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Why Physicians Override Best Practice Alerts
Research published earlier this year in the Journal of Hospital Medicine finds that rationales offered by physicians for overriding interruptive, computerized best practice alerts (BPAs) regarding whether or not to give blood transfusions vary widely, including specialty service protocolized behaviors, anticipation of surgical or procedural interventions, and imminent hospital transfers.
The electronic health record at Stanford University Medical Center in Palo Alto, Calif., has an automated alert function to check reported hemoglobin level and trigger a pop-up reminder when a doctor orders a transfusion for a patient with a hemoglobin level of 9 or above—outside of the recognized guidelines—prompting the doctor to either abort the transfusion or provide a reason for the override, explains co-author Lisa Shieh, MD, PhD, FHM, medical director of quality in the department of medicine at Stanford.
“Our study was trying to understand why providers still transfuse, even when we provide just-in-time education on transfusion recommendations,” she says. “We can’t say that all of these orders are inappropriate. But, for many reasons, blood has harms and is costly.
“We want to convey an overall understanding about why this issue is important.”
Although a substantial number of transfusions continue outside of the recommended guidelines, Stanford has reduced its numbers significantly.
“I’m a big believer in clinical decision support … if it’s designed well and doesn’t add to alert fatigue,” Dr. Shieh says. “I think this BPA was effective in education and making people stop and think why they were ordering transfusions. Our next step will be to look at the outlier practices and maybe have a conversation with them, doctor to doctor.”
Stanford is looking at sepsis treatment as a next target.
Research published earlier this year in the Journal of Hospital Medicine finds that rationales offered by physicians for overriding interruptive, computerized best practice alerts (BPAs) regarding whether or not to give blood transfusions vary widely, including specialty service protocolized behaviors, anticipation of surgical or procedural interventions, and imminent hospital transfers.
The electronic health record at Stanford University Medical Center in Palo Alto, Calif., has an automated alert function to check reported hemoglobin level and trigger a pop-up reminder when a doctor orders a transfusion for a patient with a hemoglobin level of 9 or above—outside of the recognized guidelines—prompting the doctor to either abort the transfusion or provide a reason for the override, explains co-author Lisa Shieh, MD, PhD, FHM, medical director of quality in the department of medicine at Stanford.
“Our study was trying to understand why providers still transfuse, even when we provide just-in-time education on transfusion recommendations,” she says. “We can’t say that all of these orders are inappropriate. But, for many reasons, blood has harms and is costly.
“We want to convey an overall understanding about why this issue is important.”
Although a substantial number of transfusions continue outside of the recommended guidelines, Stanford has reduced its numbers significantly.
“I’m a big believer in clinical decision support … if it’s designed well and doesn’t add to alert fatigue,” Dr. Shieh says. “I think this BPA was effective in education and making people stop and think why they were ordering transfusions. Our next step will be to look at the outlier practices and maybe have a conversation with them, doctor to doctor.”
Stanford is looking at sepsis treatment as a next target.
Research published earlier this year in the Journal of Hospital Medicine finds that rationales offered by physicians for overriding interruptive, computerized best practice alerts (BPAs) regarding whether or not to give blood transfusions vary widely, including specialty service protocolized behaviors, anticipation of surgical or procedural interventions, and imminent hospital transfers.
The electronic health record at Stanford University Medical Center in Palo Alto, Calif., has an automated alert function to check reported hemoglobin level and trigger a pop-up reminder when a doctor orders a transfusion for a patient with a hemoglobin level of 9 or above—outside of the recognized guidelines—prompting the doctor to either abort the transfusion or provide a reason for the override, explains co-author Lisa Shieh, MD, PhD, FHM, medical director of quality in the department of medicine at Stanford.
“Our study was trying to understand why providers still transfuse, even when we provide just-in-time education on transfusion recommendations,” she says. “We can’t say that all of these orders are inappropriate. But, for many reasons, blood has harms and is costly.
“We want to convey an overall understanding about why this issue is important.”
Although a substantial number of transfusions continue outside of the recommended guidelines, Stanford has reduced its numbers significantly.
“I’m a big believer in clinical decision support … if it’s designed well and doesn’t add to alert fatigue,” Dr. Shieh says. “I think this BPA was effective in education and making people stop and think why they were ordering transfusions. Our next step will be to look at the outlier practices and maybe have a conversation with them, doctor to doctor.”
Stanford is looking at sepsis treatment as a next target.
Hospitals with Hotel-Like Amenities Don’t Improve Satisfaction Scores
Hospital design may not contribute to patients’ satisfaction with the care given by their hospital professionals, according to new research from Johns Hopkins Hospital in Baltimore, published in the Journal of Hospital Medicine. Newly built hospitals often emphasize patient-centered features like reduced noise, natural light, visitor-friendly facilities, well-designed rooms, and hotel-like amenities, note the authors, led by Zishan Siddiqui, MD, attending physician and assistant professor of medicine at Johns Hopkins.
When Hopkins moved a number of its hospital units to the sleek new Sheikh Zayed Tower in 2012, researchers used a pre-post design experiment to compare patient satisfaction in the newer, more pleasing surroundings via Press Ganey and HCAHPS (Hospital Consumer Assessment of Healthcare Providers and Systems) survey scores. Patients responded positively to the new environment, with significant improvement in facility-related satisfaction, but were able to distinguish that satisfaction from their ratings of their doctors and nurses, which were not impacted by the new environment.
“It is more likely that provider-level interventions will have a greater impact on provider level and overall satisfaction,” the authors conclude. “Hospital administrators should not use outdated facilities as an excuse for suboptimal provider satisfaction scores.”
Hospital design may not contribute to patients’ satisfaction with the care given by their hospital professionals, according to new research from Johns Hopkins Hospital in Baltimore, published in the Journal of Hospital Medicine. Newly built hospitals often emphasize patient-centered features like reduced noise, natural light, visitor-friendly facilities, well-designed rooms, and hotel-like amenities, note the authors, led by Zishan Siddiqui, MD, attending physician and assistant professor of medicine at Johns Hopkins.
When Hopkins moved a number of its hospital units to the sleek new Sheikh Zayed Tower in 2012, researchers used a pre-post design experiment to compare patient satisfaction in the newer, more pleasing surroundings via Press Ganey and HCAHPS (Hospital Consumer Assessment of Healthcare Providers and Systems) survey scores. Patients responded positively to the new environment, with significant improvement in facility-related satisfaction, but were able to distinguish that satisfaction from their ratings of their doctors and nurses, which were not impacted by the new environment.
“It is more likely that provider-level interventions will have a greater impact on provider level and overall satisfaction,” the authors conclude. “Hospital administrators should not use outdated facilities as an excuse for suboptimal provider satisfaction scores.”
Hospital design may not contribute to patients’ satisfaction with the care given by their hospital professionals, according to new research from Johns Hopkins Hospital in Baltimore, published in the Journal of Hospital Medicine. Newly built hospitals often emphasize patient-centered features like reduced noise, natural light, visitor-friendly facilities, well-designed rooms, and hotel-like amenities, note the authors, led by Zishan Siddiqui, MD, attending physician and assistant professor of medicine at Johns Hopkins.
When Hopkins moved a number of its hospital units to the sleek new Sheikh Zayed Tower in 2012, researchers used a pre-post design experiment to compare patient satisfaction in the newer, more pleasing surroundings via Press Ganey and HCAHPS (Hospital Consumer Assessment of Healthcare Providers and Systems) survey scores. Patients responded positively to the new environment, with significant improvement in facility-related satisfaction, but were able to distinguish that satisfaction from their ratings of their doctors and nurses, which were not impacted by the new environment.
“It is more likely that provider-level interventions will have a greater impact on provider level and overall satisfaction,” the authors conclude. “Hospital administrators should not use outdated facilities as an excuse for suboptimal provider satisfaction scores.”
Hospitalists Should Make Commitment to Improve Healthcare Safety
Peter Pronovost, MD, PhD, FCCM, knows how to deliver a great talk. It is no wonder he is highly sought after and was asked to speak at the plenary for SHM’s annual meeting. Dr. Pronovost, also known as the “Checklist Doctor,” knows how to combine just the right amount of sadness, inspiration, and humor to make his audience feel motivated and compelled to DO something. And, in fact, he implores you—DO something.
Most of us feel excited and inspired during the annual meeting. But those feelings serve little purpose unless we translate them into actions that will make the medical industry a better place for clinicians to work and for patients to receive care. As Dr. Pronovost said, “We are the only hope that the healthcare system has of improving quality and safety.”
He was inspired years ago by the watershed event that will forever be imprinted upon Johns Hopkins Hospital in Baltimore, the preventable death of 18-month-old Josie King on Feb. 22, 2001. Years after the event, her mother, Sorrel King, a passionate patient safety advocate, wanted to know if hospitals are any safer than they were the day that Josie died. She wanted to know what patient safety experts at Hopkins had done to ensure there would not be another Josie King story.
Patients and their families consistently voice similar desires after they have suffered preventable harm. They want to know what happened, why it happened, what it means for them, and what will be done to prevent it from happening again.1 The latter question is one I am frequently asked by patients and their families at my hospital. “What are you going to do to make sure this does not happen again?”
I would venture to guess most hospitalists have been responsible for some type of preventable patient harm during their careers. We work in complex, high-volume, unpredictable, and continuously changing environments. Many of the patients and families in our care are new to us and are with us for only short periods of time. Those of us who have been responsible for preventable patient harm know that it is an unforgettable moment in time that can weigh upon your conscious. And, of course, we all want to do something to make sure it does not happen again.
That is exactly what patients and their families expect of all of us—to DO something—and they should.
But this can be an overwhelming responsibility, especially when the root causes of harm are difficult either to identify or to fix—such as a miscommunication, a diagnostic error, or an inadequate handoff.
Which gets me back to Dr. Pronovost giving a great talk. His appeal to our audience of about 3,000 hospitalists was to DO something. To make the healthcare system improve quality and safety for future patients. To not wait until we or our colleagues are involved in a preventable harm event. To do something, anything, now, that contributes to safer care, today and every day going forward.
He ended his talk with “I will….” Dr. Pronovost (and I would venture to guess patients and their families) wants each of us to fill in the blank with a statement of personal accountability for action. Unfortunately, many of us still believe that we are personally unable to make complex systems safer for patients. Many of us still believe that patients and the systems they traverse are too complex, unpredictable, unreliable, or noncompliant.
The truth is, patients and systems are indeed complex, unpredictable, unreliable, and noncompliant. The further truth is, the only way to make care safer is for each of us to start with a collective shared mental model that we can make it better—and for each of us to commit to personal accountability for action.
My “I Will”
So, while I really enjoyed Dr. Pronovost’s talk, what I enjoyed even more was reading the section in last month’s edition of The Hospitalist in which about a half dozen hospitalists interviewed after the plenary accepted the challenge of filling in the blank “I will….” A few excerpts:
- “I will let them know that everything is possible…”
- “I will improve healthcare…”
- “[I will] make sure the patient is heard…”
By a simple proclamation of personal accountability, a mere thousand hospitalists attending an annual meeting can collectively and progressively change the safety of healthcare in thousands of hospitals around the country. It starts with thinking we can do it and publicly committing to the journey. Although we are still a relatively new specialty, we have permeated almost every hospital in the country, and we have outpaced the growth of any specialty in the history of modern medicine. We are perfectly poised to be the safety change agents for every hospital system. As Margaret Meade famously said, “Never doubt that a small group of thoughtful, committed citizens can change the world; indeed, it’s the only thing that ever has….”
So don’t delay. Whether or not you had the good fortune of being inspired at the SHM annual meeting, each of us owes it to our patients to commit to improving the safety of healthcare and paving the future of hospital care. Get out your pen, craft a commitment now, follow through with it, and make hospitals safer tomorrow than they were yesterday.
I will…
Reference
- Gallagher TH, Waterman AD, Ebers AG, Fraser VJ, Levinson W. Patients’ and physicians’ attitudes regarding the disclosure of medical errors. JAMA. 2003;289(8):1001-1007.
Peter Pronovost, MD, PhD, FCCM, knows how to deliver a great talk. It is no wonder he is highly sought after and was asked to speak at the plenary for SHM’s annual meeting. Dr. Pronovost, also known as the “Checklist Doctor,” knows how to combine just the right amount of sadness, inspiration, and humor to make his audience feel motivated and compelled to DO something. And, in fact, he implores you—DO something.
Most of us feel excited and inspired during the annual meeting. But those feelings serve little purpose unless we translate them into actions that will make the medical industry a better place for clinicians to work and for patients to receive care. As Dr. Pronovost said, “We are the only hope that the healthcare system has of improving quality and safety.”
He was inspired years ago by the watershed event that will forever be imprinted upon Johns Hopkins Hospital in Baltimore, the preventable death of 18-month-old Josie King on Feb. 22, 2001. Years after the event, her mother, Sorrel King, a passionate patient safety advocate, wanted to know if hospitals are any safer than they were the day that Josie died. She wanted to know what patient safety experts at Hopkins had done to ensure there would not be another Josie King story.
Patients and their families consistently voice similar desires after they have suffered preventable harm. They want to know what happened, why it happened, what it means for them, and what will be done to prevent it from happening again.1 The latter question is one I am frequently asked by patients and their families at my hospital. “What are you going to do to make sure this does not happen again?”
I would venture to guess most hospitalists have been responsible for some type of preventable patient harm during their careers. We work in complex, high-volume, unpredictable, and continuously changing environments. Many of the patients and families in our care are new to us and are with us for only short periods of time. Those of us who have been responsible for preventable patient harm know that it is an unforgettable moment in time that can weigh upon your conscious. And, of course, we all want to do something to make sure it does not happen again.
That is exactly what patients and their families expect of all of us—to DO something—and they should.
But this can be an overwhelming responsibility, especially when the root causes of harm are difficult either to identify or to fix—such as a miscommunication, a diagnostic error, or an inadequate handoff.
Which gets me back to Dr. Pronovost giving a great talk. His appeal to our audience of about 3,000 hospitalists was to DO something. To make the healthcare system improve quality and safety for future patients. To not wait until we or our colleagues are involved in a preventable harm event. To do something, anything, now, that contributes to safer care, today and every day going forward.
He ended his talk with “I will….” Dr. Pronovost (and I would venture to guess patients and their families) wants each of us to fill in the blank with a statement of personal accountability for action. Unfortunately, many of us still believe that we are personally unable to make complex systems safer for patients. Many of us still believe that patients and the systems they traverse are too complex, unpredictable, unreliable, or noncompliant.
The truth is, patients and systems are indeed complex, unpredictable, unreliable, and noncompliant. The further truth is, the only way to make care safer is for each of us to start with a collective shared mental model that we can make it better—and for each of us to commit to personal accountability for action.
My “I Will”
So, while I really enjoyed Dr. Pronovost’s talk, what I enjoyed even more was reading the section in last month’s edition of The Hospitalist in which about a half dozen hospitalists interviewed after the plenary accepted the challenge of filling in the blank “I will….” A few excerpts:
- “I will let them know that everything is possible…”
- “I will improve healthcare…”
- “[I will] make sure the patient is heard…”
By a simple proclamation of personal accountability, a mere thousand hospitalists attending an annual meeting can collectively and progressively change the safety of healthcare in thousands of hospitals around the country. It starts with thinking we can do it and publicly committing to the journey. Although we are still a relatively new specialty, we have permeated almost every hospital in the country, and we have outpaced the growth of any specialty in the history of modern medicine. We are perfectly poised to be the safety change agents for every hospital system. As Margaret Meade famously said, “Never doubt that a small group of thoughtful, committed citizens can change the world; indeed, it’s the only thing that ever has….”
So don’t delay. Whether or not you had the good fortune of being inspired at the SHM annual meeting, each of us owes it to our patients to commit to improving the safety of healthcare and paving the future of hospital care. Get out your pen, craft a commitment now, follow through with it, and make hospitals safer tomorrow than they were yesterday.
I will…
Reference
- Gallagher TH, Waterman AD, Ebers AG, Fraser VJ, Levinson W. Patients’ and physicians’ attitudes regarding the disclosure of medical errors. JAMA. 2003;289(8):1001-1007.
Peter Pronovost, MD, PhD, FCCM, knows how to deliver a great talk. It is no wonder he is highly sought after and was asked to speak at the plenary for SHM’s annual meeting. Dr. Pronovost, also known as the “Checklist Doctor,” knows how to combine just the right amount of sadness, inspiration, and humor to make his audience feel motivated and compelled to DO something. And, in fact, he implores you—DO something.
Most of us feel excited and inspired during the annual meeting. But those feelings serve little purpose unless we translate them into actions that will make the medical industry a better place for clinicians to work and for patients to receive care. As Dr. Pronovost said, “We are the only hope that the healthcare system has of improving quality and safety.”
He was inspired years ago by the watershed event that will forever be imprinted upon Johns Hopkins Hospital in Baltimore, the preventable death of 18-month-old Josie King on Feb. 22, 2001. Years after the event, her mother, Sorrel King, a passionate patient safety advocate, wanted to know if hospitals are any safer than they were the day that Josie died. She wanted to know what patient safety experts at Hopkins had done to ensure there would not be another Josie King story.
Patients and their families consistently voice similar desires after they have suffered preventable harm. They want to know what happened, why it happened, what it means for them, and what will be done to prevent it from happening again.1 The latter question is one I am frequently asked by patients and their families at my hospital. “What are you going to do to make sure this does not happen again?”
I would venture to guess most hospitalists have been responsible for some type of preventable patient harm during their careers. We work in complex, high-volume, unpredictable, and continuously changing environments. Many of the patients and families in our care are new to us and are with us for only short periods of time. Those of us who have been responsible for preventable patient harm know that it is an unforgettable moment in time that can weigh upon your conscious. And, of course, we all want to do something to make sure it does not happen again.
That is exactly what patients and their families expect of all of us—to DO something—and they should.
But this can be an overwhelming responsibility, especially when the root causes of harm are difficult either to identify or to fix—such as a miscommunication, a diagnostic error, or an inadequate handoff.
Which gets me back to Dr. Pronovost giving a great talk. His appeal to our audience of about 3,000 hospitalists was to DO something. To make the healthcare system improve quality and safety for future patients. To not wait until we or our colleagues are involved in a preventable harm event. To do something, anything, now, that contributes to safer care, today and every day going forward.
He ended his talk with “I will….” Dr. Pronovost (and I would venture to guess patients and their families) wants each of us to fill in the blank with a statement of personal accountability for action. Unfortunately, many of us still believe that we are personally unable to make complex systems safer for patients. Many of us still believe that patients and the systems they traverse are too complex, unpredictable, unreliable, or noncompliant.
The truth is, patients and systems are indeed complex, unpredictable, unreliable, and noncompliant. The further truth is, the only way to make care safer is for each of us to start with a collective shared mental model that we can make it better—and for each of us to commit to personal accountability for action.
My “I Will”
So, while I really enjoyed Dr. Pronovost’s talk, what I enjoyed even more was reading the section in last month’s edition of The Hospitalist in which about a half dozen hospitalists interviewed after the plenary accepted the challenge of filling in the blank “I will….” A few excerpts:
- “I will let them know that everything is possible…”
- “I will improve healthcare…”
- “[I will] make sure the patient is heard…”
By a simple proclamation of personal accountability, a mere thousand hospitalists attending an annual meeting can collectively and progressively change the safety of healthcare in thousands of hospitals around the country. It starts with thinking we can do it and publicly committing to the journey. Although we are still a relatively new specialty, we have permeated almost every hospital in the country, and we have outpaced the growth of any specialty in the history of modern medicine. We are perfectly poised to be the safety change agents for every hospital system. As Margaret Meade famously said, “Never doubt that a small group of thoughtful, committed citizens can change the world; indeed, it’s the only thing that ever has….”
So don’t delay. Whether or not you had the good fortune of being inspired at the SHM annual meeting, each of us owes it to our patients to commit to improving the safety of healthcare and paving the future of hospital care. Get out your pen, craft a commitment now, follow through with it, and make hospitals safer tomorrow than they were yesterday.
I will…
Reference
- Gallagher TH, Waterman AD, Ebers AG, Fraser VJ, Levinson W. Patients’ and physicians’ attitudes regarding the disclosure of medical errors. JAMA. 2003;289(8):1001-1007.
Society of Hospital Medicine’s RIV Poster Contest Draws Best, Brightest
Palliative Care and Last-Minute Heroics
4/8/15
HM15 Presenter: Tammie Quest, MD
Summation: Heroics- a set of medical actions that attempt to prolong life with a low likelihood of success.
Palliative care- an approach of care provided to patients and families suffering from serious and/or life limiting illness; focus on physical, spiritual, psychological and social aspects of distress.
Hospice care- intense palliative care provided when the patient has terminal illness with a prognosis of 6 months or less if the disease runs its usual course.
We underutilize Palliative and Hospice care in the US. Here in the US fewer than 50% of all persons receive hospice care at EOL, of those who receive hospice care more than half receive care for less than 20 days, and 1 in 5 patients die in an ICU. Palliative Care can/should co-exist with life prolonging care following the diagnosis of serious illness.
Common therapies/interventions to be contemplated and discussed with patient at end of life: cpr, mechanical ventilation, central venous/arterial access, renal replacement therapy, surgical procedures, valve therapies, ventricular assist devices, continuous infusions, IV fluids, supplemental oxygen, artificial nutrition, antimicrobials, blood products, cancer directed therapy, antithrombotics, anticoagulation.
Practical Elements of Palliative Care: pain and symptom management, advance care planning, communication/goals of care, truth-telling, social support, spiritual support, psychological support, risk/burden assessment of treatments.
Key Points/HM Takeaways:
1-Palliative Care Bedside Talking Points-
- Cardiac arrest is the moment of death, very few people survive an attempt at reversing death
- If you are one of the few who survive to discharge, you may do well but few will survive to discharge
- Antibiotics DO improve survival, antibiotics DO NOT improve comfort
- No evidence to show that dying from pneumonia, or other infection, is painful
- Allowing natural death includes permitting the body to shut itself down through natural mechanisms, including infection
- Dialysis may extend life, but there will be progressive functional decline
2-Goals of Care define what therapies are indicated. Balance prolongation of life with illness experience.
Julianna Lindsey is a hospitalist and physician leader based in the Dallas-Fort Worth Metroplex. Her focus is patient safety/quality and physician leadership. She is a member of TeamHospitalist.
4/8/15
HM15 Presenter: Tammie Quest, MD
Summation: Heroics- a set of medical actions that attempt to prolong life with a low likelihood of success.
Palliative care- an approach of care provided to patients and families suffering from serious and/or life limiting illness; focus on physical, spiritual, psychological and social aspects of distress.
Hospice care- intense palliative care provided when the patient has terminal illness with a prognosis of 6 months or less if the disease runs its usual course.
We underutilize Palliative and Hospice care in the US. Here in the US fewer than 50% of all persons receive hospice care at EOL, of those who receive hospice care more than half receive care for less than 20 days, and 1 in 5 patients die in an ICU. Palliative Care can/should co-exist with life prolonging care following the diagnosis of serious illness.
Common therapies/interventions to be contemplated and discussed with patient at end of life: cpr, mechanical ventilation, central venous/arterial access, renal replacement therapy, surgical procedures, valve therapies, ventricular assist devices, continuous infusions, IV fluids, supplemental oxygen, artificial nutrition, antimicrobials, blood products, cancer directed therapy, antithrombotics, anticoagulation.
Practical Elements of Palliative Care: pain and symptom management, advance care planning, communication/goals of care, truth-telling, social support, spiritual support, psychological support, risk/burden assessment of treatments.
Key Points/HM Takeaways:
1-Palliative Care Bedside Talking Points-
- Cardiac arrest is the moment of death, very few people survive an attempt at reversing death
- If you are one of the few who survive to discharge, you may do well but few will survive to discharge
- Antibiotics DO improve survival, antibiotics DO NOT improve comfort
- No evidence to show that dying from pneumonia, or other infection, is painful
- Allowing natural death includes permitting the body to shut itself down through natural mechanisms, including infection
- Dialysis may extend life, but there will be progressive functional decline
2-Goals of Care define what therapies are indicated. Balance prolongation of life with illness experience.
Julianna Lindsey is a hospitalist and physician leader based in the Dallas-Fort Worth Metroplex. Her focus is patient safety/quality and physician leadership. She is a member of TeamHospitalist.
4/8/15
HM15 Presenter: Tammie Quest, MD
Summation: Heroics- a set of medical actions that attempt to prolong life with a low likelihood of success.
Palliative care- an approach of care provided to patients and families suffering from serious and/or life limiting illness; focus on physical, spiritual, psychological and social aspects of distress.
Hospice care- intense palliative care provided when the patient has terminal illness with a prognosis of 6 months or less if the disease runs its usual course.
We underutilize Palliative and Hospice care in the US. Here in the US fewer than 50% of all persons receive hospice care at EOL, of those who receive hospice care more than half receive care for less than 20 days, and 1 in 5 patients die in an ICU. Palliative Care can/should co-exist with life prolonging care following the diagnosis of serious illness.
Common therapies/interventions to be contemplated and discussed with patient at end of life: cpr, mechanical ventilation, central venous/arterial access, renal replacement therapy, surgical procedures, valve therapies, ventricular assist devices, continuous infusions, IV fluids, supplemental oxygen, artificial nutrition, antimicrobials, blood products, cancer directed therapy, antithrombotics, anticoagulation.
Practical Elements of Palliative Care: pain and symptom management, advance care planning, communication/goals of care, truth-telling, social support, spiritual support, psychological support, risk/burden assessment of treatments.
Key Points/HM Takeaways:
1-Palliative Care Bedside Talking Points-
- Cardiac arrest is the moment of death, very few people survive an attempt at reversing death
- If you are one of the few who survive to discharge, you may do well but few will survive to discharge
- Antibiotics DO improve survival, antibiotics DO NOT improve comfort
- No evidence to show that dying from pneumonia, or other infection, is painful
- Allowing natural death includes permitting the body to shut itself down through natural mechanisms, including infection
- Dialysis may extend life, but there will be progressive functional decline
2-Goals of Care define what therapies are indicated. Balance prolongation of life with illness experience.
Julianna Lindsey is a hospitalist and physician leader based in the Dallas-Fort Worth Metroplex. Her focus is patient safety/quality and physician leadership. She is a member of TeamHospitalist.
Implementing Physician Value-Based Purchasing in Your Practice: HM15 Session Analysis
HM15 Session: Putting Your Nickel Down: The What, Why, and How of Implementing Physician Value-Based Purchasing in Your Practice
Presenters: Stephen Besch, Simone Karp RPh, Patrick Torcson MD MMM SFHM, Gregory Seymann MD SFHM
Medicare is transforming itself from a “passive payer” to an “active purchaser” of high quality, efficient healthcare. As such- active participation by physicians, physician groups, and hospitals is required for payment eligibility.
At the physician/group level, hospitalists should be reporting PQRS measures. Incentive payments for PQRS ended in 2014, Medicare is now making “negative payment adjustments.” Penalties are equal to a percentage of all Medicare Part B FFS (Fee-for-Service) charges and there is a 2-year delay between reporting or performance failure and penalization.
Physician Value-Based Purchasing (P-VBP) affects all Eligible Providers (EPs) in 2015. P4P (Pay for Performance) assesses both quality and cost. Aim is for budget neutrality via “quality tiering” which rewards “high quality/low cost” practices with penalties from “low quality/high cost” practices. As of now (2015) ACPs and therapists can be penalized under P-VBP.
Key Points/HM Takeaways:
- Hospitalists should be reporting PQRS measures- penalty phase has begun
- Key PQRS Changes for 2015:
- 6 measures applicable to inpatient billing removed
- no useful inpatient measures added
- penalty avoidance requires 9 measures at 50% or higher rates, covering at least 3 of the 6 NQS (National Quality Strategy) domains- including 1 cross-cutting measure
- all 2015 PQRS data will be posted to Physician Compare website in 2016
- 3 Examples of hospitalist applicable “cross-cutting measures” are
- 47-advance care plan
- 130-documentation of current medications
- 317-preventative care: bp screening
- PQRS data must be reported with respect to MAV clusters (Measure Applicability Validation)- reporting only measure that have no MAV cluster is a safe strategy so long as one of the measures is “cross-cutting”
- Maximum P-VBP penalties automatically apply if group does not report enough PQRS data
- visit CMS website for more information
HM15 Session: Putting Your Nickel Down: The What, Why, and How of Implementing Physician Value-Based Purchasing in Your Practice
Presenters: Stephen Besch, Simone Karp RPh, Patrick Torcson MD MMM SFHM, Gregory Seymann MD SFHM
Medicare is transforming itself from a “passive payer” to an “active purchaser” of high quality, efficient healthcare. As such- active participation by physicians, physician groups, and hospitals is required for payment eligibility.
At the physician/group level, hospitalists should be reporting PQRS measures. Incentive payments for PQRS ended in 2014, Medicare is now making “negative payment adjustments.” Penalties are equal to a percentage of all Medicare Part B FFS (Fee-for-Service) charges and there is a 2-year delay between reporting or performance failure and penalization.
Physician Value-Based Purchasing (P-VBP) affects all Eligible Providers (EPs) in 2015. P4P (Pay for Performance) assesses both quality and cost. Aim is for budget neutrality via “quality tiering” which rewards “high quality/low cost” practices with penalties from “low quality/high cost” practices. As of now (2015) ACPs and therapists can be penalized under P-VBP.
Key Points/HM Takeaways:
- Hospitalists should be reporting PQRS measures- penalty phase has begun
- Key PQRS Changes for 2015:
- 6 measures applicable to inpatient billing removed
- no useful inpatient measures added
- penalty avoidance requires 9 measures at 50% or higher rates, covering at least 3 of the 6 NQS (National Quality Strategy) domains- including 1 cross-cutting measure
- all 2015 PQRS data will be posted to Physician Compare website in 2016
- 3 Examples of hospitalist applicable “cross-cutting measures” are
- 47-advance care plan
- 130-documentation of current medications
- 317-preventative care: bp screening
- PQRS data must be reported with respect to MAV clusters (Measure Applicability Validation)- reporting only measure that have no MAV cluster is a safe strategy so long as one of the measures is “cross-cutting”
- Maximum P-VBP penalties automatically apply if group does not report enough PQRS data
- visit CMS website for more information
HM15 Session: Putting Your Nickel Down: The What, Why, and How of Implementing Physician Value-Based Purchasing in Your Practice
Presenters: Stephen Besch, Simone Karp RPh, Patrick Torcson MD MMM SFHM, Gregory Seymann MD SFHM
Medicare is transforming itself from a “passive payer” to an “active purchaser” of high quality, efficient healthcare. As such- active participation by physicians, physician groups, and hospitals is required for payment eligibility.
At the physician/group level, hospitalists should be reporting PQRS measures. Incentive payments for PQRS ended in 2014, Medicare is now making “negative payment adjustments.” Penalties are equal to a percentage of all Medicare Part B FFS (Fee-for-Service) charges and there is a 2-year delay between reporting or performance failure and penalization.
Physician Value-Based Purchasing (P-VBP) affects all Eligible Providers (EPs) in 2015. P4P (Pay for Performance) assesses both quality and cost. Aim is for budget neutrality via “quality tiering” which rewards “high quality/low cost” practices with penalties from “low quality/high cost” practices. As of now (2015) ACPs and therapists can be penalized under P-VBP.
Key Points/HM Takeaways:
- Hospitalists should be reporting PQRS measures- penalty phase has begun
- Key PQRS Changes for 2015:
- 6 measures applicable to inpatient billing removed
- no useful inpatient measures added
- penalty avoidance requires 9 measures at 50% or higher rates, covering at least 3 of the 6 NQS (National Quality Strategy) domains- including 1 cross-cutting measure
- all 2015 PQRS data will be posted to Physician Compare website in 2016
- 3 Examples of hospitalist applicable “cross-cutting measures” are
- 47-advance care plan
- 130-documentation of current medications
- 317-preventative care: bp screening
- PQRS data must be reported with respect to MAV clusters (Measure Applicability Validation)- reporting only measure that have no MAV cluster is a safe strategy so long as one of the measures is “cross-cutting”
- Maximum P-VBP penalties automatically apply if group does not report enough PQRS data
- visit CMS website for more information
Hot Topics in Practice Management; HM15 Session Analysis
HM15 Presenters: Roy Sittig MD SFHM, Jeffrey Frank MD MBA, Jodi Braun
Summation: Speakers covered timely topics regarding the Accountable Care Act, namely Medicaid Expansion and Bundled Payment arrangements; and reviewed the seminal paper on “Key Principals and Characteristics of an Effective Hospitalist Medicine Group” and lessons learned in implementing those 10 Key Principles.
Medicaid Expansion: EDs serving the 29 Medicaid expansion states are reporting higher volumes, likely due to 11.4million new lives now insured under the ACA. While the ACA does provide for higher Medicaid payment rates thus far, only 34% of providers accept Medicaid, a 21% drop since the ACA went into effect.
Bundled Payment Arrangements:
- Bundled Payment Care Initiative (BPCI) lexicon:
- Model 2-Episode Anchor (anchor admission) AND 90days post d/c; Medicare pays 98% of usual cost
- Model 3-90days post d/c AFTER anchor admission; Medicare pays 97% of usual cost
- Convener-entity that brings providers together and enters into CMS agreement to bear risk for bundles
- Awardee (entity having agreement with Medicare to assume risk and receive payment via BPCI) and Convener own the Bundle
- Episode initiator (EI) triggers “bundle period”
- Bundles based on DRG
10-Key Principles of an Effective Hospitalist Medicine Group:
- Effective Leadership
- Engaged Hospitalists
- Adequate Resources
- Planning and Management Infrastructure
- Alignment with Hospital/Health System
- Care Coordination Across Settings
- Leadership in Key Clinical Issues in the Hospital/Health System
- Thoughtful Approach to Scope of Activity
- Patient/Family-Centered, Team-Based Care; Effective Communication
- Recruiting/Retaining Qualified Clinicians
Key Points/HM Takeaways:
Medicaid Expansion- many of the 11.4M newly insured lives under the ACA have moved into Medicaid. Only about 1/3 of providers now accept Medicaid- 1 in 5 covered persons now have Medicaid, nearly 20% increase since 2013.
Bundled Payments- Majority of savings opportunity lies in Post-Acute Care. Awardee and Convener make profit is total cost is less than 98% of Target Price. In gainsharing agreements individuals can be reimbursed up to 150% usual Medicare rate. Pay occurs in usual Medicare fashion but is reconciled 60-90 days after end of bundle. For more information: http://innovation.cms.gov/initiatives/bundled-payments/
Effective HM Groups- Three important areas for focus when beginning to address group performance are: engaged hospitalists, planning and management infrastructure, care coordination across settings. These three topics have broad reaching implications into the hospitalist practice and patient care. [Cawley P, et al. Journal of Hospital Medicine 2014; 9(2):123-128]
HM15 Presenters: Roy Sittig MD SFHM, Jeffrey Frank MD MBA, Jodi Braun
Summation: Speakers covered timely topics regarding the Accountable Care Act, namely Medicaid Expansion and Bundled Payment arrangements; and reviewed the seminal paper on “Key Principals and Characteristics of an Effective Hospitalist Medicine Group” and lessons learned in implementing those 10 Key Principles.
Medicaid Expansion: EDs serving the 29 Medicaid expansion states are reporting higher volumes, likely due to 11.4million new lives now insured under the ACA. While the ACA does provide for higher Medicaid payment rates thus far, only 34% of providers accept Medicaid, a 21% drop since the ACA went into effect.
Bundled Payment Arrangements:
- Bundled Payment Care Initiative (BPCI) lexicon:
- Model 2-Episode Anchor (anchor admission) AND 90days post d/c; Medicare pays 98% of usual cost
- Model 3-90days post d/c AFTER anchor admission; Medicare pays 97% of usual cost
- Convener-entity that brings providers together and enters into CMS agreement to bear risk for bundles
- Awardee (entity having agreement with Medicare to assume risk and receive payment via BPCI) and Convener own the Bundle
- Episode initiator (EI) triggers “bundle period”
- Bundles based on DRG
10-Key Principles of an Effective Hospitalist Medicine Group:
- Effective Leadership
- Engaged Hospitalists
- Adequate Resources
- Planning and Management Infrastructure
- Alignment with Hospital/Health System
- Care Coordination Across Settings
- Leadership in Key Clinical Issues in the Hospital/Health System
- Thoughtful Approach to Scope of Activity
- Patient/Family-Centered, Team-Based Care; Effective Communication
- Recruiting/Retaining Qualified Clinicians
Key Points/HM Takeaways:
Medicaid Expansion- many of the 11.4M newly insured lives under the ACA have moved into Medicaid. Only about 1/3 of providers now accept Medicaid- 1 in 5 covered persons now have Medicaid, nearly 20% increase since 2013.
Bundled Payments- Majority of savings opportunity lies in Post-Acute Care. Awardee and Convener make profit is total cost is less than 98% of Target Price. In gainsharing agreements individuals can be reimbursed up to 150% usual Medicare rate. Pay occurs in usual Medicare fashion but is reconciled 60-90 days after end of bundle. For more information: http://innovation.cms.gov/initiatives/bundled-payments/
Effective HM Groups- Three important areas for focus when beginning to address group performance are: engaged hospitalists, planning and management infrastructure, care coordination across settings. These three topics have broad reaching implications into the hospitalist practice and patient care. [Cawley P, et al. Journal of Hospital Medicine 2014; 9(2):123-128]
HM15 Presenters: Roy Sittig MD SFHM, Jeffrey Frank MD MBA, Jodi Braun
Summation: Speakers covered timely topics regarding the Accountable Care Act, namely Medicaid Expansion and Bundled Payment arrangements; and reviewed the seminal paper on “Key Principals and Characteristics of an Effective Hospitalist Medicine Group” and lessons learned in implementing those 10 Key Principles.
Medicaid Expansion: EDs serving the 29 Medicaid expansion states are reporting higher volumes, likely due to 11.4million new lives now insured under the ACA. While the ACA does provide for higher Medicaid payment rates thus far, only 34% of providers accept Medicaid, a 21% drop since the ACA went into effect.
Bundled Payment Arrangements:
- Bundled Payment Care Initiative (BPCI) lexicon:
- Model 2-Episode Anchor (anchor admission) AND 90days post d/c; Medicare pays 98% of usual cost
- Model 3-90days post d/c AFTER anchor admission; Medicare pays 97% of usual cost
- Convener-entity that brings providers together and enters into CMS agreement to bear risk for bundles
- Awardee (entity having agreement with Medicare to assume risk and receive payment via BPCI) and Convener own the Bundle
- Episode initiator (EI) triggers “bundle period”
- Bundles based on DRG
10-Key Principles of an Effective Hospitalist Medicine Group:
- Effective Leadership
- Engaged Hospitalists
- Adequate Resources
- Planning and Management Infrastructure
- Alignment with Hospital/Health System
- Care Coordination Across Settings
- Leadership in Key Clinical Issues in the Hospital/Health System
- Thoughtful Approach to Scope of Activity
- Patient/Family-Centered, Team-Based Care; Effective Communication
- Recruiting/Retaining Qualified Clinicians
Key Points/HM Takeaways:
Medicaid Expansion- many of the 11.4M newly insured lives under the ACA have moved into Medicaid. Only about 1/3 of providers now accept Medicaid- 1 in 5 covered persons now have Medicaid, nearly 20% increase since 2013.
Bundled Payments- Majority of savings opportunity lies in Post-Acute Care. Awardee and Convener make profit is total cost is less than 98% of Target Price. In gainsharing agreements individuals can be reimbursed up to 150% usual Medicare rate. Pay occurs in usual Medicare fashion but is reconciled 60-90 days after end of bundle. For more information: http://innovation.cms.gov/initiatives/bundled-payments/
Effective HM Groups- Three important areas for focus when beginning to address group performance are: engaged hospitalists, planning and management infrastructure, care coordination across settings. These three topics have broad reaching implications into the hospitalist practice and patient care. [Cawley P, et al. Journal of Hospital Medicine 2014; 9(2):123-128]
LISTEN NOW: Amy Boutwell, MD, MPP provides tips on improving care transitions
Amy Boutwell, MD, MPP, a hospitalist and founder of Collaborative Healthcare Strategies, talks about what clinicians can do to help improve care transitions based on her experience directing IHI’s STAAR Initiative (State-Action on Avoidable Re-hospitalizations).
Amy Boutwell, MD, MPP, a hospitalist and founder of Collaborative Healthcare Strategies, talks about what clinicians can do to help improve care transitions based on her experience directing IHI’s STAAR Initiative (State-Action on Avoidable Re-hospitalizations).
Amy Boutwell, MD, MPP, a hospitalist and founder of Collaborative Healthcare Strategies, talks about what clinicians can do to help improve care transitions based on her experience directing IHI’s STAAR Initiative (State-Action on Avoidable Re-hospitalizations).
LISTEN NOW: Eric Howell, MD, SFHM discusses care transitions and readmissions
Johns Hopkins hospitalist Eric Howell, MD, SFHM, discusses connections between SHM, hospitalist practices, handoffs, and successful care transitions.
Johns Hopkins hospitalist Eric Howell, MD, SFHM, discusses connections between SHM, hospitalist practices, handoffs, and successful care transitions.
Johns Hopkins hospitalist Eric Howell, MD, SFHM, discusses connections between SHM, hospitalist practices, handoffs, and successful care transitions.
The Biggest Thing in Hospital Medicine Since Patient Safety?
Editor’s note: First of a two-part series examining bundled payments and hospital medicine. Additionally, Dr. Whitcomb works for a company that is an Awardee Convener in the CMS Bundled Payments for Care Improvement (BPCI) Initiative.
The Centers for Medicare and Medicaid Services’ (CMS) bundled payment initiative was announced in August 2011 and has been “live” since October 2013, when a handful of healthcare systems launched bundled payment programs. In 2014, the CMS initiative grew substantially as a result of large-scale interest on the part of hospitals, physician groups, skilled nursing facilities (SNFs), and others in testing the model, which can be described as a single payment for an episode of care.
The BPCI initiative will be a large-scale program by July 1; it starts with an April 1 cohort launch and will result in the program’s presence in all 50 states, with hundreds of physician practices and hospitals participating. The 2015 cohort will involve a large number of hospitalist practices, participating as “episode initiators” that bear clinical and economic responsibility for the bundle, or as “gainsharers” who are eligible to receive incentive payments if they can reduce costs while maintaining measurable quality for an episode of care.
How Does Bundled Payment Work?
The BPCI initiative is a large-scale, three- to five-year demonstration to test bundled payment in patients with fee-for-service Medicare. The most common model, referred to as Model 2, involves an inpatient hospitalization for one of 48 defined episodes, which include both medical and surgical conditions, followed by a recovery period lasting 30, 60, or 90 days.
Each hospital or physician practice that is considering entering the BPCI program receives prices for all 48 episodes based on a 2009-2012 historical average of Medicare part A and B claims associated with that hospital or physician group. After analyzing those prices, the hospital or physician practice may elect to choose the bundles that have a good chance of being successful—where actual spending comes in under the historical target price—based on care improvement expectations in their local system. In Model 2, CMS takes 2% off the target price for 90-day episodes and 3% off the target price for 30- and 60-day episodes, making it all the more important to choose bundles that demonstrate a high likelihood of success.
The revenue cycle for hospitals and physicians in the program does not change. They submit claims for their services and receive reimbursement as they always have; however, after the end of each quarter, when the majority of part A and B claims have been processed, a “look back” at actual spending for all participating episodes is reconciled against the baseline price derived from 2009-2012. If there is a net savings compared to the baseline, monies can be distributed to the participating providers—the hospital or physician practice—and those providers may further share some of the savings with other physicians/providers who have signed a gainsharing contract.
Hospitalists and BPCI
Hospitalist practices participate in the CMS program either as episode initiators or gainsharers. As episode initiators, they “own” the bundle, which means they bear economic risk for the program. In this capacity, overall savings will mean the hospitalist practice has a new revenue stream, which could be substantial; however, the practice is also responsible for any losses.
Other hospitalist practices have become gainsharers in the program, which means they have signed an agreement enabling them to receive payments in addition to professional fee revenues for activities that reduce costs while maintaining or improving quality. Such activities are referred to as “care redesign” in the program. Gainsharers do not bear financial risk.
Where Will Savings Come From?
Perhaps ironically for hospitalists, the main source of savings in the BPCI program comes from post-acute care and readmissions. For example, for common conditions like heart failure, COPD, and pneumonia, Medicare spends almost as much on post-acute care and readmissions in the first 30 days after discharge as it does on the index hospitalization.1 As a result, the BPCI program adds further emphasis on preventing readmissions when added to existing pressures, and there is a new premium placed on “right-sizing” the usage of SNF and other post-acute facilities, such as inpatient rehabilitation and long-term acute care hospitals. For hospitalists, this means that new rigor is needed to connect to the post-acute setting, such as determining why a patient is being discharged to a skilled facility.
Another savings pool, called “internal cost savings,” is available to reward decreasing inpatient utilization from, for example, testing, imaging, and implantable devices.
Conclusion
Bundled payment might be the biggest thing to come along for hospitalists since the patient safety movement launched some 16 years ago. Why? Although accountable care organizations have largely focused on ambulatory practice, bundled payment has a major focus on hospital care and on the post-acute care decisions that are made during the hospitalization. If bundled payment proves to be an effective way to pay for—and organize—care, hospitalists will play a central role in the success of this innovation.
In part two of this series, I will explore specific roles hospitalists play in successful bundled payment programs.
Reference
Editor’s note: First of a two-part series examining bundled payments and hospital medicine. Additionally, Dr. Whitcomb works for a company that is an Awardee Convener in the CMS Bundled Payments for Care Improvement (BPCI) Initiative.
The Centers for Medicare and Medicaid Services’ (CMS) bundled payment initiative was announced in August 2011 and has been “live” since October 2013, when a handful of healthcare systems launched bundled payment programs. In 2014, the CMS initiative grew substantially as a result of large-scale interest on the part of hospitals, physician groups, skilled nursing facilities (SNFs), and others in testing the model, which can be described as a single payment for an episode of care.
The BPCI initiative will be a large-scale program by July 1; it starts with an April 1 cohort launch and will result in the program’s presence in all 50 states, with hundreds of physician practices and hospitals participating. The 2015 cohort will involve a large number of hospitalist practices, participating as “episode initiators” that bear clinical and economic responsibility for the bundle, or as “gainsharers” who are eligible to receive incentive payments if they can reduce costs while maintaining measurable quality for an episode of care.
How Does Bundled Payment Work?
The BPCI initiative is a large-scale, three- to five-year demonstration to test bundled payment in patients with fee-for-service Medicare. The most common model, referred to as Model 2, involves an inpatient hospitalization for one of 48 defined episodes, which include both medical and surgical conditions, followed by a recovery period lasting 30, 60, or 90 days.
Each hospital or physician practice that is considering entering the BPCI program receives prices for all 48 episodes based on a 2009-2012 historical average of Medicare part A and B claims associated with that hospital or physician group. After analyzing those prices, the hospital or physician practice may elect to choose the bundles that have a good chance of being successful—where actual spending comes in under the historical target price—based on care improvement expectations in their local system. In Model 2, CMS takes 2% off the target price for 90-day episodes and 3% off the target price for 30- and 60-day episodes, making it all the more important to choose bundles that demonstrate a high likelihood of success.
The revenue cycle for hospitals and physicians in the program does not change. They submit claims for their services and receive reimbursement as they always have; however, after the end of each quarter, when the majority of part A and B claims have been processed, a “look back” at actual spending for all participating episodes is reconciled against the baseline price derived from 2009-2012. If there is a net savings compared to the baseline, monies can be distributed to the participating providers—the hospital or physician practice—and those providers may further share some of the savings with other physicians/providers who have signed a gainsharing contract.
Hospitalists and BPCI
Hospitalist practices participate in the CMS program either as episode initiators or gainsharers. As episode initiators, they “own” the bundle, which means they bear economic risk for the program. In this capacity, overall savings will mean the hospitalist practice has a new revenue stream, which could be substantial; however, the practice is also responsible for any losses.
Other hospitalist practices have become gainsharers in the program, which means they have signed an agreement enabling them to receive payments in addition to professional fee revenues for activities that reduce costs while maintaining or improving quality. Such activities are referred to as “care redesign” in the program. Gainsharers do not bear financial risk.
Where Will Savings Come From?
Perhaps ironically for hospitalists, the main source of savings in the BPCI program comes from post-acute care and readmissions. For example, for common conditions like heart failure, COPD, and pneumonia, Medicare spends almost as much on post-acute care and readmissions in the first 30 days after discharge as it does on the index hospitalization.1 As a result, the BPCI program adds further emphasis on preventing readmissions when added to existing pressures, and there is a new premium placed on “right-sizing” the usage of SNF and other post-acute facilities, such as inpatient rehabilitation and long-term acute care hospitals. For hospitalists, this means that new rigor is needed to connect to the post-acute setting, such as determining why a patient is being discharged to a skilled facility.
Another savings pool, called “internal cost savings,” is available to reward decreasing inpatient utilization from, for example, testing, imaging, and implantable devices.
Conclusion
Bundled payment might be the biggest thing to come along for hospitalists since the patient safety movement launched some 16 years ago. Why? Although accountable care organizations have largely focused on ambulatory practice, bundled payment has a major focus on hospital care and on the post-acute care decisions that are made during the hospitalization. If bundled payment proves to be an effective way to pay for—and organize—care, hospitalists will play a central role in the success of this innovation.
In part two of this series, I will explore specific roles hospitalists play in successful bundled payment programs.
Reference
Editor’s note: First of a two-part series examining bundled payments and hospital medicine. Additionally, Dr. Whitcomb works for a company that is an Awardee Convener in the CMS Bundled Payments for Care Improvement (BPCI) Initiative.
The Centers for Medicare and Medicaid Services’ (CMS) bundled payment initiative was announced in August 2011 and has been “live” since October 2013, when a handful of healthcare systems launched bundled payment programs. In 2014, the CMS initiative grew substantially as a result of large-scale interest on the part of hospitals, physician groups, skilled nursing facilities (SNFs), and others in testing the model, which can be described as a single payment for an episode of care.
The BPCI initiative will be a large-scale program by July 1; it starts with an April 1 cohort launch and will result in the program’s presence in all 50 states, with hundreds of physician practices and hospitals participating. The 2015 cohort will involve a large number of hospitalist practices, participating as “episode initiators” that bear clinical and economic responsibility for the bundle, or as “gainsharers” who are eligible to receive incentive payments if they can reduce costs while maintaining measurable quality for an episode of care.
How Does Bundled Payment Work?
The BPCI initiative is a large-scale, three- to five-year demonstration to test bundled payment in patients with fee-for-service Medicare. The most common model, referred to as Model 2, involves an inpatient hospitalization for one of 48 defined episodes, which include both medical and surgical conditions, followed by a recovery period lasting 30, 60, or 90 days.
Each hospital or physician practice that is considering entering the BPCI program receives prices for all 48 episodes based on a 2009-2012 historical average of Medicare part A and B claims associated with that hospital or physician group. After analyzing those prices, the hospital or physician practice may elect to choose the bundles that have a good chance of being successful—where actual spending comes in under the historical target price—based on care improvement expectations in their local system. In Model 2, CMS takes 2% off the target price for 90-day episodes and 3% off the target price for 30- and 60-day episodes, making it all the more important to choose bundles that demonstrate a high likelihood of success.
The revenue cycle for hospitals and physicians in the program does not change. They submit claims for their services and receive reimbursement as they always have; however, after the end of each quarter, when the majority of part A and B claims have been processed, a “look back” at actual spending for all participating episodes is reconciled against the baseline price derived from 2009-2012. If there is a net savings compared to the baseline, monies can be distributed to the participating providers—the hospital or physician practice—and those providers may further share some of the savings with other physicians/providers who have signed a gainsharing contract.
Hospitalists and BPCI
Hospitalist practices participate in the CMS program either as episode initiators or gainsharers. As episode initiators, they “own” the bundle, which means they bear economic risk for the program. In this capacity, overall savings will mean the hospitalist practice has a new revenue stream, which could be substantial; however, the practice is also responsible for any losses.
Other hospitalist practices have become gainsharers in the program, which means they have signed an agreement enabling them to receive payments in addition to professional fee revenues for activities that reduce costs while maintaining or improving quality. Such activities are referred to as “care redesign” in the program. Gainsharers do not bear financial risk.
Where Will Savings Come From?
Perhaps ironically for hospitalists, the main source of savings in the BPCI program comes from post-acute care and readmissions. For example, for common conditions like heart failure, COPD, and pneumonia, Medicare spends almost as much on post-acute care and readmissions in the first 30 days after discharge as it does on the index hospitalization.1 As a result, the BPCI program adds further emphasis on preventing readmissions when added to existing pressures, and there is a new premium placed on “right-sizing” the usage of SNF and other post-acute facilities, such as inpatient rehabilitation and long-term acute care hospitals. For hospitalists, this means that new rigor is needed to connect to the post-acute setting, such as determining why a patient is being discharged to a skilled facility.
Another savings pool, called “internal cost savings,” is available to reward decreasing inpatient utilization from, for example, testing, imaging, and implantable devices.
Conclusion
Bundled payment might be the biggest thing to come along for hospitalists since the patient safety movement launched some 16 years ago. Why? Although accountable care organizations have largely focused on ambulatory practice, bundled payment has a major focus on hospital care and on the post-acute care decisions that are made during the hospitalization. If bundled payment proves to be an effective way to pay for—and organize—care, hospitalists will play a central role in the success of this innovation.
In part two of this series, I will explore specific roles hospitalists play in successful bundled payment programs.