private funding, and donations, said Mr. Latthivongskorn who came to the United States from Thailand when he was 9 years old. He is cofounder of Pre-Health Dreamers, a network of undocumented students who plan to pursue medical careers.

Before DACA granted his entry into UCSF, Mr. Latthivongskorn was accustomed to barriers because of his undocumented status, including having to turn down a nearly full-ride scholarship from the University of California, Davis, after high school.

“It was devastating,” Mr. Latthivongskorn said in an interview. “It was one of the very first times where I felt different and thought, ‘This is not going to work. You are undocumented.’”

Mr. Latthivongskorn and his family scraped together money for him to complete his undergraduate degree at the University of California, Berkeley. California has since passed the DREAM Act, a law that allows undocumented immigrants to receive private scholarships funded through public universities.

Not everyone believes undocumented immigrants should get the chance to become U.S. physicians. Dr. Jane M. Orient, executive director of the Association of American Physicians and Surgeons, argued that undocumented immigrants are not the answer to curbing the physician shortage.

“In a country that’s supposed to be ruled by law, it seems incomprehensible that people who are violating the law should be given privileges over people who are here legally,” she said in an interview. “We desperately do need more physicians, but we should not be blocking Americans from having this opportunity.”

Dr. Shirie Leng, a Boston anesthesiologist, said DACA is promising in theory, but falls short in practical application.

“There’s no particular reason why [undocumented students] wouldn’t make great doctors,” said Dr. Leng. “The problem is funding related. You can give kids all the opportunity you want, but if you can’t pay for it, that seems to me to be the biggest sticking point.”

Basing admission policies on programs that are vulnerable could end poorly for schools and students, Dr. Leng added.

If DACA is revoked, “it’s not just a waste of money for the school, but a waste of time for the kids,” she said.

Protections hinge on Supreme Court … and next president

During oral arguments earlier this month, justices appeared to disagree on whether DAPA and expanded DACA were properly executed.

Associate Justice Anthony M. Kennedy indicated that the normal order of government policy making had been “turned upside down,” by the creation of the programs. Associate Justice Sonia Sotomayor, meanwhile, noted that immigration policies with broader reaches have been similarly instituted in the past.

A ruling for the government would mean the president can use his executive power to enact policies that run contrary to immigration laws already in place, said Mr. Hethmon, the D.C. attorney. Current immigration laws trump informal agency discretion and do not allow for the government’s “arbitrary and capricious creation of a massive classification of nonstatus alien beneficiaries,” Mr. Hethmon wrote in his high court brief.

A decision that favors Texas would unravel opportunities for undocumented immigrants and prevent their ability to contribute to society, said Ignacia Rodriguez, a legal fellow at the National Immigration Law Center, which authored a brief in support of the government.

“What’s at stake is providing a stable environment for U.S. citizen children to grow, and providing people with the opportunity and tools to be able to contribute to the workforce [and] to the economy,” she said in an interview. “This is a payoff for everybody, not just those receiving the benefit.”

Regardless of what the Supreme Court decides, the next president could have the last word, according Ashley C. Parrish, a Washington D.C. attorney who cowrote a brief in support of the states. Mr. Parrish takes no position on the merits of the immigration programs, but rather, he is concerned with the administration’s failure to follow the Administrative Procedure Act’s requirements for notice-and-comment rule making.

“If the program were adopted as a legal rule after notice and comment, it could not be changed without going through a new notice-and-comment process,” he said. “If it is just a bare statement of policy, it can be changed at any time, without notice to anyone. The next administration could say, ‘Thank you for coming out of the shadows; we are now going to deport all of you.’ ”

Among the Democrats running for president, former Secretary of State Hillary Clinton has said she will defend DACA and Sen. Bernie Sanders (I-Vt.) has said he supports DACA and DAPA, and plans to expand them if elected.

Conversely, presumed Republican presidential nominee Donald Trump has indicated he would rescind DACA and related programs if elected.

After spending most of her life terrified of deportation, Ms. Rojas Marquez said she is not wasting time worrying about the Supreme Court’s decision or whether the next president will overturn the policy. She is keeping her studies foremost in her mind and the goal of becoming a doctor firmly in her heart.

“I have always lived with what-ifs,” she said. “This time around, I’m not going to be living in fear of the removing of DACA, because I wouldn’t have made it this far if I always lived in fear. My plan is no matter what happens, I’m going to finish medical school, and from there, I pray that I will be able to practice in the U.S.”

The Supreme Court is expected to issue its decision by June.

[email protected]

On Twitter @legal_med

MACRA will not be as hard on small and solo practices as it first appeared when draft implementing regulations were published, according to Andy Slavitt, administrator of the Centers for Medicare & Medicaid Services.

Mr. Slavitt testified May 11 before the House Ways & Means Health Subcommittee to address legislators’ concerns about how the government intends to implement the Medicare Access and CHIP Reauthorization Act of 2015.

Rep. Sam Johnson (R-Tex.) expressed concern that the draft regulations published April 27 project “the greatest negative impact on payments to practices with nine or fewer doctors and the least harm to large systems with 100 or more docs.”

The calculations in the draft regulation were based on data from 2014, a year in which few small and solo practices reported quality data.

“In 2015 and subsequent years, the reporting went up,” Mr. Slavitt testified. “So at best, this table would be very, very conservative. ... Reporting is going to be far easier going forward.”

Mr. Slavitt said that the CMS will do all it can to help ensure that small and solo practices have every opportunity to participate in the both the Merit-Based Incentive Payment System (MIPS) and in advanced alternative payment models.

“The question of making sure that small groups and solo practitioners can be successful is of utmost importance. Our data show that physicians who are in small and solo practices ... do just as well as physicians that are in practices that are larger than that,” he said, adding that technical assistance specific to solo and small practices is being developed to help them transition to these value-based payment models.

Other federal officials have been spreading the same message to physicians. Speaking May 7 at the annual meeting of the American College of Physicians, Dr. Thomas A. Mason, chief medical officer in the Office of the National Coordinator for Health Information Technology, pointed out that the MACRA legislation put aside $20 million a year for 5 years beginning in 2016 to help solo and small practices transition to MIPS and APMs.

“It is specifically to help with the shift and transforming practices to measuring quality and improving quality performance,” he said in an interview. “The MACRA statute specifically calls out what the dollars need to be used for and the two points are for assisting MIPS-eligible professionals and improving their MIPS composite score as well as the transition to advanced alternative payment models.”

The U.S. Department of Health & Human Services already has begun soliciting contractors to support small and solo practices, he added.

“Direct technical assistance through this program will target eligible clinicians in individual or small group practices of 15 or fewer, focusing on those practicing in historically under resourced areas,” according to a request for proposals. “Technical assistance is defined as provider outreach and education, practice readiness, practice facilitation, health information technology (HIT) optimization, practice workflow redesign, change management, strategic planning, assisting clinicians in fully transitioning to Alternative Payment Models, and enabling partnerships.”

The federal health IT office plans to provide more information on the availability of transition assistance soon, Dr. Mason said.

[email protected]

MACRA will not be as hard on small and solo practices as it first appeared when draft implementing regulations were published, according to Andy Slavitt, administrator of the Centers for Medicare & Medicaid Services.

Mr. Slavitt testified May 11 before the House Ways & Means Health Subcommittee to address legislators’ concerns about how the government intends to implement the Medicare Access and CHIP Reauthorization Act of 2015.

Rep. Sam Johnson (R-Tex.) expressed concern that the draft regulations published April 27 project “the greatest negative impact on payments to practices with nine or fewer doctors and the least harm to large systems with 100 or more docs.”

The calculations in the draft regulation were based on data from 2014, a year in which few small and solo practices reported quality data.

“In 2015 and subsequent years, the reporting went up,” Mr. Slavitt testified. “So at best, this table would be very, very conservative. ... Reporting is going to be far easier going forward.”

Mr. Slavitt said that the CMS will do all it can to help ensure that small and solo practices have every opportunity to participate in the both the Merit-Based Incentive Payment System (MIPS) and in advanced alternative payment models.

“The question of making sure that small groups and solo practitioners can be successful is of utmost importance. Our data show that physicians who are in small and solo practices ... do just as well as physicians that are in practices that are larger than that,” he said, adding that technical assistance specific to solo and small practices is being developed to help them transition to these value-based payment models.

Other federal officials have been spreading the same message to physicians. Speaking May 7 at the annual meeting of the American College of Physicians, Dr. Thomas A. Mason, chief medical officer in the Office of the National Coordinator for Health Information Technology, pointed out that the MACRA legislation put aside $20 million a year for 5 years beginning in 2016 to help solo and small practices transition to MIPS and APMs.

“It is specifically to help with the shift and transforming practices to measuring quality and improving quality performance,” he said in an interview. “The MACRA statute specifically calls out what the dollars need to be used for and the two points are for assisting MIPS-eligible professionals and improving their MIPS composite score as well as the transition to advanced alternative payment models.”

The U.S. Department of Health & Human Services already has begun soliciting contractors to support small and solo practices, he added.

“Direct technical assistance through this program will target eligible clinicians in individual or small group practices of 15 or fewer, focusing on those practicing in historically under resourced areas,” according to a request for proposals. “Technical assistance is defined as provider outreach and education, practice readiness, practice facilitation, health information technology (HIT) optimization, practice workflow redesign, change management, strategic planning, assisting clinicians in fully transitioning to Alternative Payment Models, and enabling partnerships.”

The federal health IT office plans to provide more information on the availability of transition assistance soon, Dr. Mason said.

[email protected]

MACRA will not be as hard on small and solo practices as it first appeared when draft implementing regulations were published, according to Andy Slavitt, administrator of the Centers for Medicare & Medicaid Services.

Mr. Slavitt testified May 11 before the House Ways & Means Health Subcommittee to address legislators’ concerns about how the government intends to implement the Medicare Access and CHIP Reauthorization Act of 2015.

Rep. Sam Johnson (R-Tex.) expressed concern that the draft regulations published April 27 project “the greatest negative impact on payments to practices with nine or fewer doctors and the least harm to large systems with 100 or more docs.”

The calculations in the draft regulation were based on data from 2014, a year in which few small and solo practices reported quality data.

“In 2015 and subsequent years, the reporting went up,” Mr. Slavitt testified. “So at best, this table would be very, very conservative. ... Reporting is going to be far easier going forward.”

Mr. Slavitt said that the CMS will do all it can to help ensure that small and solo practices have every opportunity to participate in the both the Merit-Based Incentive Payment System (MIPS) and in advanced alternative payment models.

“The question of making sure that small groups and solo practitioners can be successful is of utmost importance. Our data show that physicians who are in small and solo practices ... do just as well as physicians that are in practices that are larger than that,” he said, adding that technical assistance specific to solo and small practices is being developed to help them transition to these value-based payment models.

Other federal officials have been spreading the same message to physicians. Speaking May 7 at the annual meeting of the American College of Physicians, Dr. Thomas A. Mason, chief medical officer in the Office of the National Coordinator for Health Information Technology, pointed out that the MACRA legislation put aside $20 million a year for 5 years beginning in 2016 to help solo and small practices transition to MIPS and APMs.

“It is specifically to help with the shift and transforming practices to measuring quality and improving quality performance,” he said in an interview. “The MACRA statute specifically calls out what the dollars need to be used for and the two points are for assisting MIPS-eligible professionals and improving their MIPS composite score as well as the transition to advanced alternative payment models.”

The U.S. Department of Health & Human Services already has begun soliciting contractors to support small and solo practices, he added.

“Direct technical assistance through this program will target eligible clinicians in individual or small group practices of 15 or fewer, focusing on those practicing in historically under resourced areas,” according to a request for proposals. “Technical assistance is defined as provider outreach and education, practice readiness, practice facilitation, health information technology (HIT) optimization, practice workflow redesign, change management, strategic planning, assisting clinicians in fully transitioning to Alternative Payment Models, and enabling partnerships.”

The federal health IT office plans to provide more information on the availability of transition assistance soon, Dr. Mason said.

[email protected]

Virtually every hospital system in the country deals with the challenge of readmissions, especially 30-day readmissions, and it’s only getting worse. “With the changes in healthcare and length of stay becoming shorter, patients are being discharged sicker than they used to be,” says Kevin Tolliver, MD, FACP, of Sidney & Lois Eskenazi Hospital Outpatient Care Center. “At our large public hospital system in Indianapolis, we designed an Internal Medicine Transitional Care Practice with the goal of decreasing readmission rates.”

Since October 2015, patients without a primary care doctor and those with a high LACE score have been referred to the new Transitional Care clinic. The first step: While still hospitalized, they meet briefly with Dr. Tolliver, who tells them, “‘You’re a candidate for this hospital follow-up clinic; this is why we think you would benefit.’ Patients, universally, are very thankful and eager to come.” The patients have their follow-up appointment scheduled before they are discharged.

At that appointment, the goal is to head off anything that would put them at risk for readmission. “We have a pharmacy, social workers, substance abuse counselors, diabetes educators—it’s one-stop shopping to address their needs,” Dr. Tolliver says. “Once we ensure that they’re not at risk for readmission, we help them get back to their primary care doctor or help them get one.”

Data for the clinic’s first four months show those patients who met with Dr. Tolliver before leaving the hospital were 50% more likely to keep their hospital follow-up visit. “That’s significant, particularly for us, because we take care of an indigent population; the no-show rate is usually our biggest challenge,” he says. Patients who were seen had a 30-day readmission rate of about 13.9%, while those who qualified but weren’t seen had a readmission rate of 21.8%.

“That has all kinds of positive consequences: less frustration for providers and patients and huge financial implications for the hospital system as well,” Dr. Tolliver says. “That there are these new models of post-discharge clinics out there and that there’s data suggesting that they work, particularly for a high-risk group of people, I think is worth knowing.”

Virtually every hospital system in the country deals with the challenge of readmissions, especially 30-day readmissions, and it’s only getting worse. “With the changes in healthcare and length of stay becoming shorter, patients are being discharged sicker than they used to be,” says Kevin Tolliver, MD, FACP, of Sidney & Lois Eskenazi Hospital Outpatient Care Center. “At our large public hospital system in Indianapolis, we designed an Internal Medicine Transitional Care Practice with the goal of decreasing readmission rates.”

Since October 2015, patients without a primary care doctor and those with a high LACE score have been referred to the new Transitional Care clinic. The first step: While still hospitalized, they meet briefly with Dr. Tolliver, who tells them, “‘You’re a candidate for this hospital follow-up clinic; this is why we think you would benefit.’ Patients, universally, are very thankful and eager to come.” The patients have their follow-up appointment scheduled before they are discharged.

At that appointment, the goal is to head off anything that would put them at risk for readmission. “We have a pharmacy, social workers, substance abuse counselors, diabetes educators—it’s one-stop shopping to address their needs,” Dr. Tolliver says. “Once we ensure that they’re not at risk for readmission, we help them get back to their primary care doctor or help them get one.”

Data for the clinic’s first four months show those patients who met with Dr. Tolliver before leaving the hospital were 50% more likely to keep their hospital follow-up visit. “That’s significant, particularly for us, because we take care of an indigent population; the no-show rate is usually our biggest challenge,” he says. Patients who were seen had a 30-day readmission rate of about 13.9%, while those who qualified but weren’t seen had a readmission rate of 21.8%.

“That has all kinds of positive consequences: less frustration for providers and patients and huge financial implications for the hospital system as well,” Dr. Tolliver says. “That there are these new models of post-discharge clinics out there and that there’s data suggesting that they work, particularly for a high-risk group of people, I think is worth knowing.”

Virtually every hospital system in the country deals with the challenge of readmissions, especially 30-day readmissions, and it’s only getting worse. “With the changes in healthcare and length of stay becoming shorter, patients are being discharged sicker than they used to be,” says Kevin Tolliver, MD, FACP, of Sidney & Lois Eskenazi Hospital Outpatient Care Center. “At our large public hospital system in Indianapolis, we designed an Internal Medicine Transitional Care Practice with the goal of decreasing readmission rates.”

Since October 2015, patients without a primary care doctor and those with a high LACE score have been referred to the new Transitional Care clinic. The first step: While still hospitalized, they meet briefly with Dr. Tolliver, who tells them, “‘You’re a candidate for this hospital follow-up clinic; this is why we think you would benefit.’ Patients, universally, are very thankful and eager to come.” The patients have their follow-up appointment scheduled before they are discharged.

At that appointment, the goal is to head off anything that would put them at risk for readmission. “We have a pharmacy, social workers, substance abuse counselors, diabetes educators—it’s one-stop shopping to address their needs,” Dr. Tolliver says. “Once we ensure that they’re not at risk for readmission, we help them get back to their primary care doctor or help them get one.”

Data for the clinic’s first four months show those patients who met with Dr. Tolliver before leaving the hospital were 50% more likely to keep their hospital follow-up visit. “That’s significant, particularly for us, because we take care of an indigent population; the no-show rate is usually our biggest challenge,” he says. Patients who were seen had a 30-day readmission rate of about 13.9%, while those who qualified but weren’t seen had a readmission rate of 21.8%.

“That has all kinds of positive consequences: less frustration for providers and patients and huge financial implications for the hospital system as well,” Dr. Tolliver says. “That there are these new models of post-discharge clinics out there and that there’s data suggesting that they work, particularly for a high-risk group of people, I think is worth knowing.”

WASHINGTON – Are you ready for the way you are paid for seeing patients to change, and not just change, but change dramatically?

The value-based care system of reimbursement for primary care physicians under the Medicare Access and CHIP Reauthorization Act (MACRA) is expected to take effect beginning in 2019, but how those payments will be made will be based on measurements of your overall performance in 2017. Will you be ready?

“Times are changing, and we need to change with them,” says Dr. Nitin Damle, the incoming president of the American College of Physicians, and an internist with South County Internal Medicine, Wakefield, R.I.

In this video, part of a series of roundtable discussions with leading health policy analysts and academic primary care physicians and mental health specialists, Dr. Damle and Dr. Lee Beers, the medical director for municipal and regional affairs at Children’s National Health System, Washington, discuss the essential steps physician practices must take in order to survive – and thrive – in a value-based care environment.

These steps include: team-based care, inclusion of mental health services, flexible IT electronic health record systems, quality measures tailored to your practice’s competencies and patient panel, and adequate funding.

Whether you’ve already begun the transition to a value-based system, or have yet to begin, this video will help focus your efforts and expectations of what’s to come.

“Don’t let perfect be the enemy of good. Start with incremental steps so you can get momentum going so that you end up where you want to be,” says Dr. Beers.

[email protected]

On Twitter @whitneymcknight

WASHINGTON – Are you ready for the way you are paid for seeing patients to change, and not just change, but change dramatically?

The value-based care system of reimbursement for primary care physicians under the Medicare Access and CHIP Reauthorization Act (MACRA) is expected to take effect beginning in 2019, but how those payments will be made will be based on measurements of your overall performance in 2017. Will you be ready?

“Times are changing, and we need to change with them,” says Dr. Nitin Damle, the incoming president of the American College of Physicians, and an internist with South County Internal Medicine, Wakefield, R.I.

In this video, part of a series of roundtable discussions with leading health policy analysts and academic primary care physicians and mental health specialists, Dr. Damle and Dr. Lee Beers, the medical director for municipal and regional affairs at Children’s National Health System, Washington, discuss the essential steps physician practices must take in order to survive – and thrive – in a value-based care environment.

These steps include: team-based care, inclusion of mental health services, flexible IT electronic health record systems, quality measures tailored to your practice’s competencies and patient panel, and adequate funding.

Whether you’ve already begun the transition to a value-based system, or have yet to begin, this video will help focus your efforts and expectations of what’s to come.

“Don’t let perfect be the enemy of good. Start with incremental steps so you can get momentum going so that you end up where you want to be,” says Dr. Beers.

[email protected]

On Twitter @whitneymcknight

WASHINGTON – Are you ready for the way you are paid for seeing patients to change, and not just change, but change dramatically?

The value-based care system of reimbursement for primary care physicians under the Medicare Access and CHIP Reauthorization Act (MACRA) is expected to take effect beginning in 2019, but how those payments will be made will be based on measurements of your overall performance in 2017. Will you be ready?

“Times are changing, and we need to change with them,” says Dr. Nitin Damle, the incoming president of the American College of Physicians, and an internist with South County Internal Medicine, Wakefield, R.I.

In this video, part of a series of roundtable discussions with leading health policy analysts and academic primary care physicians and mental health specialists, Dr. Damle and Dr. Lee Beers, the medical director for municipal and regional affairs at Children’s National Health System, Washington, discuss the essential steps physician practices must take in order to survive – and thrive – in a value-based care environment.

These steps include: team-based care, inclusion of mental health services, flexible IT electronic health record systems, quality measures tailored to your practice’s competencies and patient panel, and adequate funding.

Whether you’ve already begun the transition to a value-based system, or have yet to begin, this video will help focus your efforts and expectations of what’s to come.

“Don’t let perfect be the enemy of good. Start with incremental steps so you can get momentum going so that you end up where you want to be,” says Dr. Beers.

[email protected]

On Twitter @whitneymcknight

The Centers for Medicare & Medicaid Services (CMS) recently announced that within the year hospitalists will be assigned their own specialty designation code.

Up to 85% of hospitalists are currently designated internal medicine, says Ron Greeno, MD, MHM, founding member of SHM and chair of SHM’s Public Policy Committee, but when it comes to quality metrics—and resulting penalties and bonuses—without a way to distinguish themselves from their clinic-based peers, hospitalists have been disadvantaged.

“It is almost impossible to look good when compared to a world of mostly outpatient physicians,” says Dr. Greeno, chief strategy officer at IPC Healthcare, based in North Hollywood, Calif., and SHM’s president-elect.

Today, hospitalists get lumped together with their office-based internal medicine or primary care counterparts, says Scott Sears, MD, FHM, CPE, MBA, chief clinical officer for Sound Physicians, based in Tacoma, Wash. Yet, he says, “The quality metrics should be different because it’s a different scope of practice.”

For example, with the Physician Quality Reporting System (PQRS) in recent years, hospitalists have been evaluated based on their patients’ HbA1c, a measure of their diabetic control over the three months prior to admission. But diabetic patients admitted to the hospital are there because they are sick and much less likely to have been well-managed.

“Hospitalists have had no control over their patients’ outpatient diabetes management during the time leading up to admissions, yet these admitted patients are compared to those in an outpatient setting, where their physicians do have control,” Dr. Sears says.

“[This] skews the data and real reporting patterns that are part of that specialty,” says Raemarie Jimenez, CPC, vice president of certifications and member development at AAPC, a professional organization for medical coders and more. “CMS wants the data it is using to be meaningful.”

Once the code is established, the choice to identify as a hospitalist will fall to individual physicians, hospitals, or hospitalist groups, Dr. Greeno says. The designation is noteworthy since hospital medicine does not have a board certification. Today, there are more than 48,000 hospitalists in the U.S., and the announcement comes as hospitalists celebrate 20 years as a specialty. SHM is calling 2016 the “Year of the Hospitalist.”

The decision to seek a hospitalist-specific billing code first arose at SHM several years ago, Dr. Greeno says, with discussions about the advantages, disadvantages, and possible unintended consequences of pursuing it. At the time, SHM chose to hold off, but that changed recently.

“A lot of thought was put into it, and two and a half years later, it’s very clear we made the right decision,” he says. “More and more depends on your data and a lot of different value-based measures. … The Public Policy Committee decided the benefits probably outweigh the potential risks.”

The billing code should make it easier to compare apples to apples, both for hospitalists and hospitals, and Dr. Sears says it should also enable patients to compare hospitalist performance to make better-informed healthcare decisions.

“When you have three or four hospitals in your community, you can compare inpatient hospitalist performance to determine who is providing the most consistent high-quality outcomes,” he says.

It may also enhance reimbursement, says Jimenez. Multiple providers often see patients in the hospital and handle their care. Two providers with the same designation may round on a patient on the same day and appear to CMS and private payors to deliver the same services.

“If a specialist is called in, or their family medicine provider is also seeing the patient, they will not be of the same designation, and that might help with some denials of payments that family or internal medicine physicians are getting,” she says.

Dr. Greeno also says the code may more effectively demonstrate to CMS that hospitalists do not have enough PQRS metrics to adequately qualify for value-based purchasing.

Yet challenges will remain that a specialty code cannot address. “A pediatric hospitalist may not want to be compared to an adult hospitalist. A critical-access hospitalist doesn’t want to be compared to a hospitalist in a tertiary academic medical center,” Dr. Sears says. “I don’t think it’s an end-all, be-all, but it’s a place to start.”

SHM will continue to actively push CMS to implement the code, Dr. Greeno says, and it will develop strategies for educating members to help them make the decision that is right for them or their group.

Jimenez believes SHM will be capable of doing much more with the data that emerge through robust use of the code.

“Right now, in the industry, big data is it, and the more you can segregate or report on the specifics of data, the better you are at identifying trends,” she says. “We don’t even know yet about clinical outcomes: Are hospitalists’ patients seeing a better outcome of patient experience versus waiting all day to see a family physician? Are there shorter admission times? Trying to improve patient outcomes and reduce costs are two things CMS is desperately interested in.”

Kelly April Tyrrell is a freelance writer in Madison, Wis.

The Centers for Medicare & Medicaid Services (CMS) recently announced that within the year hospitalists will be assigned their own specialty designation code.

Up to 85% of hospitalists are currently designated internal medicine, says Ron Greeno, MD, MHM, founding member of SHM and chair of SHM’s Public Policy Committee, but when it comes to quality metrics—and resulting penalties and bonuses—without a way to distinguish themselves from their clinic-based peers, hospitalists have been disadvantaged.

“It is almost impossible to look good when compared to a world of mostly outpatient physicians,” says Dr. Greeno, chief strategy officer at IPC Healthcare, based in North Hollywood, Calif., and SHM’s president-elect.

Today, hospitalists get lumped together with their office-based internal medicine or primary care counterparts, says Scott Sears, MD, FHM, CPE, MBA, chief clinical officer for Sound Physicians, based in Tacoma, Wash. Yet, he says, “The quality metrics should be different because it’s a different scope of practice.”

For example, with the Physician Quality Reporting System (PQRS) in recent years, hospitalists have been evaluated based on their patients’ HbA1c, a measure of their diabetic control over the three months prior to admission. But diabetic patients admitted to the hospital are there because they are sick and much less likely to have been well-managed.

“Hospitalists have had no control over their patients’ outpatient diabetes management during the time leading up to admissions, yet these admitted patients are compared to those in an outpatient setting, where their physicians do have control,” Dr. Sears says.

“[This] skews the data and real reporting patterns that are part of that specialty,” says Raemarie Jimenez, CPC, vice president of certifications and member development at AAPC, a professional organization for medical coders and more. “CMS wants the data it is using to be meaningful.”

Once the code is established, the choice to identify as a hospitalist will fall to individual physicians, hospitals, or hospitalist groups, Dr. Greeno says. The designation is noteworthy since hospital medicine does not have a board certification. Today, there are more than 48,000 hospitalists in the U.S., and the announcement comes as hospitalists celebrate 20 years as a specialty. SHM is calling 2016 the “Year of the Hospitalist.”

The decision to seek a hospitalist-specific billing code first arose at SHM several years ago, Dr. Greeno says, with discussions about the advantages, disadvantages, and possible unintended consequences of pursuing it. At the time, SHM chose to hold off, but that changed recently.

“A lot of thought was put into it, and two and a half years later, it’s very clear we made the right decision,” he says. “More and more depends on your data and a lot of different value-based measures. … The Public Policy Committee decided the benefits probably outweigh the potential risks.”

The billing code should make it easier to compare apples to apples, both for hospitalists and hospitals, and Dr. Sears says it should also enable patients to compare hospitalist performance to make better-informed healthcare decisions.

“When you have three or four hospitals in your community, you can compare inpatient hospitalist performance to determine who is providing the most consistent high-quality outcomes,” he says.

It may also enhance reimbursement, says Jimenez. Multiple providers often see patients in the hospital and handle their care. Two providers with the same designation may round on a patient on the same day and appear to CMS and private payors to deliver the same services.

“If a specialist is called in, or their family medicine provider is also seeing the patient, they will not be of the same designation, and that might help with some denials of payments that family or internal medicine physicians are getting,” she says.

Dr. Greeno also says the code may more effectively demonstrate to CMS that hospitalists do not have enough PQRS metrics to adequately qualify for value-based purchasing.

Yet challenges will remain that a specialty code cannot address. “A pediatric hospitalist may not want to be compared to an adult hospitalist. A critical-access hospitalist doesn’t want to be compared to a hospitalist in a tertiary academic medical center,” Dr. Sears says. “I don’t think it’s an end-all, be-all, but it’s a place to start.”

SHM will continue to actively push CMS to implement the code, Dr. Greeno says, and it will develop strategies for educating members to help them make the decision that is right for them or their group.

Jimenez believes SHM will be capable of doing much more with the data that emerge through robust use of the code.

“Right now, in the industry, big data is it, and the more you can segregate or report on the specifics of data, the better you are at identifying trends,” she says. “We don’t even know yet about clinical outcomes: Are hospitalists’ patients seeing a better outcome of patient experience versus waiting all day to see a family physician? Are there shorter admission times? Trying to improve patient outcomes and reduce costs are two things CMS is desperately interested in.”

Kelly April Tyrrell is a freelance writer in Madison, Wis.

The Centers for Medicare & Medicaid Services (CMS) recently announced that within the year hospitalists will be assigned their own specialty designation code.

Up to 85% of hospitalists are currently designated internal medicine, says Ron Greeno, MD, MHM, founding member of SHM and chair of SHM’s Public Policy Committee, but when it comes to quality metrics—and resulting penalties and bonuses—without a way to distinguish themselves from their clinic-based peers, hospitalists have been disadvantaged.

“It is almost impossible to look good when compared to a world of mostly outpatient physicians,” says Dr. Greeno, chief strategy officer at IPC Healthcare, based in North Hollywood, Calif., and SHM’s president-elect.

Today, hospitalists get lumped together with their office-based internal medicine or primary care counterparts, says Scott Sears, MD, FHM, CPE, MBA, chief clinical officer for Sound Physicians, based in Tacoma, Wash. Yet, he says, “The quality metrics should be different because it’s a different scope of practice.”

For example, with the Physician Quality Reporting System (PQRS) in recent years, hospitalists have been evaluated based on their patients’ HbA1c, a measure of their diabetic control over the three months prior to admission. But diabetic patients admitted to the hospital are there because they are sick and much less likely to have been well-managed.

“Hospitalists have had no control over their patients’ outpatient diabetes management during the time leading up to admissions, yet these admitted patients are compared to those in an outpatient setting, where their physicians do have control,” Dr. Sears says.

“[This] skews the data and real reporting patterns that are part of that specialty,” says Raemarie Jimenez, CPC, vice president of certifications and member development at AAPC, a professional organization for medical coders and more. “CMS wants the data it is using to be meaningful.”

Once the code is established, the choice to identify as a hospitalist will fall to individual physicians, hospitals, or hospitalist groups, Dr. Greeno says. The designation is noteworthy since hospital medicine does not have a board certification. Today, there are more than 48,000 hospitalists in the U.S., and the announcement comes as hospitalists celebrate 20 years as a specialty. SHM is calling 2016 the “Year of the Hospitalist.”

The decision to seek a hospitalist-specific billing code first arose at SHM several years ago, Dr. Greeno says, with discussions about the advantages, disadvantages, and possible unintended consequences of pursuing it. At the time, SHM chose to hold off, but that changed recently.

“A lot of thought was put into it, and two and a half years later, it’s very clear we made the right decision,” he says. “More and more depends on your data and a lot of different value-based measures. … The Public Policy Committee decided the benefits probably outweigh the potential risks.”

The billing code should make it easier to compare apples to apples, both for hospitalists and hospitals, and Dr. Sears says it should also enable patients to compare hospitalist performance to make better-informed healthcare decisions.

“When you have three or four hospitals in your community, you can compare inpatient hospitalist performance to determine who is providing the most consistent high-quality outcomes,” he says.

It may also enhance reimbursement, says Jimenez. Multiple providers often see patients in the hospital and handle their care. Two providers with the same designation may round on a patient on the same day and appear to CMS and private payors to deliver the same services.

“If a specialist is called in, or their family medicine provider is also seeing the patient, they will not be of the same designation, and that might help with some denials of payments that family or internal medicine physicians are getting,” she says.

Dr. Greeno also says the code may more effectively demonstrate to CMS that hospitalists do not have enough PQRS metrics to adequately qualify for value-based purchasing.

Yet challenges will remain that a specialty code cannot address. “A pediatric hospitalist may not want to be compared to an adult hospitalist. A critical-access hospitalist doesn’t want to be compared to a hospitalist in a tertiary academic medical center,” Dr. Sears says. “I don’t think it’s an end-all, be-all, but it’s a place to start.”

SHM will continue to actively push CMS to implement the code, Dr. Greeno says, and it will develop strategies for educating members to help them make the decision that is right for them or their group.

Jimenez believes SHM will be capable of doing much more with the data that emerge through robust use of the code.

“Right now, in the industry, big data is it, and the more you can segregate or report on the specifics of data, the better you are at identifying trends,” she says. “We don’t even know yet about clinical outcomes: Are hospitalists’ patients seeing a better outcome of patient experience versus waiting all day to see a family physician? Are there shorter admission times? Trying to improve patient outcomes and reduce costs are two things CMS is desperately interested in.”

Kelly April Tyrrell is a freelance writer in Madison, Wis.

Patients with a health care-acquired infection had a larger proportion of readmissions, greater associated costs, and higher mortality rates compared to patients with no HAI, according to a study published in the American Journal of Infection Control.

Investigators at Linköping (Sweden) University examined the effects of HAIs by calculating the difference in hospital length of stay (LOS) and actual direct health care costs for patients with an HAI compared with patients without HAI. They used data from the Swedish National Point Prevalence Surveys of HAI 2010-2012, merged with cost-per-patient data from the Health Care Register of the Swedish county of Östergötland. Extended LOS and costs related to an HAI were adjusted for sex, age, intensive care unit use, and surgery.

The average prevalence of HAI for all 7,981 patients in the study was 10.8%, although for the 7,062 patients in the main analyses the prevalence of HAI in the Point Prevalence Survey was 9.9%. Those patients with HAI (732 patients) had a larger proportion of readmissions compared with patients with no HAI (29.0% vs 16.5%), a significant difference, said Mikael Rahmqvist, Ph.D., of the department of medical and health sciences at Linköping University, and lead author of the study.

Of the total hospital bed days occupied by patients in the study population, 9.3% was considered to be excess days, attributed to the group of patients with an HAI. This excess LOS comprised 11.4% of total health care costs (95% confidence interval, 10.2-12.7). The 1-year overall mortality rate for patients with HAI in comparison to all other patients was 1.75 (95% CI, 1.45-2.11). The coauthors said all of the differences measured were statistically significant (P less than .001).

“Our results imply that a reduction of HAI prevalence to a significant degree could reduce health care costs, lessen patient suffering, and also increase patients’ long-term survival,” said Dr. Rahmqvist and his coauthors.

They reported having no conflicts.

Read the full study in the American Journal of Infection Control (doi:10.1016/j.ajic.2016.01.035).

[email protected]

On Twitter @richpizzi

Patients with a health care-acquired infection had a larger proportion of readmissions, greater associated costs, and higher mortality rates compared to patients with no HAI, according to a study published in the American Journal of Infection Control.

Investigators at Linköping (Sweden) University examined the effects of HAIs by calculating the difference in hospital length of stay (LOS) and actual direct health care costs for patients with an HAI compared with patients without HAI. They used data from the Swedish National Point Prevalence Surveys of HAI 2010-2012, merged with cost-per-patient data from the Health Care Register of the Swedish county of Östergötland. Extended LOS and costs related to an HAI were adjusted for sex, age, intensive care unit use, and surgery.

The average prevalence of HAI for all 7,981 patients in the study was 10.8%, although for the 7,062 patients in the main analyses the prevalence of HAI in the Point Prevalence Survey was 9.9%. Those patients with HAI (732 patients) had a larger proportion of readmissions compared with patients with no HAI (29.0% vs 16.5%), a significant difference, said Mikael Rahmqvist, Ph.D., of the department of medical and health sciences at Linköping University, and lead author of the study.

Of the total hospital bed days occupied by patients in the study population, 9.3% was considered to be excess days, attributed to the group of patients with an HAI. This excess LOS comprised 11.4% of total health care costs (95% confidence interval, 10.2-12.7). The 1-year overall mortality rate for patients with HAI in comparison to all other patients was 1.75 (95% CI, 1.45-2.11). The coauthors said all of the differences measured were statistically significant (P less than .001).

“Our results imply that a reduction of HAI prevalence to a significant degree could reduce health care costs, lessen patient suffering, and also increase patients’ long-term survival,” said Dr. Rahmqvist and his coauthors.

They reported having no conflicts.

Read the full study in the American Journal of Infection Control (doi:10.1016/j.ajic.2016.01.035).

[email protected]

On Twitter @richpizzi

Patients with a health care-acquired infection had a larger proportion of readmissions, greater associated costs, and higher mortality rates compared to patients with no HAI, according to a study published in the American Journal of Infection Control.

Investigators at Linköping (Sweden) University examined the effects of HAIs by calculating the difference in hospital length of stay (LOS) and actual direct health care costs for patients with an HAI compared with patients without HAI. They used data from the Swedish National Point Prevalence Surveys of HAI 2010-2012, merged with cost-per-patient data from the Health Care Register of the Swedish county of Östergötland. Extended LOS and costs related to an HAI were adjusted for sex, age, intensive care unit use, and surgery.

The average prevalence of HAI for all 7,981 patients in the study was 10.8%, although for the 7,062 patients in the main analyses the prevalence of HAI in the Point Prevalence Survey was 9.9%. Those patients with HAI (732 patients) had a larger proportion of readmissions compared with patients with no HAI (29.0% vs 16.5%), a significant difference, said Mikael Rahmqvist, Ph.D., of the department of medical and health sciences at Linköping University, and lead author of the study.

Of the total hospital bed days occupied by patients in the study population, 9.3% was considered to be excess days, attributed to the group of patients with an HAI. This excess LOS comprised 11.4% of total health care costs (95% confidence interval, 10.2-12.7). The 1-year overall mortality rate for patients with HAI in comparison to all other patients was 1.75 (95% CI, 1.45-2.11). The coauthors said all of the differences measured were statistically significant (P less than .001).

“Our results imply that a reduction of HAI prevalence to a significant degree could reduce health care costs, lessen patient suffering, and also increase patients’ long-term survival,” said Dr. Rahmqvist and his coauthors.

They reported having no conflicts.

Read the full study in the American Journal of Infection Control (doi:10.1016/j.ajic.2016.01.035).

[email protected]

On Twitter @richpizzi

It is inevitable that, at some point in your career, you will need to hire a healthcare attorney. Proper representation is the best way to ensure a positive outcome in any situation.

Physicians often consider tackling certain issues on their own to reduce costs and avoid complicating matters. However, there are at least five situations in which you must retain an experienced healthcare attorney, or you could end up underpaid, subject to overreaching restrictive covenants, severely fined, or responsible for a large settlement.

1. Negotiating an Employment Contract

Whether you are considering a position as an employee of a physician group, hospital, or health system, it is critical that you understand the employment agreement presented to you so you can be sure it is fair and represents your best interests. The agreement itself defines the scope and conditions of your employment and consequently impacts your personal and professional satisfaction. It usually contains confusing legal terminology, such as noncompetition and nonsolicitation clauses. If you do not understand these terms, problems may arise in the future regarding your rights and capabilities upon termination of employment.

For these reasons, it is critical to engage a healthcare attorney who is well-versed in physician employment agreements. At a minimum, an attorney can confirm whether the compensation offered is comparable to that of physicians with similar experience and skills in your geographical area. The attorney can decipher confusing bonus compensation and may be able to negotiate more favorable terms. The same is true of understanding the benefits offered and establishing your call coverage.

An attorney will be able to advise you when it is appropriate to push back and request additional benefits or propose more favorable changes to your call coverage. Most important, the attorney will clarify the term of the employment agreement, the corresponding termination provisions, and any restrictions on your ability to practice upon termination of the agreement. Although the ultimate decision to accept the employment offer rests solely with you, an experienced healthcare attorney can help you understand the agreement and give you confidence in that decision.

2. Leaving a Practice for New Opportunities or Retirement

Whether you decide to leave a practice to pursue a new opportunity or because you are retiring, it is critical that you engage a healthcare attorney to help you navigate this road. If you are leaving to pursue new opportunities, an attorney can help you understand any restrictive covenants that may apply upon your departure and who retains ownership of the medical records of patients you treated while employed by the practice. In addition, you’ll be assisted in drafting any required notifications to patients alerting them of your departure.

If you are leaving the practice due to retirement, there are additional concerns. If you own the practice, you will need to decide whether to sell the practice or wind it down. If you decide to sell, an attorney can help you negotiate a favorable merger agreement and file any required change of ownership forms. If you choose to wind down your practice, your employee agreements and service and vendor contracts, including managed care participation agreements, will need to be reviewed for specific termination and notice requirements.

As with departure from a practice, there are certain notifications that must be issued to your patients detailing the closure of your practice and addressing patient options for continuity of care. An attorney can draft such notifications for you and, in addition, will be able to assist with notifying your malpractice carrier of your retirement and ensuring you have proper continuing coverage.

Finally, an attorney can arrange custody of your medical records in accordance with applicable state record retention requirements, help wind down your financial matters, and terminate your practice’s professional entity.

3. Practice Mergers

Engaging a healthcare transaction attorney protects your investment in your practice and in the practice with which you decide to merge. Healthcare mergers, due to the complex rules and regulations governing the industry, are uniquely complicated. A traditional business lawyer with merger experience likely will not understand regulations that solely impact healthcare mergers, which can lead to regulatory fines and penalties.

Therefore, if you are considering merging your practice, it is critical that you engage an attorney who is highly experienced in the legal implications of healthcare transactions and who has a deep understanding of the Anti-Kickback Statute, Stark Law, and other applicable regulations. Doing so is the only way to ensure compliance with healthcare rules and regulations.

4. Payor Audits

The number of payor audits is increasing dramatically. Payor audits can involve Medicare, Medicaid, or third-party payors. When an audit notice is received, there often is a limited time period to respond. Therefore, it is imperative that you engage an experienced healthcare attorney upon receipt of such a notice to draft a professional response to the audit request and help you gather the requested documents in accordance with the time frames specified in the notice.

In addition, an attorney can address procedural, legal, or factual flaws in the auditor’s position, which can prevent repayment of significant monetary penalties and suspension or revocation of billing privileges.

5. Malpractice Allegations

Without question, if you are subject to a medical malpractice lawsuit, you absolutely must retain an experienced healthcare attorney. Your insurance company will usually hire one for you, but that is not always the case.

Medical malpractice cases are extremely complicated. To prevail, you need an attorney who not only understands the law but also the practice of medicine. A healthcare attorney will not only know what litigation filings are required but will be able to arrange expert witnesses to help prove that you acted in accordance with professional standards.

In Sum

It is critical that an experienced healthcare attorney be hired to help manage these situations and many more. There is no better way to protect the professional and personal interests you have worked so hard to build. TH

It is inevitable that, at some point in your career, you will need to hire a healthcare attorney. Proper representation is the best way to ensure a positive outcome in any situation.

Physicians often consider tackling certain issues on their own to reduce costs and avoid complicating matters. However, there are at least five situations in which you must retain an experienced healthcare attorney, or you could end up underpaid, subject to overreaching restrictive covenants, severely fined, or responsible for a large settlement.

1. Negotiating an Employment Contract

Whether you are considering a position as an employee of a physician group, hospital, or health system, it is critical that you understand the employment agreement presented to you so you can be sure it is fair and represents your best interests. The agreement itself defines the scope and conditions of your employment and consequently impacts your personal and professional satisfaction. It usually contains confusing legal terminology, such as noncompetition and nonsolicitation clauses. If you do not understand these terms, problems may arise in the future regarding your rights and capabilities upon termination of employment.

For these reasons, it is critical to engage a healthcare attorney who is well-versed in physician employment agreements. At a minimum, an attorney can confirm whether the compensation offered is comparable to that of physicians with similar experience and skills in your geographical area. The attorney can decipher confusing bonus compensation and may be able to negotiate more favorable terms. The same is true of understanding the benefits offered and establishing your call coverage.

An attorney will be able to advise you when it is appropriate to push back and request additional benefits or propose more favorable changes to your call coverage. Most important, the attorney will clarify the term of the employment agreement, the corresponding termination provisions, and any restrictions on your ability to practice upon termination of the agreement. Although the ultimate decision to accept the employment offer rests solely with you, an experienced healthcare attorney can help you understand the agreement and give you confidence in that decision.

2. Leaving a Practice for New Opportunities or Retirement

Whether you decide to leave a practice to pursue a new opportunity or because you are retiring, it is critical that you engage a healthcare attorney to help you navigate this road. If you are leaving to pursue new opportunities, an attorney can help you understand any restrictive covenants that may apply upon your departure and who retains ownership of the medical records of patients you treated while employed by the practice. In addition, you’ll be assisted in drafting any required notifications to patients alerting them of your departure.

If you are leaving the practice due to retirement, there are additional concerns. If you own the practice, you will need to decide whether to sell the practice or wind it down. If you decide to sell, an attorney can help you negotiate a favorable merger agreement and file any required change of ownership forms. If you choose to wind down your practice, your employee agreements and service and vendor contracts, including managed care participation agreements, will need to be reviewed for specific termination and notice requirements.

As with departure from a practice, there are certain notifications that must be issued to your patients detailing the closure of your practice and addressing patient options for continuity of care. An attorney can draft such notifications for you and, in addition, will be able to assist with notifying your malpractice carrier of your retirement and ensuring you have proper continuing coverage.

Finally, an attorney can arrange custody of your medical records in accordance with applicable state record retention requirements, help wind down your financial matters, and terminate your practice’s professional entity.

3. Practice Mergers

Engaging a healthcare transaction attorney protects your investment in your practice and in the practice with which you decide to merge. Healthcare mergers, due to the complex rules and regulations governing the industry, are uniquely complicated. A traditional business lawyer with merger experience likely will not understand regulations that solely impact healthcare mergers, which can lead to regulatory fines and penalties.

Therefore, if you are considering merging your practice, it is critical that you engage an attorney who is highly experienced in the legal implications of healthcare transactions and who has a deep understanding of the Anti-Kickback Statute, Stark Law, and other applicable regulations. Doing so is the only way to ensure compliance with healthcare rules and regulations.

4. Payor Audits

The number of payor audits is increasing dramatically. Payor audits can involve Medicare, Medicaid, or third-party payors. When an audit notice is received, there often is a limited time period to respond. Therefore, it is imperative that you engage an experienced healthcare attorney upon receipt of such a notice to draft a professional response to the audit request and help you gather the requested documents in accordance with the time frames specified in the notice.

In addition, an attorney can address procedural, legal, or factual flaws in the auditor’s position, which can prevent repayment of significant monetary penalties and suspension or revocation of billing privileges.

5. Malpractice Allegations

Without question, if you are subject to a medical malpractice lawsuit, you absolutely must retain an experienced healthcare attorney. Your insurance company will usually hire one for you, but that is not always the case.

Medical malpractice cases are extremely complicated. To prevail, you need an attorney who not only understands the law but also the practice of medicine. A healthcare attorney will not only know what litigation filings are required but will be able to arrange expert witnesses to help prove that you acted in accordance with professional standards.

In Sum

It is critical that an experienced healthcare attorney be hired to help manage these situations and many more. There is no better way to protect the professional and personal interests you have worked so hard to build. TH

It is inevitable that, at some point in your career, you will need to hire a healthcare attorney. Proper representation is the best way to ensure a positive outcome in any situation.

Physicians often consider tackling certain issues on their own to reduce costs and avoid complicating matters. However, there are at least five situations in which you must retain an experienced healthcare attorney, or you could end up underpaid, subject to overreaching restrictive covenants, severely fined, or responsible for a large settlement.

1. Negotiating an Employment Contract

Whether you are considering a position as an employee of a physician group, hospital, or health system, it is critical that you understand the employment agreement presented to you so you can be sure it is fair and represents your best interests. The agreement itself defines the scope and conditions of your employment and consequently impacts your personal and professional satisfaction. It usually contains confusing legal terminology, such as noncompetition and nonsolicitation clauses. If you do not understand these terms, problems may arise in the future regarding your rights and capabilities upon termination of employment.

For these reasons, it is critical to engage a healthcare attorney who is well-versed in physician employment agreements. At a minimum, an attorney can confirm whether the compensation offered is comparable to that of physicians with similar experience and skills in your geographical area. The attorney can decipher confusing bonus compensation and may be able to negotiate more favorable terms. The same is true of understanding the benefits offered and establishing your call coverage.

An attorney will be able to advise you when it is appropriate to push back and request additional benefits or propose more favorable changes to your call coverage. Most important, the attorney will clarify the term of the employment agreement, the corresponding termination provisions, and any restrictions on your ability to practice upon termination of the agreement. Although the ultimate decision to accept the employment offer rests solely with you, an experienced healthcare attorney can help you understand the agreement and give you confidence in that decision.

2. Leaving a Practice for New Opportunities or Retirement

Whether you decide to leave a practice to pursue a new opportunity or because you are retiring, it is critical that you engage a healthcare attorney to help you navigate this road. If you are leaving to pursue new opportunities, an attorney can help you understand any restrictive covenants that may apply upon your departure and who retains ownership of the medical records of patients you treated while employed by the practice. In addition, you’ll be assisted in drafting any required notifications to patients alerting them of your departure.

If you are leaving the practice due to retirement, there are additional concerns. If you own the practice, you will need to decide whether to sell the practice or wind it down. If you decide to sell, an attorney can help you negotiate a favorable merger agreement and file any required change of ownership forms. If you choose to wind down your practice, your employee agreements and service and vendor contracts, including managed care participation agreements, will need to be reviewed for specific termination and notice requirements.

As with departure from a practice, there are certain notifications that must be issued to your patients detailing the closure of your practice and addressing patient options for continuity of care. An attorney can draft such notifications for you and, in addition, will be able to assist with notifying your malpractice carrier of your retirement and ensuring you have proper continuing coverage.

Finally, an attorney can arrange custody of your medical records in accordance with applicable state record retention requirements, help wind down your financial matters, and terminate your practice’s professional entity.

3. Practice Mergers

Engaging a healthcare transaction attorney protects your investment in your practice and in the practice with which you decide to merge. Healthcare mergers, due to the complex rules and regulations governing the industry, are uniquely complicated. A traditional business lawyer with merger experience likely will not understand regulations that solely impact healthcare mergers, which can lead to regulatory fines and penalties.

Therefore, if you are considering merging your practice, it is critical that you engage an attorney who is highly experienced in the legal implications of healthcare transactions and who has a deep understanding of the Anti-Kickback Statute, Stark Law, and other applicable regulations. Doing so is the only way to ensure compliance with healthcare rules and regulations.

4. Payor Audits

The number of payor audits is increasing dramatically. Payor audits can involve Medicare, Medicaid, or third-party payors. When an audit notice is received, there often is a limited time period to respond. Therefore, it is imperative that you engage an experienced healthcare attorney upon receipt of such a notice to draft a professional response to the audit request and help you gather the requested documents in accordance with the time frames specified in the notice.

In addition, an attorney can address procedural, legal, or factual flaws in the auditor’s position, which can prevent repayment of significant monetary penalties and suspension or revocation of billing privileges.

5. Malpractice Allegations

Without question, if you are subject to a medical malpractice lawsuit, you absolutely must retain an experienced healthcare attorney. Your insurance company will usually hire one for you, but that is not always the case.

Medical malpractice cases are extremely complicated. To prevail, you need an attorney who not only understands the law but also the practice of medicine. A healthcare attorney will not only know what litigation filings are required but will be able to arrange expert witnesses to help prove that you acted in accordance with professional standards.

In Sum

It is critical that an experienced healthcare attorney be hired to help manage these situations and many more. There is no better way to protect the professional and personal interests you have worked so hard to build. TH