Although the bungled rollout of health exchange websites has dominated healthcare-related headlines in the last months of 2013, hospitalist leaders say the policy landscape for 2014 features bigger issues.

To set the table, The Hospitalist reached out to four hospitalists who keep a close eye on the policy sphere. Those interviewed agree that the continued shift from fee-for-service to pay-for-performance will dominate policy discussions. In tow with that are the expected quality improvements the payment model is supposed to beget.

“Pay-for-performance and quality measures will be major issues for hospitalists moving forward,” says SHM Public Policy Committee member Joshua Lenchus, DO, RPh, FACP, SFHM. “But, I am not very optimistic that these processes will lead to their desired outcomes. At the end of the day, personal patient responsibility will need to be accounted for if a real change in healthcare outcomes is to be recognized.”

Other pressing policy issues the panel will pay attention to this year include:

1. Value-Based Purchasing

Further refinement and development of just how physician value-based purchasing will be implemented. More specifically, Josh Boswell, SHM’s senior manager of government relations, is watching to see how that will be incorporated into a possible long-term fix for the sustainable growth rate (SGR) formula.

“As the costs associated with noncompliance increase, hospitals will increasingly look to hospitalists to drive better performance,” says former SHM Public Policy Committee member Eric Siegal, MD, SFHM, director, Aurora Critical Care Service, St Luke’s Medical Center, Milwaukee, and clinical associate professor of medicine, University of Wisconsin School of Medicine and Public Health. “The good news: This is job security for many hospitalists. The bad news: Increasing amounts of human capital will be dedicated to meeting Medicare’s mandates, irrespective of whether this represents the most productive or effective use of those resources.”

2. ACOs

Continued monitoring of accountable-care organizations (ACOs) as the first waves of data emerge on claims and performance. Along with managing health populations, expect consolidation of healthcare systems from nearly 700 to what some experts think could be as few as 50 to 70 mega-providers.

3. Observation Status

The rollout of the new two-midnight rule, which the Centers for Medicare & Medicaid Services (CMS) recently changed to allow physicians to admit a patient if they reasonably expect and document in the medical record that a beneficiary will need to stay in the hospital for more than two midnights. Such admissions will be presumed to be appropriate for Medicare Part A payment. CMS cited concerns about the growing trend of longer observation stays to support this change. Connected with this issue is SHM’s continued backing of the Improving Access to Medicare Coverage Act of 2013 (H.R. 1179, S. 569), which would solve the conundrum of “observation status” time not counting toward the required three consecutive overnights an inpatient needs to qualify for Medicare benefits at a skilled nursing facility.

Forward Moving

SHM Public Policy Committee chair Ron Greeno, MD, FCCP, MHM, says that while insurance reform is one of the three legs of the Affordable Care Act, hospitalists need to be focused just as vigilantly on expanding healthcare access for more patients and reforming the delivery system.

“That’s where we’re supposedly going to get the resources to do these other things,” says Dr. Greeno, chief medical officer for Cogent HMG of Brentwood, Tenn. “Hospitalists are right in the middle of those discussions—and they should be.”

Whether you are for or against the changes produced by the Affordable Care Act, Dr. Siegal says the system “just became a lot less stable.”

“The tacit, quid pro quo had been that lost revenue from Medicare would, at least in part, [be] offset when 30-plus million Americans with newly minted insurance plans became paying healthcare consumers,” Dr. Siegal adds. “With this delicate balance suddenly jeopardized, my guess is that many health systems will circle their wagons until they know which way the wind will blow.”

All told, the healthcare landscape remains one that is pockmarked by generational reform that will require deft hands to navigate. But those who are still fighting reform and its expanded access provision might be missing the larger point.

“You could repeal the Affordable Care Act today, which is not going to happen obviously, but it wouldn’t change the fact that these emerging alternative payment methodologies are still going to occur,” Dr. Siegal says. “It’s beyond Medicare. The private payors are doing it. Physician groups and hospitals and other integrated healthcare organizations are gearing up to take those payments ... because staying in fee-for-service is untenable.”

Richard Quinn is a freelance writer in New Jersey.

Although the bungled rollout of health exchange websites has dominated healthcare-related headlines in the last months of 2013, hospitalist leaders say the policy landscape for 2014 features bigger issues.

To set the table, The Hospitalist reached out to four hospitalists who keep a close eye on the policy sphere. Those interviewed agree that the continued shift from fee-for-service to pay-for-performance will dominate policy discussions. In tow with that are the expected quality improvements the payment model is supposed to beget.

“Pay-for-performance and quality measures will be major issues for hospitalists moving forward,” says SHM Public Policy Committee member Joshua Lenchus, DO, RPh, FACP, SFHM. “But, I am not very optimistic that these processes will lead to their desired outcomes. At the end of the day, personal patient responsibility will need to be accounted for if a real change in healthcare outcomes is to be recognized.”

Other pressing policy issues the panel will pay attention to this year include:

1. Value-Based Purchasing

Further refinement and development of just how physician value-based purchasing will be implemented. More specifically, Josh Boswell, SHM’s senior manager of government relations, is watching to see how that will be incorporated into a possible long-term fix for the sustainable growth rate (SGR) formula.

“As the costs associated with noncompliance increase, hospitals will increasingly look to hospitalists to drive better performance,” says former SHM Public Policy Committee member Eric Siegal, MD, SFHM, director, Aurora Critical Care Service, St Luke’s Medical Center, Milwaukee, and clinical associate professor of medicine, University of Wisconsin School of Medicine and Public Health. “The good news: This is job security for many hospitalists. The bad news: Increasing amounts of human capital will be dedicated to meeting Medicare’s mandates, irrespective of whether this represents the most productive or effective use of those resources.”

2. ACOs

Continued monitoring of accountable-care organizations (ACOs) as the first waves of data emerge on claims and performance. Along with managing health populations, expect consolidation of healthcare systems from nearly 700 to what some experts think could be as few as 50 to 70 mega-providers.

3. Observation Status

The rollout of the new two-midnight rule, which the Centers for Medicare & Medicaid Services (CMS) recently changed to allow physicians to admit a patient if they reasonably expect and document in the medical record that a beneficiary will need to stay in the hospital for more than two midnights. Such admissions will be presumed to be appropriate for Medicare Part A payment. CMS cited concerns about the growing trend of longer observation stays to support this change. Connected with this issue is SHM’s continued backing of the Improving Access to Medicare Coverage Act of 2013 (H.R. 1179, S. 569), which would solve the conundrum of “observation status” time not counting toward the required three consecutive overnights an inpatient needs to qualify for Medicare benefits at a skilled nursing facility.

Forward Moving

SHM Public Policy Committee chair Ron Greeno, MD, FCCP, MHM, says that while insurance reform is one of the three legs of the Affordable Care Act, hospitalists need to be focused just as vigilantly on expanding healthcare access for more patients and reforming the delivery system.

“That’s where we’re supposedly going to get the resources to do these other things,” says Dr. Greeno, chief medical officer for Cogent HMG of Brentwood, Tenn. “Hospitalists are right in the middle of those discussions—and they should be.”

Whether you are for or against the changes produced by the Affordable Care Act, Dr. Siegal says the system “just became a lot less stable.”

“The tacit, quid pro quo had been that lost revenue from Medicare would, at least in part, [be] offset when 30-plus million Americans with newly minted insurance plans became paying healthcare consumers,” Dr. Siegal adds. “With this delicate balance suddenly jeopardized, my guess is that many health systems will circle their wagons until they know which way the wind will blow.”

All told, the healthcare landscape remains one that is pockmarked by generational reform that will require deft hands to navigate. But those who are still fighting reform and its expanded access provision might be missing the larger point.

“You could repeal the Affordable Care Act today, which is not going to happen obviously, but it wouldn’t change the fact that these emerging alternative payment methodologies are still going to occur,” Dr. Siegal says. “It’s beyond Medicare. The private payors are doing it. Physician groups and hospitals and other integrated healthcare organizations are gearing up to take those payments ... because staying in fee-for-service is untenable.”

Richard Quinn is a freelance writer in New Jersey.

Although the bungled rollout of health exchange websites has dominated healthcare-related headlines in the last months of 2013, hospitalist leaders say the policy landscape for 2014 features bigger issues.

To set the table, The Hospitalist reached out to four hospitalists who keep a close eye on the policy sphere. Those interviewed agree that the continued shift from fee-for-service to pay-for-performance will dominate policy discussions. In tow with that are the expected quality improvements the payment model is supposed to beget.

“Pay-for-performance and quality measures will be major issues for hospitalists moving forward,” says SHM Public Policy Committee member Joshua Lenchus, DO, RPh, FACP, SFHM. “But, I am not very optimistic that these processes will lead to their desired outcomes. At the end of the day, personal patient responsibility will need to be accounted for if a real change in healthcare outcomes is to be recognized.”

Other pressing policy issues the panel will pay attention to this year include:

1. Value-Based Purchasing

Further refinement and development of just how physician value-based purchasing will be implemented. More specifically, Josh Boswell, SHM’s senior manager of government relations, is watching to see how that will be incorporated into a possible long-term fix for the sustainable growth rate (SGR) formula.

“As the costs associated with noncompliance increase, hospitals will increasingly look to hospitalists to drive better performance,” says former SHM Public Policy Committee member Eric Siegal, MD, SFHM, director, Aurora Critical Care Service, St Luke’s Medical Center, Milwaukee, and clinical associate professor of medicine, University of Wisconsin School of Medicine and Public Health. “The good news: This is job security for many hospitalists. The bad news: Increasing amounts of human capital will be dedicated to meeting Medicare’s mandates, irrespective of whether this represents the most productive or effective use of those resources.”

2. ACOs

Continued monitoring of accountable-care organizations (ACOs) as the first waves of data emerge on claims and performance. Along with managing health populations, expect consolidation of healthcare systems from nearly 700 to what some experts think could be as few as 50 to 70 mega-providers.

3. Observation Status

The rollout of the new two-midnight rule, which the Centers for Medicare & Medicaid Services (CMS) recently changed to allow physicians to admit a patient if they reasonably expect and document in the medical record that a beneficiary will need to stay in the hospital for more than two midnights. Such admissions will be presumed to be appropriate for Medicare Part A payment. CMS cited concerns about the growing trend of longer observation stays to support this change. Connected with this issue is SHM’s continued backing of the Improving Access to Medicare Coverage Act of 2013 (H.R. 1179, S. 569), which would solve the conundrum of “observation status” time not counting toward the required three consecutive overnights an inpatient needs to qualify for Medicare benefits at a skilled nursing facility.

Forward Moving

SHM Public Policy Committee chair Ron Greeno, MD, FCCP, MHM, says that while insurance reform is one of the three legs of the Affordable Care Act, hospitalists need to be focused just as vigilantly on expanding healthcare access for more patients and reforming the delivery system.

“That’s where we’re supposedly going to get the resources to do these other things,” says Dr. Greeno, chief medical officer for Cogent HMG of Brentwood, Tenn. “Hospitalists are right in the middle of those discussions—and they should be.”

Whether you are for or against the changes produced by the Affordable Care Act, Dr. Siegal says the system “just became a lot less stable.”

“The tacit, quid pro quo had been that lost revenue from Medicare would, at least in part, [be] offset when 30-plus million Americans with newly minted insurance plans became paying healthcare consumers,” Dr. Siegal adds. “With this delicate balance suddenly jeopardized, my guess is that many health systems will circle their wagons until they know which way the wind will blow.”

All told, the healthcare landscape remains one that is pockmarked by generational reform that will require deft hands to navigate. But those who are still fighting reform and its expanded access provision might be missing the larger point.

“You could repeal the Affordable Care Act today, which is not going to happen obviously, but it wouldn’t change the fact that these emerging alternative payment methodologies are still going to occur,” Dr. Siegal says. “It’s beyond Medicare. The private payors are doing it. Physician groups and hospitals and other integrated healthcare organizations are gearing up to take those payments ... because staying in fee-for-service is untenable.”

Richard Quinn is a freelance writer in New Jersey.

Flores

Hospital budgets are tight, so your administrative time has been cut back. You’re pulling extra clinical shifts because of the busy flu season. You’re weeks away from going live on the new electronic health record system. And every spare minute is spent working on improving patient satisfaction scores or reducing readmissions. Investing a few hours in the 2014 State of Hospital Medicine survey is just not on your radar screen.

I realize it may be asking a lot, but I’d like to challenge you to step back and take a longer view. Here are five compelling reasons every hospitalist leader and administrator should participate in this year’s SHM survey and in the MGMA Physician Compensation and Production Survey.

Information You and Your Colleagues Will Use

Hospitalist groups all over the country, probably including yours, use information from SHM and MGMA surveys to benchmark compensation and productivity internally and to assess options related to scope of services, staffing and scheduling, and other structural parameters. If you don’t participate, your group’s data isn’t collected, depriving HM practices everywhere of the benefits of your group’s experience.

Be Prepared to Defend Your Group’s Performance

Other people who have influence over your practice are going to use this information to make judgments about how your group stacks up. It is in your interest to understand how the survey questions are worded and how the data is analyzed and presented. Participation offers firsthand insight into what information is actually being collected and reported, which can help you explain why your group’s results might be different. And the free copy of the survey you receive ensures you will have direct access to the information others are using to evaluate you.

Small Sample Sizes Bias the Results

It’s tempting to sit back and think there are plenty of others participating. But the more groups that participate, the more robust and representative the data will be. And with larger data sets, the data analysts have more options for “cutting” the data and reporting meaningful results for different subsets of the hospitalist universe. Your group’s data just might mean the difference between numbers and blanks in some of those tables.

A Valuable Way to “Give Back” to the Specialty

HM has been good to you. Even if you don’t have the time or opportunity to write, speak, serve on SHM committees, or otherwise move your specialty forward, one important way you can “give back” to the field is to help ensure high quality, representative survey results.

You Might Just Learn Something

Some of the information the survey asks for isn’t at your fingertips. You’re going to have to dig, and probably work with others, to obtain what you need. But in the process, you’re likely to learn something useful about your group’s performance that you didn’t know before, like your CPT code distribution or the amount of financial support you received. And, once you learn it, you’ll want to keep tracking it going forward.

Leslie Flores, MHA, SFHM, is partner in Nelson Flores Hospital Medicine Consultants and an SHM Practice Analysis Committee member.

Flores

Hospital budgets are tight, so your administrative time has been cut back. You’re pulling extra clinical shifts because of the busy flu season. You’re weeks away from going live on the new electronic health record system. And every spare minute is spent working on improving patient satisfaction scores or reducing readmissions. Investing a few hours in the 2014 State of Hospital Medicine survey is just not on your radar screen.

I realize it may be asking a lot, but I’d like to challenge you to step back and take a longer view. Here are five compelling reasons every hospitalist leader and administrator should participate in this year’s SHM survey and in the MGMA Physician Compensation and Production Survey.

Information You and Your Colleagues Will Use

Hospitalist groups all over the country, probably including yours, use information from SHM and MGMA surveys to benchmark compensation and productivity internally and to assess options related to scope of services, staffing and scheduling, and other structural parameters. If you don’t participate, your group’s data isn’t collected, depriving HM practices everywhere of the benefits of your group’s experience.

Be Prepared to Defend Your Group’s Performance

Other people who have influence over your practice are going to use this information to make judgments about how your group stacks up. It is in your interest to understand how the survey questions are worded and how the data is analyzed and presented. Participation offers firsthand insight into what information is actually being collected and reported, which can help you explain why your group’s results might be different. And the free copy of the survey you receive ensures you will have direct access to the information others are using to evaluate you.

Small Sample Sizes Bias the Results

It’s tempting to sit back and think there are plenty of others participating. But the more groups that participate, the more robust and representative the data will be. And with larger data sets, the data analysts have more options for “cutting” the data and reporting meaningful results for different subsets of the hospitalist universe. Your group’s data just might mean the difference between numbers and blanks in some of those tables.

A Valuable Way to “Give Back” to the Specialty

HM has been good to you. Even if you don’t have the time or opportunity to write, speak, serve on SHM committees, or otherwise move your specialty forward, one important way you can “give back” to the field is to help ensure high quality, representative survey results.

You Might Just Learn Something

Some of the information the survey asks for isn’t at your fingertips. You’re going to have to dig, and probably work with others, to obtain what you need. But in the process, you’re likely to learn something useful about your group’s performance that you didn’t know before, like your CPT code distribution or the amount of financial support you received. And, once you learn it, you’ll want to keep tracking it going forward.

Leslie Flores, MHA, SFHM, is partner in Nelson Flores Hospital Medicine Consultants and an SHM Practice Analysis Committee member.

Flores

Hospital budgets are tight, so your administrative time has been cut back. You’re pulling extra clinical shifts because of the busy flu season. You’re weeks away from going live on the new electronic health record system. And every spare minute is spent working on improving patient satisfaction scores or reducing readmissions. Investing a few hours in the 2014 State of Hospital Medicine survey is just not on your radar screen.

I realize it may be asking a lot, but I’d like to challenge you to step back and take a longer view. Here are five compelling reasons every hospitalist leader and administrator should participate in this year’s SHM survey and in the MGMA Physician Compensation and Production Survey.

Information You and Your Colleagues Will Use

Hospitalist groups all over the country, probably including yours, use information from SHM and MGMA surveys to benchmark compensation and productivity internally and to assess options related to scope of services, staffing and scheduling, and other structural parameters. If you don’t participate, your group’s data isn’t collected, depriving HM practices everywhere of the benefits of your group’s experience.

Be Prepared to Defend Your Group’s Performance

Other people who have influence over your practice are going to use this information to make judgments about how your group stacks up. It is in your interest to understand how the survey questions are worded and how the data is analyzed and presented. Participation offers firsthand insight into what information is actually being collected and reported, which can help you explain why your group’s results might be different. And the free copy of the survey you receive ensures you will have direct access to the information others are using to evaluate you.

Small Sample Sizes Bias the Results

It’s tempting to sit back and think there are plenty of others participating. But the more groups that participate, the more robust and representative the data will be. And with larger data sets, the data analysts have more options for “cutting” the data and reporting meaningful results for different subsets of the hospitalist universe. Your group’s data just might mean the difference between numbers and blanks in some of those tables.

A Valuable Way to “Give Back” to the Specialty

HM has been good to you. Even if you don’t have the time or opportunity to write, speak, serve on SHM committees, or otherwise move your specialty forward, one important way you can “give back” to the field is to help ensure high quality, representative survey results.

You Might Just Learn Something

Some of the information the survey asks for isn’t at your fingertips. You’re going to have to dig, and probably work with others, to obtain what you need. But in the process, you’re likely to learn something useful about your group’s performance that you didn’t know before, like your CPT code distribution or the amount of financial support you received. And, once you learn it, you’ll want to keep tracking it going forward.

Leslie Flores, MHA, SFHM, is partner in Nelson Flores Hospital Medicine Consultants and an SHM Practice Analysis Committee member.

As many hospitalists are probably acutely aware, the Centers for Medicare & Medicaid Services (CMS) is putting a new rule into effect that will greatly impact how inpatient admission decisions are made. The rule, known as the “two-midnight rule,” states that if the admitting practitioner admits a Medicare beneficiary as an inpatient with the reasonable expectation that the beneficiary will require care that “crosses two midnights” and this decision is justified in the medical record, Medicare Part A payment is “generally appropriate.”

While there are multiple caveats, exceptions, and details, this rule can be simply articulated: If the admitting physician feels a patient will be in the hospital for a period longer than two midnights and the medical record supports this determination, the patient is an inpatient. Stays expected to be shorter than two midnights should be under observation status.

This new policy is an attempt to respond both to hospital calls for more guidance about when a beneficiary is appropriately treated as an inpatient—and paid by Medicare—and concerns about increasingly long hospital stays under observation status. Most hospitalists wrestle with status determination issues on a daily basis.

SHM is aware of the struggle and has been advocating on behalf of hospitalists to help shape observation status and the two-midnight rule. When the rule was first proposed, SHM voiced serious concerns about its utility and how it was unlikely to solve the overall confusion surrounding inpatient status determinations. Nevertheless, CMS finalized the rule as an attempt to begin addressing the problem.

Faced with an increasingly loud chorus of providers and hospitals concerned about the implementation of the new policy, CMS agreed to delay full enforcement from the original date of Oct. 1, 2013, until March 31, 2014.

During the delayed enforcement period, hospitals will be expected to begin implementing the two-midnight rule, and auditors will be giving hospitals non-punitive feedback on their application of the policy. To accomplish this, CMS is instructing Medicare Administrative Contractors (MACs) to review a sample of 10 to 25 inpatient hospital claims spanning less than two midnights after admission for each hospital. This probe sample will be used to assist hospitals with implementing the new requirements correctly. To give an additional level of comfort during this adjustment period, CMS has announced that it will not conduct post-payment patient status reviews for claims with dates of admission Oct. 1, 2013, through March 31, 2014.

Unfortunately, beyond the vague guidance CMS has offered thus far, there is no foolproof guide to establishing new hospital admissions policies that comply with the rule. As a result, there likely will be wide variation among hospitals.

To assist in sorting out the confusion, SHM will be hosting a webinar this month with case studies from several hospitals. The focus will be on the internal processes each hospital is using to implement the rule and how they were developed. Sharing and learning from national implementation experiences is a valuable way for hospitalists to gain new perspectives and to bring those experiences to their home institutions when considering their own roles in meeting the new admissions criteria head on.

For more information about the webinar and to register, visit www.hospitalmedicine.org today.

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

As many hospitalists are probably acutely aware, the Centers for Medicare & Medicaid Services (CMS) is putting a new rule into effect that will greatly impact how inpatient admission decisions are made. The rule, known as the “two-midnight rule,” states that if the admitting practitioner admits a Medicare beneficiary as an inpatient with the reasonable expectation that the beneficiary will require care that “crosses two midnights” and this decision is justified in the medical record, Medicare Part A payment is “generally appropriate.”

While there are multiple caveats, exceptions, and details, this rule can be simply articulated: If the admitting physician feels a patient will be in the hospital for a period longer than two midnights and the medical record supports this determination, the patient is an inpatient. Stays expected to be shorter than two midnights should be under observation status.

This new policy is an attempt to respond both to hospital calls for more guidance about when a beneficiary is appropriately treated as an inpatient—and paid by Medicare—and concerns about increasingly long hospital stays under observation status. Most hospitalists wrestle with status determination issues on a daily basis.

SHM is aware of the struggle and has been advocating on behalf of hospitalists to help shape observation status and the two-midnight rule. When the rule was first proposed, SHM voiced serious concerns about its utility and how it was unlikely to solve the overall confusion surrounding inpatient status determinations. Nevertheless, CMS finalized the rule as an attempt to begin addressing the problem.

Faced with an increasingly loud chorus of providers and hospitals concerned about the implementation of the new policy, CMS agreed to delay full enforcement from the original date of Oct. 1, 2013, until March 31, 2014.

During the delayed enforcement period, hospitals will be expected to begin implementing the two-midnight rule, and auditors will be giving hospitals non-punitive feedback on their application of the policy. To accomplish this, CMS is instructing Medicare Administrative Contractors (MACs) to review a sample of 10 to 25 inpatient hospital claims spanning less than two midnights after admission for each hospital. This probe sample will be used to assist hospitals with implementing the new requirements correctly. To give an additional level of comfort during this adjustment period, CMS has announced that it will not conduct post-payment patient status reviews for claims with dates of admission Oct. 1, 2013, through March 31, 2014.

Unfortunately, beyond the vague guidance CMS has offered thus far, there is no foolproof guide to establishing new hospital admissions policies that comply with the rule. As a result, there likely will be wide variation among hospitals.

To assist in sorting out the confusion, SHM will be hosting a webinar this month with case studies from several hospitals. The focus will be on the internal processes each hospital is using to implement the rule and how they were developed. Sharing and learning from national implementation experiences is a valuable way for hospitalists to gain new perspectives and to bring those experiences to their home institutions when considering their own roles in meeting the new admissions criteria head on.

For more information about the webinar and to register, visit www.hospitalmedicine.org today.

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

As many hospitalists are probably acutely aware, the Centers for Medicare & Medicaid Services (CMS) is putting a new rule into effect that will greatly impact how inpatient admission decisions are made. The rule, known as the “two-midnight rule,” states that if the admitting practitioner admits a Medicare beneficiary as an inpatient with the reasonable expectation that the beneficiary will require care that “crosses two midnights” and this decision is justified in the medical record, Medicare Part A payment is “generally appropriate.”

While there are multiple caveats, exceptions, and details, this rule can be simply articulated: If the admitting physician feels a patient will be in the hospital for a period longer than two midnights and the medical record supports this determination, the patient is an inpatient. Stays expected to be shorter than two midnights should be under observation status.

This new policy is an attempt to respond both to hospital calls for more guidance about when a beneficiary is appropriately treated as an inpatient—and paid by Medicare—and concerns about increasingly long hospital stays under observation status. Most hospitalists wrestle with status determination issues on a daily basis.

SHM is aware of the struggle and has been advocating on behalf of hospitalists to help shape observation status and the two-midnight rule. When the rule was first proposed, SHM voiced serious concerns about its utility and how it was unlikely to solve the overall confusion surrounding inpatient status determinations. Nevertheless, CMS finalized the rule as an attempt to begin addressing the problem.

Faced with an increasingly loud chorus of providers and hospitals concerned about the implementation of the new policy, CMS agreed to delay full enforcement from the original date of Oct. 1, 2013, until March 31, 2014.

During the delayed enforcement period, hospitals will be expected to begin implementing the two-midnight rule, and auditors will be giving hospitals non-punitive feedback on their application of the policy. To accomplish this, CMS is instructing Medicare Administrative Contractors (MACs) to review a sample of 10 to 25 inpatient hospital claims spanning less than two midnights after admission for each hospital. This probe sample will be used to assist hospitals with implementing the new requirements correctly. To give an additional level of comfort during this adjustment period, CMS has announced that it will not conduct post-payment patient status reviews for claims with dates of admission Oct. 1, 2013, through March 31, 2014.

Unfortunately, beyond the vague guidance CMS has offered thus far, there is no foolproof guide to establishing new hospital admissions policies that comply with the rule. As a result, there likely will be wide variation among hospitals.

To assist in sorting out the confusion, SHM will be hosting a webinar this month with case studies from several hospitals. The focus will be on the internal processes each hospital is using to implement the rule and how they were developed. Sharing and learning from national implementation experiences is a valuable way for hospitalists to gain new perspectives and to bring those experiences to their home institutions when considering their own roles in meeting the new admissions criteria head on.

For more information about the webinar and to register, visit www.hospitalmedicine.org today.

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

A new feature installed on HMX, LinkedIn Connect, makes it easier for you to fill out your member profile by pulling pieces of your LinkedIn profile into HMX. How does it work exactly?

Login at www.hmxchange.org and click “My Profile.” Midway down the page, you will see a section that reads, “Grab Profile Info from LinkedIn.” Click the link and follow the onscreen instructions. HMX will connect with your LinkedIn profile, pulling information like your photo, bio, education, and job history information.

It makes filling out your profile just a little bit easier.

A new feature installed on HMX, LinkedIn Connect, makes it easier for you to fill out your member profile by pulling pieces of your LinkedIn profile into HMX. How does it work exactly?

Login at www.hmxchange.org and click “My Profile.” Midway down the page, you will see a section that reads, “Grab Profile Info from LinkedIn.” Click the link and follow the onscreen instructions. HMX will connect with your LinkedIn profile, pulling information like your photo, bio, education, and job history information.

It makes filling out your profile just a little bit easier.

A new feature installed on HMX, LinkedIn Connect, makes it easier for you to fill out your member profile by pulling pieces of your LinkedIn profile into HMX. How does it work exactly?

Login at www.hmxchange.org and click “My Profile.” Midway down the page, you will see a section that reads, “Grab Profile Info from LinkedIn.” Click the link and follow the onscreen instructions. HMX will connect with your LinkedIn profile, pulling information like your photo, bio, education, and job history information.

It makes filling out your profile just a little bit easier.

Here are three simple steps to register for the FPHM MOC, according to the ABIM.

1. Click “Physician Login” at www.abim.org and enter your ABIM ID and your password. The default password is your six-digit date of birth (MMDDYY).
2. Under “My Maintenance of Certification Program,” click on “Enter Focused Practice in Hospital Medicine MOC Program.”
3. There you will begin the entry process, which requires you to complete a Web-based self-attestation, as well as the submission of the Senior Hospital Officer attestation to your eligibility. The attestations must be submitted and approved prior to entry into the program.

You can track your status in this process via the “View Status of Entry into Focused Practice in Hospital Medicine MOC Program” on your home page.

Here are three simple steps to register for the FPHM MOC, according to the ABIM.

1. Click “Physician Login” at www.abim.org and enter your ABIM ID and your password. The default password is your six-digit date of birth (MMDDYY).
2. Under “My Maintenance of Certification Program,” click on “Enter Focused Practice in Hospital Medicine MOC Program.”
3. There you will begin the entry process, which requires you to complete a Web-based self-attestation, as well as the submission of the Senior Hospital Officer attestation to your eligibility. The attestations must be submitted and approved prior to entry into the program.

You can track your status in this process via the “View Status of Entry into Focused Practice in Hospital Medicine MOC Program” on your home page.

Here are three simple steps to register for the FPHM MOC, according to the ABIM.

1. Click “Physician Login” at www.abim.org and enter your ABIM ID and your password. The default password is your six-digit date of birth (MMDDYY).
2. Under “My Maintenance of Certification Program,” click on “Enter Focused Practice in Hospital Medicine MOC Program.”
3. There you will begin the entry process, which requires you to complete a Web-based self-attestation, as well as the submission of the Senior Hospital Officer attestation to your eligibility. The attestations must be submitted and approved prior to entry into the program.

You can track your status in this process via the “View Status of Entry into Focused Practice in Hospital Medicine MOC Program” on your home page.

The Hospital Medicine MOC secure exams are offered every spring and fall. Although the dates might seem far off now, hospitalists interested in taking the Hospital Medicine MOC exam must complete the entry process for the FPHM program at least two weeks before the exam registration deadline. For the spring MOC exam, this means hospitalists must complete the FPHM program entry process by Feb. 14, 2014, for the Spring 2014 exam, and Aug. 1, 2014, for the Fall 2014 exam.

To complete the entry process, hospitalists must:

• Be licensed and in good standing.
• Hold current or previous ABIM certification in Internal Medicine and current Advanced Cardiac Life Support (ACLS) certification.
• Complete at least three years of unsupervised hospital medicine practice experience prior to entry into the Focused Practice in Hospital Medicine MOC program. Formal fellowship training in a hospital medicine fellowship program can be counted toward the three-year practice experience criteria.
• Electronically submit a self-attestation and an attestation from a Senior Hospital Officer (SHO) that they meet the patient encounter thresholds for internal medicine practice in the hospital setting.

Once enrolled, hospitalists will be eligible to schedule a seat for the Hospital Medicine MOC exam during the registration period; however, the ABIM stipulates that hospitalists must be entered into the program at least two weeks prior to the exam date.

At the same time, hospitalists must have completed 100 points of self-evaluation within the last 10 years. Twenty of the points in Self-Evaluation of Medical Knowledge and 40 points in Self-Evaluation of Practice Performance must have been completed in the last three years.

The Hospital Medicine MOC secure exams are offered every spring and fall. Although the dates might seem far off now, hospitalists interested in taking the Hospital Medicine MOC exam must complete the entry process for the FPHM program at least two weeks before the exam registration deadline. For the spring MOC exam, this means hospitalists must complete the FPHM program entry process by Feb. 14, 2014, for the Spring 2014 exam, and Aug. 1, 2014, for the Fall 2014 exam.

To complete the entry process, hospitalists must:

• Be licensed and in good standing.
• Hold current or previous ABIM certification in Internal Medicine and current Advanced Cardiac Life Support (ACLS) certification.
• Complete at least three years of unsupervised hospital medicine practice experience prior to entry into the Focused Practice in Hospital Medicine MOC program. Formal fellowship training in a hospital medicine fellowship program can be counted toward the three-year practice experience criteria.
• Electronically submit a self-attestation and an attestation from a Senior Hospital Officer (SHO) that they meet the patient encounter thresholds for internal medicine practice in the hospital setting.

Once enrolled, hospitalists will be eligible to schedule a seat for the Hospital Medicine MOC exam during the registration period; however, the ABIM stipulates that hospitalists must be entered into the program at least two weeks prior to the exam date.

At the same time, hospitalists must have completed 100 points of self-evaluation within the last 10 years. Twenty of the points in Self-Evaluation of Medical Knowledge and 40 points in Self-Evaluation of Practice Performance must have been completed in the last three years.

The Hospital Medicine MOC secure exams are offered every spring and fall. Although the dates might seem far off now, hospitalists interested in taking the Hospital Medicine MOC exam must complete the entry process for the FPHM program at least two weeks before the exam registration deadline. For the spring MOC exam, this means hospitalists must complete the FPHM program entry process by Feb. 14, 2014, for the Spring 2014 exam, and Aug. 1, 2014, for the Fall 2014 exam.

To complete the entry process, hospitalists must:

• Be licensed and in good standing.
• Hold current or previous ABIM certification in Internal Medicine and current Advanced Cardiac Life Support (ACLS) certification.
• Complete at least three years of unsupervised hospital medicine practice experience prior to entry into the Focused Practice in Hospital Medicine MOC program. Formal fellowship training in a hospital medicine fellowship program can be counted toward the three-year practice experience criteria.
• Electronically submit a self-attestation and an attestation from a Senior Hospital Officer (SHO) that they meet the patient encounter thresholds for internal medicine practice in the hospital setting.

Once enrolled, hospitalists will be eligible to schedule a seat for the Hospital Medicine MOC exam during the registration period; however, the ABIM stipulates that hospitalists must be entered into the program at least two weeks prior to the exam date.

At the same time, hospitalists must have completed 100 points of self-evaluation within the last 10 years. Twenty of the points in Self-Evaluation of Medical Knowledge and 40 points in Self-Evaluation of Practice Performance must have been completed in the last three years.

While the program is just a few years old, changes to the Focused Practice in Hospital Medicine (FPHM) Maintenance of Certification (MOC) from the American Board of Internal Medicine (ABIM) make it more attractive to hospitalists, bringing it in line with other MOC programs. And now is the time to act for 2014.

Not only do the changes to the FPHM MOC streamline the process, it remains the only ABIM certification designed exclusively for the growing ranks of hospitalists, according to hospitalists who have already earned the new certification. The hospitalist-centric program makes their board certification more applicable to their everyday practice and emphasizes their expertise in the specialty.

The alignment with the hospital medicine specialty has both practical and ideological benefits for hospitalists. On the practical side, the hospital medicine focused medical knowledge modules and preparation for the Hospital Medicine MOC exam are more focused, as the content better matches the day-to-day life of a hospitalist.

“From a content perspective, both for studying and the updates, it allows the hospitalist to focus on content that’s most relevant to their practice,” says hospitalist Jennifer Myers, MD, associate professor of clinical medicine and associate designated institutional official for graduate medical education at the Hospital of the University of Pennsylvania in Philadelphia.

Dr. Myers earned the FPHM certification in 2011. Compared to the internal medicine MOC, she says “the standard questions focused on ambulatory medicine do not always apply,” and the likelihood that hospitalists kept up on those topics was slim. Rather, “hospitalists will be better prepared to take the Focused Practice in Hospital Medicine. And as they’re updating and studying, they can focus on relevant topics for their practice,” she says.

For hospitalist and former SHM president Jeffrey Wiese, MD, MHM, the FPHM MOC program helps define his work in ways other than just the physical space of the hospital.

“If I am to have public accountability as a hospitalist, it has to be more than just geography. Intrinsic to a true hospitalist is systems architecture…improving the quality and patient safety delivered by the hospital system,” says Dr. Wiese, professor of medicine and senior associate dean of graduate medical education at Tulane University in New Orleans.

Dr. Wiese is intimately familiar with the process: He served on the ABIM’s Hospital Medicine MOC Exam Writing ABIM test writing committee for the FPHM pathway MOC program. He now serves on the new ABIM Council.

“This is a way to distinguish the ideals of the specialty,” he says. “What hospitalists do is more than just deliver inpatient care. … It’s about advancing the quality and safety of the system, and the FPHM MOC track ensures fidelity to that standard.”

FPHM’s ability to differentiate hospitalists resonates with Daniel Brotman, MD, director of the hospitalist program at Johns Hopkins Hospital in Baltimore and chair of SHM’s Annual Meeting Committee and Education Committee. And that differentiation extends from the individual hospitalist to the movement as a whole.

“If you’re a hospitalist and you’re invested in the field, this is an important statement to make on behalf of your specialty,” he says. “It can give you some added respect within your institution when people ask you about specialized training in hospital medicine.”

Even if hospitalists didn’t have specialized training, the FPHM MOC demonstrates that they “did have to pass a specialized certification process that gives different credentials,” Dr. Brotman says. “This is the best way to do that.”

He also sees it as an individual benefit for hospitalists—both for their career advancement and their peace of mind—knowing that they are more up to date with their clinical practice.

“You practice hospital medicine. If you want an exam that hits the ball to your forehand, this is it,” he says. “If you’re nervous about the board exam, I’d be more nervous about taking a generalized exam.”

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

While the program is just a few years old, changes to the Focused Practice in Hospital Medicine (FPHM) Maintenance of Certification (MOC) from the American Board of Internal Medicine (ABIM) make it more attractive to hospitalists, bringing it in line with other MOC programs. And now is the time to act for 2014.

Not only do the changes to the FPHM MOC streamline the process, it remains the only ABIM certification designed exclusively for the growing ranks of hospitalists, according to hospitalists who have already earned the new certification. The hospitalist-centric program makes their board certification more applicable to their everyday practice and emphasizes their expertise in the specialty.

The alignment with the hospital medicine specialty has both practical and ideological benefits for hospitalists. On the practical side, the hospital medicine focused medical knowledge modules and preparation for the Hospital Medicine MOC exam are more focused, as the content better matches the day-to-day life of a hospitalist.

“From a content perspective, both for studying and the updates, it allows the hospitalist to focus on content that’s most relevant to their practice,” says hospitalist Jennifer Myers, MD, associate professor of clinical medicine and associate designated institutional official for graduate medical education at the Hospital of the University of Pennsylvania in Philadelphia.

Dr. Myers earned the FPHM certification in 2011. Compared to the internal medicine MOC, she says “the standard questions focused on ambulatory medicine do not always apply,” and the likelihood that hospitalists kept up on those topics was slim. Rather, “hospitalists will be better prepared to take the Focused Practice in Hospital Medicine. And as they’re updating and studying, they can focus on relevant topics for their practice,” she says.

For hospitalist and former SHM president Jeffrey Wiese, MD, MHM, the FPHM MOC program helps define his work in ways other than just the physical space of the hospital.

“If I am to have public accountability as a hospitalist, it has to be more than just geography. Intrinsic to a true hospitalist is systems architecture…improving the quality and patient safety delivered by the hospital system,” says Dr. Wiese, professor of medicine and senior associate dean of graduate medical education at Tulane University in New Orleans.

Dr. Wiese is intimately familiar with the process: He served on the ABIM’s Hospital Medicine MOC Exam Writing ABIM test writing committee for the FPHM pathway MOC program. He now serves on the new ABIM Council.

“This is a way to distinguish the ideals of the specialty,” he says. “What hospitalists do is more than just deliver inpatient care. … It’s about advancing the quality and safety of the system, and the FPHM MOC track ensures fidelity to that standard.”

FPHM’s ability to differentiate hospitalists resonates with Daniel Brotman, MD, director of the hospitalist program at Johns Hopkins Hospital in Baltimore and chair of SHM’s Annual Meeting Committee and Education Committee. And that differentiation extends from the individual hospitalist to the movement as a whole.

“If you’re a hospitalist and you’re invested in the field, this is an important statement to make on behalf of your specialty,” he says. “It can give you some added respect within your institution when people ask you about specialized training in hospital medicine.”

Even if hospitalists didn’t have specialized training, the FPHM MOC demonstrates that they “did have to pass a specialized certification process that gives different credentials,” Dr. Brotman says. “This is the best way to do that.”

He also sees it as an individual benefit for hospitalists—both for their career advancement and their peace of mind—knowing that they are more up to date with their clinical practice.

“You practice hospital medicine. If you want an exam that hits the ball to your forehand, this is it,” he says. “If you’re nervous about the board exam, I’d be more nervous about taking a generalized exam.”

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

While the program is just a few years old, changes to the Focused Practice in Hospital Medicine (FPHM) Maintenance of Certification (MOC) from the American Board of Internal Medicine (ABIM) make it more attractive to hospitalists, bringing it in line with other MOC programs. And now is the time to act for 2014.

Not only do the changes to the FPHM MOC streamline the process, it remains the only ABIM certification designed exclusively for the growing ranks of hospitalists, according to hospitalists who have already earned the new certification. The hospitalist-centric program makes their board certification more applicable to their everyday practice and emphasizes their expertise in the specialty.

The alignment with the hospital medicine specialty has both practical and ideological benefits for hospitalists. On the practical side, the hospital medicine focused medical knowledge modules and preparation for the Hospital Medicine MOC exam are more focused, as the content better matches the day-to-day life of a hospitalist.

“From a content perspective, both for studying and the updates, it allows the hospitalist to focus on content that’s most relevant to their practice,” says hospitalist Jennifer Myers, MD, associate professor of clinical medicine and associate designated institutional official for graduate medical education at the Hospital of the University of Pennsylvania in Philadelphia.

Dr. Myers earned the FPHM certification in 2011. Compared to the internal medicine MOC, she says “the standard questions focused on ambulatory medicine do not always apply,” and the likelihood that hospitalists kept up on those topics was slim. Rather, “hospitalists will be better prepared to take the Focused Practice in Hospital Medicine. And as they’re updating and studying, they can focus on relevant topics for their practice,” she says.

For hospitalist and former SHM president Jeffrey Wiese, MD, MHM, the FPHM MOC program helps define his work in ways other than just the physical space of the hospital.

“If I am to have public accountability as a hospitalist, it has to be more than just geography. Intrinsic to a true hospitalist is systems architecture…improving the quality and patient safety delivered by the hospital system,” says Dr. Wiese, professor of medicine and senior associate dean of graduate medical education at Tulane University in New Orleans.

Dr. Wiese is intimately familiar with the process: He served on the ABIM’s Hospital Medicine MOC Exam Writing ABIM test writing committee for the FPHM pathway MOC program. He now serves on the new ABIM Council.

“This is a way to distinguish the ideals of the specialty,” he says. “What hospitalists do is more than just deliver inpatient care. … It’s about advancing the quality and safety of the system, and the FPHM MOC track ensures fidelity to that standard.”

FPHM’s ability to differentiate hospitalists resonates with Daniel Brotman, MD, director of the hospitalist program at Johns Hopkins Hospital in Baltimore and chair of SHM’s Annual Meeting Committee and Education Committee. And that differentiation extends from the individual hospitalist to the movement as a whole.

“If you’re a hospitalist and you’re invested in the field, this is an important statement to make on behalf of your specialty,” he says. “It can give you some added respect within your institution when people ask you about specialized training in hospital medicine.”

Even if hospitalists didn’t have specialized training, the FPHM MOC demonstrates that they “did have to pass a specialized certification process that gives different credentials,” Dr. Brotman says. “This is the best way to do that.”

He also sees it as an individual benefit for hospitalists—both for their career advancement and their peace of mind—knowing that they are more up to date with their clinical practice.

“You practice hospital medicine. If you want an exam that hits the ball to your forehand, this is it,” he says. “If you’re nervous about the board exam, I’d be more nervous about taking a generalized exam.”

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

Initial Efforts

1965

• President Lyndon B. Johnson signs the Social Security Act, which authorizes both Medicare and Medicaid; the law is widely labeled the biggest healthcare reform of the past century.

1993

• President Bill Clinton attempts to craft universal healthcare legislation that includes both individual and employer mandates. He appoints his wife, Hillary Rodham Clinton, as chair of the White House Task Force on Health Reform. The President’s Health Security Act ultimately fails in Congress.

1997

• State Children’s Health Insurance Program (S-CHIP) authorized by Congress, covering low-income children in families above Medicaid eligibility levels.

2006

• Massachusetts (followed by Vermont in 2011) passes legislation that expands healthcare coverage to nearly all state residents; the Massachusetts law is later deemed a template for the Patient Protection and Affordable Care Act of 2010.

The Patient Protection and Affordable Care Act (ACA)

March 23, 2010

• President Obama signs the ACA into law. Among the law’s early provisions: Medicare beneficiaries who reach the Part D drug coverage gap begin receiving $250 rebates, and the IRS begins allowing tax credits to small employers that offer health insurance to their employees.

July 1, 2010

• Federal government begins enrolling patients with pre-existing conditions in a temporary Pre-Existing Condition Insurance Plan (PCIP).

• Healthcare.gov website debuts.

• IRS begins assessing 10% tax on indoor tanning.

Sep. 23, 2010

• Patient-Centered Outcomes Research Institute (PCORI) launches with 21-member board of directors.

• For new insurance plans or those renewed on or after this date, parents are allowed to keep adult children on their health policies until they turn 26 (many private plans voluntarily offered this option earlier).

• HHS bans insurers from imposing lifetime coverage limits and from denying health coverage to children with pre-existing conditions or excluding specific conditions from coverage.

• HHS requires new and renewing health plans to eliminate cost sharing for certain preventive services recommended by U.S. Preventive Services Task Force.

Sep. 30, 2010

• U.S. Comptroller General appoints 15 members to National Health Care Workforce Commission (commission does not secure funding).

December 30, 2010

• Medicare debuts first phase of Physician Compare website.

Jan. 1, 2011

• CMS begins closing Medicare Part D drug coverage gap.

• Medicare begins paying 10% bonus for primary care services (funded through 2015).

• Center for Medicare and Medicaid Innovation debuts, with a focus on testing new payment and care delivery systems.

March 23, 2011

• HHS begins providing grants to individual states to help set up health insurance exchanges.

July 1, 2011

• CMS stops paying for Medicaid services related to specific hospital-acquired infections.

Oct. 1, 2011

• Fifteen-member Independent Payment Advisory Board is formally established (but no members are nominated). The IPAB is charged with issuing legislative recommendations to lower Medicare spending growth, but only if projected costs exceed a certain threshold.

Jan. 1, 2012

• CMS launches Medicaid bundled-payment demonstration and Accountable Care Organization (ACO) incentive program.

• CMS reduces Medicare Advantage rebates but offers bonuses to high-quality plans.

Aug. 1, 2012

• HHS requires most new and renewing health plans to eliminate cost sharing for women’s preventive health services, including contraception.

Oct. 1, 2012

• CMS begins its Value-Based Purchasing (VBP) Program in Medicare, starting with a 1% withholding in FY2013.

• CMS begins reducing Medicare payments based on excess hospital readmissions, starting with a 1% penalty in FY2013.

Jan. 1, 2013

• CMS starts five-year bundled payment pilot program for Medicare, covering 10 conditions.

• CMS increases Medicaid payments for primary care services to 100% of Medicare’s rate (funded for two years).

• IRS increases Medicare tax rate to 2.35% on individuals earning more than $200,000 and on married couples earning more than $250,000; also imposes 3.8% tax on unearned income among high-income taxpayers.

• IRS begins assessing excise tax of 2.3% on sale of taxable medical devices.

Jan. 2, 2013

• Sequestration results in across-the-board cuts of 2% in Medicare reimbursements.

July 1, 2013

• DHS officially launches Consumer Operated and Oriented Plan (CO-OP) to encourage growth of nonprofit health insurers (roughly $2 billion in loans given to co-ops in 23 states by end of 2012).

Oct. 1, 2013

• Open enrollment begins for state- and federal government-run health insurance exchanges and expanded Medicaid; the rollout is marred by multiple computer glitches.

• CMS lowers Medicare Disproportionate Share Hospital (DSH) payments by 75%, starting in FY2014 but plans to supplement these payments based on each hospital’s share of uncompensated care.

• CMS lowers Medicaid DSH payments by $22 billion over 10 years, beginning with $500 million reduction in FY2014.

Jan. 1, 2014

• Coverage begins through health insurance exchanges. Individuals and families with incomes between 100% and 400% of the federal poverty level can receive subsidies to help pay for premiums.

• Voluntary Medicaid expansions expected to take place in roughly half of all states, for individuals up to 138% of the federal poverty level.

• Insurers banned from imposing annual limits on coverage, from restricting coverage due to pre-existing conditions, and from basing premiums on gender.

• Insurers required to cover 10 “essential health benefits,” including medication and maternity care.

March 31, 2014

• Open enrollment closes for health insurance exchanges; under the “individual mandate,” people who qualify but don’t buy insurance by this date will be penalized up to 1% of income (penalty increases in subsequent years).

Oct. 1, 2014

• CMS imposes 1% reduction in payments to hospitals with excess hospital-acquired conditions (FY2015).

• CMS imposes penalties on hospitals that haven’t met electronic health record (EHR) meaningful use requirements.

Jan. 1, 2015

• Employer Shared Responsibility Payment, or the “employer mandate,” begins (delayed from Jan. 1, 2014). With a few exceptions, employers with more than 50 employees must offer coverage or pay a fine.

• CMS begins imposing fines based on doctors who didn’t meet Physician Quality Reporting System requirements during 2013, with an initial 1.5% penalty that rises to 2% in 2016.

Jan. 1, 2018

• High-cost, or so-called “Cadillac,” insurance plans—those with premiums over $10,200 for individuals or $27,500 for family coverage—will be assessed an excise tax.

Sources: Healthcare.gov, Commonwealth Fund, Kaiser Family Foundation, American Medical Association, Greater New York Hospital Association.

Initial Efforts

1965

• President Lyndon B. Johnson signs the Social Security Act, which authorizes both Medicare and Medicaid; the law is widely labeled the biggest healthcare reform of the past century.

1993

• President Bill Clinton attempts to craft universal healthcare legislation that includes both individual and employer mandates. He appoints his wife, Hillary Rodham Clinton, as chair of the White House Task Force on Health Reform. The President’s Health Security Act ultimately fails in Congress.

1997

• State Children’s Health Insurance Program (S-CHIP) authorized by Congress, covering low-income children in families above Medicaid eligibility levels.

2006

• Massachusetts (followed by Vermont in 2011) passes legislation that expands healthcare coverage to nearly all state residents; the Massachusetts law is later deemed a template for the Patient Protection and Affordable Care Act of 2010.

The Patient Protection and Affordable Care Act (ACA)

March 23, 2010

• President Obama signs the ACA into law. Among the law’s early provisions: Medicare beneficiaries who reach the Part D drug coverage gap begin receiving $250 rebates, and the IRS begins allowing tax credits to small employers that offer health insurance to their employees.

July 1, 2010

• Federal government begins enrolling patients with pre-existing conditions in a temporary Pre-Existing Condition Insurance Plan (PCIP).

• Healthcare.gov website debuts.

• IRS begins assessing 10% tax on indoor tanning.

Sep. 23, 2010

• Patient-Centered Outcomes Research Institute (PCORI) launches with 21-member board of directors.

• For new insurance plans or those renewed on or after this date, parents are allowed to keep adult children on their health policies until they turn 26 (many private plans voluntarily offered this option earlier).

• HHS bans insurers from imposing lifetime coverage limits and from denying health coverage to children with pre-existing conditions or excluding specific conditions from coverage.

• HHS requires new and renewing health plans to eliminate cost sharing for certain preventive services recommended by U.S. Preventive Services Task Force.

Sep. 30, 2010

• U.S. Comptroller General appoints 15 members to National Health Care Workforce Commission (commission does not secure funding).

December 30, 2010

• Medicare debuts first phase of Physician Compare website.

Jan. 1, 2011

• CMS begins closing Medicare Part D drug coverage gap.

• Medicare begins paying 10% bonus for primary care services (funded through 2015).

• Center for Medicare and Medicaid Innovation debuts, with a focus on testing new payment and care delivery systems.

March 23, 2011

• HHS begins providing grants to individual states to help set up health insurance exchanges.

July 1, 2011

• CMS stops paying for Medicaid services related to specific hospital-acquired infections.

Oct. 1, 2011

• Fifteen-member Independent Payment Advisory Board is formally established (but no members are nominated). The IPAB is charged with issuing legislative recommendations to lower Medicare spending growth, but only if projected costs exceed a certain threshold.

Jan. 1, 2012

• CMS launches Medicaid bundled-payment demonstration and Accountable Care Organization (ACO) incentive program.

• CMS reduces Medicare Advantage rebates but offers bonuses to high-quality plans.

Aug. 1, 2012

• HHS requires most new and renewing health plans to eliminate cost sharing for women’s preventive health services, including contraception.

Oct. 1, 2012

• CMS begins its Value-Based Purchasing (VBP) Program in Medicare, starting with a 1% withholding in FY2013.

• CMS begins reducing Medicare payments based on excess hospital readmissions, starting with a 1% penalty in FY2013.

Jan. 1, 2013

• CMS starts five-year bundled payment pilot program for Medicare, covering 10 conditions.

• CMS increases Medicaid payments for primary care services to 100% of Medicare’s rate (funded for two years).

• IRS increases Medicare tax rate to 2.35% on individuals earning more than $200,000 and on married couples earning more than $250,000; also imposes 3.8% tax on unearned income among high-income taxpayers.

• IRS begins assessing excise tax of 2.3% on sale of taxable medical devices.

Jan. 2, 2013

• Sequestration results in across-the-board cuts of 2% in Medicare reimbursements.

July 1, 2013

• DHS officially launches Consumer Operated and Oriented Plan (CO-OP) to encourage growth of nonprofit health insurers (roughly $2 billion in loans given to co-ops in 23 states by end of 2012).

Oct. 1, 2013

• Open enrollment begins for state- and federal government-run health insurance exchanges and expanded Medicaid; the rollout is marred by multiple computer glitches.

• CMS lowers Medicare Disproportionate Share Hospital (DSH) payments by 75%, starting in FY2014 but plans to supplement these payments based on each hospital’s share of uncompensated care.

• CMS lowers Medicaid DSH payments by $22 billion over 10 years, beginning with $500 million reduction in FY2014.

Jan. 1, 2014

• Coverage begins through health insurance exchanges. Individuals and families with incomes between 100% and 400% of the federal poverty level can receive subsidies to help pay for premiums.

• Voluntary Medicaid expansions expected to take place in roughly half of all states, for individuals up to 138% of the federal poverty level.

• Insurers banned from imposing annual limits on coverage, from restricting coverage due to pre-existing conditions, and from basing premiums on gender.

• Insurers required to cover 10 “essential health benefits,” including medication and maternity care.

March 31, 2014

• Open enrollment closes for health insurance exchanges; under the “individual mandate,” people who qualify but don’t buy insurance by this date will be penalized up to 1% of income (penalty increases in subsequent years).

Oct. 1, 2014

• CMS imposes 1% reduction in payments to hospitals with excess hospital-acquired conditions (FY2015).

• CMS imposes penalties on hospitals that haven’t met electronic health record (EHR) meaningful use requirements.

Jan. 1, 2015

• Employer Shared Responsibility Payment, or the “employer mandate,” begins (delayed from Jan. 1, 2014). With a few exceptions, employers with more than 50 employees must offer coverage or pay a fine.

• CMS begins imposing fines based on doctors who didn’t meet Physician Quality Reporting System requirements during 2013, with an initial 1.5% penalty that rises to 2% in 2016.

Jan. 1, 2018

• High-cost, or so-called “Cadillac,” insurance plans—those with premiums over $10,200 for individuals or $27,500 for family coverage—will be assessed an excise tax.

Sources: Healthcare.gov, Commonwealth Fund, Kaiser Family Foundation, American Medical Association, Greater New York Hospital Association.

Initial Efforts

1965

• President Lyndon B. Johnson signs the Social Security Act, which authorizes both Medicare and Medicaid; the law is widely labeled the biggest healthcare reform of the past century.

1993

• President Bill Clinton attempts to craft universal healthcare legislation that includes both individual and employer mandates. He appoints his wife, Hillary Rodham Clinton, as chair of the White House Task Force on Health Reform. The President’s Health Security Act ultimately fails in Congress.

1997

• State Children’s Health Insurance Program (S-CHIP) authorized by Congress, covering low-income children in families above Medicaid eligibility levels.

2006

• Massachusetts (followed by Vermont in 2011) passes legislation that expands healthcare coverage to nearly all state residents; the Massachusetts law is later deemed a template for the Patient Protection and Affordable Care Act of 2010.

The Patient Protection and Affordable Care Act (ACA)

March 23, 2010

• President Obama signs the ACA into law. Among the law’s early provisions: Medicare beneficiaries who reach the Part D drug coverage gap begin receiving $250 rebates, and the IRS begins allowing tax credits to small employers that offer health insurance to their employees.

July 1, 2010

• Federal government begins enrolling patients with pre-existing conditions in a temporary Pre-Existing Condition Insurance Plan (PCIP).

• Healthcare.gov website debuts.

• IRS begins assessing 10% tax on indoor tanning.

Sep. 23, 2010

• Patient-Centered Outcomes Research Institute (PCORI) launches with 21-member board of directors.

• For new insurance plans or those renewed on or after this date, parents are allowed to keep adult children on their health policies until they turn 26 (many private plans voluntarily offered this option earlier).

• HHS bans insurers from imposing lifetime coverage limits and from denying health coverage to children with pre-existing conditions or excluding specific conditions from coverage.

• HHS requires new and renewing health plans to eliminate cost sharing for certain preventive services recommended by U.S. Preventive Services Task Force.

Sep. 30, 2010

• U.S. Comptroller General appoints 15 members to National Health Care Workforce Commission (commission does not secure funding).

December 30, 2010

• Medicare debuts first phase of Physician Compare website.

Jan. 1, 2011

• CMS begins closing Medicare Part D drug coverage gap.

• Medicare begins paying 10% bonus for primary care services (funded through 2015).

• Center for Medicare and Medicaid Innovation debuts, with a focus on testing new payment and care delivery systems.

March 23, 2011

• HHS begins providing grants to individual states to help set up health insurance exchanges.

July 1, 2011

• CMS stops paying for Medicaid services related to specific hospital-acquired infections.

Oct. 1, 2011

• Fifteen-member Independent Payment Advisory Board is formally established (but no members are nominated). The IPAB is charged with issuing legislative recommendations to lower Medicare spending growth, but only if projected costs exceed a certain threshold.

Jan. 1, 2012

• CMS launches Medicaid bundled-payment demonstration and Accountable Care Organization (ACO) incentive program.

• CMS reduces Medicare Advantage rebates but offers bonuses to high-quality plans.

Aug. 1, 2012

• HHS requires most new and renewing health plans to eliminate cost sharing for women’s preventive health services, including contraception.

Oct. 1, 2012

• CMS begins its Value-Based Purchasing (VBP) Program in Medicare, starting with a 1% withholding in FY2013.

• CMS begins reducing Medicare payments based on excess hospital readmissions, starting with a 1% penalty in FY2013.

Jan. 1, 2013

• CMS starts five-year bundled payment pilot program for Medicare, covering 10 conditions.

• CMS increases Medicaid payments for primary care services to 100% of Medicare’s rate (funded for two years).

• IRS increases Medicare tax rate to 2.35% on individuals earning more than $200,000 and on married couples earning more than $250,000; also imposes 3.8% tax on unearned income among high-income taxpayers.

• IRS begins assessing excise tax of 2.3% on sale of taxable medical devices.

Jan. 2, 2013

• Sequestration results in across-the-board cuts of 2% in Medicare reimbursements.

July 1, 2013

• DHS officially launches Consumer Operated and Oriented Plan (CO-OP) to encourage growth of nonprofit health insurers (roughly $2 billion in loans given to co-ops in 23 states by end of 2012).

Oct. 1, 2013

• Open enrollment begins for state- and federal government-run health insurance exchanges and expanded Medicaid; the rollout is marred by multiple computer glitches.

• CMS lowers Medicare Disproportionate Share Hospital (DSH) payments by 75%, starting in FY2014 but plans to supplement these payments based on each hospital’s share of uncompensated care.

• CMS lowers Medicaid DSH payments by $22 billion over 10 years, beginning with $500 million reduction in FY2014.

Jan. 1, 2014

• Coverage begins through health insurance exchanges. Individuals and families with incomes between 100% and 400% of the federal poverty level can receive subsidies to help pay for premiums.

• Voluntary Medicaid expansions expected to take place in roughly half of all states, for individuals up to 138% of the federal poverty level.

• Insurers banned from imposing annual limits on coverage, from restricting coverage due to pre-existing conditions, and from basing premiums on gender.

• Insurers required to cover 10 “essential health benefits,” including medication and maternity care.

March 31, 2014

• Open enrollment closes for health insurance exchanges; under the “individual mandate,” people who qualify but don’t buy insurance by this date will be penalized up to 1% of income (penalty increases in subsequent years).

Oct. 1, 2014

• CMS imposes 1% reduction in payments to hospitals with excess hospital-acquired conditions (FY2015).

• CMS imposes penalties on hospitals that haven’t met electronic health record (EHR) meaningful use requirements.

Jan. 1, 2015

• Employer Shared Responsibility Payment, or the “employer mandate,” begins (delayed from Jan. 1, 2014). With a few exceptions, employers with more than 50 employees must offer coverage or pay a fine.

• CMS begins imposing fines based on doctors who didn’t meet Physician Quality Reporting System requirements during 2013, with an initial 1.5% penalty that rises to 2% in 2016.

Jan. 1, 2018

• High-cost, or so-called “Cadillac,” insurance plans—those with premiums over $10,200 for individuals or $27,500 for family coverage—will be assessed an excise tax.

Sources: Healthcare.gov, Commonwealth Fund, Kaiser Family Foundation, American Medical Association, Greater New York Hospital Association.

Sometimes, numbers do tell a story. The Affordable Care Act has no shortage of them, and amid the densely packed provisions, regulations, pilots, demonstrations, fines, and other elements, a few numbers provide a glimpse of the intense wrangling that created both winners and losers in the healthcare reform effort.

One of the biggest numbers is also the mostly hotly contested: whether Obamacare will blow a hole in the nation’s deficit or lead to a trillion dollars or more in savings over the first two decades. In March 2010, the Congressional Budget Office predicted the latter, with savings of $143 billion through 2019 and a hazier guess of savings equivalent to 0.5% of gross domestic product—equal to $1 trillion or more—through the 2020s.

The problem? “That calculation reflects an assumption that the provisions of the legislation are enacted and remain unchanged throughout the next two decades, which is often not the case for major legislation,” the CBO wrote at the time. That prediction, at least, was spot on.

Amid the ongoing political back and forth, one point is often overlooked: Although still unsustainably high, per capita healthcare spending is now increasing at the lowest rate in decades. Robert Berenson, MD, an Institute Fellow at the Washington, D.C.-based Urban Institute, a nonpartisan think tank focused on social and economic policy, notes that the trend (starting in 2006) predated the recession. Likewise, it is occurring in Medicare, where most beneficiaries have first-dollar coverage. Instead of being a side effect of the sluggish economy, Dr. Berenson believes fundamental change is occurring on the provider side, and that the additional focus on reform may be making a difference.

Some analysts, he says, believe that providers are responding to the anticipation of change in the system and are beginning to change their own behavior accordingly.

“That means we have more time to get it right, in terms of wholesale change in how healthcare is delivered, and, for me, that’s a good thing,” he says.

A few other numbers of note:

$1.075 trillion

The state- and federal-run healthcare exchanges are expected to cost $1.075 trillion through 2023, according to the CBO. That eye-popping number includes spending for “high-risk pools, premium review activities, loans to consumer-operated and -oriented plans, and grants to states for the establishment of exchanges.”

The big question, of course, is whether that investment will pay off, and a big part of the answer will rest with a well-balanced risk pool. In other words, long-term financial stability means getting as many young and healthy people into the exchanges as possible.

$2 billion

The ACA sought to increase competition by supporting the creation of consumer co-ops, despite opposition from the insurance industry. By the end of last year, HHS had doled out roughly $2 billion in loans to nonprofit co-ops in 23 states, as part of its Consumer Operated and Oriented Plan (CO-OP). Backers of these co-ops had initially sought $10 billion, however, based on estimates of what would be required to ensure a higher likelihood of success.

Although preliminary evidence suggests that these newcomers may be helping to drive down costs in some states, a lack of additional funding has prevented other potential co-ops from receiving startup loans. The co-ops also are barred from using any federal money for marketing, cannot jointly negotiate contracts with doctors, and have limited access to the large employer insurance market—casting doubt on their continued viability.

$0

On Sep. 30, 2010, the U.S. comptroller general appointed 15 members to the National Health Care Workforce Commission, an acknowledgment that the country needs more guidance in how to address existing shortages—expected to widen—in doctors and other healthcare providers. The commission, authorized by the ACA, has never met, however. The act didn’t appropriate any money for it, and Congress has yet to approve any funding either, meaning that the commission’s members are legally barred from conducting any work.

—Bryn Nelson, PhD

Sometimes, numbers do tell a story. The Affordable Care Act has no shortage of them, and amid the densely packed provisions, regulations, pilots, demonstrations, fines, and other elements, a few numbers provide a glimpse of the intense wrangling that created both winners and losers in the healthcare reform effort.

One of the biggest numbers is also the mostly hotly contested: whether Obamacare will blow a hole in the nation’s deficit or lead to a trillion dollars or more in savings over the first two decades. In March 2010, the Congressional Budget Office predicted the latter, with savings of $143 billion through 2019 and a hazier guess of savings equivalent to 0.5% of gross domestic product—equal to $1 trillion or more—through the 2020s.

The problem? “That calculation reflects an assumption that the provisions of the legislation are enacted and remain unchanged throughout the next two decades, which is often not the case for major legislation,” the CBO wrote at the time. That prediction, at least, was spot on.

Amid the ongoing political back and forth, one point is often overlooked: Although still unsustainably high, per capita healthcare spending is now increasing at the lowest rate in decades. Robert Berenson, MD, an Institute Fellow at the Washington, D.C.-based Urban Institute, a nonpartisan think tank focused on social and economic policy, notes that the trend (starting in 2006) predated the recession. Likewise, it is occurring in Medicare, where most beneficiaries have first-dollar coverage. Instead of being a side effect of the sluggish economy, Dr. Berenson believes fundamental change is occurring on the provider side, and that the additional focus on reform may be making a difference.

Some analysts, he says, believe that providers are responding to the anticipation of change in the system and are beginning to change their own behavior accordingly.

“That means we have more time to get it right, in terms of wholesale change in how healthcare is delivered, and, for me, that’s a good thing,” he says.

A few other numbers of note:

$1.075 trillion

The state- and federal-run healthcare exchanges are expected to cost $1.075 trillion through 2023, according to the CBO. That eye-popping number includes spending for “high-risk pools, premium review activities, loans to consumer-operated and -oriented plans, and grants to states for the establishment of exchanges.”

The big question, of course, is whether that investment will pay off, and a big part of the answer will rest with a well-balanced risk pool. In other words, long-term financial stability means getting as many young and healthy people into the exchanges as possible.

$2 billion

The ACA sought to increase competition by supporting the creation of consumer co-ops, despite opposition from the insurance industry. By the end of last year, HHS had doled out roughly $2 billion in loans to nonprofit co-ops in 23 states, as part of its Consumer Operated and Oriented Plan (CO-OP). Backers of these co-ops had initially sought $10 billion, however, based on estimates of what would be required to ensure a higher likelihood of success.

Although preliminary evidence suggests that these newcomers may be helping to drive down costs in some states, a lack of additional funding has prevented other potential co-ops from receiving startup loans. The co-ops also are barred from using any federal money for marketing, cannot jointly negotiate contracts with doctors, and have limited access to the large employer insurance market—casting doubt on their continued viability.

$0

On Sep. 30, 2010, the U.S. comptroller general appointed 15 members to the National Health Care Workforce Commission, an acknowledgment that the country needs more guidance in how to address existing shortages—expected to widen—in doctors and other healthcare providers. The commission, authorized by the ACA, has never met, however. The act didn’t appropriate any money for it, and Congress has yet to approve any funding either, meaning that the commission’s members are legally barred from conducting any work.

—Bryn Nelson, PhD

Sometimes, numbers do tell a story. The Affordable Care Act has no shortage of them, and amid the densely packed provisions, regulations, pilots, demonstrations, fines, and other elements, a few numbers provide a glimpse of the intense wrangling that created both winners and losers in the healthcare reform effort.

One of the biggest numbers is also the mostly hotly contested: whether Obamacare will blow a hole in the nation’s deficit or lead to a trillion dollars or more in savings over the first two decades. In March 2010, the Congressional Budget Office predicted the latter, with savings of $143 billion through 2019 and a hazier guess of savings equivalent to 0.5% of gross domestic product—equal to $1 trillion or more—through the 2020s.

The problem? “That calculation reflects an assumption that the provisions of the legislation are enacted and remain unchanged throughout the next two decades, which is often not the case for major legislation,” the CBO wrote at the time. That prediction, at least, was spot on.

Amid the ongoing political back and forth, one point is often overlooked: Although still unsustainably high, per capita healthcare spending is now increasing at the lowest rate in decades. Robert Berenson, MD, an Institute Fellow at the Washington, D.C.-based Urban Institute, a nonpartisan think tank focused on social and economic policy, notes that the trend (starting in 2006) predated the recession. Likewise, it is occurring in Medicare, where most beneficiaries have first-dollar coverage. Instead of being a side effect of the sluggish economy, Dr. Berenson believes fundamental change is occurring on the provider side, and that the additional focus on reform may be making a difference.

Some analysts, he says, believe that providers are responding to the anticipation of change in the system and are beginning to change their own behavior accordingly.

“That means we have more time to get it right, in terms of wholesale change in how healthcare is delivered, and, for me, that’s a good thing,” he says.

A few other numbers of note:

$1.075 trillion

The state- and federal-run healthcare exchanges are expected to cost $1.075 trillion through 2023, according to the CBO. That eye-popping number includes spending for “high-risk pools, premium review activities, loans to consumer-operated and -oriented plans, and grants to states for the establishment of exchanges.”

The big question, of course, is whether that investment will pay off, and a big part of the answer will rest with a well-balanced risk pool. In other words, long-term financial stability means getting as many young and healthy people into the exchanges as possible.

$2 billion

The ACA sought to increase competition by supporting the creation of consumer co-ops, despite opposition from the insurance industry. By the end of last year, HHS had doled out roughly $2 billion in loans to nonprofit co-ops in 23 states, as part of its Consumer Operated and Oriented Plan (CO-OP). Backers of these co-ops had initially sought $10 billion, however, based on estimates of what would be required to ensure a higher likelihood of success.

Although preliminary evidence suggests that these newcomers may be helping to drive down costs in some states, a lack of additional funding has prevented other potential co-ops from receiving startup loans. The co-ops also are barred from using any federal money for marketing, cannot jointly negotiate contracts with doctors, and have limited access to the large employer insurance market—casting doubt on their continued viability.

$0

On Sep. 30, 2010, the U.S. comptroller general appointed 15 members to the National Health Care Workforce Commission, an acknowledgment that the country needs more guidance in how to address existing shortages—expected to widen—in doctors and other healthcare providers. The commission, authorized by the ACA, has never met, however. The act didn’t appropriate any money for it, and Congress has yet to approve any funding either, meaning that the commission’s members are legally barred from conducting any work.

—Bryn Nelson, PhD

Many of the buzzwords being bandied about in discussions of the Affordable Care Act, or ACA, already are familiar to hospitalists. HM providers regularly operate in an interdisciplinary environment and have been leading the charge in quality improvement initiatives over the past few years. But as the ACA kicks into high gear, hospitalists say it will ramp up the emphasis on tighter cost controls (especially identifying and eliminating waste), greater efficiency, and smoother transitions of care.

Supporters of the law have advanced the moral and ethical argument that everyone deserves at least basic healthcare.

“Money is not going to magically appear to pay for that,”

Dr. Hilger says. “So we’re all responsible for looking at what we do and where’s the waste in the system to help improve the care for the most at-risk patients.”

Some fundamentals of the work environment haven’t changed dramatically.

“Even before the ACA, there were core measures and coding and documentation requirements,” Dr. Hilger says. What’s different now, he says, is an added sense of urgency in scrutinizing quality and cost. That expectation may be especially acute for HM providers. “I think there’s a lot of pressure on hospitalists because organizations and hospitals are expecting us to be the primary care doctors in the hospital and to eliminate waste,” he says. That mandate dovetails with campaigns like Choosing Wisely that ask doctors to ponder the necessity of often overused or misused tests and procedures.

There’s going to be two steps forward, one step back, but the simple question is: Was it ever OK to have tens of millions of patients who had no insurance or were underinsured and were using the emergency room as their primary care? I think, no matter what your political affiliation, that, in general, the answer is no.

—Rick Hilger, MD, SFHM,medical director for care management, Regions Hospital, St. Paul, Minn., hospitalist, HealthPartners, member, SHM Public Policy Committee.

Another area of added emphasis is transitioning patients out of the hospital in a high-quality, low-cost way.

“That’s something we should have been doing 10 years ago,” Dr. Hilger says. “So that’s definitely a trend in the right direction that the ACA is helping to further.”

In effect, the heightened profile of ACOs, the rise of quality-based metrics, and the shift toward pay-for-performance models are extending the expectations around what happens to patients before, during, and after a hospital stay.

“We’re expected to not only provide excellent care to the patient while they’re in the hospital, but we’re expected to make sure that there is a good transition plan at discharge,” Dr. Hilger explains. “We’re expected to make sure that the patient has appropriate appointments lined up, that they’re getting appropriate services either at home or that we try to get them appropriately to a skilled nursing facility.”

Dr. Lenchus says a major objective of healthcare reform—at least in principle—is to devote more energy to preventive care to help ward off more expensive acute care.

“If we assume the hypothesis that the ACA really tries to keep people out of the hospital, that makes their time in the hospital that much more focused and concentrated, to the point where quality, cost control, and efficiency are really going to come into play,” he says.

And, at least initially, patients who have chronic conditions or were excluded from the healthcare system due to pre-existing illnesses or an inability to pay are likely to be clamoring for access the most. Consequently, those who do end up in the hospital will require more complex care.

“With respect to the workload, I believe we’ll see patients who are farther along in their disease process, in more acute, more dire need for healthcare,” Dr. Lenchus says.

Providers already accustomed to working in teams to improve quality and to communicating with a hospital’s chief medical officer and other C-suite executives over matters of cost will have a clear advantage.

“The ACA is not perfect, and it’s going to take time to figure out what works and what doesn’t, but what we have control over on a daily basis is to really focus on high-quality, low-cost, standardized best practices,” Dr. Hilger says.

What does that mean in practice? “Really work on perfecting or maximizing your transitions of care,” he says. “Really work with care management and social workers, and work with your hospital to try to develop relationships—if you haven’t already—with the primary care systems in your community.”

Bryn Nelson is a freelance medical writer in Seattle.

Many of the buzzwords being bandied about in discussions of the Affordable Care Act, or ACA, already are familiar to hospitalists. HM providers regularly operate in an interdisciplinary environment and have been leading the charge in quality improvement initiatives over the past few years. But as the ACA kicks into high gear, hospitalists say it will ramp up the emphasis on tighter cost controls (especially identifying and eliminating waste), greater efficiency, and smoother transitions of care.

Supporters of the law have advanced the moral and ethical argument that everyone deserves at least basic healthcare.

“Money is not going to magically appear to pay for that,”

Dr. Hilger says. “So we’re all responsible for looking at what we do and where’s the waste in the system to help improve the care for the most at-risk patients.”

Some fundamentals of the work environment haven’t changed dramatically.

“Even before the ACA, there were core measures and coding and documentation requirements,” Dr. Hilger says. What’s different now, he says, is an added sense of urgency in scrutinizing quality and cost. That expectation may be especially acute for HM providers. “I think there’s a lot of pressure on hospitalists because organizations and hospitals are expecting us to be the primary care doctors in the hospital and to eliminate waste,” he says. That mandate dovetails with campaigns like Choosing Wisely that ask doctors to ponder the necessity of often overused or misused tests and procedures.

There’s going to be two steps forward, one step back, but the simple question is: Was it ever OK to have tens of millions of patients who had no insurance or were underinsured and were using the emergency room as their primary care? I think, no matter what your political affiliation, that, in general, the answer is no.

—Rick Hilger, MD, SFHM,medical director for care management, Regions Hospital, St. Paul, Minn., hospitalist, HealthPartners, member, SHM Public Policy Committee.

Another area of added emphasis is transitioning patients out of the hospital in a high-quality, low-cost way.

“That’s something we should have been doing 10 years ago,” Dr. Hilger says. “So that’s definitely a trend in the right direction that the ACA is helping to further.”

In effect, the heightened profile of ACOs, the rise of quality-based metrics, and the shift toward pay-for-performance models are extending the expectations around what happens to patients before, during, and after a hospital stay.

“We’re expected to not only provide excellent care to the patient while they’re in the hospital, but we’re expected to make sure that there is a good transition plan at discharge,” Dr. Hilger explains. “We’re expected to make sure that the patient has appropriate appointments lined up, that they’re getting appropriate services either at home or that we try to get them appropriately to a skilled nursing facility.”

Dr. Lenchus says a major objective of healthcare reform—at least in principle—is to devote more energy to preventive care to help ward off more expensive acute care.

“If we assume the hypothesis that the ACA really tries to keep people out of the hospital, that makes their time in the hospital that much more focused and concentrated, to the point where quality, cost control, and efficiency are really going to come into play,” he says.

And, at least initially, patients who have chronic conditions or were excluded from the healthcare system due to pre-existing illnesses or an inability to pay are likely to be clamoring for access the most. Consequently, those who do end up in the hospital will require more complex care.

“With respect to the workload, I believe we’ll see patients who are farther along in their disease process, in more acute, more dire need for healthcare,” Dr. Lenchus says.

Providers already accustomed to working in teams to improve quality and to communicating with a hospital’s chief medical officer and other C-suite executives over matters of cost will have a clear advantage.

“The ACA is not perfect, and it’s going to take time to figure out what works and what doesn’t, but what we have control over on a daily basis is to really focus on high-quality, low-cost, standardized best practices,” Dr. Hilger says.

What does that mean in practice? “Really work on perfecting or maximizing your transitions of care,” he says. “Really work with care management and social workers, and work with your hospital to try to develop relationships—if you haven’t already—with the primary care systems in your community.”

Bryn Nelson is a freelance medical writer in Seattle.

Many of the buzzwords being bandied about in discussions of the Affordable Care Act, or ACA, already are familiar to hospitalists. HM providers regularly operate in an interdisciplinary environment and have been leading the charge in quality improvement initiatives over the past few years. But as the ACA kicks into high gear, hospitalists say it will ramp up the emphasis on tighter cost controls (especially identifying and eliminating waste), greater efficiency, and smoother transitions of care.

Supporters of the law have advanced the moral and ethical argument that everyone deserves at least basic healthcare.

“Money is not going to magically appear to pay for that,”

Dr. Hilger says. “So we’re all responsible for looking at what we do and where’s the waste in the system to help improve the care for the most at-risk patients.”

Some fundamentals of the work environment haven’t changed dramatically.

“Even before the ACA, there were core measures and coding and documentation requirements,” Dr. Hilger says. What’s different now, he says, is an added sense of urgency in scrutinizing quality and cost. That expectation may be especially acute for HM providers. “I think there’s a lot of pressure on hospitalists because organizations and hospitals are expecting us to be the primary care doctors in the hospital and to eliminate waste,” he says. That mandate dovetails with campaigns like Choosing Wisely that ask doctors to ponder the necessity of often overused or misused tests and procedures.

There’s going to be two steps forward, one step back, but the simple question is: Was it ever OK to have tens of millions of patients who had no insurance or were underinsured and were using the emergency room as their primary care? I think, no matter what your political affiliation, that, in general, the answer is no.

—Rick Hilger, MD, SFHM,medical director for care management, Regions Hospital, St. Paul, Minn., hospitalist, HealthPartners, member, SHM Public Policy Committee.

Another area of added emphasis is transitioning patients out of the hospital in a high-quality, low-cost way.

“That’s something we should have been doing 10 years ago,” Dr. Hilger says. “So that’s definitely a trend in the right direction that the ACA is helping to further.”

In effect, the heightened profile of ACOs, the rise of quality-based metrics, and the shift toward pay-for-performance models are extending the expectations around what happens to patients before, during, and after a hospital stay.

“We’re expected to not only provide excellent care to the patient while they’re in the hospital, but we’re expected to make sure that there is a good transition plan at discharge,” Dr. Hilger explains. “We’re expected to make sure that the patient has appropriate appointments lined up, that they’re getting appropriate services either at home or that we try to get them appropriately to a skilled nursing facility.”

Dr. Lenchus says a major objective of healthcare reform—at least in principle—is to devote more energy to preventive care to help ward off more expensive acute care.

“If we assume the hypothesis that the ACA really tries to keep people out of the hospital, that makes their time in the hospital that much more focused and concentrated, to the point where quality, cost control, and efficiency are really going to come into play,” he says.

And, at least initially, patients who have chronic conditions or were excluded from the healthcare system due to pre-existing illnesses or an inability to pay are likely to be clamoring for access the most. Consequently, those who do end up in the hospital will require more complex care.

“With respect to the workload, I believe we’ll see patients who are farther along in their disease process, in more acute, more dire need for healthcare,” Dr. Lenchus says.

Providers already accustomed to working in teams to improve quality and to communicating with a hospital’s chief medical officer and other C-suite executives over matters of cost will have a clear advantage.

“The ACA is not perfect, and it’s going to take time to figure out what works and what doesn’t, but what we have control over on a daily basis is to really focus on high-quality, low-cost, standardized best practices,” Dr. Hilger says.

What does that mean in practice? “Really work on perfecting or maximizing your transitions of care,” he says. “Really work with care management and social workers, and work with your hospital to try to develop relationships—if you haven’t already—with the primary care systems in your community.”

Bryn Nelson is a freelance medical writer in Seattle.