Transitions of Care

Getting involved—and getting ahead—in hospital medicine has never been easier, with just some planning and preparation. Here are three ways to move your hospital—and your career—forward this month.

1. Add “award-winning” to your CV: SHM’s Awards of Excellence deadline is Sept. 16.

Although 2013’s award-winners are still fresh in hospitalists’ minds, now is the time to put together award applications for the 2014 Awards of Excellence.

Each year, SHM presents six different awards that recognize individuals and one award to a team that is transforming health care and revolutionizing patient care for hospitalized patients:

• Excellence in Research Award;
• Excellence in Hospital Medicine for Non-Physicians;
• Award for Excellence in Teaching;
• Award for Outstanding Service in Hospital Medicine;
• Award for Clinical Excellence; and
• Excellence in Teamwork in Quality Improvement.

Last year, SHM received award nominations from a diverse group of hospitalists and looks forward to receiving even more this year. Each winner receives an all-expenses-paid trip to HM14 in Las Vegas, including complimentary meeting registration.

The deadline for applications for SHM’s five individual awards is Sept. 16. The deadline for the Excellence in Teamwork in Quality Improvement is Oct. 15. All SHM members are eligible, and nominees can be self-nominated.

For more information, visit www.hospital medicine.org/awards.

2. Bring the experts in reducing readmissions to your hospital: Apply now for Project BOOST.

There is still time to apply for SHM’s Project BOOST, which helps hospitals design discharge programs to reduce readmissions. SHM will accept applications for Project BOOST until the end of August.

Project BOOST is based on SHM’s award-winning mentored implementation model that brings individualized attention from national experts in reducing readmissions to hospitals across the country. Each Project BOOST site receives:

• A comprehensive intervention developed by a panel of nationally recognized experts based on the best available evidence.
• A comprehensive implementation guide that provides step-by-step instructions and project-management tools, such as the teachback training curriculum, to help interdisciplinary teams redesign workflow and plan, implement, and evaluate the intervention.
• Longitudinal technical assistance providing face-to-face training and a year of expert mentoring and coaching to implement BOOST interventions that build a culture that supports safe and complete transitions. The mentoring program provides a training DVD and curriculum for nurses and case managers on using the teachback process, as well as webinars that target the educational needs of other team members, including administrators, data analysts, physicians, nurses, and others.
• Collaboration that allows sites to communicate with and learn from each other via the BOOST community site and quarterly all-site teleconferences and webinars.
• The BOOST data center, an online resource that allows sites to store and benchmark data against control units and other sites and generates reports.

For more information, visit www.hospital medicine.org/boost.

3. Start Choosing Wisely today.

In 2014, as part of a grant from the ABIM Foundation, SHM will begin its first Choosing Wisely case-study competition to highlight hospitalists’ best practices within the popular campaign.

But in order to have a successful case study next year, some preparation is in order now. Developing goals, gathering a team, and, perhaps most important, developing benchmarking data on a project motivated by Choosing Wisely will all be important parts of a compelling case study.

To start brainstorming your project to implement Choosing Wisely recommendations at your hospital, visit www.hospitalmedicine.org/choosingwisely.

Brendon Shank is SHM’s associate vice president of communications.

Getting involved—and getting ahead—in hospital medicine has never been easier, with just some planning and preparation. Here are three ways to move your hospital—and your career—forward this month.

1. Add “award-winning” to your CV: SHM’s Awards of Excellence deadline is Sept. 16.

Although 2013’s award-winners are still fresh in hospitalists’ minds, now is the time to put together award applications for the 2014 Awards of Excellence.

Each year, SHM presents six different awards that recognize individuals and one award to a team that is transforming health care and revolutionizing patient care for hospitalized patients:

• Excellence in Research Award;
• Excellence in Hospital Medicine for Non-Physicians;
• Award for Excellence in Teaching;
• Award for Outstanding Service in Hospital Medicine;
• Award for Clinical Excellence; and
• Excellence in Teamwork in Quality Improvement.

Last year, SHM received award nominations from a diverse group of hospitalists and looks forward to receiving even more this year. Each winner receives an all-expenses-paid trip to HM14 in Las Vegas, including complimentary meeting registration.

The deadline for applications for SHM’s five individual awards is Sept. 16. The deadline for the Excellence in Teamwork in Quality Improvement is Oct. 15. All SHM members are eligible, and nominees can be self-nominated.

For more information, visit www.hospital medicine.org/awards.

2. Bring the experts in reducing readmissions to your hospital: Apply now for Project BOOST.

There is still time to apply for SHM’s Project BOOST, which helps hospitals design discharge programs to reduce readmissions. SHM will accept applications for Project BOOST until the end of August.

Project BOOST is based on SHM’s award-winning mentored implementation model that brings individualized attention from national experts in reducing readmissions to hospitals across the country. Each Project BOOST site receives:

• A comprehensive intervention developed by a panel of nationally recognized experts based on the best available evidence.
• A comprehensive implementation guide that provides step-by-step instructions and project-management tools, such as the teachback training curriculum, to help interdisciplinary teams redesign workflow and plan, implement, and evaluate the intervention.
• Longitudinal technical assistance providing face-to-face training and a year of expert mentoring and coaching to implement BOOST interventions that build a culture that supports safe and complete transitions. The mentoring program provides a training DVD and curriculum for nurses and case managers on using the teachback process, as well as webinars that target the educational needs of other team members, including administrators, data analysts, physicians, nurses, and others.
• Collaboration that allows sites to communicate with and learn from each other via the BOOST community site and quarterly all-site teleconferences and webinars.
• The BOOST data center, an online resource that allows sites to store and benchmark data against control units and other sites and generates reports.

For more information, visit www.hospital medicine.org/boost.

3. Start Choosing Wisely today.

In 2014, as part of a grant from the ABIM Foundation, SHM will begin its first Choosing Wisely case-study competition to highlight hospitalists’ best practices within the popular campaign.

But in order to have a successful case study next year, some preparation is in order now. Developing goals, gathering a team, and, perhaps most important, developing benchmarking data on a project motivated by Choosing Wisely will all be important parts of a compelling case study.

To start brainstorming your project to implement Choosing Wisely recommendations at your hospital, visit www.hospitalmedicine.org/choosingwisely.

Brendon Shank is SHM’s associate vice president of communications.

Getting involved—and getting ahead—in hospital medicine has never been easier, with just some planning and preparation. Here are three ways to move your hospital—and your career—forward this month.

1. Add “award-winning” to your CV: SHM’s Awards of Excellence deadline is Sept. 16.

Although 2013’s award-winners are still fresh in hospitalists’ minds, now is the time to put together award applications for the 2014 Awards of Excellence.

Each year, SHM presents six different awards that recognize individuals and one award to a team that is transforming health care and revolutionizing patient care for hospitalized patients:

• Excellence in Research Award;
• Excellence in Hospital Medicine for Non-Physicians;
• Award for Excellence in Teaching;
• Award for Outstanding Service in Hospital Medicine;
• Award for Clinical Excellence; and
• Excellence in Teamwork in Quality Improvement.

Last year, SHM received award nominations from a diverse group of hospitalists and looks forward to receiving even more this year. Each winner receives an all-expenses-paid trip to HM14 in Las Vegas, including complimentary meeting registration.

The deadline for applications for SHM’s five individual awards is Sept. 16. The deadline for the Excellence in Teamwork in Quality Improvement is Oct. 15. All SHM members are eligible, and nominees can be self-nominated.

For more information, visit www.hospital medicine.org/awards.

2. Bring the experts in reducing readmissions to your hospital: Apply now for Project BOOST.

There is still time to apply for SHM’s Project BOOST, which helps hospitals design discharge programs to reduce readmissions. SHM will accept applications for Project BOOST until the end of August.

Project BOOST is based on SHM’s award-winning mentored implementation model that brings individualized attention from national experts in reducing readmissions to hospitals across the country. Each Project BOOST site receives:

• A comprehensive intervention developed by a panel of nationally recognized experts based on the best available evidence.
• A comprehensive implementation guide that provides step-by-step instructions and project-management tools, such as the teachback training curriculum, to help interdisciplinary teams redesign workflow and plan, implement, and evaluate the intervention.
• Longitudinal technical assistance providing face-to-face training and a year of expert mentoring and coaching to implement BOOST interventions that build a culture that supports safe and complete transitions. The mentoring program provides a training DVD and curriculum for nurses and case managers on using the teachback process, as well as webinars that target the educational needs of other team members, including administrators, data analysts, physicians, nurses, and others.
• Collaboration that allows sites to communicate with and learn from each other via the BOOST community site and quarterly all-site teleconferences and webinars.
• The BOOST data center, an online resource that allows sites to store and benchmark data against control units and other sites and generates reports.

For more information, visit www.hospital medicine.org/boost.

3. Start Choosing Wisely today.

In 2014, as part of a grant from the ABIM Foundation, SHM will begin its first Choosing Wisely case-study competition to highlight hospitalists’ best practices within the popular campaign.

But in order to have a successful case study next year, some preparation is in order now. Developing goals, gathering a team, and, perhaps most important, developing benchmarking data on a project motivated by Choosing Wisely will all be important parts of a compelling case study.

To start brainstorming your project to implement Choosing Wisely recommendations at your hospital, visit www.hospitalmedicine.org/choosingwisely.

Brendon Shank is SHM’s associate vice president of communications.

With general agreement that health-care costs in the U.S. are unsustainable, the Centers for Medicare & Medicaid Services (CMS), through the Center for Medicare and Medicaid Innovation (CMMI), and the private sector are embarking on new approaches to cost containment. On the one hand, we have value-based purchasing (VBP), which rests on the existing fee-for-service system and aims for incremental change. On the other hand, we have accountable-care organizations (ACOs), which provide a global payment for a population of patients, and bundled-payment programs, which provide a single payment for an episode of care. These reimbursement models represent a fundamental change in how we pay for health care.

On a broad scale, ACOs may be further along in development than bundled-payment programs, even though pockets of bundling prototypes have existed for years. Examples include the Prometheus payment system, Geisinger’s ProvenCare, and CMS’ Acute Care Episode demonstration project, which bundled Part A (hospital) and Part B (doctors, others) payments for cardiac and orthopedic surgery procedures. Over the past two years, we have seen a dramatic uptick in bundling activity, including programs in a number of states (including Arkansas, California, and Massachusetts). Here at Baystate Health in Massachusetts, we kicked off a total-hip-replacement bundle with our subsidiary health plan in January 2011.

Perhaps most notably, bundled payments are part of the Affordable Care Act. The Bundled Payments for Care Improvement initiative, launched earlier this year by CMMI, is enrolling traditional Medicare patients in bundled-payment programs across the country at more than 400 health systems.

How Bundled Payments Work

Bundled-payment programs provide a single payment to hospitals, doctors, post-acute providers, and other providers (for home care, lab, medical equipment, etc.) for a defined episode of care. Most bundles encompass at least an acute hospital episode and physician payments for the episode; many include some period after hospitalization, covering rehabilitation at a facility or at home and doctors’ visits during recovery. Bundling goes beyond Medicare’s diagnosis-related group (DRG) payments, which reimburse hospitals for all elements of an inpatient hospital stay for a given diagnosis but do not include services performed by nonhospital providers.

How do the finances work in a bundled-payment program? A single price for an episode of care is determined based on historical performance, factoring in all the services one wishes to include in a bundle (e.g. hospital, doctor visits in hospital, home physical therapy, follow-up doctor visits, follow up X-ray and labs for a defined time period). If the hospital, doctors, and others in the bundle generate new efficiencies in care (e.g. due to better care coordination, less wasteful test ordering, or lower implant/device costs), the savings are then distributed to these providers. What if spending exceeds the predetermined price? In some instances, the health plan bears the financial risk; in other instances, the hospital, physicians, and other bundle providers must pay back the shortfall. Important to note is that all sharing of savings is contingent on attainment of or improvement in demonstrated quality-of-care measures relevant to the bundle. In the future, bundling will evolve from shared savings to a single prospective payment for a care episode.

For now, most bundles encompass surgical procedures, although CMMI is working with health systems on several medical bundles, including acute MI, COPD, and stroke. All of these bundles are initiated by an acute hospitalization. Other types of bundles exist, such as with chronic conditions or with post-acute care only. In Massachusetts, a pediatric asthma bundle is being implemented through Medicaid, covering that population for a year or longer. The aim is to redirect dollars that normally would pay for ED visits and inpatient care to pay for interventions that promote better control of the disease and prevent acute flare-ups that lead to hospital visits.

How Hospitalists Fit In

To date, there has been little discussion of how physicians other than the surgeons doing the procedure (most bundles are for surgeries) fit into the clinical or financial model underpinning the program. However, with most patients in surgical or medical bundles being discharged to home, we now recognize that primary-care physicians (PCPs) will be essential to the success of a bundle.

Similarly, with medically complex patients enrolling in surgical bundles, hospitalists will be essential to the pre- and perioperative care of these patients. Also, transitioning bundle patients to home or to a rehabilitation will benefit from the involvement of a hospitalist.

What You Can Do Today

Although this might seem abstract for hospitalists practicing in the here and now, there are compelling opportunities for hospitalists who get involved in bundled-payment programs. Here’s what I suggest:

Find out if your hospital or post-acute facility is participating in bundling by looking at a map of CMMI bundle programs here: http://innovation.cms.gov/initiatives/bundled-payments;

• Get a seat at the table working on the bundle; and
• Negotiate a portion of the bundle’s shared savings on the basis of 1) increased efficiency and quality resulting from hospitalist involvement and 2) hospitalist direct oversight of bundled patients in post-acute facilities (if you choose).

Post-acute care may be new for your hospitalist program. Bundling programs are an important new business case for hospitalists in this setting.

Dr. Whitcomb is medical director of healthcare quality at Baystate Medical Center in Springfield, Mass. He is co-founder and past president of SHM. Email him at [email protected].

With general agreement that health-care costs in the U.S. are unsustainable, the Centers for Medicare & Medicaid Services (CMS), through the Center for Medicare and Medicaid Innovation (CMMI), and the private sector are embarking on new approaches to cost containment. On the one hand, we have value-based purchasing (VBP), which rests on the existing fee-for-service system and aims for incremental change. On the other hand, we have accountable-care organizations (ACOs), which provide a global payment for a population of patients, and bundled-payment programs, which provide a single payment for an episode of care. These reimbursement models represent a fundamental change in how we pay for health care.

On a broad scale, ACOs may be further along in development than bundled-payment programs, even though pockets of bundling prototypes have existed for years. Examples include the Prometheus payment system, Geisinger’s ProvenCare, and CMS’ Acute Care Episode demonstration project, which bundled Part A (hospital) and Part B (doctors, others) payments for cardiac and orthopedic surgery procedures. Over the past two years, we have seen a dramatic uptick in bundling activity, including programs in a number of states (including Arkansas, California, and Massachusetts). Here at Baystate Health in Massachusetts, we kicked off a total-hip-replacement bundle with our subsidiary health plan in January 2011.

Perhaps most notably, bundled payments are part of the Affordable Care Act. The Bundled Payments for Care Improvement initiative, launched earlier this year by CMMI, is enrolling traditional Medicare patients in bundled-payment programs across the country at more than 400 health systems.

How Bundled Payments Work

Bundled-payment programs provide a single payment to hospitals, doctors, post-acute providers, and other providers (for home care, lab, medical equipment, etc.) for a defined episode of care. Most bundles encompass at least an acute hospital episode and physician payments for the episode; many include some period after hospitalization, covering rehabilitation at a facility or at home and doctors’ visits during recovery. Bundling goes beyond Medicare’s diagnosis-related group (DRG) payments, which reimburse hospitals for all elements of an inpatient hospital stay for a given diagnosis but do not include services performed by nonhospital providers.

How do the finances work in a bundled-payment program? A single price for an episode of care is determined based on historical performance, factoring in all the services one wishes to include in a bundle (e.g. hospital, doctor visits in hospital, home physical therapy, follow-up doctor visits, follow up X-ray and labs for a defined time period). If the hospital, doctors, and others in the bundle generate new efficiencies in care (e.g. due to better care coordination, less wasteful test ordering, or lower implant/device costs), the savings are then distributed to these providers. What if spending exceeds the predetermined price? In some instances, the health plan bears the financial risk; in other instances, the hospital, physicians, and other bundle providers must pay back the shortfall. Important to note is that all sharing of savings is contingent on attainment of or improvement in demonstrated quality-of-care measures relevant to the bundle. In the future, bundling will evolve from shared savings to a single prospective payment for a care episode.

For now, most bundles encompass surgical procedures, although CMMI is working with health systems on several medical bundles, including acute MI, COPD, and stroke. All of these bundles are initiated by an acute hospitalization. Other types of bundles exist, such as with chronic conditions or with post-acute care only. In Massachusetts, a pediatric asthma bundle is being implemented through Medicaid, covering that population for a year or longer. The aim is to redirect dollars that normally would pay for ED visits and inpatient care to pay for interventions that promote better control of the disease and prevent acute flare-ups that lead to hospital visits.

How Hospitalists Fit In

To date, there has been little discussion of how physicians other than the surgeons doing the procedure (most bundles are for surgeries) fit into the clinical or financial model underpinning the program. However, with most patients in surgical or medical bundles being discharged to home, we now recognize that primary-care physicians (PCPs) will be essential to the success of a bundle.

Similarly, with medically complex patients enrolling in surgical bundles, hospitalists will be essential to the pre- and perioperative care of these patients. Also, transitioning bundle patients to home or to a rehabilitation will benefit from the involvement of a hospitalist.

What You Can Do Today

Although this might seem abstract for hospitalists practicing in the here and now, there are compelling opportunities for hospitalists who get involved in bundled-payment programs. Here’s what I suggest:

Find out if your hospital or post-acute facility is participating in bundling by looking at a map of CMMI bundle programs here: http://innovation.cms.gov/initiatives/bundled-payments;

• Get a seat at the table working on the bundle; and
• Negotiate a portion of the bundle’s shared savings on the basis of 1) increased efficiency and quality resulting from hospitalist involvement and 2) hospitalist direct oversight of bundled patients in post-acute facilities (if you choose).

Post-acute care may be new for your hospitalist program. Bundling programs are an important new business case for hospitalists in this setting.

Dr. Whitcomb is medical director of healthcare quality at Baystate Medical Center in Springfield, Mass. He is co-founder and past president of SHM. Email him at [email protected].

With general agreement that health-care costs in the U.S. are unsustainable, the Centers for Medicare & Medicaid Services (CMS), through the Center for Medicare and Medicaid Innovation (CMMI), and the private sector are embarking on new approaches to cost containment. On the one hand, we have value-based purchasing (VBP), which rests on the existing fee-for-service system and aims for incremental change. On the other hand, we have accountable-care organizations (ACOs), which provide a global payment for a population of patients, and bundled-payment programs, which provide a single payment for an episode of care. These reimbursement models represent a fundamental change in how we pay for health care.

On a broad scale, ACOs may be further along in development than bundled-payment programs, even though pockets of bundling prototypes have existed for years. Examples include the Prometheus payment system, Geisinger’s ProvenCare, and CMS’ Acute Care Episode demonstration project, which bundled Part A (hospital) and Part B (doctors, others) payments for cardiac and orthopedic surgery procedures. Over the past two years, we have seen a dramatic uptick in bundling activity, including programs in a number of states (including Arkansas, California, and Massachusetts). Here at Baystate Health in Massachusetts, we kicked off a total-hip-replacement bundle with our subsidiary health plan in January 2011.

Perhaps most notably, bundled payments are part of the Affordable Care Act. The Bundled Payments for Care Improvement initiative, launched earlier this year by CMMI, is enrolling traditional Medicare patients in bundled-payment programs across the country at more than 400 health systems.

How Bundled Payments Work

Bundled-payment programs provide a single payment to hospitals, doctors, post-acute providers, and other providers (for home care, lab, medical equipment, etc.) for a defined episode of care. Most bundles encompass at least an acute hospital episode and physician payments for the episode; many include some period after hospitalization, covering rehabilitation at a facility or at home and doctors’ visits during recovery. Bundling goes beyond Medicare’s diagnosis-related group (DRG) payments, which reimburse hospitals for all elements of an inpatient hospital stay for a given diagnosis but do not include services performed by nonhospital providers.

How do the finances work in a bundled-payment program? A single price for an episode of care is determined based on historical performance, factoring in all the services one wishes to include in a bundle (e.g. hospital, doctor visits in hospital, home physical therapy, follow-up doctor visits, follow up X-ray and labs for a defined time period). If the hospital, doctors, and others in the bundle generate new efficiencies in care (e.g. due to better care coordination, less wasteful test ordering, or lower implant/device costs), the savings are then distributed to these providers. What if spending exceeds the predetermined price? In some instances, the health plan bears the financial risk; in other instances, the hospital, physicians, and other bundle providers must pay back the shortfall. Important to note is that all sharing of savings is contingent on attainment of or improvement in demonstrated quality-of-care measures relevant to the bundle. In the future, bundling will evolve from shared savings to a single prospective payment for a care episode.

For now, most bundles encompass surgical procedures, although CMMI is working with health systems on several medical bundles, including acute MI, COPD, and stroke. All of these bundles are initiated by an acute hospitalization. Other types of bundles exist, such as with chronic conditions or with post-acute care only. In Massachusetts, a pediatric asthma bundle is being implemented through Medicaid, covering that population for a year or longer. The aim is to redirect dollars that normally would pay for ED visits and inpatient care to pay for interventions that promote better control of the disease and prevent acute flare-ups that lead to hospital visits.

How Hospitalists Fit In

To date, there has been little discussion of how physicians other than the surgeons doing the procedure (most bundles are for surgeries) fit into the clinical or financial model underpinning the program. However, with most patients in surgical or medical bundles being discharged to home, we now recognize that primary-care physicians (PCPs) will be essential to the success of a bundle.

Similarly, with medically complex patients enrolling in surgical bundles, hospitalists will be essential to the pre- and perioperative care of these patients. Also, transitioning bundle patients to home or to a rehabilitation will benefit from the involvement of a hospitalist.

What You Can Do Today

Although this might seem abstract for hospitalists practicing in the here and now, there are compelling opportunities for hospitalists who get involved in bundled-payment programs. Here’s what I suggest:

Find out if your hospital or post-acute facility is participating in bundling by looking at a map of CMMI bundle programs here: http://innovation.cms.gov/initiatives/bundled-payments;

• Get a seat at the table working on the bundle; and
• Negotiate a portion of the bundle’s shared savings on the basis of 1) increased efficiency and quality resulting from hospitalist involvement and 2) hospitalist direct oversight of bundled patients in post-acute facilities (if you choose).

Post-acute care may be new for your hospitalist program. Bundling programs are an important new business case for hospitalists in this setting.

Dr. Whitcomb is medical director of healthcare quality at Baystate Medical Center in Springfield, Mass. He is co-founder and past president of SHM. Email him at [email protected].

The government has made extensive efforts to combat fraud in the Medicare and Medicaid programs, recovering a record $4.2 billion in fiscal 2012 from individuals and companies trying to cheat the system. One of the largest sources of recovered monies is the Recovery Audit Contractor (RAC) program.

The RAC program was created through the Medicare Modernization Act of 2003 (MMA) to identify and recover improper Medicare payments to health-care providers under fee-for-service (FFS) Medicare plans. The goal of the RAC program is to identify improper payments made on claims of health-care services provided to Medicare beneficiaries. Improper payments could be overpayments or underpayments. Hospitals have been hit by the audits, with recoveries reaching $3.6 billion since the national program launched in 2010, according to Centers for Medicare & Medicaid Services (CMS) data.¹ About $895 million was reclaimed from just six states during the RAC Demonstration Project between 2005 and 2008.^1,2

CMS is more alert on the medical necessity of one-day length of stay (LOS) for inpatient admissions and is trying to detect and reduce Medicare waste, fraud, and abuse. Hospital charges represent about a third of the $718 billion spent on U.S. health care annually. Medicare reimbursement is a major source of revenue for hospitals, but some hospitals claim Medicare pays them only 93% to 97% of what it costs to provide patient care, whereas private insurers pay between 115% and 125% of those costs.^3,4 These data suggest that private insurers are paying hospitals far more than they need to make up for Medicare’s “underpayment.”

So the first question is: Do hospitals overcharge for care? The next question is: What can be done? Or, in today’s economy, what is being done?

How It All Works

When an RAC determines that a provider was paid for inpatient hospital services but that the patient in question should have been treated as an outpatient, CMS takes back the entire Part A payment. Moreover, CMS takes the position that once an inpatient claim paid under Medicare Part A is later denied (usually years later), the hospital cannot receive Medicare Part B payment except for a few ancillary services. As a result, when an RAC concludes that a hospital should have provided items and services on an outpatient basis rather than an inpatient basis, the hospital ends up receiving little, if any, reimbursement for reasonable and medically necessary items and services provided.^5,6

RACs function through a different model. They keep a contingency percentage—9% to 12.5%—of the entire Part A payment.⁵

Imagine a situation in which a physician decides that a patient needs to be admitted to the hospital for a surgical procedure, and the cost of care provided to the patient—surgery, drugs, and the like—amounts to $20,000. CMS reimburses the hospital under Part A. Two years later, an RAC employee reviewing hospital records overrules the physician’s judgment and decides the patient should have received basically the same care but on an outpatient basis. That decision, taken together with CMS’ Payment Denial Policy, means the hospital will end up receiving essentially no payment for the surgery and other care it provided. The RAC, by contrast, will receive approximately $2,000 for that one case alone.

To Admit or Not to Admit

Medicare expects attending physicians and physician reviewers to make the appropriate bedding status based on severity of signs and symptoms, comorbid and complicating conditions, and the practicality of outpatient management.

Let’s take two examples of patients presenting with acute asthma exacerbation (AAE) to differentiate observation and inpatient status. Asthma affects 20 million Americans, and 450,000 patients present to the ED annually with AAE. One third of these patients are hospitalized, which translates to more than $1 billion in costs annually.

Case 1: A 62-year-old female presents with two weeks of progressive shortness of breath and cough productive of white sputum. She has a history of asthma and hypertension. She presented to the ED with blood pressure of 140/90, heart rate of 101, respiratory rate of 20, temperature of 99.6°F, and pulse oximetry of 93% on room air, which increased to 99% on 2L of oxygen. She was given two breathing treatments with albuterol in the ED, IV methylprednisolone, and IV magnesium sulphate. Over the course of two hours, her wheezes improved, her heart rate decreased to 90 BPM, and her oxygen requirements were weaned to 1L of oxygen. Her WBC count was 9,800, with a potassium level of 4.0 and a creatinine level of 1.0. Her EKG showed sinus tachycardia, and her chest X-ray was negative for any infiltrates. The ED physician called the hospitalist for admission. What status should she be in?

Case 2: A 62-year-old female presents with a three-day history of shortness of breath and wheezing associated with vomiting. She was sent from her PCP’s office for asthma exacerbation and failure of resolution of symptoms despite one week of oral antibiotics and prednisone. Her past medical history includes asthma, diastolic congestive heart failure, hypertension, diabetes, and end-stage renal disease on hemodialysis. She presented to the ED with blood pressure of 90/63, pulse of 120, temperature of 97.7°F, respiratory rate of 24, and pulse oximetry of 89% on room air. She had bilateral wheezes on respiratory examination, and her WBC was 16,500, with a creatinine level of 3.5 and BNP level of 190. Her chest X-ray showed peribronchial thickening, and an EKG showed sinus tachycardia. She was given IV Solu-Medrol and two breathing treatments with albuterol, and the hospitalist was called for admission. What status should she be in?

Case 1 answer: Observation. The medical predictability of adverse clinical outcome from AAE is low due to hemodynamic stability, absence of fever, improvement in hypoxia, and negative chest X-ray for acute bronchopulmonary process in the setting of normal blood counts. She improved dramatically in the ED with no history of previous intubation or hospitalization or use of previous steroids. Her oxygen requirements decreased within 12 hours of first treatment. Even though FEV1 was not monitored, there is documented improvement in her vital signs as well as respiratory examination.

Case 2 answer: Inpatient. The medical predictability of adverse clinical outcome is significant due to hemodynamic instability evidenced by hypotension, tachycardia, and hypoxia; wheezes on respiratory examination with leukocytosis; and abnormal chest X-ray in the setting of comorbid diseases, such as end-stage renal disease and congestive heart failure.

The treatments given to both patients were similar; however, Case 2 had a higher predictability of adverse clinical outcome and would require medical evaluation and management that would exceed 24 hours. An inpatient level of care is justified based on her clinical presentation, comorbidities, and the risk for adverse clinical outcomes.

It is important that the patient be described appropriately in the medical record to support the status. Documentation should include clinical decision-making and rationale of the attending, objective findings, and the treatment given in the ED as well as the treatment planned during the hospitalization. It is expected that the physician will document the possibility and probability of adverse clinical outcome as well as follow evidence-based guidelines for treatment.

Financial Facts

The AHA collects data and anecdotal evidence from member hospitals regarding the RAC program and its effects. Those data show the following:

• More than 95% of the general medical-surgical hospitals that provided information to the AHA have been targeted by RACs;
• RACs have demanded more than a half-million medical records to audit;
• Many audits result in RAC determinations of “overpayment”; and
• Of those overpayment determinations, more than 60% relate to one- or two-day inpatient admissions that RACs deem medically unnecessary.

Hospitals thus have been required to give back hundreds of millions of dollars per year due to RAC determinations that services should have been provided in an outpatient, rather than inpatient, setting. In the first quarter of 2012 alone, information provided to the AHA by hospitals shows that they were forced to repay $236 million for medically necessary items and services that RACs deemed should have been provided on an outpatient, rather than inpatient, basis. And this amount does not include the millions of dollars recovered from hospitals that did not report data to the AHA.

The RAC program has been a continued financial success for CMS and the auditors: RACs collected $1.86 billion in overpayments from October 2009 through March 2012. Over that same time period, RACs identified only $245.2 million in underpayments.⁷

The government, no doubt, is on a mission to rein in health-care costs. All stakeholders in the system, including hospitalists and administrations, need extensive education to document appropriate patient status to ensure accurate reimbursement and prevent the fallout of future repayments.

Dr. Pahuja is founder and CEO of Aerolib Healthcare Solutions (aerolib.com). He is pursuing his MBA in health-care administration from the Isenberg School of Management at the University of Massachusetts in Amherst.

References

1. PR Web. Medicare anti-fraud recovered $19 billion, how much for private self-insured plans? Fiduciary overpayment recovery programs announced from ERISAclaim.com. PR Web website. Available at: http://www.prweb.com/releases/2013/3/prweb10501376.htm. Accessed April 4, 2013.
2. Viebeck E. GAO reports billions in overpayments to private Medicare plans. The Hill website. Available at: http://thehill.com/blogs/healthwatch/medicare/286041-gao-reports-billions-in-overpayments-to-private-medicare-plans#ixzz2NASaVVIK. Accessed April 4, 2013.
3. Centers for Medicare & Medicare Services. Cost reports. Centers for Medicare & Medicare Services website. Available at: http://www.cms.gov/Research-Statistics-Data-and-Systems/Files-for-Order/CostReports/index.html. Accessed April 4, 2013.
4. Whelan D. America’s most profitable hospitals. Forbes website. Available at: http://www.forbes.com/2010/08/30/profitable-hospitals-hca-healthcare-business-mayo-clinic.html. Accessed April 4, 2013.
5. American Medical Association. Recovery Audit Contractors. American Medical Association website. Available at: http://www.ama-assn.org/ama/pub/physician-resources/solutions-managing-your-practice/coding-billing-insurance/medicare/recovery-audit-contractors.page. Accessed April 4, 2013.
6. American Hospital Association, Missouri Baptist Sullivan Hospital, Munson Medical Center, Lancaster General Hospital, and Trinity Health Corporation v. Kathleen Sebelius. American Hospital Association website. Available at: http://www.aha.org/content/12/121101-aha-hhs-medicare-com.pdf. Accessed March 12, 2013.
7. Centers for Medicare & Medicare Services. Medicare fee-for-service Recovery Audit Program, May 2012. Centers for Medicare & Medicare Services website. Available at: http://www.cms.gov/Research-Statistics-Data-and-Systems/Monitoring-Programs/Recovery-Audit-Program/Downloads/National-Program-Corrections-FY-2012-2nd-Qtr.pdf. Accessed April 4, 2013.
8. Centers for Medicare & Medicaid Services. FY 2014 IPPS proposed rule home page items. Centers for Medicare & Medicaid Services website. Available at: http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/AcuteInpatientPPS/FY-2014-IPPS-Proposed-Rule-Home-Page-Items/FY-2014-IPPS-Proposed-Rule-CMS-1599-P-Regulations.html. Accessed June 10, 2013.

The government has made extensive efforts to combat fraud in the Medicare and Medicaid programs, recovering a record $4.2 billion in fiscal 2012 from individuals and companies trying to cheat the system. One of the largest sources of recovered monies is the Recovery Audit Contractor (RAC) program.

The RAC program was created through the Medicare Modernization Act of 2003 (MMA) to identify and recover improper Medicare payments to health-care providers under fee-for-service (FFS) Medicare plans. The goal of the RAC program is to identify improper payments made on claims of health-care services provided to Medicare beneficiaries. Improper payments could be overpayments or underpayments. Hospitals have been hit by the audits, with recoveries reaching $3.6 billion since the national program launched in 2010, according to Centers for Medicare & Medicaid Services (CMS) data.¹ About $895 million was reclaimed from just six states during the RAC Demonstration Project between 2005 and 2008.^1,2

CMS is more alert on the medical necessity of one-day length of stay (LOS) for inpatient admissions and is trying to detect and reduce Medicare waste, fraud, and abuse. Hospital charges represent about a third of the $718 billion spent on U.S. health care annually. Medicare reimbursement is a major source of revenue for hospitals, but some hospitals claim Medicare pays them only 93% to 97% of what it costs to provide patient care, whereas private insurers pay between 115% and 125% of those costs.^3,4 These data suggest that private insurers are paying hospitals far more than they need to make up for Medicare’s “underpayment.”

So the first question is: Do hospitals overcharge for care? The next question is: What can be done? Or, in today’s economy, what is being done?

How It All Works

When an RAC determines that a provider was paid for inpatient hospital services but that the patient in question should have been treated as an outpatient, CMS takes back the entire Part A payment. Moreover, CMS takes the position that once an inpatient claim paid under Medicare Part A is later denied (usually years later), the hospital cannot receive Medicare Part B payment except for a few ancillary services. As a result, when an RAC concludes that a hospital should have provided items and services on an outpatient basis rather than an inpatient basis, the hospital ends up receiving little, if any, reimbursement for reasonable and medically necessary items and services provided.^5,6

RACs function through a different model. They keep a contingency percentage—9% to 12.5%—of the entire Part A payment.⁵

Imagine a situation in which a physician decides that a patient needs to be admitted to the hospital for a surgical procedure, and the cost of care provided to the patient—surgery, drugs, and the like—amounts to $20,000. CMS reimburses the hospital under Part A. Two years later, an RAC employee reviewing hospital records overrules the physician’s judgment and decides the patient should have received basically the same care but on an outpatient basis. That decision, taken together with CMS’ Payment Denial Policy, means the hospital will end up receiving essentially no payment for the surgery and other care it provided. The RAC, by contrast, will receive approximately $2,000 for that one case alone.

To Admit or Not to Admit

Medicare expects attending physicians and physician reviewers to make the appropriate bedding status based on severity of signs and symptoms, comorbid and complicating conditions, and the practicality of outpatient management.

Let’s take two examples of patients presenting with acute asthma exacerbation (AAE) to differentiate observation and inpatient status. Asthma affects 20 million Americans, and 450,000 patients present to the ED annually with AAE. One third of these patients are hospitalized, which translates to more than $1 billion in costs annually.

Case 1: A 62-year-old female presents with two weeks of progressive shortness of breath and cough productive of white sputum. She has a history of asthma and hypertension. She presented to the ED with blood pressure of 140/90, heart rate of 101, respiratory rate of 20, temperature of 99.6°F, and pulse oximetry of 93% on room air, which increased to 99% on 2L of oxygen. She was given two breathing treatments with albuterol in the ED, IV methylprednisolone, and IV magnesium sulphate. Over the course of two hours, her wheezes improved, her heart rate decreased to 90 BPM, and her oxygen requirements were weaned to 1L of oxygen. Her WBC count was 9,800, with a potassium level of 4.0 and a creatinine level of 1.0. Her EKG showed sinus tachycardia, and her chest X-ray was negative for any infiltrates. The ED physician called the hospitalist for admission. What status should she be in?

Case 2: A 62-year-old female presents with a three-day history of shortness of breath and wheezing associated with vomiting. She was sent from her PCP’s office for asthma exacerbation and failure of resolution of symptoms despite one week of oral antibiotics and prednisone. Her past medical history includes asthma, diastolic congestive heart failure, hypertension, diabetes, and end-stage renal disease on hemodialysis. She presented to the ED with blood pressure of 90/63, pulse of 120, temperature of 97.7°F, respiratory rate of 24, and pulse oximetry of 89% on room air. She had bilateral wheezes on respiratory examination, and her WBC was 16,500, with a creatinine level of 3.5 and BNP level of 190. Her chest X-ray showed peribronchial thickening, and an EKG showed sinus tachycardia. She was given IV Solu-Medrol and two breathing treatments with albuterol, and the hospitalist was called for admission. What status should she be in?

Case 1 answer: Observation. The medical predictability of adverse clinical outcome from AAE is low due to hemodynamic stability, absence of fever, improvement in hypoxia, and negative chest X-ray for acute bronchopulmonary process in the setting of normal blood counts. She improved dramatically in the ED with no history of previous intubation or hospitalization or use of previous steroids. Her oxygen requirements decreased within 12 hours of first treatment. Even though FEV1 was not monitored, there is documented improvement in her vital signs as well as respiratory examination.

Case 2 answer: Inpatient. The medical predictability of adverse clinical outcome is significant due to hemodynamic instability evidenced by hypotension, tachycardia, and hypoxia; wheezes on respiratory examination with leukocytosis; and abnormal chest X-ray in the setting of comorbid diseases, such as end-stage renal disease and congestive heart failure.

The treatments given to both patients were similar; however, Case 2 had a higher predictability of adverse clinical outcome and would require medical evaluation and management that would exceed 24 hours. An inpatient level of care is justified based on her clinical presentation, comorbidities, and the risk for adverse clinical outcomes.

It is important that the patient be described appropriately in the medical record to support the status. Documentation should include clinical decision-making and rationale of the attending, objective findings, and the treatment given in the ED as well as the treatment planned during the hospitalization. It is expected that the physician will document the possibility and probability of adverse clinical outcome as well as follow evidence-based guidelines for treatment.

Financial Facts

The AHA collects data and anecdotal evidence from member hospitals regarding the RAC program and its effects. Those data show the following:

• More than 95% of the general medical-surgical hospitals that provided information to the AHA have been targeted by RACs;
• RACs have demanded more than a half-million medical records to audit;
• Many audits result in RAC determinations of “overpayment”; and
• Of those overpayment determinations, more than 60% relate to one- or two-day inpatient admissions that RACs deem medically unnecessary.

Hospitals thus have been required to give back hundreds of millions of dollars per year due to RAC determinations that services should have been provided in an outpatient, rather than inpatient, setting. In the first quarter of 2012 alone, information provided to the AHA by hospitals shows that they were forced to repay $236 million for medically necessary items and services that RACs deemed should have been provided on an outpatient, rather than inpatient, basis. And this amount does not include the millions of dollars recovered from hospitals that did not report data to the AHA.

The RAC program has been a continued financial success for CMS and the auditors: RACs collected $1.86 billion in overpayments from October 2009 through March 2012. Over that same time period, RACs identified only $245.2 million in underpayments.⁷

The government, no doubt, is on a mission to rein in health-care costs. All stakeholders in the system, including hospitalists and administrations, need extensive education to document appropriate patient status to ensure accurate reimbursement and prevent the fallout of future repayments.

Dr. Pahuja is founder and CEO of Aerolib Healthcare Solutions (aerolib.com). He is pursuing his MBA in health-care administration from the Isenberg School of Management at the University of Massachusetts in Amherst.

References

1. PR Web. Medicare anti-fraud recovered $19 billion, how much for private self-insured plans? Fiduciary overpayment recovery programs announced from ERISAclaim.com. PR Web website. Available at: http://www.prweb.com/releases/2013/3/prweb10501376.htm. Accessed April 4, 2013.
2. Viebeck E. GAO reports billions in overpayments to private Medicare plans. The Hill website. Available at: http://thehill.com/blogs/healthwatch/medicare/286041-gao-reports-billions-in-overpayments-to-private-medicare-plans#ixzz2NASaVVIK. Accessed April 4, 2013.
3. Centers for Medicare & Medicare Services. Cost reports. Centers for Medicare & Medicare Services website. Available at: http://www.cms.gov/Research-Statistics-Data-and-Systems/Files-for-Order/CostReports/index.html. Accessed April 4, 2013.
4. Whelan D. America’s most profitable hospitals. Forbes website. Available at: http://www.forbes.com/2010/08/30/profitable-hospitals-hca-healthcare-business-mayo-clinic.html. Accessed April 4, 2013.
5. American Medical Association. Recovery Audit Contractors. American Medical Association website. Available at: http://www.ama-assn.org/ama/pub/physician-resources/solutions-managing-your-practice/coding-billing-insurance/medicare/recovery-audit-contractors.page. Accessed April 4, 2013.
6. American Hospital Association, Missouri Baptist Sullivan Hospital, Munson Medical Center, Lancaster General Hospital, and Trinity Health Corporation v. Kathleen Sebelius. American Hospital Association website. Available at: http://www.aha.org/content/12/121101-aha-hhs-medicare-com.pdf. Accessed March 12, 2013.
7. Centers for Medicare & Medicare Services. Medicare fee-for-service Recovery Audit Program, May 2012. Centers for Medicare & Medicare Services website. Available at: http://www.cms.gov/Research-Statistics-Data-and-Systems/Monitoring-Programs/Recovery-Audit-Program/Downloads/National-Program-Corrections-FY-2012-2nd-Qtr.pdf. Accessed April 4, 2013.
8. Centers for Medicare & Medicaid Services. FY 2014 IPPS proposed rule home page items. Centers for Medicare & Medicaid Services website. Available at: http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/AcuteInpatientPPS/FY-2014-IPPS-Proposed-Rule-Home-Page-Items/FY-2014-IPPS-Proposed-Rule-CMS-1599-P-Regulations.html. Accessed June 10, 2013.

The government has made extensive efforts to combat fraud in the Medicare and Medicaid programs, recovering a record $4.2 billion in fiscal 2012 from individuals and companies trying to cheat the system. One of the largest sources of recovered monies is the Recovery Audit Contractor (RAC) program.

The RAC program was created through the Medicare Modernization Act of 2003 (MMA) to identify and recover improper Medicare payments to health-care providers under fee-for-service (FFS) Medicare plans. The goal of the RAC program is to identify improper payments made on claims of health-care services provided to Medicare beneficiaries. Improper payments could be overpayments or underpayments. Hospitals have been hit by the audits, with recoveries reaching $3.6 billion since the national program launched in 2010, according to Centers for Medicare & Medicaid Services (CMS) data.¹ About $895 million was reclaimed from just six states during the RAC Demonstration Project between 2005 and 2008.^1,2

CMS is more alert on the medical necessity of one-day length of stay (LOS) for inpatient admissions and is trying to detect and reduce Medicare waste, fraud, and abuse. Hospital charges represent about a third of the $718 billion spent on U.S. health care annually. Medicare reimbursement is a major source of revenue for hospitals, but some hospitals claim Medicare pays them only 93% to 97% of what it costs to provide patient care, whereas private insurers pay between 115% and 125% of those costs.^3,4 These data suggest that private insurers are paying hospitals far more than they need to make up for Medicare’s “underpayment.”

So the first question is: Do hospitals overcharge for care? The next question is: What can be done? Or, in today’s economy, what is being done?

How It All Works

When an RAC determines that a provider was paid for inpatient hospital services but that the patient in question should have been treated as an outpatient, CMS takes back the entire Part A payment. Moreover, CMS takes the position that once an inpatient claim paid under Medicare Part A is later denied (usually years later), the hospital cannot receive Medicare Part B payment except for a few ancillary services. As a result, when an RAC concludes that a hospital should have provided items and services on an outpatient basis rather than an inpatient basis, the hospital ends up receiving little, if any, reimbursement for reasonable and medically necessary items and services provided.^5,6

RACs function through a different model. They keep a contingency percentage—9% to 12.5%—of the entire Part A payment.⁵

Imagine a situation in which a physician decides that a patient needs to be admitted to the hospital for a surgical procedure, and the cost of care provided to the patient—surgery, drugs, and the like—amounts to $20,000. CMS reimburses the hospital under Part A. Two years later, an RAC employee reviewing hospital records overrules the physician’s judgment and decides the patient should have received basically the same care but on an outpatient basis. That decision, taken together with CMS’ Payment Denial Policy, means the hospital will end up receiving essentially no payment for the surgery and other care it provided. The RAC, by contrast, will receive approximately $2,000 for that one case alone.

To Admit or Not to Admit

Medicare expects attending physicians and physician reviewers to make the appropriate bedding status based on severity of signs and symptoms, comorbid and complicating conditions, and the practicality of outpatient management.

Let’s take two examples of patients presenting with acute asthma exacerbation (AAE) to differentiate observation and inpatient status. Asthma affects 20 million Americans, and 450,000 patients present to the ED annually with AAE. One third of these patients are hospitalized, which translates to more than $1 billion in costs annually.

Case 1: A 62-year-old female presents with two weeks of progressive shortness of breath and cough productive of white sputum. She has a history of asthma and hypertension. She presented to the ED with blood pressure of 140/90, heart rate of 101, respiratory rate of 20, temperature of 99.6°F, and pulse oximetry of 93% on room air, which increased to 99% on 2L of oxygen. She was given two breathing treatments with albuterol in the ED, IV methylprednisolone, and IV magnesium sulphate. Over the course of two hours, her wheezes improved, her heart rate decreased to 90 BPM, and her oxygen requirements were weaned to 1L of oxygen. Her WBC count was 9,800, with a potassium level of 4.0 and a creatinine level of 1.0. Her EKG showed sinus tachycardia, and her chest X-ray was negative for any infiltrates. The ED physician called the hospitalist for admission. What status should she be in?

Case 2: A 62-year-old female presents with a three-day history of shortness of breath and wheezing associated with vomiting. She was sent from her PCP’s office for asthma exacerbation and failure of resolution of symptoms despite one week of oral antibiotics and prednisone. Her past medical history includes asthma, diastolic congestive heart failure, hypertension, diabetes, and end-stage renal disease on hemodialysis. She presented to the ED with blood pressure of 90/63, pulse of 120, temperature of 97.7°F, respiratory rate of 24, and pulse oximetry of 89% on room air. She had bilateral wheezes on respiratory examination, and her WBC was 16,500, with a creatinine level of 3.5 and BNP level of 190. Her chest X-ray showed peribronchial thickening, and an EKG showed sinus tachycardia. She was given IV Solu-Medrol and two breathing treatments with albuterol, and the hospitalist was called for admission. What status should she be in?

Case 1 answer: Observation. The medical predictability of adverse clinical outcome from AAE is low due to hemodynamic stability, absence of fever, improvement in hypoxia, and negative chest X-ray for acute bronchopulmonary process in the setting of normal blood counts. She improved dramatically in the ED with no history of previous intubation or hospitalization or use of previous steroids. Her oxygen requirements decreased within 12 hours of first treatment. Even though FEV1 was not monitored, there is documented improvement in her vital signs as well as respiratory examination.

Case 2 answer: Inpatient. The medical predictability of adverse clinical outcome is significant due to hemodynamic instability evidenced by hypotension, tachycardia, and hypoxia; wheezes on respiratory examination with leukocytosis; and abnormal chest X-ray in the setting of comorbid diseases, such as end-stage renal disease and congestive heart failure.

The treatments given to both patients were similar; however, Case 2 had a higher predictability of adverse clinical outcome and would require medical evaluation and management that would exceed 24 hours. An inpatient level of care is justified based on her clinical presentation, comorbidities, and the risk for adverse clinical outcomes.

It is important that the patient be described appropriately in the medical record to support the status. Documentation should include clinical decision-making and rationale of the attending, objective findings, and the treatment given in the ED as well as the treatment planned during the hospitalization. It is expected that the physician will document the possibility and probability of adverse clinical outcome as well as follow evidence-based guidelines for treatment.

Financial Facts

The AHA collects data and anecdotal evidence from member hospitals regarding the RAC program and its effects. Those data show the following:

• More than 95% of the general medical-surgical hospitals that provided information to the AHA have been targeted by RACs;
• RACs have demanded more than a half-million medical records to audit;
• Many audits result in RAC determinations of “overpayment”; and
• Of those overpayment determinations, more than 60% relate to one- or two-day inpatient admissions that RACs deem medically unnecessary.

Hospitals thus have been required to give back hundreds of millions of dollars per year due to RAC determinations that services should have been provided in an outpatient, rather than inpatient, setting. In the first quarter of 2012 alone, information provided to the AHA by hospitals shows that they were forced to repay $236 million for medically necessary items and services that RACs deemed should have been provided on an outpatient, rather than inpatient, basis. And this amount does not include the millions of dollars recovered from hospitals that did not report data to the AHA.

The RAC program has been a continued financial success for CMS and the auditors: RACs collected $1.86 billion in overpayments from October 2009 through March 2012. Over that same time period, RACs identified only $245.2 million in underpayments.⁷

The government, no doubt, is on a mission to rein in health-care costs. All stakeholders in the system, including hospitalists and administrations, need extensive education to document appropriate patient status to ensure accurate reimbursement and prevent the fallout of future repayments.

Dr. Pahuja is founder and CEO of Aerolib Healthcare Solutions (aerolib.com). He is pursuing his MBA in health-care administration from the Isenberg School of Management at the University of Massachusetts in Amherst.

References

1. PR Web. Medicare anti-fraud recovered $19 billion, how much for private self-insured plans? Fiduciary overpayment recovery programs announced from ERISAclaim.com. PR Web website. Available at: http://www.prweb.com/releases/2013/3/prweb10501376.htm. Accessed April 4, 2013.
2. Viebeck E. GAO reports billions in overpayments to private Medicare plans. The Hill website. Available at: http://thehill.com/blogs/healthwatch/medicare/286041-gao-reports-billions-in-overpayments-to-private-medicare-plans#ixzz2NASaVVIK. Accessed April 4, 2013.
3. Centers for Medicare & Medicare Services. Cost reports. Centers for Medicare & Medicare Services website. Available at: http://www.cms.gov/Research-Statistics-Data-and-Systems/Files-for-Order/CostReports/index.html. Accessed April 4, 2013.
4. Whelan D. America’s most profitable hospitals. Forbes website. Available at: http://www.forbes.com/2010/08/30/profitable-hospitals-hca-healthcare-business-mayo-clinic.html. Accessed April 4, 2013.
5. American Medical Association. Recovery Audit Contractors. American Medical Association website. Available at: http://www.ama-assn.org/ama/pub/physician-resources/solutions-managing-your-practice/coding-billing-insurance/medicare/recovery-audit-contractors.page. Accessed April 4, 2013.
6. American Hospital Association, Missouri Baptist Sullivan Hospital, Munson Medical Center, Lancaster General Hospital, and Trinity Health Corporation v. Kathleen Sebelius. American Hospital Association website. Available at: http://www.aha.org/content/12/121101-aha-hhs-medicare-com.pdf. Accessed March 12, 2013.
7. Centers for Medicare & Medicare Services. Medicare fee-for-service Recovery Audit Program, May 2012. Centers for Medicare & Medicare Services website. Available at: http://www.cms.gov/Research-Statistics-Data-and-Systems/Monitoring-Programs/Recovery-Audit-Program/Downloads/National-Program-Corrections-FY-2012-2nd-Qtr.pdf. Accessed April 4, 2013.
8. Centers for Medicare & Medicaid Services. FY 2014 IPPS proposed rule home page items. Centers for Medicare & Medicaid Services website. Available at: http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/AcuteInpatientPPS/FY-2014-IPPS-Proposed-Rule-Home-Page-Items/FY-2014-IPPS-Proposed-Rule-CMS-1599-P-Regulations.html. Accessed June 10, 2013.

Although it was more than a decade ago (the last century, in fact), I remember it like it was yesterday. It was my first month as chief resident at Johns Hopkins Bayview Medical Center in Baltimore, our 335-bed hospital, with the ED chair and my chair of medicine in a heated argument. Very heated. There was no yelling; it was the kind of discussion where, even as a kid, you knew the severely stern voices meant that this was beyond the yelling stage.

“Medicine patients clog up my ED. Your docs take hours to arrive and then hours more on the workup,” the ED chair said. “They block and delay. Patients are suffering.”

“If your ED knew who to admit to which service, we wouldn’t have to spend hours figuring out where to admit them. We have a lot of work upstairs; we’re not sitting around waiting for the ED to call,” my chair replied.

They both were right, of course.

The ED chair had internal data that showed medicine did, in fact, cause delays, hours and hours of delays, every day. The department of medicine had concrete examples of less-than-ideal disposition decisions that, in hindsight, could have been done better (and sometimes a lot better).

This was the late 1990s, and all of us were just beginning to understand the adverse impact that ED boarding (admissions stuck in the ED) has on patients and our institution. Over the last decade, a number of studies have proved the fears we had in the 1990s right: From increased pain to higher mortality, admitted patients suffer when they need to be “upstairs” but are stuck in the ED.^1-4

Prior to this meeting of chairmen, we tried multiple “ED fixes” over the years. Like so many other institutions, we mandated medicine physician response times to the ED, drew policies, sent memos, and even gave the ED admitting privileges to medicine. None of them worked. Culture and cultural divide trumped policy every time, and the more than 100 house staff and attendings, both in the ED and in medicine, never made a change that positively impacted ED boarding during my entire three-year residency.

In hindsight, that’s not surprising. There has been a lot of study on ED flow and quality improvement (QI) more broadly.^5-8 To expect individuals to “do better” in a broken system is asking for failure. Asking hundreds of physicians to change behavior is an exercise in futility, especially when resources are limited and systems force “silo” behavior. Even drastic measures, such as expanding total ED capacity, don’t impact ED flow favorably. Institutions must find ways to open the “admission door.”

To the Rescue

Mirroring the rest of the country, in the late 1990s, a new group of doctors were being hired at my hospital. Ex-chief residents were staying on a year or two to run a new inpatient service. Although hospitalists were still new at the time, the idea to give them the “admission problem” took about a nanosecond.

Hospitalists across the country have become adept at tackling many institutional challenges, from readmissions (think Project BOOST) to teaching attendings from comanagement to neuromanagement. If it happens inside the walls of the hospital (and sometimes outside), hospitalists likely have played an important role in making it better somewhere.

Our hospitalists became a vital partner with the ED and within our own department of medicine, of course. We did the usual: seeing inpatients. But we also began experimenting with new and radical ways to get admitted patients out of the ED and upstairs as quickly as possible. We tried a number of admission systems, and many failed initially. We learned important lessons from the failures and continued to innovate.

Soon, hospitalists were successfully triaging admitted patients to all of general medicine using a combination of telephone and in-person triage based on the needs of the patient. This process had the triage hospitalist doing a limited ED assessment and then assigning the admission duties, often done after transfer upstairs to the best available medicine team, including the four house staff inpatient teams and hospitalist group. Later, this hospitalist admission process was expanded to all of medicine, using hospitalists to triage to the ICUs as well as specialty units in addition to general medicine. The hospital dedicated large amounts of money to allow a dedicated triage shift 24-7, staffed exclusively by hospitalists. A few years later, the hospitalists developed an in-house Web-based triage program, allowing accurate tracking of the more than 14,000 admissions annually.

The results have been better than anyone could have imagined 15 years ago. ED length of stay for admitted patients has continued to decrease dramatically—by hours, not minutes. Certain types of ambulance diversion (red alert in the state of Maryland) that were commonplace a decade ago, to the tune of 2,000-plus hours a year, virtually have been eliminated. Since ambulance diversion is known to harm patients and drive away business, this was a true win for patients as well as our hospital.⁹ Our ED volumes continued to grow, and patient-care indicators show the care provided by the current admissions process is at least as safe as before.

Hospitalists partnering with EDs to improve the admissions process are not isolated to Johns Hopkins Bayview. Many hospitalist leaders recognize that there are a variety of options for improving the care our patients get during the admissions process:

• Virginia Commonwealth University’s hospitalist group, led by Dr. Heather Masters, has worked tirelessly for years on a triage program.
• Dr. Melinda Kantsiper has done something similar at Howard County General Hospital in Maryland.
• Dr. MaryEllen Pfeiffer of Wellspan in York, Pa., is launching a triage program for admissions in the fall, and Dr. Christine Soong has focused on educating her house staff on the triage process at Mount Sinai in Toronto.

The Institute of Medicine reports that 91% of EDs are crowded routinely, an issue unlikely to go away on its own. I believe that hospitalists hold the key to unlocking the “admission door.” Hospitalists are critical partners in quality improvement, including ED flow, and can positively impact our patients, our institutions, and our specialty.

If that’s not enough to convince you, then let me tell you the true story of how the Hopkins Bayview ED physicians and hospitalists became close colleagues and the time I had Thanksgiving dinner at the ED chairman’s house. It was a lovely dinner, really.

Dr. Howell is president of SHM, chief of the division of hospital medicine at Johns Hopkins Bayview in Baltimore, and spends a significant part of his time and research on hospital operations. Email questions or comments to [email protected].

References

1. Chaflin DB, Trzeciak S, Likourezos A, Baumann BM, Dellinger RP. Impact of delayed transfer of critically ill patients from the ED to the ICU. Crit Care Med. 2007;35(6):1477-1483.
2. Duke G, Green J, Briedis J. Survival of critically ill patients is time-critical. Crit Care Resusc. 2004;6(4):261-267.
3. Scheulen JJ, Li G, Kelen GD. Impact of ambulance diversion policies in urban, suburban and rural areas of central Maryland. Acad Emerg Med. 2001;8(1):36-40.
4. Sikka R, Metha S, Kaucky C, Kulstad EB. ED crowding is associated with increased time to pneumonia treatment. Am J of Emerg Med. 2010; 28(7):809-812.
5. Holroyd BR, Bullard MJ, Latoszek K. Impact of a triage physician on emergency department overcrowding and throughput: a randomized trial. Acad Emerg Med. 2007;14(8)702-708.
6. Han JH, Zhou C, France DJ. The effect of emergency department expansion on emergency department overcrowding. Acad Emerg Med. 2007;14(4)338-343.
7. Howell E, Bessman E, Kravet S, Kolodner K, Marshall R, Wright S. Active bed management by hospitalists and emergency department throughput. Ann Intern Med. 2008;149(11):804-811.
8. Briones A, Markoff B, Kathuria N. A model of a hospitalist role in the care of admitted patients in the emergency department. J Hosp Med. 2010;5(6):360-364.
9. Nicholl J, West J, Goodacre S, Turner J. The relationship between distance to hospital and patient mortality in emergencies: an observational study. Emerg Med J. 2007; 24(9):665-668.

Although it was more than a decade ago (the last century, in fact), I remember it like it was yesterday. It was my first month as chief resident at Johns Hopkins Bayview Medical Center in Baltimore, our 335-bed hospital, with the ED chair and my chair of medicine in a heated argument. Very heated. There was no yelling; it was the kind of discussion where, even as a kid, you knew the severely stern voices meant that this was beyond the yelling stage.

“Medicine patients clog up my ED. Your docs take hours to arrive and then hours more on the workup,” the ED chair said. “They block and delay. Patients are suffering.”

“If your ED knew who to admit to which service, we wouldn’t have to spend hours figuring out where to admit them. We have a lot of work upstairs; we’re not sitting around waiting for the ED to call,” my chair replied.

They both were right, of course.

The ED chair had internal data that showed medicine did, in fact, cause delays, hours and hours of delays, every day. The department of medicine had concrete examples of less-than-ideal disposition decisions that, in hindsight, could have been done better (and sometimes a lot better).

This was the late 1990s, and all of us were just beginning to understand the adverse impact that ED boarding (admissions stuck in the ED) has on patients and our institution. Over the last decade, a number of studies have proved the fears we had in the 1990s right: From increased pain to higher mortality, admitted patients suffer when they need to be “upstairs” but are stuck in the ED.^1-4

Prior to this meeting of chairmen, we tried multiple “ED fixes” over the years. Like so many other institutions, we mandated medicine physician response times to the ED, drew policies, sent memos, and even gave the ED admitting privileges to medicine. None of them worked. Culture and cultural divide trumped policy every time, and the more than 100 house staff and attendings, both in the ED and in medicine, never made a change that positively impacted ED boarding during my entire three-year residency.

In hindsight, that’s not surprising. There has been a lot of study on ED flow and quality improvement (QI) more broadly.^5-8 To expect individuals to “do better” in a broken system is asking for failure. Asking hundreds of physicians to change behavior is an exercise in futility, especially when resources are limited and systems force “silo” behavior. Even drastic measures, such as expanding total ED capacity, don’t impact ED flow favorably. Institutions must find ways to open the “admission door.”

To the Rescue

Mirroring the rest of the country, in the late 1990s, a new group of doctors were being hired at my hospital. Ex-chief residents were staying on a year or two to run a new inpatient service. Although hospitalists were still new at the time, the idea to give them the “admission problem” took about a nanosecond.

Hospitalists across the country have become adept at tackling many institutional challenges, from readmissions (think Project BOOST) to teaching attendings from comanagement to neuromanagement. If it happens inside the walls of the hospital (and sometimes outside), hospitalists likely have played an important role in making it better somewhere.

Our hospitalists became a vital partner with the ED and within our own department of medicine, of course. We did the usual: seeing inpatients. But we also began experimenting with new and radical ways to get admitted patients out of the ED and upstairs as quickly as possible. We tried a number of admission systems, and many failed initially. We learned important lessons from the failures and continued to innovate.

Soon, hospitalists were successfully triaging admitted patients to all of general medicine using a combination of telephone and in-person triage based on the needs of the patient. This process had the triage hospitalist doing a limited ED assessment and then assigning the admission duties, often done after transfer upstairs to the best available medicine team, including the four house staff inpatient teams and hospitalist group. Later, this hospitalist admission process was expanded to all of medicine, using hospitalists to triage to the ICUs as well as specialty units in addition to general medicine. The hospital dedicated large amounts of money to allow a dedicated triage shift 24-7, staffed exclusively by hospitalists. A few years later, the hospitalists developed an in-house Web-based triage program, allowing accurate tracking of the more than 14,000 admissions annually.

The results have been better than anyone could have imagined 15 years ago. ED length of stay for admitted patients has continued to decrease dramatically—by hours, not minutes. Certain types of ambulance diversion (red alert in the state of Maryland) that were commonplace a decade ago, to the tune of 2,000-plus hours a year, virtually have been eliminated. Since ambulance diversion is known to harm patients and drive away business, this was a true win for patients as well as our hospital.⁹ Our ED volumes continued to grow, and patient-care indicators show the care provided by the current admissions process is at least as safe as before.

Hospitalists partnering with EDs to improve the admissions process are not isolated to Johns Hopkins Bayview. Many hospitalist leaders recognize that there are a variety of options for improving the care our patients get during the admissions process:

• Virginia Commonwealth University’s hospitalist group, led by Dr. Heather Masters, has worked tirelessly for years on a triage program.
• Dr. Melinda Kantsiper has done something similar at Howard County General Hospital in Maryland.
• Dr. MaryEllen Pfeiffer of Wellspan in York, Pa., is launching a triage program for admissions in the fall, and Dr. Christine Soong has focused on educating her house staff on the triage process at Mount Sinai in Toronto.

The Institute of Medicine reports that 91% of EDs are crowded routinely, an issue unlikely to go away on its own. I believe that hospitalists hold the key to unlocking the “admission door.” Hospitalists are critical partners in quality improvement, including ED flow, and can positively impact our patients, our institutions, and our specialty.

If that’s not enough to convince you, then let me tell you the true story of how the Hopkins Bayview ED physicians and hospitalists became close colleagues and the time I had Thanksgiving dinner at the ED chairman’s house. It was a lovely dinner, really.

Dr. Howell is president of SHM, chief of the division of hospital medicine at Johns Hopkins Bayview in Baltimore, and spends a significant part of his time and research on hospital operations. Email questions or comments to [email protected].

References

1. Chaflin DB, Trzeciak S, Likourezos A, Baumann BM, Dellinger RP. Impact of delayed transfer of critically ill patients from the ED to the ICU. Crit Care Med. 2007;35(6):1477-1483.
2. Duke G, Green J, Briedis J. Survival of critically ill patients is time-critical. Crit Care Resusc. 2004;6(4):261-267.
3. Scheulen JJ, Li G, Kelen GD. Impact of ambulance diversion policies in urban, suburban and rural areas of central Maryland. Acad Emerg Med. 2001;8(1):36-40.
4. Sikka R, Metha S, Kaucky C, Kulstad EB. ED crowding is associated with increased time to pneumonia treatment. Am J of Emerg Med. 2010; 28(7):809-812.
5. Holroyd BR, Bullard MJ, Latoszek K. Impact of a triage physician on emergency department overcrowding and throughput: a randomized trial. Acad Emerg Med. 2007;14(8)702-708.
6. Han JH, Zhou C, France DJ. The effect of emergency department expansion on emergency department overcrowding. Acad Emerg Med. 2007;14(4)338-343.
7. Howell E, Bessman E, Kravet S, Kolodner K, Marshall R, Wright S. Active bed management by hospitalists and emergency department throughput. Ann Intern Med. 2008;149(11):804-811.
8. Briones A, Markoff B, Kathuria N. A model of a hospitalist role in the care of admitted patients in the emergency department. J Hosp Med. 2010;5(6):360-364.
9. Nicholl J, West J, Goodacre S, Turner J. The relationship between distance to hospital and patient mortality in emergencies: an observational study. Emerg Med J. 2007; 24(9):665-668.

Although it was more than a decade ago (the last century, in fact), I remember it like it was yesterday. It was my first month as chief resident at Johns Hopkins Bayview Medical Center in Baltimore, our 335-bed hospital, with the ED chair and my chair of medicine in a heated argument. Very heated. There was no yelling; it was the kind of discussion where, even as a kid, you knew the severely stern voices meant that this was beyond the yelling stage.

“Medicine patients clog up my ED. Your docs take hours to arrive and then hours more on the workup,” the ED chair said. “They block and delay. Patients are suffering.”

“If your ED knew who to admit to which service, we wouldn’t have to spend hours figuring out where to admit them. We have a lot of work upstairs; we’re not sitting around waiting for the ED to call,” my chair replied.

They both were right, of course.

The ED chair had internal data that showed medicine did, in fact, cause delays, hours and hours of delays, every day. The department of medicine had concrete examples of less-than-ideal disposition decisions that, in hindsight, could have been done better (and sometimes a lot better).

This was the late 1990s, and all of us were just beginning to understand the adverse impact that ED boarding (admissions stuck in the ED) has on patients and our institution. Over the last decade, a number of studies have proved the fears we had in the 1990s right: From increased pain to higher mortality, admitted patients suffer when they need to be “upstairs” but are stuck in the ED.^1-4

Prior to this meeting of chairmen, we tried multiple “ED fixes” over the years. Like so many other institutions, we mandated medicine physician response times to the ED, drew policies, sent memos, and even gave the ED admitting privileges to medicine. None of them worked. Culture and cultural divide trumped policy every time, and the more than 100 house staff and attendings, both in the ED and in medicine, never made a change that positively impacted ED boarding during my entire three-year residency.

In hindsight, that’s not surprising. There has been a lot of study on ED flow and quality improvement (QI) more broadly.^5-8 To expect individuals to “do better” in a broken system is asking for failure. Asking hundreds of physicians to change behavior is an exercise in futility, especially when resources are limited and systems force “silo” behavior. Even drastic measures, such as expanding total ED capacity, don’t impact ED flow favorably. Institutions must find ways to open the “admission door.”

To the Rescue

Mirroring the rest of the country, in the late 1990s, a new group of doctors were being hired at my hospital. Ex-chief residents were staying on a year or two to run a new inpatient service. Although hospitalists were still new at the time, the idea to give them the “admission problem” took about a nanosecond.

Hospitalists across the country have become adept at tackling many institutional challenges, from readmissions (think Project BOOST) to teaching attendings from comanagement to neuromanagement. If it happens inside the walls of the hospital (and sometimes outside), hospitalists likely have played an important role in making it better somewhere.

Our hospitalists became a vital partner with the ED and within our own department of medicine, of course. We did the usual: seeing inpatients. But we also began experimenting with new and radical ways to get admitted patients out of the ED and upstairs as quickly as possible. We tried a number of admission systems, and many failed initially. We learned important lessons from the failures and continued to innovate.

Soon, hospitalists were successfully triaging admitted patients to all of general medicine using a combination of telephone and in-person triage based on the needs of the patient. This process had the triage hospitalist doing a limited ED assessment and then assigning the admission duties, often done after transfer upstairs to the best available medicine team, including the four house staff inpatient teams and hospitalist group. Later, this hospitalist admission process was expanded to all of medicine, using hospitalists to triage to the ICUs as well as specialty units in addition to general medicine. The hospital dedicated large amounts of money to allow a dedicated triage shift 24-7, staffed exclusively by hospitalists. A few years later, the hospitalists developed an in-house Web-based triage program, allowing accurate tracking of the more than 14,000 admissions annually.

The results have been better than anyone could have imagined 15 years ago. ED length of stay for admitted patients has continued to decrease dramatically—by hours, not minutes. Certain types of ambulance diversion (red alert in the state of Maryland) that were commonplace a decade ago, to the tune of 2,000-plus hours a year, virtually have been eliminated. Since ambulance diversion is known to harm patients and drive away business, this was a true win for patients as well as our hospital.⁹ Our ED volumes continued to grow, and patient-care indicators show the care provided by the current admissions process is at least as safe as before.

Hospitalists partnering with EDs to improve the admissions process are not isolated to Johns Hopkins Bayview. Many hospitalist leaders recognize that there are a variety of options for improving the care our patients get during the admissions process:

• Virginia Commonwealth University’s hospitalist group, led by Dr. Heather Masters, has worked tirelessly for years on a triage program.
• Dr. Melinda Kantsiper has done something similar at Howard County General Hospital in Maryland.
• Dr. MaryEllen Pfeiffer of Wellspan in York, Pa., is launching a triage program for admissions in the fall, and Dr. Christine Soong has focused on educating her house staff on the triage process at Mount Sinai in Toronto.

The Institute of Medicine reports that 91% of EDs are crowded routinely, an issue unlikely to go away on its own. I believe that hospitalists hold the key to unlocking the “admission door.” Hospitalists are critical partners in quality improvement, including ED flow, and can positively impact our patients, our institutions, and our specialty.

If that’s not enough to convince you, then let me tell you the true story of how the Hopkins Bayview ED physicians and hospitalists became close colleagues and the time I had Thanksgiving dinner at the ED chairman’s house. It was a lovely dinner, really.

Dr. Howell is president of SHM, chief of the division of hospital medicine at Johns Hopkins Bayview in Baltimore, and spends a significant part of his time and research on hospital operations. Email questions or comments to [email protected].

References

1. Chaflin DB, Trzeciak S, Likourezos A, Baumann BM, Dellinger RP. Impact of delayed transfer of critically ill patients from the ED to the ICU. Crit Care Med. 2007;35(6):1477-1483.
2. Duke G, Green J, Briedis J. Survival of critically ill patients is time-critical. Crit Care Resusc. 2004;6(4):261-267.
3. Scheulen JJ, Li G, Kelen GD. Impact of ambulance diversion policies in urban, suburban and rural areas of central Maryland. Acad Emerg Med. 2001;8(1):36-40.
4. Sikka R, Metha S, Kaucky C, Kulstad EB. ED crowding is associated with increased time to pneumonia treatment. Am J of Emerg Med. 2010; 28(7):809-812.
5. Holroyd BR, Bullard MJ, Latoszek K. Impact of a triage physician on emergency department overcrowding and throughput: a randomized trial. Acad Emerg Med. 2007;14(8)702-708.
6. Han JH, Zhou C, France DJ. The effect of emergency department expansion on emergency department overcrowding. Acad Emerg Med. 2007;14(4)338-343.
7. Howell E, Bessman E, Kravet S, Kolodner K, Marshall R, Wright S. Active bed management by hospitalists and emergency department throughput. Ann Intern Med. 2008;149(11):804-811.
8. Briones A, Markoff B, Kathuria N. A model of a hospitalist role in the care of admitted patients in the emergency department. J Hosp Med. 2010;5(6):360-364.
9. Nicholl J, West J, Goodacre S, Turner J. The relationship between distance to hospital and patient mortality in emergencies: an observational study. Emerg Med J. 2007; 24(9):665-668.

I continue to believe that hospitalists should routinely provide patients a copy of their discharge summary. I made the case for this in a 2006 column (“Keeping Patients in the Loop,” October 2006, p. 74), but I don’t see the idea catching on. I bet this simple act would have all kinds of benefits, including at least modest reductions in overall health-care expenditures and readmissions.

The whole dynamic of this issue seems to be changing as a result of “patient portals” allowing direct access to review test results and, in some cases, physician documentation. Typically, these are integrated with or at least connected to an electronic health record (EHR) and allow a patient, and those provided access (e.g. the password) by the patient, to review records. My own PCP provides access to a portal that I’ve found very useful, but I think, like most others, it doesn’t provide access to physician notes.

So there still is a case to be made for hospitalists (and all specialties) to provide copies of the discharge summary directly to patients and perhaps other forms of documentation as well.

Timeliness

I think all discharge summaries should be completed before the patient leaves the hospital and amended as needed to capture any last-minute changes and details. The act of generating the summary often leads the discharging doctor to notice, and have a chance to address, important details that may have dropped off the daily problem list. Things like the need to recheck a lab test to ensure normalization prior to discharge, or make arrangements for outpatient colonoscopy to pursue the heme-positive stool found on admission, have sometimes slipped off the radar during the hospital stay and can be caught when preparing discharge summary.

Preparing a discharge summary the night before anticipated discharge can have many advantages, including improving early discharge times the next morning. And it means the doctor can prepare the summary late in the day after routine rounding is finished and interruptions are less likely. Although I think quality of care is enhanced by generating the summary the night before (and amending it as needed), I worked with a hospital that was cited by the Centers for Medicare & Medicaid Services (CMS) for doing this and was told they can’t be done prior to the calendar day of discharge.

Creation of the discharge summary isn’t the only relevant step. It should be transcribed on a stat basis (e.g. within two to four hours) and pushed to the PCP and other treating physicians. It isn’t enough that the document is available to the PCP via an EHR; these doctors need some sort of notice, such as an email.

To take advantage of the new “transitional-care management” codes (99495 and 99496), PCPs must make telephone contact with patients within two days of discharge and must have a face-to-face visit within one or two weeks of discharge (depending on whether the patient is high- or moderate-risk). Making the summary available to the PCP quickly can be crucial in ensuring these phone calls and visits are meaningful. (For an excellent review of the TCM codes, see Dr. Lauren Doctoroff’s article “New Codes Bridge Hospitals’ Post-Discharge Billing Gap” in the February 2013 issue of The Hospitalist.)

So I think both patients and other treating physicians should get the discharge summary on the day of discharge or no more than a day or two after. I bet this improves quality of care and readmissions, but one study found no association, and another found a trend toward reduced readmissions that did not reach statistical significance.^1,2

Content

Just what information should go in a discharge summary? There are lots of opinions here, but it is worth starting with the components required by The Joint Commission. (You were aware of these, right?) The commission requires:

• Reason for hospitalization;
• Significant findings;
• Procedures and treatment provided;
• Patient’s discharge condition;
• Patient and family instructions; and
• Attending physician’s signature

To this list, I would add enumeration of tests pending at discharge.

The May/June 2005 issue of The Hospitalist has a terrific article by three thoughtful hospitalists titled “Advancing Toward the Ideal Hospital Discharge for the Elderly Patient.” It summarizes a 2005 workshop at the SHM annual meeting that produced a checklist of elements to consider including in every summary.

Brevity is a worthwhile goal but not at the expense of conveying the thought processes behind decisions. Things like how a decision was made to pursue watchful waiting versus aggressive workup now should be spelled out. Was it simply patient preference? It is common to start a trial of a medical therapy during a hospital stay, and it should be made clear that its effect should be assessed and a deliberate decision regarding continuing or stopping the therapy will be needed after discharge.

Lots of things need context and explanation for subsequent caregivers.

Format

The hospital in which I practice recently switched to a new EHR, and our hospitalist group has talked some about all of us using the same basic template for our notes. This should be valuable to all other caregivers who read a reasonable number of our notes and might improve our communication with one another around handoffs, etc. Although we haven’t reached a final decision about this, I’m an advocate for a shared template rather than each doctor using his or her own. This would be a worthwhile thing for all groups to consider.

Dr. Nelson has been a practicing hospitalist since 1988. He is co-founder and past president of SHM, and principal in Nelson Flores Hospital Medicine Consultants. He is co-director for SHM’s “Best Practices in Managing a Hospital Medicine Program” course. Write to him at [email protected].

References

1. Hanson LO. Hospital discharge documentation and risk of rehospitalization. BMJ Qual Saf. 2011;20(9):773-778.
2. Van Walraven C, Seth R, Austin PC, Laupacis A. Effect of discharge summary availability during post-discharge visits on hospital readmission. J Gen Intern Med. 2002;17(3):186-192.

I continue to believe that hospitalists should routinely provide patients a copy of their discharge summary. I made the case for this in a 2006 column (“Keeping Patients in the Loop,” October 2006, p. 74), but I don’t see the idea catching on. I bet this simple act would have all kinds of benefits, including at least modest reductions in overall health-care expenditures and readmissions.

The whole dynamic of this issue seems to be changing as a result of “patient portals” allowing direct access to review test results and, in some cases, physician documentation. Typically, these are integrated with or at least connected to an electronic health record (EHR) and allow a patient, and those provided access (e.g. the password) by the patient, to review records. My own PCP provides access to a portal that I’ve found very useful, but I think, like most others, it doesn’t provide access to physician notes.

So there still is a case to be made for hospitalists (and all specialties) to provide copies of the discharge summary directly to patients and perhaps other forms of documentation as well.

Timeliness

I think all discharge summaries should be completed before the patient leaves the hospital and amended as needed to capture any last-minute changes and details. The act of generating the summary often leads the discharging doctor to notice, and have a chance to address, important details that may have dropped off the daily problem list. Things like the need to recheck a lab test to ensure normalization prior to discharge, or make arrangements for outpatient colonoscopy to pursue the heme-positive stool found on admission, have sometimes slipped off the radar during the hospital stay and can be caught when preparing discharge summary.

Preparing a discharge summary the night before anticipated discharge can have many advantages, including improving early discharge times the next morning. And it means the doctor can prepare the summary late in the day after routine rounding is finished and interruptions are less likely. Although I think quality of care is enhanced by generating the summary the night before (and amending it as needed), I worked with a hospital that was cited by the Centers for Medicare & Medicaid Services (CMS) for doing this and was told they can’t be done prior to the calendar day of discharge.

Creation of the discharge summary isn’t the only relevant step. It should be transcribed on a stat basis (e.g. within two to four hours) and pushed to the PCP and other treating physicians. It isn’t enough that the document is available to the PCP via an EHR; these doctors need some sort of notice, such as an email.

To take advantage of the new “transitional-care management” codes (99495 and 99496), PCPs must make telephone contact with patients within two days of discharge and must have a face-to-face visit within one or two weeks of discharge (depending on whether the patient is high- or moderate-risk). Making the summary available to the PCP quickly can be crucial in ensuring these phone calls and visits are meaningful. (For an excellent review of the TCM codes, see Dr. Lauren Doctoroff’s article “New Codes Bridge Hospitals’ Post-Discharge Billing Gap” in the February 2013 issue of The Hospitalist.)

So I think both patients and other treating physicians should get the discharge summary on the day of discharge or no more than a day or two after. I bet this improves quality of care and readmissions, but one study found no association, and another found a trend toward reduced readmissions that did not reach statistical significance.^1,2

Content

Just what information should go in a discharge summary? There are lots of opinions here, but it is worth starting with the components required by The Joint Commission. (You were aware of these, right?) The commission requires:

• Reason for hospitalization;
• Significant findings;
• Procedures and treatment provided;
• Patient’s discharge condition;
• Patient and family instructions; and
• Attending physician’s signature

To this list, I would add enumeration of tests pending at discharge.

The May/June 2005 issue of The Hospitalist has a terrific article by three thoughtful hospitalists titled “Advancing Toward the Ideal Hospital Discharge for the Elderly Patient.” It summarizes a 2005 workshop at the SHM annual meeting that produced a checklist of elements to consider including in every summary.

Brevity is a worthwhile goal but not at the expense of conveying the thought processes behind decisions. Things like how a decision was made to pursue watchful waiting versus aggressive workup now should be spelled out. Was it simply patient preference? It is common to start a trial of a medical therapy during a hospital stay, and it should be made clear that its effect should be assessed and a deliberate decision regarding continuing or stopping the therapy will be needed after discharge.

Lots of things need context and explanation for subsequent caregivers.

Format

The hospital in which I practice recently switched to a new EHR, and our hospitalist group has talked some about all of us using the same basic template for our notes. This should be valuable to all other caregivers who read a reasonable number of our notes and might improve our communication with one another around handoffs, etc. Although we haven’t reached a final decision about this, I’m an advocate for a shared template rather than each doctor using his or her own. This would be a worthwhile thing for all groups to consider.

Dr. Nelson has been a practicing hospitalist since 1988. He is co-founder and past president of SHM, and principal in Nelson Flores Hospital Medicine Consultants. He is co-director for SHM’s “Best Practices in Managing a Hospital Medicine Program” course. Write to him at [email protected].

References

1. Hanson LO. Hospital discharge documentation and risk of rehospitalization. BMJ Qual Saf. 2011;20(9):773-778.
2. Van Walraven C, Seth R, Austin PC, Laupacis A. Effect of discharge summary availability during post-discharge visits on hospital readmission. J Gen Intern Med. 2002;17(3):186-192.

I continue to believe that hospitalists should routinely provide patients a copy of their discharge summary. I made the case for this in a 2006 column (“Keeping Patients in the Loop,” October 2006, p. 74), but I don’t see the idea catching on. I bet this simple act would have all kinds of benefits, including at least modest reductions in overall health-care expenditures and readmissions.

The whole dynamic of this issue seems to be changing as a result of “patient portals” allowing direct access to review test results and, in some cases, physician documentation. Typically, these are integrated with or at least connected to an electronic health record (EHR) and allow a patient, and those provided access (e.g. the password) by the patient, to review records. My own PCP provides access to a portal that I’ve found very useful, but I think, like most others, it doesn’t provide access to physician notes.

So there still is a case to be made for hospitalists (and all specialties) to provide copies of the discharge summary directly to patients and perhaps other forms of documentation as well.

Timeliness

I think all discharge summaries should be completed before the patient leaves the hospital and amended as needed to capture any last-minute changes and details. The act of generating the summary often leads the discharging doctor to notice, and have a chance to address, important details that may have dropped off the daily problem list. Things like the need to recheck a lab test to ensure normalization prior to discharge, or make arrangements for outpatient colonoscopy to pursue the heme-positive stool found on admission, have sometimes slipped off the radar during the hospital stay and can be caught when preparing discharge summary.

Preparing a discharge summary the night before anticipated discharge can have many advantages, including improving early discharge times the next morning. And it means the doctor can prepare the summary late in the day after routine rounding is finished and interruptions are less likely. Although I think quality of care is enhanced by generating the summary the night before (and amending it as needed), I worked with a hospital that was cited by the Centers for Medicare & Medicaid Services (CMS) for doing this and was told they can’t be done prior to the calendar day of discharge.

Creation of the discharge summary isn’t the only relevant step. It should be transcribed on a stat basis (e.g. within two to four hours) and pushed to the PCP and other treating physicians. It isn’t enough that the document is available to the PCP via an EHR; these doctors need some sort of notice, such as an email.

To take advantage of the new “transitional-care management” codes (99495 and 99496), PCPs must make telephone contact with patients within two days of discharge and must have a face-to-face visit within one or two weeks of discharge (depending on whether the patient is high- or moderate-risk). Making the summary available to the PCP quickly can be crucial in ensuring these phone calls and visits are meaningful. (For an excellent review of the TCM codes, see Dr. Lauren Doctoroff’s article “New Codes Bridge Hospitals’ Post-Discharge Billing Gap” in the February 2013 issue of The Hospitalist.)

So I think both patients and other treating physicians should get the discharge summary on the day of discharge or no more than a day or two after. I bet this improves quality of care and readmissions, but one study found no association, and another found a trend toward reduced readmissions that did not reach statistical significance.^1,2

Content

Just what information should go in a discharge summary? There are lots of opinions here, but it is worth starting with the components required by The Joint Commission. (You were aware of these, right?) The commission requires:

• Reason for hospitalization;
• Significant findings;
• Procedures and treatment provided;
• Patient’s discharge condition;
• Patient and family instructions; and
• Attending physician’s signature

To this list, I would add enumeration of tests pending at discharge.

The May/June 2005 issue of The Hospitalist has a terrific article by three thoughtful hospitalists titled “Advancing Toward the Ideal Hospital Discharge for the Elderly Patient.” It summarizes a 2005 workshop at the SHM annual meeting that produced a checklist of elements to consider including in every summary.

Brevity is a worthwhile goal but not at the expense of conveying the thought processes behind decisions. Things like how a decision was made to pursue watchful waiting versus aggressive workup now should be spelled out. Was it simply patient preference? It is common to start a trial of a medical therapy during a hospital stay, and it should be made clear that its effect should be assessed and a deliberate decision regarding continuing or stopping the therapy will be needed after discharge.

Lots of things need context and explanation for subsequent caregivers.

Format

The hospital in which I practice recently switched to a new EHR, and our hospitalist group has talked some about all of us using the same basic template for our notes. This should be valuable to all other caregivers who read a reasonable number of our notes and might improve our communication with one another around handoffs, etc. Although we haven’t reached a final decision about this, I’m an advocate for a shared template rather than each doctor using his or her own. This would be a worthwhile thing for all groups to consider.

Dr. Nelson has been a practicing hospitalist since 1988. He is co-founder and past president of SHM, and principal in Nelson Flores Hospital Medicine Consultants. He is co-director for SHM’s “Best Practices in Managing a Hospital Medicine Program” course. Write to him at [email protected].

References

1. Hanson LO. Hospital discharge documentation and risk of rehospitalization. BMJ Qual Saf. 2011;20(9):773-778.
2. Van Walraven C, Seth R, Austin PC, Laupacis A. Effect of discharge summary availability during post-discharge visits on hospital readmission. J Gen Intern Med. 2002;17(3):186-192.

Clinical question: Can a prediction model based on administrative and clinical data identify potentially avoidable 30-day readmissions in medical patients prior to discharge?

Background: An estimated 18% of Medicare beneficiaries are readmitted to the hospital within 30 days of discharge, costing nearly $17 billion per year. Interventions to reduce readmission rates are costly and should be focused on high-risk patients. To date, using models to predict 30-day readmission has been problematic and unreliable.

Study design: Retrospective cohort.

Setting: Academic medical center in Boston.

Synopsis: Using consecutive discharges from all medical services of Brigham and Women’s Hospital occurring over one year, this study derived and internally validated a prediction model for potentially avoidable 30-day readmissions. Of 10,731 discharges, there were 2,399 (22%) 30-day readmissions, and 879 (8.5%) were deemed potentially avoidable. Seven independent predictors for readmission were identified and used to create a predictor score referred to as the HOSPITAL score. Predictors included hemoglobin and sodium levels at discharge, number of hospitalizations in the past year, and four features of the index hospitalization, including type, discharge from an oncology service, presence of procedures, and length of stay. The score was internally validated and found to predict potentially avoidable 30-day readmission in medical patients with fair discriminatory power and good calibration.

This study is unique in that none of the classic comorbidities (e.g. congestive heart failure) were associated with a higher risk of 30-day readmission. Previously unrecognized predictors, including hemoglobin, sodium, and number of procedures performed, were incorporated. This suggests that comorbidities are not as important as illness severity or clinical instability. Hospitalists should await studies that externally validate the HOSPITAL score before incorporating it into practice.

Bottom line: A unique and simple seven-item prediction model identifies potentially avoidable 30-day readmissions but needs to be externally validated before being widely utilized.

Citation: Donze J, Drahomir A, Williams D, Schnipper JL. Potentially avoidable 30-day hospital readmissions in medical patients. JAMA Intern Med. 2013;137(8):632-638.

Clinical question: Can a prediction model based on administrative and clinical data identify potentially avoidable 30-day readmissions in medical patients prior to discharge?

Background: An estimated 18% of Medicare beneficiaries are readmitted to the hospital within 30 days of discharge, costing nearly $17 billion per year. Interventions to reduce readmission rates are costly and should be focused on high-risk patients. To date, using models to predict 30-day readmission has been problematic and unreliable.

Study design: Retrospective cohort.

Setting: Academic medical center in Boston.

Synopsis: Using consecutive discharges from all medical services of Brigham and Women’s Hospital occurring over one year, this study derived and internally validated a prediction model for potentially avoidable 30-day readmissions. Of 10,731 discharges, there were 2,399 (22%) 30-day readmissions, and 879 (8.5%) were deemed potentially avoidable. Seven independent predictors for readmission were identified and used to create a predictor score referred to as the HOSPITAL score. Predictors included hemoglobin and sodium levels at discharge, number of hospitalizations in the past year, and four features of the index hospitalization, including type, discharge from an oncology service, presence of procedures, and length of stay. The score was internally validated and found to predict potentially avoidable 30-day readmission in medical patients with fair discriminatory power and good calibration.

This study is unique in that none of the classic comorbidities (e.g. congestive heart failure) were associated with a higher risk of 30-day readmission. Previously unrecognized predictors, including hemoglobin, sodium, and number of procedures performed, were incorporated. This suggests that comorbidities are not as important as illness severity or clinical instability. Hospitalists should await studies that externally validate the HOSPITAL score before incorporating it into practice.

Bottom line: A unique and simple seven-item prediction model identifies potentially avoidable 30-day readmissions but needs to be externally validated before being widely utilized.

Citation: Donze J, Drahomir A, Williams D, Schnipper JL. Potentially avoidable 30-day hospital readmissions in medical patients. JAMA Intern Med. 2013;137(8):632-638.

Clinical question: Can a prediction model based on administrative and clinical data identify potentially avoidable 30-day readmissions in medical patients prior to discharge?

Background: An estimated 18% of Medicare beneficiaries are readmitted to the hospital within 30 days of discharge, costing nearly $17 billion per year. Interventions to reduce readmission rates are costly and should be focused on high-risk patients. To date, using models to predict 30-day readmission has been problematic and unreliable.

Study design: Retrospective cohort.

Setting: Academic medical center in Boston.

Synopsis: Using consecutive discharges from all medical services of Brigham and Women’s Hospital occurring over one year, this study derived and internally validated a prediction model for potentially avoidable 30-day readmissions. Of 10,731 discharges, there were 2,399 (22%) 30-day readmissions, and 879 (8.5%) were deemed potentially avoidable. Seven independent predictors for readmission were identified and used to create a predictor score referred to as the HOSPITAL score. Predictors included hemoglobin and sodium levels at discharge, number of hospitalizations in the past year, and four features of the index hospitalization, including type, discharge from an oncology service, presence of procedures, and length of stay. The score was internally validated and found to predict potentially avoidable 30-day readmission in medical patients with fair discriminatory power and good calibration.

This study is unique in that none of the classic comorbidities (e.g. congestive heart failure) were associated with a higher risk of 30-day readmission. Previously unrecognized predictors, including hemoglobin, sodium, and number of procedures performed, were incorporated. This suggests that comorbidities are not as important as illness severity or clinical instability. Hospitalists should await studies that externally validate the HOSPITAL score before incorporating it into practice.

Bottom line: A unique and simple seven-item prediction model identifies potentially avoidable 30-day readmissions but needs to be externally validated before being widely utilized.

Citation: Donze J, Drahomir A, Williams D, Schnipper JL. Potentially avoidable 30-day hospital readmissions in medical patients. JAMA Intern Med. 2013;137(8):632-638.

Many health-care-reform initiatives are so new that few data are available to assess whether they are working as intended. The Centers for Medicare & Medicaid Services (CMS), however, has touted the early numbers from its Hospital Readmission Reduction Program to suggest that the policy is making a difference in curbing bounce-backs. The overall impact, however, might be decidedly more nuanced and provides a telling example of the challenges that such programs can present to hospitalists and other health-care providers.

At a Senate Finance Committee Hearing in February, Jonathan Blum, deputy administrator and director for the Center of Medicare at CMS, released data suggesting that 30-day readmission rates for all causes dropped to 17.8% of hospitalizations near the end of 2012 after remaining at roughly 19% in each of the five previous years. The difference translates into 70,000 fewer readmissions annually.

During the first round of penalties, CMS dinged 2,213 hospitals for an estimated $280 million, or an average of about $126,500 per hospital, for excessive readmissions linked to heart attack, heart failure, and pneumonia care. Blum made the case that the penalties—or the threat thereof—are helping to improve rates.

Those arguing that the policy could disproportionately impact institutions caring for more vulnerable, high-risk patients also found new support in a recent New England Journal of Medicine perspective suggesting that academic medical centers and safety-net hospitals were more likely to be penalized.¹ Among their suggestions, the perspective’s co-authors, from Harvard’s School of Public Health, suggested that the policy take patient socioeconomic status into account to provide a fairer basis of comparison.

A second recent study suggested that even the reduced readmission rates might not be telling the whole story. An analysis of patients released in 2010 from safety-net hospital Boston Medical Center showed that nearly 1 in 4 returned to the ED within a month of discharge.2 But more than half of those patients weren’t readmitted as inpatients, meaning that they wouldn’t show up under Medicare’s readmissions statistics.

Along with the mixed early reviews of EHR rollouts and the HCAHPS portion of the Hospital Value-Based Purchasing program, it’s another reminder that CMS metrics and incentives might not always add up as envisioned. In the near future, it seems, hospitals and health-care providers might have to contend with some imperfect numbers. TH

Bryn Nelson is a freelance medical writer in Seattle.

References

1. Joynt KE, Jha AK. Thirty-day readmissions–truth and consequences. N Engl J Med. 2012;366:1366-1369.

2. Rising KL, White LF, Fernandez WG, Boutwell, AE. Emergency department visits after hospital discharge: a missing part of the equation. Ann Emerg Med. 2013; in press.

Many health-care-reform initiatives are so new that few data are available to assess whether they are working as intended. The Centers for Medicare & Medicaid Services (CMS), however, has touted the early numbers from its Hospital Readmission Reduction Program to suggest that the policy is making a difference in curbing bounce-backs. The overall impact, however, might be decidedly more nuanced and provides a telling example of the challenges that such programs can present to hospitalists and other health-care providers.

At a Senate Finance Committee Hearing in February, Jonathan Blum, deputy administrator and director for the Center of Medicare at CMS, released data suggesting that 30-day readmission rates for all causes dropped to 17.8% of hospitalizations near the end of 2012 after remaining at roughly 19% in each of the five previous years. The difference translates into 70,000 fewer readmissions annually.

During the first round of penalties, CMS dinged 2,213 hospitals for an estimated $280 million, or an average of about $126,500 per hospital, for excessive readmissions linked to heart attack, heart failure, and pneumonia care. Blum made the case that the penalties—or the threat thereof—are helping to improve rates.

Those arguing that the policy could disproportionately impact institutions caring for more vulnerable, high-risk patients also found new support in a recent New England Journal of Medicine perspective suggesting that academic medical centers and safety-net hospitals were more likely to be penalized.¹ Among their suggestions, the perspective’s co-authors, from Harvard’s School of Public Health, suggested that the policy take patient socioeconomic status into account to provide a fairer basis of comparison.

A second recent study suggested that even the reduced readmission rates might not be telling the whole story. An analysis of patients released in 2010 from safety-net hospital Boston Medical Center showed that nearly 1 in 4 returned to the ED within a month of discharge.2 But more than half of those patients weren’t readmitted as inpatients, meaning that they wouldn’t show up under Medicare’s readmissions statistics.

Along with the mixed early reviews of EHR rollouts and the HCAHPS portion of the Hospital Value-Based Purchasing program, it’s another reminder that CMS metrics and incentives might not always add up as envisioned. In the near future, it seems, hospitals and health-care providers might have to contend with some imperfect numbers. TH

Bryn Nelson is a freelance medical writer in Seattle.

References

1. Joynt KE, Jha AK. Thirty-day readmissions–truth and consequences. N Engl J Med. 2012;366:1366-1369.

2. Rising KL, White LF, Fernandez WG, Boutwell, AE. Emergency department visits after hospital discharge: a missing part of the equation. Ann Emerg Med. 2013; in press.

Many health-care-reform initiatives are so new that few data are available to assess whether they are working as intended. The Centers for Medicare & Medicaid Services (CMS), however, has touted the early numbers from its Hospital Readmission Reduction Program to suggest that the policy is making a difference in curbing bounce-backs. The overall impact, however, might be decidedly more nuanced and provides a telling example of the challenges that such programs can present to hospitalists and other health-care providers.

At a Senate Finance Committee Hearing in February, Jonathan Blum, deputy administrator and director for the Center of Medicare at CMS, released data suggesting that 30-day readmission rates for all causes dropped to 17.8% of hospitalizations near the end of 2012 after remaining at roughly 19% in each of the five previous years. The difference translates into 70,000 fewer readmissions annually.

During the first round of penalties, CMS dinged 2,213 hospitals for an estimated $280 million, or an average of about $126,500 per hospital, for excessive readmissions linked to heart attack, heart failure, and pneumonia care. Blum made the case that the penalties—or the threat thereof—are helping to improve rates.

Those arguing that the policy could disproportionately impact institutions caring for more vulnerable, high-risk patients also found new support in a recent New England Journal of Medicine perspective suggesting that academic medical centers and safety-net hospitals were more likely to be penalized.¹ Among their suggestions, the perspective’s co-authors, from Harvard’s School of Public Health, suggested that the policy take patient socioeconomic status into account to provide a fairer basis of comparison.

A second recent study suggested that even the reduced readmission rates might not be telling the whole story. An analysis of patients released in 2010 from safety-net hospital Boston Medical Center showed that nearly 1 in 4 returned to the ED within a month of discharge.2 But more than half of those patients weren’t readmitted as inpatients, meaning that they wouldn’t show up under Medicare’s readmissions statistics.

Along with the mixed early reviews of EHR rollouts and the HCAHPS portion of the Hospital Value-Based Purchasing program, it’s another reminder that CMS metrics and incentives might not always add up as envisioned. In the near future, it seems, hospitals and health-care providers might have to contend with some imperfect numbers. TH

Bryn Nelson is a freelance medical writer in Seattle.

References

1. Joynt KE, Jha AK. Thirty-day readmissions–truth and consequences. N Engl J Med. 2012;366:1366-1369.

2. Rising KL, White LF, Fernandez WG, Boutwell, AE. Emergency department visits after hospital discharge: a missing part of the equation. Ann Emerg Med. 2013; in press.

You have to make a difficult decision, to try to help the family. You’re trying to provide good care, but on the other hand, there are rules and regulations and bylaws you work under. They don’t align that well, in this case.

—Karim Godamunne, MD, MBA, SFHM

Hospitalists are pushing hard for a change to a Medicare rule requiring beneficiaries to accumulate at least three consecutive days of inpatient treatment at a hospital (not counting day of discharge) before it will cover care in a skilled nursing facility (SNF).

The issue was one of the talking points during last month’s Hospitalists on the Hill, SHM’s annual daylong advocacy campaign that this year coincided with the annual meeting in the nation’s capital. The issue gained attention from hospitalists and others in recent years, in part because of penalties hospitals face for readmissions—and also in part because hospitalists increasingly are providing care at SNFs and other post-acute-care facilities.

The spotlight is brighter now because a group of legislators is trying to identify Medicare beneficiaries previously given “observation status” as inpatients. The Improving Access to Medicare Coverage Act (H.R. 1179 and S. 569) also would establish a 90-day appeal period for those who have been denied the benefit.

SHM senior vice president Joe Miller says hospitalists used HM13 and the Hospitalists on the Hill advocacy day to discuss the issues and the proposed legislation with members of Congress, their staffs, and federal officials. He urges members to continue lobbying for changes. Although the topic might not have the resonance and impact of a fix to the sustainable growth rate (SGR), Miller says, “anybody that deals with admitting or discharging a patient will recognize the importance of this issue.”

The issue, according to Toby Edelman, a senior policy attorney for the Center for Medicare Advocacy in Washington, D.C, is that Medicare mandates that its program enrollees have at least three days of inpatient treatment before it will pay for SNF care. Medicare also covers the costs of post-acute care in other settings but does not require three days of inpatient treatment before doing so. The construct can be confusing to patients who spend time in a hospital but don’t realize that some or all of their stay is spent in “observation status,” meaning none of that time counts toward Medicare’s three-day threshold for reimbursement.

“Most people can’t believe you could be in a hospital bed for a week and then be told as you leave, ‘By the way, bring your checkbook to the nursing home because you weren’t an inpatient here and so now Medicare won’t pay for your stay in the nursing home,’” Edelman says. “This has been an issue for us for quite a while because the consequence for beneficiaries of being in observation is that people have to pay out of pocket for their nursing home care, and that cost is typically hundreds of dollars a day.”

The particular dilemma for hospitalists is managing transitions of care. Hospitalist Karim Godamunne, MD, MBA, SFHM, chief medical officer of North Fulton Hospital in Roswell, Ga., says hospitalists don’t want financial burdens to dictate care decisions, but they are caught in the middle of decisions that could saddle patients with uncovered costs.

He also worries that the issue will only grow in coming years as baby boomers put more pressure on the health-care system. “We have an aging population,” he adds. “This is not going to go away.”

That is one reason SHM is supporting the Improving Access to Medicare Coverage Act. SHM supported the bill when it was first introduced in March and it has been rapidly gaining cosponsors in recent weeks. This uptick in Congressional interest may be partly a response to the efforts of hospitalists during their time on the Hill. SHM staff and hospitalists are continuing their push now as society officials say hospitalists, who often handle both discharges from the hospital and care provided at SNFs, are in a position to lead discussions on how to sensibly fix the problem.

To that end, a recent SHM letter to the bill’s sponsors casts the issue as one of fiscal responsibility.¹ Medicare not covering beneficiaries’ observation days cost patients out-of-pocket money and could cost hospitals in the long run.

“Patients who are admitted with observation status often choose to return home rather than paying out of pocket for a SNF stay,” SHM’s letter reads. “The resultant lack of appropriate post-acute SNF care can result in additional problems such as dehydration, falls, and many other avoidable complications. These complications can not only lead to otherwise preventable readmissions but also increase costs to Medicare for the treatment of conditions that were not present at the time of the original hospital stay.”

Given the debate on observation, Miller says, adopting the bill into law should be a no-brainer. The biggest sticking point likely is the perceived added cost to Medicare. Still, to streamline care and remove an added hurdle to coordinated care, Dr. Godamunne believes the bill should be embraced. He also says that many private insurers look to Medicare decisions to determine their own coverage approaches.

Basically, if Medicare changes its rules, that will carry a lot of weight in the private insurance world.

“This creates a lot of situations for the provider and the family,” Dr. Godamunne says. “You have to make a difficult decision, to try to help the family. You’re trying to provide good care, but on the other hand, there are rules and regulations and bylaws you work under. They don’t align that well, in this case.”

Richard Quinn is a freelance writer in New Jersey.

References

1. SHM. Letter to Congress members. SHM website. Available at: http://www.hospitalmedicine.org/AM/Template.cfm?Section=Letters_to_Congress_and_Regulatory_Agencies&Template=/CM/ContentDisplay.cfm&ContentID=33169. Accessed May 3, 2013.

You have to make a difficult decision, to try to help the family. You’re trying to provide good care, but on the other hand, there are rules and regulations and bylaws you work under. They don’t align that well, in this case.

—Karim Godamunne, MD, MBA, SFHM

Hospitalists are pushing hard for a change to a Medicare rule requiring beneficiaries to accumulate at least three consecutive days of inpatient treatment at a hospital (not counting day of discharge) before it will cover care in a skilled nursing facility (SNF).

The issue was one of the talking points during last month’s Hospitalists on the Hill, SHM’s annual daylong advocacy campaign that this year coincided with the annual meeting in the nation’s capital. The issue gained attention from hospitalists and others in recent years, in part because of penalties hospitals face for readmissions—and also in part because hospitalists increasingly are providing care at SNFs and other post-acute-care facilities.

The spotlight is brighter now because a group of legislators is trying to identify Medicare beneficiaries previously given “observation status” as inpatients. The Improving Access to Medicare Coverage Act (H.R. 1179 and S. 569) also would establish a 90-day appeal period for those who have been denied the benefit.

SHM senior vice president Joe Miller says hospitalists used HM13 and the Hospitalists on the Hill advocacy day to discuss the issues and the proposed legislation with members of Congress, their staffs, and federal officials. He urges members to continue lobbying for changes. Although the topic might not have the resonance and impact of a fix to the sustainable growth rate (SGR), Miller says, “anybody that deals with admitting or discharging a patient will recognize the importance of this issue.”

The issue, according to Toby Edelman, a senior policy attorney for the Center for Medicare Advocacy in Washington, D.C, is that Medicare mandates that its program enrollees have at least three days of inpatient treatment before it will pay for SNF care. Medicare also covers the costs of post-acute care in other settings but does not require three days of inpatient treatment before doing so. The construct can be confusing to patients who spend time in a hospital but don’t realize that some or all of their stay is spent in “observation status,” meaning none of that time counts toward Medicare’s three-day threshold for reimbursement.

“Most people can’t believe you could be in a hospital bed for a week and then be told as you leave, ‘By the way, bring your checkbook to the nursing home because you weren’t an inpatient here and so now Medicare won’t pay for your stay in the nursing home,’” Edelman says. “This has been an issue for us for quite a while because the consequence for beneficiaries of being in observation is that people have to pay out of pocket for their nursing home care, and that cost is typically hundreds of dollars a day.”

The particular dilemma for hospitalists is managing transitions of care. Hospitalist Karim Godamunne, MD, MBA, SFHM, chief medical officer of North Fulton Hospital in Roswell, Ga., says hospitalists don’t want financial burdens to dictate care decisions, but they are caught in the middle of decisions that could saddle patients with uncovered costs.

He also worries that the issue will only grow in coming years as baby boomers put more pressure on the health-care system. “We have an aging population,” he adds. “This is not going to go away.”

That is one reason SHM is supporting the Improving Access to Medicare Coverage Act. SHM supported the bill when it was first introduced in March and it has been rapidly gaining cosponsors in recent weeks. This uptick in Congressional interest may be partly a response to the efforts of hospitalists during their time on the Hill. SHM staff and hospitalists are continuing their push now as society officials say hospitalists, who often handle both discharges from the hospital and care provided at SNFs, are in a position to lead discussions on how to sensibly fix the problem.

To that end, a recent SHM letter to the bill’s sponsors casts the issue as one of fiscal responsibility.¹ Medicare not covering beneficiaries’ observation days cost patients out-of-pocket money and could cost hospitals in the long run.

“Patients who are admitted with observation status often choose to return home rather than paying out of pocket for a SNF stay,” SHM’s letter reads. “The resultant lack of appropriate post-acute SNF care can result in additional problems such as dehydration, falls, and many other avoidable complications. These complications can not only lead to otherwise preventable readmissions but also increase costs to Medicare for the treatment of conditions that were not present at the time of the original hospital stay.”

Given the debate on observation, Miller says, adopting the bill into law should be a no-brainer. The biggest sticking point likely is the perceived added cost to Medicare. Still, to streamline care and remove an added hurdle to coordinated care, Dr. Godamunne believes the bill should be embraced. He also says that many private insurers look to Medicare decisions to determine their own coverage approaches.

Basically, if Medicare changes its rules, that will carry a lot of weight in the private insurance world.

“This creates a lot of situations for the provider and the family,” Dr. Godamunne says. “You have to make a difficult decision, to try to help the family. You’re trying to provide good care, but on the other hand, there are rules and regulations and bylaws you work under. They don’t align that well, in this case.”

Richard Quinn is a freelance writer in New Jersey.

References

1. SHM. Letter to Congress members. SHM website. Available at: http://www.hospitalmedicine.org/AM/Template.cfm?Section=Letters_to_Congress_and_Regulatory_Agencies&Template=/CM/ContentDisplay.cfm&ContentID=33169. Accessed May 3, 2013.

You have to make a difficult decision, to try to help the family. You’re trying to provide good care, but on the other hand, there are rules and regulations and bylaws you work under. They don’t align that well, in this case.

—Karim Godamunne, MD, MBA, SFHM

Hospitalists are pushing hard for a change to a Medicare rule requiring beneficiaries to accumulate at least three consecutive days of inpatient treatment at a hospital (not counting day of discharge) before it will cover care in a skilled nursing facility (SNF).

The issue was one of the talking points during last month’s Hospitalists on the Hill, SHM’s annual daylong advocacy campaign that this year coincided with the annual meeting in the nation’s capital. The issue gained attention from hospitalists and others in recent years, in part because of penalties hospitals face for readmissions—and also in part because hospitalists increasingly are providing care at SNFs and other post-acute-care facilities.

The spotlight is brighter now because a group of legislators is trying to identify Medicare beneficiaries previously given “observation status” as inpatients. The Improving Access to Medicare Coverage Act (H.R. 1179 and S. 569) also would establish a 90-day appeal period for those who have been denied the benefit.

SHM senior vice president Joe Miller says hospitalists used HM13 and the Hospitalists on the Hill advocacy day to discuss the issues and the proposed legislation with members of Congress, their staffs, and federal officials. He urges members to continue lobbying for changes. Although the topic might not have the resonance and impact of a fix to the sustainable growth rate (SGR), Miller says, “anybody that deals with admitting or discharging a patient will recognize the importance of this issue.”

The issue, according to Toby Edelman, a senior policy attorney for the Center for Medicare Advocacy in Washington, D.C, is that Medicare mandates that its program enrollees have at least three days of inpatient treatment before it will pay for SNF care. Medicare also covers the costs of post-acute care in other settings but does not require three days of inpatient treatment before doing so. The construct can be confusing to patients who spend time in a hospital but don’t realize that some or all of their stay is spent in “observation status,” meaning none of that time counts toward Medicare’s three-day threshold for reimbursement.

“Most people can’t believe you could be in a hospital bed for a week and then be told as you leave, ‘By the way, bring your checkbook to the nursing home because you weren’t an inpatient here and so now Medicare won’t pay for your stay in the nursing home,’” Edelman says. “This has been an issue for us for quite a while because the consequence for beneficiaries of being in observation is that people have to pay out of pocket for their nursing home care, and that cost is typically hundreds of dollars a day.”

The particular dilemma for hospitalists is managing transitions of care. Hospitalist Karim Godamunne, MD, MBA, SFHM, chief medical officer of North Fulton Hospital in Roswell, Ga., says hospitalists don’t want financial burdens to dictate care decisions, but they are caught in the middle of decisions that could saddle patients with uncovered costs.

He also worries that the issue will only grow in coming years as baby boomers put more pressure on the health-care system. “We have an aging population,” he adds. “This is not going to go away.”

That is one reason SHM is supporting the Improving Access to Medicare Coverage Act. SHM supported the bill when it was first introduced in March and it has been rapidly gaining cosponsors in recent weeks. This uptick in Congressional interest may be partly a response to the efforts of hospitalists during their time on the Hill. SHM staff and hospitalists are continuing their push now as society officials say hospitalists, who often handle both discharges from the hospital and care provided at SNFs, are in a position to lead discussions on how to sensibly fix the problem.

To that end, a recent SHM letter to the bill’s sponsors casts the issue as one of fiscal responsibility.¹ Medicare not covering beneficiaries’ observation days cost patients out-of-pocket money and could cost hospitals in the long run.

“Patients who are admitted with observation status often choose to return home rather than paying out of pocket for a SNF stay,” SHM’s letter reads. “The resultant lack of appropriate post-acute SNF care can result in additional problems such as dehydration, falls, and many other avoidable complications. These complications can not only lead to otherwise preventable readmissions but also increase costs to Medicare for the treatment of conditions that were not present at the time of the original hospital stay.”

Given the debate on observation, Miller says, adopting the bill into law should be a no-brainer. The biggest sticking point likely is the perceived added cost to Medicare. Still, to streamline care and remove an added hurdle to coordinated care, Dr. Godamunne believes the bill should be embraced. He also says that many private insurers look to Medicare decisions to determine their own coverage approaches.

Basically, if Medicare changes its rules, that will carry a lot of weight in the private insurance world.

“This creates a lot of situations for the provider and the family,” Dr. Godamunne says. “You have to make a difficult decision, to try to help the family. You’re trying to provide good care, but on the other hand, there are rules and regulations and bylaws you work under. They don’t align that well, in this case.”

Richard Quinn is a freelance writer in New Jersey.

References

1. SHM. Letter to Congress members. SHM website. Available at: http://www.hospitalmedicine.org/AM/Template.cfm?Section=Letters_to_Congress_and_Regulatory_Agencies&Template=/CM/ContentDisplay.cfm&ContentID=33169. Accessed May 3, 2013.

Alarms about our nation’s health-care costs have been sounding for well over a decade. According to the Centers for Medicare & Medicaid Services (CMS), spending on U.S. health care doubled between 1999 and 2011, climbing to $2.7 trillion from $1.3 trillion, and now represents 17.9% of the United States’ GDP.¹

“The medical care system is bankrupting the country,” Paul B. Ginsburg, PhD, president of the Center for Studying Health System Change (HSC), based in Washington, D.C., says bluntly. A four-decade-long upward spending trend is “unsustainable,” he wrote in the New England Journal of Medicine with Chapin White, PhD, a senior health researcher at HSC.²

Recent reports suggest that rising premiums and out-of-pocket costs are rendering the price of health care untenable for the average consumer. A 2011 RAND Corp. study found that, for the average American family, the rate of increased costs for health care had outpaced growth in earnings from 1999 to 2009.³ And last year, for the first time, the cost of health care for a typical American family of four surpassed $20,000, the annual Milliman Medical Index reported.⁴

Should hospitalists be concerned, professionally and personally, about these trends? Absolutely, say hospitalist leaders who spoke with The Hospitalist. HM clinicians have much to contribute at both the macro level (addressing systemic causes of overutilization through quality improvement and other initiatives) and at the micro level, by understanding their personal contributions and by engaging patients and their families in shared decision-making.

But getting at and addressing the root causes of rising health-care costs, according to health-care policy analysts and veteran hospitalists, will require major shifts in thinking and processes.

Contributors to Rising Costs

It’s difficult to pinpoint the root causes of the recent surge in health-care costs. Victor Fuchs, emeritus professor of economics and health research and policy at Stanford University, points to the U.S.’ high administrative costs and complicated billing systems.⁵ A fragmented, nontransparent system for negotiating fees between insurers and providers also plays a role, as demonstrated in a Consumer Reports investigation into geographic variations in costs for common tests and procedures. A complete blood count might be as low as $15 or as high as $105; a colonoscopy ranges from $800 to $3,160.⁶

Bradley Flansbaum, DO, MPH, SFHM, an SHM Public Policy Committee member and AMA delegate, says rising costs are a provider-specific issue. He challenges colleagues to take an honest look at their own practice patterns to assess whether they’re contributing to overuse of resources (see “A Lesson in Change,”).

“The culture of practice has developed so that this is not going to change overnight,” says Dr. Flansbaum, director of hospitalist services at Lenox Hill Hospital in New York City. That’s because many physicians fail to view their own decisions as a problem. For example, says Dr. Flansbaum, “an oncologist may not identify a third round of chemotherapy as an embodiment of the problem, or a gastroenterologist might not embody the colonoscopy at Year Four instead of Year Five as the problem. We must come to grips with the usual mindset, look in the mirror, and admit, ‘Maybe we are part of the problem.’”

The culture of practice has developed so that this is not going to change overnight. An oncologist may not identify a third round of chemotherapy as an embodiment of the problem. We must come to grips with the usual mindset, look in the mirror, and admit, 'Maybe we are part of the problem.'

—Bradley Flansbaum, DO, MPH, SFHM

Potential Solutions

Hospitalists, intensivists, and ED clinicians are tasked with finding a balance between being prudent stewards of resources and staying within a comfort zone that promotes patient safety. SHM supports the goals of the ABIM Foundation’s Choosing Wisely campaign, which aims to reduce waste by curtailing duplicative and unnecessary care (see “Better Choices, Better Care,” March 2013). Also included in the campaign (www.ChoosingWisely.org) are the American College of Physicians’ recommendations against low-value testing (e.g. obtaining imaging studies in patients with nonspecific low back pain).

“Those recommendations are not going to solve our health spending problem,” says White, “but they are part of a broader move to give permission to clinicians, based on evidence, to follow more conservative practice patterns.”

Still, counters David I. Auerbach, PhD, a health economist at RAND in Boston and author of the RAND study, “there’s another value to these tests that the cost-effectiveness equations do not always consider, which is, they can bring peace of mind. We’re trying to nudge patients down the pathway that we think is best for them without rationing care. That’s a delicate balance.”

Dr. Flansbaum says SHM’s Public Policy Committee has discussed a variety of issues related to rising costs, although the group has not directly tackled advice in the form of a white paper. He suggests some ways that hospitalists can address cost savings:

• Involve patients in shared decision-making, and discuss the evidence against unnecessary testing;
• Utilize generic medications on discharge, when available, especially if patients are uninsured or have limited drug coverage with their insurance plans;
• Use palliative care whenever appropriate; and
• Adhere to transitional-care standards.

On the macro level, HM has “always been the specialty invited to champion the important discussion relating to resource utilization, and the evidence-based medicine driving that resource utilization,” says Christopher Frost, MD, FHM, medical director of hospital medicine at the Hospital Corporation of America (HCA) in Nashville, Tenn. He points to SHM’s leadership with Project BOOST (www.hospitalmedicine.org/boost) as one example of addressing the utilization of resources in caring for older adults (see “Resources for Improving Transitions in Care,”).

What else can hospitalists do? Going forward, says Dan Fuller, president and co-founder of IN Compass Health in Alpharetta, Ga., it might be a good idea for the SHM Practice Analysis Committee, of which he’s a member, to look at its possible role in the issue.

We need the time to make these calls [to PCPs], to sit down with families. This adds value to our health system and to society at large.

—Dr. Frederickson

Embrace Reality

Whatever the downstream developments around the Affordable Care Act, Dr. Ginsburg is “confident” that Medicare policies will continue in a direction of reduced reimbursements. Thomas Frederickson, MD, FACP, FHM, MBA, medical director of the hospital medicine service at Alegent Health in Omaha, Neb., agrees with such an assessment. He also believes that hospitalists are in a prime position to improve care delivery at less cost. To do so, though, requires deliberate partnership-building with outpatient providers to better bridge the transitions of care.

At his institution, Dr. Frederickson says, hospitalists invite themselves to primary-care physicians’ (PCP) meetings. This facilitates rapport so that calls to PCPs at discharge not only communicate essential clinical information, but also build confidence in the hospitalists’ care of their patients. As hospitalists demonstrate value, they must intentionally put metrics in place so that administrators appreciate the need to keep the census at a certain level, Dr. Frederickson says.

“We need the time to make these calls, to sit down with families,” he says. “This adds value to our health system and to society at large.”

SHM does a good job, says Dr. Frost, of being part of the conversation as the hospital C-suite focuses more on episodes of care.

“The intensity of that discussion is getting dialed up and will be driven more by government and the payors,” he adds. The challenge going forward will be to bridge those arenas just outside the acute episode of care, where hospitalists have ownership of processes, to those where they do not have as much control. If payors apply broader definitions to the episode of care, Dr. Frost says, hospitalists might be “invited to play an increasing role, that of ‘transitionist.’”

And in that context, he says, hospitalists need to look at length of stay with a new lens.

Partnership-building will become more important as the definition of “episode of care” expands beyond the hospital stay to the post-acute setting.

“Including post-acute care in the episode of care is a core aspect of the whole” value-based purchasing approach, Dr. Ginsburg says. “Hospitals [and hospitalists] will be wise to opt for the model with the greatest potential to reduce costs, particularly costs incurred by other providers.”

Gretchen Henkel is a freelance writer in California.

References

1. Centers for Medicare & Medicaid Services. National health expenditures 2011 highlights. Centers for Medicare & Medicaid Services website. Available at: http://www.cms.gov/Research-Statistics-Data-and-Systems/Statistics-Trends-and-Reports/NationalHealthExpendData/Downloads/highlights.pdf. Accessed May 6, 2013. costs how much? Consumer Reports website. Available at: http://www.consumerreports.org/cro/magazine/ 2012/07/that-ct-scan-costs-how-much/index.htm. Accessed Aug. 2, 2012.
2. White C, Ginsburg PB. Slower growth in Medicare spending—is this the new normal? N Engl J Med. 2012;366(12):1073-1075.
3. Auerbach DI, Kellermann AL. A decade of health care cost growth has wiped out real income gains for an average US family. Health Aff (Millwood). 2011;30(9):1630-1636.
4. Milliman Inc. 2012 Milliman Medical Index. Milliman Inc. website. Available at: http://publications.milliman.com/periodicals/mmi/pdfs/milliman-medical-index-2012.pdf. Accessed Aug. 1, 2012.
5. Kolata G. Knotty challenges in health care costs. The New York Times website. Available at: http://www.nytimes.com/2012/03/06/health/policy/an-interview-with-victor-fuchs-on-health-care-costs.html. Accessed March 8, 2012.
6. Consumer Reports. That CT scan costs how much? Consumer Reports website. Available at: http://www.consumerreports.org/cro/magazine/ 2012/07/that-ct-scan-costs-how-much/index.htm.

Alarms about our nation’s health-care costs have been sounding for well over a decade. According to the Centers for Medicare & Medicaid Services (CMS), spending on U.S. health care doubled between 1999 and 2011, climbing to $2.7 trillion from $1.3 trillion, and now represents 17.9% of the United States’ GDP.¹

“The medical care system is bankrupting the country,” Paul B. Ginsburg, PhD, president of the Center for Studying Health System Change (HSC), based in Washington, D.C., says bluntly. A four-decade-long upward spending trend is “unsustainable,” he wrote in the New England Journal of Medicine with Chapin White, PhD, a senior health researcher at HSC.²

Recent reports suggest that rising premiums and out-of-pocket costs are rendering the price of health care untenable for the average consumer. A 2011 RAND Corp. study found that, for the average American family, the rate of increased costs for health care had outpaced growth in earnings from 1999 to 2009.³ And last year, for the first time, the cost of health care for a typical American family of four surpassed $20,000, the annual Milliman Medical Index reported.⁴

Should hospitalists be concerned, professionally and personally, about these trends? Absolutely, say hospitalist leaders who spoke with The Hospitalist. HM clinicians have much to contribute at both the macro level (addressing systemic causes of overutilization through quality improvement and other initiatives) and at the micro level, by understanding their personal contributions and by engaging patients and their families in shared decision-making.

But getting at and addressing the root causes of rising health-care costs, according to health-care policy analysts and veteran hospitalists, will require major shifts in thinking and processes.

Contributors to Rising Costs

It’s difficult to pinpoint the root causes of the recent surge in health-care costs. Victor Fuchs, emeritus professor of economics and health research and policy at Stanford University, points to the U.S.’ high administrative costs and complicated billing systems.⁵ A fragmented, nontransparent system for negotiating fees between insurers and providers also plays a role, as demonstrated in a Consumer Reports investigation into geographic variations in costs for common tests and procedures. A complete blood count might be as low as $15 or as high as $105; a colonoscopy ranges from $800 to $3,160.⁶

Bradley Flansbaum, DO, MPH, SFHM, an SHM Public Policy Committee member and AMA delegate, says rising costs are a provider-specific issue. He challenges colleagues to take an honest look at their own practice patterns to assess whether they’re contributing to overuse of resources (see “A Lesson in Change,”).

“The culture of practice has developed so that this is not going to change overnight,” says Dr. Flansbaum, director of hospitalist services at Lenox Hill Hospital in New York City. That’s because many physicians fail to view their own decisions as a problem. For example, says Dr. Flansbaum, “an oncologist may not identify a third round of chemotherapy as an embodiment of the problem, or a gastroenterologist might not embody the colonoscopy at Year Four instead of Year Five as the problem. We must come to grips with the usual mindset, look in the mirror, and admit, ‘Maybe we are part of the problem.’”

The culture of practice has developed so that this is not going to change overnight. An oncologist may not identify a third round of chemotherapy as an embodiment of the problem. We must come to grips with the usual mindset, look in the mirror, and admit, 'Maybe we are part of the problem.'

—Bradley Flansbaum, DO, MPH, SFHM

Potential Solutions

Hospitalists, intensivists, and ED clinicians are tasked with finding a balance between being prudent stewards of resources and staying within a comfort zone that promotes patient safety. SHM supports the goals of the ABIM Foundation’s Choosing Wisely campaign, which aims to reduce waste by curtailing duplicative and unnecessary care (see “Better Choices, Better Care,” March 2013). Also included in the campaign (www.ChoosingWisely.org) are the American College of Physicians’ recommendations against low-value testing (e.g. obtaining imaging studies in patients with nonspecific low back pain).

“Those recommendations are not going to solve our health spending problem,” says White, “but they are part of a broader move to give permission to clinicians, based on evidence, to follow more conservative practice patterns.”

Still, counters David I. Auerbach, PhD, a health economist at RAND in Boston and author of the RAND study, “there’s another value to these tests that the cost-effectiveness equations do not always consider, which is, they can bring peace of mind. We’re trying to nudge patients down the pathway that we think is best for them without rationing care. That’s a delicate balance.”

Dr. Flansbaum says SHM’s Public Policy Committee has discussed a variety of issues related to rising costs, although the group has not directly tackled advice in the form of a white paper. He suggests some ways that hospitalists can address cost savings:

• Involve patients in shared decision-making, and discuss the evidence against unnecessary testing;
• Utilize generic medications on discharge, when available, especially if patients are uninsured or have limited drug coverage with their insurance plans;
• Use palliative care whenever appropriate; and
• Adhere to transitional-care standards.

On the macro level, HM has “always been the specialty invited to champion the important discussion relating to resource utilization, and the evidence-based medicine driving that resource utilization,” says Christopher Frost, MD, FHM, medical director of hospital medicine at the Hospital Corporation of America (HCA) in Nashville, Tenn. He points to SHM’s leadership with Project BOOST (www.hospitalmedicine.org/boost) as one example of addressing the utilization of resources in caring for older adults (see “Resources for Improving Transitions in Care,”).

What else can hospitalists do? Going forward, says Dan Fuller, president and co-founder of IN Compass Health in Alpharetta, Ga., it might be a good idea for the SHM Practice Analysis Committee, of which he’s a member, to look at its possible role in the issue.

We need the time to make these calls [to PCPs], to sit down with families. This adds value to our health system and to society at large.

—Dr. Frederickson

Embrace Reality

Whatever the downstream developments around the Affordable Care Act, Dr. Ginsburg is “confident” that Medicare policies will continue in a direction of reduced reimbursements. Thomas Frederickson, MD, FACP, FHM, MBA, medical director of the hospital medicine service at Alegent Health in Omaha, Neb., agrees with such an assessment. He also believes that hospitalists are in a prime position to improve care delivery at less cost. To do so, though, requires deliberate partnership-building with outpatient providers to better bridge the transitions of care.

At his institution, Dr. Frederickson says, hospitalists invite themselves to primary-care physicians’ (PCP) meetings. This facilitates rapport so that calls to PCPs at discharge not only communicate essential clinical information, but also build confidence in the hospitalists’ care of their patients. As hospitalists demonstrate value, they must intentionally put metrics in place so that administrators appreciate the need to keep the census at a certain level, Dr. Frederickson says.

“We need the time to make these calls, to sit down with families,” he says. “This adds value to our health system and to society at large.”

SHM does a good job, says Dr. Frost, of being part of the conversation as the hospital C-suite focuses more on episodes of care.

“The intensity of that discussion is getting dialed up and will be driven more by government and the payors,” he adds. The challenge going forward will be to bridge those arenas just outside the acute episode of care, where hospitalists have ownership of processes, to those where they do not have as much control. If payors apply broader definitions to the episode of care, Dr. Frost says, hospitalists might be “invited to play an increasing role, that of ‘transitionist.’”

And in that context, he says, hospitalists need to look at length of stay with a new lens.

Partnership-building will become more important as the definition of “episode of care” expands beyond the hospital stay to the post-acute setting.

“Including post-acute care in the episode of care is a core aspect of the whole” value-based purchasing approach, Dr. Ginsburg says. “Hospitals [and hospitalists] will be wise to opt for the model with the greatest potential to reduce costs, particularly costs incurred by other providers.”

Gretchen Henkel is a freelance writer in California.

References

1. Centers for Medicare & Medicaid Services. National health expenditures 2011 highlights. Centers for Medicare & Medicaid Services website. Available at: http://www.cms.gov/Research-Statistics-Data-and-Systems/Statistics-Trends-and-Reports/NationalHealthExpendData/Downloads/highlights.pdf. Accessed May 6, 2013. costs how much? Consumer Reports website. Available at: http://www.consumerreports.org/cro/magazine/ 2012/07/that-ct-scan-costs-how-much/index.htm. Accessed Aug. 2, 2012.
2. White C, Ginsburg PB. Slower growth in Medicare spending—is this the new normal? N Engl J Med. 2012;366(12):1073-1075.
3. Auerbach DI, Kellermann AL. A decade of health care cost growth has wiped out real income gains for an average US family. Health Aff (Millwood). 2011;30(9):1630-1636.
4. Milliman Inc. 2012 Milliman Medical Index. Milliman Inc. website. Available at: http://publications.milliman.com/periodicals/mmi/pdfs/milliman-medical-index-2012.pdf. Accessed Aug. 1, 2012.
5. Kolata G. Knotty challenges in health care costs. The New York Times website. Available at: http://www.nytimes.com/2012/03/06/health/policy/an-interview-with-victor-fuchs-on-health-care-costs.html. Accessed March 8, 2012.
6. Consumer Reports. That CT scan costs how much? Consumer Reports website. Available at: http://www.consumerreports.org/cro/magazine/ 2012/07/that-ct-scan-costs-how-much/index.htm.

Alarms about our nation’s health-care costs have been sounding for well over a decade. According to the Centers for Medicare & Medicaid Services (CMS), spending on U.S. health care doubled between 1999 and 2011, climbing to $2.7 trillion from $1.3 trillion, and now represents 17.9% of the United States’ GDP.¹

“The medical care system is bankrupting the country,” Paul B. Ginsburg, PhD, president of the Center for Studying Health System Change (HSC), based in Washington, D.C., says bluntly. A four-decade-long upward spending trend is “unsustainable,” he wrote in the New England Journal of Medicine with Chapin White, PhD, a senior health researcher at HSC.²

Recent reports suggest that rising premiums and out-of-pocket costs are rendering the price of health care untenable for the average consumer. A 2011 RAND Corp. study found that, for the average American family, the rate of increased costs for health care had outpaced growth in earnings from 1999 to 2009.³ And last year, for the first time, the cost of health care for a typical American family of four surpassed $20,000, the annual Milliman Medical Index reported.⁴

Should hospitalists be concerned, professionally and personally, about these trends? Absolutely, say hospitalist leaders who spoke with The Hospitalist. HM clinicians have much to contribute at both the macro level (addressing systemic causes of overutilization through quality improvement and other initiatives) and at the micro level, by understanding their personal contributions and by engaging patients and their families in shared decision-making.

But getting at and addressing the root causes of rising health-care costs, according to health-care policy analysts and veteran hospitalists, will require major shifts in thinking and processes.

Contributors to Rising Costs

It’s difficult to pinpoint the root causes of the recent surge in health-care costs. Victor Fuchs, emeritus professor of economics and health research and policy at Stanford University, points to the U.S.’ high administrative costs and complicated billing systems.⁵ A fragmented, nontransparent system for negotiating fees between insurers and providers also plays a role, as demonstrated in a Consumer Reports investigation into geographic variations in costs for common tests and procedures. A complete blood count might be as low as $15 or as high as $105; a colonoscopy ranges from $800 to $3,160.⁶

Bradley Flansbaum, DO, MPH, SFHM, an SHM Public Policy Committee member and AMA delegate, says rising costs are a provider-specific issue. He challenges colleagues to take an honest look at their own practice patterns to assess whether they’re contributing to overuse of resources (see “A Lesson in Change,”).

“The culture of practice has developed so that this is not going to change overnight,” says Dr. Flansbaum, director of hospitalist services at Lenox Hill Hospital in New York City. That’s because many physicians fail to view their own decisions as a problem. For example, says Dr. Flansbaum, “an oncologist may not identify a third round of chemotherapy as an embodiment of the problem, or a gastroenterologist might not embody the colonoscopy at Year Four instead of Year Five as the problem. We must come to grips with the usual mindset, look in the mirror, and admit, ‘Maybe we are part of the problem.’”

The culture of practice has developed so that this is not going to change overnight. An oncologist may not identify a third round of chemotherapy as an embodiment of the problem. We must come to grips with the usual mindset, look in the mirror, and admit, 'Maybe we are part of the problem.'

—Bradley Flansbaum, DO, MPH, SFHM

Potential Solutions

Hospitalists, intensivists, and ED clinicians are tasked with finding a balance between being prudent stewards of resources and staying within a comfort zone that promotes patient safety. SHM supports the goals of the ABIM Foundation’s Choosing Wisely campaign, which aims to reduce waste by curtailing duplicative and unnecessary care (see “Better Choices, Better Care,” March 2013). Also included in the campaign (www.ChoosingWisely.org) are the American College of Physicians’ recommendations against low-value testing (e.g. obtaining imaging studies in patients with nonspecific low back pain).

“Those recommendations are not going to solve our health spending problem,” says White, “but they are part of a broader move to give permission to clinicians, based on evidence, to follow more conservative practice patterns.”

Still, counters David I. Auerbach, PhD, a health economist at RAND in Boston and author of the RAND study, “there’s another value to these tests that the cost-effectiveness equations do not always consider, which is, they can bring peace of mind. We’re trying to nudge patients down the pathway that we think is best for them without rationing care. That’s a delicate balance.”

Dr. Flansbaum says SHM’s Public Policy Committee has discussed a variety of issues related to rising costs, although the group has not directly tackled advice in the form of a white paper. He suggests some ways that hospitalists can address cost savings:

• Involve patients in shared decision-making, and discuss the evidence against unnecessary testing;
• Utilize generic medications on discharge, when available, especially if patients are uninsured or have limited drug coverage with their insurance plans;
• Use palliative care whenever appropriate; and
• Adhere to transitional-care standards.

On the macro level, HM has “always been the specialty invited to champion the important discussion relating to resource utilization, and the evidence-based medicine driving that resource utilization,” says Christopher Frost, MD, FHM, medical director of hospital medicine at the Hospital Corporation of America (HCA) in Nashville, Tenn. He points to SHM’s leadership with Project BOOST (www.hospitalmedicine.org/boost) as one example of addressing the utilization of resources in caring for older adults (see “Resources for Improving Transitions in Care,”).

What else can hospitalists do? Going forward, says Dan Fuller, president and co-founder of IN Compass Health in Alpharetta, Ga., it might be a good idea for the SHM Practice Analysis Committee, of which he’s a member, to look at its possible role in the issue.

We need the time to make these calls [to PCPs], to sit down with families. This adds value to our health system and to society at large.

—Dr. Frederickson

Embrace Reality

Whatever the downstream developments around the Affordable Care Act, Dr. Ginsburg is “confident” that Medicare policies will continue in a direction of reduced reimbursements. Thomas Frederickson, MD, FACP, FHM, MBA, medical director of the hospital medicine service at Alegent Health in Omaha, Neb., agrees with such an assessment. He also believes that hospitalists are in a prime position to improve care delivery at less cost. To do so, though, requires deliberate partnership-building with outpatient providers to better bridge the transitions of care.

At his institution, Dr. Frederickson says, hospitalists invite themselves to primary-care physicians’ (PCP) meetings. This facilitates rapport so that calls to PCPs at discharge not only communicate essential clinical information, but also build confidence in the hospitalists’ care of their patients. As hospitalists demonstrate value, they must intentionally put metrics in place so that administrators appreciate the need to keep the census at a certain level, Dr. Frederickson says.

“We need the time to make these calls, to sit down with families,” he says. “This adds value to our health system and to society at large.”

SHM does a good job, says Dr. Frost, of being part of the conversation as the hospital C-suite focuses more on episodes of care.

“The intensity of that discussion is getting dialed up and will be driven more by government and the payors,” he adds. The challenge going forward will be to bridge those arenas just outside the acute episode of care, where hospitalists have ownership of processes, to those where they do not have as much control. If payors apply broader definitions to the episode of care, Dr. Frost says, hospitalists might be “invited to play an increasing role, that of ‘transitionist.’”

And in that context, he says, hospitalists need to look at length of stay with a new lens.

Partnership-building will become more important as the definition of “episode of care” expands beyond the hospital stay to the post-acute setting.

“Including post-acute care in the episode of care is a core aspect of the whole” value-based purchasing approach, Dr. Ginsburg says. “Hospitals [and hospitalists] will be wise to opt for the model with the greatest potential to reduce costs, particularly costs incurred by other providers.”

Gretchen Henkel is a freelance writer in California.

References

1. Centers for Medicare & Medicaid Services. National health expenditures 2011 highlights. Centers for Medicare & Medicaid Services website. Available at: http://www.cms.gov/Research-Statistics-Data-and-Systems/Statistics-Trends-and-Reports/NationalHealthExpendData/Downloads/highlights.pdf. Accessed May 6, 2013. costs how much? Consumer Reports website. Available at: http://www.consumerreports.org/cro/magazine/ 2012/07/that-ct-scan-costs-how-much/index.htm. Accessed Aug. 2, 2012.
2. White C, Ginsburg PB. Slower growth in Medicare spending—is this the new normal? N Engl J Med. 2012;366(12):1073-1075.
3. Auerbach DI, Kellermann AL. A decade of health care cost growth has wiped out real income gains for an average US family. Health Aff (Millwood). 2011;30(9):1630-1636.
4. Milliman Inc. 2012 Milliman Medical Index. Milliman Inc. website. Available at: http://publications.milliman.com/periodicals/mmi/pdfs/milliman-medical-index-2012.pdf. Accessed Aug. 1, 2012.
5. Kolata G. Knotty challenges in health care costs. The New York Times website. Available at: http://www.nytimes.com/2012/03/06/health/policy/an-interview-with-victor-fuchs-on-health-care-costs.html. Accessed March 8, 2012.
6. Consumer Reports. That CT scan costs how much? Consumer Reports website. Available at: http://www.consumerreports.org/cro/magazine/ 2012/07/that-ct-scan-costs-how-much/index.htm.

Medicare requires beneficiaries to have at least three consecutive days as a hospital inpatient to qualify for Medicare-covered skilled nursing facility (SNF) care. As the use and duration of observation status continues to rise throughout the nation, patients have been getting caught more frequently within a policy trap: Even though they are physically within the hospital and generally receive care that is indistinguishable from the care received by other inpatients, Medicare is not covering their subsequent SNF stays.

Why? Observation status is considered “outpatient” by both the hospital and Medicare and, therefore, is not counted toward Medicare’s three-day rule.

This leaves seniors on the hook for their skilled nursing care costs, which often exceed their ability to pay. Further, this shortsighted policy might actually result in a net greater cost to Medicare and the health-care system. Faced with mounting costs, many seniors truncate or opt out of SNF care altogether, leaving them vulnerable to added health issues (e.g. dehydration, falls). With new conditions that were not present at the time of the original hospital stay, many of these seniors are at risk to return to the hospital and become another readmission statistic.

As key players in hospitals and, increasingly, in skilled nursing facilities, hospitalists are caught squarely in the middle of this policy. Transitions of care both in and out of these institutions should be guided by sound medical decision-making, not whether Medicare will cover the costs incurred. Although the three-day rule—and, indeed, observation status itself—was originally cast as a cost-containment policy, such policies should incorporate broader care process and delivery reforms that do not add burden to patients when they are at their most vulnerable.

SHM affirms that it is sensible for Medicare to provide coverage for skilled nursing care if a clinician recommends it as part of a treatment plan. Coverage determination should not be beholden to a patient status subject to other systemic pressures, but should reflect the best interest of the patient and the care ordered by providers.

The Improving Access to Medicare Coverage Act, sponsored by Rep. Joe Courtney (D-Conn.), Rep. Tom Latham (R-Iowa), and Sen. Sherrod Brown (D-Ohio), would clarify the law to indicate that Medicare beneficiaries in observation status are deemed inpatients in the hospital for the purposes of the three-day requirement for SNF coverage. This simple adjustment would ensure that patients are able to access the skilled nursing care they need and that providers do not have to worry about this systemic barrier to patient care.

SHM is actively supporting this legislation. A letter of support was sent to Courtney and Brown earlier this year, and membership was mobilized to take action through our Legislative Action Center (www.hospitalmedicine.org/advocacy). Hospitalists also plan to voice their support for the legislation during Hospitalists on the Hill, to be held this month in conjunction with HM13.

As one of only a few specialty medical societies that are active on this issue, SHM stands out as a leader on health-care-system reforms that improve access to care for patients and reduce administrative barriers to medically appropriate care.

Joshua Lapps is SHM’s government relations specialist.

Medicare requires beneficiaries to have at least three consecutive days as a hospital inpatient to qualify for Medicare-covered skilled nursing facility (SNF) care. As the use and duration of observation status continues to rise throughout the nation, patients have been getting caught more frequently within a policy trap: Even though they are physically within the hospital and generally receive care that is indistinguishable from the care received by other inpatients, Medicare is not covering their subsequent SNF stays.

Why? Observation status is considered “outpatient” by both the hospital and Medicare and, therefore, is not counted toward Medicare’s three-day rule.

This leaves seniors on the hook for their skilled nursing care costs, which often exceed their ability to pay. Further, this shortsighted policy might actually result in a net greater cost to Medicare and the health-care system. Faced with mounting costs, many seniors truncate or opt out of SNF care altogether, leaving them vulnerable to added health issues (e.g. dehydration, falls). With new conditions that were not present at the time of the original hospital stay, many of these seniors are at risk to return to the hospital and become another readmission statistic.

As key players in hospitals and, increasingly, in skilled nursing facilities, hospitalists are caught squarely in the middle of this policy. Transitions of care both in and out of these institutions should be guided by sound medical decision-making, not whether Medicare will cover the costs incurred. Although the three-day rule—and, indeed, observation status itself—was originally cast as a cost-containment policy, such policies should incorporate broader care process and delivery reforms that do not add burden to patients when they are at their most vulnerable.

SHM affirms that it is sensible for Medicare to provide coverage for skilled nursing care if a clinician recommends it as part of a treatment plan. Coverage determination should not be beholden to a patient status subject to other systemic pressures, but should reflect the best interest of the patient and the care ordered by providers.

The Improving Access to Medicare Coverage Act, sponsored by Rep. Joe Courtney (D-Conn.), Rep. Tom Latham (R-Iowa), and Sen. Sherrod Brown (D-Ohio), would clarify the law to indicate that Medicare beneficiaries in observation status are deemed inpatients in the hospital for the purposes of the three-day requirement for SNF coverage. This simple adjustment would ensure that patients are able to access the skilled nursing care they need and that providers do not have to worry about this systemic barrier to patient care.

SHM is actively supporting this legislation. A letter of support was sent to Courtney and Brown earlier this year, and membership was mobilized to take action through our Legislative Action Center (www.hospitalmedicine.org/advocacy). Hospitalists also plan to voice their support for the legislation during Hospitalists on the Hill, to be held this month in conjunction with HM13.

As one of only a few specialty medical societies that are active on this issue, SHM stands out as a leader on health-care-system reforms that improve access to care for patients and reduce administrative barriers to medically appropriate care.

Joshua Lapps is SHM’s government relations specialist.

Medicare requires beneficiaries to have at least three consecutive days as a hospital inpatient to qualify for Medicare-covered skilled nursing facility (SNF) care. As the use and duration of observation status continues to rise throughout the nation, patients have been getting caught more frequently within a policy trap: Even though they are physically within the hospital and generally receive care that is indistinguishable from the care received by other inpatients, Medicare is not covering their subsequent SNF stays.

Why? Observation status is considered “outpatient” by both the hospital and Medicare and, therefore, is not counted toward Medicare’s three-day rule.

This leaves seniors on the hook for their skilled nursing care costs, which often exceed their ability to pay. Further, this shortsighted policy might actually result in a net greater cost to Medicare and the health-care system. Faced with mounting costs, many seniors truncate or opt out of SNF care altogether, leaving them vulnerable to added health issues (e.g. dehydration, falls). With new conditions that were not present at the time of the original hospital stay, many of these seniors are at risk to return to the hospital and become another readmission statistic.

As key players in hospitals and, increasingly, in skilled nursing facilities, hospitalists are caught squarely in the middle of this policy. Transitions of care both in and out of these institutions should be guided by sound medical decision-making, not whether Medicare will cover the costs incurred. Although the three-day rule—and, indeed, observation status itself—was originally cast as a cost-containment policy, such policies should incorporate broader care process and delivery reforms that do not add burden to patients when they are at their most vulnerable.

SHM affirms that it is sensible for Medicare to provide coverage for skilled nursing care if a clinician recommends it as part of a treatment plan. Coverage determination should not be beholden to a patient status subject to other systemic pressures, but should reflect the best interest of the patient and the care ordered by providers.

The Improving Access to Medicare Coverage Act, sponsored by Rep. Joe Courtney (D-Conn.), Rep. Tom Latham (R-Iowa), and Sen. Sherrod Brown (D-Ohio), would clarify the law to indicate that Medicare beneficiaries in observation status are deemed inpatients in the hospital for the purposes of the three-day requirement for SNF coverage. This simple adjustment would ensure that patients are able to access the skilled nursing care they need and that providers do not have to worry about this systemic barrier to patient care.

SHM is actively supporting this legislation. A letter of support was sent to Courtney and Brown earlier this year, and membership was mobilized to take action through our Legislative Action Center (www.hospitalmedicine.org/advocacy). Hospitalists also plan to voice their support for the legislation during Hospitalists on the Hill, to be held this month in conjunction with HM13.

As one of only a few specialty medical societies that are active on this issue, SHM stands out as a leader on health-care-system reforms that improve access to care for patients and reduce administrative barriers to medically appropriate care.

Joshua Lapps is SHM’s government relations specialist.