User login
U.S. health care policy: What lies ahead?
The New Year brings new leadership in the United States, with President-elect Donald Trump taking office later this month. With a Republican-controlled Congress, party leaders have the opportunity to shape the nation’s policies around conservative ideals. This includes health care.
Since the Affordable Care Act (ACA) was passed in 2010, Republicans have vowed to repeal and replace it. This could be their opportunity.
However, “there is no clear coalescence around specific policy reforms that would replace the Affordable Care Act,” says Christine Eibner, PhD, a senior economist at Rand and a professor at the Pardee Rand Graduate School.
As a candidate, Trump did little to advance policy ideas around health care. Meanwhile, House Speaker Paul Ryan (R-Wis.) and others have, over the years, proposed reforms with which Trump may or may not agree.
“The Republicans now have a hard issue in their hands,” says Allison Hoffman, JD, professor of law at UCLA School of Law and an expert on health care law and policy. “It was hard before the Affordable Care Act, and it will be hard after. There is not an easy solution.”
By 2016, the ACA had expanded health coverage to 20 million people through Medicaid and private insurance on health care marketplaces. It extended the solvency of the Medicare Hospital Insurance Trust Fund. It accelerated the pace of delivery system and payment reform through creation of the Center for Medicare & Medicaid Innovation.
The law, however, has not been without its challenges.
“It was a strong achievement to get 20 million people insured, but it’s not clear that it bent the cost curve,” says Dr. Eibner. “There are high premiums on the individual market and still 31 million people without coverage. There is still opportunity to improve.”
Where we stand January 2017
Whether the Republicans can or will repeal the ACA in its entirety and improve it remains unknown. But, the experts say, the landmark law has left its mark on the American health care system.
“Everyone is complaining about the uncertainty created by the election, but we have been dealing with a highly uncertain environment for many years,” says Ron Greeno, MD, FCCP, MHM, senior advisor for medical affairs at TeamHealth, chair of the SHM Public Policy Committee, and SHM president-elect. “There will be changes, but things were going to change no matter the outcome of the election. It continues to require tolerance for change and tolerance for uncertainty.”
In an analysis for the Commonwealth Fund, Dr. Eibner investigated the economic implications of aspects of Trump’s plans as a candidate. Using a computer model that incorporates economic theory and data to simulate the effects of health policy changes, Dr. Eibner found that Trump’s plans (full repeal alone or repeal with tax deductions for health care premiums, Medicaid block grants, or selling health insurance across state lines) would increase the number of uninsured people by 16 million to 25 million, disproportionately impact low-income and sicker patients, expose individual market enrollees to higher out-of-pocket costs, and increase the federal deficit by $0.5 billion to $41 billion.1 The Congressional Budget Office (CBO) estimates full repeal could increase the federal deficit by $137 billion to $353 billion by 2025.2 Rep. Ryan’s plan, A Better Way, proposes providing people more control over their health care, giving tax credits instead of subsidies for premiums, capping the employer-sponsored health insurance tax exclusion, and expanding use of health savings accounts.3 However, Rep. Ryan’s plan “doesn’t reduce the cost of health care. It puts more onus on individuals, and their costs go up,” Ms. Hoffman says. “The weight of that will be more on people who have preexisting conditions.”
Joshua Lenchus, DO, RPh, FACP, SFHM, a member of SHM’s Public Policy Committee and hospitalist at the University of Miami/Jackson Memorial Hospital in Florida, is no fan of entitlement programs like Medicaid but says, “The safety-net hospital where I work would rather have people covered with something than nothing.”
Dr. Lenchus is optimistic that economic reforms under Trump will lead to more jobs, increasing the number of people covered by employer plans. “The economy drives health care reform,” he says. “He has to up his ante now and show people that he can stimulate job growth in this country so we don’t have this middle class that is continuously squeezed.”
Dr. Greeno and Ms. Hoffman, who is also a faculty associate at the UCLA Center for Health Policy Research and vice chair of the Insurance Law Section of the Association of American Law Schools, suggest hospitalists get involved as rules are being shaped and written.
“We want to help reform the delivery system, and we want it to be done right and to be done fairly. We want to have say in how our patients are treated,” Dr. Greeno says.
Key provisions: A delicate balance
Many people equate the ACA with the individual mandate, which requires nearly all Americans to purchase health insurance or pay a fine. The federal government provides subsidies to enrollees between 138% and 400% of the federal poverty level so their out-of-pocket costs never exceed a defined threshold even if premiums go up. These could be on the chopping block.
“The last bill Congress passed to repeal the Affordable Care Act, which Obama vetoed, repealed the individual mandate and subsidies for people to buy insurance,” Ms. Hoffman says. “If they do repeal it, private insurance through the exchanges will crumble.”
Mr. Trump’s tax deductions to offset premium costs are based on income, making them more generous for higher-income earners than low-income ones, Hoffman adds.
As a result, she says, people may choose high-deductible plans and face high out-of-pocket costs if they do seek care.
“It’s asking individuals to save by deciding how they’re going to ration care, where someone says they’re not going to go to the doctor today or fill a prescription drug they need,” Ms. Hoffman says.
Meanwhile, Mr. Trump has said he would like to keep the provision of the ACA that bans insurers from denying individuals with preexisting conditions. This, experts agree, may not be possible if other parts of the law are repealed and not replaced with similar protections for insurers.
“If you try to keep the rules about not including preexisting conditions and get rid of subsidies and the individual mandate, it just won’t work,” Ms. Hoffman says. “You end up with extraordinarily expensive health insurance.”
Rep. Ryan’s plan would prohibit insurers from denying patients with preexisting conditions but only if patients maintain continuous coverage, with a single open-enrollment period. He has promised to provide at least $25 billion in federal funding for state high-risk pools.
Prior to the passage of the ACA, 35 states offered high-risk pools to people excluded from the individual market. The Kaiser Family Foundation shows the net annual losses in these states averaged $5,510 per enrollee in 2011. Premiums ranged from 100% to 200% higher than non–high-risk group coverage. Government subsidies to cover losses amounted to $1 billion in each state.4
Meanwhile, both Mr. Trump and Rep. Ryan have proposed profound changes for Medicaid. Dr. Greeno calls this a “massive political challenge” unless they can provide an alternative way to cover people who currently rely on the federal-state entitlement, as well as those who gained coverage through ACA expansion. Currently, 70 million people are enrolled in Medicaid and the Children’s Health Insurance Program.5 Through Mr. Trump’s suggested block grants, states would receive a fixed amount of money to administer their program with increased flexibility. Rep. Ryan’s plan calls for enrollment caps that would distribute a dollar amount to each participant in the program with no limit on the number of enrollees. Either would be adjusted for inflation.
States could implement work requirements for beneficiaries or ask them to pay a small amount toward their premiums. Expansion states could also lower the Medicaid threshold below 138%.
Some states will struggle to provide for all their enrollees, Ms. Hoffman says, particularly since health spending generally outpaces inflation. Dr. Lenchus is more optimistic. “I believe states that didn’t expand Medicaid, one way or another, will figure out a way to deal with that population,” he says.
And … Medicare
The other entitlement program facing abrupt change is Medicare, typically considered the third rail of American politics.
“This is the hot political moment,” Ms. Hoffman says. “This is the point where the Republicans think they can tick off their wish list. For many Republicans, this kind of entitlement program is the opposite of what they believe in.”
Though Mr. Trump has said before he would not alter Medicare, he remained quiet on this point in the aftermath of the election. Repealing the ACA would affect Medicare by potentially reopening the Part D prescription drug doughnut hole and eliminating some of the savings provisions in the law. In fact, the CBO estimates Medicare’s direct spending would increase $802 billion between 2016 and 2025.1 Rep. Ryan has talked about privatizing Medicare by offering seniors who rely on it vouchers to apply toward private insurance.
“At the highest level, it’s moving Medicare from a defined benefit to a defined contribution program,” Ms. Hoffman says. “It shifts financial risk from the federal government onto beneficiaries. If Medicare spending continues to grow faster than the rest of the economy, Medicare beneficiaries will pay more and more.”
Seniors may also find themselves rationing or skimping on care.
Despite Rep. Ryan’s statements to the contrary, Medicare is not broken because of the ACA, Ms. Hoffman says. Its solvency has been prolonged, and though the reasons are not clear, Medicare spending has slowed since the passage of the ACA.6
MACRA launch
Another key factor in the health care policy landscape is MACRA, the Medicare Access and CHIP Reauthorization Act, which fundamentally shifts the way the government administrates and reimburses physicians for health care. MACRA begins in 2017. Dr. Greeno is concerned that changes to the ACA will impact the testing of payment models CMS is testing.
“There are hundreds of hospitals and thousands of physicians already invested in different models, so I don’t expect anybody has any desire to pull the rug from under physicians who are testing alternative payment models [APMs],” he says. “MACRA was passed on a strong bipartisan vote, and it created an APM track. Obviously, Congress intended APM models to continue to expand.”
Dr. Greeno says hospitalists are helping “shape these models,” working with the CMS and the Physician-Focused Payment Model Technical Advisory Committee (PTAC) “to ensure physicians participate in APMs and feel engaged rather than being a worker in a model someone else controls.”
On the campaign trail, Mr. Trump spoke of importing pharmaceuticals from overseas in an effort to control high prices. This policy is no longer part of his online plan. He also proposes allowing the sale of health insurance across state lines.
“It would be giving enrollees in states with stricter regulations the opportunity to circumvent to a looser state, which undermines the state with the stricter regulations,” Dr. Eibner says. “That would really create winners and losers. People who are healthy can buy a policy in a state with looser regulations, and their costs would likely fall. But someone sicker and older, it would be harder.”
Ms. Hoffman defines such a plan as a “race to the bottom.” Without well-established networks of physicians and hospitals, startup costs in new states are prohibitive, and many insurers may not wish to compete across state lines, she adds.
Repeal of the ACA could also limit some of the health benefits it required of plans on the individual market. For example, policymakers might be allowed to strip the contraceptive coverage regulation, which provides for free birth control.
“The reality is a lot of things changing in health care now were changing before the Affordable Care Act passed – PQRS, value-based purchasing, hospital-acquired infections,” Dr. Greeno says. “MACRA will continue the journey away from fee-for-service toward outcome-based models.”
At such a pivotal time, he strongly encourages hospitalists to join SHM if they are not already members and to get involved in SHM’s Grassroots Network.
“For a society of our age – young – and size, we’ve been tremendously impactful in helping with delivery system reform,” Dr. Greeno says. “I think it’s because we’re supporting change, not trying to stop it. We just want it to be intelligent change.”
He also is “convinced” hospitalists will be “critical to the redesign of the health care system. Since we are going to be taking care of the majority of hospitalized adult patients in hospitals, hospitalists want to have our say.”
Kelly April Tyrrell is a freelance writer in Madison, Wis.
References
1. Eibner C. Donald Trump’s health care reform proposals: Anticipated effects on insurance coverage, out-of-pocket costs, and the federal deficit. The Commonweath Fund website. Available at: http://www.commonwealthfund.org/publications/issue-briefs/2016/sep/trump-presidential-health-care-proposal. Accessed Nov. 17, 2016.
2. Budgetary and economic effects of repealing the Affordable Care Act. Congressional Budget Office website. Available at: https://www.cbo.gov/sites/default/files/114th-congress-2015-2016/reports/50252-Effects_of_ACA_Repeal.pdf. Accessed Nov. 15, 2016.
3. Our vision for a confident America. A Better Way website. Available at: http://abetterway.speaker.gov. Accessed Nov. 17, 2016.
4. Pollitz K. High-risk pools for uninsurable individuals. Kaiser Family Foundation website. Available at: http://kff.org/health-reform/issue-brief/high-risk-pools-for-uninsurable-individuals/. Accessed Nov. 17, 2016.
5. How accessible is individual health insurance for consumers in less-than-ideal health? Kaiser Family Foundation website. Available at: https://kaiserfamilyfoundation.files.wordpress.com/2013/01/how-accessible-is-individual-health-insurance-for-consumer-in-less-than-perfect-health-report.pdf. Accessed Nov. 17, 2016.
6. The Affordable Care Act and Medicare. The Commonwealth Fund website. Available at: http://www.commonwealthfund.org/publications/fund-reports/2015/jun/medicare-affordable-care-act Accessed Nov. 17, 2016.
The New Year brings new leadership in the United States, with President-elect Donald Trump taking office later this month. With a Republican-controlled Congress, party leaders have the opportunity to shape the nation’s policies around conservative ideals. This includes health care.
Since the Affordable Care Act (ACA) was passed in 2010, Republicans have vowed to repeal and replace it. This could be their opportunity.
However, “there is no clear coalescence around specific policy reforms that would replace the Affordable Care Act,” says Christine Eibner, PhD, a senior economist at Rand and a professor at the Pardee Rand Graduate School.
As a candidate, Trump did little to advance policy ideas around health care. Meanwhile, House Speaker Paul Ryan (R-Wis.) and others have, over the years, proposed reforms with which Trump may or may not agree.
“The Republicans now have a hard issue in their hands,” says Allison Hoffman, JD, professor of law at UCLA School of Law and an expert on health care law and policy. “It was hard before the Affordable Care Act, and it will be hard after. There is not an easy solution.”
By 2016, the ACA had expanded health coverage to 20 million people through Medicaid and private insurance on health care marketplaces. It extended the solvency of the Medicare Hospital Insurance Trust Fund. It accelerated the pace of delivery system and payment reform through creation of the Center for Medicare & Medicaid Innovation.
The law, however, has not been without its challenges.
“It was a strong achievement to get 20 million people insured, but it’s not clear that it bent the cost curve,” says Dr. Eibner. “There are high premiums on the individual market and still 31 million people without coverage. There is still opportunity to improve.”
Where we stand January 2017
Whether the Republicans can or will repeal the ACA in its entirety and improve it remains unknown. But, the experts say, the landmark law has left its mark on the American health care system.
“Everyone is complaining about the uncertainty created by the election, but we have been dealing with a highly uncertain environment for many years,” says Ron Greeno, MD, FCCP, MHM, senior advisor for medical affairs at TeamHealth, chair of the SHM Public Policy Committee, and SHM president-elect. “There will be changes, but things were going to change no matter the outcome of the election. It continues to require tolerance for change and tolerance for uncertainty.”
In an analysis for the Commonwealth Fund, Dr. Eibner investigated the economic implications of aspects of Trump’s plans as a candidate. Using a computer model that incorporates economic theory and data to simulate the effects of health policy changes, Dr. Eibner found that Trump’s plans (full repeal alone or repeal with tax deductions for health care premiums, Medicaid block grants, or selling health insurance across state lines) would increase the number of uninsured people by 16 million to 25 million, disproportionately impact low-income and sicker patients, expose individual market enrollees to higher out-of-pocket costs, and increase the federal deficit by $0.5 billion to $41 billion.1 The Congressional Budget Office (CBO) estimates full repeal could increase the federal deficit by $137 billion to $353 billion by 2025.2 Rep. Ryan’s plan, A Better Way, proposes providing people more control over their health care, giving tax credits instead of subsidies for premiums, capping the employer-sponsored health insurance tax exclusion, and expanding use of health savings accounts.3 However, Rep. Ryan’s plan “doesn’t reduce the cost of health care. It puts more onus on individuals, and their costs go up,” Ms. Hoffman says. “The weight of that will be more on people who have preexisting conditions.”
Joshua Lenchus, DO, RPh, FACP, SFHM, a member of SHM’s Public Policy Committee and hospitalist at the University of Miami/Jackson Memorial Hospital in Florida, is no fan of entitlement programs like Medicaid but says, “The safety-net hospital where I work would rather have people covered with something than nothing.”
Dr. Lenchus is optimistic that economic reforms under Trump will lead to more jobs, increasing the number of people covered by employer plans. “The economy drives health care reform,” he says. “He has to up his ante now and show people that he can stimulate job growth in this country so we don’t have this middle class that is continuously squeezed.”
Dr. Greeno and Ms. Hoffman, who is also a faculty associate at the UCLA Center for Health Policy Research and vice chair of the Insurance Law Section of the Association of American Law Schools, suggest hospitalists get involved as rules are being shaped and written.
“We want to help reform the delivery system, and we want it to be done right and to be done fairly. We want to have say in how our patients are treated,” Dr. Greeno says.
Key provisions: A delicate balance
Many people equate the ACA with the individual mandate, which requires nearly all Americans to purchase health insurance or pay a fine. The federal government provides subsidies to enrollees between 138% and 400% of the federal poverty level so their out-of-pocket costs never exceed a defined threshold even if premiums go up. These could be on the chopping block.
“The last bill Congress passed to repeal the Affordable Care Act, which Obama vetoed, repealed the individual mandate and subsidies for people to buy insurance,” Ms. Hoffman says. “If they do repeal it, private insurance through the exchanges will crumble.”
Mr. Trump’s tax deductions to offset premium costs are based on income, making them more generous for higher-income earners than low-income ones, Hoffman adds.
As a result, she says, people may choose high-deductible plans and face high out-of-pocket costs if they do seek care.
“It’s asking individuals to save by deciding how they’re going to ration care, where someone says they’re not going to go to the doctor today or fill a prescription drug they need,” Ms. Hoffman says.
Meanwhile, Mr. Trump has said he would like to keep the provision of the ACA that bans insurers from denying individuals with preexisting conditions. This, experts agree, may not be possible if other parts of the law are repealed and not replaced with similar protections for insurers.
“If you try to keep the rules about not including preexisting conditions and get rid of subsidies and the individual mandate, it just won’t work,” Ms. Hoffman says. “You end up with extraordinarily expensive health insurance.”
Rep. Ryan’s plan would prohibit insurers from denying patients with preexisting conditions but only if patients maintain continuous coverage, with a single open-enrollment period. He has promised to provide at least $25 billion in federal funding for state high-risk pools.
Prior to the passage of the ACA, 35 states offered high-risk pools to people excluded from the individual market. The Kaiser Family Foundation shows the net annual losses in these states averaged $5,510 per enrollee in 2011. Premiums ranged from 100% to 200% higher than non–high-risk group coverage. Government subsidies to cover losses amounted to $1 billion in each state.4
Meanwhile, both Mr. Trump and Rep. Ryan have proposed profound changes for Medicaid. Dr. Greeno calls this a “massive political challenge” unless they can provide an alternative way to cover people who currently rely on the federal-state entitlement, as well as those who gained coverage through ACA expansion. Currently, 70 million people are enrolled in Medicaid and the Children’s Health Insurance Program.5 Through Mr. Trump’s suggested block grants, states would receive a fixed amount of money to administer their program with increased flexibility. Rep. Ryan’s plan calls for enrollment caps that would distribute a dollar amount to each participant in the program with no limit on the number of enrollees. Either would be adjusted for inflation.
States could implement work requirements for beneficiaries or ask them to pay a small amount toward their premiums. Expansion states could also lower the Medicaid threshold below 138%.
Some states will struggle to provide for all their enrollees, Ms. Hoffman says, particularly since health spending generally outpaces inflation. Dr. Lenchus is more optimistic. “I believe states that didn’t expand Medicaid, one way or another, will figure out a way to deal with that population,” he says.
And … Medicare
The other entitlement program facing abrupt change is Medicare, typically considered the third rail of American politics.
“This is the hot political moment,” Ms. Hoffman says. “This is the point where the Republicans think they can tick off their wish list. For many Republicans, this kind of entitlement program is the opposite of what they believe in.”
Though Mr. Trump has said before he would not alter Medicare, he remained quiet on this point in the aftermath of the election. Repealing the ACA would affect Medicare by potentially reopening the Part D prescription drug doughnut hole and eliminating some of the savings provisions in the law. In fact, the CBO estimates Medicare’s direct spending would increase $802 billion between 2016 and 2025.1 Rep. Ryan has talked about privatizing Medicare by offering seniors who rely on it vouchers to apply toward private insurance.
“At the highest level, it’s moving Medicare from a defined benefit to a defined contribution program,” Ms. Hoffman says. “It shifts financial risk from the federal government onto beneficiaries. If Medicare spending continues to grow faster than the rest of the economy, Medicare beneficiaries will pay more and more.”
Seniors may also find themselves rationing or skimping on care.
Despite Rep. Ryan’s statements to the contrary, Medicare is not broken because of the ACA, Ms. Hoffman says. Its solvency has been prolonged, and though the reasons are not clear, Medicare spending has slowed since the passage of the ACA.6
MACRA launch
Another key factor in the health care policy landscape is MACRA, the Medicare Access and CHIP Reauthorization Act, which fundamentally shifts the way the government administrates and reimburses physicians for health care. MACRA begins in 2017. Dr. Greeno is concerned that changes to the ACA will impact the testing of payment models CMS is testing.
“There are hundreds of hospitals and thousands of physicians already invested in different models, so I don’t expect anybody has any desire to pull the rug from under physicians who are testing alternative payment models [APMs],” he says. “MACRA was passed on a strong bipartisan vote, and it created an APM track. Obviously, Congress intended APM models to continue to expand.”
Dr. Greeno says hospitalists are helping “shape these models,” working with the CMS and the Physician-Focused Payment Model Technical Advisory Committee (PTAC) “to ensure physicians participate in APMs and feel engaged rather than being a worker in a model someone else controls.”
On the campaign trail, Mr. Trump spoke of importing pharmaceuticals from overseas in an effort to control high prices. This policy is no longer part of his online plan. He also proposes allowing the sale of health insurance across state lines.
“It would be giving enrollees in states with stricter regulations the opportunity to circumvent to a looser state, which undermines the state with the stricter regulations,” Dr. Eibner says. “That would really create winners and losers. People who are healthy can buy a policy in a state with looser regulations, and their costs would likely fall. But someone sicker and older, it would be harder.”
Ms. Hoffman defines such a plan as a “race to the bottom.” Without well-established networks of physicians and hospitals, startup costs in new states are prohibitive, and many insurers may not wish to compete across state lines, she adds.
Repeal of the ACA could also limit some of the health benefits it required of plans on the individual market. For example, policymakers might be allowed to strip the contraceptive coverage regulation, which provides for free birth control.
“The reality is a lot of things changing in health care now were changing before the Affordable Care Act passed – PQRS, value-based purchasing, hospital-acquired infections,” Dr. Greeno says. “MACRA will continue the journey away from fee-for-service toward outcome-based models.”
At such a pivotal time, he strongly encourages hospitalists to join SHM if they are not already members and to get involved in SHM’s Grassroots Network.
“For a society of our age – young – and size, we’ve been tremendously impactful in helping with delivery system reform,” Dr. Greeno says. “I think it’s because we’re supporting change, not trying to stop it. We just want it to be intelligent change.”
He also is “convinced” hospitalists will be “critical to the redesign of the health care system. Since we are going to be taking care of the majority of hospitalized adult patients in hospitals, hospitalists want to have our say.”
Kelly April Tyrrell is a freelance writer in Madison, Wis.
References
1. Eibner C. Donald Trump’s health care reform proposals: Anticipated effects on insurance coverage, out-of-pocket costs, and the federal deficit. The Commonweath Fund website. Available at: http://www.commonwealthfund.org/publications/issue-briefs/2016/sep/trump-presidential-health-care-proposal. Accessed Nov. 17, 2016.
2. Budgetary and economic effects of repealing the Affordable Care Act. Congressional Budget Office website. Available at: https://www.cbo.gov/sites/default/files/114th-congress-2015-2016/reports/50252-Effects_of_ACA_Repeal.pdf. Accessed Nov. 15, 2016.
3. Our vision for a confident America. A Better Way website. Available at: http://abetterway.speaker.gov. Accessed Nov. 17, 2016.
4. Pollitz K. High-risk pools for uninsurable individuals. Kaiser Family Foundation website. Available at: http://kff.org/health-reform/issue-brief/high-risk-pools-for-uninsurable-individuals/. Accessed Nov. 17, 2016.
5. How accessible is individual health insurance for consumers in less-than-ideal health? Kaiser Family Foundation website. Available at: https://kaiserfamilyfoundation.files.wordpress.com/2013/01/how-accessible-is-individual-health-insurance-for-consumer-in-less-than-perfect-health-report.pdf. Accessed Nov. 17, 2016.
6. The Affordable Care Act and Medicare. The Commonwealth Fund website. Available at: http://www.commonwealthfund.org/publications/fund-reports/2015/jun/medicare-affordable-care-act Accessed Nov. 17, 2016.
The New Year brings new leadership in the United States, with President-elect Donald Trump taking office later this month. With a Republican-controlled Congress, party leaders have the opportunity to shape the nation’s policies around conservative ideals. This includes health care.
Since the Affordable Care Act (ACA) was passed in 2010, Republicans have vowed to repeal and replace it. This could be their opportunity.
However, “there is no clear coalescence around specific policy reforms that would replace the Affordable Care Act,” says Christine Eibner, PhD, a senior economist at Rand and a professor at the Pardee Rand Graduate School.
As a candidate, Trump did little to advance policy ideas around health care. Meanwhile, House Speaker Paul Ryan (R-Wis.) and others have, over the years, proposed reforms with which Trump may or may not agree.
“The Republicans now have a hard issue in their hands,” says Allison Hoffman, JD, professor of law at UCLA School of Law and an expert on health care law and policy. “It was hard before the Affordable Care Act, and it will be hard after. There is not an easy solution.”
By 2016, the ACA had expanded health coverage to 20 million people through Medicaid and private insurance on health care marketplaces. It extended the solvency of the Medicare Hospital Insurance Trust Fund. It accelerated the pace of delivery system and payment reform through creation of the Center for Medicare & Medicaid Innovation.
The law, however, has not been without its challenges.
“It was a strong achievement to get 20 million people insured, but it’s not clear that it bent the cost curve,” says Dr. Eibner. “There are high premiums on the individual market and still 31 million people without coverage. There is still opportunity to improve.”
Where we stand January 2017
Whether the Republicans can or will repeal the ACA in its entirety and improve it remains unknown. But, the experts say, the landmark law has left its mark on the American health care system.
“Everyone is complaining about the uncertainty created by the election, but we have been dealing with a highly uncertain environment for many years,” says Ron Greeno, MD, FCCP, MHM, senior advisor for medical affairs at TeamHealth, chair of the SHM Public Policy Committee, and SHM president-elect. “There will be changes, but things were going to change no matter the outcome of the election. It continues to require tolerance for change and tolerance for uncertainty.”
In an analysis for the Commonwealth Fund, Dr. Eibner investigated the economic implications of aspects of Trump’s plans as a candidate. Using a computer model that incorporates economic theory and data to simulate the effects of health policy changes, Dr. Eibner found that Trump’s plans (full repeal alone or repeal with tax deductions for health care premiums, Medicaid block grants, or selling health insurance across state lines) would increase the number of uninsured people by 16 million to 25 million, disproportionately impact low-income and sicker patients, expose individual market enrollees to higher out-of-pocket costs, and increase the federal deficit by $0.5 billion to $41 billion.1 The Congressional Budget Office (CBO) estimates full repeal could increase the federal deficit by $137 billion to $353 billion by 2025.2 Rep. Ryan’s plan, A Better Way, proposes providing people more control over their health care, giving tax credits instead of subsidies for premiums, capping the employer-sponsored health insurance tax exclusion, and expanding use of health savings accounts.3 However, Rep. Ryan’s plan “doesn’t reduce the cost of health care. It puts more onus on individuals, and their costs go up,” Ms. Hoffman says. “The weight of that will be more on people who have preexisting conditions.”
Joshua Lenchus, DO, RPh, FACP, SFHM, a member of SHM’s Public Policy Committee and hospitalist at the University of Miami/Jackson Memorial Hospital in Florida, is no fan of entitlement programs like Medicaid but says, “The safety-net hospital where I work would rather have people covered with something than nothing.”
Dr. Lenchus is optimistic that economic reforms under Trump will lead to more jobs, increasing the number of people covered by employer plans. “The economy drives health care reform,” he says. “He has to up his ante now and show people that he can stimulate job growth in this country so we don’t have this middle class that is continuously squeezed.”
Dr. Greeno and Ms. Hoffman, who is also a faculty associate at the UCLA Center for Health Policy Research and vice chair of the Insurance Law Section of the Association of American Law Schools, suggest hospitalists get involved as rules are being shaped and written.
“We want to help reform the delivery system, and we want it to be done right and to be done fairly. We want to have say in how our patients are treated,” Dr. Greeno says.
Key provisions: A delicate balance
Many people equate the ACA with the individual mandate, which requires nearly all Americans to purchase health insurance or pay a fine. The federal government provides subsidies to enrollees between 138% and 400% of the federal poverty level so their out-of-pocket costs never exceed a defined threshold even if premiums go up. These could be on the chopping block.
“The last bill Congress passed to repeal the Affordable Care Act, which Obama vetoed, repealed the individual mandate and subsidies for people to buy insurance,” Ms. Hoffman says. “If they do repeal it, private insurance through the exchanges will crumble.”
Mr. Trump’s tax deductions to offset premium costs are based on income, making them more generous for higher-income earners than low-income ones, Hoffman adds.
As a result, she says, people may choose high-deductible plans and face high out-of-pocket costs if they do seek care.
“It’s asking individuals to save by deciding how they’re going to ration care, where someone says they’re not going to go to the doctor today or fill a prescription drug they need,” Ms. Hoffman says.
Meanwhile, Mr. Trump has said he would like to keep the provision of the ACA that bans insurers from denying individuals with preexisting conditions. This, experts agree, may not be possible if other parts of the law are repealed and not replaced with similar protections for insurers.
“If you try to keep the rules about not including preexisting conditions and get rid of subsidies and the individual mandate, it just won’t work,” Ms. Hoffman says. “You end up with extraordinarily expensive health insurance.”
Rep. Ryan’s plan would prohibit insurers from denying patients with preexisting conditions but only if patients maintain continuous coverage, with a single open-enrollment period. He has promised to provide at least $25 billion in federal funding for state high-risk pools.
Prior to the passage of the ACA, 35 states offered high-risk pools to people excluded from the individual market. The Kaiser Family Foundation shows the net annual losses in these states averaged $5,510 per enrollee in 2011. Premiums ranged from 100% to 200% higher than non–high-risk group coverage. Government subsidies to cover losses amounted to $1 billion in each state.4
Meanwhile, both Mr. Trump and Rep. Ryan have proposed profound changes for Medicaid. Dr. Greeno calls this a “massive political challenge” unless they can provide an alternative way to cover people who currently rely on the federal-state entitlement, as well as those who gained coverage through ACA expansion. Currently, 70 million people are enrolled in Medicaid and the Children’s Health Insurance Program.5 Through Mr. Trump’s suggested block grants, states would receive a fixed amount of money to administer their program with increased flexibility. Rep. Ryan’s plan calls for enrollment caps that would distribute a dollar amount to each participant in the program with no limit on the number of enrollees. Either would be adjusted for inflation.
States could implement work requirements for beneficiaries or ask them to pay a small amount toward their premiums. Expansion states could also lower the Medicaid threshold below 138%.
Some states will struggle to provide for all their enrollees, Ms. Hoffman says, particularly since health spending generally outpaces inflation. Dr. Lenchus is more optimistic. “I believe states that didn’t expand Medicaid, one way or another, will figure out a way to deal with that population,” he says.
And … Medicare
The other entitlement program facing abrupt change is Medicare, typically considered the third rail of American politics.
“This is the hot political moment,” Ms. Hoffman says. “This is the point where the Republicans think they can tick off their wish list. For many Republicans, this kind of entitlement program is the opposite of what they believe in.”
Though Mr. Trump has said before he would not alter Medicare, he remained quiet on this point in the aftermath of the election. Repealing the ACA would affect Medicare by potentially reopening the Part D prescription drug doughnut hole and eliminating some of the savings provisions in the law. In fact, the CBO estimates Medicare’s direct spending would increase $802 billion between 2016 and 2025.1 Rep. Ryan has talked about privatizing Medicare by offering seniors who rely on it vouchers to apply toward private insurance.
“At the highest level, it’s moving Medicare from a defined benefit to a defined contribution program,” Ms. Hoffman says. “It shifts financial risk from the federal government onto beneficiaries. If Medicare spending continues to grow faster than the rest of the economy, Medicare beneficiaries will pay more and more.”
Seniors may also find themselves rationing or skimping on care.
Despite Rep. Ryan’s statements to the contrary, Medicare is not broken because of the ACA, Ms. Hoffman says. Its solvency has been prolonged, and though the reasons are not clear, Medicare spending has slowed since the passage of the ACA.6
MACRA launch
Another key factor in the health care policy landscape is MACRA, the Medicare Access and CHIP Reauthorization Act, which fundamentally shifts the way the government administrates and reimburses physicians for health care. MACRA begins in 2017. Dr. Greeno is concerned that changes to the ACA will impact the testing of payment models CMS is testing.
“There are hundreds of hospitals and thousands of physicians already invested in different models, so I don’t expect anybody has any desire to pull the rug from under physicians who are testing alternative payment models [APMs],” he says. “MACRA was passed on a strong bipartisan vote, and it created an APM track. Obviously, Congress intended APM models to continue to expand.”
Dr. Greeno says hospitalists are helping “shape these models,” working with the CMS and the Physician-Focused Payment Model Technical Advisory Committee (PTAC) “to ensure physicians participate in APMs and feel engaged rather than being a worker in a model someone else controls.”
On the campaign trail, Mr. Trump spoke of importing pharmaceuticals from overseas in an effort to control high prices. This policy is no longer part of his online plan. He also proposes allowing the sale of health insurance across state lines.
“It would be giving enrollees in states with stricter regulations the opportunity to circumvent to a looser state, which undermines the state with the stricter regulations,” Dr. Eibner says. “That would really create winners and losers. People who are healthy can buy a policy in a state with looser regulations, and their costs would likely fall. But someone sicker and older, it would be harder.”
Ms. Hoffman defines such a plan as a “race to the bottom.” Without well-established networks of physicians and hospitals, startup costs in new states are prohibitive, and many insurers may not wish to compete across state lines, she adds.
Repeal of the ACA could also limit some of the health benefits it required of plans on the individual market. For example, policymakers might be allowed to strip the contraceptive coverage regulation, which provides for free birth control.
“The reality is a lot of things changing in health care now were changing before the Affordable Care Act passed – PQRS, value-based purchasing, hospital-acquired infections,” Dr. Greeno says. “MACRA will continue the journey away from fee-for-service toward outcome-based models.”
At such a pivotal time, he strongly encourages hospitalists to join SHM if they are not already members and to get involved in SHM’s Grassroots Network.
“For a society of our age – young – and size, we’ve been tremendously impactful in helping with delivery system reform,” Dr. Greeno says. “I think it’s because we’re supporting change, not trying to stop it. We just want it to be intelligent change.”
He also is “convinced” hospitalists will be “critical to the redesign of the health care system. Since we are going to be taking care of the majority of hospitalized adult patients in hospitals, hospitalists want to have our say.”
Kelly April Tyrrell is a freelance writer in Madison, Wis.
References
1. Eibner C. Donald Trump’s health care reform proposals: Anticipated effects on insurance coverage, out-of-pocket costs, and the federal deficit. The Commonweath Fund website. Available at: http://www.commonwealthfund.org/publications/issue-briefs/2016/sep/trump-presidential-health-care-proposal. Accessed Nov. 17, 2016.
2. Budgetary and economic effects of repealing the Affordable Care Act. Congressional Budget Office website. Available at: https://www.cbo.gov/sites/default/files/114th-congress-2015-2016/reports/50252-Effects_of_ACA_Repeal.pdf. Accessed Nov. 15, 2016.
3. Our vision for a confident America. A Better Way website. Available at: http://abetterway.speaker.gov. Accessed Nov. 17, 2016.
4. Pollitz K. High-risk pools for uninsurable individuals. Kaiser Family Foundation website. Available at: http://kff.org/health-reform/issue-brief/high-risk-pools-for-uninsurable-individuals/. Accessed Nov. 17, 2016.
5. How accessible is individual health insurance for consumers in less-than-ideal health? Kaiser Family Foundation website. Available at: https://kaiserfamilyfoundation.files.wordpress.com/2013/01/how-accessible-is-individual-health-insurance-for-consumer-in-less-than-perfect-health-report.pdf. Accessed Nov. 17, 2016.
6. The Affordable Care Act and Medicare. The Commonwealth Fund website. Available at: http://www.commonwealthfund.org/publications/fund-reports/2015/jun/medicare-affordable-care-act Accessed Nov. 17, 2016.
Theranos Receives Biggest Blow as CMS Revokes Certificate for Government Payments
Theranos Inc founder and CEO Elizabeth Holmes, once touted as the Steve Jobs of biotech for her company's innovative blood-testing technology, has been barred by a U.S. regulator from owning or operating a lab for at least two years.
Dealing the biggest blow yet to the privately held company, the Centers for Medicare & Medicaid Services revoked a key certificate for its California lab and terminated the facility's approval to receive government payments.
Medicare is the government's medical insurance program for the elderly, while Medicaid is for the poor.
The sanctions, which also include an unspecified monetary penalty, come six months after the regulator sent a scathing letter to the company, saying its practices were jeopardizing patient health and safety.
Theranos said late on Thursday that it would continue to service its customers through its Arizona lab.
The company, once valued at $9 billion, was founded by Holmes in 2003 to develop an innovative blood testing device that would give quicker results using just one drop of blood.
However, its fortunes waned after the Wall Street Journal published a series of articles starting in October last year that suggested the devices were flawed and inaccurate.
Forbes magazine said last month that the company's value had fallen to about $800 million, while Holmes' own net worth had shrunk to zero from about $4.5 billion - a figure the magazine had said had made her the richest self-made woman in America.
"Everyone wanted her to succeed," Steve Brozak, president of WBB Securities, told Reuters, noting that the basic blood diagnostics sector has not had a significant advance in technology in 90 years.
Walgreens Boots Alliance terminated its relationship with the company last month and closed operations at all 40 Theranos Wellness Centers at its drug stores in Arizona.
Theranos is also facing a class action lawsuit filed in May accusing it of endangering customer health through "massive failures" that misrepresented test results.
The Palo Alto, California-based company is also being investigated by other federal and state agencies, including the U.S. Securities and Exchange Commission and the State Department of Health in Arizona.
Theranos Inc founder and CEO Elizabeth Holmes, once touted as the Steve Jobs of biotech for her company's innovative blood-testing technology, has been barred by a U.S. regulator from owning or operating a lab for at least two years.
Dealing the biggest blow yet to the privately held company, the Centers for Medicare & Medicaid Services revoked a key certificate for its California lab and terminated the facility's approval to receive government payments.
Medicare is the government's medical insurance program for the elderly, while Medicaid is for the poor.
The sanctions, which also include an unspecified monetary penalty, come six months after the regulator sent a scathing letter to the company, saying its practices were jeopardizing patient health and safety.
Theranos said late on Thursday that it would continue to service its customers through its Arizona lab.
The company, once valued at $9 billion, was founded by Holmes in 2003 to develop an innovative blood testing device that would give quicker results using just one drop of blood.
However, its fortunes waned after the Wall Street Journal published a series of articles starting in October last year that suggested the devices were flawed and inaccurate.
Forbes magazine said last month that the company's value had fallen to about $800 million, while Holmes' own net worth had shrunk to zero from about $4.5 billion - a figure the magazine had said had made her the richest self-made woman in America.
"Everyone wanted her to succeed," Steve Brozak, president of WBB Securities, told Reuters, noting that the basic blood diagnostics sector has not had a significant advance in technology in 90 years.
Walgreens Boots Alliance terminated its relationship with the company last month and closed operations at all 40 Theranos Wellness Centers at its drug stores in Arizona.
Theranos is also facing a class action lawsuit filed in May accusing it of endangering customer health through "massive failures" that misrepresented test results.
The Palo Alto, California-based company is also being investigated by other federal and state agencies, including the U.S. Securities and Exchange Commission and the State Department of Health in Arizona.
Theranos Inc founder and CEO Elizabeth Holmes, once touted as the Steve Jobs of biotech for her company's innovative blood-testing technology, has been barred by a U.S. regulator from owning or operating a lab for at least two years.
Dealing the biggest blow yet to the privately held company, the Centers for Medicare & Medicaid Services revoked a key certificate for its California lab and terminated the facility's approval to receive government payments.
Medicare is the government's medical insurance program for the elderly, while Medicaid is for the poor.
The sanctions, which also include an unspecified monetary penalty, come six months after the regulator sent a scathing letter to the company, saying its practices were jeopardizing patient health and safety.
Theranos said late on Thursday that it would continue to service its customers through its Arizona lab.
The company, once valued at $9 billion, was founded by Holmes in 2003 to develop an innovative blood testing device that would give quicker results using just one drop of blood.
However, its fortunes waned after the Wall Street Journal published a series of articles starting in October last year that suggested the devices were flawed and inaccurate.
Forbes magazine said last month that the company's value had fallen to about $800 million, while Holmes' own net worth had shrunk to zero from about $4.5 billion - a figure the magazine had said had made her the richest self-made woman in America.
"Everyone wanted her to succeed," Steve Brozak, president of WBB Securities, told Reuters, noting that the basic blood diagnostics sector has not had a significant advance in technology in 90 years.
Walgreens Boots Alliance terminated its relationship with the company last month and closed operations at all 40 Theranos Wellness Centers at its drug stores in Arizona.
Theranos is also facing a class action lawsuit filed in May accusing it of endangering customer health through "massive failures" that misrepresented test results.
The Palo Alto, California-based company is also being investigated by other federal and state agencies, including the U.S. Securities and Exchange Commission and the State Department of Health in Arizona.
When Introducing Innovations, Context Matters
“We are missing an important opportunity to learn from what is going on in health systems every day that could tell us how to make healthcare better and cheaper,” says Dr. Fisher, lead author of a January 2016 JAMA “Viewpoint” called “Implementation Science: A Potential Catalyst for Delivery System Reform.” “That’s the argument for the the field of implementation science.”
Implementation science studies ways to promote the integration of research findings and evidence into the healthcare system. Dr. Fisher says that integration is influenced by multiple factors: the characteristic of the innovation itself, the organizational setting, and the policy or community environment within which that organization is working. Context matters.
“We tend to think about adopting innovations like a new blood pressure medication or a new device,” Dr. Fisher says. “Those decisions rest almost entirely on the shoulders of physicians, so adoption requires thinking about the attributes of biomedical innovations and how physicians think.”
With care delivery innovations—for example, how to provide optimal care for people with heart failure across home, hospital, and nursing home—those are often developed with clinical input but by people who are fundamentally managers.
“It’s a more complex set of actors,” he says, “so you have to think about those decision makers if you’re going to get the best evidence-based practice into their setting.”
A third category of innovation focuses on individual behavior change, where the decision makers are the clinician and the patient and family. “You’ve got to persuade the patient the innovation is worth doing, so different factors may influence the successful adoptions of those interventions,” Dr. Fisher says.
Reference
1. Fisher ES, Shortell SM, Savitz LA. Implementation science: a potential catalyst for delivery system reform. JAMA. 2016;315(4):339-340. doi:10.1001/jama.2015.17949.
“We are missing an important opportunity to learn from what is going on in health systems every day that could tell us how to make healthcare better and cheaper,” says Dr. Fisher, lead author of a January 2016 JAMA “Viewpoint” called “Implementation Science: A Potential Catalyst for Delivery System Reform.” “That’s the argument for the the field of implementation science.”
Implementation science studies ways to promote the integration of research findings and evidence into the healthcare system. Dr. Fisher says that integration is influenced by multiple factors: the characteristic of the innovation itself, the organizational setting, and the policy or community environment within which that organization is working. Context matters.
“We tend to think about adopting innovations like a new blood pressure medication or a new device,” Dr. Fisher says. “Those decisions rest almost entirely on the shoulders of physicians, so adoption requires thinking about the attributes of biomedical innovations and how physicians think.”
With care delivery innovations—for example, how to provide optimal care for people with heart failure across home, hospital, and nursing home—those are often developed with clinical input but by people who are fundamentally managers.
“It’s a more complex set of actors,” he says, “so you have to think about those decision makers if you’re going to get the best evidence-based practice into their setting.”
A third category of innovation focuses on individual behavior change, where the decision makers are the clinician and the patient and family. “You’ve got to persuade the patient the innovation is worth doing, so different factors may influence the successful adoptions of those interventions,” Dr. Fisher says.
Reference
1. Fisher ES, Shortell SM, Savitz LA. Implementation science: a potential catalyst for delivery system reform. JAMA. 2016;315(4):339-340. doi:10.1001/jama.2015.17949.
“We are missing an important opportunity to learn from what is going on in health systems every day that could tell us how to make healthcare better and cheaper,” says Dr. Fisher, lead author of a January 2016 JAMA “Viewpoint” called “Implementation Science: A Potential Catalyst for Delivery System Reform.” “That’s the argument for the the field of implementation science.”
Implementation science studies ways to promote the integration of research findings and evidence into the healthcare system. Dr. Fisher says that integration is influenced by multiple factors: the characteristic of the innovation itself, the organizational setting, and the policy or community environment within which that organization is working. Context matters.
“We tend to think about adopting innovations like a new blood pressure medication or a new device,” Dr. Fisher says. “Those decisions rest almost entirely on the shoulders of physicians, so adoption requires thinking about the attributes of biomedical innovations and how physicians think.”
With care delivery innovations—for example, how to provide optimal care for people with heart failure across home, hospital, and nursing home—those are often developed with clinical input but by people who are fundamentally managers.
“It’s a more complex set of actors,” he says, “so you have to think about those decision makers if you’re going to get the best evidence-based practice into their setting.”
A third category of innovation focuses on individual behavior change, where the decision makers are the clinician and the patient and family. “You’ve got to persuade the patient the innovation is worth doing, so different factors may influence the successful adoptions of those interventions,” Dr. Fisher says.
Reference
1. Fisher ES, Shortell SM, Savitz LA. Implementation science: a potential catalyst for delivery system reform. JAMA. 2016;315(4):339-340. doi:10.1001/jama.2015.17949.
LISTEN NOW: UCSF's Christopher Moriates, MD, discusses waste-reduction efforts in hospitals
CHRISTOPHER MORIATES, MD, assistant clinical professor in the Division of Hospital Medicine at the University of California, San Francisco, talks about the change in focus and priorities needed for medicine to make progress in waste-reduction efforts.
CHRISTOPHER MORIATES, MD, assistant clinical professor in the Division of Hospital Medicine at the University of California, San Francisco, talks about the change in focus and priorities needed for medicine to make progress in waste-reduction efforts.
CHRISTOPHER MORIATES, MD, assistant clinical professor in the Division of Hospital Medicine at the University of California, San Francisco, talks about the change in focus and priorities needed for medicine to make progress in waste-reduction efforts.
Technology May Offer Solutions to Hospitalists' Readmissions Exposure
Almost weekly, a white paper, report, journal article, or press release touts a new program, software, or technology system offering to help hospitals improve their readmissions avoidance processes and penalty exposure. Does this new readmissions cottage industry offer value to hospitals?
Some technologies focus on interdisciplinary team communication, with electronic repositories or virtual rounding, automated communications to the PCP, personalized patient instructions booklets, or telecommunications or mobile applications. Others aim to help coordinate patients’ care transitions and providers’ post-discharge outreach, empower patients, increase compliance with discharge instructions, or schedule and coordinate follow-up activities.
An August 16, 2013, blog post at HISTalk identified other technologies and services being employed by advisory panelists’ hospitals to reduce their readmissions, including electronic health record (EHR) vendors, predictive modeling vendors, home-grown analytics reports, decision support, niche software vendors focused on supporting case management, telemonitoring programs, and use of the LACE (length of stay, acuity of admission, co-morbidities, and number of previous ED visits in the last six months) index to identify patients at risk.
“I view these as tools and, like any tool, they can be helpful if they are the right tool for the job, applied correctly,” says Gregory Maynard, MD, MSc, SFHM, clinical professor and chief quality officer at the University of California Davis Medical Center in Sacramento. “In many cases, these tech tools are trying to reproduce virtually what ideally would be done in person—interdisciplinary bedside rounds with the active engagement of the patient.”
Mark V. Williams, MD, FACP, MHM, director of the Center for Health Services Research and vice chair of the department of internal medicine at the University of Kentucky in Lexington, says he’s stunned by the sheer number of entrepreneurial readmissions management programs and systems on the market.
“Obviously, people see a need. But I’m not that sanguine about this new tech stuff,” says Dr. Williams, Project BOOST’s principal investigator.
There has to be some kind of integration with the hospital’s EHR, he says; otherwise, it just makes extra work.
“I wish our existing EHRs had the capacity to develop their own readmissions applications,” he says.
Larry Beresford is a freelance writer in Alameda, Calif.
Almost weekly, a white paper, report, journal article, or press release touts a new program, software, or technology system offering to help hospitals improve their readmissions avoidance processes and penalty exposure. Does this new readmissions cottage industry offer value to hospitals?
Some technologies focus on interdisciplinary team communication, with electronic repositories or virtual rounding, automated communications to the PCP, personalized patient instructions booklets, or telecommunications or mobile applications. Others aim to help coordinate patients’ care transitions and providers’ post-discharge outreach, empower patients, increase compliance with discharge instructions, or schedule and coordinate follow-up activities.
An August 16, 2013, blog post at HISTalk identified other technologies and services being employed by advisory panelists’ hospitals to reduce their readmissions, including electronic health record (EHR) vendors, predictive modeling vendors, home-grown analytics reports, decision support, niche software vendors focused on supporting case management, telemonitoring programs, and use of the LACE (length of stay, acuity of admission, co-morbidities, and number of previous ED visits in the last six months) index to identify patients at risk.
“I view these as tools and, like any tool, they can be helpful if they are the right tool for the job, applied correctly,” says Gregory Maynard, MD, MSc, SFHM, clinical professor and chief quality officer at the University of California Davis Medical Center in Sacramento. “In many cases, these tech tools are trying to reproduce virtually what ideally would be done in person—interdisciplinary bedside rounds with the active engagement of the patient.”
Mark V. Williams, MD, FACP, MHM, director of the Center for Health Services Research and vice chair of the department of internal medicine at the University of Kentucky in Lexington, says he’s stunned by the sheer number of entrepreneurial readmissions management programs and systems on the market.
“Obviously, people see a need. But I’m not that sanguine about this new tech stuff,” says Dr. Williams, Project BOOST’s principal investigator.
There has to be some kind of integration with the hospital’s EHR, he says; otherwise, it just makes extra work.
“I wish our existing EHRs had the capacity to develop their own readmissions applications,” he says.
Larry Beresford is a freelance writer in Alameda, Calif.
Almost weekly, a white paper, report, journal article, or press release touts a new program, software, or technology system offering to help hospitals improve their readmissions avoidance processes and penalty exposure. Does this new readmissions cottage industry offer value to hospitals?
Some technologies focus on interdisciplinary team communication, with electronic repositories or virtual rounding, automated communications to the PCP, personalized patient instructions booklets, or telecommunications or mobile applications. Others aim to help coordinate patients’ care transitions and providers’ post-discharge outreach, empower patients, increase compliance with discharge instructions, or schedule and coordinate follow-up activities.
An August 16, 2013, blog post at HISTalk identified other technologies and services being employed by advisory panelists’ hospitals to reduce their readmissions, including electronic health record (EHR) vendors, predictive modeling vendors, home-grown analytics reports, decision support, niche software vendors focused on supporting case management, telemonitoring programs, and use of the LACE (length of stay, acuity of admission, co-morbidities, and number of previous ED visits in the last six months) index to identify patients at risk.
“I view these as tools and, like any tool, they can be helpful if they are the right tool for the job, applied correctly,” says Gregory Maynard, MD, MSc, SFHM, clinical professor and chief quality officer at the University of California Davis Medical Center in Sacramento. “In many cases, these tech tools are trying to reproduce virtually what ideally would be done in person—interdisciplinary bedside rounds with the active engagement of the patient.”
Mark V. Williams, MD, FACP, MHM, director of the Center for Health Services Research and vice chair of the department of internal medicine at the University of Kentucky in Lexington, says he’s stunned by the sheer number of entrepreneurial readmissions management programs and systems on the market.
“Obviously, people see a need. But I’m not that sanguine about this new tech stuff,” says Dr. Williams, Project BOOST’s principal investigator.
There has to be some kind of integration with the hospital’s EHR, he says; otherwise, it just makes extra work.
“I wish our existing EHRs had the capacity to develop their own readmissions applications,” he says.
Larry Beresford is a freelance writer in Alameda, Calif.
Mobile Apps to Improve Quality, Value at Point-of-Care for Inpatients
Summary: The panel of high-tech doctors helped a standing-room-only crowd navigate numerous apps to be used at point-of-care [PDF, 458 kb]. Groups worked through case studies utilizing applicable mobile apps. Examples and most useful apps, including occasional user reviews, follow:
Provider-to-Provider Communication, HIPAA secure
- Doximity.
- HIPAA-chat.
- Pros: HIPAA-secure, real-time communication.
- Cons: Both parties must be on app to securely communicate.
Provider-to-Patient Communication, Language Translators
- Google Translate: multiple platforms, free, 90 languages.
- MediBabble: iOS only, free, seven languages, dedicated medical application.
Diagnostic Apps for Providers
- Calculate by QxM.
- PreOpEval14: iOS only.
- PreopRisk Assessment: Android only.
- ASCVD Risk Estimator.
- MDCalc.com in addition to usual formulas, great abg-analyzer (online version only).
- AnticoagEvaluator.
- epocrates: calculators.
Click here for a PDF of useful apps and resource links [PDF, 177 kb]
Resources for Evidence-Based Practice
- ACP Clinical Guidelines.
- ACP Smart Medicine.
- Read by QxMD.
- UpToDate.
- AHRQ ePPS: identifies clinical preventive services.
- epocrates.
Patient Engagement Apps
- Medication reminders: MediSafe, CareZone.
- Pharmaceutical costs: Walmart, Target Healthful, GoodRx.
- Proper inhaler usage: User Inhalers App.
- Smoking cessation: QuitSTART.
HM15 takeaways
- Apps are available to providers and patients to enhance quality, value, and compliance;
- Before “prescribing” any app to patients, vet the application yourself; and
- Use apps to supplement your clinical practice, but be wary of becoming over-reliant upon them, to the detriment of long-term memory. In order to utilize information in critical-thinking processes, it must be stored in long-term memory. TH
Summary: The panel of high-tech doctors helped a standing-room-only crowd navigate numerous apps to be used at point-of-care [PDF, 458 kb]. Groups worked through case studies utilizing applicable mobile apps. Examples and most useful apps, including occasional user reviews, follow:
Provider-to-Provider Communication, HIPAA secure
- Doximity.
- HIPAA-chat.
- Pros: HIPAA-secure, real-time communication.
- Cons: Both parties must be on app to securely communicate.
Provider-to-Patient Communication, Language Translators
- Google Translate: multiple platforms, free, 90 languages.
- MediBabble: iOS only, free, seven languages, dedicated medical application.
Diagnostic Apps for Providers
- Calculate by QxM.
- PreOpEval14: iOS only.
- PreopRisk Assessment: Android only.
- ASCVD Risk Estimator.
- MDCalc.com in addition to usual formulas, great abg-analyzer (online version only).
- AnticoagEvaluator.
- epocrates: calculators.
Click here for a PDF of useful apps and resource links [PDF, 177 kb]
Resources for Evidence-Based Practice
- ACP Clinical Guidelines.
- ACP Smart Medicine.
- Read by QxMD.
- UpToDate.
- AHRQ ePPS: identifies clinical preventive services.
- epocrates.
Patient Engagement Apps
- Medication reminders: MediSafe, CareZone.
- Pharmaceutical costs: Walmart, Target Healthful, GoodRx.
- Proper inhaler usage: User Inhalers App.
- Smoking cessation: QuitSTART.
HM15 takeaways
- Apps are available to providers and patients to enhance quality, value, and compliance;
- Before “prescribing” any app to patients, vet the application yourself; and
- Use apps to supplement your clinical practice, but be wary of becoming over-reliant upon them, to the detriment of long-term memory. In order to utilize information in critical-thinking processes, it must be stored in long-term memory. TH
Summary: The panel of high-tech doctors helped a standing-room-only crowd navigate numerous apps to be used at point-of-care [PDF, 458 kb]. Groups worked through case studies utilizing applicable mobile apps. Examples and most useful apps, including occasional user reviews, follow:
Provider-to-Provider Communication, HIPAA secure
- Doximity.
- HIPAA-chat.
- Pros: HIPAA-secure, real-time communication.
- Cons: Both parties must be on app to securely communicate.
Provider-to-Patient Communication, Language Translators
- Google Translate: multiple platforms, free, 90 languages.
- MediBabble: iOS only, free, seven languages, dedicated medical application.
Diagnostic Apps for Providers
- Calculate by QxM.
- PreOpEval14: iOS only.
- PreopRisk Assessment: Android only.
- ASCVD Risk Estimator.
- MDCalc.com in addition to usual formulas, great abg-analyzer (online version only).
- AnticoagEvaluator.
- epocrates: calculators.
Click here for a PDF of useful apps and resource links [PDF, 177 kb]
Resources for Evidence-Based Practice
- ACP Clinical Guidelines.
- ACP Smart Medicine.
- Read by QxMD.
- UpToDate.
- AHRQ ePPS: identifies clinical preventive services.
- epocrates.
Patient Engagement Apps
- Medication reminders: MediSafe, CareZone.
- Pharmaceutical costs: Walmart, Target Healthful, GoodRx.
- Proper inhaler usage: User Inhalers App.
- Smoking cessation: QuitSTART.
HM15 takeaways
- Apps are available to providers and patients to enhance quality, value, and compliance;
- Before “prescribing” any app to patients, vet the application yourself; and
- Use apps to supplement your clinical practice, but be wary of becoming over-reliant upon them, to the detriment of long-term memory. In order to utilize information in critical-thinking processes, it must be stored in long-term memory. TH
WATCH: Hospital Medicine 2015 Day Four Highlights
Day Four highlights from HM15, the Society of Hospital Medicine’s (SHM) annual meeting in National Harbor, Md., just outside Washington, D.C.
The video associated with this article is no longer available on this site. Please view all of our videos on the MDedge YouTube channel
Day Four highlights from HM15, the Society of Hospital Medicine’s (SHM) annual meeting in National Harbor, Md., just outside Washington, D.C.
The video associated with this article is no longer available on this site. Please view all of our videos on the MDedge YouTube channel
Day Four highlights from HM15, the Society of Hospital Medicine’s (SHM) annual meeting in National Harbor, Md., just outside Washington, D.C.
The video associated with this article is no longer available on this site. Please view all of our videos on the MDedge YouTube channel
Health Information Technology Could Improve Hospital Discharge Planning
An RIV poster presented at SHM’s annual meeting describes the application of health information technology to improve the quality of hospital discharge summaries.4 Lead author Kristen Lewis, MD, in the clinical division of hospital medicine at The Ohio State University (OSU) Wexner Medical Center in Columbus, described how SHM’s 2009 “Transitions of Care Consensus Policy Statement” was adopted as the medical center’s standard of care—although at baseline this standard was being fully met at the hospital only 4% of the time.5 Discharge summaries frequently lacked important information, including tests pending at discharge, and were not made available to those clinicians who needed them following discharge.
“We developed, piloted, and implemented an innovative electronic discharge summary template that incorporated prompts and automatically populated core components of a quality discharge summary,” Dr. Lewis says, adding that the process also offered opportunities for customization and free-text entries. Initial experience following a series of multidisciplinary educational initiatives to help physicians and case managers understand these mechanisms found full compliance rising to 75%.
Next steps for the project include improving the availability of discharge data for primary care providers, specialist physicians, and extended care facilities not affiliated with OSU; inclusion of the discharge summary in the “After Visit Summary” given to patients; and assessment of outpatient providers’ satisfaction with the process.
For more information about the electronic discharge template, contact Dr. Lewis at [email protected].
Larry Beresford is a freelance writer in Alameda, Calif.
References
- Bailey FA, Williams BR, Woodby LL, et al. Intervention to improve care at life's end in inpatient settings: The BEACON trial. J Gen Intern Med. 2014;29(6):836-843.
- Burling S. Yogurt a solution to hospital infection? Philadelphia Inquirer website. December 10, 2013. Available at: http://articles.philly.com/2013-12-10/news/44946926_1_holy-redeemer-probiotics-yogurt. Accessed June 5, 2014.
- Landelle C, Verachten M, Legrand P, Girou E, Barbut F, Buisson CB. Contamination of healthcare workers’ hands with Clostridium difficile spores after caring for patients with C. difficile infection. Infect Control Hosp Epidemiol. 2014;35(1):10-15.
- Lewis K, Walker C. Development and application of information technology solutions to improve the quality and availability of discharge summaries. Journal of Hospital Medicine RIV abstracts website. Available at: http://www.shmabstracts.com/abstract.asp?MeetingID=793&id=104276&meeting=JHM201305. Published May 2013. Accessed June 14, 2014.
- Snow V, Beck D, Budnitz T, et al. Transitions of Care Consensus Policy Statement. American College of Physicians; Society of General Internal Medicine; Society of Hospital Medicine; American Geriatrics Society; American College of Emergency Physicians; Society of Academic Emergency Medicine. J Gen Intern Med. 2009;24(8):971-976.
- American Hospital Association: Uncompensated hospital care cost fact sheet. January 2014. Available at: http://www.aha.org/content/14/14uncompensatedcare.pdf. Accessed June 5, 2014.
An RIV poster presented at SHM’s annual meeting describes the application of health information technology to improve the quality of hospital discharge summaries.4 Lead author Kristen Lewis, MD, in the clinical division of hospital medicine at The Ohio State University (OSU) Wexner Medical Center in Columbus, described how SHM’s 2009 “Transitions of Care Consensus Policy Statement” was adopted as the medical center’s standard of care—although at baseline this standard was being fully met at the hospital only 4% of the time.5 Discharge summaries frequently lacked important information, including tests pending at discharge, and were not made available to those clinicians who needed them following discharge.
“We developed, piloted, and implemented an innovative electronic discharge summary template that incorporated prompts and automatically populated core components of a quality discharge summary,” Dr. Lewis says, adding that the process also offered opportunities for customization and free-text entries. Initial experience following a series of multidisciplinary educational initiatives to help physicians and case managers understand these mechanisms found full compliance rising to 75%.
Next steps for the project include improving the availability of discharge data for primary care providers, specialist physicians, and extended care facilities not affiliated with OSU; inclusion of the discharge summary in the “After Visit Summary” given to patients; and assessment of outpatient providers’ satisfaction with the process.
For more information about the electronic discharge template, contact Dr. Lewis at [email protected].
Larry Beresford is a freelance writer in Alameda, Calif.
References
- Bailey FA, Williams BR, Woodby LL, et al. Intervention to improve care at life's end in inpatient settings: The BEACON trial. J Gen Intern Med. 2014;29(6):836-843.
- Burling S. Yogurt a solution to hospital infection? Philadelphia Inquirer website. December 10, 2013. Available at: http://articles.philly.com/2013-12-10/news/44946926_1_holy-redeemer-probiotics-yogurt. Accessed June 5, 2014.
- Landelle C, Verachten M, Legrand P, Girou E, Barbut F, Buisson CB. Contamination of healthcare workers’ hands with Clostridium difficile spores after caring for patients with C. difficile infection. Infect Control Hosp Epidemiol. 2014;35(1):10-15.
- Lewis K, Walker C. Development and application of information technology solutions to improve the quality and availability of discharge summaries. Journal of Hospital Medicine RIV abstracts website. Available at: http://www.shmabstracts.com/abstract.asp?MeetingID=793&id=104276&meeting=JHM201305. Published May 2013. Accessed June 14, 2014.
- Snow V, Beck D, Budnitz T, et al. Transitions of Care Consensus Policy Statement. American College of Physicians; Society of General Internal Medicine; Society of Hospital Medicine; American Geriatrics Society; American College of Emergency Physicians; Society of Academic Emergency Medicine. J Gen Intern Med. 2009;24(8):971-976.
- American Hospital Association: Uncompensated hospital care cost fact sheet. January 2014. Available at: http://www.aha.org/content/14/14uncompensatedcare.pdf. Accessed June 5, 2014.
An RIV poster presented at SHM’s annual meeting describes the application of health information technology to improve the quality of hospital discharge summaries.4 Lead author Kristen Lewis, MD, in the clinical division of hospital medicine at The Ohio State University (OSU) Wexner Medical Center in Columbus, described how SHM’s 2009 “Transitions of Care Consensus Policy Statement” was adopted as the medical center’s standard of care—although at baseline this standard was being fully met at the hospital only 4% of the time.5 Discharge summaries frequently lacked important information, including tests pending at discharge, and were not made available to those clinicians who needed them following discharge.
“We developed, piloted, and implemented an innovative electronic discharge summary template that incorporated prompts and automatically populated core components of a quality discharge summary,” Dr. Lewis says, adding that the process also offered opportunities for customization and free-text entries. Initial experience following a series of multidisciplinary educational initiatives to help physicians and case managers understand these mechanisms found full compliance rising to 75%.
Next steps for the project include improving the availability of discharge data for primary care providers, specialist physicians, and extended care facilities not affiliated with OSU; inclusion of the discharge summary in the “After Visit Summary” given to patients; and assessment of outpatient providers’ satisfaction with the process.
For more information about the electronic discharge template, contact Dr. Lewis at [email protected].
Larry Beresford is a freelance writer in Alameda, Calif.
References
- Bailey FA, Williams BR, Woodby LL, et al. Intervention to improve care at life's end in inpatient settings: The BEACON trial. J Gen Intern Med. 2014;29(6):836-843.
- Burling S. Yogurt a solution to hospital infection? Philadelphia Inquirer website. December 10, 2013. Available at: http://articles.philly.com/2013-12-10/news/44946926_1_holy-redeemer-probiotics-yogurt. Accessed June 5, 2014.
- Landelle C, Verachten M, Legrand P, Girou E, Barbut F, Buisson CB. Contamination of healthcare workers’ hands with Clostridium difficile spores after caring for patients with C. difficile infection. Infect Control Hosp Epidemiol. 2014;35(1):10-15.
- Lewis K, Walker C. Development and application of information technology solutions to improve the quality and availability of discharge summaries. Journal of Hospital Medicine RIV abstracts website. Available at: http://www.shmabstracts.com/abstract.asp?MeetingID=793&id=104276&meeting=JHM201305. Published May 2013. Accessed June 14, 2014.
- Snow V, Beck D, Budnitz T, et al. Transitions of Care Consensus Policy Statement. American College of Physicians; Society of General Internal Medicine; Society of Hospital Medicine; American Geriatrics Society; American College of Emergency Physicians; Society of Academic Emergency Medicine. J Gen Intern Med. 2009;24(8):971-976.
- American Hospital Association: Uncompensated hospital care cost fact sheet. January 2014. Available at: http://www.aha.org/content/14/14uncompensatedcare.pdf. Accessed June 5, 2014.
Registration for ASHP’s Medication Safety Collaborative Still Open
Maybe you just returned from HM14 in Las Vegas and are ready to head back. Or maybe you missed out on SHM’s annual meeting but would like to meet up with an important part of the hospitalist team: hospital and health system pharmacists.
Regardless of your motivation, the American Society of Health-System Pharmacist’s (ASHP’s) combination of three meetings in one brings a wealth of information to hospitalists—physicians and pharmacists alike—and now SHM members can register for the Medication Safety Collaborative at the applicable ASHP member rates.
SHM members receive the ASHP member rate at ASHP’s meeting within a meeting for hospital and health system pharmacists, to be held May 31-June 4 in Las Vegas.
Many hospitalists will be especially interested in the Medication Safety Collaborative, which brings the entire hospital team together to share best practices in medication and patient safety.
The Medication Safety Collaborative consists of three meetings:
- ASHP Informatics Institute: An event for informaticists to innovate, interact, and improve the use of information technology in healthcare;
- The Medication Safety Collaborative: For inter-professional teams of health system-based clinicians, coordinators, managers, and administrators who focus on patient safety and quality; and
- Pharmacy Practice Policy: The most relevant issues affecting health system pharmacy practice today at ASHP’s first Pharmacy Practice and Policy Meeting.
Maybe you just returned from HM14 in Las Vegas and are ready to head back. Or maybe you missed out on SHM’s annual meeting but would like to meet up with an important part of the hospitalist team: hospital and health system pharmacists.
Regardless of your motivation, the American Society of Health-System Pharmacist’s (ASHP’s) combination of three meetings in one brings a wealth of information to hospitalists—physicians and pharmacists alike—and now SHM members can register for the Medication Safety Collaborative at the applicable ASHP member rates.
SHM members receive the ASHP member rate at ASHP’s meeting within a meeting for hospital and health system pharmacists, to be held May 31-June 4 in Las Vegas.
Many hospitalists will be especially interested in the Medication Safety Collaborative, which brings the entire hospital team together to share best practices in medication and patient safety.
The Medication Safety Collaborative consists of three meetings:
- ASHP Informatics Institute: An event for informaticists to innovate, interact, and improve the use of information technology in healthcare;
- The Medication Safety Collaborative: For inter-professional teams of health system-based clinicians, coordinators, managers, and administrators who focus on patient safety and quality; and
- Pharmacy Practice Policy: The most relevant issues affecting health system pharmacy practice today at ASHP’s first Pharmacy Practice and Policy Meeting.
Maybe you just returned from HM14 in Las Vegas and are ready to head back. Or maybe you missed out on SHM’s annual meeting but would like to meet up with an important part of the hospitalist team: hospital and health system pharmacists.
Regardless of your motivation, the American Society of Health-System Pharmacist’s (ASHP’s) combination of three meetings in one brings a wealth of information to hospitalists—physicians and pharmacists alike—and now SHM members can register for the Medication Safety Collaborative at the applicable ASHP member rates.
SHM members receive the ASHP member rate at ASHP’s meeting within a meeting for hospital and health system pharmacists, to be held May 31-June 4 in Las Vegas.
Many hospitalists will be especially interested in the Medication Safety Collaborative, which brings the entire hospital team together to share best practices in medication and patient safety.
The Medication Safety Collaborative consists of three meetings:
- ASHP Informatics Institute: An event for informaticists to innovate, interact, and improve the use of information technology in healthcare;
- The Medication Safety Collaborative: For inter-professional teams of health system-based clinicians, coordinators, managers, and administrators who focus on patient safety and quality; and
- Pharmacy Practice Policy: The most relevant issues affecting health system pharmacy practice today at ASHP’s first Pharmacy Practice and Policy Meeting.
Two Hospitalist Groups Join SHM's Hospital Medicine Exchange
HMX: Two New Communities, Lots of New Conversations
More than 2,500 hospitalists have logged in to HMX (www.hmxchange.org) to share their experiences and learn from the experiences of other hospitalists. And now, two other groups of hospitalists have a new reason to check out HMX.
The first community, for family medicine hospitalists, was launched in October. Approximately 10% of SHM’s active members are hospitalists trained in family medicine (HTFM), many of whom are very active within SHM. More than 60 hospitalists trained in family medicine are either Fellows in Hospital Medicine or Senior Fellows in Hospital Medicine.
And, in December, hospitalists who work in post-acute care can work together to tackle the challenges unique to post-acute care. This new community was an outgrowth of SHM’s Post-Acute Care Task Force.
Brendon Shank is SHM’s associate vice president of communications.
HMX: Two New Communities, Lots of New Conversations
More than 2,500 hospitalists have logged in to HMX (www.hmxchange.org) to share their experiences and learn from the experiences of other hospitalists. And now, two other groups of hospitalists have a new reason to check out HMX.
The first community, for family medicine hospitalists, was launched in October. Approximately 10% of SHM’s active members are hospitalists trained in family medicine (HTFM), many of whom are very active within SHM. More than 60 hospitalists trained in family medicine are either Fellows in Hospital Medicine or Senior Fellows in Hospital Medicine.
And, in December, hospitalists who work in post-acute care can work together to tackle the challenges unique to post-acute care. This new community was an outgrowth of SHM’s Post-Acute Care Task Force.
Brendon Shank is SHM’s associate vice president of communications.
HMX: Two New Communities, Lots of New Conversations
More than 2,500 hospitalists have logged in to HMX (www.hmxchange.org) to share their experiences and learn from the experiences of other hospitalists. And now, two other groups of hospitalists have a new reason to check out HMX.
The first community, for family medicine hospitalists, was launched in October. Approximately 10% of SHM’s active members are hospitalists trained in family medicine (HTFM), many of whom are very active within SHM. More than 60 hospitalists trained in family medicine are either Fellows in Hospital Medicine or Senior Fellows in Hospital Medicine.
And, in December, hospitalists who work in post-acute care can work together to tackle the challenges unique to post-acute care. This new community was an outgrowth of SHM’s Post-Acute Care Task Force.
Brendon Shank is SHM’s associate vice president of communications.