SHM's Policy Corner

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.

A veritable perfect storm of relationships brought hospitalist Jairy Hunter, MD, MBA, SFHM, to “Hospitalists on the Hill 2013,” a daylong advocacy affair that preceded HM13 last month.

First, Dr. Hunter was born and bred—and now lives—in South Carolina, a close-knit state where leaders across industries tend to run in the same circles, or at least have relatives who do. Second, Dr. Hunter’s father, Jairy Hunter Jr., is the longtime president of Charleston Southern University, where Sen. Tim Scott (R-S.C.) earned his undergraduate degree when it was still called Baptist College at Charleston. And three, Dr. Hunter is associate executive medical director of one of the state’s flagship health-care institutions, Medical University of South Carolina in Charleston.

So it was that SHM set Dr. Hunter up in meetings with the offices of Scott, Sen. Lindsey Graham (R-S.C.), and Rep. Jim Clyburn (D-S.C.), and—for the day at least—made Dr. Hunter the voice of hospital medicine.

“It was a little bit demystifying of an experience to be able to know there’s actually people you can talk to and you can develop a relationship with,” says Dr. Hunter, who also serves on Team Hospitalist. “I thought that was very rewarding.”

The connections made by Dr. Hunter are the point of the annual trek made by SHM leaders and members to lobby legislators and federal staffers “on the way policies affect your practice and your patients,” SHM says on its website (www.hospitalmedicine.org/advocacy). This year’s volunteer effort was by far the largest ever, says Public Policy Committee chair Ron Greeno, MD, FCCP, MHM. More than 150 hospitalists participated in training, 113 hospitalists visited Capitol Hill, and scores more had to be turned away. All told, hospitalists held 409 individual meetings with legislators and staff members.

“Quite frankly, if we’d have had the budget, we could have had another 100 to 150 people come,” Dr. Greeno says. “That’s how many people wanted to go.”

Dr. Greeno attributes the interest to two factors. One, having the annual meeting at the Gaylord National Resort & Convention Center, just outside Washington, D.C, makes the Hill trip a natural extension. Two, the current landscape of health-care reform has motivated many physicians to become more involved than they might otherwise be. One challenge of having so many first-timers making this year’s trip was making sure they were properly prepared. To hone the message, SHM gave the group a few hours of education by former legislative staffer Stephanie Vance of Advocacy Associates, a communications firm that helps organizations, such as medical societies, tailor their message to policymakers. Vance told hospitalists a personal visit with a constituent often becomes the most influential type of advocacy.

“That’s why it was easy to make an initial connection, because these staffers are from where I’m from, friends with people that I’m friends with,” Dr. Hunter says.

Unique Approach

SHM CEO Larry Wellikson, MD, SFHM, says the society tries to differentiate itself from other organizations through its grassroots approach to advocacy. More important, the society refrains from giving a long list of legislative requests that are self-serving.

“We’re someone they want to talk to because we’re not coming there to just say, ‘Here’s a power play for hospitalists,’” Dr. Wellikson says. “We come and try to provide solutions.”

To that end, this year’s lobbying effort was targeted to topics important both to HM and the health-care system:

• Repealing the sustainable growth rate (SGR) formula for Medicare payments, specifically via the proposed Medicare Physician Payment Innovation Act of 2013 (H.R. 574);
• Solving the quagmire of observation status time not counting toward the required three consecutive overnights as an inpatient needed to qualify for Medicare benefits at a skilled nursing facility, by supporting the Improving Access to Medicare Coverage Act of 2013 (H.R. 1179, S. 569); and
• Getting the federal government to commit to providing $434 million in funding for the Agency for Healthcare Research and Quality (AHRQ) in fiscal 2014.

“The message that we’re sending resonated with the people we met with on both sides of the aisle,” Dr. Greeno says. “The SGR, for instance, they know there needs to be a fix. We want to serve as a resource for them as they start to figure out the answer to the question: What are we going to replace it with?

“What we want to do is make everybody on the Hill understand that we can be relied upon as a resource when they’re looking for solutions,” he says.

Focused on Follow-Up

And that’s where rank-and-filers, such as Dr. Hunter, have to take charge. So for his Hill Day visits, he tried to stand out. Everyone he met with got a lapel pin in the shape of a South Carolina state flag, which has become a popular fashion statement in recent years. And Scott also got a pin from Charleston Southern University, his alma mater. The gestures were small, but they served as icebreakers and reminders that Dr. Hunter and the people he met are bound by service to the residents of the Palmetto State.

Dr. Hunter also hopes the small token will be that little extra that makes him memorable enough that the next time a Congressional staffer has an SGR question, they’ll ask him and not a doctor from another specialty.

“I’m interested to see how much feedback I get back from them,” he says. “I can feed them all day long, but I don’t want to be that crazy guy bugging them. If they respond back to me, I can hopefully make more inroads.”

He certainly would if Dr. Greeno gets his way. Moving forward, SHM hopes to be able to rely more on local advocates pushing for reform than just a once-a-year major event and formal positions drafted by SHM’s staffers or the Public Policy Committee. Dr. Greeno says the physicians who participated in this year’s Hill trip are likely to find they will be asked to be the first cohort of a grassroots initiative meant to deliver the society’s message more routinely.

“These are not easy things to change because there are not easy solutions,” Dr. Greeno adds. “If you have just one meeting on the Hill, you’ll have no impact at all. You have to follow up. You have to do it consistently. And you have to have a consistent message. And we will.”

Richard Quinn is a freelance writer in New Jersey.

A veritable perfect storm of relationships brought hospitalist Jairy Hunter, MD, MBA, SFHM, to “Hospitalists on the Hill 2013,” a daylong advocacy affair that preceded HM13 last month.

First, Dr. Hunter was born and bred—and now lives—in South Carolina, a close-knit state where leaders across industries tend to run in the same circles, or at least have relatives who do. Second, Dr. Hunter’s father, Jairy Hunter Jr., is the longtime president of Charleston Southern University, where Sen. Tim Scott (R-S.C.) earned his undergraduate degree when it was still called Baptist College at Charleston. And three, Dr. Hunter is associate executive medical director of one of the state’s flagship health-care institutions, Medical University of South Carolina in Charleston.

So it was that SHM set Dr. Hunter up in meetings with the offices of Scott, Sen. Lindsey Graham (R-S.C.), and Rep. Jim Clyburn (D-S.C.), and—for the day at least—made Dr. Hunter the voice of hospital medicine.

“It was a little bit demystifying of an experience to be able to know there’s actually people you can talk to and you can develop a relationship with,” says Dr. Hunter, who also serves on Team Hospitalist. “I thought that was very rewarding.”

The connections made by Dr. Hunter are the point of the annual trek made by SHM leaders and members to lobby legislators and federal staffers “on the way policies affect your practice and your patients,” SHM says on its website (www.hospitalmedicine.org/advocacy). This year’s volunteer effort was by far the largest ever, says Public Policy Committee chair Ron Greeno, MD, FCCP, MHM. More than 150 hospitalists participated in training, 113 hospitalists visited Capitol Hill, and scores more had to be turned away. All told, hospitalists held 409 individual meetings with legislators and staff members.

“Quite frankly, if we’d have had the budget, we could have had another 100 to 150 people come,” Dr. Greeno says. “That’s how many people wanted to go.”

Dr. Greeno attributes the interest to two factors. One, having the annual meeting at the Gaylord National Resort & Convention Center, just outside Washington, D.C, makes the Hill trip a natural extension. Two, the current landscape of health-care reform has motivated many physicians to become more involved than they might otherwise be. One challenge of having so many first-timers making this year’s trip was making sure they were properly prepared. To hone the message, SHM gave the group a few hours of education by former legislative staffer Stephanie Vance of Advocacy Associates, a communications firm that helps organizations, such as medical societies, tailor their message to policymakers. Vance told hospitalists a personal visit with a constituent often becomes the most influential type of advocacy.

“That’s why it was easy to make an initial connection, because these staffers are from where I’m from, friends with people that I’m friends with,” Dr. Hunter says.

Unique Approach

SHM CEO Larry Wellikson, MD, SFHM, says the society tries to differentiate itself from other organizations through its grassroots approach to advocacy. More important, the society refrains from giving a long list of legislative requests that are self-serving.

“We’re someone they want to talk to because we’re not coming there to just say, ‘Here’s a power play for hospitalists,’” Dr. Wellikson says. “We come and try to provide solutions.”

To that end, this year’s lobbying effort was targeted to topics important both to HM and the health-care system:

• Repealing the sustainable growth rate (SGR) formula for Medicare payments, specifically via the proposed Medicare Physician Payment Innovation Act of 2013 (H.R. 574);
• Solving the quagmire of observation status time not counting toward the required three consecutive overnights as an inpatient needed to qualify for Medicare benefits at a skilled nursing facility, by supporting the Improving Access to Medicare Coverage Act of 2013 (H.R. 1179, S. 569); and
• Getting the federal government to commit to providing $434 million in funding for the Agency for Healthcare Research and Quality (AHRQ) in fiscal 2014.

“The message that we’re sending resonated with the people we met with on both sides of the aisle,” Dr. Greeno says. “The SGR, for instance, they know there needs to be a fix. We want to serve as a resource for them as they start to figure out the answer to the question: What are we going to replace it with?

“What we want to do is make everybody on the Hill understand that we can be relied upon as a resource when they’re looking for solutions,” he says.

Focused on Follow-Up

And that’s where rank-and-filers, such as Dr. Hunter, have to take charge. So for his Hill Day visits, he tried to stand out. Everyone he met with got a lapel pin in the shape of a South Carolina state flag, which has become a popular fashion statement in recent years. And Scott also got a pin from Charleston Southern University, his alma mater. The gestures were small, but they served as icebreakers and reminders that Dr. Hunter and the people he met are bound by service to the residents of the Palmetto State.

Dr. Hunter also hopes the small token will be that little extra that makes him memorable enough that the next time a Congressional staffer has an SGR question, they’ll ask him and not a doctor from another specialty.

“I’m interested to see how much feedback I get back from them,” he says. “I can feed them all day long, but I don’t want to be that crazy guy bugging them. If they respond back to me, I can hopefully make more inroads.”

He certainly would if Dr. Greeno gets his way. Moving forward, SHM hopes to be able to rely more on local advocates pushing for reform than just a once-a-year major event and formal positions drafted by SHM’s staffers or the Public Policy Committee. Dr. Greeno says the physicians who participated in this year’s Hill trip are likely to find they will be asked to be the first cohort of a grassroots initiative meant to deliver the society’s message more routinely.

“These are not easy things to change because there are not easy solutions,” Dr. Greeno adds. “If you have just one meeting on the Hill, you’ll have no impact at all. You have to follow up. You have to do it consistently. And you have to have a consistent message. And we will.”

Richard Quinn is a freelance writer in New Jersey.

A veritable perfect storm of relationships brought hospitalist Jairy Hunter, MD, MBA, SFHM, to “Hospitalists on the Hill 2013,” a daylong advocacy affair that preceded HM13 last month.

First, Dr. Hunter was born and bred—and now lives—in South Carolina, a close-knit state where leaders across industries tend to run in the same circles, or at least have relatives who do. Second, Dr. Hunter’s father, Jairy Hunter Jr., is the longtime president of Charleston Southern University, where Sen. Tim Scott (R-S.C.) earned his undergraduate degree when it was still called Baptist College at Charleston. And three, Dr. Hunter is associate executive medical director of one of the state’s flagship health-care institutions, Medical University of South Carolina in Charleston.

So it was that SHM set Dr. Hunter up in meetings with the offices of Scott, Sen. Lindsey Graham (R-S.C.), and Rep. Jim Clyburn (D-S.C.), and—for the day at least—made Dr. Hunter the voice of hospital medicine.

“It was a little bit demystifying of an experience to be able to know there’s actually people you can talk to and you can develop a relationship with,” says Dr. Hunter, who also serves on Team Hospitalist. “I thought that was very rewarding.”

The connections made by Dr. Hunter are the point of the annual trek made by SHM leaders and members to lobby legislators and federal staffers “on the way policies affect your practice and your patients,” SHM says on its website (www.hospitalmedicine.org/advocacy). This year’s volunteer effort was by far the largest ever, says Public Policy Committee chair Ron Greeno, MD, FCCP, MHM. More than 150 hospitalists participated in training, 113 hospitalists visited Capitol Hill, and scores more had to be turned away. All told, hospitalists held 409 individual meetings with legislators and staff members.

“Quite frankly, if we’d have had the budget, we could have had another 100 to 150 people come,” Dr. Greeno says. “That’s how many people wanted to go.”

Dr. Greeno attributes the interest to two factors. One, having the annual meeting at the Gaylord National Resort & Convention Center, just outside Washington, D.C, makes the Hill trip a natural extension. Two, the current landscape of health-care reform has motivated many physicians to become more involved than they might otherwise be. One challenge of having so many first-timers making this year’s trip was making sure they were properly prepared. To hone the message, SHM gave the group a few hours of education by former legislative staffer Stephanie Vance of Advocacy Associates, a communications firm that helps organizations, such as medical societies, tailor their message to policymakers. Vance told hospitalists a personal visit with a constituent often becomes the most influential type of advocacy.

“That’s why it was easy to make an initial connection, because these staffers are from where I’m from, friends with people that I’m friends with,” Dr. Hunter says.

Unique Approach

SHM CEO Larry Wellikson, MD, SFHM, says the society tries to differentiate itself from other organizations through its grassroots approach to advocacy. More important, the society refrains from giving a long list of legislative requests that are self-serving.

“We’re someone they want to talk to because we’re not coming there to just say, ‘Here’s a power play for hospitalists,’” Dr. Wellikson says. “We come and try to provide solutions.”

To that end, this year’s lobbying effort was targeted to topics important both to HM and the health-care system:

• Repealing the sustainable growth rate (SGR) formula for Medicare payments, specifically via the proposed Medicare Physician Payment Innovation Act of 2013 (H.R. 574);
• Solving the quagmire of observation status time not counting toward the required three consecutive overnights as an inpatient needed to qualify for Medicare benefits at a skilled nursing facility, by supporting the Improving Access to Medicare Coverage Act of 2013 (H.R. 1179, S. 569); and
• Getting the federal government to commit to providing $434 million in funding for the Agency for Healthcare Research and Quality (AHRQ) in fiscal 2014.

“The message that we’re sending resonated with the people we met with on both sides of the aisle,” Dr. Greeno says. “The SGR, for instance, they know there needs to be a fix. We want to serve as a resource for them as they start to figure out the answer to the question: What are we going to replace it with?

“What we want to do is make everybody on the Hill understand that we can be relied upon as a resource when they’re looking for solutions,” he says.

Focused on Follow-Up

And that’s where rank-and-filers, such as Dr. Hunter, have to take charge. So for his Hill Day visits, he tried to stand out. Everyone he met with got a lapel pin in the shape of a South Carolina state flag, which has become a popular fashion statement in recent years. And Scott also got a pin from Charleston Southern University, his alma mater. The gestures were small, but they served as icebreakers and reminders that Dr. Hunter and the people he met are bound by service to the residents of the Palmetto State.

Dr. Hunter also hopes the small token will be that little extra that makes him memorable enough that the next time a Congressional staffer has an SGR question, they’ll ask him and not a doctor from another specialty.

“I’m interested to see how much feedback I get back from them,” he says. “I can feed them all day long, but I don’t want to be that crazy guy bugging them. If they respond back to me, I can hopefully make more inroads.”

He certainly would if Dr. Greeno gets his way. Moving forward, SHM hopes to be able to rely more on local advocates pushing for reform than just a once-a-year major event and formal positions drafted by SHM’s staffers or the Public Policy Committee. Dr. Greeno says the physicians who participated in this year’s Hill trip are likely to find they will be asked to be the first cohort of a grassroots initiative meant to deliver the society’s message more routinely.

“These are not easy things to change because there are not easy solutions,” Dr. Greeno adds. “If you have just one meeting on the Hill, you’ll have no impact at all. You have to follow up. You have to do it consistently. And you have to have a consistent message. And we will.”

Richard Quinn is a freelance writer in New Jersey.

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.

What this has done is impose additional administrative requirements that now take time away from our seeing patients or doing clinical activity.

—Joshua Lenchus, DO, RPh, FACP, SFHM

Hospitalist leaders are taking a wait-and-see approach to the Physician Payment Sunshine Act, which requires reporting of payments and gifts from drug and medical device companies. But as wary as many are after publication of the Final Rule 1 in February, SHM and other groups already have claimed at least one victory in tweaking the new rules.

The Sunshine Rule, as it’s known, was included in the Affordable Care Act of 2010. The rule, created by the Centers for Medicaid & Medicare Services (CMS), requires manufacturers to publicly report gifts, payments, or other transfers of value to physicians from pharmaceutical and medical device manufacturers worth more than $10 (see “Dos and Don’ts,” below).¹

One major change to the law sought by SHM and others was tied to the reporting of indirect payments to speakers at accredited continuing medical education (CME) classes or courses. The proposed rule required reporting of those payments even if a particular industry group did not select the speakers or pay them. SHM and three dozen other societies lobbied CMS to change the rule.² The final rule says indirect payments don’t have to be reported if the CME program meets widely accepted accreditation standards and the industry participant is neither directly paid nor selected by the vendor.

CME Coalition, a Washington, D.C.-based advocacy group, said in a statement the caveat recognizes that CMS “is sending a strong message to commercial supporters: Underwriting accredited continuing education programs for health-care providers is to be applauded, not restricted.”

SHM Public Policy Committee member Joshua Lenchus, DO, RPh, FACP, SFHM, said the initial rule was too restrictive and could have reduced physician participation in important CME activities. He said the Accreditation Council for Continuing Medical Education (ACCME) and other industry groups already govern the ethical issue of accepting direct payments that could imply bias to patients.

“I’m not so sure we needed the Sunshine Act as part of the ACA at all because these same things were in effect from the ACCME and other CME accrediting organizations,” said Dr. Lenchus, a Team Hospitalist member and president of the medical staff at Jackson Health System in Miami. “What this has done is impose additional administrative requirements that now take time away from our seeing patients or doing clinical activity.”

Those costs will add up quickly, according to figures from the Federal Register, Dr. Lenchus said. CMS projects the administrative costs of reviewing reports at $1.9 million for teaching hospital staff—the category Dr. Lenchus says is most applicable to hospitalists.

Dr. Lenchus says there was discussion within the Public Policy Committee about how much information needed to be publicly reported in relation to CME. Some members “wanted nothing recorded” and “some people wanted everything recorded.”

“The rule that has been implemented strikes a nice balance between the two,” he said.

Transparent Process

Industry groups and group purchasing organizations (GPOs) currently are working to put in place systems and procedures to begin collecting the data in August. Data will be collected through the end of 2013 and must be reported to CMS by March 31, 2014. CMS will then unveil a public website showcasing the information by Sept. 30, 2014.

Public Policy Committee member Jack Percelay, MD, MPH, FAAP, SFHM, said some hospitalists might feel they are “being picked on again” by having to report the added information. He instead looks at the intended push toward added transparency as “a set of obligations we have as physicians.”

“We have tremendous discretion about how health-care dollars are spent and with that comes a fiduciary responsibility, both to the patient and to the public,” he said. “This does not seem terribly burdensome to me. If I was getting nickel and dimed for every piece of candy I took through the exhibit hall during a meeting, that would be ridiculous. I’m happy to do this in a reasoned way.”

Dr. Percelay noted that the Sunshine Rule does not prevent industry payments to physicians or groups, but simply requires the public reporting and display of the remuneration. In that vein, he likened it to ethical rules that govern those who hold elected office.

“Someone should be able to Google and see that I’ve [received] funds from market research,” he said. “It’s not much different from politicians. It’s then up to the public and the media to do their due diligence.”

Dr. Lenchus said the public database has the potential to be misinterpreted by a public unfamiliar with how health care works. In particular, patients might not be able to discern the differences between the value of lunches, the payments for being on advisory boards, and industry-funded research.

“I really fear the public will look at this website, see there is any financial inducement to any physician, and erroneously conclude that any prescription of that company’s medication means that person is getting a kickback,” he says. “And we know that’s absolutely false.”

Richard Quinn is a freelance writer in New Jersey.

References

1. Centers for Medicare & Medicaid Services. Medicare, Medicaid, Children’s Health Insurance Programs; transparency reports and reporting of physician ownership or investment interests. Federal Register website. Available at: https://www.federalregister.gov/articles/2013/02/08/2013-02572/medicare-mediaid-childrens-health-insurance-programs-transparency-reports-and-reporting-of. Accessed March 24, 2013.
2. Council of Medical Specialty Societies. Letter to CMS. SHM website. Available at: http://www.hospitalmedicine.org/AM/Template.cfm?Section=Letters_to_Congress_ and_Regulatory_Agencies&Template=/CM/ContentDisplay.cfm&ContentID=30674. Accessed March 24, 2013.

What this has done is impose additional administrative requirements that now take time away from our seeing patients or doing clinical activity.

—Joshua Lenchus, DO, RPh, FACP, SFHM

Hospitalist leaders are taking a wait-and-see approach to the Physician Payment Sunshine Act, which requires reporting of payments and gifts from drug and medical device companies. But as wary as many are after publication of the Final Rule 1 in February, SHM and other groups already have claimed at least one victory in tweaking the new rules.

The Sunshine Rule, as it’s known, was included in the Affordable Care Act of 2010. The rule, created by the Centers for Medicaid & Medicare Services (CMS), requires manufacturers to publicly report gifts, payments, or other transfers of value to physicians from pharmaceutical and medical device manufacturers worth more than $10 (see “Dos and Don’ts,” below).¹

One major change to the law sought by SHM and others was tied to the reporting of indirect payments to speakers at accredited continuing medical education (CME) classes or courses. The proposed rule required reporting of those payments even if a particular industry group did not select the speakers or pay them. SHM and three dozen other societies lobbied CMS to change the rule.² The final rule says indirect payments don’t have to be reported if the CME program meets widely accepted accreditation standards and the industry participant is neither directly paid nor selected by the vendor.

CME Coalition, a Washington, D.C.-based advocacy group, said in a statement the caveat recognizes that CMS “is sending a strong message to commercial supporters: Underwriting accredited continuing education programs for health-care providers is to be applauded, not restricted.”

SHM Public Policy Committee member Joshua Lenchus, DO, RPh, FACP, SFHM, said the initial rule was too restrictive and could have reduced physician participation in important CME activities. He said the Accreditation Council for Continuing Medical Education (ACCME) and other industry groups already govern the ethical issue of accepting direct payments that could imply bias to patients.

“I’m not so sure we needed the Sunshine Act as part of the ACA at all because these same things were in effect from the ACCME and other CME accrediting organizations,” said Dr. Lenchus, a Team Hospitalist member and president of the medical staff at Jackson Health System in Miami. “What this has done is impose additional administrative requirements that now take time away from our seeing patients or doing clinical activity.”

Those costs will add up quickly, according to figures from the Federal Register, Dr. Lenchus said. CMS projects the administrative costs of reviewing reports at $1.9 million for teaching hospital staff—the category Dr. Lenchus says is most applicable to hospitalists.

Dr. Lenchus says there was discussion within the Public Policy Committee about how much information needed to be publicly reported in relation to CME. Some members “wanted nothing recorded” and “some people wanted everything recorded.”

“The rule that has been implemented strikes a nice balance between the two,” he said.

Transparent Process

Industry groups and group purchasing organizations (GPOs) currently are working to put in place systems and procedures to begin collecting the data in August. Data will be collected through the end of 2013 and must be reported to CMS by March 31, 2014. CMS will then unveil a public website showcasing the information by Sept. 30, 2014.

Public Policy Committee member Jack Percelay, MD, MPH, FAAP, SFHM, said some hospitalists might feel they are “being picked on again” by having to report the added information. He instead looks at the intended push toward added transparency as “a set of obligations we have as physicians.”

“We have tremendous discretion about how health-care dollars are spent and with that comes a fiduciary responsibility, both to the patient and to the public,” he said. “This does not seem terribly burdensome to me. If I was getting nickel and dimed for every piece of candy I took through the exhibit hall during a meeting, that would be ridiculous. I’m happy to do this in a reasoned way.”

Dr. Percelay noted that the Sunshine Rule does not prevent industry payments to physicians or groups, but simply requires the public reporting and display of the remuneration. In that vein, he likened it to ethical rules that govern those who hold elected office.

“Someone should be able to Google and see that I’ve [received] funds from market research,” he said. “It’s not much different from politicians. It’s then up to the public and the media to do their due diligence.”

Dr. Lenchus said the public database has the potential to be misinterpreted by a public unfamiliar with how health care works. In particular, patients might not be able to discern the differences between the value of lunches, the payments for being on advisory boards, and industry-funded research.

“I really fear the public will look at this website, see there is any financial inducement to any physician, and erroneously conclude that any prescription of that company’s medication means that person is getting a kickback,” he says. “And we know that’s absolutely false.”

Richard Quinn is a freelance writer in New Jersey.

References

1. Centers for Medicare & Medicaid Services. Medicare, Medicaid, Children’s Health Insurance Programs; transparency reports and reporting of physician ownership or investment interests. Federal Register website. Available at: https://www.federalregister.gov/articles/2013/02/08/2013-02572/medicare-mediaid-childrens-health-insurance-programs-transparency-reports-and-reporting-of. Accessed March 24, 2013.
2. Council of Medical Specialty Societies. Letter to CMS. SHM website. Available at: http://www.hospitalmedicine.org/AM/Template.cfm?Section=Letters_to_Congress_ and_Regulatory_Agencies&Template=/CM/ContentDisplay.cfm&ContentID=30674. Accessed March 24, 2013.

What this has done is impose additional administrative requirements that now take time away from our seeing patients or doing clinical activity.

—Joshua Lenchus, DO, RPh, FACP, SFHM

Hospitalist leaders are taking a wait-and-see approach to the Physician Payment Sunshine Act, which requires reporting of payments and gifts from drug and medical device companies. But as wary as many are after publication of the Final Rule 1 in February, SHM and other groups already have claimed at least one victory in tweaking the new rules.

The Sunshine Rule, as it’s known, was included in the Affordable Care Act of 2010. The rule, created by the Centers for Medicaid & Medicare Services (CMS), requires manufacturers to publicly report gifts, payments, or other transfers of value to physicians from pharmaceutical and medical device manufacturers worth more than $10 (see “Dos and Don’ts,” below).¹

One major change to the law sought by SHM and others was tied to the reporting of indirect payments to speakers at accredited continuing medical education (CME) classes or courses. The proposed rule required reporting of those payments even if a particular industry group did not select the speakers or pay them. SHM and three dozen other societies lobbied CMS to change the rule.² The final rule says indirect payments don’t have to be reported if the CME program meets widely accepted accreditation standards and the industry participant is neither directly paid nor selected by the vendor.

CME Coalition, a Washington, D.C.-based advocacy group, said in a statement the caveat recognizes that CMS “is sending a strong message to commercial supporters: Underwriting accredited continuing education programs for health-care providers is to be applauded, not restricted.”

SHM Public Policy Committee member Joshua Lenchus, DO, RPh, FACP, SFHM, said the initial rule was too restrictive and could have reduced physician participation in important CME activities. He said the Accreditation Council for Continuing Medical Education (ACCME) and other industry groups already govern the ethical issue of accepting direct payments that could imply bias to patients.

“I’m not so sure we needed the Sunshine Act as part of the ACA at all because these same things were in effect from the ACCME and other CME accrediting organizations,” said Dr. Lenchus, a Team Hospitalist member and president of the medical staff at Jackson Health System in Miami. “What this has done is impose additional administrative requirements that now take time away from our seeing patients or doing clinical activity.”

Those costs will add up quickly, according to figures from the Federal Register, Dr. Lenchus said. CMS projects the administrative costs of reviewing reports at $1.9 million for teaching hospital staff—the category Dr. Lenchus says is most applicable to hospitalists.

Dr. Lenchus says there was discussion within the Public Policy Committee about how much information needed to be publicly reported in relation to CME. Some members “wanted nothing recorded” and “some people wanted everything recorded.”

“The rule that has been implemented strikes a nice balance between the two,” he said.

Transparent Process

Industry groups and group purchasing organizations (GPOs) currently are working to put in place systems and procedures to begin collecting the data in August. Data will be collected through the end of 2013 and must be reported to CMS by March 31, 2014. CMS will then unveil a public website showcasing the information by Sept. 30, 2014.

Public Policy Committee member Jack Percelay, MD, MPH, FAAP, SFHM, said some hospitalists might feel they are “being picked on again” by having to report the added information. He instead looks at the intended push toward added transparency as “a set of obligations we have as physicians.”

“We have tremendous discretion about how health-care dollars are spent and with that comes a fiduciary responsibility, both to the patient and to the public,” he said. “This does not seem terribly burdensome to me. If I was getting nickel and dimed for every piece of candy I took through the exhibit hall during a meeting, that would be ridiculous. I’m happy to do this in a reasoned way.”

Dr. Percelay noted that the Sunshine Rule does not prevent industry payments to physicians or groups, but simply requires the public reporting and display of the remuneration. In that vein, he likened it to ethical rules that govern those who hold elected office.

“Someone should be able to Google and see that I’ve [received] funds from market research,” he said. “It’s not much different from politicians. It’s then up to the public and the media to do their due diligence.”

Dr. Lenchus said the public database has the potential to be misinterpreted by a public unfamiliar with how health care works. In particular, patients might not be able to discern the differences between the value of lunches, the payments for being on advisory boards, and industry-funded research.

“I really fear the public will look at this website, see there is any financial inducement to any physician, and erroneously conclude that any prescription of that company’s medication means that person is getting a kickback,” he says. “And we know that’s absolutely false.”

Richard Quinn is a freelance writer in New Jersey.

References

1. Centers for Medicare & Medicaid Services. Medicare, Medicaid, Children’s Health Insurance Programs; transparency reports and reporting of physician ownership or investment interests. Federal Register website. Available at: https://www.federalregister.gov/articles/2013/02/08/2013-02572/medicare-mediaid-childrens-health-insurance-programs-transparency-reports-and-reporting-of. Accessed March 24, 2013.
2. Council of Medical Specialty Societies. Letter to CMS. SHM website. Available at: http://www.hospitalmedicine.org/AM/Template.cfm?Section=Letters_to_Congress_ and_Regulatory_Agencies&Template=/CM/ContentDisplay.cfm&ContentID=30674. Accessed March 24, 2013.

For those who remain unaware, hospitalists who care for Medicaid patients will be getting a raise in 2013 and 2014. The reason is that the Affordable Care Act (ACA) requires Medicaid rates for specified primary-care services to be equal to those of Medicare rates during those two years, with the federal government paying the difference. Hospitalists generally meet the requirements and, therefore, will see this pay increase for their applicable Medicaid billing. For some context of the scope of this change, on average, Medicaid pays physicians at 66% of the national Medicare rates, although there is significant variation among the states.

To qualify, a physician must have a specialty designation of family medicine, internal medicine, or pediatrics, then further attest to board certification in one of those specialties or related subspecialties. Alternatively, the physician must have a 60% claims history for the specified evaluation and management (E&M) codes.

Multiple parties who have heard reports about state plans for Medicaid parity recently have contacted SHM; the plans, they report, intentionally would exclude hospitalists from the promised increase. There are variations on the explanation for the exclusion and where the idea is coming from, but the inquiries follow this general theme: “Since the definition of eligible physicians remains a grey area, states are developing alternative plans with a more narrow interpretation of the qualifying factors for the increase. These plans are only including physicians who practice in the community setting (i.e. not the hospital setting).”

This is demonstrably wrong. Even if states are having these discussions, such a plan is not going to come to fruition. The final rule for Medicaid parity, which essentially has the effect of law, is very clear: It does not allow for differing eligibility or alternate state plans.

The Centers for Medicare & Medicaid Services (CMS) specifically stated in the final rule that the increase is not limited to office-based primary-care services, but it will also include hospital observation and consultation for inpatient services provided by nonadmitting physicians, ED services, and critical-care services. In other words, a hospitalist who attests eligibility for their respective state Medicaid agency and bills 99231-3, 99221-3, 99238-9, etc., will receive the increased payment for these codes.

In response to an SHM inquiry for further clarification, CMS officials have stated, “The regulation requires that qualified physicians billing eligible codes receive higher payment. States do not have the latitude to exclude physicians simply because they practice in hospitals.”

It is possible that some confusion might be arising due to the recent controversies around the upcoming Medicaid expansion, which would extend Medicaid eligibility to individuals who earn up to 138% of the federal poverty line. Some states have chosen to opt out of this expansion and have publicly fought its implementation. The Medicaid parity provision is parallel to, but independent of, Medicaid expansion. Even if a state opts out of the expansion, the Medicaid payment increase for primary-care services should remain unaffected.

This isn’t to say that the Medicaid parity provision is a certainty. With the eyes of Congress turned toward budget cuts and austerity, the funds allocated for this temporary increase could easily be targeted. Regardless, any change in eligibility would require a rule change at the federal level, which is unlikely.

Many states have already devoted much time and effort on plans to implement the provision, and the plans were due to be submitted to CMS on March 31. It is pretty late in the game to consider changes. Barring an unlikely rule change or total elimination of funding, it is clear that hospitalists are eligible for the payment bump and should remain so.

Josh Boswell is SHM’s senior manager of government relations.

For those who remain unaware, hospitalists who care for Medicaid patients will be getting a raise in 2013 and 2014. The reason is that the Affordable Care Act (ACA) requires Medicaid rates for specified primary-care services to be equal to those of Medicare rates during those two years, with the federal government paying the difference. Hospitalists generally meet the requirements and, therefore, will see this pay increase for their applicable Medicaid billing. For some context of the scope of this change, on average, Medicaid pays physicians at 66% of the national Medicare rates, although there is significant variation among the states.

To qualify, a physician must have a specialty designation of family medicine, internal medicine, or pediatrics, then further attest to board certification in one of those specialties or related subspecialties. Alternatively, the physician must have a 60% claims history for the specified evaluation and management (E&M) codes.

Multiple parties who have heard reports about state plans for Medicaid parity recently have contacted SHM; the plans, they report, intentionally would exclude hospitalists from the promised increase. There are variations on the explanation for the exclusion and where the idea is coming from, but the inquiries follow this general theme: “Since the definition of eligible physicians remains a grey area, states are developing alternative plans with a more narrow interpretation of the qualifying factors for the increase. These plans are only including physicians who practice in the community setting (i.e. not the hospital setting).”

This is demonstrably wrong. Even if states are having these discussions, such a plan is not going to come to fruition. The final rule for Medicaid parity, which essentially has the effect of law, is very clear: It does not allow for differing eligibility or alternate state plans.

The Centers for Medicare & Medicaid Services (CMS) specifically stated in the final rule that the increase is not limited to office-based primary-care services, but it will also include hospital observation and consultation for inpatient services provided by nonadmitting physicians, ED services, and critical-care services. In other words, a hospitalist who attests eligibility for their respective state Medicaid agency and bills 99231-3, 99221-3, 99238-9, etc., will receive the increased payment for these codes.

In response to an SHM inquiry for further clarification, CMS officials have stated, “The regulation requires that qualified physicians billing eligible codes receive higher payment. States do not have the latitude to exclude physicians simply because they practice in hospitals.”

It is possible that some confusion might be arising due to the recent controversies around the upcoming Medicaid expansion, which would extend Medicaid eligibility to individuals who earn up to 138% of the federal poverty line. Some states have chosen to opt out of this expansion and have publicly fought its implementation. The Medicaid parity provision is parallel to, but independent of, Medicaid expansion. Even if a state opts out of the expansion, the Medicaid payment increase for primary-care services should remain unaffected.

This isn’t to say that the Medicaid parity provision is a certainty. With the eyes of Congress turned toward budget cuts and austerity, the funds allocated for this temporary increase could easily be targeted. Regardless, any change in eligibility would require a rule change at the federal level, which is unlikely.

Many states have already devoted much time and effort on plans to implement the provision, and the plans were due to be submitted to CMS on March 31. It is pretty late in the game to consider changes. Barring an unlikely rule change or total elimination of funding, it is clear that hospitalists are eligible for the payment bump and should remain so.

Josh Boswell is SHM’s senior manager of government relations.

For those who remain unaware, hospitalists who care for Medicaid patients will be getting a raise in 2013 and 2014. The reason is that the Affordable Care Act (ACA) requires Medicaid rates for specified primary-care services to be equal to those of Medicare rates during those two years, with the federal government paying the difference. Hospitalists generally meet the requirements and, therefore, will see this pay increase for their applicable Medicaid billing. For some context of the scope of this change, on average, Medicaid pays physicians at 66% of the national Medicare rates, although there is significant variation among the states.

To qualify, a physician must have a specialty designation of family medicine, internal medicine, or pediatrics, then further attest to board certification in one of those specialties or related subspecialties. Alternatively, the physician must have a 60% claims history for the specified evaluation and management (E&M) codes.

Multiple parties who have heard reports about state plans for Medicaid parity recently have contacted SHM; the plans, they report, intentionally would exclude hospitalists from the promised increase. There are variations on the explanation for the exclusion and where the idea is coming from, but the inquiries follow this general theme: “Since the definition of eligible physicians remains a grey area, states are developing alternative plans with a more narrow interpretation of the qualifying factors for the increase. These plans are only including physicians who practice in the community setting (i.e. not the hospital setting).”

This is demonstrably wrong. Even if states are having these discussions, such a plan is not going to come to fruition. The final rule for Medicaid parity, which essentially has the effect of law, is very clear: It does not allow for differing eligibility or alternate state plans.

The Centers for Medicare & Medicaid Services (CMS) specifically stated in the final rule that the increase is not limited to office-based primary-care services, but it will also include hospital observation and consultation for inpatient services provided by nonadmitting physicians, ED services, and critical-care services. In other words, a hospitalist who attests eligibility for their respective state Medicaid agency and bills 99231-3, 99221-3, 99238-9, etc., will receive the increased payment for these codes.

In response to an SHM inquiry for further clarification, CMS officials have stated, “The regulation requires that qualified physicians billing eligible codes receive higher payment. States do not have the latitude to exclude physicians simply because they practice in hospitals.”

It is possible that some confusion might be arising due to the recent controversies around the upcoming Medicaid expansion, which would extend Medicaid eligibility to individuals who earn up to 138% of the federal poverty line. Some states have chosen to opt out of this expansion and have publicly fought its implementation. The Medicaid parity provision is parallel to, but independent of, Medicaid expansion. Even if a state opts out of the expansion, the Medicaid payment increase for primary-care services should remain unaffected.

This isn’t to say that the Medicaid parity provision is a certainty. With the eyes of Congress turned toward budget cuts and austerity, the funds allocated for this temporary increase could easily be targeted. Regardless, any change in eligibility would require a rule change at the federal level, which is unlikely.

Many states have already devoted much time and effort on plans to implement the provision, and the plans were due to be submitted to CMS on March 31. It is pretty late in the game to consider changes. Barring an unlikely rule change or total elimination of funding, it is clear that hospitalists are eligible for the payment bump and should remain so.

Josh Boswell is SHM’s senior manager of government relations.

Danielle Scheurer, MD, MSCR, SFHM

Old habits are hard to break. We all get used to doing things in certain ways, and the longer we do it, it becomes increasingly difficult to do them differently. We clearly are clinging to old habits in the healthcare industry, despite compelling evidence that we need to figure out better ways of doing business. Our industry has been in a crisis for a very long time—rising costs, drastic reimbursement reductions from payors, and continually escalating risks and medical errors.

Clearly, something is not working.

This is a time when hospitalists should start thinking about dropping some of our Pulaskis.

Handy, Useful, Versatile, Reliable

A Pulaski is a versatile tool that combines an axe and an adze; it’s most commonly used in firefighting, but it is also used in trail-blazing, gardening, and woodworking (see right). The Pulaski was invented by Ed Pulaski, a forest ranger in the 1910s who almost died in a forest fire after being trapped in an old mine tunnel. After he barely survived, he invented the Pulaski as a means to reduce the risk of future firefighters being trapped in his same situation. For more than 100 years, this tool has come in handy in countless situations. It is versatile, irreplaceable, reliable—a must-have. Unless you don’t need it. And then it becomes a 22-pound handicap.

Donald Berwick, MD, MPP, spoke about the Pulaski 13 years ago in a powerful speech to the National Forum on Quality Improvement in Health Care; his presentation was titled “Escape Fire.”¹ He described the Mann Gulch fire of 1949, which took the lives of 13 young men when the fire did not behave as expected. The men were forced to outrun this fire, up a hill at a 76% slope, with the fire racing at them at 7 miles per hour, at an air temperature of 100 degrees. Only two firefighters survived. Those who perished tried to run up the hill with all of their gear, including their Pulaski, which served, at the time, only to slow them down. One survivor was lucky; he managed to get to the top of hill before the fire engulfed him. The other survivor, Wagner Dodge, was heroic. He realized the situation was hopeless and created a radical, innovative, and immediate solution to the problem at hand: He not only dropped his 22-pound handicap, but he also stopped running up the hill, stood still, and lit his own escape fire to avoid the larger fire at hand. The rest of the pack clung to the only option they could conceive of, which was outrunning the beast, despite the fact that it was traveling twice as fast as they were.

During his speech, Dr. Berwick also spoke of some of his personal experiences within U.S. hospitals that were filled with fear, uncertainty, and at times downright outrage; of misunderstandings, despicable care transitions, and daily medical errors or near misses. About how he and his wife struggled for security, appropriate treatments, and more answers than questions. He spoke of being in some of the best hospitals in the nation, and of being more organized and informed than most patients. Most patients would not possibly fare as well as the Berwicks, being under- or uninsured, of low health literacy, undereducated, or uninformed. It is incomprehensible that we have created a system that is so complicated and difficult to navigate that even the best and the brightest cannot traverse it unscathed. So it seems that sometimes the key to doing something better (or surviving, in the case of the Mann Gulch fire) is not knowing what new tools to adopt, but instead knowing what tools to get rid of.

Seize the Day

There is a dog park near my house that we take our dog to whenever we get a chance. There is a dog that frequents the park, a brown Labrador by the name of Gracie. Gracie’s favorite activity is fetching tennis balls; she dutifully catches the ball (usually in midair) and brings it back to her owner. When she gets back to her owner, she stands in front of him waiting for her order: “Drop it, Gracie.” As soon as Gracie hears the order, she drops the ball immediately. But she won’t drop the ball until ordered to do so—even though, by keeping the ball, she is that much further away from her next favorite activity. It seems like, to do the best for herself, she should come back and drop the ball, which would bring her that much closer to the one thing she loves best.

But she doesn’t. She waits dutifully for someone else to tell her when to drop the ball.

And interestingly, Gracie will not just drop it for anyone. When others at the park want to play with Gracie, and follow the lead of Gracie’s owner, and say “Drop it, Gracie,” she will look at the visitor, and then at her owner, looking for the approval that it really is in fact OK for her to drop it. Even after an approving look, she will hesitatingly drop the ball, and only after the stranger is a safe distance away, in case she needs to retrieve it sooner than later.

Many of us in the healthcare industry often wait for someone else to tell us when to start doing new things, but rarely do we expect, do we hear, or do we initiate the order to stop doing something. We need to think deeply about all the things we do that are useless Pulaskis, and about how to radically change the industry in which we work. Because this inching along is not going fast enough, and there is little evidence that we have made much progress in the last decade. So if you find yourself lugging around a Pulaski (or two), don’t just think about how to drop it, or when to drop it, or whether to drop it on certain days of the week. Just drop it, Gracie.

Dr. Scheurer is a hospitalist and chief quality officer at the Medical University of South Carolina in Charleston. She is physician editor of The Hospitalist. Email her at scheured@musc.edu.

Reference

1. Berwick D. Escape fire: lessons for the future of health care. The Commonwealth Fund website. Available at: http://www.commonwealthfund.org/usr_doc/berwick_escapefire_563.pdf. Accessed Jan. 11, 2013.

Danielle Scheurer, MD, MSCR, SFHM

Old habits are hard to break. We all get used to doing things in certain ways, and the longer we do it, it becomes increasingly difficult to do them differently. We clearly are clinging to old habits in the healthcare industry, despite compelling evidence that we need to figure out better ways of doing business. Our industry has been in a crisis for a very long time—rising costs, drastic reimbursement reductions from payors, and continually escalating risks and medical errors.

Clearly, something is not working.

This is a time when hospitalists should start thinking about dropping some of our Pulaskis.

Handy, Useful, Versatile, Reliable

A Pulaski is a versatile tool that combines an axe and an adze; it’s most commonly used in firefighting, but it is also used in trail-blazing, gardening, and woodworking (see right). The Pulaski was invented by Ed Pulaski, a forest ranger in the 1910s who almost died in a forest fire after being trapped in an old mine tunnel. After he barely survived, he invented the Pulaski as a means to reduce the risk of future firefighters being trapped in his same situation. For more than 100 years, this tool has come in handy in countless situations. It is versatile, irreplaceable, reliable—a must-have. Unless you don’t need it. And then it becomes a 22-pound handicap.

Donald Berwick, MD, MPP, spoke about the Pulaski 13 years ago in a powerful speech to the National Forum on Quality Improvement in Health Care; his presentation was titled “Escape Fire.”¹ He described the Mann Gulch fire of 1949, which took the lives of 13 young men when the fire did not behave as expected. The men were forced to outrun this fire, up a hill at a 76% slope, with the fire racing at them at 7 miles per hour, at an air temperature of 100 degrees. Only two firefighters survived. Those who perished tried to run up the hill with all of their gear, including their Pulaski, which served, at the time, only to slow them down. One survivor was lucky; he managed to get to the top of hill before the fire engulfed him. The other survivor, Wagner Dodge, was heroic. He realized the situation was hopeless and created a radical, innovative, and immediate solution to the problem at hand: He not only dropped his 22-pound handicap, but he also stopped running up the hill, stood still, and lit his own escape fire to avoid the larger fire at hand. The rest of the pack clung to the only option they could conceive of, which was outrunning the beast, despite the fact that it was traveling twice as fast as they were.

During his speech, Dr. Berwick also spoke of some of his personal experiences within U.S. hospitals that were filled with fear, uncertainty, and at times downright outrage; of misunderstandings, despicable care transitions, and daily medical errors or near misses. About how he and his wife struggled for security, appropriate treatments, and more answers than questions. He spoke of being in some of the best hospitals in the nation, and of being more organized and informed than most patients. Most patients would not possibly fare as well as the Berwicks, being under- or uninsured, of low health literacy, undereducated, or uninformed. It is incomprehensible that we have created a system that is so complicated and difficult to navigate that even the best and the brightest cannot traverse it unscathed. So it seems that sometimes the key to doing something better (or surviving, in the case of the Mann Gulch fire) is not knowing what new tools to adopt, but instead knowing what tools to get rid of.

Seize the Day

There is a dog park near my house that we take our dog to whenever we get a chance. There is a dog that frequents the park, a brown Labrador by the name of Gracie. Gracie’s favorite activity is fetching tennis balls; she dutifully catches the ball (usually in midair) and brings it back to her owner. When she gets back to her owner, she stands in front of him waiting for her order: “Drop it, Gracie.” As soon as Gracie hears the order, she drops the ball immediately. But she won’t drop the ball until ordered to do so—even though, by keeping the ball, she is that much further away from her next favorite activity. It seems like, to do the best for herself, she should come back and drop the ball, which would bring her that much closer to the one thing she loves best.

But she doesn’t. She waits dutifully for someone else to tell her when to drop the ball.

And interestingly, Gracie will not just drop it for anyone. When others at the park want to play with Gracie, and follow the lead of Gracie’s owner, and say “Drop it, Gracie,” she will look at the visitor, and then at her owner, looking for the approval that it really is in fact OK for her to drop it. Even after an approving look, she will hesitatingly drop the ball, and only after the stranger is a safe distance away, in case she needs to retrieve it sooner than later.

Many of us in the healthcare industry often wait for someone else to tell us when to start doing new things, but rarely do we expect, do we hear, or do we initiate the order to stop doing something. We need to think deeply about all the things we do that are useless Pulaskis, and about how to radically change the industry in which we work. Because this inching along is not going fast enough, and there is little evidence that we have made much progress in the last decade. So if you find yourself lugging around a Pulaski (or two), don’t just think about how to drop it, or when to drop it, or whether to drop it on certain days of the week. Just drop it, Gracie.

Dr. Scheurer is a hospitalist and chief quality officer at the Medical University of South Carolina in Charleston. She is physician editor of The Hospitalist. Email her at scheured@musc.edu.

Reference

1. Berwick D. Escape fire: lessons for the future of health care. The Commonwealth Fund website. Available at: http://www.commonwealthfund.org/usr_doc/berwick_escapefire_563.pdf. Accessed Jan. 11, 2013.

Danielle Scheurer, MD, MSCR, SFHM

Old habits are hard to break. We all get used to doing things in certain ways, and the longer we do it, it becomes increasingly difficult to do them differently. We clearly are clinging to old habits in the healthcare industry, despite compelling evidence that we need to figure out better ways of doing business. Our industry has been in a crisis for a very long time—rising costs, drastic reimbursement reductions from payors, and continually escalating risks and medical errors.

Clearly, something is not working.

This is a time when hospitalists should start thinking about dropping some of our Pulaskis.

Handy, Useful, Versatile, Reliable

A Pulaski is a versatile tool that combines an axe and an adze; it’s most commonly used in firefighting, but it is also used in trail-blazing, gardening, and woodworking (see right). The Pulaski was invented by Ed Pulaski, a forest ranger in the 1910s who almost died in a forest fire after being trapped in an old mine tunnel. After he barely survived, he invented the Pulaski as a means to reduce the risk of future firefighters being trapped in his same situation. For more than 100 years, this tool has come in handy in countless situations. It is versatile, irreplaceable, reliable—a must-have. Unless you don’t need it. And then it becomes a 22-pound handicap.

Donald Berwick, MD, MPP, spoke about the Pulaski 13 years ago in a powerful speech to the National Forum on Quality Improvement in Health Care; his presentation was titled “Escape Fire.”¹ He described the Mann Gulch fire of 1949, which took the lives of 13 young men when the fire did not behave as expected. The men were forced to outrun this fire, up a hill at a 76% slope, with the fire racing at them at 7 miles per hour, at an air temperature of 100 degrees. Only two firefighters survived. Those who perished tried to run up the hill with all of their gear, including their Pulaski, which served, at the time, only to slow them down. One survivor was lucky; he managed to get to the top of hill before the fire engulfed him. The other survivor, Wagner Dodge, was heroic. He realized the situation was hopeless and created a radical, innovative, and immediate solution to the problem at hand: He not only dropped his 22-pound handicap, but he also stopped running up the hill, stood still, and lit his own escape fire to avoid the larger fire at hand. The rest of the pack clung to the only option they could conceive of, which was outrunning the beast, despite the fact that it was traveling twice as fast as they were.

During his speech, Dr. Berwick also spoke of some of his personal experiences within U.S. hospitals that were filled with fear, uncertainty, and at times downright outrage; of misunderstandings, despicable care transitions, and daily medical errors or near misses. About how he and his wife struggled for security, appropriate treatments, and more answers than questions. He spoke of being in some of the best hospitals in the nation, and of being more organized and informed than most patients. Most patients would not possibly fare as well as the Berwicks, being under- or uninsured, of low health literacy, undereducated, or uninformed. It is incomprehensible that we have created a system that is so complicated and difficult to navigate that even the best and the brightest cannot traverse it unscathed. So it seems that sometimes the key to doing something better (or surviving, in the case of the Mann Gulch fire) is not knowing what new tools to adopt, but instead knowing what tools to get rid of.

Seize the Day

There is a dog park near my house that we take our dog to whenever we get a chance. There is a dog that frequents the park, a brown Labrador by the name of Gracie. Gracie’s favorite activity is fetching tennis balls; she dutifully catches the ball (usually in midair) and brings it back to her owner. When she gets back to her owner, she stands in front of him waiting for her order: “Drop it, Gracie.” As soon as Gracie hears the order, she drops the ball immediately. But she won’t drop the ball until ordered to do so—even though, by keeping the ball, she is that much further away from her next favorite activity. It seems like, to do the best for herself, she should come back and drop the ball, which would bring her that much closer to the one thing she loves best.

But she doesn’t. She waits dutifully for someone else to tell her when to drop the ball.

And interestingly, Gracie will not just drop it for anyone. When others at the park want to play with Gracie, and follow the lead of Gracie’s owner, and say “Drop it, Gracie,” she will look at the visitor, and then at her owner, looking for the approval that it really is in fact OK for her to drop it. Even after an approving look, she will hesitatingly drop the ball, and only after the stranger is a safe distance away, in case she needs to retrieve it sooner than later.

Many of us in the healthcare industry often wait for someone else to tell us when to start doing new things, but rarely do we expect, do we hear, or do we initiate the order to stop doing something. We need to think deeply about all the things we do that are useless Pulaskis, and about how to radically change the industry in which we work. Because this inching along is not going fast enough, and there is little evidence that we have made much progress in the last decade. So if you find yourself lugging around a Pulaski (or two), don’t just think about how to drop it, or when to drop it, or whether to drop it on certain days of the week. Just drop it, Gracie.

Dr. Scheurer is a hospitalist and chief quality officer at the Medical University of South Carolina in Charleston. She is physician editor of The Hospitalist. Email her at scheured@musc.edu.

Reference

1. Berwick D. Escape fire: lessons for the future of health care. The Commonwealth Fund website. Available at: http://www.commonwealthfund.org/usr_doc/berwick_escapefire_563.pdf. Accessed Jan. 11, 2013.

Some hospitalist groups can expect a bump in total revenue over the next two years, thanks to the Medicaid-to-Medicare parity regulation that was included in the Affordable Care Act. But whether the increase in reimbursement lasts beyond 2014 is anyone’s guess.

The regulation, which the Centers for Medicare & Medicaid Services (CMS) released in November and made effective Jan. 1, increases Medicaid payments for certain primary-care services to 100% of Medicare levels this year and next. States will receive an estimated $11 billion over the next two years to fund the program, according to the American Academy of Family Physicians (AAFP). Eligible providers include physicians, physician assistants (PAs), and nurse practitioners (NPs), who self-attest they are board-certified in family, pediatric, or general internal medicine; it also includes those doctors, PAs, or NPs who self-attest that at least 60% of all Medicaid services they bill or provide in a managed-care environment are for specific evaluation and management (E&M) and vaccine administration codes.¹

The concept is to boost Medicaid participation by improving historically lagging reimbursement rates.² To wit, CMS’ Office of the Actuary estimates the parity rule will add more than 10,000 new primary-care physicians (PCPs) to the Medicaid participation ranks.³

SHM Public Policy Committee member Brad Flansbaum, DO, MPH, SFHM, says that hospitalists who deal with Medicaid populations can expect at least some increase in their revenue over the next two years. For example, he says, take an HM group earning $100,000 a year in Medicaid revenue. Now consider Urban Institute figures that show, in 2012, Medicaid physician fees on average were 66% of Medicare physician fees (with wide state variations). The parity rule now pays that hypothetical HM group about $150,000.

“It’s simple math,” Dr. Flansbaum says. “I would emphasize that the bump in pay is going to be proportional to the percentage of Medicaid patients that you see. There are some doctors who see an awful lot of Medicaid patients in safety-net and public hospitals, and that money, when it comes back to departments and divisions, can be used for things that a lot of these places never had the means to do before. It could be salary, but it could also mean hiring more people, more resources. It makes a difference.”

Public Policy Committee chair Ron Greeno, MD, FCCP, MHM, says SHM advocated for the parity regulation, as Medicaid has historically paid for only about 70% of the healthcare delivered to patients. Although the parity issue has not gathered as much attention as other facets of the healthcare reform movement, having CMS recognize that delivery of primary care is not restricted to traditional offices is one he and SHM are particularly proud of.

“This is a correction long in coming,” Dr. Greeno says. “We’re happy hospitalists were included in the group of people that will achieve that parity.”

Dr. Greeno

Dr. Flansbaum, director of hospitalist services at Lenox Hill Hospital in New York City, says few physicians are even aware of the provision, in part because of a widespread frustration with Medicaid’s historic reimbursements rates.

“It’s almost a foregone conclusion that Medicaid never pays, reimbursement always goes down, and the interactions with Medicaid are always increasingly difficult,” Dr. Flansbaum adds.

The question for physicians and policy wonks now is what happens to the parity regulation after its scheduled expiration Dec. 31, 2014. Several medical societies, including SHM and the American College of Physicians (ACP), lobbied Congress to make sure the parity regulation was not impacted by the “fiscal cliff” negotiations. The next step is to craft a permanent funding source to pay for it.

“Unless Congress acts to permanently extend and fund this provision, a sudden return to disparate and inadequate payment for primary services needed by Medicaid patients after only two years will again threaten to restrict their access to such needed services,” AAFP said in a statement after the rule was implemented. “It would once again shut out people who have come to know and depend on their primary care physicians. Only by extending Medicaid parity with Medicare can we ensure that these Americans continue to have uninterrupted medical care in the future.”

There are some doctors who see an awful lot of Medicaid patients in safety-net and public hospitals, and that money, when it comes back to departments and divisions, can be used for things that a lot of these places never had the means to do before. It could be salary, but it could also mean hiring more people, more resources. It makes a difference.

—Brad Flansbaum, DO, MPH, SFHM, Lenox Hill Hospital, New York City, SHM Public Policy Committee member

SHM recommended that CMS work with the states to facilitate timely data collection designed to determine the effects on the quality and efficiency of care being received under Medicaid as a result of the enhanced fees. CMS agreed with this recommendation and the resulting data, hopefully, will make the case for continuing the enhanced payment following 2014.

Dr. Flansbaum says SHM’s policy team will continue to work on the issue, but given the precarious state of federal budgets and political dysfunction in Washington, it’s too early to know whether a funding source will be identified to pay for parity in 2015 and beyond—especially as politicians have yet to craft long-term solutions to issues including the sustainable-growth rate formula and other specialists, including radiologists and obstetricians, lobby to be eligible for the parity pay. However, he is hopeful that physicians who see the added impact of parity pay in the next two years will lobby Congress to find a way to continue the higher reimbursement.

“I can’t tell you whether or not when you put on the scale of all the priorities whether it’s going to be a new Air Force bomber, another $50 billion into Medicare for physicians, or an educational system upgrade,” he says. “I don’t know where the government is going to assign its priorities. Will the money be there to extend both the two-year Medicaid and the reprieve? And if the answer is yes, will it be extended to other providers beyond just primary-care practitioners? It’s anyone’s guess.”

Richard Quinn is a freelance writer in New Jersey.

References

1. FAQ: Medicaid/Medicare Parity Regulation. Society of Hospital Medicine website. Available at: http://www.hospitalmedicine.org/AM/Images/Advocacy_Image/pdf/Parity_FAQ_Final.pdf. Accessed Jan. 27, 2013.
2. Centers for Medicare & Medicaid Services. Medicaid program; payments for services furnished by certain primary care physicians and charges for vaccine administration under the Vaccines for Children program. Federal Register website. Available at: http://www.gpo.gov/fdsys/pkg/FR-2012-11-06/pdf/2012-26507.pdf. Accessed Jan. 15, 2013.
3. Bindman A. JAMA Forum: Warning: Dangerous physician payment cliffs ahead. Journal of the American Medical Association website. Available at: http://newsatjama.jama.com/2013/01/10/jama-forum-warning-dangerous-physician-payment-cliffs-ahead/.Accessed Jan. 15, 2013.

Some hospitalist groups can expect a bump in total revenue over the next two years, thanks to the Medicaid-to-Medicare parity regulation that was included in the Affordable Care Act. But whether the increase in reimbursement lasts beyond 2014 is anyone’s guess.

The regulation, which the Centers for Medicare & Medicaid Services (CMS) released in November and made effective Jan. 1, increases Medicaid payments for certain primary-care services to 100% of Medicare levels this year and next. States will receive an estimated $11 billion over the next two years to fund the program, according to the American Academy of Family Physicians (AAFP). Eligible providers include physicians, physician assistants (PAs), and nurse practitioners (NPs), who self-attest they are board-certified in family, pediatric, or general internal medicine; it also includes those doctors, PAs, or NPs who self-attest that at least 60% of all Medicaid services they bill or provide in a managed-care environment are for specific evaluation and management (E&M) and vaccine administration codes.¹

The concept is to boost Medicaid participation by improving historically lagging reimbursement rates.² To wit, CMS’ Office of the Actuary estimates the parity rule will add more than 10,000 new primary-care physicians (PCPs) to the Medicaid participation ranks.³

SHM Public Policy Committee member Brad Flansbaum, DO, MPH, SFHM, says that hospitalists who deal with Medicaid populations can expect at least some increase in their revenue over the next two years. For example, he says, take an HM group earning $100,000 a year in Medicaid revenue. Now consider Urban Institute figures that show, in 2012, Medicaid physician fees on average were 66% of Medicare physician fees (with wide state variations). The parity rule now pays that hypothetical HM group about $150,000.

“It’s simple math,” Dr. Flansbaum says. “I would emphasize that the bump in pay is going to be proportional to the percentage of Medicaid patients that you see. There are some doctors who see an awful lot of Medicaid patients in safety-net and public hospitals, and that money, when it comes back to departments and divisions, can be used for things that a lot of these places never had the means to do before. It could be salary, but it could also mean hiring more people, more resources. It makes a difference.”

Public Policy Committee chair Ron Greeno, MD, FCCP, MHM, says SHM advocated for the parity regulation, as Medicaid has historically paid for only about 70% of the healthcare delivered to patients. Although the parity issue has not gathered as much attention as other facets of the healthcare reform movement, having CMS recognize that delivery of primary care is not restricted to traditional offices is one he and SHM are particularly proud of.

“This is a correction long in coming,” Dr. Greeno says. “We’re happy hospitalists were included in the group of people that will achieve that parity.”

Dr. Greeno

Dr. Flansbaum, director of hospitalist services at Lenox Hill Hospital in New York City, says few physicians are even aware of the provision, in part because of a widespread frustration with Medicaid’s historic reimbursements rates.

“It’s almost a foregone conclusion that Medicaid never pays, reimbursement always goes down, and the interactions with Medicaid are always increasingly difficult,” Dr. Flansbaum adds.

The question for physicians and policy wonks now is what happens to the parity regulation after its scheduled expiration Dec. 31, 2014. Several medical societies, including SHM and the American College of Physicians (ACP), lobbied Congress to make sure the parity regulation was not impacted by the “fiscal cliff” negotiations. The next step is to craft a permanent funding source to pay for it.

“Unless Congress acts to permanently extend and fund this provision, a sudden return to disparate and inadequate payment for primary services needed by Medicaid patients after only two years will again threaten to restrict their access to such needed services,” AAFP said in a statement after the rule was implemented. “It would once again shut out people who have come to know and depend on their primary care physicians. Only by extending Medicaid parity with Medicare can we ensure that these Americans continue to have uninterrupted medical care in the future.”

There are some doctors who see an awful lot of Medicaid patients in safety-net and public hospitals, and that money, when it comes back to departments and divisions, can be used for things that a lot of these places never had the means to do before. It could be salary, but it could also mean hiring more people, more resources. It makes a difference.

—Brad Flansbaum, DO, MPH, SFHM, Lenox Hill Hospital, New York City, SHM Public Policy Committee member

SHM recommended that CMS work with the states to facilitate timely data collection designed to determine the effects on the quality and efficiency of care being received under Medicaid as a result of the enhanced fees. CMS agreed with this recommendation and the resulting data, hopefully, will make the case for continuing the enhanced payment following 2014.

Dr. Flansbaum says SHM’s policy team will continue to work on the issue, but given the precarious state of federal budgets and political dysfunction in Washington, it’s too early to know whether a funding source will be identified to pay for parity in 2015 and beyond—especially as politicians have yet to craft long-term solutions to issues including the sustainable-growth rate formula and other specialists, including radiologists and obstetricians, lobby to be eligible for the parity pay. However, he is hopeful that physicians who see the added impact of parity pay in the next two years will lobby Congress to find a way to continue the higher reimbursement.

“I can’t tell you whether or not when you put on the scale of all the priorities whether it’s going to be a new Air Force bomber, another $50 billion into Medicare for physicians, or an educational system upgrade,” he says. “I don’t know where the government is going to assign its priorities. Will the money be there to extend both the two-year Medicaid and the reprieve? And if the answer is yes, will it be extended to other providers beyond just primary-care practitioners? It’s anyone’s guess.”

Richard Quinn is a freelance writer in New Jersey.

References

1. FAQ: Medicaid/Medicare Parity Regulation. Society of Hospital Medicine website. Available at: http://www.hospitalmedicine.org/AM/Images/Advocacy_Image/pdf/Parity_FAQ_Final.pdf. Accessed Jan. 27, 2013.
2. Centers for Medicare & Medicaid Services. Medicaid program; payments for services furnished by certain primary care physicians and charges for vaccine administration under the Vaccines for Children program. Federal Register website. Available at: http://www.gpo.gov/fdsys/pkg/FR-2012-11-06/pdf/2012-26507.pdf. Accessed Jan. 15, 2013.
3. Bindman A. JAMA Forum: Warning: Dangerous physician payment cliffs ahead. Journal of the American Medical Association website. Available at: http://newsatjama.jama.com/2013/01/10/jama-forum-warning-dangerous-physician-payment-cliffs-ahead/.Accessed Jan. 15, 2013.

Some hospitalist groups can expect a bump in total revenue over the next two years, thanks to the Medicaid-to-Medicare parity regulation that was included in the Affordable Care Act. But whether the increase in reimbursement lasts beyond 2014 is anyone’s guess.

The regulation, which the Centers for Medicare & Medicaid Services (CMS) released in November and made effective Jan. 1, increases Medicaid payments for certain primary-care services to 100% of Medicare levels this year and next. States will receive an estimated $11 billion over the next two years to fund the program, according to the American Academy of Family Physicians (AAFP). Eligible providers include physicians, physician assistants (PAs), and nurse practitioners (NPs), who self-attest they are board-certified in family, pediatric, or general internal medicine; it also includes those doctors, PAs, or NPs who self-attest that at least 60% of all Medicaid services they bill or provide in a managed-care environment are for specific evaluation and management (E&M) and vaccine administration codes.¹

The concept is to boost Medicaid participation by improving historically lagging reimbursement rates.² To wit, CMS’ Office of the Actuary estimates the parity rule will add more than 10,000 new primary-care physicians (PCPs) to the Medicaid participation ranks.³

SHM Public Policy Committee member Brad Flansbaum, DO, MPH, SFHM, says that hospitalists who deal with Medicaid populations can expect at least some increase in their revenue over the next two years. For example, he says, take an HM group earning $100,000 a year in Medicaid revenue. Now consider Urban Institute figures that show, in 2012, Medicaid physician fees on average were 66% of Medicare physician fees (with wide state variations). The parity rule now pays that hypothetical HM group about $150,000.

“It’s simple math,” Dr. Flansbaum says. “I would emphasize that the bump in pay is going to be proportional to the percentage of Medicaid patients that you see. There are some doctors who see an awful lot of Medicaid patients in safety-net and public hospitals, and that money, when it comes back to departments and divisions, can be used for things that a lot of these places never had the means to do before. It could be salary, but it could also mean hiring more people, more resources. It makes a difference.”

Public Policy Committee chair Ron Greeno, MD, FCCP, MHM, says SHM advocated for the parity regulation, as Medicaid has historically paid for only about 70% of the healthcare delivered to patients. Although the parity issue has not gathered as much attention as other facets of the healthcare reform movement, having CMS recognize that delivery of primary care is not restricted to traditional offices is one he and SHM are particularly proud of.

“This is a correction long in coming,” Dr. Greeno says. “We’re happy hospitalists were included in the group of people that will achieve that parity.”

Dr. Greeno

Dr. Flansbaum, director of hospitalist services at Lenox Hill Hospital in New York City, says few physicians are even aware of the provision, in part because of a widespread frustration with Medicaid’s historic reimbursements rates.

“It’s almost a foregone conclusion that Medicaid never pays, reimbursement always goes down, and the interactions with Medicaid are always increasingly difficult,” Dr. Flansbaum adds.

The question for physicians and policy wonks now is what happens to the parity regulation after its scheduled expiration Dec. 31, 2014. Several medical societies, including SHM and the American College of Physicians (ACP), lobbied Congress to make sure the parity regulation was not impacted by the “fiscal cliff” negotiations. The next step is to craft a permanent funding source to pay for it.

“Unless Congress acts to permanently extend and fund this provision, a sudden return to disparate and inadequate payment for primary services needed by Medicaid patients after only two years will again threaten to restrict their access to such needed services,” AAFP said in a statement after the rule was implemented. “It would once again shut out people who have come to know and depend on their primary care physicians. Only by extending Medicaid parity with Medicare can we ensure that these Americans continue to have uninterrupted medical care in the future.”

There are some doctors who see an awful lot of Medicaid patients in safety-net and public hospitals, and that money, when it comes back to departments and divisions, can be used for things that a lot of these places never had the means to do before. It could be salary, but it could also mean hiring more people, more resources. It makes a difference.

—Brad Flansbaum, DO, MPH, SFHM, Lenox Hill Hospital, New York City, SHM Public Policy Committee member

SHM recommended that CMS work with the states to facilitate timely data collection designed to determine the effects on the quality and efficiency of care being received under Medicaid as a result of the enhanced fees. CMS agreed with this recommendation and the resulting data, hopefully, will make the case for continuing the enhanced payment following 2014.

Dr. Flansbaum says SHM’s policy team will continue to work on the issue, but given the precarious state of federal budgets and political dysfunction in Washington, it’s too early to know whether a funding source will be identified to pay for parity in 2015 and beyond—especially as politicians have yet to craft long-term solutions to issues including the sustainable-growth rate formula and other specialists, including radiologists and obstetricians, lobby to be eligible for the parity pay. However, he is hopeful that physicians who see the added impact of parity pay in the next two years will lobby Congress to find a way to continue the higher reimbursement.

“I can’t tell you whether or not when you put on the scale of all the priorities whether it’s going to be a new Air Force bomber, another $50 billion into Medicare for physicians, or an educational system upgrade,” he says. “I don’t know where the government is going to assign its priorities. Will the money be there to extend both the two-year Medicaid and the reprieve? And if the answer is yes, will it be extended to other providers beyond just primary-care practitioners? It’s anyone’s guess.”

Richard Quinn is a freelance writer in New Jersey.

References

1. FAQ: Medicaid/Medicare Parity Regulation. Society of Hospital Medicine website. Available at: http://www.hospitalmedicine.org/AM/Images/Advocacy_Image/pdf/Parity_FAQ_Final.pdf. Accessed Jan. 27, 2013.
2. Centers for Medicare & Medicaid Services. Medicaid program; payments for services furnished by certain primary care physicians and charges for vaccine administration under the Vaccines for Children program. Federal Register website. Available at: http://www.gpo.gov/fdsys/pkg/FR-2012-11-06/pdf/2012-26507.pdf. Accessed Jan. 15, 2013.
3. Bindman A. JAMA Forum: Warning: Dangerous physician payment cliffs ahead. Journal of the American Medical Association website. Available at: http://newsatjama.jama.com/2013/01/10/jama-forum-warning-dangerous-physician-payment-cliffs-ahead/.Accessed Jan. 15, 2013.

When it comes to Medicare, the Affordable Care Act, and a host of other healthcare-reform-related topics, hospitalists have lots of good questions, such as:

• When does the Physician Value-Based Payment Modifier (VBPM) take effect? And will I be included?
• Which primary-care services are covered by the increased Medicaid payments?
• Are hospitalists eligible to bill for Medicare’s new CPT Transitional Care Management (TCM) codes? (see “New Codes Bridge Billing Gap,”).

Now, SHM’s Public Policy Committee has answered all of the above—and many more—in a set of three “Frequently Asked Questions” documents available at www.hospitalmedicine.org/advocacy. Each document goes in-depth on the most cutting-edge policy issues that are top of mind for hospitalists and the hospitals they serve on these issues:

The Physician Value-Based Payment Modifier (VBPM): The VBPM seeks to connect cost and quality of services in order to begin reimbursement for the value, rather than the quantity, of care. It combines the quality measuring in the Physician Quality Reporting System (PQRS), cost measures, and a payment adjustment for physicians. Measurement begins this year, and many hospitalists will be included.

Medicaid/Medicare parity regulation: On Nov. 1, 2012, the Centers for Medicare & Medicaid Services (CMS) released the final regulations implementing Section 1202 of the Affordable Care Act, which increases Medicaid payments for specified primary-care services to 100% of Medicare levels in 2013 and 2014.

New CPT Transitional Care Management (TCM) codes 99495-99496: CMS has created two new CPT Transitional Care Management (TCM) codes designed to improve care coordination and provide better incentives to ensure patients are seen in a physician’s office, rather than be at risk for readmission.

New Action: Getting Involved Just Got Easier

SHM’s Legislative Action Center also makes getting involved easier with a new grassroots outreach tool called Voter Voice. SHM’s first action alert on Voter Voice was sent to members in December. Hospitalists’ willingness to take a few minutes and contact their congressional leaders using Voter Voice increased SHM’s visibility to Congress by nearly five times compared with prior similar alerts.

Getting involved is easy and only takes a few seconds. You can use either your ZIP code to look up your members of Congress or search active legislation by keyword. SHM members can sign up for SHM Legislative Action Center alerts by entering their email address.

To download the new SHM advocacy FAQs or use the improved Legislative Action Center, visit www.hospitalmedicine.org/advocacy.

When it comes to Medicare, the Affordable Care Act, and a host of other healthcare-reform-related topics, hospitalists have lots of good questions, such as:

• When does the Physician Value-Based Payment Modifier (VBPM) take effect? And will I be included?
• Which primary-care services are covered by the increased Medicaid payments?
• Are hospitalists eligible to bill for Medicare’s new CPT Transitional Care Management (TCM) codes? (see “New Codes Bridge Billing Gap,”).

Now, SHM’s Public Policy Committee has answered all of the above—and many more—in a set of three “Frequently Asked Questions” documents available at www.hospitalmedicine.org/advocacy. Each document goes in-depth on the most cutting-edge policy issues that are top of mind for hospitalists and the hospitals they serve on these issues:

The Physician Value-Based Payment Modifier (VBPM): The VBPM seeks to connect cost and quality of services in order to begin reimbursement for the value, rather than the quantity, of care. It combines the quality measuring in the Physician Quality Reporting System (PQRS), cost measures, and a payment adjustment for physicians. Measurement begins this year, and many hospitalists will be included.

Medicaid/Medicare parity regulation: On Nov. 1, 2012, the Centers for Medicare & Medicaid Services (CMS) released the final regulations implementing Section 1202 of the Affordable Care Act, which increases Medicaid payments for specified primary-care services to 100% of Medicare levels in 2013 and 2014.

New CPT Transitional Care Management (TCM) codes 99495-99496: CMS has created two new CPT Transitional Care Management (TCM) codes designed to improve care coordination and provide better incentives to ensure patients are seen in a physician’s office, rather than be at risk for readmission.

New Action: Getting Involved Just Got Easier

SHM’s Legislative Action Center also makes getting involved easier with a new grassroots outreach tool called Voter Voice. SHM’s first action alert on Voter Voice was sent to members in December. Hospitalists’ willingness to take a few minutes and contact their congressional leaders using Voter Voice increased SHM’s visibility to Congress by nearly five times compared with prior similar alerts.

Getting involved is easy and only takes a few seconds. You can use either your ZIP code to look up your members of Congress or search active legislation by keyword. SHM members can sign up for SHM Legislative Action Center alerts by entering their email address.

To download the new SHM advocacy FAQs or use the improved Legislative Action Center, visit www.hospitalmedicine.org/advocacy.

When it comes to Medicare, the Affordable Care Act, and a host of other healthcare-reform-related topics, hospitalists have lots of good questions, such as:

• When does the Physician Value-Based Payment Modifier (VBPM) take effect? And will I be included?
• Which primary-care services are covered by the increased Medicaid payments?
• Are hospitalists eligible to bill for Medicare’s new CPT Transitional Care Management (TCM) codes? (see “New Codes Bridge Billing Gap,”).

Now, SHM’s Public Policy Committee has answered all of the above—and many more—in a set of three “Frequently Asked Questions” documents available at www.hospitalmedicine.org/advocacy. Each document goes in-depth on the most cutting-edge policy issues that are top of mind for hospitalists and the hospitals they serve on these issues:

The Physician Value-Based Payment Modifier (VBPM): The VBPM seeks to connect cost and quality of services in order to begin reimbursement for the value, rather than the quantity, of care. It combines the quality measuring in the Physician Quality Reporting System (PQRS), cost measures, and a payment adjustment for physicians. Measurement begins this year, and many hospitalists will be included.

Medicaid/Medicare parity regulation: On Nov. 1, 2012, the Centers for Medicare & Medicaid Services (CMS) released the final regulations implementing Section 1202 of the Affordable Care Act, which increases Medicaid payments for specified primary-care services to 100% of Medicare levels in 2013 and 2014.

New CPT Transitional Care Management (TCM) codes 99495-99496: CMS has created two new CPT Transitional Care Management (TCM) codes designed to improve care coordination and provide better incentives to ensure patients are seen in a physician’s office, rather than be at risk for readmission.

New Action: Getting Involved Just Got Easier

SHM’s Legislative Action Center also makes getting involved easier with a new grassroots outreach tool called Voter Voice. SHM’s first action alert on Voter Voice was sent to members in December. Hospitalists’ willingness to take a few minutes and contact their congressional leaders using Voter Voice increased SHM’s visibility to Congress by nearly five times compared with prior similar alerts.

Getting involved is easy and only takes a few seconds. You can use either your ZIP code to look up your members of Congress or search active legislation by keyword. SHM members can sign up for SHM Legislative Action Center alerts by entering their email address.

To download the new SHM advocacy FAQs or use the improved Legislative Action Center, visit www.hospitalmedicine.org/advocacy.

Payment bundling may create new opportunities for hospitalists to start an important discussion with hospital executives. And forward-looking hospitalist leaders will use the new model to shape their own financial destinies.

The concept of payment bundling broadly means paying for healthcare with a single, comprehensive payment, which is intended to cover all services received by a patient. Due to the promise bundling holds when it comes to both cost containment and quality, the Affordable Care Act (ACA) includes a provision requiring the establishment of a voluntary national pilot program on payment bundling. This provision calls for bundled payments for 10 unnamed conditions by Jan. 1, 2013, and states that payment for each bundle will surround an episode of care consisting of three days prior to admission and 30 days post-hospital discharge. There is some flexibility built in because the ACA also allows for different episodes of care to be defined by the secretary of Health and Human Services.

Due to this flexibility, the discussion at SHM is probably similar to that of other forward-thinking organizations: What conditions would benefit from a hospitalist-led bundle and what is the appropriate episode of care?

In late August, the Centers for Medicare & Medicaid Services (CMS) and the Center for Medicare and Medicaid Innovation (CMMI) answered these questions with the introduction of the Bundled Payments for Care Improvement initiative. This initiative outlines four models as options for the bundling pilot while maintaining a degree of flexibility in the details for participating providers to define:

• The first model will cover all Medicare DRGs for inpatient hospital services.
• Model two will include hospital and physician inpatient and post-discharge services.
• Model three will be for post-discharge services only.
• Under the fourth model, CMS would make a single, prospective bundled payment that would encompass all services furnished during an inpatient stay by the hospital, physicians, and other practitioners.

With the exception of the first model, providers wishing to participate may propose the condition (or conditions) their bundle will cover, the episode of care, and even the measures they will use for quality purposes.

CMMI clearly is aiming for a high level of provider involvement in developing bundling models that will work, and the inpatient focus for three out of four bundling models means that hospitalists should be prepared to play a part. For example, at press time, a tight application deadline and an unclear return on investment posed potential barriers.

Nevertheless, the inpatient focus for three out of four bundling models means that hospitalists should be prepared to play a part. At a minimum, hospitalists should be prepared to negotiate their level of involvement and how they will get paid for their work, should their institutions participate. But there is nothing preventing hospitalists from taking the lead in bringing bundled payments to their institutions by approaching hospital administrators with their own bundle for a condition they will manage.

If your group or institution is planning to participate in the bundled payments initiative, please let us know by emailing jboswell@hospitalmedicine.org.

Payment bundling may create new opportunities for hospitalists to start an important discussion with hospital executives. And forward-looking hospitalist leaders will use the new model to shape their own financial destinies.

The concept of payment bundling broadly means paying for healthcare with a single, comprehensive payment, which is intended to cover all services received by a patient. Due to the promise bundling holds when it comes to both cost containment and quality, the Affordable Care Act (ACA) includes a provision requiring the establishment of a voluntary national pilot program on payment bundling. This provision calls for bundled payments for 10 unnamed conditions by Jan. 1, 2013, and states that payment for each bundle will surround an episode of care consisting of three days prior to admission and 30 days post-hospital discharge. There is some flexibility built in because the ACA also allows for different episodes of care to be defined by the secretary of Health and Human Services.

Due to this flexibility, the discussion at SHM is probably similar to that of other forward-thinking organizations: What conditions would benefit from a hospitalist-led bundle and what is the appropriate episode of care?

In late August, the Centers for Medicare & Medicaid Services (CMS) and the Center for Medicare and Medicaid Innovation (CMMI) answered these questions with the introduction of the Bundled Payments for Care Improvement initiative. This initiative outlines four models as options for the bundling pilot while maintaining a degree of flexibility in the details for participating providers to define:

• The first model will cover all Medicare DRGs for inpatient hospital services.
• Model two will include hospital and physician inpatient and post-discharge services.
• Model three will be for post-discharge services only.
• Under the fourth model, CMS would make a single, prospective bundled payment that would encompass all services furnished during an inpatient stay by the hospital, physicians, and other practitioners.

With the exception of the first model, providers wishing to participate may propose the condition (or conditions) their bundle will cover, the episode of care, and even the measures they will use for quality purposes.

CMMI clearly is aiming for a high level of provider involvement in developing bundling models that will work, and the inpatient focus for three out of four bundling models means that hospitalists should be prepared to play a part. For example, at press time, a tight application deadline and an unclear return on investment posed potential barriers.

Nevertheless, the inpatient focus for three out of four bundling models means that hospitalists should be prepared to play a part. At a minimum, hospitalists should be prepared to negotiate their level of involvement and how they will get paid for their work, should their institutions participate. But there is nothing preventing hospitalists from taking the lead in bringing bundled payments to their institutions by approaching hospital administrators with their own bundle for a condition they will manage.

If your group or institution is planning to participate in the bundled payments initiative, please let us know by emailing jboswell@hospitalmedicine.org.

Payment bundling may create new opportunities for hospitalists to start an important discussion with hospital executives. And forward-looking hospitalist leaders will use the new model to shape their own financial destinies.

The concept of payment bundling broadly means paying for healthcare with a single, comprehensive payment, which is intended to cover all services received by a patient. Due to the promise bundling holds when it comes to both cost containment and quality, the Affordable Care Act (ACA) includes a provision requiring the establishment of a voluntary national pilot program on payment bundling. This provision calls for bundled payments for 10 unnamed conditions by Jan. 1, 2013, and states that payment for each bundle will surround an episode of care consisting of three days prior to admission and 30 days post-hospital discharge. There is some flexibility built in because the ACA also allows for different episodes of care to be defined by the secretary of Health and Human Services.

Due to this flexibility, the discussion at SHM is probably similar to that of other forward-thinking organizations: What conditions would benefit from a hospitalist-led bundle and what is the appropriate episode of care?

In late August, the Centers for Medicare & Medicaid Services (CMS) and the Center for Medicare and Medicaid Innovation (CMMI) answered these questions with the introduction of the Bundled Payments for Care Improvement initiative. This initiative outlines four models as options for the bundling pilot while maintaining a degree of flexibility in the details for participating providers to define:

• The first model will cover all Medicare DRGs for inpatient hospital services.
• Model two will include hospital and physician inpatient and post-discharge services.
• Model three will be for post-discharge services only.
• Under the fourth model, CMS would make a single, prospective bundled payment that would encompass all services furnished during an inpatient stay by the hospital, physicians, and other practitioners.

With the exception of the first model, providers wishing to participate may propose the condition (or conditions) their bundle will cover, the episode of care, and even the measures they will use for quality purposes.

CMMI clearly is aiming for a high level of provider involvement in developing bundling models that will work, and the inpatient focus for three out of four bundling models means that hospitalists should be prepared to play a part. For example, at press time, a tight application deadline and an unclear return on investment posed potential barriers.

Nevertheless, the inpatient focus for three out of four bundling models means that hospitalists should be prepared to play a part. At a minimum, hospitalists should be prepared to negotiate their level of involvement and how they will get paid for their work, should their institutions participate. But there is nothing preventing hospitalists from taking the lead in bringing bundled payments to their institutions by approaching hospital administrators with their own bundle for a condition they will manage.

If your group or institution is planning to participate in the bundled payments initiative, please let us know by emailing jboswell@hospitalmedicine.org.