SHM's Policy Corner

The 2010 Affordable Care Act (ACA) mandates a hospital value-based purchasing (VBP) program to begin this time next year. But hospitalists should start preparing now to be integral parts of the program in their hospitals.

Though the ACA provision states the VBP program for hospital payments will begin with discharges on Oct. 1, 2012, performance on clinical quality and patient experience measures began impacting hospitals’ bottom lines on July 1, 2011. The VBP’s “baseline period” actually lasted from July 1, 2009, through March 31, 2010. The performance period started July 1 and will last through March 31, 2012.

On Aug. 2, 2012, CMS will notify hospitals of estimated performance scores, delivering the actual performance scores on Nov. 1, 2012. The result: Payments for any discharge on or after Oct. 1, 2012 (the beginning of fiscal-year 2013), will be paid based on the performance period currently under way.

Hospitalists and program leaders might wonder how an ACA provision could start before the ACA was passed. The HVBP program actually is a transition of the well-established “Reporting Hospital Quality Data for Annual Payment Update,” or pay-for-reporting program, which in 2003 initially provided a 0.4% payment differential for public reporting through the Hospital Compare website. The 2005 Deficit Reduction Act increased the payment to 2%, and authorized CMS to develop a HVBP plan for FY2009—it just didn’t materialize.

The ACA created the HVBP program with the intention of transforming Medicare from a passive payor to an active purchaser of higher-quality, more efficient healthcare. In essence, Medicare wants to pay for performance rather than simply accurate reporting.

So hospitalists once again are faced with partnering with their hospitals to ensure payout. Reducing a hospital’s base operating Medicare Severity Diagnosis Related Groups (MS-DRG) by the applicable percentage, which will be phased in through 2017 (starting at 1% in 2013 and increasing 0.25% each year), will generate the HVBP’s source of ongoing incentive payments.

To help, SHM this month launched the “Hospital Value-Based Purchasing Toolkit.” It will help hospitalists and hospital executives gain a better understanding of what all the information above really means (including performance measures), and what to expect when your performance scores arrive.

The toolkit is different from any other product SHM has ever produced, as subscribers will be added to their own social collaboration network, similar to a tool like LinkedIn, putting them in touch with our panel of experts and other subscribers across the nation. We also will be putting on a series of roundtables: short presentations from a subject or quality-measure expert, followed by an opportunity to ask questions of our HVBP panel. All of the information will be based on best practices pulled from case studies we have spent the last 12 months scouring the country for. Most important, the best practices will be hospitalist-relevant. The free portal to the toolkit, which includes detailed background information on each piece of the program, can be accessed at www.hospitalmedicine.org/hvbp.

A subscription to the full toolkit can be purchased through the SHM store.

The 2010 Affordable Care Act (ACA) mandates a hospital value-based purchasing (VBP) program to begin this time next year. But hospitalists should start preparing now to be integral parts of the program in their hospitals.

Though the ACA provision states the VBP program for hospital payments will begin with discharges on Oct. 1, 2012, performance on clinical quality and patient experience measures began impacting hospitals’ bottom lines on July 1, 2011. The VBP’s “baseline period” actually lasted from July 1, 2009, through March 31, 2010. The performance period started July 1 and will last through March 31, 2012.

On Aug. 2, 2012, CMS will notify hospitals of estimated performance scores, delivering the actual performance scores on Nov. 1, 2012. The result: Payments for any discharge on or after Oct. 1, 2012 (the beginning of fiscal-year 2013), will be paid based on the performance period currently under way.

Hospitalists and program leaders might wonder how an ACA provision could start before the ACA was passed. The HVBP program actually is a transition of the well-established “Reporting Hospital Quality Data for Annual Payment Update,” or pay-for-reporting program, which in 2003 initially provided a 0.4% payment differential for public reporting through the Hospital Compare website. The 2005 Deficit Reduction Act increased the payment to 2%, and authorized CMS to develop a HVBP plan for FY2009—it just didn’t materialize.

The ACA created the HVBP program with the intention of transforming Medicare from a passive payor to an active purchaser of higher-quality, more efficient healthcare. In essence, Medicare wants to pay for performance rather than simply accurate reporting.

So hospitalists once again are faced with partnering with their hospitals to ensure payout. Reducing a hospital’s base operating Medicare Severity Diagnosis Related Groups (MS-DRG) by the applicable percentage, which will be phased in through 2017 (starting at 1% in 2013 and increasing 0.25% each year), will generate the HVBP’s source of ongoing incentive payments.

To help, SHM this month launched the “Hospital Value-Based Purchasing Toolkit.” It will help hospitalists and hospital executives gain a better understanding of what all the information above really means (including performance measures), and what to expect when your performance scores arrive.

The toolkit is different from any other product SHM has ever produced, as subscribers will be added to their own social collaboration network, similar to a tool like LinkedIn, putting them in touch with our panel of experts and other subscribers across the nation. We also will be putting on a series of roundtables: short presentations from a subject or quality-measure expert, followed by an opportunity to ask questions of our HVBP panel. All of the information will be based on best practices pulled from case studies we have spent the last 12 months scouring the country for. Most important, the best practices will be hospitalist-relevant. The free portal to the toolkit, which includes detailed background information on each piece of the program, can be accessed at www.hospitalmedicine.org/hvbp.

A subscription to the full toolkit can be purchased through the SHM store.

The 2010 Affordable Care Act (ACA) mandates a hospital value-based purchasing (VBP) program to begin this time next year. But hospitalists should start preparing now to be integral parts of the program in their hospitals.

Though the ACA provision states the VBP program for hospital payments will begin with discharges on Oct. 1, 2012, performance on clinical quality and patient experience measures began impacting hospitals’ bottom lines on July 1, 2011. The VBP’s “baseline period” actually lasted from July 1, 2009, through March 31, 2010. The performance period started July 1 and will last through March 31, 2012.

On Aug. 2, 2012, CMS will notify hospitals of estimated performance scores, delivering the actual performance scores on Nov. 1, 2012. The result: Payments for any discharge on or after Oct. 1, 2012 (the beginning of fiscal-year 2013), will be paid based on the performance period currently under way.

Hospitalists and program leaders might wonder how an ACA provision could start before the ACA was passed. The HVBP program actually is a transition of the well-established “Reporting Hospital Quality Data for Annual Payment Update,” or pay-for-reporting program, which in 2003 initially provided a 0.4% payment differential for public reporting through the Hospital Compare website. The 2005 Deficit Reduction Act increased the payment to 2%, and authorized CMS to develop a HVBP plan for FY2009—it just didn’t materialize.

The ACA created the HVBP program with the intention of transforming Medicare from a passive payor to an active purchaser of higher-quality, more efficient healthcare. In essence, Medicare wants to pay for performance rather than simply accurate reporting.

So hospitalists once again are faced with partnering with their hospitals to ensure payout. Reducing a hospital’s base operating Medicare Severity Diagnosis Related Groups (MS-DRG) by the applicable percentage, which will be phased in through 2017 (starting at 1% in 2013 and increasing 0.25% each year), will generate the HVBP’s source of ongoing incentive payments.

To help, SHM this month launched the “Hospital Value-Based Purchasing Toolkit.” It will help hospitalists and hospital executives gain a better understanding of what all the information above really means (including performance measures), and what to expect when your performance scores arrive.

The toolkit is different from any other product SHM has ever produced, as subscribers will be added to their own social collaboration network, similar to a tool like LinkedIn, putting them in touch with our panel of experts and other subscribers across the nation. We also will be putting on a series of roundtables: short presentations from a subject or quality-measure expert, followed by an opportunity to ask questions of our HVBP panel. All of the information will be based on best practices pulled from case studies we have spent the last 12 months scouring the country for. Most important, the best practices will be hospitalist-relevant. The free portal to the toolkit, which includes detailed background information on each piece of the program, can be accessed at www.hospitalmedicine.org/hvbp.

A subscription to the full toolkit can be purchased through the SHM store.

Section 10332 of the Affordable Care Act (ACA) allows the Centers for Medicare & Medicaid Services (CMS) to provide Medicare claims data to “qualified” private organizations for the purpose of reporting provider performance information. On June 8, CMS issued a proposed rule that includes tight parameters on who qualifies to receive the data, beneficiary privacy protections, and the rights of providers to correct errors before reports are made public. CMS also included estimates of the fees to receive the claims data: $275,000.

The fees are not a price as much as an effort to recoup the expense associated with providing the data. CMS has interpreted expenses to include the cost of providing technical assistance, processing qualified entities’ applications, and monitoring of qualified entities to ensure appropriate use of the data and appropriate adherence to data privacy and security standards.

For hospitalists, the opportunity to access this data presents both positives and negatives. On the positive side, research and QI data sources will be greatly expanded. Currently, it is not unheard of to receive multiple, sometimes contradictory, reports from different sources because they are based on different data from piecemeal claims or measures. This initiative grants the ability to combine private sector data with the enormous amount of data at CMS, which should result in the more useful quality reports. This broad pool of data also will allow for a new level of accuracy when it comes to analyzing quality, efficiency, and resource use.

On the negative side, the expense of obtaining this data could be cost-prohibitive for smaller organizations, and access could end up being limited to those with deeper pockets. Additionally, it will be critical to identify errors and inaccuracies in reports. As a result, hospitalists could be forced to spend time and resources reviewing privately produced performance reports before they are made public.

There is potential in this initiative to change the quality measurement landscape. If done well, the opportunity to combine claims data from both Medicare and the private sector will produce a wealth of information related to how providers and suppliers are performing.

SHM will be voicing support for the concept because it serves to increase performance transparency, not just for hospitalists but for all stakeholders.

Ready to Lead Hospital Medicine?

Join an SHM Committee

Dr. Li

When Kim Dickinson, MD, joined SHM’s Administrators Committee, it expanded her network of HM professionals. It also gave her an opportunity to take some of the best practices in the specialty to others within her company.

For other hospitalists interested in flexing leadership muscles and growing their network of hospitalists, now is the time to apply for positions on more than 30 of SHM’s committees and task forces. Potential applicants are encouraged to apply before January 2012.

Committee information and applications are available at www.hospitalmedicine.org/committees.

“SHM’s committees and task forces are the engines that drive SHM toward a vision of transforming healthcare and revolutionizing patient care in the hospital,” says SHM president Joseph Li, MD, SFHM. “And the broad span of issues covered by our committees gives every aspiring hospitalist an opportunity to channel their energy into something meaningful.”

Dr. Dickinson sees committee participation as a way to learn and grow.

“I always tell people about being on committees,” she says. “It’s a good learning experience for people, and it exposes you to a wide variety of people and different perspectives. What applies to a four-member group is very different than what applies to 40-member group.

“A lot of learning that can come from that.”

SHM’s Atchley Leadership Fund Supports the Next Generation of Hospitalist Leaders

Dr. Atchley

Hospitalist Bill Atchley, MD, SFHM, was there at the beginning of SHM’s Leadership Academy. Now, he’s helping it to endure.

After participating in the first Leadership Academy, he was hooked on the concept and later became a course facilitator.

As much as Bill has been a fixture at Leadership Academy, so has his wife, Anne. There, she saw firsthand her husband’s passion not only for the specialty, but also his passion for helping groom the next generation of hospitalist leaders. The academies also were the place where many got to see Bill and Anne together after hours, a scene that reminds hospitalists that leadership is not a solitary journey, but one to embark on with both colleagues and those closest to us.

When Anne passed in December 2009, following a valiant fight against cancer, Bill worked with SHM to create the Atchley Leadership Fund. The fund honors Anne’s memory by providing partial scholarships for Leadership Academy participants.

Hospitalists can join Bill in paying tribute to Anne and paving the way for new hospitalist leaders in healthcare by making a tax-free donation to the Atchley Leadership Fund. For more information, visit www.hospitalmedicine.org/atchley.

Section 10332 of the Affordable Care Act (ACA) allows the Centers for Medicare & Medicaid Services (CMS) to provide Medicare claims data to “qualified” private organizations for the purpose of reporting provider performance information. On June 8, CMS issued a proposed rule that includes tight parameters on who qualifies to receive the data, beneficiary privacy protections, and the rights of providers to correct errors before reports are made public. CMS also included estimates of the fees to receive the claims data: $275,000.

The fees are not a price as much as an effort to recoup the expense associated with providing the data. CMS has interpreted expenses to include the cost of providing technical assistance, processing qualified entities’ applications, and monitoring of qualified entities to ensure appropriate use of the data and appropriate adherence to data privacy and security standards.

For hospitalists, the opportunity to access this data presents both positives and negatives. On the positive side, research and QI data sources will be greatly expanded. Currently, it is not unheard of to receive multiple, sometimes contradictory, reports from different sources because they are based on different data from piecemeal claims or measures. This initiative grants the ability to combine private sector data with the enormous amount of data at CMS, which should result in the more useful quality reports. This broad pool of data also will allow for a new level of accuracy when it comes to analyzing quality, efficiency, and resource use.

On the negative side, the expense of obtaining this data could be cost-prohibitive for smaller organizations, and access could end up being limited to those with deeper pockets. Additionally, it will be critical to identify errors and inaccuracies in reports. As a result, hospitalists could be forced to spend time and resources reviewing privately produced performance reports before they are made public.

There is potential in this initiative to change the quality measurement landscape. If done well, the opportunity to combine claims data from both Medicare and the private sector will produce a wealth of information related to how providers and suppliers are performing.

SHM will be voicing support for the concept because it serves to increase performance transparency, not just for hospitalists but for all stakeholders.

Ready to Lead Hospital Medicine?

Join an SHM Committee

Dr. Li

When Kim Dickinson, MD, joined SHM’s Administrators Committee, it expanded her network of HM professionals. It also gave her an opportunity to take some of the best practices in the specialty to others within her company.

For other hospitalists interested in flexing leadership muscles and growing their network of hospitalists, now is the time to apply for positions on more than 30 of SHM’s committees and task forces. Potential applicants are encouraged to apply before January 2012.

Committee information and applications are available at www.hospitalmedicine.org/committees.

“SHM’s committees and task forces are the engines that drive SHM toward a vision of transforming healthcare and revolutionizing patient care in the hospital,” says SHM president Joseph Li, MD, SFHM. “And the broad span of issues covered by our committees gives every aspiring hospitalist an opportunity to channel their energy into something meaningful.”

Dr. Dickinson sees committee participation as a way to learn and grow.

“I always tell people about being on committees,” she says. “It’s a good learning experience for people, and it exposes you to a wide variety of people and different perspectives. What applies to a four-member group is very different than what applies to 40-member group.

“A lot of learning that can come from that.”

SHM’s Atchley Leadership Fund Supports the Next Generation of Hospitalist Leaders

Dr. Atchley

Hospitalist Bill Atchley, MD, SFHM, was there at the beginning of SHM’s Leadership Academy. Now, he’s helping it to endure.

After participating in the first Leadership Academy, he was hooked on the concept and later became a course facilitator.

As much as Bill has been a fixture at Leadership Academy, so has his wife, Anne. There, she saw firsthand her husband’s passion not only for the specialty, but also his passion for helping groom the next generation of hospitalist leaders. The academies also were the place where many got to see Bill and Anne together after hours, a scene that reminds hospitalists that leadership is not a solitary journey, but one to embark on with both colleagues and those closest to us.

When Anne passed in December 2009, following a valiant fight against cancer, Bill worked with SHM to create the Atchley Leadership Fund. The fund honors Anne’s memory by providing partial scholarships for Leadership Academy participants.

Hospitalists can join Bill in paying tribute to Anne and paving the way for new hospitalist leaders in healthcare by making a tax-free donation to the Atchley Leadership Fund. For more information, visit www.hospitalmedicine.org/atchley.

Section 10332 of the Affordable Care Act (ACA) allows the Centers for Medicare & Medicaid Services (CMS) to provide Medicare claims data to “qualified” private organizations for the purpose of reporting provider performance information. On June 8, CMS issued a proposed rule that includes tight parameters on who qualifies to receive the data, beneficiary privacy protections, and the rights of providers to correct errors before reports are made public. CMS also included estimates of the fees to receive the claims data: $275,000.

The fees are not a price as much as an effort to recoup the expense associated with providing the data. CMS has interpreted expenses to include the cost of providing technical assistance, processing qualified entities’ applications, and monitoring of qualified entities to ensure appropriate use of the data and appropriate adherence to data privacy and security standards.

For hospitalists, the opportunity to access this data presents both positives and negatives. On the positive side, research and QI data sources will be greatly expanded. Currently, it is not unheard of to receive multiple, sometimes contradictory, reports from different sources because they are based on different data from piecemeal claims or measures. This initiative grants the ability to combine private sector data with the enormous amount of data at CMS, which should result in the more useful quality reports. This broad pool of data also will allow for a new level of accuracy when it comes to analyzing quality, efficiency, and resource use.

On the negative side, the expense of obtaining this data could be cost-prohibitive for smaller organizations, and access could end up being limited to those with deeper pockets. Additionally, it will be critical to identify errors and inaccuracies in reports. As a result, hospitalists could be forced to spend time and resources reviewing privately produced performance reports before they are made public.

There is potential in this initiative to change the quality measurement landscape. If done well, the opportunity to combine claims data from both Medicare and the private sector will produce a wealth of information related to how providers and suppliers are performing.

SHM will be voicing support for the concept because it serves to increase performance transparency, not just for hospitalists but for all stakeholders.

Ready to Lead Hospital Medicine?

Join an SHM Committee

Dr. Li

When Kim Dickinson, MD, joined SHM’s Administrators Committee, it expanded her network of HM professionals. It also gave her an opportunity to take some of the best practices in the specialty to others within her company.

For other hospitalists interested in flexing leadership muscles and growing their network of hospitalists, now is the time to apply for positions on more than 30 of SHM’s committees and task forces. Potential applicants are encouraged to apply before January 2012.

Committee information and applications are available at www.hospitalmedicine.org/committees.

“SHM’s committees and task forces are the engines that drive SHM toward a vision of transforming healthcare and revolutionizing patient care in the hospital,” says SHM president Joseph Li, MD, SFHM. “And the broad span of issues covered by our committees gives every aspiring hospitalist an opportunity to channel their energy into something meaningful.”

Dr. Dickinson sees committee participation as a way to learn and grow.

“I always tell people about being on committees,” she says. “It’s a good learning experience for people, and it exposes you to a wide variety of people and different perspectives. What applies to a four-member group is very different than what applies to 40-member group.

“A lot of learning that can come from that.”

SHM’s Atchley Leadership Fund Supports the Next Generation of Hospitalist Leaders

Dr. Atchley

Hospitalist Bill Atchley, MD, SFHM, was there at the beginning of SHM’s Leadership Academy. Now, he’s helping it to endure.

After participating in the first Leadership Academy, he was hooked on the concept and later became a course facilitator.

As much as Bill has been a fixture at Leadership Academy, so has his wife, Anne. There, she saw firsthand her husband’s passion not only for the specialty, but also his passion for helping groom the next generation of hospitalist leaders. The academies also were the place where many got to see Bill and Anne together after hours, a scene that reminds hospitalists that leadership is not a solitary journey, but one to embark on with both colleagues and those closest to us.

When Anne passed in December 2009, following a valiant fight against cancer, Bill worked with SHM to create the Atchley Leadership Fund. The fund honors Anne’s memory by providing partial scholarships for Leadership Academy participants.

Hospitalists can join Bill in paying tribute to Anne and paving the way for new hospitalist leaders in healthcare by making a tax-free donation to the Atchley Leadership Fund. For more information, visit www.hospitalmedicine.org/atchley.

The federal government is taking a hard look at many of its regulations, and hospitalists might have the chance to help identify those that no longer make sense.

On Jan. 18, President Obama issued Executive Order 13563, which calls, in part, for a comprehensive retrospective review of existing government regulations. The stated goal of this review is to improve or remove those rules that are out of date, unnecessary, excessively burdensome, or in conflict with other rules.

The Office of Information and Regulatory Affairs (OIRA), the executive-level department charged with overseeing the execution of this order, asked federal agencies to submit preliminary plans for how they will conduct their internal reviews. The agencies responded, and on May 26, the White House released 30 agency preliminary plans to the public, including those prepared by the Department of Commerce, the Department of Energy, and the Department of Health and Human Services (HHS).

When reviewing some of these publicly available preliminary plans, the easy answer for some observers is to say that most rules should be eliminated. Rules requiring the use of such technologies as film X-rays instead of digital images are obvious culprits in the out-of date category; rules defining milk as "oil" (subjecting it to the same costly environmental safeguards as real oil) are just as absurd. Both of these regulations are being lifted as a result of the review.

In contrast, many rules actually do protect public health and safety and will not be subject to review. For example, as a result of federal rulemaking, highway deaths are at the lowest level in 60 years and the risk of contracting salmonella from eggs is relatively low.

As part of HHS, the Center for Medicare & Medicaid Services (CMS) specifically stated that "the goal of the retrospective review will be to identify opportunities to improve patient care and outcomes and reduce system costs by removing obsolete or burdensome requirements." A major CMS concern will be to prevent the elimination or revision of a regulation only to find that the problem it sought to solve resurfaces, or that its removal or revision results in unanticipated and more serious outcomes.

This review could significantly impact HM in areas of quality measurement and reporting requirements:

• What quality measurements might not accomplish their intent?
• What measures might result in more harm than good?
• What reporting or process requirements could be changed to make for less duplication?
• If requirements cannot be eliminated, how can they be improved?

Due to hospitalist expertise in quality-improvement (QI) efforts and cost containment, these stated goals and the concerns that come with them are areas where hospitalists are likely to have some good answers. Hospitalists should not hesitate to provide their input to SHM Government Relations staff so that your ideas can be shared with CMS.

A complete list of agency proposals is available at www.whitehouse.gov/21stcentury gov/actions/21st-century-regulatory-system.

The federal government is taking a hard look at many of its regulations, and hospitalists might have the chance to help identify those that no longer make sense.

On Jan. 18, President Obama issued Executive Order 13563, which calls, in part, for a comprehensive retrospective review of existing government regulations. The stated goal of this review is to improve or remove those rules that are out of date, unnecessary, excessively burdensome, or in conflict with other rules.

The Office of Information and Regulatory Affairs (OIRA), the executive-level department charged with overseeing the execution of this order, asked federal agencies to submit preliminary plans for how they will conduct their internal reviews. The agencies responded, and on May 26, the White House released 30 agency preliminary plans to the public, including those prepared by the Department of Commerce, the Department of Energy, and the Department of Health and Human Services (HHS).

When reviewing some of these publicly available preliminary plans, the easy answer for some observers is to say that most rules should be eliminated. Rules requiring the use of such technologies as film X-rays instead of digital images are obvious culprits in the out-of date category; rules defining milk as "oil" (subjecting it to the same costly environmental safeguards as real oil) are just as absurd. Both of these regulations are being lifted as a result of the review.

In contrast, many rules actually do protect public health and safety and will not be subject to review. For example, as a result of federal rulemaking, highway deaths are at the lowest level in 60 years and the risk of contracting salmonella from eggs is relatively low.

As part of HHS, the Center for Medicare & Medicaid Services (CMS) specifically stated that "the goal of the retrospective review will be to identify opportunities to improve patient care and outcomes and reduce system costs by removing obsolete or burdensome requirements." A major CMS concern will be to prevent the elimination or revision of a regulation only to find that the problem it sought to solve resurfaces, or that its removal or revision results in unanticipated and more serious outcomes.

This review could significantly impact HM in areas of quality measurement and reporting requirements:

• What quality measurements might not accomplish their intent?
• What measures might result in more harm than good?
• What reporting or process requirements could be changed to make for less duplication?
• If requirements cannot be eliminated, how can they be improved?

Due to hospitalist expertise in quality-improvement (QI) efforts and cost containment, these stated goals and the concerns that come with them are areas where hospitalists are likely to have some good answers. Hospitalists should not hesitate to provide their input to SHM Government Relations staff so that your ideas can be shared with CMS.

A complete list of agency proposals is available at www.whitehouse.gov/21stcentury gov/actions/21st-century-regulatory-system.

The federal government is taking a hard look at many of its regulations, and hospitalists might have the chance to help identify those that no longer make sense.

On Jan. 18, President Obama issued Executive Order 13563, which calls, in part, for a comprehensive retrospective review of existing government regulations. The stated goal of this review is to improve or remove those rules that are out of date, unnecessary, excessively burdensome, or in conflict with other rules.

The Office of Information and Regulatory Affairs (OIRA), the executive-level department charged with overseeing the execution of this order, asked federal agencies to submit preliminary plans for how they will conduct their internal reviews. The agencies responded, and on May 26, the White House released 30 agency preliminary plans to the public, including those prepared by the Department of Commerce, the Department of Energy, and the Department of Health and Human Services (HHS).

When reviewing some of these publicly available preliminary plans, the easy answer for some observers is to say that most rules should be eliminated. Rules requiring the use of such technologies as film X-rays instead of digital images are obvious culprits in the out-of date category; rules defining milk as "oil" (subjecting it to the same costly environmental safeguards as real oil) are just as absurd. Both of these regulations are being lifted as a result of the review.

In contrast, many rules actually do protect public health and safety and will not be subject to review. For example, as a result of federal rulemaking, highway deaths are at the lowest level in 60 years and the risk of contracting salmonella from eggs is relatively low.

As part of HHS, the Center for Medicare & Medicaid Services (CMS) specifically stated that "the goal of the retrospective review will be to identify opportunities to improve patient care and outcomes and reduce system costs by removing obsolete or burdensome requirements." A major CMS concern will be to prevent the elimination or revision of a regulation only to find that the problem it sought to solve resurfaces, or that its removal or revision results in unanticipated and more serious outcomes.

This review could significantly impact HM in areas of quality measurement and reporting requirements:

• What quality measurements might not accomplish their intent?
• What measures might result in more harm than good?
• What reporting or process requirements could be changed to make for less duplication?
• If requirements cannot be eliminated, how can they be improved?

Due to hospitalist expertise in quality-improvement (QI) efforts and cost containment, these stated goals and the concerns that come with them are areas where hospitalists are likely to have some good answers. Hospitalists should not hesitate to provide their input to SHM Government Relations staff so that your ideas can be shared with CMS.

A complete list of agency proposals is available at www.whitehouse.gov/21stcentury gov/actions/21st-century-regulatory-system.

“ACO” is probably the most common acronym to come out of the Affordable Care Act of 2010 (ACA). Over the last several months, much of the public dialogue has focused on the confusion surrounding the “ACO Proposed Rule.” And now there are three new ACO initiatives, which were announced in May by the Centers for Medicare & Medicaid Services (CMS).

So, what’s the difference? And what does it mean for hospitalists?

The ACA provides multiple pathways to develop and support ACOs, or accountable-care organizations. The proposed rule released in March 2011 was for the Medicare Shared Savings Program (MSSP). Through this program, healthcare providers can join together in ACOs to integrate and coordinate services in return for a share of any savings to the Medicare program. These ACOs will be rewarded for lowering growth in Medicare costs while meeting performance standards on quality of care and putting patients first.

Three other initiatives from the newly created Center for Medicare and Medicaid Innovation give providers a broad range of options and support, and reflect the varying needs of providers in embarking on delivery system reforms. They are:

• Pioneer ACO Model: Provides a faster path for mature ACOs that already have begun coordinating care for patients. This model is estimated to save Medicare as much as $430 million over three years through better managing care for beneficiaries and eliminating duplication. It is designed to move away from the fee-for-service (FFS) payment model more quickly than its MSSP counterpart. In year three of the program, Pioneer ACOs that have shown savings over the first two years will be eligible to move to a population-based payment model. The MSSP version is based completely on FFS.
• Advance Payment ACO Initiative: Would allow certain ACOs participating in the MSSP access to a portion of their shared savings up front, helping providers make the infrastructure and staff investments crucial to successful ACOs.
• Accelerated Development Learning Sessions: These sessions will provide the executive leadership teams from existing or emerging ACO entities the opportunity to learn about essential ACO functions and ways to build capacity needed to achieve better care, better health, and lower costs through integrated care models. Three sessions will be offered in the fall: San Francisco in September, Philadelphia in October, and Atlanta in November. For more info, visit https://acoregister.rti.org.

For more information about ACOs, visit www.healthcare.gov.

How hospitalists will be impacted under the ACO model is largely up to the individual hospitalists. Hospitalists are uniquely positioned to lead the system-level changes and quality-improvement (QI) efforts that will be critical to ACO success, and will bring significant value to the ACO model due to the central role that many hospitalists play in promoting team-based care, care coordination, and improving transitions of care. All of these roles are critical to delivering higher-quality care more efficiently.

CMS has provided detailed information on the above programs via Healthcare.gov. SHM submitted comments on the Medicare Shared Savings Program and the Advance Payment ACO Initiative, which can be found in the Advocacy section of www.hospitalmedicine.org under “SHM Letters.” TH

“ACO” is probably the most common acronym to come out of the Affordable Care Act of 2010 (ACA). Over the last several months, much of the public dialogue has focused on the confusion surrounding the “ACO Proposed Rule.” And now there are three new ACO initiatives, which were announced in May by the Centers for Medicare & Medicaid Services (CMS).

So, what’s the difference? And what does it mean for hospitalists?

The ACA provides multiple pathways to develop and support ACOs, or accountable-care organizations. The proposed rule released in March 2011 was for the Medicare Shared Savings Program (MSSP). Through this program, healthcare providers can join together in ACOs to integrate and coordinate services in return for a share of any savings to the Medicare program. These ACOs will be rewarded for lowering growth in Medicare costs while meeting performance standards on quality of care and putting patients first.

Three other initiatives from the newly created Center for Medicare and Medicaid Innovation give providers a broad range of options and support, and reflect the varying needs of providers in embarking on delivery system reforms. They are:

• Pioneer ACO Model: Provides a faster path for mature ACOs that already have begun coordinating care for patients. This model is estimated to save Medicare as much as $430 million over three years through better managing care for beneficiaries and eliminating duplication. It is designed to move away from the fee-for-service (FFS) payment model more quickly than its MSSP counterpart. In year three of the program, Pioneer ACOs that have shown savings over the first two years will be eligible to move to a population-based payment model. The MSSP version is based completely on FFS.
• Advance Payment ACO Initiative: Would allow certain ACOs participating in the MSSP access to a portion of their shared savings up front, helping providers make the infrastructure and staff investments crucial to successful ACOs.
• Accelerated Development Learning Sessions: These sessions will provide the executive leadership teams from existing or emerging ACO entities the opportunity to learn about essential ACO functions and ways to build capacity needed to achieve better care, better health, and lower costs through integrated care models. Three sessions will be offered in the fall: San Francisco in September, Philadelphia in October, and Atlanta in November. For more info, visit https://acoregister.rti.org.

For more information about ACOs, visit www.healthcare.gov.

How hospitalists will be impacted under the ACO model is largely up to the individual hospitalists. Hospitalists are uniquely positioned to lead the system-level changes and quality-improvement (QI) efforts that will be critical to ACO success, and will bring significant value to the ACO model due to the central role that many hospitalists play in promoting team-based care, care coordination, and improving transitions of care. All of these roles are critical to delivering higher-quality care more efficiently.

CMS has provided detailed information on the above programs via Healthcare.gov. SHM submitted comments on the Medicare Shared Savings Program and the Advance Payment ACO Initiative, which can be found in the Advocacy section of www.hospitalmedicine.org under “SHM Letters.” TH

“ACO” is probably the most common acronym to come out of the Affordable Care Act of 2010 (ACA). Over the last several months, much of the public dialogue has focused on the confusion surrounding the “ACO Proposed Rule.” And now there are three new ACO initiatives, which were announced in May by the Centers for Medicare & Medicaid Services (CMS).

So, what’s the difference? And what does it mean for hospitalists?

The ACA provides multiple pathways to develop and support ACOs, or accountable-care organizations. The proposed rule released in March 2011 was for the Medicare Shared Savings Program (MSSP). Through this program, healthcare providers can join together in ACOs to integrate and coordinate services in return for a share of any savings to the Medicare program. These ACOs will be rewarded for lowering growth in Medicare costs while meeting performance standards on quality of care and putting patients first.

Three other initiatives from the newly created Center for Medicare and Medicaid Innovation give providers a broad range of options and support, and reflect the varying needs of providers in embarking on delivery system reforms. They are:

• Pioneer ACO Model: Provides a faster path for mature ACOs that already have begun coordinating care for patients. This model is estimated to save Medicare as much as $430 million over three years through better managing care for beneficiaries and eliminating duplication. It is designed to move away from the fee-for-service (FFS) payment model more quickly than its MSSP counterpart. In year three of the program, Pioneer ACOs that have shown savings over the first two years will be eligible to move to a population-based payment model. The MSSP version is based completely on FFS.
• Advance Payment ACO Initiative: Would allow certain ACOs participating in the MSSP access to a portion of their shared savings up front, helping providers make the infrastructure and staff investments crucial to successful ACOs.
• Accelerated Development Learning Sessions: These sessions will provide the executive leadership teams from existing or emerging ACO entities the opportunity to learn about essential ACO functions and ways to build capacity needed to achieve better care, better health, and lower costs through integrated care models. Three sessions will be offered in the fall: San Francisco in September, Philadelphia in October, and Atlanta in November. For more info, visit https://acoregister.rti.org.

For more information about ACOs, visit www.healthcare.gov.

How hospitalists will be impacted under the ACO model is largely up to the individual hospitalists. Hospitalists are uniquely positioned to lead the system-level changes and quality-improvement (QI) efforts that will be critical to ACO success, and will bring significant value to the ACO model due to the central role that many hospitalists play in promoting team-based care, care coordination, and improving transitions of care. All of these roles are critical to delivering higher-quality care more efficiently.

CMS has provided detailed information on the above programs via Healthcare.gov. SHM submitted comments on the Medicare Shared Savings Program and the Advance Payment ACO Initiative, which can be found in the Advocacy section of www.hospitalmedicine.org under “SHM Letters.” TH

As of April 1, physicians who order home care services for their Medicare patients are required to document that they had a face-to-face encounter with the patient prior to certifying the patient’s eligibility for home care services. The face-to-face encounter is a mandated provision of the Affordable Care Act (ACA) of 2010, which is intended to reduce fraud and abuse among home health providers.

Despite this goal, the new documentation requirement poses the threat of a significant paperwork burden on practitioners, including hospitalists.

Many providers have remained unaware of this new requirement, but those who are aware have been experiencing confusion as to what, if any, additional paperwork is required of physicians. SHM, along with the American Medical Association (AMA) and other physician groups, have requested clarification from the Centers for Medicare & Medicaid Services (CMS) regarding the documentation requirement. SHM also is advocating that CMS keep the additional paperwork burden to a minimum.

CMS denied a request to extend the implementation deadline to allow for more provider education. Despite denying the extension, CMS has committed to continue monitoring for problems and unintended consequences caused by the new requirement.

CMS also has clarified the face-to-face documentation requirements: “Physicians may attach existing documentation as long as it includes necessary information and evidences the need for home health services.”

An example would be for a physician to attach the patient’s discharge summary or relevant portion of the patient’s medical record that evidences the need for home health services. Instead of creating an entirely new document or filling out an additional form to evidence the face-to-face encounter, physicians will have some flexibility in determining the existing documentation they will use. This is an option that hopefully will reduce some of the burden.

CMS could produce further guidelines in the future. SHM intends to continue following the issue and advocating on behalf of hospitalists. For the most up-to-date information, visit http://questions.cms.hhs.gov and enter the search term “home health face-to-face.” TH

As of April 1, physicians who order home care services for their Medicare patients are required to document that they had a face-to-face encounter with the patient prior to certifying the patient’s eligibility for home care services. The face-to-face encounter is a mandated provision of the Affordable Care Act (ACA) of 2010, which is intended to reduce fraud and abuse among home health providers.

Despite this goal, the new documentation requirement poses the threat of a significant paperwork burden on practitioners, including hospitalists.

Many providers have remained unaware of this new requirement, but those who are aware have been experiencing confusion as to what, if any, additional paperwork is required of physicians. SHM, along with the American Medical Association (AMA) and other physician groups, have requested clarification from the Centers for Medicare & Medicaid Services (CMS) regarding the documentation requirement. SHM also is advocating that CMS keep the additional paperwork burden to a minimum.

CMS denied a request to extend the implementation deadline to allow for more provider education. Despite denying the extension, CMS has committed to continue monitoring for problems and unintended consequences caused by the new requirement.

CMS also has clarified the face-to-face documentation requirements: “Physicians may attach existing documentation as long as it includes necessary information and evidences the need for home health services.”

An example would be for a physician to attach the patient’s discharge summary or relevant portion of the patient’s medical record that evidences the need for home health services. Instead of creating an entirely new document or filling out an additional form to evidence the face-to-face encounter, physicians will have some flexibility in determining the existing documentation they will use. This is an option that hopefully will reduce some of the burden.

CMS could produce further guidelines in the future. SHM intends to continue following the issue and advocating on behalf of hospitalists. For the most up-to-date information, visit http://questions.cms.hhs.gov and enter the search term “home health face-to-face.” TH

As of April 1, physicians who order home care services for their Medicare patients are required to document that they had a face-to-face encounter with the patient prior to certifying the patient’s eligibility for home care services. The face-to-face encounter is a mandated provision of the Affordable Care Act (ACA) of 2010, which is intended to reduce fraud and abuse among home health providers.

Despite this goal, the new documentation requirement poses the threat of a significant paperwork burden on practitioners, including hospitalists.

Many providers have remained unaware of this new requirement, but those who are aware have been experiencing confusion as to what, if any, additional paperwork is required of physicians. SHM, along with the American Medical Association (AMA) and other physician groups, have requested clarification from the Centers for Medicare & Medicaid Services (CMS) regarding the documentation requirement. SHM also is advocating that CMS keep the additional paperwork burden to a minimum.

CMS denied a request to extend the implementation deadline to allow for more provider education. Despite denying the extension, CMS has committed to continue monitoring for problems and unintended consequences caused by the new requirement.

CMS also has clarified the face-to-face documentation requirements: “Physicians may attach existing documentation as long as it includes necessary information and evidences the need for home health services.”

An example would be for a physician to attach the patient’s discharge summary or relevant portion of the patient’s medical record that evidences the need for home health services. Instead of creating an entirely new document or filling out an additional form to evidence the face-to-face encounter, physicians will have some flexibility in determining the existing documentation they will use. This is an option that hopefully will reduce some of the burden.

CMS could produce further guidelines in the future. SHM intends to continue following the issue and advocating on behalf of hospitalists. For the most up-to-date information, visit http://questions.cms.hhs.gov and enter the search term “home health face-to-face.” TH

The Agency for Healthcare Research and Quality (AHRQ) recently released the annual National Healthcare Quality & Disparities Reports. The reports provide in-depth quality information on the overall population and divide this information along such subgroups as race, ethnicity, and education level. The report is more than 200 pages long, but it can be summarized in one sentence: If you are poor, the quality of your healthcare is likely to be poor.

Despite significant quality improvement (QI) in a number of areas, disparities among poor Americans persist. For example, the percentage of heart-attack patients who underwent procedures to unblock heart arteries within 90 minutes improved to 81% in 2008 from 42% in 2005. This is very positive news, but unfortunately, these and many other gains in quality only apply to higher-income populations.

A new section of the report focused on care coordination and transitions of care contains some statistics of particular interest to hospitalists. One statistic shows that the percentage of hospitalized adult patients with heart failure who were given complete written discharge instructions improved to 82.0% in 2008, up from 57.5% in 2005.

It is important to note that this number remains more or less constant across all racial/ethnic divisions. Could part of this improvement be attributed to the growth and success of the hospitalist movement?

Hospitalists know that despite the numbers, a successful transition does not simply include discharge instructions; it is the combination of those instructions, along with coordination with primary care, that prevents avoidable readmissions.

Unfortunately, 15% to 20% of low-income patients have no regular primary-care physician (PCP). If a condition begins to deteriorate, this group often has little choice but to return to the hospital.

In the absence of a PCP, it is the hospitalist who can provide patients with the tools they need to stay healthy after leaving the hospital.

Such assistance can range from ensuring that patients truly understand their discharge instructions to being a resource for future questions. Hospitalists are ahead of the game when it comes to quality and reducing disparities; it is just a matter of the other facets of healthcare catching up.

The National Healthcare Quality & Disparities reports are available at www.ahrq.gov/qual/qrdr10.htm. TH

The Agency for Healthcare Research and Quality (AHRQ) recently released the annual National Healthcare Quality & Disparities Reports. The reports provide in-depth quality information on the overall population and divide this information along such subgroups as race, ethnicity, and education level. The report is more than 200 pages long, but it can be summarized in one sentence: If you are poor, the quality of your healthcare is likely to be poor.

Despite significant quality improvement (QI) in a number of areas, disparities among poor Americans persist. For example, the percentage of heart-attack patients who underwent procedures to unblock heart arteries within 90 minutes improved to 81% in 2008 from 42% in 2005. This is very positive news, but unfortunately, these and many other gains in quality only apply to higher-income populations.

A new section of the report focused on care coordination and transitions of care contains some statistics of particular interest to hospitalists. One statistic shows that the percentage of hospitalized adult patients with heart failure who were given complete written discharge instructions improved to 82.0% in 2008, up from 57.5% in 2005.

It is important to note that this number remains more or less constant across all racial/ethnic divisions. Could part of this improvement be attributed to the growth and success of the hospitalist movement?

Hospitalists know that despite the numbers, a successful transition does not simply include discharge instructions; it is the combination of those instructions, along with coordination with primary care, that prevents avoidable readmissions.

Unfortunately, 15% to 20% of low-income patients have no regular primary-care physician (PCP). If a condition begins to deteriorate, this group often has little choice but to return to the hospital.

In the absence of a PCP, it is the hospitalist who can provide patients with the tools they need to stay healthy after leaving the hospital.

Such assistance can range from ensuring that patients truly understand their discharge instructions to being a resource for future questions. Hospitalists are ahead of the game when it comes to quality and reducing disparities; it is just a matter of the other facets of healthcare catching up.

The National Healthcare Quality & Disparities reports are available at www.ahrq.gov/qual/qrdr10.htm. TH

The Agency for Healthcare Research and Quality (AHRQ) recently released the annual National Healthcare Quality & Disparities Reports. The reports provide in-depth quality information on the overall population and divide this information along such subgroups as race, ethnicity, and education level. The report is more than 200 pages long, but it can be summarized in one sentence: If you are poor, the quality of your healthcare is likely to be poor.

Despite significant quality improvement (QI) in a number of areas, disparities among poor Americans persist. For example, the percentage of heart-attack patients who underwent procedures to unblock heart arteries within 90 minutes improved to 81% in 2008 from 42% in 2005. This is very positive news, but unfortunately, these and many other gains in quality only apply to higher-income populations.

A new section of the report focused on care coordination and transitions of care contains some statistics of particular interest to hospitalists. One statistic shows that the percentage of hospitalized adult patients with heart failure who were given complete written discharge instructions improved to 82.0% in 2008, up from 57.5% in 2005.

It is important to note that this number remains more or less constant across all racial/ethnic divisions. Could part of this improvement be attributed to the growth and success of the hospitalist movement?

Hospitalists know that despite the numbers, a successful transition does not simply include discharge instructions; it is the combination of those instructions, along with coordination with primary care, that prevents avoidable readmissions.

Unfortunately, 15% to 20% of low-income patients have no regular primary-care physician (PCP). If a condition begins to deteriorate, this group often has little choice but to return to the hospital.

In the absence of a PCP, it is the hospitalist who can provide patients with the tools they need to stay healthy after leaving the hospital.

Such assistance can range from ensuring that patients truly understand their discharge instructions to being a resource for future questions. Hospitalists are ahead of the game when it comes to quality and reducing disparities; it is just a matter of the other facets of healthcare catching up.

The National Healthcare Quality & Disparities reports are available at www.ahrq.gov/qual/qrdr10.htm. TH

This year, hospitalists will begin to see health reform affect the way they work, and SHM is bringing the best perspective and access to its members.

With the proposed rules anticipated to have been in effect by the end of January, the definition and development of accountable care organizations (ACOs) will answer two long-awaited questions: How will these organizations impact the practice of hospital medicine … and when? Additionally, the Community-Based Care Transitions Program available to hospitals identified as having high readmission rates is scheduled to begin in early 2011.

So how can hospitalists get the information they need to prepare for, and succeed under, all of these new rules? Launched in mid-January, our new Advocacy & Public Policy portal at www.hospitalmedicine.org provides summaries and background material for relevant reform provisions, educational resources, headlines, and coming events—along with an easy way to reach out to elected officials through our Legislative Action Center.

Specifically outlined are SHM’s top priority issues (hospital value-based purchasing [HVBP], bundled payments, and reducing readmissions/improving care transitions), identified by the Public Policy Committee. The summaries also include SHM’s position statement so hospitalists know where SHM stands and what we’re doing to help hospitalists best position themselves to succeed.

In addition to provisions of the Affordable Care Act (ACA) of 2010, we’ve devoted a section to health information technology and updated the Physician Quality Reporting System to reflect ACA changes (including Maintenance of Certification [MOC] and the Physician Compare website).

In January, Patrick Conway, MD, and Patrick Torcson, MD, MMM, FACP, SFHM, chairmen of the Public Policy Committee and Performance & Standards Committee, respectively, presented the “Health Reform: Highlights and Practical Implications for Hospitalists” webinar, which explored ACOs, readmissions, HVBP, and the Centers for Medicare & Medicaid Services’ role in the implementation process. If you missed the presentation, it is available on demand at www.hospitalmedicine.org/webinars.

HM11, which is May 10-13 in Grapevine, Texas, will feature a session on the latest reform news: “The Biggest Changes in Healthcare Reform: What We Know Now.” Though the final presentation likely will change in the days leading up to the meeting, the panel plans to review how other ACA provisions will set hospitalists up to succeed under the new ACO model.

Now is the time for hospitalists to get up to speed. TH

Find all this and more by visiting www.hospitalmedicine.org/advocacy and let us know what you think by e-mailing [email protected].

This year, hospitalists will begin to see health reform affect the way they work, and SHM is bringing the best perspective and access to its members.

With the proposed rules anticipated to have been in effect by the end of January, the definition and development of accountable care organizations (ACOs) will answer two long-awaited questions: How will these organizations impact the practice of hospital medicine … and when? Additionally, the Community-Based Care Transitions Program available to hospitals identified as having high readmission rates is scheduled to begin in early 2011.

So how can hospitalists get the information they need to prepare for, and succeed under, all of these new rules? Launched in mid-January, our new Advocacy & Public Policy portal at www.hospitalmedicine.org provides summaries and background material for relevant reform provisions, educational resources, headlines, and coming events—along with an easy way to reach out to elected officials through our Legislative Action Center.

Specifically outlined are SHM’s top priority issues (hospital value-based purchasing [HVBP], bundled payments, and reducing readmissions/improving care transitions), identified by the Public Policy Committee. The summaries also include SHM’s position statement so hospitalists know where SHM stands and what we’re doing to help hospitalists best position themselves to succeed.

In addition to provisions of the Affordable Care Act (ACA) of 2010, we’ve devoted a section to health information technology and updated the Physician Quality Reporting System to reflect ACA changes (including Maintenance of Certification [MOC] and the Physician Compare website).

In January, Patrick Conway, MD, and Patrick Torcson, MD, MMM, FACP, SFHM, chairmen of the Public Policy Committee and Performance & Standards Committee, respectively, presented the “Health Reform: Highlights and Practical Implications for Hospitalists” webinar, which explored ACOs, readmissions, HVBP, and the Centers for Medicare & Medicaid Services’ role in the implementation process. If you missed the presentation, it is available on demand at www.hospitalmedicine.org/webinars.

HM11, which is May 10-13 in Grapevine, Texas, will feature a session on the latest reform news: “The Biggest Changes in Healthcare Reform: What We Know Now.” Though the final presentation likely will change in the days leading up to the meeting, the panel plans to review how other ACA provisions will set hospitalists up to succeed under the new ACO model.

Now is the time for hospitalists to get up to speed. TH

Find all this and more by visiting www.hospitalmedicine.org/advocacy and let us know what you think by e-mailing [email protected].

This year, hospitalists will begin to see health reform affect the way they work, and SHM is bringing the best perspective and access to its members.

With the proposed rules anticipated to have been in effect by the end of January, the definition and development of accountable care organizations (ACOs) will answer two long-awaited questions: How will these organizations impact the practice of hospital medicine … and when? Additionally, the Community-Based Care Transitions Program available to hospitals identified as having high readmission rates is scheduled to begin in early 2011.

So how can hospitalists get the information they need to prepare for, and succeed under, all of these new rules? Launched in mid-January, our new Advocacy & Public Policy portal at www.hospitalmedicine.org provides summaries and background material for relevant reform provisions, educational resources, headlines, and coming events—along with an easy way to reach out to elected officials through our Legislative Action Center.

Specifically outlined are SHM’s top priority issues (hospital value-based purchasing [HVBP], bundled payments, and reducing readmissions/improving care transitions), identified by the Public Policy Committee. The summaries also include SHM’s position statement so hospitalists know where SHM stands and what we’re doing to help hospitalists best position themselves to succeed.

In addition to provisions of the Affordable Care Act (ACA) of 2010, we’ve devoted a section to health information technology and updated the Physician Quality Reporting System to reflect ACA changes (including Maintenance of Certification [MOC] and the Physician Compare website).

In January, Patrick Conway, MD, and Patrick Torcson, MD, MMM, FACP, SFHM, chairmen of the Public Policy Committee and Performance & Standards Committee, respectively, presented the “Health Reform: Highlights and Practical Implications for Hospitalists” webinar, which explored ACOs, readmissions, HVBP, and the Centers for Medicare & Medicaid Services’ role in the implementation process. If you missed the presentation, it is available on demand at www.hospitalmedicine.org/webinars.

HM11, which is May 10-13 in Grapevine, Texas, will feature a session on the latest reform news: “The Biggest Changes in Healthcare Reform: What We Know Now.” Though the final presentation likely will change in the days leading up to the meeting, the panel plans to review how other ACA provisions will set hospitalists up to succeed under the new ACO model.

Now is the time for hospitalists to get up to speed. TH

Find all this and more by visiting www.hospitalmedicine.org/advocacy and let us know what you think by e-mailing [email protected].

The Centers for Medicare & Medicaid Services (CMS) in November announced the official launch of the Center for Medicare & Medicaid Innovation (CMMI). The CMI was authorized under the Affordable Care Act (ACA) to test innovative ways to reduce costs, while preserving or enhancing the quality. This sounds very similar to many other reform initiatives, so why have a separate center when ACOs, value-based purchasing, and payment bundling already are in the ACA?

A quick glance at the CMMI website didn’t provide much detail beyond uplifting language about the promise that the center represents. Don Berwick, MD, the new CMS administrator, has even gone so far as to call the center the “jewel in the crown” of the ACA.

Inspirational language aside, the center can be summed up using a simple analogy: The “other” ACA initiatives (bundling, VBP, etc.) are like a factory floor. The tools are in place, the processes are more or less defined, and they will be carried out regardless of the degree of positive impact. CMMI is more like a research and development lab, with the freedom to tinker with new ideas before wide-scale implementation.

The keys to CMMI success are twofold. First, it will implement pilot projects rather than demonstrations. A pilot gives the Secretary of Health and Human Services the power to implement and expand promising projects without Congressional approval. A demonstration requires Congressional approval for its continuation.. Second, CMMI does not require proposals to be budget neutral. Initial training and staffing costs alone can disqualify a program on budget neutrality grounds. Since CMMI does not require budget neutrality, promising programs with significant start-up costs are less likely to be cast aside.

Dr. Berwick has asked for provider partnership and input, and says he “would like to help forge an unprecedented level of shared aim, shared vision, and synergy in action among the public and private stewards and leaders of healthcare.” This vision and a $10 billion appropriation over the next decade present a tremendous opportunity for SHM’s quality initiatives, and the promising hospitalist-created protocol.

However, this large appropriation presents both the greatest strength and the greatest threat to the center. With the Republican takeover of the House of Representatives, the CMMI budget likely is to be a target for the “repeal, replace, or revise” agenda. Therefore, increasing awareness of CMMI’s role will be imperative over the coming months. Hospitalists can help by educating themselves, then passing their knowledge along to those who might not understand the importance of the center. TH

The Centers for Medicare & Medicaid Services (CMS) in November announced the official launch of the Center for Medicare & Medicaid Innovation (CMMI). The CMI was authorized under the Affordable Care Act (ACA) to test innovative ways to reduce costs, while preserving or enhancing the quality. This sounds very similar to many other reform initiatives, so why have a separate center when ACOs, value-based purchasing, and payment bundling already are in the ACA?

A quick glance at the CMMI website didn’t provide much detail beyond uplifting language about the promise that the center represents. Don Berwick, MD, the new CMS administrator, has even gone so far as to call the center the “jewel in the crown” of the ACA.

Inspirational language aside, the center can be summed up using a simple analogy: The “other” ACA initiatives (bundling, VBP, etc.) are like a factory floor. The tools are in place, the processes are more or less defined, and they will be carried out regardless of the degree of positive impact. CMMI is more like a research and development lab, with the freedom to tinker with new ideas before wide-scale implementation.

The keys to CMMI success are twofold. First, it will implement pilot projects rather than demonstrations. A pilot gives the Secretary of Health and Human Services the power to implement and expand promising projects without Congressional approval. A demonstration requires Congressional approval for its continuation.. Second, CMMI does not require proposals to be budget neutral. Initial training and staffing costs alone can disqualify a program on budget neutrality grounds. Since CMMI does not require budget neutrality, promising programs with significant start-up costs are less likely to be cast aside.

Dr. Berwick has asked for provider partnership and input, and says he “would like to help forge an unprecedented level of shared aim, shared vision, and synergy in action among the public and private stewards and leaders of healthcare.” This vision and a $10 billion appropriation over the next decade present a tremendous opportunity for SHM’s quality initiatives, and the promising hospitalist-created protocol.

However, this large appropriation presents both the greatest strength and the greatest threat to the center. With the Republican takeover of the House of Representatives, the CMMI budget likely is to be a target for the “repeal, replace, or revise” agenda. Therefore, increasing awareness of CMMI’s role will be imperative over the coming months. Hospitalists can help by educating themselves, then passing their knowledge along to those who might not understand the importance of the center. TH

The Centers for Medicare & Medicaid Services (CMS) in November announced the official launch of the Center for Medicare & Medicaid Innovation (CMMI). The CMI was authorized under the Affordable Care Act (ACA) to test innovative ways to reduce costs, while preserving or enhancing the quality. This sounds very similar to many other reform initiatives, so why have a separate center when ACOs, value-based purchasing, and payment bundling already are in the ACA?

A quick glance at the CMMI website didn’t provide much detail beyond uplifting language about the promise that the center represents. Don Berwick, MD, the new CMS administrator, has even gone so far as to call the center the “jewel in the crown” of the ACA.

Inspirational language aside, the center can be summed up using a simple analogy: The “other” ACA initiatives (bundling, VBP, etc.) are like a factory floor. The tools are in place, the processes are more or less defined, and they will be carried out regardless of the degree of positive impact. CMMI is more like a research and development lab, with the freedom to tinker with new ideas before wide-scale implementation.

The keys to CMMI success are twofold. First, it will implement pilot projects rather than demonstrations. A pilot gives the Secretary of Health and Human Services the power to implement and expand promising projects without Congressional approval. A demonstration requires Congressional approval for its continuation.. Second, CMMI does not require proposals to be budget neutral. Initial training and staffing costs alone can disqualify a program on budget neutrality grounds. Since CMMI does not require budget neutrality, promising programs with significant start-up costs are less likely to be cast aside.

Dr. Berwick has asked for provider partnership and input, and says he “would like to help forge an unprecedented level of shared aim, shared vision, and synergy in action among the public and private stewards and leaders of healthcare.” This vision and a $10 billion appropriation over the next decade present a tremendous opportunity for SHM’s quality initiatives, and the promising hospitalist-created protocol.

However, this large appropriation presents both the greatest strength and the greatest threat to the center. With the Republican takeover of the House of Representatives, the CMMI budget likely is to be a target for the “repeal, replace, or revise” agenda. Therefore, increasing awareness of CMMI’s role will be imperative over the coming months. Hospitalists can help by educating themselves, then passing their knowledge along to those who might not understand the importance of the center. TH

Now that I have your attention, I hope no one thinks the “40 patients per day” suggestion is in any way SHM current policy. But it is becoming increasingly clear that demands for the hospitalist workforce and demands on ongoing accountability for performance will require a redefinition of the role the hospitalist should have in patient care.

This isn’t unique to HM. In many ways, the patient-centered medical home (PCMH) and accountable-care organizations (ACOs) will in their own ways redefine the physician’s role at many steps along the healthcare continuum. But, as usual, HM might very well be at the leading edge.

Scope of Practice

There just aren’t enough qualified hospitalists to do the work, let alone all of the things coming our way with an ever-expanding scope of practice. Sure, hospitalists will always have a central role in managing the acute care of most medical illnesses. We already manage more inpatient heart-failure patients and more chest pain than cardiologists; more seizures, strokes, and dementia than neurologists; and more diabetes than endocrinologists. In many hospitals, we have replaced PCPs in managing acutely ill patients on medical floors.

But in recent years, hospitalists have played an increasing role in comanaging orthopedic and other surgical patients, and are playing a larger role in the care of patients formerly managed solely by subspecialists. As neurologists have left the building, hospitalists have had to expand our management of patients with acute neurologic problems. And as the critical-care shortage expands, hospitalists are playing a greater role in our nation’s ICUs.

Forward-thinking hospitals are redefining the roles of ED physicians in an era of hospitalists. Patients who present with a temperature of 104, a BP of 90/60, and a pulmonary infiltrate get a 60-second evaluation in the ED and are quickly admitted upstairs to the hospitalists. No need for two to three hours of an ED workup for a patient everyone knows is coming into the house. More and more EDs are routinely using hospitalists as in-house consultants on difficult patient decisions.

As ACOs become commonplace and as hospitals become responsible for the gaps post-discharge, look for some HM groups to be asked to manage the subacute patient experience, those critical first post-hospital visits in the 30 days after hospitalization. PCPs and medical homes will have their own capacity issues and difficulties in managing these fragile patients just out of the hospital.

Add to this all the time hospitalists need to spend each day in developing and implementing performance improvement, and in creating and participating in the new hospital team, it is no wonder that a limited HM workforce is being stretched beyond its capacity.

Workforce Issues

In many ways, this is a blessing for an individual hospitalist, especially one with a track record of competency and skill. This is at least part of the reason that HM was one of only five medical specialties in which incomes increased in 2009, and why hospitals everywhere are looking for strategies to attract and retain the best talent.

While this trend might bode well for the individual hospitalist looking for career flexibility, the ever-enlarging specialty of HM cannot easily fill all the needs described above, even with a large influx of medical students or residents in internal medicine, family medicine, and pediatrics, or even with recruitment of additional nonphysician providers. The work is growing too fast and the people just aren’t available.

Job Description

It is time to rethink the job description for the physician hospitalists. How do we want to deploy the $100-plus-per-hour hospitalist, who is in short supply, to get the most out of this limited resource?

If we step back a minute and start to list all the roles hospitalists have played in patient care, we might see ways to involve existing health professionals, and we might also see a need to add some new players, to alter the current hierarchy and authority. If we keep the focus on always providing the best care for the patient and to only ask each member of the team to play roles consistent with their training and competencies, then we can come out the other side of all this in better shape than we are in now.

Hospitalists today are asked to take a detailed history, do a complete physical examination, review any old records, speak to the referring physicians, talk to the doctor and possibly the nurse in the ED, meet with the nurse on the floor, make an initial diagnosis, order initial and subsequent tests to confirm or deny each specific diagnosis, order initial therapies (pharmaceutical and other), adjust therapy as the tests clarify or muddy the diagnostic approach, order additional tests to make sure the therapies are helpful and not toxic, record all of these ideas, directions, assumptions, and guesses in the medical record, generate a bill to collect payment for care rendered, meet with the patient and possibly the family to educate them about the potential disease states and each therapy ordered, assess the home (or nonhospital) situation, and make plans and arrangements for discharge, round on the patient at least once daily to redo and revise many of these steps as the course of the disease and new information warrants, produce instructions at discharge to include a summary of the hospital course, new therapies, future testing at a level for the patient and their family, and also for the future physicians in compliance with the requirements for billing and in compliance with hospital regulations and the community standards, make sure your care elements are being documented for performance evaluations and to satisfy whatever alphabet soup is looking at measurement and accountability, and along the way figure out what information any consultants, comanagers, other hospitalists, nurses, etc. might need to know, and create a venue or process to communicate the information. And I am sure there are more roles I have left out.

The point is, do we really need an MD to do all of these things? Is it time to create a process, a trusted team, and a new way to deliver the best care and deploy our limited resources more economically and effectively?

What are the unique roles and skill sets that physician hospitalists can bring to their patients’ care? And, more important, what are the current roles that would be better handed off to another member of the team?

The hospitalist should be the integrator of information, who then works with the entire team to set a direction and plan for diagnosis and therapy. Most everything else could be delegated to someone else.

But that presupposes a trust in the competencies of the rest of the team. Do I believe the history and physical already performed in the ED, by the nurse, by the NPP, or by another physician, or do I need to repeat this again? Do I trust the pharmacist to select the correct agent and know how to monitor its effectiveness and potential toxicity, and to be prepared to transition to outpatient therapy? Do I trust that the nurse (and every nurse on every shift) will be able educate the patient about their disease and hospital course and to provide accurate and timely information about the patient? And on and on.

Some EDs right now have a new person, the scribe, who sees the patient side by side with the physician, transcribing the orders, writing the notes, and interfacing with the hospital’s electronic health record (EHR). Does this free up the ED physician to see more patients? Does this lead to better care? Does this lead to better payment collection or fewer liability suits?

And this is just replacing one element of the doctors’ job. Think how existing healthcare professionals and new ones on the horizon can change the workforce.

The point is, the role and the need for the unique skill set of the well-tuned hospitalist have grown too broad for us to continue with business as usual. It is time to systematically look at the tasks that need to be accomplished for each acutely ill patient and to evaluate the entire healthcare team available, their competencies and their skill sets, and to set a “new paradigm” for their deployment.

This will require some documentation of each professional’s competence and a trust that they can deliver on a daily basis. In this new world, the hospitalist moves from playing lead trumpet to being the conductor of the orchestra, to being the coxswain for a crew team, or the quarterback of a multiskilled team.

In this world, the hospitalist could oversee 40 patients a day in a very different role than occurs today. The team would be empowered by viewing the “hospitalist’s patients” as all of our patients, and the patients would benefit from an accountable team focused directly on them.

This is a world not taught in residency, but one that the future clamors for. There is not an easy path from today to the future, but as in many things in the last decade or so, I trust that the best of HM is up to the task of playing a leading role in designing and implementing the future of healthcare.

SHM will continue to do its part to help you at every step along the way. TH

Dr. Wellikson is CEO of SHM.

Now that I have your attention, I hope no one thinks the “40 patients per day” suggestion is in any way SHM current policy. But it is becoming increasingly clear that demands for the hospitalist workforce and demands on ongoing accountability for performance will require a redefinition of the role the hospitalist should have in patient care.

This isn’t unique to HM. In many ways, the patient-centered medical home (PCMH) and accountable-care organizations (ACOs) will in their own ways redefine the physician’s role at many steps along the healthcare continuum. But, as usual, HM might very well be at the leading edge.

Scope of Practice

There just aren’t enough qualified hospitalists to do the work, let alone all of the things coming our way with an ever-expanding scope of practice. Sure, hospitalists will always have a central role in managing the acute care of most medical illnesses. We already manage more inpatient heart-failure patients and more chest pain than cardiologists; more seizures, strokes, and dementia than neurologists; and more diabetes than endocrinologists. In many hospitals, we have replaced PCPs in managing acutely ill patients on medical floors.

But in recent years, hospitalists have played an increasing role in comanaging orthopedic and other surgical patients, and are playing a larger role in the care of patients formerly managed solely by subspecialists. As neurologists have left the building, hospitalists have had to expand our management of patients with acute neurologic problems. And as the critical-care shortage expands, hospitalists are playing a greater role in our nation’s ICUs.

Forward-thinking hospitals are redefining the roles of ED physicians in an era of hospitalists. Patients who present with a temperature of 104, a BP of 90/60, and a pulmonary infiltrate get a 60-second evaluation in the ED and are quickly admitted upstairs to the hospitalists. No need for two to three hours of an ED workup for a patient everyone knows is coming into the house. More and more EDs are routinely using hospitalists as in-house consultants on difficult patient decisions.

As ACOs become commonplace and as hospitals become responsible for the gaps post-discharge, look for some HM groups to be asked to manage the subacute patient experience, those critical first post-hospital visits in the 30 days after hospitalization. PCPs and medical homes will have their own capacity issues and difficulties in managing these fragile patients just out of the hospital.

Add to this all the time hospitalists need to spend each day in developing and implementing performance improvement, and in creating and participating in the new hospital team, it is no wonder that a limited HM workforce is being stretched beyond its capacity.

Workforce Issues

In many ways, this is a blessing for an individual hospitalist, especially one with a track record of competency and skill. This is at least part of the reason that HM was one of only five medical specialties in which incomes increased in 2009, and why hospitals everywhere are looking for strategies to attract and retain the best talent.

While this trend might bode well for the individual hospitalist looking for career flexibility, the ever-enlarging specialty of HM cannot easily fill all the needs described above, even with a large influx of medical students or residents in internal medicine, family medicine, and pediatrics, or even with recruitment of additional nonphysician providers. The work is growing too fast and the people just aren’t available.

Job Description

It is time to rethink the job description for the physician hospitalists. How do we want to deploy the $100-plus-per-hour hospitalist, who is in short supply, to get the most out of this limited resource?

If we step back a minute and start to list all the roles hospitalists have played in patient care, we might see ways to involve existing health professionals, and we might also see a need to add some new players, to alter the current hierarchy and authority. If we keep the focus on always providing the best care for the patient and to only ask each member of the team to play roles consistent with their training and competencies, then we can come out the other side of all this in better shape than we are in now.

Hospitalists today are asked to take a detailed history, do a complete physical examination, review any old records, speak to the referring physicians, talk to the doctor and possibly the nurse in the ED, meet with the nurse on the floor, make an initial diagnosis, order initial and subsequent tests to confirm or deny each specific diagnosis, order initial therapies (pharmaceutical and other), adjust therapy as the tests clarify or muddy the diagnostic approach, order additional tests to make sure the therapies are helpful and not toxic, record all of these ideas, directions, assumptions, and guesses in the medical record, generate a bill to collect payment for care rendered, meet with the patient and possibly the family to educate them about the potential disease states and each therapy ordered, assess the home (or nonhospital) situation, and make plans and arrangements for discharge, round on the patient at least once daily to redo and revise many of these steps as the course of the disease and new information warrants, produce instructions at discharge to include a summary of the hospital course, new therapies, future testing at a level for the patient and their family, and also for the future physicians in compliance with the requirements for billing and in compliance with hospital regulations and the community standards, make sure your care elements are being documented for performance evaluations and to satisfy whatever alphabet soup is looking at measurement and accountability, and along the way figure out what information any consultants, comanagers, other hospitalists, nurses, etc. might need to know, and create a venue or process to communicate the information. And I am sure there are more roles I have left out.

The point is, do we really need an MD to do all of these things? Is it time to create a process, a trusted team, and a new way to deliver the best care and deploy our limited resources more economically and effectively?

What are the unique roles and skill sets that physician hospitalists can bring to their patients’ care? And, more important, what are the current roles that would be better handed off to another member of the team?

The hospitalist should be the integrator of information, who then works with the entire team to set a direction and plan for diagnosis and therapy. Most everything else could be delegated to someone else.

But that presupposes a trust in the competencies of the rest of the team. Do I believe the history and physical already performed in the ED, by the nurse, by the NPP, or by another physician, or do I need to repeat this again? Do I trust the pharmacist to select the correct agent and know how to monitor its effectiveness and potential toxicity, and to be prepared to transition to outpatient therapy? Do I trust that the nurse (and every nurse on every shift) will be able educate the patient about their disease and hospital course and to provide accurate and timely information about the patient? And on and on.

Some EDs right now have a new person, the scribe, who sees the patient side by side with the physician, transcribing the orders, writing the notes, and interfacing with the hospital’s electronic health record (EHR). Does this free up the ED physician to see more patients? Does this lead to better care? Does this lead to better payment collection or fewer liability suits?

And this is just replacing one element of the doctors’ job. Think how existing healthcare professionals and new ones on the horizon can change the workforce.

The point is, the role and the need for the unique skill set of the well-tuned hospitalist have grown too broad for us to continue with business as usual. It is time to systematically look at the tasks that need to be accomplished for each acutely ill patient and to evaluate the entire healthcare team available, their competencies and their skill sets, and to set a “new paradigm” for their deployment.

This will require some documentation of each professional’s competence and a trust that they can deliver on a daily basis. In this new world, the hospitalist moves from playing lead trumpet to being the conductor of the orchestra, to being the coxswain for a crew team, or the quarterback of a multiskilled team.

In this world, the hospitalist could oversee 40 patients a day in a very different role than occurs today. The team would be empowered by viewing the “hospitalist’s patients” as all of our patients, and the patients would benefit from an accountable team focused directly on them.

This is a world not taught in residency, but one that the future clamors for. There is not an easy path from today to the future, but as in many things in the last decade or so, I trust that the best of HM is up to the task of playing a leading role in designing and implementing the future of healthcare.

SHM will continue to do its part to help you at every step along the way. TH

Dr. Wellikson is CEO of SHM.

Now that I have your attention, I hope no one thinks the “40 patients per day” suggestion is in any way SHM current policy. But it is becoming increasingly clear that demands for the hospitalist workforce and demands on ongoing accountability for performance will require a redefinition of the role the hospitalist should have in patient care.

This isn’t unique to HM. In many ways, the patient-centered medical home (PCMH) and accountable-care organizations (ACOs) will in their own ways redefine the physician’s role at many steps along the healthcare continuum. But, as usual, HM might very well be at the leading edge.

Scope of Practice

There just aren’t enough qualified hospitalists to do the work, let alone all of the things coming our way with an ever-expanding scope of practice. Sure, hospitalists will always have a central role in managing the acute care of most medical illnesses. We already manage more inpatient heart-failure patients and more chest pain than cardiologists; more seizures, strokes, and dementia than neurologists; and more diabetes than endocrinologists. In many hospitals, we have replaced PCPs in managing acutely ill patients on medical floors.

But in recent years, hospitalists have played an increasing role in comanaging orthopedic and other surgical patients, and are playing a larger role in the care of patients formerly managed solely by subspecialists. As neurologists have left the building, hospitalists have had to expand our management of patients with acute neurologic problems. And as the critical-care shortage expands, hospitalists are playing a greater role in our nation’s ICUs.

Forward-thinking hospitals are redefining the roles of ED physicians in an era of hospitalists. Patients who present with a temperature of 104, a BP of 90/60, and a pulmonary infiltrate get a 60-second evaluation in the ED and are quickly admitted upstairs to the hospitalists. No need for two to three hours of an ED workup for a patient everyone knows is coming into the house. More and more EDs are routinely using hospitalists as in-house consultants on difficult patient decisions.

As ACOs become commonplace and as hospitals become responsible for the gaps post-discharge, look for some HM groups to be asked to manage the subacute patient experience, those critical first post-hospital visits in the 30 days after hospitalization. PCPs and medical homes will have their own capacity issues and difficulties in managing these fragile patients just out of the hospital.

Add to this all the time hospitalists need to spend each day in developing and implementing performance improvement, and in creating and participating in the new hospital team, it is no wonder that a limited HM workforce is being stretched beyond its capacity.

Workforce Issues

In many ways, this is a blessing for an individual hospitalist, especially one with a track record of competency and skill. This is at least part of the reason that HM was one of only five medical specialties in which incomes increased in 2009, and why hospitals everywhere are looking for strategies to attract and retain the best talent.

While this trend might bode well for the individual hospitalist looking for career flexibility, the ever-enlarging specialty of HM cannot easily fill all the needs described above, even with a large influx of medical students or residents in internal medicine, family medicine, and pediatrics, or even with recruitment of additional nonphysician providers. The work is growing too fast and the people just aren’t available.

Job Description

It is time to rethink the job description for the physician hospitalists. How do we want to deploy the $100-plus-per-hour hospitalist, who is in short supply, to get the most out of this limited resource?

If we step back a minute and start to list all the roles hospitalists have played in patient care, we might see ways to involve existing health professionals, and we might also see a need to add some new players, to alter the current hierarchy and authority. If we keep the focus on always providing the best care for the patient and to only ask each member of the team to play roles consistent with their training and competencies, then we can come out the other side of all this in better shape than we are in now.

Hospitalists today are asked to take a detailed history, do a complete physical examination, review any old records, speak to the referring physicians, talk to the doctor and possibly the nurse in the ED, meet with the nurse on the floor, make an initial diagnosis, order initial and subsequent tests to confirm or deny each specific diagnosis, order initial therapies (pharmaceutical and other), adjust therapy as the tests clarify or muddy the diagnostic approach, order additional tests to make sure the therapies are helpful and not toxic, record all of these ideas, directions, assumptions, and guesses in the medical record, generate a bill to collect payment for care rendered, meet with the patient and possibly the family to educate them about the potential disease states and each therapy ordered, assess the home (or nonhospital) situation, and make plans and arrangements for discharge, round on the patient at least once daily to redo and revise many of these steps as the course of the disease and new information warrants, produce instructions at discharge to include a summary of the hospital course, new therapies, future testing at a level for the patient and their family, and also for the future physicians in compliance with the requirements for billing and in compliance with hospital regulations and the community standards, make sure your care elements are being documented for performance evaluations and to satisfy whatever alphabet soup is looking at measurement and accountability, and along the way figure out what information any consultants, comanagers, other hospitalists, nurses, etc. might need to know, and create a venue or process to communicate the information. And I am sure there are more roles I have left out.

The point is, do we really need an MD to do all of these things? Is it time to create a process, a trusted team, and a new way to deliver the best care and deploy our limited resources more economically and effectively?

What are the unique roles and skill sets that physician hospitalists can bring to their patients’ care? And, more important, what are the current roles that would be better handed off to another member of the team?

The hospitalist should be the integrator of information, who then works with the entire team to set a direction and plan for diagnosis and therapy. Most everything else could be delegated to someone else.

But that presupposes a trust in the competencies of the rest of the team. Do I believe the history and physical already performed in the ED, by the nurse, by the NPP, or by another physician, or do I need to repeat this again? Do I trust the pharmacist to select the correct agent and know how to monitor its effectiveness and potential toxicity, and to be prepared to transition to outpatient therapy? Do I trust that the nurse (and every nurse on every shift) will be able educate the patient about their disease and hospital course and to provide accurate and timely information about the patient? And on and on.

Some EDs right now have a new person, the scribe, who sees the patient side by side with the physician, transcribing the orders, writing the notes, and interfacing with the hospital’s electronic health record (EHR). Does this free up the ED physician to see more patients? Does this lead to better care? Does this lead to better payment collection or fewer liability suits?

And this is just replacing one element of the doctors’ job. Think how existing healthcare professionals and new ones on the horizon can change the workforce.

The point is, the role and the need for the unique skill set of the well-tuned hospitalist have grown too broad for us to continue with business as usual. It is time to systematically look at the tasks that need to be accomplished for each acutely ill patient and to evaluate the entire healthcare team available, their competencies and their skill sets, and to set a “new paradigm” for their deployment.

This will require some documentation of each professional’s competence and a trust that they can deliver on a daily basis. In this new world, the hospitalist moves from playing lead trumpet to being the conductor of the orchestra, to being the coxswain for a crew team, or the quarterback of a multiskilled team.

In this world, the hospitalist could oversee 40 patients a day in a very different role than occurs today. The team would be empowered by viewing the “hospitalist’s patients” as all of our patients, and the patients would benefit from an accountable team focused directly on them.

This is a world not taught in residency, but one that the future clamors for. There is not an easy path from today to the future, but as in many things in the last decade or so, I trust that the best of HM is up to the task of playing a leading role in designing and implementing the future of healthcare.

SHM will continue to do its part to help you at every step along the way. TH

Dr. Wellikson is CEO of SHM.

The 1961 classic “The Ecology of Medical Care,” published in the New England Journal of Medicine, mapped out the broad features of the American healthcare landscape.¹ For every 1,000 adult, the study suggested, 750 reported an illness, 250 consulted a doctor, and nine were admitted to a hospital in any given month. The subsequent arrival of Medicare and Medicaid fundamentally changed the U.S. healthcare system. And yet an updated version of the study, released in 2001, yielded surprisingly similar numbers, with 800 residents experiencing symptoms, 217 visiting a physician’s office, and eight being hospitalized in an average month.²

“It helps kind of put in perspective where the bulk of care really occurs,” says Ann O’Malley, MD, a senior researcher at the Washington, D.C.-based Center for Studying Health System Change. “It’s in outpatient provider offices, mostly primary-care provider offices.”

Dr. O’Malley and a host of other observers, however, are warning that the keystone members of this healthcare ecosystem are in serious trouble. As organizations such as SHM have likewise made clear, the accelerating shortage of general internists, family practitioners, and other PCPs has created sizable cracks in the supports of the entire healthcare infrastructure.

How big are the cracks? The number of medical school students pursuing a primary-care career has dropped by more than half since 1997, according to the American Academy of Family Physicians. And with the number of medical students entering the field unable to keep up with attrition, the remaining doctors are facing increasingly difficult working conditions. “Overloaded primary-care practices, whose doctors are aptly compared to hamsters on a treadmill, struggle to provide prompt access and high-quality care,” asserted a 2009 op-ed in the New England Journal of Medicine.³ The result: a vicious circle of decline leading to an anticipated shortfall of roughly 21,000 PCPs by 2015, according to the Association of American Medical Colleges.

Many primary-care providers had already stopped taking new patients when June’s Medicare reimbursement rate fiasco allowed the sustainable growth rate (SGR) formula’s mandated 21.² percent rate cut to temporarily go into effect. Legislators eventually plugged the hole, but not before a new round of jitters seized the nation’s physicians, and reports proliferated throughout the summer about Medicare beneficiaries being unable to find a doctor willing to see them. The recession hasn’t helped, with more privately insured patients waiting longer to see their doctors to avoid copays, and with hospital emergency departments becoming de facto primary-care centers for those patients who have waited too long or have no other alternatives.

Uneven Challenges

Not only is there an acute shortage of primary-care physicians, Dr. O’Malley says, but there is also a distinctly uneven distribution throughout the country. For hospitalists, she says, the implications could be profound. “Hospitalists are increasingly going to be evaluated around issues such as avoiding hospital readmissions and [reducing] length of stay,” she says, “and if they want to improve both of those things, one of the keys is improving chronic care management in the outpatient setting, and improving follow-up post discharge.”

Both metrics will require the involvement of outpatient care providers, underscoring the importance of good communication and mutual respect. Despite the longstanding support of hospitalists for their primary-care counterparts, however, leaders are still being forced to address the perception that HM is somehow bad for what ails PCPs.

In a recent online article posted on the Becker’s Hospital Review website, SHM President Jeff Wiese, MD, SFHM, responded to one such criticism: that hospitalists make primary care less attractive for physicians. Hospitalists are not to blame for the decrease in interest, he asserted, but are actually complementary to the PCP role. And with millions more Americans about to be newly insured, that complementary relationship will be even more important. “It’s a tremendous waste of resources to use a primary-care provider for [a hospital visit]. We need to move into proactive mode, not reactive mode,” Dr. Wiese said. “More PCPs are going to need even more time in the clinic to handle the increased number of patients, and you lose the luxury to run back and forth between the clinic and the hospital. For those that can develop a trusting relationship with a hospitalist, you can work together to see more patients and provide more care.”

So what’s the real root of the problem? Money. According to recent surveys, PCPs earn about half the salary of dermatologists and an even smaller fraction of an average cardiologist’s pay. With medical school debt routinely reaching $200,000, Dr. O’Malley and other analysts say, many doctors simply can’t afford to go into primary care.

“It all comes down to payment, basically,” she says. “At present, our payment system for physician services and for medical procedures is quite skewed. It overcompensates for certain types of diagnostics and procedures, and it undercompensates for the more cognitive type of care that primary-care providers provide.”

The Road Ahead

Fortunately, some relief is trickling in. One measure strongly supported by SHM and included in the Affordable Care Act is a 10% Medicare reimbursement bonus for primary care delivered by qualified doctors, slated to begin next year. In June, U.S. Department of Health and Human Services Secretary Kathleen Sebelius announced a separate, $250 million initiative to boost the primary-care workforce. The money would help train PCPs by creating more residency slots, and offer new support for physician assistants, nurses, and nurse practitioners. Among the measures included in last year’s stimulus package, an expansion of the National Health Service Corps will provide more debt-relief opportunities for PCPs. And in mid-September, HHS tapped stimulus funds to award another $50.³ million for primary care training programs and loan repayment.

The Obama administration has claimed its combined actions “will support the training and development of more than 16,000 new primary-care providers over the next five years,” according to a June 16 HHS press release.

Observers say those measures alone are unlikely to be enough to stem the tide, however. “It’s definitely a step in the right direction,” Dr. O’Malley says of the Medicare bonus. “I don’t think it’s going to solve the primary-care workforce issue, because a 10% bonus, given how low primary-care physician salaries are compared to their specialist counterparts, is not going to be that much of an increase. Among the physicians that I’ve talked to and other healthcare providers, few feel that that’s sufficient enough to really encourage a lot of people to pursue primary care.”

Several other efforts now underway might help:

• Texas Tech University Health Sciences Center unveiled a new Family Medicine Accelerated Track program, which will allow primary-care medical students to complete a degree in three years. Certain students will receive a one-year scholarship, meaning that overall debt for some could be half that of the standard four-year program.
• Reid Hospital and Health Care Services in Richmond, Ind., successfully reversed a downward trend in primary-care referrals by forming its own nonprofit subsidiary corporation, Reid Physician Associates. The nonprofit will include about 50 employed outpatient providers by year’s end to complement the 233-bed hospital’s inpatient staff.
• Danville, Pa.-based Geisinger Health System has begun paying the salaries of extra nurses for both in-network and independent primary-care practices. The nurses manage patients’ chronic conditions, ensure that they are following prescribed treatments, and communicate with hospitalists and other providers about transitions of care. Although still in its early stages, the experiment suggests the nurses are helping to spot problems, prevent unnecessary hospitalizations, and save money.

The Geisinger experiment is among the first steps toward a patient-centered medical home model of care. An eventual Medicare-led expansion of such medical homes and accountable-care organizations, now in the early experimental stages, could provide even more direct support to PCPs. To be successful, though, Dr. O’Malley says the models will need to focus on paying providers fairly for the value they bring to the system. “Obviously, payment reform is what we need if we’re ever going to develop a sustainable primary-care workforce in this country,” she says. TH

Bryn Nelson is a freelance medical writer based in Seattle.

References

1. White KL, Williams TF, Greenberg BG. The ecology of medical care. N Engl J Med. 1961;265:885-992.
2. Green LA, Fryer GE Jr., Yawn BP, Lanier D, Dovey SM. The ecology of medical care revisited. N Engl J Med. 2001;344(26):2021-2025.
3. Bodenheimer T, Grumbach K, Berenson RA. A lifeline for primary care. N Engl J Med. 2009;360(26):2693-2696.

The 1961 classic “The Ecology of Medical Care,” published in the New England Journal of Medicine, mapped out the broad features of the American healthcare landscape.¹ For every 1,000 adult, the study suggested, 750 reported an illness, 250 consulted a doctor, and nine were admitted to a hospital in any given month. The subsequent arrival of Medicare and Medicaid fundamentally changed the U.S. healthcare system. And yet an updated version of the study, released in 2001, yielded surprisingly similar numbers, with 800 residents experiencing symptoms, 217 visiting a physician’s office, and eight being hospitalized in an average month.²

“It helps kind of put in perspective where the bulk of care really occurs,” says Ann O’Malley, MD, a senior researcher at the Washington, D.C.-based Center for Studying Health System Change. “It’s in outpatient provider offices, mostly primary-care provider offices.”

Dr. O’Malley and a host of other observers, however, are warning that the keystone members of this healthcare ecosystem are in serious trouble. As organizations such as SHM have likewise made clear, the accelerating shortage of general internists, family practitioners, and other PCPs has created sizable cracks in the supports of the entire healthcare infrastructure.

How big are the cracks? The number of medical school students pursuing a primary-care career has dropped by more than half since 1997, according to the American Academy of Family Physicians. And with the number of medical students entering the field unable to keep up with attrition, the remaining doctors are facing increasingly difficult working conditions. “Overloaded primary-care practices, whose doctors are aptly compared to hamsters on a treadmill, struggle to provide prompt access and high-quality care,” asserted a 2009 op-ed in the New England Journal of Medicine.³ The result: a vicious circle of decline leading to an anticipated shortfall of roughly 21,000 PCPs by 2015, according to the Association of American Medical Colleges.

Many primary-care providers had already stopped taking new patients when June’s Medicare reimbursement rate fiasco allowed the sustainable growth rate (SGR) formula’s mandated 21.² percent rate cut to temporarily go into effect. Legislators eventually plugged the hole, but not before a new round of jitters seized the nation’s physicians, and reports proliferated throughout the summer about Medicare beneficiaries being unable to find a doctor willing to see them. The recession hasn’t helped, with more privately insured patients waiting longer to see their doctors to avoid copays, and with hospital emergency departments becoming de facto primary-care centers for those patients who have waited too long or have no other alternatives.

Uneven Challenges

Not only is there an acute shortage of primary-care physicians, Dr. O’Malley says, but there is also a distinctly uneven distribution throughout the country. For hospitalists, she says, the implications could be profound. “Hospitalists are increasingly going to be evaluated around issues such as avoiding hospital readmissions and [reducing] length of stay,” she says, “and if they want to improve both of those things, one of the keys is improving chronic care management in the outpatient setting, and improving follow-up post discharge.”

Both metrics will require the involvement of outpatient care providers, underscoring the importance of good communication and mutual respect. Despite the longstanding support of hospitalists for their primary-care counterparts, however, leaders are still being forced to address the perception that HM is somehow bad for what ails PCPs.

In a recent online article posted on the Becker’s Hospital Review website, SHM President Jeff Wiese, MD, SFHM, responded to one such criticism: that hospitalists make primary care less attractive for physicians. Hospitalists are not to blame for the decrease in interest, he asserted, but are actually complementary to the PCP role. And with millions more Americans about to be newly insured, that complementary relationship will be even more important. “It’s a tremendous waste of resources to use a primary-care provider for [a hospital visit]. We need to move into proactive mode, not reactive mode,” Dr. Wiese said. “More PCPs are going to need even more time in the clinic to handle the increased number of patients, and you lose the luxury to run back and forth between the clinic and the hospital. For those that can develop a trusting relationship with a hospitalist, you can work together to see more patients and provide more care.”

So what’s the real root of the problem? Money. According to recent surveys, PCPs earn about half the salary of dermatologists and an even smaller fraction of an average cardiologist’s pay. With medical school debt routinely reaching $200,000, Dr. O’Malley and other analysts say, many doctors simply can’t afford to go into primary care.

“It all comes down to payment, basically,” she says. “At present, our payment system for physician services and for medical procedures is quite skewed. It overcompensates for certain types of diagnostics and procedures, and it undercompensates for the more cognitive type of care that primary-care providers provide.”

The Road Ahead

Fortunately, some relief is trickling in. One measure strongly supported by SHM and included in the Affordable Care Act is a 10% Medicare reimbursement bonus for primary care delivered by qualified doctors, slated to begin next year. In June, U.S. Department of Health and Human Services Secretary Kathleen Sebelius announced a separate, $250 million initiative to boost the primary-care workforce. The money would help train PCPs by creating more residency slots, and offer new support for physician assistants, nurses, and nurse practitioners. Among the measures included in last year’s stimulus package, an expansion of the National Health Service Corps will provide more debt-relief opportunities for PCPs. And in mid-September, HHS tapped stimulus funds to award another $50.³ million for primary care training programs and loan repayment.

The Obama administration has claimed its combined actions “will support the training and development of more than 16,000 new primary-care providers over the next five years,” according to a June 16 HHS press release.

Observers say those measures alone are unlikely to be enough to stem the tide, however. “It’s definitely a step in the right direction,” Dr. O’Malley says of the Medicare bonus. “I don’t think it’s going to solve the primary-care workforce issue, because a 10% bonus, given how low primary-care physician salaries are compared to their specialist counterparts, is not going to be that much of an increase. Among the physicians that I’ve talked to and other healthcare providers, few feel that that’s sufficient enough to really encourage a lot of people to pursue primary care.”

Several other efforts now underway might help:

• Texas Tech University Health Sciences Center unveiled a new Family Medicine Accelerated Track program, which will allow primary-care medical students to complete a degree in three years. Certain students will receive a one-year scholarship, meaning that overall debt for some could be half that of the standard four-year program.
• Reid Hospital and Health Care Services in Richmond, Ind., successfully reversed a downward trend in primary-care referrals by forming its own nonprofit subsidiary corporation, Reid Physician Associates. The nonprofit will include about 50 employed outpatient providers by year’s end to complement the 233-bed hospital’s inpatient staff.
• Danville, Pa.-based Geisinger Health System has begun paying the salaries of extra nurses for both in-network and independent primary-care practices. The nurses manage patients’ chronic conditions, ensure that they are following prescribed treatments, and communicate with hospitalists and other providers about transitions of care. Although still in its early stages, the experiment suggests the nurses are helping to spot problems, prevent unnecessary hospitalizations, and save money.

The Geisinger experiment is among the first steps toward a patient-centered medical home model of care. An eventual Medicare-led expansion of such medical homes and accountable-care organizations, now in the early experimental stages, could provide even more direct support to PCPs. To be successful, though, Dr. O’Malley says the models will need to focus on paying providers fairly for the value they bring to the system. “Obviously, payment reform is what we need if we’re ever going to develop a sustainable primary-care workforce in this country,” she says. TH

Bryn Nelson is a freelance medical writer based in Seattle.

References

1. White KL, Williams TF, Greenberg BG. The ecology of medical care. N Engl J Med. 1961;265:885-992.
2. Green LA, Fryer GE Jr., Yawn BP, Lanier D, Dovey SM. The ecology of medical care revisited. N Engl J Med. 2001;344(26):2021-2025.
3. Bodenheimer T, Grumbach K, Berenson RA. A lifeline for primary care. N Engl J Med. 2009;360(26):2693-2696.

The 1961 classic “The Ecology of Medical Care,” published in the New England Journal of Medicine, mapped out the broad features of the American healthcare landscape.¹ For every 1,000 adult, the study suggested, 750 reported an illness, 250 consulted a doctor, and nine were admitted to a hospital in any given month. The subsequent arrival of Medicare and Medicaid fundamentally changed the U.S. healthcare system. And yet an updated version of the study, released in 2001, yielded surprisingly similar numbers, with 800 residents experiencing symptoms, 217 visiting a physician’s office, and eight being hospitalized in an average month.²

“It helps kind of put in perspective where the bulk of care really occurs,” says Ann O’Malley, MD, a senior researcher at the Washington, D.C.-based Center for Studying Health System Change. “It’s in outpatient provider offices, mostly primary-care provider offices.”

Dr. O’Malley and a host of other observers, however, are warning that the keystone members of this healthcare ecosystem are in serious trouble. As organizations such as SHM have likewise made clear, the accelerating shortage of general internists, family practitioners, and other PCPs has created sizable cracks in the supports of the entire healthcare infrastructure.

How big are the cracks? The number of medical school students pursuing a primary-care career has dropped by more than half since 1997, according to the American Academy of Family Physicians. And with the number of medical students entering the field unable to keep up with attrition, the remaining doctors are facing increasingly difficult working conditions. “Overloaded primary-care practices, whose doctors are aptly compared to hamsters on a treadmill, struggle to provide prompt access and high-quality care,” asserted a 2009 op-ed in the New England Journal of Medicine.³ The result: a vicious circle of decline leading to an anticipated shortfall of roughly 21,000 PCPs by 2015, according to the Association of American Medical Colleges.

Many primary-care providers had already stopped taking new patients when June’s Medicare reimbursement rate fiasco allowed the sustainable growth rate (SGR) formula’s mandated 21.² percent rate cut to temporarily go into effect. Legislators eventually plugged the hole, but not before a new round of jitters seized the nation’s physicians, and reports proliferated throughout the summer about Medicare beneficiaries being unable to find a doctor willing to see them. The recession hasn’t helped, with more privately insured patients waiting longer to see their doctors to avoid copays, and with hospital emergency departments becoming de facto primary-care centers for those patients who have waited too long or have no other alternatives.

Uneven Challenges

Not only is there an acute shortage of primary-care physicians, Dr. O’Malley says, but there is also a distinctly uneven distribution throughout the country. For hospitalists, she says, the implications could be profound. “Hospitalists are increasingly going to be evaluated around issues such as avoiding hospital readmissions and [reducing] length of stay,” she says, “and if they want to improve both of those things, one of the keys is improving chronic care management in the outpatient setting, and improving follow-up post discharge.”

Both metrics will require the involvement of outpatient care providers, underscoring the importance of good communication and mutual respect. Despite the longstanding support of hospitalists for their primary-care counterparts, however, leaders are still being forced to address the perception that HM is somehow bad for what ails PCPs.

In a recent online article posted on the Becker’s Hospital Review website, SHM President Jeff Wiese, MD, SFHM, responded to one such criticism: that hospitalists make primary care less attractive for physicians. Hospitalists are not to blame for the decrease in interest, he asserted, but are actually complementary to the PCP role. And with millions more Americans about to be newly insured, that complementary relationship will be even more important. “It’s a tremendous waste of resources to use a primary-care provider for [a hospital visit]. We need to move into proactive mode, not reactive mode,” Dr. Wiese said. “More PCPs are going to need even more time in the clinic to handle the increased number of patients, and you lose the luxury to run back and forth between the clinic and the hospital. For those that can develop a trusting relationship with a hospitalist, you can work together to see more patients and provide more care.”

So what’s the real root of the problem? Money. According to recent surveys, PCPs earn about half the salary of dermatologists and an even smaller fraction of an average cardiologist’s pay. With medical school debt routinely reaching $200,000, Dr. O’Malley and other analysts say, many doctors simply can’t afford to go into primary care.

“It all comes down to payment, basically,” she says. “At present, our payment system for physician services and for medical procedures is quite skewed. It overcompensates for certain types of diagnostics and procedures, and it undercompensates for the more cognitive type of care that primary-care providers provide.”

The Road Ahead

Fortunately, some relief is trickling in. One measure strongly supported by SHM and included in the Affordable Care Act is a 10% Medicare reimbursement bonus for primary care delivered by qualified doctors, slated to begin next year. In June, U.S. Department of Health and Human Services Secretary Kathleen Sebelius announced a separate, $250 million initiative to boost the primary-care workforce. The money would help train PCPs by creating more residency slots, and offer new support for physician assistants, nurses, and nurse practitioners. Among the measures included in last year’s stimulus package, an expansion of the National Health Service Corps will provide more debt-relief opportunities for PCPs. And in mid-September, HHS tapped stimulus funds to award another $50.³ million for primary care training programs and loan repayment.

The Obama administration has claimed its combined actions “will support the training and development of more than 16,000 new primary-care providers over the next five years,” according to a June 16 HHS press release.

Observers say those measures alone are unlikely to be enough to stem the tide, however. “It’s definitely a step in the right direction,” Dr. O’Malley says of the Medicare bonus. “I don’t think it’s going to solve the primary-care workforce issue, because a 10% bonus, given how low primary-care physician salaries are compared to their specialist counterparts, is not going to be that much of an increase. Among the physicians that I’ve talked to and other healthcare providers, few feel that that’s sufficient enough to really encourage a lot of people to pursue primary care.”

Several other efforts now underway might help:

• Texas Tech University Health Sciences Center unveiled a new Family Medicine Accelerated Track program, which will allow primary-care medical students to complete a degree in three years. Certain students will receive a one-year scholarship, meaning that overall debt for some could be half that of the standard four-year program.
• Reid Hospital and Health Care Services in Richmond, Ind., successfully reversed a downward trend in primary-care referrals by forming its own nonprofit subsidiary corporation, Reid Physician Associates. The nonprofit will include about 50 employed outpatient providers by year’s end to complement the 233-bed hospital’s inpatient staff.
• Danville, Pa.-based Geisinger Health System has begun paying the salaries of extra nurses for both in-network and independent primary-care practices. The nurses manage patients’ chronic conditions, ensure that they are following prescribed treatments, and communicate with hospitalists and other providers about transitions of care. Although still in its early stages, the experiment suggests the nurses are helping to spot problems, prevent unnecessary hospitalizations, and save money.

The Geisinger experiment is among the first steps toward a patient-centered medical home model of care. An eventual Medicare-led expansion of such medical homes and accountable-care organizations, now in the early experimental stages, could provide even more direct support to PCPs. To be successful, though, Dr. O’Malley says the models will need to focus on paying providers fairly for the value they bring to the system. “Obviously, payment reform is what we need if we’re ever going to develop a sustainable primary-care workforce in this country,” she says. TH

Bryn Nelson is a freelance medical writer based in Seattle.

References

1. White KL, Williams TF, Greenberg BG. The ecology of medical care. N Engl J Med. 1961;265:885-992.
2. Green LA, Fryer GE Jr., Yawn BP, Lanier D, Dovey SM. The ecology of medical care revisited. N Engl J Med. 2001;344(26):2021-2025.
3. Bodenheimer T, Grumbach K, Berenson RA. A lifeline for primary care. N Engl J Med. 2009;360(26):2693-2696.