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Battling biases with the 5 Rs of cultural humility
How do we, as hospitalists, win the hearts and minds of patients, families, and care team members whom we do not know? What are the obstacles that we face when encountering patients and gaining the trust needed to improve patient care and patient experience?
With these questions in mind, the Cultural Humility Work Group, part of SHM’s Practice Management Committee, set out to develop a simple, universal framework to provide a foundation for strengthening communication skills and raising awareness of the basic tenets of cultural humility. According to Tervalon and Murray-Garcia, cultural humility is defined as a “process that requires humility as individuals continually engage in self-reflection and self-critique as lifelong learners and reflective practitioners. It requires humility in how physicians bring into check the power imbalances that exist in the dynamics of physician-patient communication by using patient-focused interviewing and care, and it is a process that requires humility to develop and maintain mutually respectful and dynamic partnerships with communities” (Tervalon, M. & Murray-García, J. “Cultural Humility Versus Cultural Competence: A Critical Distinction in Defining Physician Training Outcomes in Multicultural Education.” J Health Care Poor Underserved. 1998;9[2]:117-25).
How do we win this battle? The first step is to simply be aware that everyone is a victim of unconscious biases. Once we come to this (often uncomfortable) realization, we must make a conscious effort to change our mindset and make conscious decisions to not allow these biases to manifest.
Practicing cultural humility is extremely important in this process. It puts everyone on the same platform because there is no “minority,” “majority,” or “ethnicity” associated with it. It takes away the need to know everything about a certain culture and encourages us to approach every patient encounter acknowledging that we will humble ourselves, learn what is important to the patient, and leave having learned something from the interaction.
The work group developed “The 5 Rs of Cultural Humility” as a simple tool for hospitalists to incorporate into their practice. The first four Rs (Reflection, Respect, Regard and Relevance) are extrinsically focused, while the 5th R (Resiliency) is intrinsic. Our theory posits that, if you attain the first 4 Rs in every interaction, these will serve to build on and develop your own personal resiliency. Here are the 5 Rs:
- Reflection – Hospitalists will approach every encounter with humility and understanding that there is always something to learn from everyone.
- Respect – Hospitalists will treat every person with the utmost respect and strive to preserve dignity at all times.
- Regard – Hospitalists will hold every person in their highest regard while being aware of and not allowing unconscious biases to interfere in any interactions.
- Relevance – Hospitalists will expect cultural humility to be relevant to the patient and apply this practice to every encounter.
- Resiliency – Hospitalists will embody the practice of cultural humility to enhance personal resilience and globally focused compassion.
The content will be available as a downloadable pocket card that can be easily referenced on rounds and shared with colleagues. Our hope is to achieve heightened awareness of effective interaction. In addition to the definitions of each of the Rs, the card will feature questions to ask yourself before, during, and after every interaction to aid in attaining cultural humility.
The card will be printed and disseminated at Hospital Medicine 2017, and the 5 Rs will be discussed in a few sessions: “Making ‘Everything We Say and Do’ a Positive Patient Experience” in the Practice Management track on Thursday, May 4, and during a 20-minute “MEDtalk” in Product Theater 1 on May 3, at 10:15 a.m.
Keep on the lookout for future blog posts, where you’ll read about the 5 R’s in action through vignettes and a deeper dive into each aspect.
For more information and the downloadable pocket card, visit www.hospitalmedicine.org/5Rs.
Dr. Ansari is associate professor and associate division director of hospital medicine at Loyola University Medical Center, Maywood, Ill., and serves on SHM’s Cultural Humility Work Group.
How do we, as hospitalists, win the hearts and minds of patients, families, and care team members whom we do not know? What are the obstacles that we face when encountering patients and gaining the trust needed to improve patient care and patient experience?
With these questions in mind, the Cultural Humility Work Group, part of SHM’s Practice Management Committee, set out to develop a simple, universal framework to provide a foundation for strengthening communication skills and raising awareness of the basic tenets of cultural humility. According to Tervalon and Murray-Garcia, cultural humility is defined as a “process that requires humility as individuals continually engage in self-reflection and self-critique as lifelong learners and reflective practitioners. It requires humility in how physicians bring into check the power imbalances that exist in the dynamics of physician-patient communication by using patient-focused interviewing and care, and it is a process that requires humility to develop and maintain mutually respectful and dynamic partnerships with communities” (Tervalon, M. & Murray-García, J. “Cultural Humility Versus Cultural Competence: A Critical Distinction in Defining Physician Training Outcomes in Multicultural Education.” J Health Care Poor Underserved. 1998;9[2]:117-25).
How do we win this battle? The first step is to simply be aware that everyone is a victim of unconscious biases. Once we come to this (often uncomfortable) realization, we must make a conscious effort to change our mindset and make conscious decisions to not allow these biases to manifest.
Practicing cultural humility is extremely important in this process. It puts everyone on the same platform because there is no “minority,” “majority,” or “ethnicity” associated with it. It takes away the need to know everything about a certain culture and encourages us to approach every patient encounter acknowledging that we will humble ourselves, learn what is important to the patient, and leave having learned something from the interaction.
The work group developed “The 5 Rs of Cultural Humility” as a simple tool for hospitalists to incorporate into their practice. The first four Rs (Reflection, Respect, Regard and Relevance) are extrinsically focused, while the 5th R (Resiliency) is intrinsic. Our theory posits that, if you attain the first 4 Rs in every interaction, these will serve to build on and develop your own personal resiliency. Here are the 5 Rs:
- Reflection – Hospitalists will approach every encounter with humility and understanding that there is always something to learn from everyone.
- Respect – Hospitalists will treat every person with the utmost respect and strive to preserve dignity at all times.
- Regard – Hospitalists will hold every person in their highest regard while being aware of and not allowing unconscious biases to interfere in any interactions.
- Relevance – Hospitalists will expect cultural humility to be relevant to the patient and apply this practice to every encounter.
- Resiliency – Hospitalists will embody the practice of cultural humility to enhance personal resilience and globally focused compassion.
The content will be available as a downloadable pocket card that can be easily referenced on rounds and shared with colleagues. Our hope is to achieve heightened awareness of effective interaction. In addition to the definitions of each of the Rs, the card will feature questions to ask yourself before, during, and after every interaction to aid in attaining cultural humility.
The card will be printed and disseminated at Hospital Medicine 2017, and the 5 Rs will be discussed in a few sessions: “Making ‘Everything We Say and Do’ a Positive Patient Experience” in the Practice Management track on Thursday, May 4, and during a 20-minute “MEDtalk” in Product Theater 1 on May 3, at 10:15 a.m.
Keep on the lookout for future blog posts, where you’ll read about the 5 R’s in action through vignettes and a deeper dive into each aspect.
For more information and the downloadable pocket card, visit www.hospitalmedicine.org/5Rs.
Dr. Ansari is associate professor and associate division director of hospital medicine at Loyola University Medical Center, Maywood, Ill., and serves on SHM’s Cultural Humility Work Group.
How do we, as hospitalists, win the hearts and minds of patients, families, and care team members whom we do not know? What are the obstacles that we face when encountering patients and gaining the trust needed to improve patient care and patient experience?
With these questions in mind, the Cultural Humility Work Group, part of SHM’s Practice Management Committee, set out to develop a simple, universal framework to provide a foundation for strengthening communication skills and raising awareness of the basic tenets of cultural humility. According to Tervalon and Murray-Garcia, cultural humility is defined as a “process that requires humility as individuals continually engage in self-reflection and self-critique as lifelong learners and reflective practitioners. It requires humility in how physicians bring into check the power imbalances that exist in the dynamics of physician-patient communication by using patient-focused interviewing and care, and it is a process that requires humility to develop and maintain mutually respectful and dynamic partnerships with communities” (Tervalon, M. & Murray-García, J. “Cultural Humility Versus Cultural Competence: A Critical Distinction in Defining Physician Training Outcomes in Multicultural Education.” J Health Care Poor Underserved. 1998;9[2]:117-25).
How do we win this battle? The first step is to simply be aware that everyone is a victim of unconscious biases. Once we come to this (often uncomfortable) realization, we must make a conscious effort to change our mindset and make conscious decisions to not allow these biases to manifest.
Practicing cultural humility is extremely important in this process. It puts everyone on the same platform because there is no “minority,” “majority,” or “ethnicity” associated with it. It takes away the need to know everything about a certain culture and encourages us to approach every patient encounter acknowledging that we will humble ourselves, learn what is important to the patient, and leave having learned something from the interaction.
The work group developed “The 5 Rs of Cultural Humility” as a simple tool for hospitalists to incorporate into their practice. The first four Rs (Reflection, Respect, Regard and Relevance) are extrinsically focused, while the 5th R (Resiliency) is intrinsic. Our theory posits that, if you attain the first 4 Rs in every interaction, these will serve to build on and develop your own personal resiliency. Here are the 5 Rs:
- Reflection – Hospitalists will approach every encounter with humility and understanding that there is always something to learn from everyone.
- Respect – Hospitalists will treat every person with the utmost respect and strive to preserve dignity at all times.
- Regard – Hospitalists will hold every person in their highest regard while being aware of and not allowing unconscious biases to interfere in any interactions.
- Relevance – Hospitalists will expect cultural humility to be relevant to the patient and apply this practice to every encounter.
- Resiliency – Hospitalists will embody the practice of cultural humility to enhance personal resilience and globally focused compassion.
The content will be available as a downloadable pocket card that can be easily referenced on rounds and shared with colleagues. Our hope is to achieve heightened awareness of effective interaction. In addition to the definitions of each of the Rs, the card will feature questions to ask yourself before, during, and after every interaction to aid in attaining cultural humility.
The card will be printed and disseminated at Hospital Medicine 2017, and the 5 Rs will be discussed in a few sessions: “Making ‘Everything We Say and Do’ a Positive Patient Experience” in the Practice Management track on Thursday, May 4, and during a 20-minute “MEDtalk” in Product Theater 1 on May 3, at 10:15 a.m.
Keep on the lookout for future blog posts, where you’ll read about the 5 R’s in action through vignettes and a deeper dive into each aspect.
For more information and the downloadable pocket card, visit www.hospitalmedicine.org/5Rs.
Dr. Ansari is associate professor and associate division director of hospital medicine at Loyola University Medical Center, Maywood, Ill., and serves on SHM’s Cultural Humility Work Group.
Hospitalists prepare for MACRA, seek more changes
“We heard you and will continue listening.”
Those were the words that Andrew Slavitt, then-acting administrator of the Centers for Medicare and Medicaid Services, used in a blog post on Oct. 14, 2016.1 (Slavitt no longer maintains that title since the new federal administration took office on Jan. 20, 2017.)
And, it seems they are still listening. Since issuing the final rule, CMS has continued to seek input from stakeholders. The SHM and other groups are working to clarify and pursue improvements to the bipartisan law. Reporting under MACRA begins this year and several changes that appeared in the final rule already may make living with the law less challenging for hospitalists.
For instance, 13 specialty measures were required under the final rule in order for hospitalists to begin reporting under the Quality category of the Merit-based Incentive Payment System (MIPS), one of two pathways to reimbursement available to all physicians under MACRA’s Quality Payment Program. However, of these, Dr. Greeno said that just seven are relevant to the hospitalist practice. The CMS now requires six reported measures in the Quality category, reduced from the initial nine.3
The measures include:
- Heart failure: ACE inhibitor/angiotensin receptor blocker for left ventricular systolic dysfunction
- Heart failure: Beta-blocker for LVSD
- Stroke: DC on antithrombotic therapy
- Advance Care Plan
- Prevention of catheter-related bloodstream infection: CVC (central venous catheter) Insertion Protocol
- Documentation of current medications
- Appropriate treatment of methicillin-susceptible Staphylococcus aureus bacteremia
“Of the seven available, not all will be reportable because hospitalist practices have a lot of variation, both in their practices and in their patient mix,” Dr. Greeno said. “Most hospitalists will only be able to successfully report on four measures, but we are seeking clarification on what they call a validation test and how that will function.”
In the final rule, CMS said that it will perform that “validation test” to evaluate physicians who cannot report the minimum number of measures to ensure they are not penalized for it.
In addition to Quality, the other reporting categories under the umbrella of MIPS include Advancing Care Information, Cost, and Improvement Activities. For 2017, CMS gave physicians the option to “pick your pace.”4 As long as doctors report just one quality measure, one improvement activity, or the required advancing care information measures (most hospitalists will be exempt from this category), they will avoid a penalty.1,5 Cost will not be included for 2017, the first performance year for MIPS. This year’s reporting will be used to determine payments in 2019, though all physicians will see a 0.5 percent fee increase between now and 2019.
Additionally, just for this year, physicians can choose to report for either a full or partial year (90 days). They will not be subject to the penalty and may be eligible for a positive payment adjustment. However, those who submit nothing are subject to a negative 4% adjustment penalty.
Additionally, CMS took steps to make MACRA easier on small and rural physician practices. The final rule exempts physicians who bill $30,000 or less in Medicare Part B or 100 or fewer Medicare patients, up from the previous $10,000 threshold.1
However, this is unlikely to apply to the majority of – if any – hospitalists, Dr. Dutta said. “By virtue of being a hospitalist, you are seeing all comers to your institution. We don’t really have the choice to see fewer Medicare patients, to be honest, and, [for] most hospitalists – whether employed by a hospital or contracting – one of the main reasons we are in place is to help the hospital and take the patients nobody else will take.”
The CMS has also allotted $20 million each year for five years to support training and education for practices of 15 providers or fewer, for rural providers, and for those working in geographic health professional shortage areas.1,6 According to CMS, as of December 2016, experienced organizations (regional health collaboratives, quality improvement organizations, and others) began receiving funds to help these practices choose appropriate quality measures, train in improvement techniques, select the right health information technology, and more.
Under MACRA, small practices (10 clinicians or fewer) may also join “virtual groups” in order to combine their MIPS reporting into a composite score. However, this is not yet well defined, and the option is not available in 2017. The CMS said that it will continue to seek feedback on the structure and implementation of virtual groups in future years.1
Hospitalists may find themselves presented with another option for performance measurement, Dr. Greeno said. The SHM has asked CMS to consider allowing hospitalists to align with their hospital facility instead of being measured separately.
“Hospitalists are in the unique position of working at only one acute care hospital, for the most part, and we actually floated this idea around years ago, to give hospitalists the option for all their quality metrics – not as a standalone physician group – to be judged on hospital performance metrics,” he said, adding, “It would be easier if we could do this for everybody, but not all hospitalist groups that work for hospitals may want to do that.”
Dr. Dutta said that this would be “a great and efficient option,” especially since hospitalists oversee the bulk of quality improvement activities in their hospitals.
“Hospital-level data would be a reflection of what we’re involved in, as the bulk of hospitalists not only provide clinical care but also participate in a multitude of hospital activities,” she said, like: “helping to develop and promote practices around high-value care, to serving on groups like safe transitions in care. It’s hospitalists who are usually the hospital leaders around quality improvement.”
This includes coming up with ways to work with pharmacists at patient admission and on medication reconciliation upon discharge, as well as providing input on clinical protocols, such as what should be done when someone falls or when potassium is high, Dr. Dutta said.
“Performance should be tied to the performance of the hospital. It moves in the right direction to force more collaboration and a joint fate,” Dr. Berenson added.
Alternative payment models
While MIPS is the pathway most physicians expect to find themselves on in 2017, the other option is the Alternative Payment Models (APMs) pathway, which moves away from the pay-for-performance, semi-fee-for-service structure of MIPS and, instead, follows the rules established by the models themselves, which include select qualified accountable care organizations and patient-centered medical homes.7 Participating physicians are eligible for a 5% incentive payment in 2019. Many health experts say that it’s clear CMS would like to ultimately steer most physicians from MIPS to APMs.
However, very few – if any – hospitalists will find themselves on an APM track. This is, in part, because models considered APMs require the use of Certified Electronic Health Record Technology (CEHRT) and must present “more than nominal risk” to providers.
“Right now, the only alternative payment model where hospitalists can directly take risk is BPCI [Bundled Payments for Care Improvement], but it does not qualify as an APM,” Dr. Greeno said.
It will also be difficult because CMS requires patient and payer thresholds under APMs that hospitalists simply are not poised to meet. In 2019, this means 25% of Medicare payments must come from an Advanced APM in 2017, or 20% of providers’ Medicare patients must be seen through an Advanced APM.8
Advanced APMs are those with which, at least in 2019 and 2020, providers face the risk of losing the lesser of 8% of their revenue or repaying CMS up to 3% of their total Medicare expenditures, if expenditures are higher than expected.8,9
“It is going to be very difficult for hospitalists to qualify for APMs because we’re not in the position to hit the thresholds,” said Dr. Dutta.
However, SHM has urged CMS to consider other BPCI models for qualification as APMs, and Dr. Greeno said that CMS is currently looking into developing bundles that may be appropriate for hospitalists. For instance, Dr. Dutta said, “What we do often in medicine is chronic disease management, and the time is coming to get into chronic disease bundles, such as [those for] management of heart failure or kidney disease.”
In December, SHM submitted a letter to PTAC (the Physician-Focused Payment Model Technical Advisory Committee) to show support for a model created by the American College of Surgeons, called ACS-Brandeis, which they hope will be considered as an Advanced Alternative Payment Model. In the proposal that ACS submitted, the authors noted, “The core model is focused on procedure episodes but can easily be expanded to include acute and chronic conditions.”
The SHM notes in its letter that, while the initial proposal is intended for surgical patients, the term-based nature of surgical care provides a platform for expanding the model more broadly to hospitalists and other specialties.
Some skepticism remains
Even if BPCI or other models are accepted as APMs, hospitalists may still be challenged to meet the required payment or patient thresholds, Dr. Greeno said. Additionally, Dr. Berenson is skeptical of bundled payments, particularly for hospitalists.
“Are hospitalists the right organization to be held accountable for the total cost of care for 90 days of spending, any more than oncologists under Oncology Care Models should be accountable for the total cost of cancer where some patients are getting palliative care and that’s not a driver of healthcare costs?” he asked. “I could see that as problematic for hospitalists.”
While he believes there are many positive aspects to MACRA, in general, Dr. Berenson considers it bad policy. While he does not want to see the Sustainable Growth Rate return, he believes many physicians would have seen reimbursement reductions sooner without MACRA (under the prior quality measurement programs) and that the law provides some perverse incentives.
For one thing, the Quality Payment Program is budget neutral, which means that, for every winner, there is also a loser. Before CMS expanded exemptions for smaller and rural practices, Dr. Berenson said that some larger groups – which are often better equipped to pursue APMs – were planning to stay in MIPS because they figured they were more likely to be the winners when compared with smaller physician practices. And MIPS comes with a 9% payment boost by 2022 (or 9% penalty), plus the possibility of an extra bonus for top performers, compared with the 5% incentive of APMs that same year.7
“There were literally groups saying they were going to go for the MIPS pathway because it’s a bigger upside,” Dr. Berenson said. “When CMS said it was exempting those [smaller, rural] groups, the [larger] groups turned around and said [that the smaller, rural groups] were the downside. ... That kind of game theory is bad public policy.”
Dr. Berenson also believes MACRA will be detrimental to some small and independent practices. Others may decide not to bill Medicare altogether, though that is not an option open to most hospitalists who care to stay in practice. It could, however, drive more hospitalists to consolidate or to become employees of their hospitals.10
“I don’t think there is any doubt this is going to drive consolidation,” Dr. Greeno said, citing numbers released by CMS that show an inverse relationship between practice size and the negative impact of MACRA.11 “I think it’s going to be pretty tough unless you’re big enough to commit the resources you need to do it right.”
At TeamHealth, where Dr. Greeno is senior advisor of medical affairs, he said that they have invested in information technology compliance, developed systems and trained providers to ensure the creation of favorable metrics for the organization’ and built the infrastructure to gather, report, and validate data. These are steps that may be out of reach for most smaller practices.
As Dr. Greeno said, no one expected this to be easy. “You’re trying to get doctors to change the way they practice. Anybody who has ever worked with doctors knows that’s not an easy things to do,” he said. “CMS is changing things to create enough incentive so the pain of not changing becomes greater than the pain of changing.”
While hospitalists may bear more of the pressure than other physician specialties, by virtue of their role in improving the quality of care in hospitals, they were born from reform efforts of the past, Dr. Greeno adds.
“If there had never been an attempt to change the way that physicians were paid, hospitalists wouldn’t exist,” he said. “We were created by physician groups who took capitated payments from HMOs, who had to find more efficient ways to treat patients in the hospital or go out of business.”
“Hospitalists are a delivery system reform and people look to us to lead. We can create a tremendous amount of value for whomever we work for,” Dr. Greeno said.
This is also why SHM continues to work with CMS to advocate for all its members. Dr. Greeno is in Washington at least once a month, participating in critical meetings and helping to guide decisions.
“The Public Policy Committee has to get into the weeds and get involved in advocating for measures that truly get at the work we do and push back on metrics and categories that do not relate to the care we are delivering for our patients,” said Dr. Dutta. “The group worked hard to push back on having to comply with Meaningful Use standards for hospitalists, and now we’re exempt from that category. CMS does listen. It sometimes just takes a while.”
References
1. Slavitt A. (2016 Oct 14). A letter from CMS to Medicare clinicians in the Quality Payment Program: We heard you and will continue listening. The CMS Blog (archived). Retrieved from http://wayback.archive-it.org/2744/20161109123921/https://blog.cms.gov/2016/10/14/a-letter-from-cms-to-medicare-clinicians-in-the-quality-payment-program/.
2. Department of Health & Human Services and Centers for Medicare & Medicaid Services. (2016 Oct 14). Quality Payment Program executive summary. Retrieved from https://qpp.cms.gov/docs/QPP_Executive_Summary_of_Final_Rule.pdf.
3. American Medical Association. (2016 Oct 19). Medicare Access and CHIP Reauthorization Act (MACRA) Quality Payment Program final rule AMA summary. Retrieved from https://www.ama-assn.org/sites/default/files/media-browser/public/physicians/macra/macra-qpp-summary.pdf.
4. Slavitt A. (2016 Sept 8). Plans for the Quality Payment Program in 2017: Pick your pace. The CMS Blog (archived). Retrieved from http://wayback.archive-it.org/2744/20161109123909/https://blog.cms.gov/2016/09/08/qualitypaymentprogram-pickyourpace/.
5. The Society of Hospital Medicine. Medicare physician payments are changing. Retrieved from http://www.macraforhm.org/.
6. Department of Health & Human Services and Centers for Medicare & Medicaid Services. (2016 Oct 14). Quality Payment Program fact sheet. Retrieved from https://qpp.cms.gov/docs/QPP_Small_Practice.pdf.
7. The Society of Hospital Medicine. (2017). MACRA and the Quality Payment Program. Retrieved from http://www.macraforhm.org/MACRA_FAQ_m1_final.pdf.
8. Department of Health & Human Services and Centers for Medicare & Medicaid Services. Quality Payment Program: Modernizing Medicare to provide better care and smarter spending for a healthier America. Retrieved from https://qpp.cms.gov/.
9. Wynne B. (2016 Oct 17). MACRA Final Rule: CMS strikes a balance; will docs hang on? Retrieved from http://healthaffairs.org/blog/2016/10/17/macra-final-rule-cms-strikes-a-balance-will-docs-hang-on/.
10. Quinn R. (2015 Aug). TeamHealth-IPC Deal Latest in consolidation trend. The Hospitalist. 2015(8). Retrieved from http://www.the-hospitalist.org/hospitalist/article/122210/teamhealth-ipc-deal-latest-consolidation-trend
11. Barkholz D. (2016 Jun 30). Potential MACRA byproduct: physician consolidation. Retrieved from http://www.modernhealthcare.com/article/20160630/NEWS/160639995.
“We heard you and will continue listening.”
Those were the words that Andrew Slavitt, then-acting administrator of the Centers for Medicare and Medicaid Services, used in a blog post on Oct. 14, 2016.1 (Slavitt no longer maintains that title since the new federal administration took office on Jan. 20, 2017.)
And, it seems they are still listening. Since issuing the final rule, CMS has continued to seek input from stakeholders. The SHM and other groups are working to clarify and pursue improvements to the bipartisan law. Reporting under MACRA begins this year and several changes that appeared in the final rule already may make living with the law less challenging for hospitalists.
For instance, 13 specialty measures were required under the final rule in order for hospitalists to begin reporting under the Quality category of the Merit-based Incentive Payment System (MIPS), one of two pathways to reimbursement available to all physicians under MACRA’s Quality Payment Program. However, of these, Dr. Greeno said that just seven are relevant to the hospitalist practice. The CMS now requires six reported measures in the Quality category, reduced from the initial nine.3
The measures include:
- Heart failure: ACE inhibitor/angiotensin receptor blocker for left ventricular systolic dysfunction
- Heart failure: Beta-blocker for LVSD
- Stroke: DC on antithrombotic therapy
- Advance Care Plan
- Prevention of catheter-related bloodstream infection: CVC (central venous catheter) Insertion Protocol
- Documentation of current medications
- Appropriate treatment of methicillin-susceptible Staphylococcus aureus bacteremia
“Of the seven available, not all will be reportable because hospitalist practices have a lot of variation, both in their practices and in their patient mix,” Dr. Greeno said. “Most hospitalists will only be able to successfully report on four measures, but we are seeking clarification on what they call a validation test and how that will function.”
In the final rule, CMS said that it will perform that “validation test” to evaluate physicians who cannot report the minimum number of measures to ensure they are not penalized for it.
In addition to Quality, the other reporting categories under the umbrella of MIPS include Advancing Care Information, Cost, and Improvement Activities. For 2017, CMS gave physicians the option to “pick your pace.”4 As long as doctors report just one quality measure, one improvement activity, or the required advancing care information measures (most hospitalists will be exempt from this category), they will avoid a penalty.1,5 Cost will not be included for 2017, the first performance year for MIPS. This year’s reporting will be used to determine payments in 2019, though all physicians will see a 0.5 percent fee increase between now and 2019.
Additionally, just for this year, physicians can choose to report for either a full or partial year (90 days). They will not be subject to the penalty and may be eligible for a positive payment adjustment. However, those who submit nothing are subject to a negative 4% adjustment penalty.
Additionally, CMS took steps to make MACRA easier on small and rural physician practices. The final rule exempts physicians who bill $30,000 or less in Medicare Part B or 100 or fewer Medicare patients, up from the previous $10,000 threshold.1
However, this is unlikely to apply to the majority of – if any – hospitalists, Dr. Dutta said. “By virtue of being a hospitalist, you are seeing all comers to your institution. We don’t really have the choice to see fewer Medicare patients, to be honest, and, [for] most hospitalists – whether employed by a hospital or contracting – one of the main reasons we are in place is to help the hospital and take the patients nobody else will take.”
The CMS has also allotted $20 million each year for five years to support training and education for practices of 15 providers or fewer, for rural providers, and for those working in geographic health professional shortage areas.1,6 According to CMS, as of December 2016, experienced organizations (regional health collaboratives, quality improvement organizations, and others) began receiving funds to help these practices choose appropriate quality measures, train in improvement techniques, select the right health information technology, and more.
Under MACRA, small practices (10 clinicians or fewer) may also join “virtual groups” in order to combine their MIPS reporting into a composite score. However, this is not yet well defined, and the option is not available in 2017. The CMS said that it will continue to seek feedback on the structure and implementation of virtual groups in future years.1
Hospitalists may find themselves presented with another option for performance measurement, Dr. Greeno said. The SHM has asked CMS to consider allowing hospitalists to align with their hospital facility instead of being measured separately.
“Hospitalists are in the unique position of working at only one acute care hospital, for the most part, and we actually floated this idea around years ago, to give hospitalists the option for all their quality metrics – not as a standalone physician group – to be judged on hospital performance metrics,” he said, adding, “It would be easier if we could do this for everybody, but not all hospitalist groups that work for hospitals may want to do that.”
Dr. Dutta said that this would be “a great and efficient option,” especially since hospitalists oversee the bulk of quality improvement activities in their hospitals.
“Hospital-level data would be a reflection of what we’re involved in, as the bulk of hospitalists not only provide clinical care but also participate in a multitude of hospital activities,” she said, like: “helping to develop and promote practices around high-value care, to serving on groups like safe transitions in care. It’s hospitalists who are usually the hospital leaders around quality improvement.”
This includes coming up with ways to work with pharmacists at patient admission and on medication reconciliation upon discharge, as well as providing input on clinical protocols, such as what should be done when someone falls or when potassium is high, Dr. Dutta said.
“Performance should be tied to the performance of the hospital. It moves in the right direction to force more collaboration and a joint fate,” Dr. Berenson added.
Alternative payment models
While MIPS is the pathway most physicians expect to find themselves on in 2017, the other option is the Alternative Payment Models (APMs) pathway, which moves away from the pay-for-performance, semi-fee-for-service structure of MIPS and, instead, follows the rules established by the models themselves, which include select qualified accountable care organizations and patient-centered medical homes.7 Participating physicians are eligible for a 5% incentive payment in 2019. Many health experts say that it’s clear CMS would like to ultimately steer most physicians from MIPS to APMs.
However, very few – if any – hospitalists will find themselves on an APM track. This is, in part, because models considered APMs require the use of Certified Electronic Health Record Technology (CEHRT) and must present “more than nominal risk” to providers.
“Right now, the only alternative payment model where hospitalists can directly take risk is BPCI [Bundled Payments for Care Improvement], but it does not qualify as an APM,” Dr. Greeno said.
It will also be difficult because CMS requires patient and payer thresholds under APMs that hospitalists simply are not poised to meet. In 2019, this means 25% of Medicare payments must come from an Advanced APM in 2017, or 20% of providers’ Medicare patients must be seen through an Advanced APM.8
Advanced APMs are those with which, at least in 2019 and 2020, providers face the risk of losing the lesser of 8% of their revenue or repaying CMS up to 3% of their total Medicare expenditures, if expenditures are higher than expected.8,9
“It is going to be very difficult for hospitalists to qualify for APMs because we’re not in the position to hit the thresholds,” said Dr. Dutta.
However, SHM has urged CMS to consider other BPCI models for qualification as APMs, and Dr. Greeno said that CMS is currently looking into developing bundles that may be appropriate for hospitalists. For instance, Dr. Dutta said, “What we do often in medicine is chronic disease management, and the time is coming to get into chronic disease bundles, such as [those for] management of heart failure or kidney disease.”
In December, SHM submitted a letter to PTAC (the Physician-Focused Payment Model Technical Advisory Committee) to show support for a model created by the American College of Surgeons, called ACS-Brandeis, which they hope will be considered as an Advanced Alternative Payment Model. In the proposal that ACS submitted, the authors noted, “The core model is focused on procedure episodes but can easily be expanded to include acute and chronic conditions.”
The SHM notes in its letter that, while the initial proposal is intended for surgical patients, the term-based nature of surgical care provides a platform for expanding the model more broadly to hospitalists and other specialties.
Some skepticism remains
Even if BPCI or other models are accepted as APMs, hospitalists may still be challenged to meet the required payment or patient thresholds, Dr. Greeno said. Additionally, Dr. Berenson is skeptical of bundled payments, particularly for hospitalists.
“Are hospitalists the right organization to be held accountable for the total cost of care for 90 days of spending, any more than oncologists under Oncology Care Models should be accountable for the total cost of cancer where some patients are getting palliative care and that’s not a driver of healthcare costs?” he asked. “I could see that as problematic for hospitalists.”
While he believes there are many positive aspects to MACRA, in general, Dr. Berenson considers it bad policy. While he does not want to see the Sustainable Growth Rate return, he believes many physicians would have seen reimbursement reductions sooner without MACRA (under the prior quality measurement programs) and that the law provides some perverse incentives.
For one thing, the Quality Payment Program is budget neutral, which means that, for every winner, there is also a loser. Before CMS expanded exemptions for smaller and rural practices, Dr. Berenson said that some larger groups – which are often better equipped to pursue APMs – were planning to stay in MIPS because they figured they were more likely to be the winners when compared with smaller physician practices. And MIPS comes with a 9% payment boost by 2022 (or 9% penalty), plus the possibility of an extra bonus for top performers, compared with the 5% incentive of APMs that same year.7
“There were literally groups saying they were going to go for the MIPS pathway because it’s a bigger upside,” Dr. Berenson said. “When CMS said it was exempting those [smaller, rural] groups, the [larger] groups turned around and said [that the smaller, rural groups] were the downside. ... That kind of game theory is bad public policy.”
Dr. Berenson also believes MACRA will be detrimental to some small and independent practices. Others may decide not to bill Medicare altogether, though that is not an option open to most hospitalists who care to stay in practice. It could, however, drive more hospitalists to consolidate or to become employees of their hospitals.10
“I don’t think there is any doubt this is going to drive consolidation,” Dr. Greeno said, citing numbers released by CMS that show an inverse relationship between practice size and the negative impact of MACRA.11 “I think it’s going to be pretty tough unless you’re big enough to commit the resources you need to do it right.”
At TeamHealth, where Dr. Greeno is senior advisor of medical affairs, he said that they have invested in information technology compliance, developed systems and trained providers to ensure the creation of favorable metrics for the organization’ and built the infrastructure to gather, report, and validate data. These are steps that may be out of reach for most smaller practices.
As Dr. Greeno said, no one expected this to be easy. “You’re trying to get doctors to change the way they practice. Anybody who has ever worked with doctors knows that’s not an easy things to do,” he said. “CMS is changing things to create enough incentive so the pain of not changing becomes greater than the pain of changing.”
While hospitalists may bear more of the pressure than other physician specialties, by virtue of their role in improving the quality of care in hospitals, they were born from reform efforts of the past, Dr. Greeno adds.
“If there had never been an attempt to change the way that physicians were paid, hospitalists wouldn’t exist,” he said. “We were created by physician groups who took capitated payments from HMOs, who had to find more efficient ways to treat patients in the hospital or go out of business.”
“Hospitalists are a delivery system reform and people look to us to lead. We can create a tremendous amount of value for whomever we work for,” Dr. Greeno said.
This is also why SHM continues to work with CMS to advocate for all its members. Dr. Greeno is in Washington at least once a month, participating in critical meetings and helping to guide decisions.
“The Public Policy Committee has to get into the weeds and get involved in advocating for measures that truly get at the work we do and push back on metrics and categories that do not relate to the care we are delivering for our patients,” said Dr. Dutta. “The group worked hard to push back on having to comply with Meaningful Use standards for hospitalists, and now we’re exempt from that category. CMS does listen. It sometimes just takes a while.”
References
1. Slavitt A. (2016 Oct 14). A letter from CMS to Medicare clinicians in the Quality Payment Program: We heard you and will continue listening. The CMS Blog (archived). Retrieved from http://wayback.archive-it.org/2744/20161109123921/https://blog.cms.gov/2016/10/14/a-letter-from-cms-to-medicare-clinicians-in-the-quality-payment-program/.
2. Department of Health & Human Services and Centers for Medicare & Medicaid Services. (2016 Oct 14). Quality Payment Program executive summary. Retrieved from https://qpp.cms.gov/docs/QPP_Executive_Summary_of_Final_Rule.pdf.
3. American Medical Association. (2016 Oct 19). Medicare Access and CHIP Reauthorization Act (MACRA) Quality Payment Program final rule AMA summary. Retrieved from https://www.ama-assn.org/sites/default/files/media-browser/public/physicians/macra/macra-qpp-summary.pdf.
4. Slavitt A. (2016 Sept 8). Plans for the Quality Payment Program in 2017: Pick your pace. The CMS Blog (archived). Retrieved from http://wayback.archive-it.org/2744/20161109123909/https://blog.cms.gov/2016/09/08/qualitypaymentprogram-pickyourpace/.
5. The Society of Hospital Medicine. Medicare physician payments are changing. Retrieved from http://www.macraforhm.org/.
6. Department of Health & Human Services and Centers for Medicare & Medicaid Services. (2016 Oct 14). Quality Payment Program fact sheet. Retrieved from https://qpp.cms.gov/docs/QPP_Small_Practice.pdf.
7. The Society of Hospital Medicine. (2017). MACRA and the Quality Payment Program. Retrieved from http://www.macraforhm.org/MACRA_FAQ_m1_final.pdf.
8. Department of Health & Human Services and Centers for Medicare & Medicaid Services. Quality Payment Program: Modernizing Medicare to provide better care and smarter spending for a healthier America. Retrieved from https://qpp.cms.gov/.
9. Wynne B. (2016 Oct 17). MACRA Final Rule: CMS strikes a balance; will docs hang on? Retrieved from http://healthaffairs.org/blog/2016/10/17/macra-final-rule-cms-strikes-a-balance-will-docs-hang-on/.
10. Quinn R. (2015 Aug). TeamHealth-IPC Deal Latest in consolidation trend. The Hospitalist. 2015(8). Retrieved from http://www.the-hospitalist.org/hospitalist/article/122210/teamhealth-ipc-deal-latest-consolidation-trend
11. Barkholz D. (2016 Jun 30). Potential MACRA byproduct: physician consolidation. Retrieved from http://www.modernhealthcare.com/article/20160630/NEWS/160639995.
“We heard you and will continue listening.”
Those were the words that Andrew Slavitt, then-acting administrator of the Centers for Medicare and Medicaid Services, used in a blog post on Oct. 14, 2016.1 (Slavitt no longer maintains that title since the new federal administration took office on Jan. 20, 2017.)
And, it seems they are still listening. Since issuing the final rule, CMS has continued to seek input from stakeholders. The SHM and other groups are working to clarify and pursue improvements to the bipartisan law. Reporting under MACRA begins this year and several changes that appeared in the final rule already may make living with the law less challenging for hospitalists.
For instance, 13 specialty measures were required under the final rule in order for hospitalists to begin reporting under the Quality category of the Merit-based Incentive Payment System (MIPS), one of two pathways to reimbursement available to all physicians under MACRA’s Quality Payment Program. However, of these, Dr. Greeno said that just seven are relevant to the hospitalist practice. The CMS now requires six reported measures in the Quality category, reduced from the initial nine.3
The measures include:
- Heart failure: ACE inhibitor/angiotensin receptor blocker for left ventricular systolic dysfunction
- Heart failure: Beta-blocker for LVSD
- Stroke: DC on antithrombotic therapy
- Advance Care Plan
- Prevention of catheter-related bloodstream infection: CVC (central venous catheter) Insertion Protocol
- Documentation of current medications
- Appropriate treatment of methicillin-susceptible Staphylococcus aureus bacteremia
“Of the seven available, not all will be reportable because hospitalist practices have a lot of variation, both in their practices and in their patient mix,” Dr. Greeno said. “Most hospitalists will only be able to successfully report on four measures, but we are seeking clarification on what they call a validation test and how that will function.”
In the final rule, CMS said that it will perform that “validation test” to evaluate physicians who cannot report the minimum number of measures to ensure they are not penalized for it.
In addition to Quality, the other reporting categories under the umbrella of MIPS include Advancing Care Information, Cost, and Improvement Activities. For 2017, CMS gave physicians the option to “pick your pace.”4 As long as doctors report just one quality measure, one improvement activity, or the required advancing care information measures (most hospitalists will be exempt from this category), they will avoid a penalty.1,5 Cost will not be included for 2017, the first performance year for MIPS. This year’s reporting will be used to determine payments in 2019, though all physicians will see a 0.5 percent fee increase between now and 2019.
Additionally, just for this year, physicians can choose to report for either a full or partial year (90 days). They will not be subject to the penalty and may be eligible for a positive payment adjustment. However, those who submit nothing are subject to a negative 4% adjustment penalty.
Additionally, CMS took steps to make MACRA easier on small and rural physician practices. The final rule exempts physicians who bill $30,000 or less in Medicare Part B or 100 or fewer Medicare patients, up from the previous $10,000 threshold.1
However, this is unlikely to apply to the majority of – if any – hospitalists, Dr. Dutta said. “By virtue of being a hospitalist, you are seeing all comers to your institution. We don’t really have the choice to see fewer Medicare patients, to be honest, and, [for] most hospitalists – whether employed by a hospital or contracting – one of the main reasons we are in place is to help the hospital and take the patients nobody else will take.”
The CMS has also allotted $20 million each year for five years to support training and education for practices of 15 providers or fewer, for rural providers, and for those working in geographic health professional shortage areas.1,6 According to CMS, as of December 2016, experienced organizations (regional health collaboratives, quality improvement organizations, and others) began receiving funds to help these practices choose appropriate quality measures, train in improvement techniques, select the right health information technology, and more.
Under MACRA, small practices (10 clinicians or fewer) may also join “virtual groups” in order to combine their MIPS reporting into a composite score. However, this is not yet well defined, and the option is not available in 2017. The CMS said that it will continue to seek feedback on the structure and implementation of virtual groups in future years.1
Hospitalists may find themselves presented with another option for performance measurement, Dr. Greeno said. The SHM has asked CMS to consider allowing hospitalists to align with their hospital facility instead of being measured separately.
“Hospitalists are in the unique position of working at only one acute care hospital, for the most part, and we actually floated this idea around years ago, to give hospitalists the option for all their quality metrics – not as a standalone physician group – to be judged on hospital performance metrics,” he said, adding, “It would be easier if we could do this for everybody, but not all hospitalist groups that work for hospitals may want to do that.”
Dr. Dutta said that this would be “a great and efficient option,” especially since hospitalists oversee the bulk of quality improvement activities in their hospitals.
“Hospital-level data would be a reflection of what we’re involved in, as the bulk of hospitalists not only provide clinical care but also participate in a multitude of hospital activities,” she said, like: “helping to develop and promote practices around high-value care, to serving on groups like safe transitions in care. It’s hospitalists who are usually the hospital leaders around quality improvement.”
This includes coming up with ways to work with pharmacists at patient admission and on medication reconciliation upon discharge, as well as providing input on clinical protocols, such as what should be done when someone falls or when potassium is high, Dr. Dutta said.
“Performance should be tied to the performance of the hospital. It moves in the right direction to force more collaboration and a joint fate,” Dr. Berenson added.
Alternative payment models
While MIPS is the pathway most physicians expect to find themselves on in 2017, the other option is the Alternative Payment Models (APMs) pathway, which moves away from the pay-for-performance, semi-fee-for-service structure of MIPS and, instead, follows the rules established by the models themselves, which include select qualified accountable care organizations and patient-centered medical homes.7 Participating physicians are eligible for a 5% incentive payment in 2019. Many health experts say that it’s clear CMS would like to ultimately steer most physicians from MIPS to APMs.
However, very few – if any – hospitalists will find themselves on an APM track. This is, in part, because models considered APMs require the use of Certified Electronic Health Record Technology (CEHRT) and must present “more than nominal risk” to providers.
“Right now, the only alternative payment model where hospitalists can directly take risk is BPCI [Bundled Payments for Care Improvement], but it does not qualify as an APM,” Dr. Greeno said.
It will also be difficult because CMS requires patient and payer thresholds under APMs that hospitalists simply are not poised to meet. In 2019, this means 25% of Medicare payments must come from an Advanced APM in 2017, or 20% of providers’ Medicare patients must be seen through an Advanced APM.8
Advanced APMs are those with which, at least in 2019 and 2020, providers face the risk of losing the lesser of 8% of their revenue or repaying CMS up to 3% of their total Medicare expenditures, if expenditures are higher than expected.8,9
“It is going to be very difficult for hospitalists to qualify for APMs because we’re not in the position to hit the thresholds,” said Dr. Dutta.
However, SHM has urged CMS to consider other BPCI models for qualification as APMs, and Dr. Greeno said that CMS is currently looking into developing bundles that may be appropriate for hospitalists. For instance, Dr. Dutta said, “What we do often in medicine is chronic disease management, and the time is coming to get into chronic disease bundles, such as [those for] management of heart failure or kidney disease.”
In December, SHM submitted a letter to PTAC (the Physician-Focused Payment Model Technical Advisory Committee) to show support for a model created by the American College of Surgeons, called ACS-Brandeis, which they hope will be considered as an Advanced Alternative Payment Model. In the proposal that ACS submitted, the authors noted, “The core model is focused on procedure episodes but can easily be expanded to include acute and chronic conditions.”
The SHM notes in its letter that, while the initial proposal is intended for surgical patients, the term-based nature of surgical care provides a platform for expanding the model more broadly to hospitalists and other specialties.
Some skepticism remains
Even if BPCI or other models are accepted as APMs, hospitalists may still be challenged to meet the required payment or patient thresholds, Dr. Greeno said. Additionally, Dr. Berenson is skeptical of bundled payments, particularly for hospitalists.
“Are hospitalists the right organization to be held accountable for the total cost of care for 90 days of spending, any more than oncologists under Oncology Care Models should be accountable for the total cost of cancer where some patients are getting palliative care and that’s not a driver of healthcare costs?” he asked. “I could see that as problematic for hospitalists.”
While he believes there are many positive aspects to MACRA, in general, Dr. Berenson considers it bad policy. While he does not want to see the Sustainable Growth Rate return, he believes many physicians would have seen reimbursement reductions sooner without MACRA (under the prior quality measurement programs) and that the law provides some perverse incentives.
For one thing, the Quality Payment Program is budget neutral, which means that, for every winner, there is also a loser. Before CMS expanded exemptions for smaller and rural practices, Dr. Berenson said that some larger groups – which are often better equipped to pursue APMs – were planning to stay in MIPS because they figured they were more likely to be the winners when compared with smaller physician practices. And MIPS comes with a 9% payment boost by 2022 (or 9% penalty), plus the possibility of an extra bonus for top performers, compared with the 5% incentive of APMs that same year.7
“There were literally groups saying they were going to go for the MIPS pathway because it’s a bigger upside,” Dr. Berenson said. “When CMS said it was exempting those [smaller, rural] groups, the [larger] groups turned around and said [that the smaller, rural groups] were the downside. ... That kind of game theory is bad public policy.”
Dr. Berenson also believes MACRA will be detrimental to some small and independent practices. Others may decide not to bill Medicare altogether, though that is not an option open to most hospitalists who care to stay in practice. It could, however, drive more hospitalists to consolidate or to become employees of their hospitals.10
“I don’t think there is any doubt this is going to drive consolidation,” Dr. Greeno said, citing numbers released by CMS that show an inverse relationship between practice size and the negative impact of MACRA.11 “I think it’s going to be pretty tough unless you’re big enough to commit the resources you need to do it right.”
At TeamHealth, where Dr. Greeno is senior advisor of medical affairs, he said that they have invested in information technology compliance, developed systems and trained providers to ensure the creation of favorable metrics for the organization’ and built the infrastructure to gather, report, and validate data. These are steps that may be out of reach for most smaller practices.
As Dr. Greeno said, no one expected this to be easy. “You’re trying to get doctors to change the way they practice. Anybody who has ever worked with doctors knows that’s not an easy things to do,” he said. “CMS is changing things to create enough incentive so the pain of not changing becomes greater than the pain of changing.”
While hospitalists may bear more of the pressure than other physician specialties, by virtue of their role in improving the quality of care in hospitals, they were born from reform efforts of the past, Dr. Greeno adds.
“If there had never been an attempt to change the way that physicians were paid, hospitalists wouldn’t exist,” he said. “We were created by physician groups who took capitated payments from HMOs, who had to find more efficient ways to treat patients in the hospital or go out of business.”
“Hospitalists are a delivery system reform and people look to us to lead. We can create a tremendous amount of value for whomever we work for,” Dr. Greeno said.
This is also why SHM continues to work with CMS to advocate for all its members. Dr. Greeno is in Washington at least once a month, participating in critical meetings and helping to guide decisions.
“The Public Policy Committee has to get into the weeds and get involved in advocating for measures that truly get at the work we do and push back on metrics and categories that do not relate to the care we are delivering for our patients,” said Dr. Dutta. “The group worked hard to push back on having to comply with Meaningful Use standards for hospitalists, and now we’re exempt from that category. CMS does listen. It sometimes just takes a while.”
References
1. Slavitt A. (2016 Oct 14). A letter from CMS to Medicare clinicians in the Quality Payment Program: We heard you and will continue listening. The CMS Blog (archived). Retrieved from http://wayback.archive-it.org/2744/20161109123921/https://blog.cms.gov/2016/10/14/a-letter-from-cms-to-medicare-clinicians-in-the-quality-payment-program/.
2. Department of Health & Human Services and Centers for Medicare & Medicaid Services. (2016 Oct 14). Quality Payment Program executive summary. Retrieved from https://qpp.cms.gov/docs/QPP_Executive_Summary_of_Final_Rule.pdf.
3. American Medical Association. (2016 Oct 19). Medicare Access and CHIP Reauthorization Act (MACRA) Quality Payment Program final rule AMA summary. Retrieved from https://www.ama-assn.org/sites/default/files/media-browser/public/physicians/macra/macra-qpp-summary.pdf.
4. Slavitt A. (2016 Sept 8). Plans for the Quality Payment Program in 2017: Pick your pace. The CMS Blog (archived). Retrieved from http://wayback.archive-it.org/2744/20161109123909/https://blog.cms.gov/2016/09/08/qualitypaymentprogram-pickyourpace/.
5. The Society of Hospital Medicine. Medicare physician payments are changing. Retrieved from http://www.macraforhm.org/.
6. Department of Health & Human Services and Centers for Medicare & Medicaid Services. (2016 Oct 14). Quality Payment Program fact sheet. Retrieved from https://qpp.cms.gov/docs/QPP_Small_Practice.pdf.
7. The Society of Hospital Medicine. (2017). MACRA and the Quality Payment Program. Retrieved from http://www.macraforhm.org/MACRA_FAQ_m1_final.pdf.
8. Department of Health & Human Services and Centers for Medicare & Medicaid Services. Quality Payment Program: Modernizing Medicare to provide better care and smarter spending for a healthier America. Retrieved from https://qpp.cms.gov/.
9. Wynne B. (2016 Oct 17). MACRA Final Rule: CMS strikes a balance; will docs hang on? Retrieved from http://healthaffairs.org/blog/2016/10/17/macra-final-rule-cms-strikes-a-balance-will-docs-hang-on/.
10. Quinn R. (2015 Aug). TeamHealth-IPC Deal Latest in consolidation trend. The Hospitalist. 2015(8). Retrieved from http://www.the-hospitalist.org/hospitalist/article/122210/teamhealth-ipc-deal-latest-consolidation-trend
11. Barkholz D. (2016 Jun 30). Potential MACRA byproduct: physician consolidation. Retrieved from http://www.modernhealthcare.com/article/20160630/NEWS/160639995.
Hospitalist specialty code goes live: What ‘C6’ means for you
The long wait for the introduction of the C6 hospitalist specialty code has ended. If you are a provider, hospital, or hospitalist administrator, this new specialty designation is important.
The Centers for Medicare & Medicaid Services tracks specialty utilization and compares providers across the country using codes attached to medical specialties, such as cardiology, emergency medicine, pediatrics, etc. Until the CMS designated hospital medicine as a unique specialty, hospitalists were grouped together with office-based internal medicine physicians and general practitioners. This lack of recognition of the hospitalist specialty created two issues. 
The first is one of location. Hospitalists practice in hospitals and utilize codes that are hospital based, not office based. Yet hospitalists have been benchmarked against their primary care peers’ utilization for many years. At this point in time, most if not all primary care physicians practice exclusively in the office, so comparison of CPT utilization looks unusual when benchmarked nationally. What appeared as a ‘spike’ was actually normal utilization for a hospitalist; however, this coding anomaly can lead to pre- or postpayment audits.
The second issue is being able to benchmark utilization against one’s peers. For the first time, hospitalist utilization will be considered unique, facilitating more accurate comparisons and fairer assessments of hospitalist performance.
Hospitalists can use the C6 specialty code during initial enrollment or as an update, depending on the individual situation. Note that this is a designation for the individual, not the practice, organization, or billing company. The C6 specialty code was recognized as of April 1, 2017, on submitted claims. You may now change your designation and should avoid any disruption or denial of claims.
There are two places to designate the C6 specialty codes, depending on whether the provider is new to Medicare enrollment or is an existing provider:
• Paper: Initial enrollment in the Medicare program on form CMS-855I or CMS 855O (https://www.cms.gov/Medicare/CMS-Forms/CMS-Forms/CMS-Forms-List.html).
• Electronically: Utilizing the PECOS system, provider credentialing offices can update existing specialty codes to C6 (https://pecos.cms.hhs.gov/PECOSWebMaintenance.htm).
This major milestone for hospital medicine demonstrates the continued growth and impact of the specialty. Ensure your self-election in the PECOS system reflects “C6,” your specialty as a hospitalist and your commitment to the hospital medicine movement.
For more information, visit www.hospitalmedicine.org/C6.
Dea Robinson is a member of SHM’s Practice Management Committee, Cultural Competency Workgroup and Physician Burnout Workgroup.
Reference: MLN Matters Number: MM9716 ( https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/MM9716.pdf)
The long wait for the introduction of the C6 hospitalist specialty code has ended. If you are a provider, hospital, or hospitalist administrator, this new specialty designation is important.
The Centers for Medicare & Medicaid Services tracks specialty utilization and compares providers across the country using codes attached to medical specialties, such as cardiology, emergency medicine, pediatrics, etc. Until the CMS designated hospital medicine as a unique specialty, hospitalists were grouped together with office-based internal medicine physicians and general practitioners. This lack of recognition of the hospitalist specialty created two issues.
The first is one of location. Hospitalists practice in hospitals and utilize codes that are hospital based, not office based. Yet hospitalists have been benchmarked against their primary care peers’ utilization for many years. At this point in time, most if not all primary care physicians practice exclusively in the office, so comparison of CPT utilization looks unusual when benchmarked nationally. What appeared as a ‘spike’ was actually normal utilization for a hospitalist; however, this coding anomaly can lead to pre- or postpayment audits.
The second issue is being able to benchmark utilization against one’s peers. For the first time, hospitalist utilization will be considered unique, facilitating more accurate comparisons and fairer assessments of hospitalist performance.
Hospitalists can use the C6 specialty code during initial enrollment or as an update, depending on the individual situation. Note that this is a designation for the individual, not the practice, organization, or billing company. The C6 specialty code was recognized as of April 1, 2017, on submitted claims. You may now change your designation and should avoid any disruption or denial of claims.
There are two places to designate the C6 specialty codes, depending on whether the provider is new to Medicare enrollment or is an existing provider:
• Paper: Initial enrollment in the Medicare program on form CMS-855I or CMS 855O (https://www.cms.gov/Medicare/CMS-Forms/CMS-Forms/CMS-Forms-List.html).
• Electronically: Utilizing the PECOS system, provider credentialing offices can update existing specialty codes to C6 (https://pecos.cms.hhs.gov/PECOSWebMaintenance.htm).
This major milestone for hospital medicine demonstrates the continued growth and impact of the specialty. Ensure your self-election in the PECOS system reflects “C6,” your specialty as a hospitalist and your commitment to the hospital medicine movement.
For more information, visit www.hospitalmedicine.org/C6.
Dea Robinson is a member of SHM’s Practice Management Committee, Cultural Competency Workgroup and Physician Burnout Workgroup.
Reference: MLN Matters Number: MM9716 ( https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/MM9716.pdf)
The long wait for the introduction of the C6 hospitalist specialty code has ended. If you are a provider, hospital, or hospitalist administrator, this new specialty designation is important.
The Centers for Medicare & Medicaid Services tracks specialty utilization and compares providers across the country using codes attached to medical specialties, such as cardiology, emergency medicine, pediatrics, etc. Until the CMS designated hospital medicine as a unique specialty, hospitalists were grouped together with office-based internal medicine physicians and general practitioners. This lack of recognition of the hospitalist specialty created two issues.
The first is one of location. Hospitalists practice in hospitals and utilize codes that are hospital based, not office based. Yet hospitalists have been benchmarked against their primary care peers’ utilization for many years. At this point in time, most if not all primary care physicians practice exclusively in the office, so comparison of CPT utilization looks unusual when benchmarked nationally. What appeared as a ‘spike’ was actually normal utilization for a hospitalist; however, this coding anomaly can lead to pre- or postpayment audits.
The second issue is being able to benchmark utilization against one’s peers. For the first time, hospitalist utilization will be considered unique, facilitating more accurate comparisons and fairer assessments of hospitalist performance.
Hospitalists can use the C6 specialty code during initial enrollment or as an update, depending on the individual situation. Note that this is a designation for the individual, not the practice, organization, or billing company. The C6 specialty code was recognized as of April 1, 2017, on submitted claims. You may now change your designation and should avoid any disruption or denial of claims.
There are two places to designate the C6 specialty codes, depending on whether the provider is new to Medicare enrollment or is an existing provider:
• Paper: Initial enrollment in the Medicare program on form CMS-855I or CMS 855O (https://www.cms.gov/Medicare/CMS-Forms/CMS-Forms/CMS-Forms-List.html).
• Electronically: Utilizing the PECOS system, provider credentialing offices can update existing specialty codes to C6 (https://pecos.cms.hhs.gov/PECOSWebMaintenance.htm).
This major milestone for hospital medicine demonstrates the continued growth and impact of the specialty. Ensure your self-election in the PECOS system reflects “C6,” your specialty as a hospitalist and your commitment to the hospital medicine movement.
For more information, visit www.hospitalmedicine.org/C6.
Dea Robinson is a member of SHM’s Practice Management Committee, Cultural Competency Workgroup and Physician Burnout Workgroup.
Reference: MLN Matters Number: MM9716 ( https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/MM9716.pdf)
Transitioning from your current medical practice: an abbreviated step-by-step guide
You have decided it is time to move on from your current hospital or medical group position and transition into a new role. While this decision is exciting and well-earned after years of hard work, it is critical that you make a plan and take specific steps to ensure that the transition is seamless.
The steps below are recommendations to make this process smoother.
Step 1: Determine how you are leaving the practice and your proposed timeline
Before anything else, you should decide how you are leaving your practice. Are you leaving the practice of medicine altogether, or are you simply leaving your current position for a different position elsewhere? This distinction will dictate what steps are necessary. Timing is also critical when leaving a practice, as it will dictate what steps should be taken and when. Having specific but realistic goals is imperative. Select a goal date for leaving the practice, but be aware that this goal may need to be adjusted.
Step 2: Create your team of advisers
Whether you are leaving your current practice or transitioning to a different position, it is extremely important to have the right individuals on your team. You should consider enlisting an attorney, a financial adviser, and an accountant to help facilitate the process. Enlisting lawyers with certain areas of expertise, such as in the areas of employment restrictive covenants, health care, or tax, may also be extremely beneficial and helpful throughout the process.
Step 3: Review your current employment agreement
It is quite likely that at the onset of your current employment arrangement, you signed an employment agreement with your hospital or group. You will want to carefully review this agreement, as it may contain provisions that can affect the steps you should take before you leave your current practice and work elsewhere. These provisions include the following:
a) Noncompetition provisions
It is critical to determine whether or not there are any restrictive covenants in your employment agreement that limit where you can work after you transition from your current practice into a new role. Restrictive covenants include noncompetition and nonsolicitation provisions, and prohibit employees from working at certain places or in certain geographic areas after they leave their current place of employment. Rules surrounding restrictive covenants vary from state to state. If there are restrictive covenants in your agreement, be sure to understand the scope of the covenant, including the geographic and temporal scope, as well as the types of medicine you are prohibited from practicing. If the covenants seem too broad or unnecessarily restrictive, consult with an attorney, as overly broad or unduly burdensome covenants are often unenforceable. However, a state-by-state analysis is required.
b) Notice and termination provisions
It is important to review whether or not there are any notice requirements in your employment agreement, which may require you to notify your employer in advance of a departure. Make sure to comply with the time requirements in the notice provision to avoid a breach of the agreement. It is also critical to determine whether terminating an agreement early will result in any termination penalties. At times, employers will impose a penalty if an employee prematurely terminates a working relationship. Understanding the penalties associated with terminating your agreement will allow you to decide whether you want to cancel the agreement and pay the penalty or push back your timeline until the end of the agreement’s term to avoid termination fees.
Step 4: Licensure obligations
Further, if your practice bills Medicare, you will want to file certain forms with Medicare to show that you are either changing your practice location or leaving medicine. For example, if you are leaving the hospital or group to practice elsewhere, you will need to fill out forms in order for your old group to submit claims and receive payments for Medicare services you provided while you were still part of that group. Furthermore, you will need to file reassignment forms to allow your new practice to bill on your behalf. Understanding which forms to complete can be confusing, so enlisting the help of a healthcare attorney may be worthwhile.
Step 5: Discuss your transition with your insurance representative
Even after you leave your current practice, you may be exposed to litigation for services you provided while you were employed or otherwise retained by such practice. To ensure that you are protected, discuss your insurance policy with your insurance representative. Review whether your insurance policy is “occurrence” or “claims-made.” If you have an occurrence policy, you are protected from covered incidents that occur during the policy period, regardless if your policy is still in existence. Claims-made policies only provide coverage for claims where both the incident and the claim occur during the policy period. For example, if you cancel your policy on March 1, and are sued on April 1 for an incident that allegedly occurred on Feb. 1, your claims-made insurance policy will not protect you. Therefore, it is important to analyze your policies to determine if tail insurance is needed.
There are a number of other issues you will want to address before you leave your practice, including financial responsibilities and medical record and privacy obligations. To ensure that you leave your practice properly, you should contact an experienced lawyer who can help you navigate this process.
Steven M. Harris is a nationally recognized health care attorney and a member of the law firm McDonald Hopkins LLC in Chicago. Write to him at [email protected].
You have decided it is time to move on from your current hospital or medical group position and transition into a new role. While this decision is exciting and well-earned after years of hard work, it is critical that you make a plan and take specific steps to ensure that the transition is seamless.
The steps below are recommendations to make this process smoother.
Step 1: Determine how you are leaving the practice and your proposed timeline
Before anything else, you should decide how you are leaving your practice. Are you leaving the practice of medicine altogether, or are you simply leaving your current position for a different position elsewhere? This distinction will dictate what steps are necessary. Timing is also critical when leaving a practice, as it will dictate what steps should be taken and when. Having specific but realistic goals is imperative. Select a goal date for leaving the practice, but be aware that this goal may need to be adjusted.
Step 2: Create your team of advisers
Whether you are leaving your current practice or transitioning to a different position, it is extremely important to have the right individuals on your team. You should consider enlisting an attorney, a financial adviser, and an accountant to help facilitate the process. Enlisting lawyers with certain areas of expertise, such as in the areas of employment restrictive covenants, health care, or tax, may also be extremely beneficial and helpful throughout the process.
Step 3: Review your current employment agreement
It is quite likely that at the onset of your current employment arrangement, you signed an employment agreement with your hospital or group. You will want to carefully review this agreement, as it may contain provisions that can affect the steps you should take before you leave your current practice and work elsewhere. These provisions include the following:
a) Noncompetition provisions
It is critical to determine whether or not there are any restrictive covenants in your employment agreement that limit where you can work after you transition from your current practice into a new role. Restrictive covenants include noncompetition and nonsolicitation provisions, and prohibit employees from working at certain places or in certain geographic areas after they leave their current place of employment. Rules surrounding restrictive covenants vary from state to state. If there are restrictive covenants in your agreement, be sure to understand the scope of the covenant, including the geographic and temporal scope, as well as the types of medicine you are prohibited from practicing. If the covenants seem too broad or unnecessarily restrictive, consult with an attorney, as overly broad or unduly burdensome covenants are often unenforceable. However, a state-by-state analysis is required.
b) Notice and termination provisions
It is important to review whether or not there are any notice requirements in your employment agreement, which may require you to notify your employer in advance of a departure. Make sure to comply with the time requirements in the notice provision to avoid a breach of the agreement. It is also critical to determine whether terminating an agreement early will result in any termination penalties. At times, employers will impose a penalty if an employee prematurely terminates a working relationship. Understanding the penalties associated with terminating your agreement will allow you to decide whether you want to cancel the agreement and pay the penalty or push back your timeline until the end of the agreement’s term to avoid termination fees.
Step 4: Licensure obligations
Further, if your practice bills Medicare, you will want to file certain forms with Medicare to show that you are either changing your practice location or leaving medicine. For example, if you are leaving the hospital or group to practice elsewhere, you will need to fill out forms in order for your old group to submit claims and receive payments for Medicare services you provided while you were still part of that group. Furthermore, you will need to file reassignment forms to allow your new practice to bill on your behalf. Understanding which forms to complete can be confusing, so enlisting the help of a healthcare attorney may be worthwhile.
Step 5: Discuss your transition with your insurance representative
Even after you leave your current practice, you may be exposed to litigation for services you provided while you were employed or otherwise retained by such practice. To ensure that you are protected, discuss your insurance policy with your insurance representative. Review whether your insurance policy is “occurrence” or “claims-made.” If you have an occurrence policy, you are protected from covered incidents that occur during the policy period, regardless if your policy is still in existence. Claims-made policies only provide coverage for claims where both the incident and the claim occur during the policy period. For example, if you cancel your policy on March 1, and are sued on April 1 for an incident that allegedly occurred on Feb. 1, your claims-made insurance policy will not protect you. Therefore, it is important to analyze your policies to determine if tail insurance is needed.
There are a number of other issues you will want to address before you leave your practice, including financial responsibilities and medical record and privacy obligations. To ensure that you leave your practice properly, you should contact an experienced lawyer who can help you navigate this process.
Steven M. Harris is a nationally recognized health care attorney and a member of the law firm McDonald Hopkins LLC in Chicago. Write to him at [email protected].
You have decided it is time to move on from your current hospital or medical group position and transition into a new role. While this decision is exciting and well-earned after years of hard work, it is critical that you make a plan and take specific steps to ensure that the transition is seamless.
The steps below are recommendations to make this process smoother.
Step 1: Determine how you are leaving the practice and your proposed timeline
Before anything else, you should decide how you are leaving your practice. Are you leaving the practice of medicine altogether, or are you simply leaving your current position for a different position elsewhere? This distinction will dictate what steps are necessary. Timing is also critical when leaving a practice, as it will dictate what steps should be taken and when. Having specific but realistic goals is imperative. Select a goal date for leaving the practice, but be aware that this goal may need to be adjusted.
Step 2: Create your team of advisers
Whether you are leaving your current practice or transitioning to a different position, it is extremely important to have the right individuals on your team. You should consider enlisting an attorney, a financial adviser, and an accountant to help facilitate the process. Enlisting lawyers with certain areas of expertise, such as in the areas of employment restrictive covenants, health care, or tax, may also be extremely beneficial and helpful throughout the process.
Step 3: Review your current employment agreement
It is quite likely that at the onset of your current employment arrangement, you signed an employment agreement with your hospital or group. You will want to carefully review this agreement, as it may contain provisions that can affect the steps you should take before you leave your current practice and work elsewhere. These provisions include the following:
a) Noncompetition provisions
It is critical to determine whether or not there are any restrictive covenants in your employment agreement that limit where you can work after you transition from your current practice into a new role. Restrictive covenants include noncompetition and nonsolicitation provisions, and prohibit employees from working at certain places or in certain geographic areas after they leave their current place of employment. Rules surrounding restrictive covenants vary from state to state. If there are restrictive covenants in your agreement, be sure to understand the scope of the covenant, including the geographic and temporal scope, as well as the types of medicine you are prohibited from practicing. If the covenants seem too broad or unnecessarily restrictive, consult with an attorney, as overly broad or unduly burdensome covenants are often unenforceable. However, a state-by-state analysis is required.
b) Notice and termination provisions
It is important to review whether or not there are any notice requirements in your employment agreement, which may require you to notify your employer in advance of a departure. Make sure to comply with the time requirements in the notice provision to avoid a breach of the agreement. It is also critical to determine whether terminating an agreement early will result in any termination penalties. At times, employers will impose a penalty if an employee prematurely terminates a working relationship. Understanding the penalties associated with terminating your agreement will allow you to decide whether you want to cancel the agreement and pay the penalty or push back your timeline until the end of the agreement’s term to avoid termination fees.
Step 4: Licensure obligations
Further, if your practice bills Medicare, you will want to file certain forms with Medicare to show that you are either changing your practice location or leaving medicine. For example, if you are leaving the hospital or group to practice elsewhere, you will need to fill out forms in order for your old group to submit claims and receive payments for Medicare services you provided while you were still part of that group. Furthermore, you will need to file reassignment forms to allow your new practice to bill on your behalf. Understanding which forms to complete can be confusing, so enlisting the help of a healthcare attorney may be worthwhile.
Step 5: Discuss your transition with your insurance representative
Even after you leave your current practice, you may be exposed to litigation for services you provided while you were employed or otherwise retained by such practice. To ensure that you are protected, discuss your insurance policy with your insurance representative. Review whether your insurance policy is “occurrence” or “claims-made.” If you have an occurrence policy, you are protected from covered incidents that occur during the policy period, regardless if your policy is still in existence. Claims-made policies only provide coverage for claims where both the incident and the claim occur during the policy period. For example, if you cancel your policy on March 1, and are sued on April 1 for an incident that allegedly occurred on Feb. 1, your claims-made insurance policy will not protect you. Therefore, it is important to analyze your policies to determine if tail insurance is needed.
There are a number of other issues you will want to address before you leave your practice, including financial responsibilities and medical record and privacy obligations. To ensure that you leave your practice properly, you should contact an experienced lawyer who can help you navigate this process.
Steven M. Harris is a nationally recognized health care attorney and a member of the law firm McDonald Hopkins LLC in Chicago. Write to him at [email protected].
Evolution of a movement
One of the most enduring lessons I have learned during my time in hospital medicine is that hospitalists are always evolving, much like the specialty and healthcare system of which they are a part. And during my time as president of the Society of Hospital Medicine (SHM), I have come to realize how SHM provides its members with the resources to help us continue that evolution through our career journeys as a part of the hospital medicine movement.
Over a year ago, I ascended to president of SHM’s board of directors at HM16, the annual meeting in San Diego. Now, I am eagerly looking forward to HM17 next month, in Las Vegas, which we expect to be, yet again, the biggest, best, most innovative and most energetic gathering of hospitalists. As that meeting will mark the end of my tenure as president of the board, I’m also inclined to look back and survey what has happened over the last year, both personally and professionally.
The personal perspective is easy. I have a different position within my organization: president of Cleveland Clinic Akron General and the Southern Region, one which I would and could never have anticipated a year ago. It challenges, exhausts, exhilarates, and teaches me every day. I am also celebrating my 15th wedding anniversary and have three amazing children who seem to evolve in front of my eyes every day.
And, professionally, at HM16 (and on these pages a year ago), I framed what I felt were four critical directions for SHM and have a few thoughts on the work we have done over the last year.
1. Expand and engage SHM’s membership. SHM continues to be the envy of professional organizations, growing each year. More important than sole growth is our pursuit of connecting hospitalists to SHM’s resources and to each other; we have been incredibly active this past year. For instance, SHM is embarking on an engagement survey of HM groups, and is investing in new technologies to support membership. We are now a CME-accrediting organization and are moving the SHM Learning Portal to a new, enhanced platform. We launched a long-term communications strategy that is tied to engagement and a more nimble and mobile experience for our members. The SHM Leadership Academy sold out. HM17 is poised to be another success. And finally, we are increasingly appreciating that a strong SHM must have a vibrant chapter structure to ensure connections between our membership, staff, and board.
2. Focus on patient- and family-centered care. A look at the HM17 curriculum reinforces SHM’s awareness that patients and hospitalists must be more assertive in developing skills in communication and empathy. By doing so, they support a culture and environment wherein patients are active participants their care. Members of our Patient Experience Committee are presenting courses and workshops in Las Vegas, and last year’s annual meeting featured an entire pre-course on communication skills. Hospitalists play a signature role in the Cleveland Clinic’s national conference on improving the patient experience, and the committee has an advisory council of patients and advocates to guide their work.
3. Move assertively to define our role in an era of risk and reform. Last year’s national election will probably create policy upheavals that are difficult to either anticipate or plan for. However, the evolution of Medicare, Medicaid, and commercial payers toward passing risk (and reward) onto physicians, hospitals, and systems, likely is unstoppable. SHM held a board retreat with key hospital leaders (including Patrick Conway, MD, MSc, MHM, deputy administrator for Innovation and Quality at CMS and director of the Center for Medicare and Medicaid Innovation, and a keynote speaker at HM17) to outline a framework to engage and educate our membership by leveraging the work of our Public Policy, Education, and Practice Management committees.
4. Define our stance regarding specialty recognition: The complexities of this issue are political as well as logistical. SHM has continued to build out the infrastructure for Recognition of Focused Practice with the launch of SPARK ONE (our Focused Practice in Hospital Medicine exam preparation product), but the gaps between the curricula of internal medicine and family medicine residencies, and our daily clinical realities, will continue to exist for the foreseeable future. Pediatrics has established a board requirement for pediatric hospital medicine, but it is still unclear if this is the future of adult hospital medicine.
In sum
As I prepare to the pass to baton to Dr. Ron Greeno for 2017-18, I am reminded of one of the pearls of a former boss and mentor of mine who preached that career satisfaction comes from finding opportunities to achieve three goals: addressing meaningful challenges, working with compelling individuals, and learning something new every day. I would like to thank the board, SHM CEO Larry Wellikson, MD, MHM, and the society staff and volunteers, and, most of all, the many SHM members with whom I have met and spoken over the last year for providing me with exactly that opportunity.
I look forward to continuing to serve an active role in SHM, an organization that can provide you with those same opportunities and resources to help you grow, evolve and be an active participant in the hospital medicine movement.
One of the most enduring lessons I have learned during my time in hospital medicine is that hospitalists are always evolving, much like the specialty and healthcare system of which they are a part. And during my time as president of the Society of Hospital Medicine (SHM), I have come to realize how SHM provides its members with the resources to help us continue that evolution through our career journeys as a part of the hospital medicine movement.
Over a year ago, I ascended to president of SHM’s board of directors at HM16, the annual meeting in San Diego. Now, I am eagerly looking forward to HM17 next month, in Las Vegas, which we expect to be, yet again, the biggest, best, most innovative and most energetic gathering of hospitalists. As that meeting will mark the end of my tenure as president of the board, I’m also inclined to look back and survey what has happened over the last year, both personally and professionally.
The personal perspective is easy. I have a different position within my organization: president of Cleveland Clinic Akron General and the Southern Region, one which I would and could never have anticipated a year ago. It challenges, exhausts, exhilarates, and teaches me every day. I am also celebrating my 15th wedding anniversary and have three amazing children who seem to evolve in front of my eyes every day.
And, professionally, at HM16 (and on these pages a year ago), I framed what I felt were four critical directions for SHM and have a few thoughts on the work we have done over the last year.
1. Expand and engage SHM’s membership. SHM continues to be the envy of professional organizations, growing each year. More important than sole growth is our pursuit of connecting hospitalists to SHM’s resources and to each other; we have been incredibly active this past year. For instance, SHM is embarking on an engagement survey of HM groups, and is investing in new technologies to support membership. We are now a CME-accrediting organization and are moving the SHM Learning Portal to a new, enhanced platform. We launched a long-term communications strategy that is tied to engagement and a more nimble and mobile experience for our members. The SHM Leadership Academy sold out. HM17 is poised to be another success. And finally, we are increasingly appreciating that a strong SHM must have a vibrant chapter structure to ensure connections between our membership, staff, and board.
2. Focus on patient- and family-centered care. A look at the HM17 curriculum reinforces SHM’s awareness that patients and hospitalists must be more assertive in developing skills in communication and empathy. By doing so, they support a culture and environment wherein patients are active participants their care. Members of our Patient Experience Committee are presenting courses and workshops in Las Vegas, and last year’s annual meeting featured an entire pre-course on communication skills. Hospitalists play a signature role in the Cleveland Clinic’s national conference on improving the patient experience, and the committee has an advisory council of patients and advocates to guide their work.
3. Move assertively to define our role in an era of risk and reform. Last year’s national election will probably create policy upheavals that are difficult to either anticipate or plan for. However, the evolution of Medicare, Medicaid, and commercial payers toward passing risk (and reward) onto physicians, hospitals, and systems, likely is unstoppable. SHM held a board retreat with key hospital leaders (including Patrick Conway, MD, MSc, MHM, deputy administrator for Innovation and Quality at CMS and director of the Center for Medicare and Medicaid Innovation, and a keynote speaker at HM17) to outline a framework to engage and educate our membership by leveraging the work of our Public Policy, Education, and Practice Management committees.
4. Define our stance regarding specialty recognition: The complexities of this issue are political as well as logistical. SHM has continued to build out the infrastructure for Recognition of Focused Practice with the launch of SPARK ONE (our Focused Practice in Hospital Medicine exam preparation product), but the gaps between the curricula of internal medicine and family medicine residencies, and our daily clinical realities, will continue to exist for the foreseeable future. Pediatrics has established a board requirement for pediatric hospital medicine, but it is still unclear if this is the future of adult hospital medicine.
In sum
As I prepare to the pass to baton to Dr. Ron Greeno for 2017-18, I am reminded of one of the pearls of a former boss and mentor of mine who preached that career satisfaction comes from finding opportunities to achieve three goals: addressing meaningful challenges, working with compelling individuals, and learning something new every day. I would like to thank the board, SHM CEO Larry Wellikson, MD, MHM, and the society staff and volunteers, and, most of all, the many SHM members with whom I have met and spoken over the last year for providing me with exactly that opportunity.
I look forward to continuing to serve an active role in SHM, an organization that can provide you with those same opportunities and resources to help you grow, evolve and be an active participant in the hospital medicine movement.
One of the most enduring lessons I have learned during my time in hospital medicine is that hospitalists are always evolving, much like the specialty and healthcare system of which they are a part. And during my time as president of the Society of Hospital Medicine (SHM), I have come to realize how SHM provides its members with the resources to help us continue that evolution through our career journeys as a part of the hospital medicine movement.
Over a year ago, I ascended to president of SHM’s board of directors at HM16, the annual meeting in San Diego. Now, I am eagerly looking forward to HM17 next month, in Las Vegas, which we expect to be, yet again, the biggest, best, most innovative and most energetic gathering of hospitalists. As that meeting will mark the end of my tenure as president of the board, I’m also inclined to look back and survey what has happened over the last year, both personally and professionally.
The personal perspective is easy. I have a different position within my organization: president of Cleveland Clinic Akron General and the Southern Region, one which I would and could never have anticipated a year ago. It challenges, exhausts, exhilarates, and teaches me every day. I am also celebrating my 15th wedding anniversary and have three amazing children who seem to evolve in front of my eyes every day.
And, professionally, at HM16 (and on these pages a year ago), I framed what I felt were four critical directions for SHM and have a few thoughts on the work we have done over the last year.
1. Expand and engage SHM’s membership. SHM continues to be the envy of professional organizations, growing each year. More important than sole growth is our pursuit of connecting hospitalists to SHM’s resources and to each other; we have been incredibly active this past year. For instance, SHM is embarking on an engagement survey of HM groups, and is investing in new technologies to support membership. We are now a CME-accrediting organization and are moving the SHM Learning Portal to a new, enhanced platform. We launched a long-term communications strategy that is tied to engagement and a more nimble and mobile experience for our members. The SHM Leadership Academy sold out. HM17 is poised to be another success. And finally, we are increasingly appreciating that a strong SHM must have a vibrant chapter structure to ensure connections between our membership, staff, and board.
2. Focus on patient- and family-centered care. A look at the HM17 curriculum reinforces SHM’s awareness that patients and hospitalists must be more assertive in developing skills in communication and empathy. By doing so, they support a culture and environment wherein patients are active participants their care. Members of our Patient Experience Committee are presenting courses and workshops in Las Vegas, and last year’s annual meeting featured an entire pre-course on communication skills. Hospitalists play a signature role in the Cleveland Clinic’s national conference on improving the patient experience, and the committee has an advisory council of patients and advocates to guide their work.
3. Move assertively to define our role in an era of risk and reform. Last year’s national election will probably create policy upheavals that are difficult to either anticipate or plan for. However, the evolution of Medicare, Medicaid, and commercial payers toward passing risk (and reward) onto physicians, hospitals, and systems, likely is unstoppable. SHM held a board retreat with key hospital leaders (including Patrick Conway, MD, MSc, MHM, deputy administrator for Innovation and Quality at CMS and director of the Center for Medicare and Medicaid Innovation, and a keynote speaker at HM17) to outline a framework to engage and educate our membership by leveraging the work of our Public Policy, Education, and Practice Management committees.
4. Define our stance regarding specialty recognition: The complexities of this issue are political as well as logistical. SHM has continued to build out the infrastructure for Recognition of Focused Practice with the launch of SPARK ONE (our Focused Practice in Hospital Medicine exam preparation product), but the gaps between the curricula of internal medicine and family medicine residencies, and our daily clinical realities, will continue to exist for the foreseeable future. Pediatrics has established a board requirement for pediatric hospital medicine, but it is still unclear if this is the future of adult hospital medicine.
In sum
As I prepare to the pass to baton to Dr. Ron Greeno for 2017-18, I am reminded of one of the pearls of a former boss and mentor of mine who preached that career satisfaction comes from finding opportunities to achieve three goals: addressing meaningful challenges, working with compelling individuals, and learning something new every day. I would like to thank the board, SHM CEO Larry Wellikson, MD, MHM, and the society staff and volunteers, and, most of all, the many SHM members with whom I have met and spoken over the last year for providing me with exactly that opportunity.
I look forward to continuing to serve an active role in SHM, an organization that can provide you with those same opportunities and resources to help you grow, evolve and be an active participant in the hospital medicine movement.
Adapting to change: Dr. Robert Wachter
Robert Wachter, MD, MHM, has given the final plenary address at every SHM annual meeting since 2007. His talks are peppered with his one-of-a-kind take on the confluence of medicine, politics, and policy – and at least once he broke into an Elton John parody.
Where does that point of view come from? As the “dean” of hospital medicine says in his ever-popular Twitter bio, he is “what happens when a poli sci major becomes an academic physician.”
That’s a needed perspective this year, as the level of political upheaval in the United States ups the ante on the tumult the health care field has experienced over the past few years. Questions surrounding the implementation of the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) and the continued struggles experienced by clinicians using electronic health records (EHR) are among the topics to be addressed.
“While [President] Trump brings massive uncertainty, the shift to value and the increasing importance of building a strong culture, a method to continuously improve, and a way to use the EHR to make things better is unlikely to go away,” Dr. Wachter said. His closing plenary is titled, “Mergers, MACRA, and Mission-Creep: Can Hospitalists Thrive in the New World of Health Care?”
In an email interview with The Hospitalist, Dr. Wachter, chair of the department of medicine at the University of California San Francisco, said the Trump administration is a once-in-a-lifetime anomaly that has both physicians and patients nervous, especially at a time when health care reform seemed to be stabilizing.
The new president “adds an amazing wild card, at every level,” he said. “If it weren’t for his administration, I think we’d be on a fairly stable, predictable path. Not that that path didn’t include a ton of change, but at least it was a predictable path.”
Dr. Wachter, who famously helped coin the term “hospitalist” in a 1996 New England Journal of Medicine paper, said that one of the biggest challenges to hospital medicine in the future is how hospitals will be paid – and how they pay their employees.
“The business model for hospitals will be massively challenged, and it could get worse if a lot of your patients lose insurance or their payments go way down,” he said.
But if the past decade of Dr. Wachter’s insights delivered at SHM annual meetings are any indication, his message of trepidation and concern will end on a high note.
The veteran doctor in him says “don’t get too distracted by all of the zigs and zags.” The utopian politico in him says “don’t ever forget the core values and imperatives remain.”
Perhaps that really is what happens when a political science major becomes an academic physician.
Robert Wachter, MD, MHM, has given the final plenary address at every SHM annual meeting since 2007. His talks are peppered with his one-of-a-kind take on the confluence of medicine, politics, and policy – and at least once he broke into an Elton John parody.
Where does that point of view come from? As the “dean” of hospital medicine says in his ever-popular Twitter bio, he is “what happens when a poli sci major becomes an academic physician.”
That’s a needed perspective this year, as the level of political upheaval in the United States ups the ante on the tumult the health care field has experienced over the past few years. Questions surrounding the implementation of the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) and the continued struggles experienced by clinicians using electronic health records (EHR) are among the topics to be addressed.
“While [President] Trump brings massive uncertainty, the shift to value and the increasing importance of building a strong culture, a method to continuously improve, and a way to use the EHR to make things better is unlikely to go away,” Dr. Wachter said. His closing plenary is titled, “Mergers, MACRA, and Mission-Creep: Can Hospitalists Thrive in the New World of Health Care?”
In an email interview with The Hospitalist, Dr. Wachter, chair of the department of medicine at the University of California San Francisco, said the Trump administration is a once-in-a-lifetime anomaly that has both physicians and patients nervous, especially at a time when health care reform seemed to be stabilizing.
The new president “adds an amazing wild card, at every level,” he said. “If it weren’t for his administration, I think we’d be on a fairly stable, predictable path. Not that that path didn’t include a ton of change, but at least it was a predictable path.”
Dr. Wachter, who famously helped coin the term “hospitalist” in a 1996 New England Journal of Medicine paper, said that one of the biggest challenges to hospital medicine in the future is how hospitals will be paid – and how they pay their employees.
“The business model for hospitals will be massively challenged, and it could get worse if a lot of your patients lose insurance or their payments go way down,” he said.
But if the past decade of Dr. Wachter’s insights delivered at SHM annual meetings are any indication, his message of trepidation and concern will end on a high note.
The veteran doctor in him says “don’t get too distracted by all of the zigs and zags.” The utopian politico in him says “don’t ever forget the core values and imperatives remain.”
Perhaps that really is what happens when a political science major becomes an academic physician.
Robert Wachter, MD, MHM, has given the final plenary address at every SHM annual meeting since 2007. His talks are peppered with his one-of-a-kind take on the confluence of medicine, politics, and policy – and at least once he broke into an Elton John parody.
Where does that point of view come from? As the “dean” of hospital medicine says in his ever-popular Twitter bio, he is “what happens when a poli sci major becomes an academic physician.”
That’s a needed perspective this year, as the level of political upheaval in the United States ups the ante on the tumult the health care field has experienced over the past few years. Questions surrounding the implementation of the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) and the continued struggles experienced by clinicians using electronic health records (EHR) are among the topics to be addressed.
“While [President] Trump brings massive uncertainty, the shift to value and the increasing importance of building a strong culture, a method to continuously improve, and a way to use the EHR to make things better is unlikely to go away,” Dr. Wachter said. His closing plenary is titled, “Mergers, MACRA, and Mission-Creep: Can Hospitalists Thrive in the New World of Health Care?”
In an email interview with The Hospitalist, Dr. Wachter, chair of the department of medicine at the University of California San Francisco, said the Trump administration is a once-in-a-lifetime anomaly that has both physicians and patients nervous, especially at a time when health care reform seemed to be stabilizing.
The new president “adds an amazing wild card, at every level,” he said. “If it weren’t for his administration, I think we’d be on a fairly stable, predictable path. Not that that path didn’t include a ton of change, but at least it was a predictable path.”
Dr. Wachter, who famously helped coin the term “hospitalist” in a 1996 New England Journal of Medicine paper, said that one of the biggest challenges to hospital medicine in the future is how hospitals will be paid – and how they pay their employees.
“The business model for hospitals will be massively challenged, and it could get worse if a lot of your patients lose insurance or their payments go way down,” he said.
But if the past decade of Dr. Wachter’s insights delivered at SHM annual meetings are any indication, his message of trepidation and concern will end on a high note.
The veteran doctor in him says “don’t get too distracted by all of the zigs and zags.” The utopian politico in him says “don’t ever forget the core values and imperatives remain.”
Perhaps that really is what happens when a political science major becomes an academic physician.
Fellow in Hospital Medicine designation symbolizes physician commitment to hospital medicine
Editor’s note: Each month, SHM puts the spotlight on some of our most active members who are making substantial contributions to hospital medicine. Log on to www.hospitalmedicine.org/getinvolved for more information on how you can lend your expertise to help SHM improve the care of hospitalized patients.
This month, The Hospitalist spotlights Umesh Sharma, MD, MBA, FHM, chair of the division of community hospital medicine at Mayo Clinic. Umesh became a Fellow in Hospital Medicine in 2016 and has found great value in attending the annual meeting each year.
What inspired you to join SHM, and what prompted you to apply for the Fellow in Hospital Medicine designation?
How did you use SHM resources to help you in your pathway to Fellowship in Hospital Medicine?
There are specific eligibility requirements for the Fellow in Hospital Medicine designation, including a minimum of 5 years as a practicing hospitalist and 3 years as an SHM member, endorsements from two active members, regular meeting attendance and more. SHM provides a checklist for Fellow applicants online and an FAQ page to make the application process as user-friendly as possible. A friend of mine, Dr. Deepak Pahuja, is a Fellow, and he mentored me throughout the process.
How else has SHM contributed to your professional growth and provided you with tools you need to lead hospitalists at Mayo Clinic?
There are many resources that SHM provides to help with professional growth both online and at in-person meetings. I referenced the Key Principles and Characteristics of an Effective Hospital Medicine Group, an online assessment guide, in my role as department chair in La Crosse, Wisc., to resurrect a hospital medicine group, secure resources, hire career hospitalists, and create a well-functioning, well-managed, efficient, effective group with zero turnover during a span of 4 years.
By focusing on the leadership track at annual meetings, I have been able to gain knowledge on proven leadership strategies and enhance my skills, which I have applied on many occasions in my practice. Being able to talk to multisite hospital medicine group colleagues in person helped me to learn best practices in how to successfully manage the integration of 14 hospital medicine community hospital sites across Mayo Midwest. I was able to get ideas on effectively understanding and managing challenges, like recruitment retention, staffing to workloads, and scope of practice, among others. SHM promotes peer-to-peer learning and has helped me share and learn best practices as it relates to the clinical and nonclinical aspect of the practice of hospital medicine.
What one piece of advice would you give fellow hospitalists during this transformational time in health care?
This is an exciting time in health care, especially for hospital medicine professionals, who are at the forefront of providing value-based care. Every change is an opportunity to improve and innovate; the best way to handle change is to embrace and lead it.
Ms. Steele is SHM’s communications coordinator.
To apply for the Fellow in Hospital Medicine designation, visit www.hospitalmedicine.org/fellows.
Editor’s note: Each month, SHM puts the spotlight on some of our most active members who are making substantial contributions to hospital medicine. Log on to www.hospitalmedicine.org/getinvolved for more information on how you can lend your expertise to help SHM improve the care of hospitalized patients.
This month, The Hospitalist spotlights Umesh Sharma, MD, MBA, FHM, chair of the division of community hospital medicine at Mayo Clinic. Umesh became a Fellow in Hospital Medicine in 2016 and has found great value in attending the annual meeting each year.
What inspired you to join SHM, and what prompted you to apply for the Fellow in Hospital Medicine designation?
How did you use SHM resources to help you in your pathway to Fellowship in Hospital Medicine?
There are specific eligibility requirements for the Fellow in Hospital Medicine designation, including a minimum of 5 years as a practicing hospitalist and 3 years as an SHM member, endorsements from two active members, regular meeting attendance and more. SHM provides a checklist for Fellow applicants online and an FAQ page to make the application process as user-friendly as possible. A friend of mine, Dr. Deepak Pahuja, is a Fellow, and he mentored me throughout the process.
How else has SHM contributed to your professional growth and provided you with tools you need to lead hospitalists at Mayo Clinic?
There are many resources that SHM provides to help with professional growth both online and at in-person meetings. I referenced the Key Principles and Characteristics of an Effective Hospital Medicine Group, an online assessment guide, in my role as department chair in La Crosse, Wisc., to resurrect a hospital medicine group, secure resources, hire career hospitalists, and create a well-functioning, well-managed, efficient, effective group with zero turnover during a span of 4 years.
By focusing on the leadership track at annual meetings, I have been able to gain knowledge on proven leadership strategies and enhance my skills, which I have applied on many occasions in my practice. Being able to talk to multisite hospital medicine group colleagues in person helped me to learn best practices in how to successfully manage the integration of 14 hospital medicine community hospital sites across Mayo Midwest. I was able to get ideas on effectively understanding and managing challenges, like recruitment retention, staffing to workloads, and scope of practice, among others. SHM promotes peer-to-peer learning and has helped me share and learn best practices as it relates to the clinical and nonclinical aspect of the practice of hospital medicine.
What one piece of advice would you give fellow hospitalists during this transformational time in health care?
This is an exciting time in health care, especially for hospital medicine professionals, who are at the forefront of providing value-based care. Every change is an opportunity to improve and innovate; the best way to handle change is to embrace and lead it.
Ms. Steele is SHM’s communications coordinator.
To apply for the Fellow in Hospital Medicine designation, visit www.hospitalmedicine.org/fellows.
Editor’s note: Each month, SHM puts the spotlight on some of our most active members who are making substantial contributions to hospital medicine. Log on to www.hospitalmedicine.org/getinvolved for more information on how you can lend your expertise to help SHM improve the care of hospitalized patients.
This month, The Hospitalist spotlights Umesh Sharma, MD, MBA, FHM, chair of the division of community hospital medicine at Mayo Clinic. Umesh became a Fellow in Hospital Medicine in 2016 and has found great value in attending the annual meeting each year.
What inspired you to join SHM, and what prompted you to apply for the Fellow in Hospital Medicine designation?
How did you use SHM resources to help you in your pathway to Fellowship in Hospital Medicine?
There are specific eligibility requirements for the Fellow in Hospital Medicine designation, including a minimum of 5 years as a practicing hospitalist and 3 years as an SHM member, endorsements from two active members, regular meeting attendance and more. SHM provides a checklist for Fellow applicants online and an FAQ page to make the application process as user-friendly as possible. A friend of mine, Dr. Deepak Pahuja, is a Fellow, and he mentored me throughout the process.
How else has SHM contributed to your professional growth and provided you with tools you need to lead hospitalists at Mayo Clinic?
There are many resources that SHM provides to help with professional growth both online and at in-person meetings. I referenced the Key Principles and Characteristics of an Effective Hospital Medicine Group, an online assessment guide, in my role as department chair in La Crosse, Wisc., to resurrect a hospital medicine group, secure resources, hire career hospitalists, and create a well-functioning, well-managed, efficient, effective group with zero turnover during a span of 4 years.
By focusing on the leadership track at annual meetings, I have been able to gain knowledge on proven leadership strategies and enhance my skills, which I have applied on many occasions in my practice. Being able to talk to multisite hospital medicine group colleagues in person helped me to learn best practices in how to successfully manage the integration of 14 hospital medicine community hospital sites across Mayo Midwest. I was able to get ideas on effectively understanding and managing challenges, like recruitment retention, staffing to workloads, and scope of practice, among others. SHM promotes peer-to-peer learning and has helped me share and learn best practices as it relates to the clinical and nonclinical aspect of the practice of hospital medicine.
What one piece of advice would you give fellow hospitalists during this transformational time in health care?
This is an exciting time in health care, especially for hospital medicine professionals, who are at the forefront of providing value-based care. Every change is an opportunity to improve and innovate; the best way to handle change is to embrace and lead it.
Ms. Steele is SHM’s communications coordinator.
To apply for the Fellow in Hospital Medicine designation, visit www.hospitalmedicine.org/fellows.
Disappointment in article on NP, PA roles in HM groups
Editor’s note: The following “Letter to the Editor” was first emailed to the Society of Hospital Medicine, its board president, and John Nelson, MD, MHM, the author of the article, “Hospitalist Roles for NPs and PAs,” which published in the January 2017 issue. All parties agreed to publish the email exchange in The Hospitalist.
Sent: Sunday, February 12, 2017 9:59 AM
Subject: Offensive article on hospitalist roles for NPs, PAs
All,
I have been a hospitalist NP (nurse practitioner) for a decade and found the article in the January issue of The Hospitalist, Volume 21, Number 1, on the Hospitalist Roles for NPs and PAs, offensive and uninformed, with an intolerable amount of personal opinion not backed by research.
I am disappointed that The Hospitalist would publish such a low-class article. Your [magazine] promotes membership to all APPs (advanced practice providers), yet you publish articles that show a study with a positive finding yet allow and highlight an incredibly negative and offensive snippet. The highlighted box states that “Any group that thinks this study is evidence that adding more APPs and having them manage a high number of patients relatively independently will go well in any setting is MISTAKEN ... But it does offer a STORY of one place where, with careful planning and execution, it went OK.”
I can only say that the physicians, APPs, and hospital group who did this study would likely also be offended for taking their study and turning it into a “story.”
EDUCATE yourselves. There are numerous studies out there showing care by APP’s is cost effective, efficient, and with excellent care outcomes. There is a national group, APPex (Advanced Practice Provider Executives), that can give you all the studies you would want showing this information. Or contact the national NP or PA groups.
I am a working hospitalist NP and appreciate my physician colleagues and have their respect. This “John” person obviously doesn’t respect APPs and to publish him is just disheartening.
This publication could have and should have done better. You have one APP on your editorial advisory board – it appears you need more.
Marci Harris, MSN, FNP, ACNP
Acute Care Nurse Practitioner
Hospitalist/Internal Medicine
McKee Medical Center, Loveland, Colo.
Dr. Nelson responds:
Thanks for your message, Marci. It seems clear you’ve thought a lot about NPs and PAs in hospitalist practices and have arrived at conclusions that differ from what I wrote. Your voice and views are welcome.
I certainly didn’t intend to offend anyone, including those who might see all of this very differently from me.
As I mention in the first paragraph, I’m very supportive of NPs and PAs in hospitalist practices. And I wanted to write about this particular study precisely because it provides data that is very supportive of their contributions.
The point I was trying to make in the column is that there is value in careful planning around roles and who does what. A sports team could recruit the most talented players but still won’t perform well if they don’t develop and execute a good plan around who does what and how they work together. Simply having talented people on the team isn’t enough. I think the same is true of hospitalist teams.
The hospitalist group in the study has an impressively detailed plan for new provider (APC and MD alike) orientation and has a lot of operating processes that help ensure the PAs and MDs work effectively together. My experience is that many hospitalists groups have never developed such a plan.
John Nelson, MD, MHM
Partner, Nelson Flores Hospital Medicine Consultants, Bellevue, Wash.
Editor’s note: The following “Letter to the Editor” was first emailed to the Society of Hospital Medicine, its board president, and John Nelson, MD, MHM, the author of the article, “Hospitalist Roles for NPs and PAs,” which published in the January 2017 issue. All parties agreed to publish the email exchange in The Hospitalist.
Sent: Sunday, February 12, 2017 9:59 AM
Subject: Offensive article on hospitalist roles for NPs, PAs
All,
I have been a hospitalist NP (nurse practitioner) for a decade and found the article in the January issue of The Hospitalist, Volume 21, Number 1, on the Hospitalist Roles for NPs and PAs, offensive and uninformed, with an intolerable amount of personal opinion not backed by research.
I am disappointed that The Hospitalist would publish such a low-class article. Your [magazine] promotes membership to all APPs (advanced practice providers), yet you publish articles that show a study with a positive finding yet allow and highlight an incredibly negative and offensive snippet. The highlighted box states that “Any group that thinks this study is evidence that adding more APPs and having them manage a high number of patients relatively independently will go well in any setting is MISTAKEN ... But it does offer a STORY of one place where, with careful planning and execution, it went OK.”
I can only say that the physicians, APPs, and hospital group who did this study would likely also be offended for taking their study and turning it into a “story.”
EDUCATE yourselves. There are numerous studies out there showing care by APP’s is cost effective, efficient, and with excellent care outcomes. There is a national group, APPex (Advanced Practice Provider Executives), that can give you all the studies you would want showing this information. Or contact the national NP or PA groups.
I am a working hospitalist NP and appreciate my physician colleagues and have their respect. This “John” person obviously doesn’t respect APPs and to publish him is just disheartening.
This publication could have and should have done better. You have one APP on your editorial advisory board – it appears you need more.
Marci Harris, MSN, FNP, ACNP
Acute Care Nurse Practitioner
Hospitalist/Internal Medicine
McKee Medical Center, Loveland, Colo.
Dr. Nelson responds:
Thanks for your message, Marci. It seems clear you’ve thought a lot about NPs and PAs in hospitalist practices and have arrived at conclusions that differ from what I wrote. Your voice and views are welcome.
I certainly didn’t intend to offend anyone, including those who might see all of this very differently from me.
As I mention in the first paragraph, I’m very supportive of NPs and PAs in hospitalist practices. And I wanted to write about this particular study precisely because it provides data that is very supportive of their contributions.
The point I was trying to make in the column is that there is value in careful planning around roles and who does what. A sports team could recruit the most talented players but still won’t perform well if they don’t develop and execute a good plan around who does what and how they work together. Simply having talented people on the team isn’t enough. I think the same is true of hospitalist teams.
The hospitalist group in the study has an impressively detailed plan for new provider (APC and MD alike) orientation and has a lot of operating processes that help ensure the PAs and MDs work effectively together. My experience is that many hospitalists groups have never developed such a plan.
John Nelson, MD, MHM
Partner, Nelson Flores Hospital Medicine Consultants, Bellevue, Wash.
Editor’s note: The following “Letter to the Editor” was first emailed to the Society of Hospital Medicine, its board president, and John Nelson, MD, MHM, the author of the article, “Hospitalist Roles for NPs and PAs,” which published in the January 2017 issue. All parties agreed to publish the email exchange in The Hospitalist.
Sent: Sunday, February 12, 2017 9:59 AM
Subject: Offensive article on hospitalist roles for NPs, PAs
All,
I have been a hospitalist NP (nurse practitioner) for a decade and found the article in the January issue of The Hospitalist, Volume 21, Number 1, on the Hospitalist Roles for NPs and PAs, offensive and uninformed, with an intolerable amount of personal opinion not backed by research.
I am disappointed that The Hospitalist would publish such a low-class article. Your [magazine] promotes membership to all APPs (advanced practice providers), yet you publish articles that show a study with a positive finding yet allow and highlight an incredibly negative and offensive snippet. The highlighted box states that “Any group that thinks this study is evidence that adding more APPs and having them manage a high number of patients relatively independently will go well in any setting is MISTAKEN ... But it does offer a STORY of one place where, with careful planning and execution, it went OK.”
I can only say that the physicians, APPs, and hospital group who did this study would likely also be offended for taking their study and turning it into a “story.”
EDUCATE yourselves. There are numerous studies out there showing care by APP’s is cost effective, efficient, and with excellent care outcomes. There is a national group, APPex (Advanced Practice Provider Executives), that can give you all the studies you would want showing this information. Or contact the national NP or PA groups.
I am a working hospitalist NP and appreciate my physician colleagues and have their respect. This “John” person obviously doesn’t respect APPs and to publish him is just disheartening.
This publication could have and should have done better. You have one APP on your editorial advisory board – it appears you need more.
Marci Harris, MSN, FNP, ACNP
Acute Care Nurse Practitioner
Hospitalist/Internal Medicine
McKee Medical Center, Loveland, Colo.
Dr. Nelson responds:
Thanks for your message, Marci. It seems clear you’ve thought a lot about NPs and PAs in hospitalist practices and have arrived at conclusions that differ from what I wrote. Your voice and views are welcome.
I certainly didn’t intend to offend anyone, including those who might see all of this very differently from me.
As I mention in the first paragraph, I’m very supportive of NPs and PAs in hospitalist practices. And I wanted to write about this particular study precisely because it provides data that is very supportive of their contributions.
The point I was trying to make in the column is that there is value in careful planning around roles and who does what. A sports team could recruit the most talented players but still won’t perform well if they don’t develop and execute a good plan around who does what and how they work together. Simply having talented people on the team isn’t enough. I think the same is true of hospitalist teams.
The hospitalist group in the study has an impressively detailed plan for new provider (APC and MD alike) orientation and has a lot of operating processes that help ensure the PAs and MDs work effectively together. My experience is that many hospitalists groups have never developed such a plan.
John Nelson, MD, MHM
Partner, Nelson Flores Hospital Medicine Consultants, Bellevue, Wash.
Create hospitalist-patient partnerships for safety and quality
Hospitalists can help enlist patients in the movement toward improved patient safety, and they can begin simply by sharing their notes.
OpenNotes offers a new platform to do that, according to a BMJ Quality & Safety article, “A patient feedback reporting tool for OpenNotes: implications for patient-clinician safety and quality partnerships.”1
In their study, the researchers invited 6,225 patients to read clinicians’ notes and, through a patient portal, provide feedback. Forty-four percent of patients read the notes; nearly all (96%) respondents reported understanding the notes; 1 in 12 submitted feedback.
“Patients can [and did] find documentation errors in their notes and were willing to report them without any apparent negative effect on the patient-clinician relationship,” Dr. Bell says. “The majority of patients also wanted to share positive feedback with their providers. Sharing notes can also facilitate information transfer across care settings.”
Investigators also reported on feedback from patients that hearing the notes helped them to remember next steps.
“Reading discharge summaries and visit notes from follow-up visits after a hospitalization may prove particularly important,” Dr. Bell says. “Providing patients with access to their notes may help them to adhere to the care plan, better remember recommended follow up tests or visits, and potentially stem preventable readmissions.”
What hospitalists can do now, Dr. Bell adds, is:
- Share their notes with patients and families (by printing the discharge summaries if they are not available on the portal and/or sharing notes from post-discharge follow-up visits).
- Emphasize for patients and families the important role they play as safety partners.
- Ask patients who receive care in other healthcare centers if they have OpenNotes, which can help hospitalists obtain medical records quickly and efficiently.
- Encourage patients to sign up for the patient portal and ask for their notes, for ambulatory visits to begin with and for in-patient notes when they become available.
Suzanne Bopp is a freelance medical writer in New York City.
Reference
1. Bell SK, Gerard M, Fossa A, et al. A patient feedback reporting tool for OpenNotes: implications for patient-clinician safety and quality partnerships [published online ahead of print, Dec. 13, 2016]. BMJ Qual Saf. doi: 10.1136/bmjqs-2016-006020.
Hospitalists can help enlist patients in the movement toward improved patient safety, and they can begin simply by sharing their notes.
OpenNotes offers a new platform to do that, according to a BMJ Quality & Safety article, “A patient feedback reporting tool for OpenNotes: implications for patient-clinician safety and quality partnerships.”1
In their study, the researchers invited 6,225 patients to read clinicians’ notes and, through a patient portal, provide feedback. Forty-four percent of patients read the notes; nearly all (96%) respondents reported understanding the notes; 1 in 12 submitted feedback.
“Patients can [and did] find documentation errors in their notes and were willing to report them without any apparent negative effect on the patient-clinician relationship,” Dr. Bell says. “The majority of patients also wanted to share positive feedback with their providers. Sharing notes can also facilitate information transfer across care settings.”
Investigators also reported on feedback from patients that hearing the notes helped them to remember next steps.
“Reading discharge summaries and visit notes from follow-up visits after a hospitalization may prove particularly important,” Dr. Bell says. “Providing patients with access to their notes may help them to adhere to the care plan, better remember recommended follow up tests or visits, and potentially stem preventable readmissions.”
What hospitalists can do now, Dr. Bell adds, is:
- Share their notes with patients and families (by printing the discharge summaries if they are not available on the portal and/or sharing notes from post-discharge follow-up visits).
- Emphasize for patients and families the important role they play as safety partners.
- Ask patients who receive care in other healthcare centers if they have OpenNotes, which can help hospitalists obtain medical records quickly and efficiently.
- Encourage patients to sign up for the patient portal and ask for their notes, for ambulatory visits to begin with and for in-patient notes when they become available.
Suzanne Bopp is a freelance medical writer in New York City.
Reference
1. Bell SK, Gerard M, Fossa A, et al. A patient feedback reporting tool for OpenNotes: implications for patient-clinician safety and quality partnerships [published online ahead of print, Dec. 13, 2016]. BMJ Qual Saf. doi: 10.1136/bmjqs-2016-006020.
Hospitalists can help enlist patients in the movement toward improved patient safety, and they can begin simply by sharing their notes.
OpenNotes offers a new platform to do that, according to a BMJ Quality & Safety article, “A patient feedback reporting tool for OpenNotes: implications for patient-clinician safety and quality partnerships.”1
In their study, the researchers invited 6,225 patients to read clinicians’ notes and, through a patient portal, provide feedback. Forty-four percent of patients read the notes; nearly all (96%) respondents reported understanding the notes; 1 in 12 submitted feedback.
“Patients can [and did] find documentation errors in their notes and were willing to report them without any apparent negative effect on the patient-clinician relationship,” Dr. Bell says. “The majority of patients also wanted to share positive feedback with their providers. Sharing notes can also facilitate information transfer across care settings.”
Investigators also reported on feedback from patients that hearing the notes helped them to remember next steps.
“Reading discharge summaries and visit notes from follow-up visits after a hospitalization may prove particularly important,” Dr. Bell says. “Providing patients with access to their notes may help them to adhere to the care plan, better remember recommended follow up tests or visits, and potentially stem preventable readmissions.”
What hospitalists can do now, Dr. Bell adds, is:
- Share their notes with patients and families (by printing the discharge summaries if they are not available on the portal and/or sharing notes from post-discharge follow-up visits).
- Emphasize for patients and families the important role they play as safety partners.
- Ask patients who receive care in other healthcare centers if they have OpenNotes, which can help hospitalists obtain medical records quickly and efficiently.
- Encourage patients to sign up for the patient portal and ask for their notes, for ambulatory visits to begin with and for in-patient notes when they become available.
Suzanne Bopp is a freelance medical writer in New York City.
Reference
1. Bell SK, Gerard M, Fossa A, et al. A patient feedback reporting tool for OpenNotes: implications for patient-clinician safety and quality partnerships [published online ahead of print, Dec. 13, 2016]. BMJ Qual Saf. doi: 10.1136/bmjqs-2016-006020.
Sneak Peek: The Hospital Leader Blog
Editor’s note: This article first appeared on “The Hospital Leader” blog. Read the full post at hospitalleader.org.
In December, I wrote a letter to hospital executives, urging them to deliberately invest their own personal time and effort in fostering hospitalist well-being. I suggested several actions that leaders can take to enhance hospitalist job satisfaction and reduce the risk of burnout and turnover.
Following publication of that post, I heard from several hospital executives and was pleasantly surprised that they all responded positively to my message. Several execs told me that they gained valuable new insights about their hospitalists’ challenges and needs; others said they planned to take action on one or more of my suggestions that had never occurred to them before.
Their feedback reinforced my belief that most hospital leaders actually do care a lot about promoting healthy, stable, and sustainable hospitalist programs, but the hospital leaders I talked with also had some messages for their hospitalist colleagues, and I think it’s important to share them in the spirit of fostering a healthy exchange of perspectives. Your hospital’s leaders would be delighted and encouraged if you engaged them in dialogue about these issues.
Help us help you
Several hospital leaders told me that their hospitalists grumble about being treated by the medical staff (and even nurses) like second-class citizens or glorified residents. Those same hospitalists, however, routinely show up for work dressed in scrubs and tennis shoes rather than professional attire. They rarely come in early when it’s busy or invest more time than is absolutely needed to see the patients on their list, making it easy for others to dismiss them as shift workers.
Hospitalists, they say, are unwilling to come in on their own time to attend a medical staff meeting, something other doctors do as a matter of course. And instead of interacting as social peers with other physicians when opportunity arises (i.e., in the cafeteria or doctors’ lounge), the hospitalists just grab food and head back to eat together in their work room.
The executives said they want to help enhance the stature of their hospitalists within the medical staff, but the Here’s a typical comment:
“[Hospitalists] also need to be willing to participate in hospital and system committees. Although this may require them to interrupt their workflow and stay late on some days they are working or come in on days off, they will never garner the respect of their colleagues if they are unwilling to do so.”
Read the full post at hospitalleader.org.
Leslie Flores is a hospital medicine consultant and member of SHM’s Practice Analysis Committee.
Also on The Hospital Leader. . .
• Creating Value through Crowdsourcing & Finding ‘Value’ in the New Year, by Vineet Arora, MD, MPP, FHM
• BREAKING NEWS: “Physicians Deemed Unnecessary”; Social Worker Promoted to Hospital CEO, by Jordan Messler, MD, SFHM
• ER Docs and Out-of-Network Billing: Are We in the Same Boat?, by Brad Flansbaum, DO, MPH, MHM
• The Best Way to Die?, by David Brabeck, MD
Editor’s note: This article first appeared on “The Hospital Leader” blog. Read the full post at hospitalleader.org.
In December, I wrote a letter to hospital executives, urging them to deliberately invest their own personal time and effort in fostering hospitalist well-being. I suggested several actions that leaders can take to enhance hospitalist job satisfaction and reduce the risk of burnout and turnover.
Following publication of that post, I heard from several hospital executives and was pleasantly surprised that they all responded positively to my message. Several execs told me that they gained valuable new insights about their hospitalists’ challenges and needs; others said they planned to take action on one or more of my suggestions that had never occurred to them before.
Their feedback reinforced my belief that most hospital leaders actually do care a lot about promoting healthy, stable, and sustainable hospitalist programs, but the hospital leaders I talked with also had some messages for their hospitalist colleagues, and I think it’s important to share them in the spirit of fostering a healthy exchange of perspectives. Your hospital’s leaders would be delighted and encouraged if you engaged them in dialogue about these issues.
Help us help you
Several hospital leaders told me that their hospitalists grumble about being treated by the medical staff (and even nurses) like second-class citizens or glorified residents. Those same hospitalists, however, routinely show up for work dressed in scrubs and tennis shoes rather than professional attire. They rarely come in early when it’s busy or invest more time than is absolutely needed to see the patients on their list, making it easy for others to dismiss them as shift workers.
Hospitalists, they say, are unwilling to come in on their own time to attend a medical staff meeting, something other doctors do as a matter of course. And instead of interacting as social peers with other physicians when opportunity arises (i.e., in the cafeteria or doctors’ lounge), the hospitalists just grab food and head back to eat together in their work room.
The executives said they want to help enhance the stature of their hospitalists within the medical staff, but the Here’s a typical comment:
“[Hospitalists] also need to be willing to participate in hospital and system committees. Although this may require them to interrupt their workflow and stay late on some days they are working or come in on days off, they will never garner the respect of their colleagues if they are unwilling to do so.”
Read the full post at hospitalleader.org.
Leslie Flores is a hospital medicine consultant and member of SHM’s Practice Analysis Committee.
Also on The Hospital Leader. . .
• Creating Value through Crowdsourcing & Finding ‘Value’ in the New Year, by Vineet Arora, MD, MPP, FHM
• BREAKING NEWS: “Physicians Deemed Unnecessary”; Social Worker Promoted to Hospital CEO, by Jordan Messler, MD, SFHM
• ER Docs and Out-of-Network Billing: Are We in the Same Boat?, by Brad Flansbaum, DO, MPH, MHM
• The Best Way to Die?, by David Brabeck, MD
Editor’s note: This article first appeared on “The Hospital Leader” blog. Read the full post at hospitalleader.org.
In December, I wrote a letter to hospital executives, urging them to deliberately invest their own personal time and effort in fostering hospitalist well-being. I suggested several actions that leaders can take to enhance hospitalist job satisfaction and reduce the risk of burnout and turnover.
Following publication of that post, I heard from several hospital executives and was pleasantly surprised that they all responded positively to my message. Several execs told me that they gained valuable new insights about their hospitalists’ challenges and needs; others said they planned to take action on one or more of my suggestions that had never occurred to them before.
Their feedback reinforced my belief that most hospital leaders actually do care a lot about promoting healthy, stable, and sustainable hospitalist programs, but the hospital leaders I talked with also had some messages for their hospitalist colleagues, and I think it’s important to share them in the spirit of fostering a healthy exchange of perspectives. Your hospital’s leaders would be delighted and encouraged if you engaged them in dialogue about these issues.
Help us help you
Several hospital leaders told me that their hospitalists grumble about being treated by the medical staff (and even nurses) like second-class citizens or glorified residents. Those same hospitalists, however, routinely show up for work dressed in scrubs and tennis shoes rather than professional attire. They rarely come in early when it’s busy or invest more time than is absolutely needed to see the patients on their list, making it easy for others to dismiss them as shift workers.
Hospitalists, they say, are unwilling to come in on their own time to attend a medical staff meeting, something other doctors do as a matter of course. And instead of interacting as social peers with other physicians when opportunity arises (i.e., in the cafeteria or doctors’ lounge), the hospitalists just grab food and head back to eat together in their work room.
The executives said they want to help enhance the stature of their hospitalists within the medical staff, but the Here’s a typical comment:
“[Hospitalists] also need to be willing to participate in hospital and system committees. Although this may require them to interrupt their workflow and stay late on some days they are working or come in on days off, they will never garner the respect of their colleagues if they are unwilling to do so.”
Read the full post at hospitalleader.org.
Leslie Flores is a hospital medicine consultant and member of SHM’s Practice Analysis Committee.
Also on The Hospital Leader. . .
• Creating Value through Crowdsourcing & Finding ‘Value’ in the New Year, by Vineet Arora, MD, MPP, FHM
• BREAKING NEWS: “Physicians Deemed Unnecessary”; Social Worker Promoted to Hospital CEO, by Jordan Messler, MD, SFHM
• ER Docs and Out-of-Network Billing: Are We in the Same Boat?, by Brad Flansbaum, DO, MPH, MHM
• The Best Way to Die?, by David Brabeck, MD
