Medicare

The reviews are in, and most healthcare provider groups are finding little to their liking in the proposed rules for the Centers for Medicare & Medicaid Services’ (CMS) voluntary Accountable Care Organization (ACO) program. Organizations like SHM have publically supported the concept of an ACO, but details in the 128 pages of proposed rules released March 31 apparently were not what they had in mind. The problem, as many provider groups detailed in a flurry of letters sent before the June 6 deadline for comments, is too much stick and not enough carrot.

The Patient Protection and Affordable Care Act of 2010, which authorized the program, stipulates that any Medicare savings deriving from ACOs must be divided between CMS and participating organizations. Organizations can choose between two financial models: One track allows participants to retain 60% of overall savings but also requires them to assume financial risk from the start; a second track delays any risk until the third year and offers 50% savings. In exchange, ACOs must achieve an average savings of 2% per patient, as well as meet or beat thresholds for 65 measures of quality.

Organizational Uproar

Critics contend that the recommended rules are so onerous and bureaucratic that the program is likely to attract few takers. In its comment letter, SHM expressed an opinion shared by many: "Although the ACO concept holds much promise, the proposed rule as written presents many barriers to successful ACO development and operations. Establishing an ACO will require an enormous upfront investment from participating providers, but the proposed rule does not allow for enough flexibility to ensure a reasonable return on investment." (Read SHM’s response letter at www.hospital medicine.org/advocacy.)

The American College of Physicians similarly warned that the proposed rules set the bar too high for many would-be participants. "The required administrative, infrastructure, service delivery, and financial resources and the need to accept risk will effectively limit participation to those few large entities already organized under an ACO-like structure; that already have ready access to capital, substantial infrastructure development, and experience operating under an integrative service/payment model (e.g. Medicare Advantage)," the ACP wrote in its response letter (www.acponline.org/run ning_practice/aco/acp_comments.pdf).

The tone was markedly different in letters from consumer and advocacy groups, including one by the Campaign for Better Care, signed by more than 40 organizations (www.national­partnership.org). "Overall we believe you are moving in the right direction with the proposed rule, and we applaud your commitment to ensuring ACOs deliver truly patient-centered care," the letter stated. Acknowledging the negative feedback, the letter continued, "While some are concerned about asking too much of ACOs, we cannot expect genuine transformation to be easy, and we know that these new models must be held to standards that ensure they deliver on the promise of better care, better health, and lower cost."

Accountability Gap

Michael W. Painter, JD, MD, senior program officer at the Robert Wood Johnson Foundation in Princeton, N.J., helped research and write the foundation’s own comment letter, which he says tried to bridge the divide between provider and patient groups.

"We did get behind the notion of ratcheting up the accountability for quality and cost, including the risk, as soon as it makes sense to do it," he says. "Not dragging our feet, recognizing that we have to do it rapidly, but it has to be balanced by being reasonable to help move from where we are."

Given the mandate for change, Dr. Painter says, the negative tone of many letters from provider organizations shouldn’t be surprising. "What we’re asking the hospital, the health professionals, to do is to change fairly radically and embrace this accountability. So as you just walk through the door of this conversation, it’s not surprising that they would balk," he says. "Nobody wants to take on all of this new responsibility. It’s no fault of theirs; they’ve just been following the rules of the road of the current system and the payment schemes to try to be successful in that environment."

Success, of course, depends on financial stability, and Dr. Painter says the worry that participating ACOs could open themselves up to financial risk too soon is "absolutely a legitimate concern." CMS, he says, should give providers clear guidance and assistance, as well as assurance that the regulations won’t change on them once they’ve enrolled.

So far, at least, CMS has not swayed some of the very institutions that government officials have lauded as examples of how ACOs should be run. In June, the Mayo Clinic in Rochester, Minn., announced that it would not participate. As reported by the Minneapolis Star Tribune, clinic officials said the proposed regulations clashed with Mayo’s existing Medicare operations. One of the clinic’s chief complaints is the proposed requirement that patients be added to oversight boards charged with assessing performance, something that Mayo argues is unnecessary to deliver patient-centered care. Antitrust rules represent another major concern for Mayo and others that argue their dominant position as healthcare providers in rural communities could run afoul of the regulations.

Cleveland Clinic likewise blasted the proposed ACO rules in a letter. "Rather than providing a broad framework that focuses on results as the key criteria of success, the Proposed Rule is replete with (1) prescriptive requirements that have little to do with outcomes, and (2) many detailed governance and reporting requirements that create significant administrative burdens," stated Delos Cosgrove, MD, the clinic’s CEO and president.

Furthermore, Cosgrove’s letter concluded that the shared-savings component "is structured in such a way that creates real uncertainty about whether applicants will be able to achieve success."

The American Medical Group Association went so far as to include in its letter the results of a member survey, which showed 93% would not enroll under the current ACO rules.

No Turning Back

Dr. Painter says the pushback is to be expected. Although the country has no choice but to move toward more accountability, he says, it’s impossible for the first attempt at a proposed rule to be the "magic bullet" that gets it exactly right. "One, this is a radical departure, and two, when you get into the nitty-gritty of the proposed rule and people crunch the numbers, if it’s not going to work for them or it’s simply not enticing enough for them, they [CMS] need to go back to the table and make it that way," he says.

Organizations like the American Medical Association have been particularly vocal about asking CMS to delay issuing its final rule, slated for January. So far, Dr. Painter says, CMS officials have indicated that the timeline will proceed according to schedule, though he notes that providers have raised plenty of valid concerns that should be addressed.

"Would I be surprised if there’s a delay? No. This is a big deal," he says.

Along with some expected rule changes, he says the newly formed Center for Medicare and Medicaid Innovation could play a key role in offering assistance and developing alternative ACO models and pilot programs.

Regardless of whether the voluntary CMS program ultimately pleases both providers and patients, though, one thing seems certain: The accountable-care concept is here to stay.

Bryn Nelson is a freelance medical writer based in Seattle

The reviews are in, and most healthcare provider groups are finding little to their liking in the proposed rules for the Centers for Medicare & Medicaid Services’ (CMS) voluntary Accountable Care Organization (ACO) program. Organizations like SHM have publically supported the concept of an ACO, but details in the 128 pages of proposed rules released March 31 apparently were not what they had in mind. The problem, as many provider groups detailed in a flurry of letters sent before the June 6 deadline for comments, is too much stick and not enough carrot.

The Patient Protection and Affordable Care Act of 2010, which authorized the program, stipulates that any Medicare savings deriving from ACOs must be divided between CMS and participating organizations. Organizations can choose between two financial models: One track allows participants to retain 60% of overall savings but also requires them to assume financial risk from the start; a second track delays any risk until the third year and offers 50% savings. In exchange, ACOs must achieve an average savings of 2% per patient, as well as meet or beat thresholds for 65 measures of quality.

Organizational Uproar

Critics contend that the recommended rules are so onerous and bureaucratic that the program is likely to attract few takers. In its comment letter, SHM expressed an opinion shared by many: "Although the ACO concept holds much promise, the proposed rule as written presents many barriers to successful ACO development and operations. Establishing an ACO will require an enormous upfront investment from participating providers, but the proposed rule does not allow for enough flexibility to ensure a reasonable return on investment." (Read SHM’s response letter at www.hospital medicine.org/advocacy.)

The American College of Physicians similarly warned that the proposed rules set the bar too high for many would-be participants. "The required administrative, infrastructure, service delivery, and financial resources and the need to accept risk will effectively limit participation to those few large entities already organized under an ACO-like structure; that already have ready access to capital, substantial infrastructure development, and experience operating under an integrative service/payment model (e.g. Medicare Advantage)," the ACP wrote in its response letter (www.acponline.org/run ning_practice/aco/acp_comments.pdf).

The tone was markedly different in letters from consumer and advocacy groups, including one by the Campaign for Better Care, signed by more than 40 organizations (www.national­partnership.org). "Overall we believe you are moving in the right direction with the proposed rule, and we applaud your commitment to ensuring ACOs deliver truly patient-centered care," the letter stated. Acknowledging the negative feedback, the letter continued, "While some are concerned about asking too much of ACOs, we cannot expect genuine transformation to be easy, and we know that these new models must be held to standards that ensure they deliver on the promise of better care, better health, and lower cost."

Accountability Gap

Michael W. Painter, JD, MD, senior program officer at the Robert Wood Johnson Foundation in Princeton, N.J., helped research and write the foundation’s own comment letter, which he says tried to bridge the divide between provider and patient groups.

"We did get behind the notion of ratcheting up the accountability for quality and cost, including the risk, as soon as it makes sense to do it," he says. "Not dragging our feet, recognizing that we have to do it rapidly, but it has to be balanced by being reasonable to help move from where we are."

Given the mandate for change, Dr. Painter says, the negative tone of many letters from provider organizations shouldn’t be surprising. "What we’re asking the hospital, the health professionals, to do is to change fairly radically and embrace this accountability. So as you just walk through the door of this conversation, it’s not surprising that they would balk," he says. "Nobody wants to take on all of this new responsibility. It’s no fault of theirs; they’ve just been following the rules of the road of the current system and the payment schemes to try to be successful in that environment."

Success, of course, depends on financial stability, and Dr. Painter says the worry that participating ACOs could open themselves up to financial risk too soon is "absolutely a legitimate concern." CMS, he says, should give providers clear guidance and assistance, as well as assurance that the regulations won’t change on them once they’ve enrolled.

So far, at least, CMS has not swayed some of the very institutions that government officials have lauded as examples of how ACOs should be run. In June, the Mayo Clinic in Rochester, Minn., announced that it would not participate. As reported by the Minneapolis Star Tribune, clinic officials said the proposed regulations clashed with Mayo’s existing Medicare operations. One of the clinic’s chief complaints is the proposed requirement that patients be added to oversight boards charged with assessing performance, something that Mayo argues is unnecessary to deliver patient-centered care. Antitrust rules represent another major concern for Mayo and others that argue their dominant position as healthcare providers in rural communities could run afoul of the regulations.

Cleveland Clinic likewise blasted the proposed ACO rules in a letter. "Rather than providing a broad framework that focuses on results as the key criteria of success, the Proposed Rule is replete with (1) prescriptive requirements that have little to do with outcomes, and (2) many detailed governance and reporting requirements that create significant administrative burdens," stated Delos Cosgrove, MD, the clinic’s CEO and president.

Furthermore, Cosgrove’s letter concluded that the shared-savings component "is structured in such a way that creates real uncertainty about whether applicants will be able to achieve success."

The American Medical Group Association went so far as to include in its letter the results of a member survey, which showed 93% would not enroll under the current ACO rules.

No Turning Back

Dr. Painter says the pushback is to be expected. Although the country has no choice but to move toward more accountability, he says, it’s impossible for the first attempt at a proposed rule to be the "magic bullet" that gets it exactly right. "One, this is a radical departure, and two, when you get into the nitty-gritty of the proposed rule and people crunch the numbers, if it’s not going to work for them or it’s simply not enticing enough for them, they [CMS] need to go back to the table and make it that way," he says.

Organizations like the American Medical Association have been particularly vocal about asking CMS to delay issuing its final rule, slated for January. So far, Dr. Painter says, CMS officials have indicated that the timeline will proceed according to schedule, though he notes that providers have raised plenty of valid concerns that should be addressed.

"Would I be surprised if there’s a delay? No. This is a big deal," he says.

Along with some expected rule changes, he says the newly formed Center for Medicare and Medicaid Innovation could play a key role in offering assistance and developing alternative ACO models and pilot programs.

Regardless of whether the voluntary CMS program ultimately pleases both providers and patients, though, one thing seems certain: The accountable-care concept is here to stay.

Bryn Nelson is a freelance medical writer based in Seattle

The reviews are in, and most healthcare provider groups are finding little to their liking in the proposed rules for the Centers for Medicare & Medicaid Services’ (CMS) voluntary Accountable Care Organization (ACO) program. Organizations like SHM have publically supported the concept of an ACO, but details in the 128 pages of proposed rules released March 31 apparently were not what they had in mind. The problem, as many provider groups detailed in a flurry of letters sent before the June 6 deadline for comments, is too much stick and not enough carrot.

The Patient Protection and Affordable Care Act of 2010, which authorized the program, stipulates that any Medicare savings deriving from ACOs must be divided between CMS and participating organizations. Organizations can choose between two financial models: One track allows participants to retain 60% of overall savings but also requires them to assume financial risk from the start; a second track delays any risk until the third year and offers 50% savings. In exchange, ACOs must achieve an average savings of 2% per patient, as well as meet or beat thresholds for 65 measures of quality.

Organizational Uproar

Critics contend that the recommended rules are so onerous and bureaucratic that the program is likely to attract few takers. In its comment letter, SHM expressed an opinion shared by many: "Although the ACO concept holds much promise, the proposed rule as written presents many barriers to successful ACO development and operations. Establishing an ACO will require an enormous upfront investment from participating providers, but the proposed rule does not allow for enough flexibility to ensure a reasonable return on investment." (Read SHM’s response letter at www.hospital medicine.org/advocacy.)

The American College of Physicians similarly warned that the proposed rules set the bar too high for many would-be participants. "The required administrative, infrastructure, service delivery, and financial resources and the need to accept risk will effectively limit participation to those few large entities already organized under an ACO-like structure; that already have ready access to capital, substantial infrastructure development, and experience operating under an integrative service/payment model (e.g. Medicare Advantage)," the ACP wrote in its response letter (www.acponline.org/run ning_practice/aco/acp_comments.pdf).

The tone was markedly different in letters from consumer and advocacy groups, including one by the Campaign for Better Care, signed by more than 40 organizations (www.national­partnership.org). "Overall we believe you are moving in the right direction with the proposed rule, and we applaud your commitment to ensuring ACOs deliver truly patient-centered care," the letter stated. Acknowledging the negative feedback, the letter continued, "While some are concerned about asking too much of ACOs, we cannot expect genuine transformation to be easy, and we know that these new models must be held to standards that ensure they deliver on the promise of better care, better health, and lower cost."

Accountability Gap

Michael W. Painter, JD, MD, senior program officer at the Robert Wood Johnson Foundation in Princeton, N.J., helped research and write the foundation’s own comment letter, which he says tried to bridge the divide between provider and patient groups.

"We did get behind the notion of ratcheting up the accountability for quality and cost, including the risk, as soon as it makes sense to do it," he says. "Not dragging our feet, recognizing that we have to do it rapidly, but it has to be balanced by being reasonable to help move from where we are."

Given the mandate for change, Dr. Painter says, the negative tone of many letters from provider organizations shouldn’t be surprising. "What we’re asking the hospital, the health professionals, to do is to change fairly radically and embrace this accountability. So as you just walk through the door of this conversation, it’s not surprising that they would balk," he says. "Nobody wants to take on all of this new responsibility. It’s no fault of theirs; they’ve just been following the rules of the road of the current system and the payment schemes to try to be successful in that environment."

Success, of course, depends on financial stability, and Dr. Painter says the worry that participating ACOs could open themselves up to financial risk too soon is "absolutely a legitimate concern." CMS, he says, should give providers clear guidance and assistance, as well as assurance that the regulations won’t change on them once they’ve enrolled.

So far, at least, CMS has not swayed some of the very institutions that government officials have lauded as examples of how ACOs should be run. In June, the Mayo Clinic in Rochester, Minn., announced that it would not participate. As reported by the Minneapolis Star Tribune, clinic officials said the proposed regulations clashed with Mayo’s existing Medicare operations. One of the clinic’s chief complaints is the proposed requirement that patients be added to oversight boards charged with assessing performance, something that Mayo argues is unnecessary to deliver patient-centered care. Antitrust rules represent another major concern for Mayo and others that argue their dominant position as healthcare providers in rural communities could run afoul of the regulations.

Cleveland Clinic likewise blasted the proposed ACO rules in a letter. "Rather than providing a broad framework that focuses on results as the key criteria of success, the Proposed Rule is replete with (1) prescriptive requirements that have little to do with outcomes, and (2) many detailed governance and reporting requirements that create significant administrative burdens," stated Delos Cosgrove, MD, the clinic’s CEO and president.

Furthermore, Cosgrove’s letter concluded that the shared-savings component "is structured in such a way that creates real uncertainty about whether applicants will be able to achieve success."

The American Medical Group Association went so far as to include in its letter the results of a member survey, which showed 93% would not enroll under the current ACO rules.

No Turning Back

Dr. Painter says the pushback is to be expected. Although the country has no choice but to move toward more accountability, he says, it’s impossible for the first attempt at a proposed rule to be the "magic bullet" that gets it exactly right. "One, this is a radical departure, and two, when you get into the nitty-gritty of the proposed rule and people crunch the numbers, if it’s not going to work for them or it’s simply not enticing enough for them, they [CMS] need to go back to the table and make it that way," he says.

Organizations like the American Medical Association have been particularly vocal about asking CMS to delay issuing its final rule, slated for January. So far, Dr. Painter says, CMS officials have indicated that the timeline will proceed according to schedule, though he notes that providers have raised plenty of valid concerns that should be addressed.

"Would I be surprised if there’s a delay? No. This is a big deal," he says.

Along with some expected rule changes, he says the newly formed Center for Medicare and Medicaid Innovation could play a key role in offering assistance and developing alternative ACO models and pilot programs.

Regardless of whether the voluntary CMS program ultimately pleases both providers and patients, though, one thing seems certain: The accountable-care concept is here to stay.

Bryn Nelson is a freelance medical writer based in Seattle

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Dr. Conway

Patrick Conway, MD, MSc, SFHM, a pediatric hospitalist and director of hospital medicine at Cincinnati Children’s Hospital Medical Center, has been appointed chief medical officer of the Centers for Medicare & Medicaid Services (CMS). Dr. Conway’s key responsibilities will be administering federal healthcare quality initiatives and setting the government’s quality agenda in an era of massive changes resulting from the Patient Protection and Accountable Care Act of 2010 (ACA).

Dr. Conway, who previously served as CMO of the Policy Division of the Office of Secretary of Health and Human Services and was a 2007-2008 White House fellow assigned to the Agency for Healthcare Research and Quality (AHRQ), is a leader in safety, quality, and outcomes initiatives at Cincinnati Children’s, and is the immediate past chair of SHM’s Public Policy Committee. He also served on the Federal Coordinating Council for Comparative Effectiveness Research. In his new job, which he started May 9, he is directing CMS’ Office of Clinical Standards and Quality, which coordinates development and implementation of a CMS-wide approach to promoting health quality.

“Patrick Conway’s appointment represents a major milestone for hospitalists and patients alike,” says Larry Wellikson, MD, SFHM, CEO of SHM. “As hospitalists approach the 15th anniversary of the specialty, it is fitting that one of our own takes on the considerable responsibility of caring for millions of Americans through Medicare and Medicaid. Dr. Conway and thousands of other hospitalists have been on the front lines of systematically improving patient care for more than a decade; his sound judgment and compassion as a clinician are now a major national asset.”

Dr. Conway maintains his associate professorship at the University of Cincinnati and will work some weekends seeing patients at Children’s National Medical Center in Washington, D.C. “I love patient care, so I don’t want to stop doing that. Plus, it helps me connect to the front lines of providing medical care,” he says.

“Dr. Conway’s passion for improving healthcare delivery systems, his day-to-day experience as a hospitalist physician, and his accomplishments in quality-improvement research, such as implementing evidence-based healthcare for all children, provide a strong background for his critical role at CMS as chief medical officer,” says Arnold W. Strauss, MD, chair of pediatrics at the University of Cincinnati, where many of the pediatric physicians at Children’s Hospital hold academic appointments. “Dr. Conway and our colleagues at Cincinnati Children’s have demonstrated that improving patient outcomes at lower cost—the goal of healthcare reform—is feasible.”

Dr. Conway’s role at CMS will include major components of surveys, certification, and accreditation issues for hospitals and other Medicare providers; healthcare information technology; and hospital value-based purchasing initiatives (see “Value-Based Purchasing Raises the Stakes,” The Hospitalist, May 2011, p. 1).

But his initial priorities will focus on quality-measures development, illustrated by CMS’ Hospital Compare website (www.hospitalcompare.hhs.gov), and quality improvement. Another major issue involves care transitions and readmissions, “which I try to frame positively—how can we have the most effective care transitions possible?” he says. “SHM and its publications have done a good job of stressing how hospitals and hospitalists can add value.”

Emphasizing his own experience directing an HM department for a health system that admits 7,000 pediatric patients per year, Dr. Conway says other hospitalists can take a similar lead in embracing quality measurement in their hospitals. “I may be working on quality measures for fiscal years 2013 and 2014, but you already know what will be measured in 2012. Don’t wait until September 2012 to get started,” he explains. “Hospitalists can help their institution pose the question: ‘What do we want to get better at in the next year?’ Then you test. Understand your current performance, set a goal, compare benchmarks with other hospitals, and keep working on improvement.”

Over the course of a year, he adds, quality will improve, and then your HM group will have “something to talk about with hospital administrators.”

Married with two children, says his experience at both the macro and micro levels of healthcare will benefit the overall system. “I actually think if we realign incentives, the system can perform better,” he says. “So I see it as an opportunity to perform a public service. But we also need front-line clinicians, including hospitalists, working to improve our healthcare system. … We need frontline providers that are measuring the quality of their care and improving it.” TH

Larry Beresford is a freelance writer based in California.

Dr. Conway

Patrick Conway, MD, MSc, SFHM, a pediatric hospitalist and director of hospital medicine at Cincinnati Children’s Hospital Medical Center, has been appointed chief medical officer of the Centers for Medicare & Medicaid Services (CMS). Dr. Conway’s key responsibilities will be administering federal healthcare quality initiatives and setting the government’s quality agenda in an era of massive changes resulting from the Patient Protection and Accountable Care Act of 2010 (ACA).

Dr. Conway, who previously served as CMO of the Policy Division of the Office of Secretary of Health and Human Services and was a 2007-2008 White House fellow assigned to the Agency for Healthcare Research and Quality (AHRQ), is a leader in safety, quality, and outcomes initiatives at Cincinnati Children’s, and is the immediate past chair of SHM’s Public Policy Committee. He also served on the Federal Coordinating Council for Comparative Effectiveness Research. In his new job, which he started May 9, he is directing CMS’ Office of Clinical Standards and Quality, which coordinates development and implementation of a CMS-wide approach to promoting health quality.

“Patrick Conway’s appointment represents a major milestone for hospitalists and patients alike,” says Larry Wellikson, MD, SFHM, CEO of SHM. “As hospitalists approach the 15th anniversary of the specialty, it is fitting that one of our own takes on the considerable responsibility of caring for millions of Americans through Medicare and Medicaid. Dr. Conway and thousands of other hospitalists have been on the front lines of systematically improving patient care for more than a decade; his sound judgment and compassion as a clinician are now a major national asset.”

Dr. Conway maintains his associate professorship at the University of Cincinnati and will work some weekends seeing patients at Children’s National Medical Center in Washington, D.C. “I love patient care, so I don’t want to stop doing that. Plus, it helps me connect to the front lines of providing medical care,” he says.

“Dr. Conway’s passion for improving healthcare delivery systems, his day-to-day experience as a hospitalist physician, and his accomplishments in quality-improvement research, such as implementing evidence-based healthcare for all children, provide a strong background for his critical role at CMS as chief medical officer,” says Arnold W. Strauss, MD, chair of pediatrics at the University of Cincinnati, where many of the pediatric physicians at Children’s Hospital hold academic appointments. “Dr. Conway and our colleagues at Cincinnati Children’s have demonstrated that improving patient outcomes at lower cost—the goal of healthcare reform—is feasible.”

Dr. Conway’s role at CMS will include major components of surveys, certification, and accreditation issues for hospitals and other Medicare providers; healthcare information technology; and hospital value-based purchasing initiatives (see “Value-Based Purchasing Raises the Stakes,” The Hospitalist, May 2011, p. 1).

But his initial priorities will focus on quality-measures development, illustrated by CMS’ Hospital Compare website (www.hospitalcompare.hhs.gov), and quality improvement. Another major issue involves care transitions and readmissions, “which I try to frame positively—how can we have the most effective care transitions possible?” he says. “SHM and its publications have done a good job of stressing how hospitals and hospitalists can add value.”

Emphasizing his own experience directing an HM department for a health system that admits 7,000 pediatric patients per year, Dr. Conway says other hospitalists can take a similar lead in embracing quality measurement in their hospitals. “I may be working on quality measures for fiscal years 2013 and 2014, but you already know what will be measured in 2012. Don’t wait until September 2012 to get started,” he explains. “Hospitalists can help their institution pose the question: ‘What do we want to get better at in the next year?’ Then you test. Understand your current performance, set a goal, compare benchmarks with other hospitals, and keep working on improvement.”

Over the course of a year, he adds, quality will improve, and then your HM group will have “something to talk about with hospital administrators.”

Married with two children, says his experience at both the macro and micro levels of healthcare will benefit the overall system. “I actually think if we realign incentives, the system can perform better,” he says. “So I see it as an opportunity to perform a public service. But we also need front-line clinicians, including hospitalists, working to improve our healthcare system. … We need frontline providers that are measuring the quality of their care and improving it.” TH

Larry Beresford is a freelance writer based in California.

Dr. Conway

Patrick Conway, MD, MSc, SFHM, a pediatric hospitalist and director of hospital medicine at Cincinnati Children’s Hospital Medical Center, has been appointed chief medical officer of the Centers for Medicare & Medicaid Services (CMS). Dr. Conway’s key responsibilities will be administering federal healthcare quality initiatives and setting the government’s quality agenda in an era of massive changes resulting from the Patient Protection and Accountable Care Act of 2010 (ACA).

Dr. Conway, who previously served as CMO of the Policy Division of the Office of Secretary of Health and Human Services and was a 2007-2008 White House fellow assigned to the Agency for Healthcare Research and Quality (AHRQ), is a leader in safety, quality, and outcomes initiatives at Cincinnati Children’s, and is the immediate past chair of SHM’s Public Policy Committee. He also served on the Federal Coordinating Council for Comparative Effectiveness Research. In his new job, which he started May 9, he is directing CMS’ Office of Clinical Standards and Quality, which coordinates development and implementation of a CMS-wide approach to promoting health quality.

“Patrick Conway’s appointment represents a major milestone for hospitalists and patients alike,” says Larry Wellikson, MD, SFHM, CEO of SHM. “As hospitalists approach the 15th anniversary of the specialty, it is fitting that one of our own takes on the considerable responsibility of caring for millions of Americans through Medicare and Medicaid. Dr. Conway and thousands of other hospitalists have been on the front lines of systematically improving patient care for more than a decade; his sound judgment and compassion as a clinician are now a major national asset.”

Dr. Conway maintains his associate professorship at the University of Cincinnati and will work some weekends seeing patients at Children’s National Medical Center in Washington, D.C. “I love patient care, so I don’t want to stop doing that. Plus, it helps me connect to the front lines of providing medical care,” he says.

“Dr. Conway’s passion for improving healthcare delivery systems, his day-to-day experience as a hospitalist physician, and his accomplishments in quality-improvement research, such as implementing evidence-based healthcare for all children, provide a strong background for his critical role at CMS as chief medical officer,” says Arnold W. Strauss, MD, chair of pediatrics at the University of Cincinnati, where many of the pediatric physicians at Children’s Hospital hold academic appointments. “Dr. Conway and our colleagues at Cincinnati Children’s have demonstrated that improving patient outcomes at lower cost—the goal of healthcare reform—is feasible.”

Dr. Conway’s role at CMS will include major components of surveys, certification, and accreditation issues for hospitals and other Medicare providers; healthcare information technology; and hospital value-based purchasing initiatives (see “Value-Based Purchasing Raises the Stakes,” The Hospitalist, May 2011, p. 1).

But his initial priorities will focus on quality-measures development, illustrated by CMS’ Hospital Compare website (www.hospitalcompare.hhs.gov), and quality improvement. Another major issue involves care transitions and readmissions, “which I try to frame positively—how can we have the most effective care transitions possible?” he says. “SHM and its publications have done a good job of stressing how hospitals and hospitalists can add value.”

Emphasizing his own experience directing an HM department for a health system that admits 7,000 pediatric patients per year, Dr. Conway says other hospitalists can take a similar lead in embracing quality measurement in their hospitals. “I may be working on quality measures for fiscal years 2013 and 2014, but you already know what will be measured in 2012. Don’t wait until September 2012 to get started,” he explains. “Hospitalists can help their institution pose the question: ‘What do we want to get better at in the next year?’ Then you test. Understand your current performance, set a goal, compare benchmarks with other hospitals, and keep working on improvement.”

Over the course of a year, he adds, quality will improve, and then your HM group will have “something to talk about with hospital administrators.”

Married with two children, says his experience at both the macro and micro levels of healthcare will benefit the overall system. “I actually think if we realign incentives, the system can perform better,” he says. “So I see it as an opportunity to perform a public service. But we also need front-line clinicians, including hospitalists, working to improve our healthcare system. … We need frontline providers that are measuring the quality of their care and improving it.” TH

Larry Beresford is a freelance writer based in California.

I’ve been told by home health agencies that I have to fill out some additional paperwork to get my patients outpatient services. Can you explain to me what these new rules are all about?

Alicia Farrouk, MD

Evansville, Ind.

Dr. Hospitalist responds: In June 2010, the Affordable Care Act changed the rules regarding physician orders for durable medical equipment and for certifying or recertifying the need for home health services. Last November, the Center for Medicare & Medicaid Services (CMS) published the final rules in the Federal Register.

The new law went into effect Jan. 1, and I suspect that is why you have been asked to adjust the way you fill out your paperwork. The upshot of the change in the law is that providers can no longer use the discharge plan or transfer form as evidence of “certification” of need for home health services. The ordering provider, as a condition for payment for services, must document an in-person encounter within the 90 days prior or 30 days after the initiation of home health services. The documentation must detail the clinical findings supporting the need for home health services.

If you are a hospitalist and discharging the patient from the hospital but will not be following the patient as an outpatient, you must document the name of the primary-care physician (PCP) who will follow the patient’s need for home health services and initiate the order and plan of care. The PCP will then sign the home health certification and document that they reviewed your note and plan for home health services and agree with the plan.

If you are a hospitalist working in a teaching hospital, the resident can fill out the form, but it must list your name (as attending physician) and your NPI number. This new rule applies only to home health services and durable medical equipment (things that can be used over and over again for medical purposes, such as crutches, walkers, wheelchairs, etc.) but does not include drugs or supplemental oxygen.

HM Model Spreads to Surgical Specialists

I have a friend who told me there is a neurologist in the hospital where he works who I understand is calling himself a hospitalist. What gives? I thought hospitalists were all internists or family physicians.

Bill Mulley, MD

Flagstaff, Ariz.

Dr. Hospitalist responds: The vast majority of hospitalists in the U.S. are general internists. There are smaller numbers of family physicians, pediatricians, and medical subspecialists who also work as hospitalists. Although this is the face of HM in America, we are seeing other fields of medicine adopting this model of care.

I know of surgical hospitalists, OB-GYN hospitalists, and yes, even neurohospitalists (see “Generation Next,” October 2010, p. 1). It is hard for some people to get their heads around the notion of a surgeon as a hospitalist because when one thinks of a surgeon, you are thinking of a physician who works in the operating room. But the traditional surgeon also has a clinic where they provide pre- and post-operative care.

Herein lies the difference between traditional surgeons and surgical hospitalists: The surgical hospitalist is, for the most part, only doing work in the hospital—sound familiar? (Think traditional internist vs. internist working as hospitalist.) The traditional general surgeon performs scheduled elective surgeries and typically only does emergency surgeries when they are on call for the hospital. As I understand it, the life of a surgical hospitalist is spending a shift in the hospital waiting for a patient to show up needing emergency surgery.

The hospital CEO today has increasing challenges convincing physicians to take hospital call. Some find themselves paying sizable sums of money for surgeons to take call from home. Some have decided their money is better spent paying for surgical hospitalists to spend nights in the hospital waiting for their pager to go off.

From a patient’s perspective, this seems to be a no-brainer. Having a surgeon in the hospital increases their chances of more timely care. You have to believe the providers in the ED and the medical hospitalist also love having a surgeon in-house, available to provide consults when requested.

I am a bit surprised that we don’t already have a large number of surgical hospitalists in the country. Then again, I have no idea of how many surgeons are working as surgical hospitalists. I am not sure anybody knows that answer.

There is a belief that we are going to see the continued growth of “specialty hospitalists” in the U.S. I believe we are going to see neurohospitalists managing inpatients with stroke and other neurosurgical issues, working side by side with medical hospitalists. I share in the excitement that was pervasive in the early days of the hospitalist movement, even though I’m not sure what we are going to see next.

I never imagined that we would have more than 30,000 hospitalists, as we do today. But while the HM model can help improve care, I will always feel strongly that no system will improve care without the dedication of motivated and compassionate healthcare providers driving the system. TH

I’ve been told by home health agencies that I have to fill out some additional paperwork to get my patients outpatient services. Can you explain to me what these new rules are all about?

Alicia Farrouk, MD

Evansville, Ind.

Dr. Hospitalist responds: In June 2010, the Affordable Care Act changed the rules regarding physician orders for durable medical equipment and for certifying or recertifying the need for home health services. Last November, the Center for Medicare & Medicaid Services (CMS) published the final rules in the Federal Register.

The new law went into effect Jan. 1, and I suspect that is why you have been asked to adjust the way you fill out your paperwork. The upshot of the change in the law is that providers can no longer use the discharge plan or transfer form as evidence of “certification” of need for home health services. The ordering provider, as a condition for payment for services, must document an in-person encounter within the 90 days prior or 30 days after the initiation of home health services. The documentation must detail the clinical findings supporting the need for home health services.

If you are a hospitalist and discharging the patient from the hospital but will not be following the patient as an outpatient, you must document the name of the primary-care physician (PCP) who will follow the patient’s need for home health services and initiate the order and plan of care. The PCP will then sign the home health certification and document that they reviewed your note and plan for home health services and agree with the plan.

If you are a hospitalist working in a teaching hospital, the resident can fill out the form, but it must list your name (as attending physician) and your NPI number. This new rule applies only to home health services and durable medical equipment (things that can be used over and over again for medical purposes, such as crutches, walkers, wheelchairs, etc.) but does not include drugs or supplemental oxygen.

HM Model Spreads to Surgical Specialists

I have a friend who told me there is a neurologist in the hospital where he works who I understand is calling himself a hospitalist. What gives? I thought hospitalists were all internists or family physicians.

Bill Mulley, MD

Flagstaff, Ariz.

Dr. Hospitalist responds: The vast majority of hospitalists in the U.S. are general internists. There are smaller numbers of family physicians, pediatricians, and medical subspecialists who also work as hospitalists. Although this is the face of HM in America, we are seeing other fields of medicine adopting this model of care.

I know of surgical hospitalists, OB-GYN hospitalists, and yes, even neurohospitalists (see “Generation Next,” October 2010, p. 1). It is hard for some people to get their heads around the notion of a surgeon as a hospitalist because when one thinks of a surgeon, you are thinking of a physician who works in the operating room. But the traditional surgeon also has a clinic where they provide pre- and post-operative care.

Herein lies the difference between traditional surgeons and surgical hospitalists: The surgical hospitalist is, for the most part, only doing work in the hospital—sound familiar? (Think traditional internist vs. internist working as hospitalist.) The traditional general surgeon performs scheduled elective surgeries and typically only does emergency surgeries when they are on call for the hospital. As I understand it, the life of a surgical hospitalist is spending a shift in the hospital waiting for a patient to show up needing emergency surgery.

The hospital CEO today has increasing challenges convincing physicians to take hospital call. Some find themselves paying sizable sums of money for surgeons to take call from home. Some have decided their money is better spent paying for surgical hospitalists to spend nights in the hospital waiting for their pager to go off.

From a patient’s perspective, this seems to be a no-brainer. Having a surgeon in the hospital increases their chances of more timely care. You have to believe the providers in the ED and the medical hospitalist also love having a surgeon in-house, available to provide consults when requested.

I am a bit surprised that we don’t already have a large number of surgical hospitalists in the country. Then again, I have no idea of how many surgeons are working as surgical hospitalists. I am not sure anybody knows that answer.

There is a belief that we are going to see the continued growth of “specialty hospitalists” in the U.S. I believe we are going to see neurohospitalists managing inpatients with stroke and other neurosurgical issues, working side by side with medical hospitalists. I share in the excitement that was pervasive in the early days of the hospitalist movement, even though I’m not sure what we are going to see next.

I never imagined that we would have more than 30,000 hospitalists, as we do today. But while the HM model can help improve care, I will always feel strongly that no system will improve care without the dedication of motivated and compassionate healthcare providers driving the system. TH

I’ve been told by home health agencies that I have to fill out some additional paperwork to get my patients outpatient services. Can you explain to me what these new rules are all about?

Alicia Farrouk, MD

Evansville, Ind.

Dr. Hospitalist responds: In June 2010, the Affordable Care Act changed the rules regarding physician orders for durable medical equipment and for certifying or recertifying the need for home health services. Last November, the Center for Medicare & Medicaid Services (CMS) published the final rules in the Federal Register.

The new law went into effect Jan. 1, and I suspect that is why you have been asked to adjust the way you fill out your paperwork. The upshot of the change in the law is that providers can no longer use the discharge plan or transfer form as evidence of “certification” of need for home health services. The ordering provider, as a condition for payment for services, must document an in-person encounter within the 90 days prior or 30 days after the initiation of home health services. The documentation must detail the clinical findings supporting the need for home health services.

If you are a hospitalist and discharging the patient from the hospital but will not be following the patient as an outpatient, you must document the name of the primary-care physician (PCP) who will follow the patient’s need for home health services and initiate the order and plan of care. The PCP will then sign the home health certification and document that they reviewed your note and plan for home health services and agree with the plan.

If you are a hospitalist working in a teaching hospital, the resident can fill out the form, but it must list your name (as attending physician) and your NPI number. This new rule applies only to home health services and durable medical equipment (things that can be used over and over again for medical purposes, such as crutches, walkers, wheelchairs, etc.) but does not include drugs or supplemental oxygen.

HM Model Spreads to Surgical Specialists

I have a friend who told me there is a neurologist in the hospital where he works who I understand is calling himself a hospitalist. What gives? I thought hospitalists were all internists or family physicians.

Bill Mulley, MD

Flagstaff, Ariz.

Dr. Hospitalist responds: The vast majority of hospitalists in the U.S. are general internists. There are smaller numbers of family physicians, pediatricians, and medical subspecialists who also work as hospitalists. Although this is the face of HM in America, we are seeing other fields of medicine adopting this model of care.

I know of surgical hospitalists, OB-GYN hospitalists, and yes, even neurohospitalists (see “Generation Next,” October 2010, p. 1). It is hard for some people to get their heads around the notion of a surgeon as a hospitalist because when one thinks of a surgeon, you are thinking of a physician who works in the operating room. But the traditional surgeon also has a clinic where they provide pre- and post-operative care.

Herein lies the difference between traditional surgeons and surgical hospitalists: The surgical hospitalist is, for the most part, only doing work in the hospital—sound familiar? (Think traditional internist vs. internist working as hospitalist.) The traditional general surgeon performs scheduled elective surgeries and typically only does emergency surgeries when they are on call for the hospital. As I understand it, the life of a surgical hospitalist is spending a shift in the hospital waiting for a patient to show up needing emergency surgery.

The hospital CEO today has increasing challenges convincing physicians to take hospital call. Some find themselves paying sizable sums of money for surgeons to take call from home. Some have decided their money is better spent paying for surgical hospitalists to spend nights in the hospital waiting for their pager to go off.

From a patient’s perspective, this seems to be a no-brainer. Having a surgeon in the hospital increases their chances of more timely care. You have to believe the providers in the ED and the medical hospitalist also love having a surgeon in-house, available to provide consults when requested.

I am a bit surprised that we don’t already have a large number of surgical hospitalists in the country. Then again, I have no idea of how many surgeons are working as surgical hospitalists. I am not sure anybody knows that answer.

There is a belief that we are going to see the continued growth of “specialty hospitalists” in the U.S. I believe we are going to see neurohospitalists managing inpatients with stroke and other neurosurgical issues, working side by side with medical hospitalists. I share in the excitement that was pervasive in the early days of the hospitalist movement, even though I’m not sure what we are going to see next.

I never imagined that we would have more than 30,000 hospitalists, as we do today. But while the HM model can help improve care, I will always feel strongly that no system will improve care without the dedication of motivated and compassionate healthcare providers driving the system. TH

Click here to listen to Dr. Kocher

Click here to listen to Dr. Kocher

Click here to listen to Dr. Kocher

A two-time cancer survivor and obstetrician who has delivered thousands of babies, U.S. Sen. Tom Coburn (R-Okla.) has a unique perspective on healthcare as a provider, recipient, and influential advocate for change. Minutes after voting to repeal the Patient Protection and Affordable Care Act of 2010—an effort that ultimately failed in the Democratic-controlled Senate—Dr. Coburn talked with The Hospitalist about his objections to the existing law, his views on the main drivers of upwardly spiraling healthcare costs, and the Republican Party’s alternatives for achieving the elusive goals of better quality and cost control.

Question: What are your main concerns about the healthcare reform law?

Answer: I think, first of all, the healthcare reform bill doesn’t fix the problem, and the question is, what is the problem in healthcare in America? Is it quality, is it outcome, is it access, or is it cost?

If we had no insurance in this country, none whatsoever, and we had no Medicare and people were buying their healthcare, I guarantee the prices would go down drastically, and we’d eliminate this bureaucracy.—U.S. Sen. Tom Coburn, R-Okla.

And the problem is we spend twice as much per capita as anybody else in the world on healthcare to get 30% better outcomes on average. So the problem with healthcare in our country is it costs too much, and there’s a lot of reasons it costs too much. But the number-one reason is that everybody in the country, except those without insurance, thinks somebody else is paying their bill. So there’s no consumer discretionary choices that are made once you’ve met your deductible.

Having practiced for a long period of time and cared for the Amish, they always bought healthcare about 40% to 60% less than everybody else, because they pay cash for it and they deal [with] it, and they ask, “Why am I having this test?” and “Where can I get this test done more cheaply?” and “Are you sure I need this test?”

Being trained in the early 1980s and late ’70s as a physician, we’re trained different than the way doctors are trained today. Doctors today don’t think a thing about utilization. … What this bill did was expand coverage but didn’t fix the system, except that Washington’s now going to tell your hospitalists who they’re going to treat, how they’re going to treat them, and when they’re going to treat them.

Q: How do we fix the right problem?

A: You have to reconnect the purchaser with the payment; that’s No. 1. No. 2 is, you cannot continue to allow people to think somebody else is paying their bill, even when they’re not. If you work for a large company or you work for the government, the fact is, you’re paying money out every year for your portion of the coverage, and your employer is paying it out. They’re paying, in most instances, the vast majority of it, and so once you’ve met a deductible, you’re no longer a discretionary consumer because your assumption is, it’s going to get paid for.

And the other side of this is, how do we put in the doctors’ hands cost consciousness? In other words, can I do this and get the same outcome without spending this money? And quite frankly, we’ve trained a generation-and-a-half of physicians not to think about that.

Q: How else can we reduce costs?

A: It’s amazing what could happen if we start driving toward cost reduction. We have veterans who have to drive … to get to a VA. Give the veteran a card. If you’re service-connected, you can go wherever you want. Why should a veteran only be able to get access at a veterans’ healthcare center where the care isn’t as good, the outcomes aren’t as good, when they can go in their own hometown and buy something that’s better? So, you know, it’s about real freedom of choice and it’s about letting markets allocate scarce resources.

We’ve got a whole host of things that we’ve talked about on how to do this. The [Patients’ Freedom to Choose Act], it saves the states billions in terms of cost.

Q: Do you have any optimism that Congress can work together in a bipartisan way to address some of your concerns with the existing law?

A: No. This isn’t fixable in the way that they have it. To make this fixable, you have to take out the individual mandate, you have to take out the employer mandate, and you have to go to a system of risk reallocation on the insurance industry. If you want to really cover people with pre-existing illnesses, what you have to do is keep the insurance industry from cherry-picking. And what they tried to do is to get everybody covered so you could actually indemnify the whole population.

Our other problem is we’re spending money. You know, if we spent a lot of money on prevention that actually worked, we would in fact save some dollars. But we haven’t created a situation where the insurance industry is interested in keeping you as a long-term insuree, so, therefore, I don’t have any incentive to work on your wellness. Now they’re doing a little bit of that, but they’re not to a great extent. And if you knew you could buy your health insurance over a period of 20 years and be with the same company and they’d actually help teach you, get the things that are going to lower your risk and your cost, they’d both save money.

So there are all sorts of things, but what we’ve done is we’ve abandoned the thing that we use in the rest of the country to allocate scarce resources, and that’s market forces. Ask yourself why the best hospitalists in the country get paid the same as the worst. Well, why wouldn’t we want to incentivize and pay for higher quality and pay less for poorer quality and poorer outcomes, to the point where we promote excellence rather than mediocrity? But we don’t do that.

Q: What’s the next step for Republicans in trying to push forward some of your own ideas?

A: We’re going to take our [Patients’ Freedom to Choose Act] and we’re going to modify it somewhat and we’re going to introduce it and have, you know, “Here’s what we believe. You all believe this, we believe in individual freedom and personal responsibility and accountability,” and we’re going to try to do that. That won’t go anywhere because we don’t have the votes to have it go anywhere. What we’re going to wait for if the court cases. My suspicion is the president loses the court case when it gets to the Supreme Court.

Q: Do you believe the entire act will be struck down or just the individual mandate?

A: No, no. I think the entire act will be struck. The bill doesn’t work without the individual mandate because you don’t get enough revenues in to cover what—and the bill is scored so stupidly anyhow. I don’t know if you know much about government budgeting, but this thing’s a farce in terms of its cost. It’s going to cost fully $600 billion to a trillion dollars more in the first year [2014] than they’re saying it will.

Q: What’s your view on accountable-care organizations?

A: Accountable-care organizations (ACOs) aren’t going to work, and let me tell you why they’re not going to work: because the ACOs are going to be grouped in the large metropolitan areas and you’re going to have less competition rather than more. And so what you’re doing is you’re seeing hospitals buy physician practices, and then they’re going to get into this accountable care, and what they’re going to find is it’s not going to save them any money because you’ve got less competition.

Just go look at Boston; it’s happening right now. Prices aren’t going to go down with ACOs—they’re going to go up because you’re forcing.

What we really need is groups of physicians who say, “We’ll bid outside of the hospital; we’ll bid to make this care available.” In other words, you take 100 cardiologists and say, “Here are our rates to do these things for these people, on average.”

Let the physicians compete outside of being owned by the hospital. If you know anything about hospitals, their bureaucracy is amazing. It looks just like the federal government.

Q: What about bundling payments around episodes of care as a way to try to align incentives?

A: Well, why not let cost and outcome align incentives and let individuals do it? In other words, you’re talking about: “Here’s another system. The American consumer isn’t smart enough to buy their healthcare, so therefore, we have to have somebody else tell us how to do it.” And I would tell you, if we had no insurance in this country, none whatsoever, and we had no Medicare and people were buying their healthcare, I guarantee the prices would go down drastically, and we’d eliminate all this bureaucracy.

So what you’re suggesting is: “Here’s all these things that we can do because of the problem,” but that’s fixing the wrong problem. The problem is there’s no market force in play to control or check the cost. We’re just always looking for another gimmick. TH

Bryn Nelson is a freelance medical writer based in Seattle.

A two-time cancer survivor and obstetrician who has delivered thousands of babies, U.S. Sen. Tom Coburn (R-Okla.) has a unique perspective on healthcare as a provider, recipient, and influential advocate for change. Minutes after voting to repeal the Patient Protection and Affordable Care Act of 2010—an effort that ultimately failed in the Democratic-controlled Senate—Dr. Coburn talked with The Hospitalist about his objections to the existing law, his views on the main drivers of upwardly spiraling healthcare costs, and the Republican Party’s alternatives for achieving the elusive goals of better quality and cost control.

Question: What are your main concerns about the healthcare reform law?

Answer: I think, first of all, the healthcare reform bill doesn’t fix the problem, and the question is, what is the problem in healthcare in America? Is it quality, is it outcome, is it access, or is it cost?

If we had no insurance in this country, none whatsoever, and we had no Medicare and people were buying their healthcare, I guarantee the prices would go down drastically, and we’d eliminate this bureaucracy.—U.S. Sen. Tom Coburn, R-Okla.

And the problem is we spend twice as much per capita as anybody else in the world on healthcare to get 30% better outcomes on average. So the problem with healthcare in our country is it costs too much, and there’s a lot of reasons it costs too much. But the number-one reason is that everybody in the country, except those without insurance, thinks somebody else is paying their bill. So there’s no consumer discretionary choices that are made once you’ve met your deductible.

Having practiced for a long period of time and cared for the Amish, they always bought healthcare about 40% to 60% less than everybody else, because they pay cash for it and they deal [with] it, and they ask, “Why am I having this test?” and “Where can I get this test done more cheaply?” and “Are you sure I need this test?”

Being trained in the early 1980s and late ’70s as a physician, we’re trained different than the way doctors are trained today. Doctors today don’t think a thing about utilization. … What this bill did was expand coverage but didn’t fix the system, except that Washington’s now going to tell your hospitalists who they’re going to treat, how they’re going to treat them, and when they’re going to treat them.

Q: How do we fix the right problem?

A: You have to reconnect the purchaser with the payment; that’s No. 1. No. 2 is, you cannot continue to allow people to think somebody else is paying their bill, even when they’re not. If you work for a large company or you work for the government, the fact is, you’re paying money out every year for your portion of the coverage, and your employer is paying it out. They’re paying, in most instances, the vast majority of it, and so once you’ve met a deductible, you’re no longer a discretionary consumer because your assumption is, it’s going to get paid for.

And the other side of this is, how do we put in the doctors’ hands cost consciousness? In other words, can I do this and get the same outcome without spending this money? And quite frankly, we’ve trained a generation-and-a-half of physicians not to think about that.

Q: How else can we reduce costs?

A: It’s amazing what could happen if we start driving toward cost reduction. We have veterans who have to drive … to get to a VA. Give the veteran a card. If you’re service-connected, you can go wherever you want. Why should a veteran only be able to get access at a veterans’ healthcare center where the care isn’t as good, the outcomes aren’t as good, when they can go in their own hometown and buy something that’s better? So, you know, it’s about real freedom of choice and it’s about letting markets allocate scarce resources.

We’ve got a whole host of things that we’ve talked about on how to do this. The [Patients’ Freedom to Choose Act], it saves the states billions in terms of cost.

Q: Do you have any optimism that Congress can work together in a bipartisan way to address some of your concerns with the existing law?

A: No. This isn’t fixable in the way that they have it. To make this fixable, you have to take out the individual mandate, you have to take out the employer mandate, and you have to go to a system of risk reallocation on the insurance industry. If you want to really cover people with pre-existing illnesses, what you have to do is keep the insurance industry from cherry-picking. And what they tried to do is to get everybody covered so you could actually indemnify the whole population.

Our other problem is we’re spending money. You know, if we spent a lot of money on prevention that actually worked, we would in fact save some dollars. But we haven’t created a situation where the insurance industry is interested in keeping you as a long-term insuree, so, therefore, I don’t have any incentive to work on your wellness. Now they’re doing a little bit of that, but they’re not to a great extent. And if you knew you could buy your health insurance over a period of 20 years and be with the same company and they’d actually help teach you, get the things that are going to lower your risk and your cost, they’d both save money.

So there are all sorts of things, but what we’ve done is we’ve abandoned the thing that we use in the rest of the country to allocate scarce resources, and that’s market forces. Ask yourself why the best hospitalists in the country get paid the same as the worst. Well, why wouldn’t we want to incentivize and pay for higher quality and pay less for poorer quality and poorer outcomes, to the point where we promote excellence rather than mediocrity? But we don’t do that.

Q: What’s the next step for Republicans in trying to push forward some of your own ideas?

A: We’re going to take our [Patients’ Freedom to Choose Act] and we’re going to modify it somewhat and we’re going to introduce it and have, you know, “Here’s what we believe. You all believe this, we believe in individual freedom and personal responsibility and accountability,” and we’re going to try to do that. That won’t go anywhere because we don’t have the votes to have it go anywhere. What we’re going to wait for if the court cases. My suspicion is the president loses the court case when it gets to the Supreme Court.

Q: Do you believe the entire act will be struck down or just the individual mandate?

A: No, no. I think the entire act will be struck. The bill doesn’t work without the individual mandate because you don’t get enough revenues in to cover what—and the bill is scored so stupidly anyhow. I don’t know if you know much about government budgeting, but this thing’s a farce in terms of its cost. It’s going to cost fully $600 billion to a trillion dollars more in the first year [2014] than they’re saying it will.

Q: What’s your view on accountable-care organizations?

A: Accountable-care organizations (ACOs) aren’t going to work, and let me tell you why they’re not going to work: because the ACOs are going to be grouped in the large metropolitan areas and you’re going to have less competition rather than more. And so what you’re doing is you’re seeing hospitals buy physician practices, and then they’re going to get into this accountable care, and what they’re going to find is it’s not going to save them any money because you’ve got less competition.

Just go look at Boston; it’s happening right now. Prices aren’t going to go down with ACOs—they’re going to go up because you’re forcing.

What we really need is groups of physicians who say, “We’ll bid outside of the hospital; we’ll bid to make this care available.” In other words, you take 100 cardiologists and say, “Here are our rates to do these things for these people, on average.”

Let the physicians compete outside of being owned by the hospital. If you know anything about hospitals, their bureaucracy is amazing. It looks just like the federal government.

Q: What about bundling payments around episodes of care as a way to try to align incentives?

A: Well, why not let cost and outcome align incentives and let individuals do it? In other words, you’re talking about: “Here’s another system. The American consumer isn’t smart enough to buy their healthcare, so therefore, we have to have somebody else tell us how to do it.” And I would tell you, if we had no insurance in this country, none whatsoever, and we had no Medicare and people were buying their healthcare, I guarantee the prices would go down drastically, and we’d eliminate all this bureaucracy.

So what you’re suggesting is: “Here’s all these things that we can do because of the problem,” but that’s fixing the wrong problem. The problem is there’s no market force in play to control or check the cost. We’re just always looking for another gimmick. TH

Bryn Nelson is a freelance medical writer based in Seattle.

A two-time cancer survivor and obstetrician who has delivered thousands of babies, U.S. Sen. Tom Coburn (R-Okla.) has a unique perspective on healthcare as a provider, recipient, and influential advocate for change. Minutes after voting to repeal the Patient Protection and Affordable Care Act of 2010—an effort that ultimately failed in the Democratic-controlled Senate—Dr. Coburn talked with The Hospitalist about his objections to the existing law, his views on the main drivers of upwardly spiraling healthcare costs, and the Republican Party’s alternatives for achieving the elusive goals of better quality and cost control.

Question: What are your main concerns about the healthcare reform law?

Answer: I think, first of all, the healthcare reform bill doesn’t fix the problem, and the question is, what is the problem in healthcare in America? Is it quality, is it outcome, is it access, or is it cost?

If we had no insurance in this country, none whatsoever, and we had no Medicare and people were buying their healthcare, I guarantee the prices would go down drastically, and we’d eliminate this bureaucracy.—U.S. Sen. Tom Coburn, R-Okla.

And the problem is we spend twice as much per capita as anybody else in the world on healthcare to get 30% better outcomes on average. So the problem with healthcare in our country is it costs too much, and there’s a lot of reasons it costs too much. But the number-one reason is that everybody in the country, except those without insurance, thinks somebody else is paying their bill. So there’s no consumer discretionary choices that are made once you’ve met your deductible.

Having practiced for a long period of time and cared for the Amish, they always bought healthcare about 40% to 60% less than everybody else, because they pay cash for it and they deal [with] it, and they ask, “Why am I having this test?” and “Where can I get this test done more cheaply?” and “Are you sure I need this test?”

Being trained in the early 1980s and late ’70s as a physician, we’re trained different than the way doctors are trained today. Doctors today don’t think a thing about utilization. … What this bill did was expand coverage but didn’t fix the system, except that Washington’s now going to tell your hospitalists who they’re going to treat, how they’re going to treat them, and when they’re going to treat them.

Q: How do we fix the right problem?

A: You have to reconnect the purchaser with the payment; that’s No. 1. No. 2 is, you cannot continue to allow people to think somebody else is paying their bill, even when they’re not. If you work for a large company or you work for the government, the fact is, you’re paying money out every year for your portion of the coverage, and your employer is paying it out. They’re paying, in most instances, the vast majority of it, and so once you’ve met a deductible, you’re no longer a discretionary consumer because your assumption is, it’s going to get paid for.

And the other side of this is, how do we put in the doctors’ hands cost consciousness? In other words, can I do this and get the same outcome without spending this money? And quite frankly, we’ve trained a generation-and-a-half of physicians not to think about that.

Q: How else can we reduce costs?

A: It’s amazing what could happen if we start driving toward cost reduction. We have veterans who have to drive … to get to a VA. Give the veteran a card. If you’re service-connected, you can go wherever you want. Why should a veteran only be able to get access at a veterans’ healthcare center where the care isn’t as good, the outcomes aren’t as good, when they can go in their own hometown and buy something that’s better? So, you know, it’s about real freedom of choice and it’s about letting markets allocate scarce resources.

We’ve got a whole host of things that we’ve talked about on how to do this. The [Patients’ Freedom to Choose Act], it saves the states billions in terms of cost.

Q: Do you have any optimism that Congress can work together in a bipartisan way to address some of your concerns with the existing law?

A: No. This isn’t fixable in the way that they have it. To make this fixable, you have to take out the individual mandate, you have to take out the employer mandate, and you have to go to a system of risk reallocation on the insurance industry. If you want to really cover people with pre-existing illnesses, what you have to do is keep the insurance industry from cherry-picking. And what they tried to do is to get everybody covered so you could actually indemnify the whole population.

Our other problem is we’re spending money. You know, if we spent a lot of money on prevention that actually worked, we would in fact save some dollars. But we haven’t created a situation where the insurance industry is interested in keeping you as a long-term insuree, so, therefore, I don’t have any incentive to work on your wellness. Now they’re doing a little bit of that, but they’re not to a great extent. And if you knew you could buy your health insurance over a period of 20 years and be with the same company and they’d actually help teach you, get the things that are going to lower your risk and your cost, they’d both save money.

So there are all sorts of things, but what we’ve done is we’ve abandoned the thing that we use in the rest of the country to allocate scarce resources, and that’s market forces. Ask yourself why the best hospitalists in the country get paid the same as the worst. Well, why wouldn’t we want to incentivize and pay for higher quality and pay less for poorer quality and poorer outcomes, to the point where we promote excellence rather than mediocrity? But we don’t do that.

Q: What’s the next step for Republicans in trying to push forward some of your own ideas?

A: We’re going to take our [Patients’ Freedom to Choose Act] and we’re going to modify it somewhat and we’re going to introduce it and have, you know, “Here’s what we believe. You all believe this, we believe in individual freedom and personal responsibility and accountability,” and we’re going to try to do that. That won’t go anywhere because we don’t have the votes to have it go anywhere. What we’re going to wait for if the court cases. My suspicion is the president loses the court case when it gets to the Supreme Court.

Q: Do you believe the entire act will be struck down or just the individual mandate?

A: No, no. I think the entire act will be struck. The bill doesn’t work without the individual mandate because you don’t get enough revenues in to cover what—and the bill is scored so stupidly anyhow. I don’t know if you know much about government budgeting, but this thing’s a farce in terms of its cost. It’s going to cost fully $600 billion to a trillion dollars more in the first year [2014] than they’re saying it will.

Q: What’s your view on accountable-care organizations?

A: Accountable-care organizations (ACOs) aren’t going to work, and let me tell you why they’re not going to work: because the ACOs are going to be grouped in the large metropolitan areas and you’re going to have less competition rather than more. And so what you’re doing is you’re seeing hospitals buy physician practices, and then they’re going to get into this accountable care, and what they’re going to find is it’s not going to save them any money because you’ve got less competition.

Just go look at Boston; it’s happening right now. Prices aren’t going to go down with ACOs—they’re going to go up because you’re forcing.

What we really need is groups of physicians who say, “We’ll bid outside of the hospital; we’ll bid to make this care available.” In other words, you take 100 cardiologists and say, “Here are our rates to do these things for these people, on average.”

Let the physicians compete outside of being owned by the hospital. If you know anything about hospitals, their bureaucracy is amazing. It looks just like the federal government.

Q: What about bundling payments around episodes of care as a way to try to align incentives?

A: Well, why not let cost and outcome align incentives and let individuals do it? In other words, you’re talking about: “Here’s another system. The American consumer isn’t smart enough to buy their healthcare, so therefore, we have to have somebody else tell us how to do it.” And I would tell you, if we had no insurance in this country, none whatsoever, and we had no Medicare and people were buying their healthcare, I guarantee the prices would go down drastically, and we’d eliminate all this bureaucracy.

So what you’re suggesting is: “Here’s all these things that we can do because of the problem,” but that’s fixing the wrong problem. The problem is there’s no market force in play to control or check the cost. We’re just always looking for another gimmick. TH

Bryn Nelson is a freelance medical writer based in Seattle.

As America’s love-hate relationship with healthcare reform approaches its first anniversary, the law is proving just as divisive now as it was during the midterm elections. Fittingly, the Patient Protection and Affordable Care Act of 2010 (ACA), which has polarized the country, is moving forward along three separate tracks.

“Usually, at this point of the game one would only be worrying about the implementation,” says Leighton Ku, a health-policy analyst at George Washington University. “But, obviously, there’s been enough discord that the political route and the legal route are now equally important.”

Here’s a look at where the ACA stands from practical, political, and legal standpoints, along with the major players involved in the ongoing tussle.

The Battle of Public Perception

America is hopelessly divided. Despite pollsters’ best efforts to break the stalemate, the collective numbers still suggest that roughly equal numbers of respondents favor and oppose healthcare reform (with a slight advantage to opponents). It’s a trend line that has barely budged since the bill’s enactment last March.

In January, the Republican-led House of Representatives voted to repeal the entire reform act in what analysts have called a largely symbolic gesture, given that the repeal effort subsequently failed in the Democratic-controlled Senate. Even so, Ku says, the vote fulfills a Republican campaign promise and sends a strong signal to the party’s political base. “What’s driving the Republicans is that their constituencies really don’t like it,” agrees Robert J. Blendon, a professor of health policy and political analysis at the Harvard School of Public Health. “Almost all Republican congressmen who ran had on their website, ‘I will repeal this bill if elected.’ ”

But opposition doesn’t necessarily mean voters want everything repealed, a caveat also borne out by recent polling. “Where the public stands is a little more ambiguous than what the campaign rhetoric is,” Ku says. That ambiguity could present an opportunity for both parties to reframe the debate in the coming months in an effort to win over a clear majority of the public. With the economy of paramount concern, Republicans have cast healthcare reform as a “job-destroying” act that will speed the country’s descent into bankruptcy.

If the economy improves, however, opposition to the law is likely to soften. And with their “no” vote behind them, Republicans in the House will be expected to craft a coherent alternative to the legislation. “Now comes the tough part,” Ku says.

Democrats, meanwhile, have largely regrouped and are being more vocal about the law’s necessity—after a campaign season in which many conservative Democrats largely avoided talking about it, or even touted their opposition to it, and were beaten anyway.

In the absence of wholesale repeal, a few individual provisions might be stripped away. Most key elements cannot be defunded, although Republicans could cut funding streams to Health and Human Services (HHS) or the IRS to hamper implementation. Congress also could choose not to appropriate money to the estimated $106 billion worth of new spending authorizations. A sizable percentage of that pool covers popular pre-existing programs, however, which makes a “no” vote politically more risky.

A Matter of Time

The nonpartisan Congressional Budget Office has predicted that repealing the healthcare reform legislation would increase the federal deficit by $230 billion over the next decade. Even so, the law’s supporters are finding little traction among voters who have heard repeated claims by Republicans that the act itself will push the country deeper into debt (many Republicans say the CBO estimate is based on faulty numbers provided by the law’s supporters). One big reason why: The tanking economy has eroded public trust in the government. “The ratings of trust in the federal government are so low,” Blendon says, “you need a stethoscope to try to hear them.”

And then there’s the matter of time. Because the act’s biggest provisions don’t go into effect until 2014, there are no made-for-media moments—like the large numbers of previously uninsured receiving health insurance cards—to counter the dire predictions that patients will lose their doctors. Instead, the White House has tried to make the most of smaller provisions now in effect, such as one that allows children to stay on a parent’s insurance until their 26th birthday, another that lifts the lifetime caps on insurance coverage, and a third that bans insurers from dropping children with pre-existing conditions (a video explaining what the ACA does and doesn’t do, produced by the Kaiser Family Foundation, is available at http://healthreform.kff.org/The Animation.aspx).

In mid-January, on the eve of the House vote to repeal the entire act, the White House released an HHS study to bolster its contention that the law will eventually aid tens of millions, and, conversely, that any repeal would harm them (www.healthcare.gov/center/reports/preexisting.html). The study estimates that 50 million to 129 million Americans under the age of 65 have pre-existing conditions that would, theoretically, make it harder for them to buy insurance in the absence of regulations requiring coverage. But the study also reports that up to 82 million of these people already have employer-provided insurance, meaning they wouldn’t be affected either way unless they switch jobs or become unemployed.

The White House’s case has been made harder by the confluence of a poor economy, growing concern over the deficit, and the ongoing battle over whether and how to fix the Medicare reimbursement rate paid to doctors, according to Blendon. When the rate paid to doctors temporarily nosedived last June, stories about doctors refusing to see Medicare beneficiaries proliferated among alarmed seniors (Congress eventually passed another short-term patch). The memory of that lack of medical access is now being conflated with the potential side effects of the new law by the constituency most likely to vote (seniors) and most skeptical in general about healthcare reform.

Legal Limbo

More than half the states have now joined lawsuits challenging the ACA’s constitutionality. In the first of what observers expect to be a multitude of legal decisions, federal judges in two cases upheld the law, and the individual mandate requiring people to buy health insurance was ruled unconstitutional in a third.

Ultimately, most experts believe the Supreme Court will have the final say, likely before the 2012 elections. Ku says analysts already are talking about a possible 5-4 decision, with Justice Anthony Kennedy as the potential swing vote—though so far, he’s given no clear hints about which way he may be leaning. Even if the individual mandate component is struck down, Ku says, the court could uphold everything else, changing its overall impact but not the implementation of most provisions. TH

Bryn Nelson is a freelance medical writer based in Seattle.

Key Players in the Healthcare Debate

Rep. Boehner

John Boehner (R-Ohio), the new Speaker of the House, is the public face of many Republican talking points on healthcare reform and the leader in trying to maintain a unified front against the existing law.

Paul Ryan (R-Wis.), chairman of the House Budget Committee and a senior member of the Ways and Means Committee, delivered the GOP response to President Obama’s State of the Union address. He will help the party craft a coherent ACA alternative.

Many conservative “Blue Dog” Democrats either actively opposed the law or stayed silent about it—and got routed in November anyway. Most remaining Blue Dogs have since rejoined the party in highlighting the ACA’s benefits. If Republicans pass an alternative measure, it would need to attract some Democratic support to be seen as bipartisan.

Sen. Reid

Although Sen. Majority Leader Harry Reid (D-Nev.) is opposing any attempt to bring up a vote on repealing the law, Minority Leader Mitch McConnell (R-Ky.) has kept the pressure on, vowing to find a way to force a vote on repealing what he told Fox News Sunday was “the single worst piece of legislation passed in my time in the Senate.” Obama was criticized by other Democrats for not being more vocal about healthcare reform’s benefits in the leadup to the November elections. The repeal effort gives him another chance to make his case.

Sebelius

HHS Secretary Kathleen Sebelius likely will testify repeatedly in hearings called by the Republican leadership to scrutinize how the law is being implemented.

Supreme Court Justice Anthony Kennedy, appointed by President Reagan, is expected to be the swing vote in a closely divided court. The issue: whether an individual mandate requiring people to buy insurance is constitutional. So far, he has given little indication as to how he might rule.

—BN

As America’s love-hate relationship with healthcare reform approaches its first anniversary, the law is proving just as divisive now as it was during the midterm elections. Fittingly, the Patient Protection and Affordable Care Act of 2010 (ACA), which has polarized the country, is moving forward along three separate tracks.

“Usually, at this point of the game one would only be worrying about the implementation,” says Leighton Ku, a health-policy analyst at George Washington University. “But, obviously, there’s been enough discord that the political route and the legal route are now equally important.”

Here’s a look at where the ACA stands from practical, political, and legal standpoints, along with the major players involved in the ongoing tussle.

The Battle of Public Perception

America is hopelessly divided. Despite pollsters’ best efforts to break the stalemate, the collective numbers still suggest that roughly equal numbers of respondents favor and oppose healthcare reform (with a slight advantage to opponents). It’s a trend line that has barely budged since the bill’s enactment last March.

In January, the Republican-led House of Representatives voted to repeal the entire reform act in what analysts have called a largely symbolic gesture, given that the repeal effort subsequently failed in the Democratic-controlled Senate. Even so, Ku says, the vote fulfills a Republican campaign promise and sends a strong signal to the party’s political base. “What’s driving the Republicans is that their constituencies really don’t like it,” agrees Robert J. Blendon, a professor of health policy and political analysis at the Harvard School of Public Health. “Almost all Republican congressmen who ran had on their website, ‘I will repeal this bill if elected.’ ”

But opposition doesn’t necessarily mean voters want everything repealed, a caveat also borne out by recent polling. “Where the public stands is a little more ambiguous than what the campaign rhetoric is,” Ku says. That ambiguity could present an opportunity for both parties to reframe the debate in the coming months in an effort to win over a clear majority of the public. With the economy of paramount concern, Republicans have cast healthcare reform as a “job-destroying” act that will speed the country’s descent into bankruptcy.

If the economy improves, however, opposition to the law is likely to soften. And with their “no” vote behind them, Republicans in the House will be expected to craft a coherent alternative to the legislation. “Now comes the tough part,” Ku says.

Democrats, meanwhile, have largely regrouped and are being more vocal about the law’s necessity—after a campaign season in which many conservative Democrats largely avoided talking about it, or even touted their opposition to it, and were beaten anyway.

In the absence of wholesale repeal, a few individual provisions might be stripped away. Most key elements cannot be defunded, although Republicans could cut funding streams to Health and Human Services (HHS) or the IRS to hamper implementation. Congress also could choose not to appropriate money to the estimated $106 billion worth of new spending authorizations. A sizable percentage of that pool covers popular pre-existing programs, however, which makes a “no” vote politically more risky.

A Matter of Time

The nonpartisan Congressional Budget Office has predicted that repealing the healthcare reform legislation would increase the federal deficit by $230 billion over the next decade. Even so, the law’s supporters are finding little traction among voters who have heard repeated claims by Republicans that the act itself will push the country deeper into debt (many Republicans say the CBO estimate is based on faulty numbers provided by the law’s supporters). One big reason why: The tanking economy has eroded public trust in the government. “The ratings of trust in the federal government are so low,” Blendon says, “you need a stethoscope to try to hear them.”

And then there’s the matter of time. Because the act’s biggest provisions don’t go into effect until 2014, there are no made-for-media moments—like the large numbers of previously uninsured receiving health insurance cards—to counter the dire predictions that patients will lose their doctors. Instead, the White House has tried to make the most of smaller provisions now in effect, such as one that allows children to stay on a parent’s insurance until their 26th birthday, another that lifts the lifetime caps on insurance coverage, and a third that bans insurers from dropping children with pre-existing conditions (a video explaining what the ACA does and doesn’t do, produced by the Kaiser Family Foundation, is available at http://healthreform.kff.org/The Animation.aspx).

In mid-January, on the eve of the House vote to repeal the entire act, the White House released an HHS study to bolster its contention that the law will eventually aid tens of millions, and, conversely, that any repeal would harm them (www.healthcare.gov/center/reports/preexisting.html). The study estimates that 50 million to 129 million Americans under the age of 65 have pre-existing conditions that would, theoretically, make it harder for them to buy insurance in the absence of regulations requiring coverage. But the study also reports that up to 82 million of these people already have employer-provided insurance, meaning they wouldn’t be affected either way unless they switch jobs or become unemployed.

The White House’s case has been made harder by the confluence of a poor economy, growing concern over the deficit, and the ongoing battle over whether and how to fix the Medicare reimbursement rate paid to doctors, according to Blendon. When the rate paid to doctors temporarily nosedived last June, stories about doctors refusing to see Medicare beneficiaries proliferated among alarmed seniors (Congress eventually passed another short-term patch). The memory of that lack of medical access is now being conflated with the potential side effects of the new law by the constituency most likely to vote (seniors) and most skeptical in general about healthcare reform.

Legal Limbo

More than half the states have now joined lawsuits challenging the ACA’s constitutionality. In the first of what observers expect to be a multitude of legal decisions, federal judges in two cases upheld the law, and the individual mandate requiring people to buy health insurance was ruled unconstitutional in a third.

Ultimately, most experts believe the Supreme Court will have the final say, likely before the 2012 elections. Ku says analysts already are talking about a possible 5-4 decision, with Justice Anthony Kennedy as the potential swing vote—though so far, he’s given no clear hints about which way he may be leaning. Even if the individual mandate component is struck down, Ku says, the court could uphold everything else, changing its overall impact but not the implementation of most provisions. TH

Bryn Nelson is a freelance medical writer based in Seattle.

Key Players in the Healthcare Debate

Rep. Boehner

John Boehner (R-Ohio), the new Speaker of the House, is the public face of many Republican talking points on healthcare reform and the leader in trying to maintain a unified front against the existing law.

Paul Ryan (R-Wis.), chairman of the House Budget Committee and a senior member of the Ways and Means Committee, delivered the GOP response to President Obama’s State of the Union address. He will help the party craft a coherent ACA alternative.

Many conservative “Blue Dog” Democrats either actively opposed the law or stayed silent about it—and got routed in November anyway. Most remaining Blue Dogs have since rejoined the party in highlighting the ACA’s benefits. If Republicans pass an alternative measure, it would need to attract some Democratic support to be seen as bipartisan.

Sen. Reid

Although Sen. Majority Leader Harry Reid (D-Nev.) is opposing any attempt to bring up a vote on repealing the law, Minority Leader Mitch McConnell (R-Ky.) has kept the pressure on, vowing to find a way to force a vote on repealing what he told Fox News Sunday was “the single worst piece of legislation passed in my time in the Senate.” Obama was criticized by other Democrats for not being more vocal about healthcare reform’s benefits in the leadup to the November elections. The repeal effort gives him another chance to make his case.

Sebelius

HHS Secretary Kathleen Sebelius likely will testify repeatedly in hearings called by the Republican leadership to scrutinize how the law is being implemented.

Supreme Court Justice Anthony Kennedy, appointed by President Reagan, is expected to be the swing vote in a closely divided court. The issue: whether an individual mandate requiring people to buy insurance is constitutional. So far, he has given little indication as to how he might rule.

—BN

As America’s love-hate relationship with healthcare reform approaches its first anniversary, the law is proving just as divisive now as it was during the midterm elections. Fittingly, the Patient Protection and Affordable Care Act of 2010 (ACA), which has polarized the country, is moving forward along three separate tracks.

“Usually, at this point of the game one would only be worrying about the implementation,” says Leighton Ku, a health-policy analyst at George Washington University. “But, obviously, there’s been enough discord that the political route and the legal route are now equally important.”

Here’s a look at where the ACA stands from practical, political, and legal standpoints, along with the major players involved in the ongoing tussle.

The Battle of Public Perception

America is hopelessly divided. Despite pollsters’ best efforts to break the stalemate, the collective numbers still suggest that roughly equal numbers of respondents favor and oppose healthcare reform (with a slight advantage to opponents). It’s a trend line that has barely budged since the bill’s enactment last March.

In January, the Republican-led House of Representatives voted to repeal the entire reform act in what analysts have called a largely symbolic gesture, given that the repeal effort subsequently failed in the Democratic-controlled Senate. Even so, Ku says, the vote fulfills a Republican campaign promise and sends a strong signal to the party’s political base. “What’s driving the Republicans is that their constituencies really don’t like it,” agrees Robert J. Blendon, a professor of health policy and political analysis at the Harvard School of Public Health. “Almost all Republican congressmen who ran had on their website, ‘I will repeal this bill if elected.’ ”

But opposition doesn’t necessarily mean voters want everything repealed, a caveat also borne out by recent polling. “Where the public stands is a little more ambiguous than what the campaign rhetoric is,” Ku says. That ambiguity could present an opportunity for both parties to reframe the debate in the coming months in an effort to win over a clear majority of the public. With the economy of paramount concern, Republicans have cast healthcare reform as a “job-destroying” act that will speed the country’s descent into bankruptcy.

If the economy improves, however, opposition to the law is likely to soften. And with their “no” vote behind them, Republicans in the House will be expected to craft a coherent alternative to the legislation. “Now comes the tough part,” Ku says.

Democrats, meanwhile, have largely regrouped and are being more vocal about the law’s necessity—after a campaign season in which many conservative Democrats largely avoided talking about it, or even touted their opposition to it, and were beaten anyway.

In the absence of wholesale repeal, a few individual provisions might be stripped away. Most key elements cannot be defunded, although Republicans could cut funding streams to Health and Human Services (HHS) or the IRS to hamper implementation. Congress also could choose not to appropriate money to the estimated $106 billion worth of new spending authorizations. A sizable percentage of that pool covers popular pre-existing programs, however, which makes a “no” vote politically more risky.

A Matter of Time

The nonpartisan Congressional Budget Office has predicted that repealing the healthcare reform legislation would increase the federal deficit by $230 billion over the next decade. Even so, the law’s supporters are finding little traction among voters who have heard repeated claims by Republicans that the act itself will push the country deeper into debt (many Republicans say the CBO estimate is based on faulty numbers provided by the law’s supporters). One big reason why: The tanking economy has eroded public trust in the government. “The ratings of trust in the federal government are so low,” Blendon says, “you need a stethoscope to try to hear them.”

And then there’s the matter of time. Because the act’s biggest provisions don’t go into effect until 2014, there are no made-for-media moments—like the large numbers of previously uninsured receiving health insurance cards—to counter the dire predictions that patients will lose their doctors. Instead, the White House has tried to make the most of smaller provisions now in effect, such as one that allows children to stay on a parent’s insurance until their 26th birthday, another that lifts the lifetime caps on insurance coverage, and a third that bans insurers from dropping children with pre-existing conditions (a video explaining what the ACA does and doesn’t do, produced by the Kaiser Family Foundation, is available at http://healthreform.kff.org/The Animation.aspx).

In mid-January, on the eve of the House vote to repeal the entire act, the White House released an HHS study to bolster its contention that the law will eventually aid tens of millions, and, conversely, that any repeal would harm them (www.healthcare.gov/center/reports/preexisting.html). The study estimates that 50 million to 129 million Americans under the age of 65 have pre-existing conditions that would, theoretically, make it harder for them to buy insurance in the absence of regulations requiring coverage. But the study also reports that up to 82 million of these people already have employer-provided insurance, meaning they wouldn’t be affected either way unless they switch jobs or become unemployed.

The White House’s case has been made harder by the confluence of a poor economy, growing concern over the deficit, and the ongoing battle over whether and how to fix the Medicare reimbursement rate paid to doctors, according to Blendon. When the rate paid to doctors temporarily nosedived last June, stories about doctors refusing to see Medicare beneficiaries proliferated among alarmed seniors (Congress eventually passed another short-term patch). The memory of that lack of medical access is now being conflated with the potential side effects of the new law by the constituency most likely to vote (seniors) and most skeptical in general about healthcare reform.

Legal Limbo

More than half the states have now joined lawsuits challenging the ACA’s constitutionality. In the first of what observers expect to be a multitude of legal decisions, federal judges in two cases upheld the law, and the individual mandate requiring people to buy health insurance was ruled unconstitutional in a third.

Ultimately, most experts believe the Supreme Court will have the final say, likely before the 2012 elections. Ku says analysts already are talking about a possible 5-4 decision, with Justice Anthony Kennedy as the potential swing vote—though so far, he’s given no clear hints about which way he may be leaning. Even if the individual mandate component is struck down, Ku says, the court could uphold everything else, changing its overall impact but not the implementation of most provisions. TH

Bryn Nelson is a freelance medical writer based in Seattle.

Key Players in the Healthcare Debate

Rep. Boehner

John Boehner (R-Ohio), the new Speaker of the House, is the public face of many Republican talking points on healthcare reform and the leader in trying to maintain a unified front against the existing law.

Paul Ryan (R-Wis.), chairman of the House Budget Committee and a senior member of the Ways and Means Committee, delivered the GOP response to President Obama’s State of the Union address. He will help the party craft a coherent ACA alternative.

Many conservative “Blue Dog” Democrats either actively opposed the law or stayed silent about it—and got routed in November anyway. Most remaining Blue Dogs have since rejoined the party in highlighting the ACA’s benefits. If Republicans pass an alternative measure, it would need to attract some Democratic support to be seen as bipartisan.

Sen. Reid

Although Sen. Majority Leader Harry Reid (D-Nev.) is opposing any attempt to bring up a vote on repealing the law, Minority Leader Mitch McConnell (R-Ky.) has kept the pressure on, vowing to find a way to force a vote on repealing what he told Fox News Sunday was “the single worst piece of legislation passed in my time in the Senate.” Obama was criticized by other Democrats for not being more vocal about healthcare reform’s benefits in the leadup to the November elections. The repeal effort gives him another chance to make his case.

Sebelius

HHS Secretary Kathleen Sebelius likely will testify repeatedly in hearings called by the Republican leadership to scrutinize how the law is being implemented.

Supreme Court Justice Anthony Kennedy, appointed by President Reagan, is expected to be the swing vote in a closely divided court. The issue: whether an individual mandate requiring people to buy insurance is constitutional. So far, he has given little indication as to how he might rule.

—BN

After the wild ride of 2010, public-policy watchers could be forgiven for fervently hoping that 2011 offers a calmer year on the healthcare front.

Fat chance.

The turbulence could begin immediately, with the seating of the 112th Congress on Jan. 3. “I think the first question that’s on everybody’s mind is, ‘What will the Republican majority in the House do to Obama’s healthcare reform initiative?’ ” says Eric Siegal, MD, SFHM, a member of SHM’s Public Policy Committee (PPC) and a clinical assistant professor of medicine at the University of Wisconsin School of Medicine and Public Health.

For most issues of direct concern to hospitalists, he says, especially those centered on healthcare delivery, “the wheels were in motion” long before the reform bill became law. Dr. Siegal also says most healthcare experts support the substance of accountable care organizations (ACOs), pay for performance, and reforming Medicare in ways that reward quality instead of quantity. “I think that ship is out of the harbor,” he says.

Throughout the year, the PPC will focus on three priorities identified in the Affordable Care Act: hospital value-based purchasing, bundled payments including ACOs, and hospital readmissions and transitions of care.

Debate, Delay, Defund?

There are several ways that Congress can delay or thwart the launch of specific reform initiatives. The first is to hold hearings about reform measures, Dr. Siegal says, “with the hope that they can somehow undermine it by raising questions about either the finances of it or about the implications for average Americans in terms of what kind of healthcare they’re going to get.” Such tactics carry significant risk, however, because highlighting specific aspects of the reform law could actually increase overall public support. “It has the potential to backfire on them,” he says.

“Repeal won’t happen anytime soon,” predicts Pat Conway, MD, chair of the PPC and director of hospital medicine at Cincinnati Children’s Hospital. “However, Congress could gut or significantly reduce funding to multiple programs within the bill, and then if you significantly reduce the funding, this may make it nearly impossible for those programs to be successful.”

Rough estimates suggest that some $150 billion worth of programs over the 10-year life of the healthcare reform act remain unfunded and are at risk. As an example, Dr. Conway cites wording in the bill that authorizes a program to help ease patient transitions in and out of the hospital. “If you reduce that funding to near zero, hospitals and hospitalists may still be successful, but you’ve essentially removed the program to learn how to be successful,” he says.

Bill Vaughan, a senior policy analyst in healthcare with the Washington, D.C.-based organization Consumers Union, says targeted riders could be added to appropriations bills. For instance, one rider could prohibit the Centers for Medicare & Medicaid Services (CMS) from spending any money to help develop government-supported insurance exchanges. Another could prevent the IRS from collecting money to be channeled into the trust fund for the Patient-Centered Outcomes Research Institute and its focus on comparative-effectiveness research. “There’s no end to mischief,” Vaughan says. “There are as many opportunities as the day is long.”

A major confrontation could arrive in March or April, when the U.S. runs into its debt ceiling. A continuing resolution would then be required to continue the appropriations process (and increase the U.S. debt ceiling past its current limit of $14.3 trillion). At that point or soon thereafter, Vaughan says, an opportunity could arise for legislators to say they won’t vote for a critical appropriations bill unless it includes certain spending reductions cited by one of several commissions tasked with recommending ways to reduce the deficit. “That could include hospital cuts, more doctor cuts, significant cost shifting to beneficiaries, higher copays,” he says.

Amid a “firestorm of ideas” on how to further cut Medicare and Medicaid spending, ideas once deemed radical could gain more traction. Some legislators have tossed around the idea of shutting down the government, if need be. “There’s nothing on the radar scope but static and fuzz,” Vaughan says. “It is totally unclear what is going to happen.”

Dearth of Drugs

Another trend generating both uncertainty and headaches in the nation’s hospitals is an unprecedented prescription drug shortage that could last well into the New Year, based on the number of medicines now in scarce supply across the country. In mid-November, for example, the American Society of Clinical Oncology announced “severe and worsening shortages of many critical therapies,” including doxorubicin, leucovorin, etoposide, nitrogen mustard, vincristine, propofol, and morphine.

Valerie Jensen, associate director of the FDA’s drug shortage program, told the Associated Press that her agency was seeing a record number of drug shortfalls in 2010. In mid-November, the FDA’s Current Drug Shortages list (www.fda.gov/Drugs/DrugSafety/DrugShortages/ucm050792.htm) included multiple formulations of 50 different medicines. Why so many? Jensen blamed the scarcity, in part, on the fact that many older drugs are not as profitable as newer ones. Manufacturing issues or delays and increased demand were the two biggest official reasons, though the FDA reported that at least eight formulations had been pulled or held from the market.

Vaughan says he’s heard plenty of buzz about the problem showing up quickly and unexpectedly in hospitals. Drug companies are supposed to give the FDA six months’ notice if they stop producing a drug, he says, but there’s no penalty if they don’t. “It’s amazing the number of people who are starting to worry about it,” he says. TH

Bryn Nelson is a freelance medical writer based in Seattle.

After the wild ride of 2010, public-policy watchers could be forgiven for fervently hoping that 2011 offers a calmer year on the healthcare front.

Fat chance.

The turbulence could begin immediately, with the seating of the 112th Congress on Jan. 3. “I think the first question that’s on everybody’s mind is, ‘What will the Republican majority in the House do to Obama’s healthcare reform initiative?’ ” says Eric Siegal, MD, SFHM, a member of SHM’s Public Policy Committee (PPC) and a clinical assistant professor of medicine at the University of Wisconsin School of Medicine and Public Health.

For most issues of direct concern to hospitalists, he says, especially those centered on healthcare delivery, “the wheels were in motion” long before the reform bill became law. Dr. Siegal also says most healthcare experts support the substance of accountable care organizations (ACOs), pay for performance, and reforming Medicare in ways that reward quality instead of quantity. “I think that ship is out of the harbor,” he says.

Throughout the year, the PPC will focus on three priorities identified in the Affordable Care Act: hospital value-based purchasing, bundled payments including ACOs, and hospital readmissions and transitions of care.

Debate, Delay, Defund?

There are several ways that Congress can delay or thwart the launch of specific reform initiatives. The first is to hold hearings about reform measures, Dr. Siegal says, “with the hope that they can somehow undermine it by raising questions about either the finances of it or about the implications for average Americans in terms of what kind of healthcare they’re going to get.” Such tactics carry significant risk, however, because highlighting specific aspects of the reform law could actually increase overall public support. “It has the potential to backfire on them,” he says.

“Repeal won’t happen anytime soon,” predicts Pat Conway, MD, chair of the PPC and director of hospital medicine at Cincinnati Children’s Hospital. “However, Congress could gut or significantly reduce funding to multiple programs within the bill, and then if you significantly reduce the funding, this may make it nearly impossible for those programs to be successful.”

Rough estimates suggest that some $150 billion worth of programs over the 10-year life of the healthcare reform act remain unfunded and are at risk. As an example, Dr. Conway cites wording in the bill that authorizes a program to help ease patient transitions in and out of the hospital. “If you reduce that funding to near zero, hospitals and hospitalists may still be successful, but you’ve essentially removed the program to learn how to be successful,” he says.

Bill Vaughan, a senior policy analyst in healthcare with the Washington, D.C.-based organization Consumers Union, says targeted riders could be added to appropriations bills. For instance, one rider could prohibit the Centers for Medicare & Medicaid Services (CMS) from spending any money to help develop government-supported insurance exchanges. Another could prevent the IRS from collecting money to be channeled into the trust fund for the Patient-Centered Outcomes Research Institute and its focus on comparative-effectiveness research. “There’s no end to mischief,” Vaughan says. “There are as many opportunities as the day is long.”

A major confrontation could arrive in March or April, when the U.S. runs into its debt ceiling. A continuing resolution would then be required to continue the appropriations process (and increase the U.S. debt ceiling past its current limit of $14.3 trillion). At that point or soon thereafter, Vaughan says, an opportunity could arise for legislators to say they won’t vote for a critical appropriations bill unless it includes certain spending reductions cited by one of several commissions tasked with recommending ways to reduce the deficit. “That could include hospital cuts, more doctor cuts, significant cost shifting to beneficiaries, higher copays,” he says.

Amid a “firestorm of ideas” on how to further cut Medicare and Medicaid spending, ideas once deemed radical could gain more traction. Some legislators have tossed around the idea of shutting down the government, if need be. “There’s nothing on the radar scope but static and fuzz,” Vaughan says. “It is totally unclear what is going to happen.”

Dearth of Drugs

Another trend generating both uncertainty and headaches in the nation’s hospitals is an unprecedented prescription drug shortage that could last well into the New Year, based on the number of medicines now in scarce supply across the country. In mid-November, for example, the American Society of Clinical Oncology announced “severe and worsening shortages of many critical therapies,” including doxorubicin, leucovorin, etoposide, nitrogen mustard, vincristine, propofol, and morphine.

Valerie Jensen, associate director of the FDA’s drug shortage program, told the Associated Press that her agency was seeing a record number of drug shortfalls in 2010. In mid-November, the FDA’s Current Drug Shortages list (www.fda.gov/Drugs/DrugSafety/DrugShortages/ucm050792.htm) included multiple formulations of 50 different medicines. Why so many? Jensen blamed the scarcity, in part, on the fact that many older drugs are not as profitable as newer ones. Manufacturing issues or delays and increased demand were the two biggest official reasons, though the FDA reported that at least eight formulations had been pulled or held from the market.

Vaughan says he’s heard plenty of buzz about the problem showing up quickly and unexpectedly in hospitals. Drug companies are supposed to give the FDA six months’ notice if they stop producing a drug, he says, but there’s no penalty if they don’t. “It’s amazing the number of people who are starting to worry about it,” he says. TH

Bryn Nelson is a freelance medical writer based in Seattle.

After the wild ride of 2010, public-policy watchers could be forgiven for fervently hoping that 2011 offers a calmer year on the healthcare front.

Fat chance.

The turbulence could begin immediately, with the seating of the 112th Congress on Jan. 3. “I think the first question that’s on everybody’s mind is, ‘What will the Republican majority in the House do to Obama’s healthcare reform initiative?’ ” says Eric Siegal, MD, SFHM, a member of SHM’s Public Policy Committee (PPC) and a clinical assistant professor of medicine at the University of Wisconsin School of Medicine and Public Health.

For most issues of direct concern to hospitalists, he says, especially those centered on healthcare delivery, “the wheels were in motion” long before the reform bill became law. Dr. Siegal also says most healthcare experts support the substance of accountable care organizations (ACOs), pay for performance, and reforming Medicare in ways that reward quality instead of quantity. “I think that ship is out of the harbor,” he says.

Throughout the year, the PPC will focus on three priorities identified in the Affordable Care Act: hospital value-based purchasing, bundled payments including ACOs, and hospital readmissions and transitions of care.

Debate, Delay, Defund?

There are several ways that Congress can delay or thwart the launch of specific reform initiatives. The first is to hold hearings about reform measures, Dr. Siegal says, “with the hope that they can somehow undermine it by raising questions about either the finances of it or about the implications for average Americans in terms of what kind of healthcare they’re going to get.” Such tactics carry significant risk, however, because highlighting specific aspects of the reform law could actually increase overall public support. “It has the potential to backfire on them,” he says.

“Repeal won’t happen anytime soon,” predicts Pat Conway, MD, chair of the PPC and director of hospital medicine at Cincinnati Children’s Hospital. “However, Congress could gut or significantly reduce funding to multiple programs within the bill, and then if you significantly reduce the funding, this may make it nearly impossible for those programs to be successful.”

Rough estimates suggest that some $150 billion worth of programs over the 10-year life of the healthcare reform act remain unfunded and are at risk. As an example, Dr. Conway cites wording in the bill that authorizes a program to help ease patient transitions in and out of the hospital. “If you reduce that funding to near zero, hospitals and hospitalists may still be successful, but you’ve essentially removed the program to learn how to be successful,” he says.

Bill Vaughan, a senior policy analyst in healthcare with the Washington, D.C.-based organization Consumers Union, says targeted riders could be added to appropriations bills. For instance, one rider could prohibit the Centers for Medicare & Medicaid Services (CMS) from spending any money to help develop government-supported insurance exchanges. Another could prevent the IRS from collecting money to be channeled into the trust fund for the Patient-Centered Outcomes Research Institute and its focus on comparative-effectiveness research. “There’s no end to mischief,” Vaughan says. “There are as many opportunities as the day is long.”

A major confrontation could arrive in March or April, when the U.S. runs into its debt ceiling. A continuing resolution would then be required to continue the appropriations process (and increase the U.S. debt ceiling past its current limit of $14.3 trillion). At that point or soon thereafter, Vaughan says, an opportunity could arise for legislators to say they won’t vote for a critical appropriations bill unless it includes certain spending reductions cited by one of several commissions tasked with recommending ways to reduce the deficit. “That could include hospital cuts, more doctor cuts, significant cost shifting to beneficiaries, higher copays,” he says.

Amid a “firestorm of ideas” on how to further cut Medicare and Medicaid spending, ideas once deemed radical could gain more traction. Some legislators have tossed around the idea of shutting down the government, if need be. “There’s nothing on the radar scope but static and fuzz,” Vaughan says. “It is totally unclear what is going to happen.”

Dearth of Drugs

Another trend generating both uncertainty and headaches in the nation’s hospitals is an unprecedented prescription drug shortage that could last well into the New Year, based on the number of medicines now in scarce supply across the country. In mid-November, for example, the American Society of Clinical Oncology announced “severe and worsening shortages of many critical therapies,” including doxorubicin, leucovorin, etoposide, nitrogen mustard, vincristine, propofol, and morphine.

Valerie Jensen, associate director of the FDA’s drug shortage program, told the Associated Press that her agency was seeing a record number of drug shortfalls in 2010. In mid-November, the FDA’s Current Drug Shortages list (www.fda.gov/Drugs/DrugSafety/DrugShortages/ucm050792.htm) included multiple formulations of 50 different medicines. Why so many? Jensen blamed the scarcity, in part, on the fact that many older drugs are not as profitable as newer ones. Manufacturing issues or delays and increased demand were the two biggest official reasons, though the FDA reported that at least eight formulations had been pulled or held from the market.

Vaughan says he’s heard plenty of buzz about the problem showing up quickly and unexpectedly in hospitals. Drug companies are supposed to give the FDA six months’ notice if they stop producing a drug, he says, but there’s no penalty if they don’t. “It’s amazing the number of people who are starting to worry about it,” he says. TH

Bryn Nelson is a freelance medical writer based in Seattle.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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