Practice Management

Several months into 2017, physicians around the country are preparing for the first benchmark year of MACRA, the Medicare Access and CHIP Reauthorization Act. Passed in 2015, MACRA is the bipartisan health care law responsible for eliminating the Sustainable Growth Rate and it promises to continue to fundamentally alter the way providers are paid. This year determines reimbursement in 2019.

Under the law, physicians must report performance under one of two pathways: MIPS, the Merit-based Incentive Payment System, or participation in a qualified Advanced Alternative Payment Model, or Advanced APM. The first, MIPS, replaces the Physician Quality Reporting System, Meaningful Use and the Physician Value-Based Payment Modifier and is the track most providers can expect to follow, at least initially, because most will not meet the requirements for Advanced APMs.^1,2

This is especially true for hospitalists, most of whom are not yet participating in qualifying alternative payment models.²

The MIPS track is budget neutral, which means for every physician or physician group that receives a boost in reimbursement, another will receive a cut. Others will receive a neutral adjustment. All physicians see an annual 0.5% increase in payment between 2016 and 2019 and MIPS clinicians receive a 0.25% annual boost starting in 2026. Providers participating in Advanced APMs will also receive an annual 5% payment bonus between 2019 and 2024, and a 0.75% annual increase in payments beginning in 2026.¹

Both pathways are complex and will affect different clinicians in unique ways, particularly hospitalists.

MIPS

All providers who receive Medicare Physician Fee Schedule payments and do not participate in an Advanced APM will fall into MIPS, and reporting applies to all patients, not just Medicare beneficiaries.³ There are, however, exemptions: providers in their first year of Medicare, those billing Medicare Part B less than $30,000 annually, and those who see 100 or fewer Medicare patients.⁴

Under MIPS, physicians are scored on a scale of 1 to 100 based on performance across four weighted categories: Quality (60%), Advancing Care Information (25%), Improvement Activities (15%), and Cost (not included for 2017). Hospitalists who provide 75% or more of their services in hospital inpatient or outpatient settings, or in the emergency department, are exempt from Advancing Care Information, which replaced meaningful use. As a result, the Quality category will make up 85% of the overall score in 2017.

The CMS also announced added flexibility for 2017 with regard to reporting under MIPS, intended to give providers who need it extra time to prepare.⁵ Physicians and physician groups can report for a full year, starting January 1, 2017, or report for just 90 days, to be eligible for a positive payment adjustment. To avoid a negative adjustment, they can simply submit more than one quality measure, improvement activity, or advancing care information measure (for those not exempt). Or, providers can choose to report nothing and incur a negative 4% payment.

The approach to MIPS in 2017 will vary widely among SHM members, said Joshua Boswell, SHM’s director of government relations.

“Some are looking to do just the bare minimum, not because of their lack of readiness, but for at least this year, to avoid the time, resources, and cost associated with reporting.” he said. “Other groups are considering jumping in with both feet and fully reporting, their thinking being that they can’t lose, and if there is money on the table for high performers, they might as well go for it.”

For 2017, providers who score 70 or more points are eligible for a performance bonus, drawn from a $500 million pool set aside by CMS. The minimum point threshold defined by CMS is three, which a clinician can earn by submitting just one of the six required quality measures.⁴

Advanced APMs

Physicians who participate in Advanced APMs are exempt from MIPS. Advanced APMs must use Certified Electronic Health Record Technology (CEHRT) and take on a minimum amount of risk. For 2017 and 2018, providers must risk losing the lesser of 3% of their total Medicare expenditures or 8% of their revenue.⁹ They are paid based on the parameters of their particular model.

Additionally, for the 2019 payment year, 25% of a provider’s or group’s Medicare payments or 20% of their patients must be through the Advanced APM. This increases to 50% of payments and 35% of patients for 2021 and 2022, and in 2023, to 75% of payments and 50% of patients.

In 2017, APMs that meet the criteria for Advanced include: Comprehensive End-Stage Renal Disease Care, Comprehensive Primary Care Plus, Next Generation ACO Model, Shared Savings Program Tracks 2 and 3, Comprehensive Joint Replacement Payment Model Track 1, the Vermont Medicare ACO Initiative, and the Oncology Care Model. (APMs that do not qualify must report under MIPS.)⁵

The CMS also says that services provided at critical access hospitals, rural health clinics, and federally qualified health centers may qualify using patient counts, and medical home models and the Medicaid Medical Home Model may also be considered Advanced APMs using financial criteria.⁴

At this time, SHM is unable to quantify the number of hospitalists participating in Advanced APMs, and some, Dr. Greeno said, may not know whether they are part of an Advanced APM.

Currently, BPCI (Bundled Payments for Care Improvement) is the only alternative payment model in which hospitalists can directly take risk, Dr. Greeno says, but it does not yet qualify as an Advanced APM. However, that could change.

Prior to the passage of MACRA, Brandeis University worked with CMS to create the Episode Grouper for Medicare (EGM), software that converts claims data into episodes of care based on a patient’s condition or conditions or procedures. The American College of Surgeons (ACS) has since proposed an alternative payment model, called ACS-Brandeis, that would use the diagnostic grouper to take into account all of the work done by every provider on any episode admitted to the hospital and use algorithms to decide who affected a particular patient’s care.

“Anyone who takes care of the patient can take risk or gain share if the episode initiator allows them,” said Dr. Greeno.

For example, if a patient is admitted for surgery, but has an internist on their case because they have diabetes and heart failure, and they also have an anesthesiologist and an infectious disease specialist, everybody has an impact on their care and makes decisions about the resources used on the case. The risk associated with the case is effectively divided.

The ACS submitted the proposal to PTAC (the Physician-Focused Payment Model Technical Advisory Committee) in 2016 and SHM submitted a letter of support.

“In this model, everybody’s taking risk and everybody has the opportunity to gain share if the patient is managed well,” said Dr. Greeno. “It’s a very complicated, very complex model... Theoretically, everybody on that case should be optimally engaged – that’s the beauty of it – but we don’t know if it will work.”

The SHM got involved at the request of ACS, because it would not apply solely to surgical patients. Dr. Greeno says ACS asked SHM to look at common surgical diagnoses and review every medical scenario that could come to pass, from heart failure and pneumonia to infection.

“There’s bundles within bundles, medical bundles within surgical bundles,” he said. “It’s fascinating and it’s daunting but it is truly a big data approach to episodes of care. We’re thrilled to be invited and ACS was very enthusiastic about our involvement.”

Dr. Patel, who sits on PTAC, is heartened by the amount of physician-led innovation taking place. “Proposals are coming directly from doctors; they are telling us what they want,” she said.

For Dr. Greeno, this captures the intent of MACRA: “There is going to be a continual increase in the sophistication of models, and hopefully toward ones that are better and better and create the right incentives for everyone involved in the health care system.”


References

1. S. Findlay. Medicare’s new physician payment system. http://www.healthaffairs.org/healthpolicybriefs/brief.php?brief_id=156. Published April 21, 2016. Accessed March 6, 2017.

2. The Society of Hospital Medicine. Medicare physician payments are changing. http://www.macraforhm.org/. Accessed March 6, 2017.

3. A. Maciejowski. MACRA: What’s really in the final rule. http://blog.ncqa.org/macra-whats-really-in-the-final-rule/. Blog post published November 15, 2016. Accessed March 6, 2017.

4. Department of Health and Human Services, Centers for Medicare and Medicaid Services. Quality Payment Program executive summary. https://qpp.cms.gov/docs/QPP_Executive_Summary_of_Final_Rule.pdf. Published Oct. 14, 2016. Accessed March 6, 2017.

5. Department of Health and Human Services, Centers for Medicare and Medicaid Services. Quality Payment Program: Modernizing Medicare to provide better care and smarter spending for a healthier America. https://qpp.cms.gov/. Accessed March 6, 2017.

6. D. Barkholz. Potential MACRA byproduct: physician consolidation. http://www.modernhealthcare.com/article/20160630/NEWS/160639995. Published June 30, 2016. Accessed March 6, 2017.

7. United States Department of Health and Human Services. Better, smarter, healthier: In historic announcement, HHS sets clear goals and timeline for shifting Medicare reimbursement from volume to value. http://wayback.archive-it.org/3926/20170127185400/https://www.hhs.gov/about/news/2015/01/26/better-smarter-healthier-in-historic-announcement-hhs-sets-clear-goals-and-timeline-for-shifting-medicare-reimbursements-from-volume-to-value.html. Published January 26, 2015. Accessed March 6, 2017.

8. B. Wynne. MACRA Final Rule: CMS strikes a balance; will docs hang on? http://healthaffairs.org/blog/2016/10/17/macra-final-rule-cms-strikes-a-balance-will-docs-hang-on/. Published October 17, 2016. Accessed March 6, 2017.

9. United States Department of Health and Human Services, Office of the Assistant Secretary for Planning and Evaluation. Documents for Public Comment: Physician-Focused Payment Model Technical Advisory Committee. Proposal for a Physician-Focused Payment Model: CAS-Brandeis Advanced Alternative Payment Model, American College of Surgeons. https://aspe.hhs.gov/system/files/pdf/253406/TheACSBrandeisAdvancedAPM-ACS.pdf. Published December 13, 2016. Accessed March 6, 2017.

Several months into 2017, physicians around the country are preparing for the first benchmark year of MACRA, the Medicare Access and CHIP Reauthorization Act. Passed in 2015, MACRA is the bipartisan health care law responsible for eliminating the Sustainable Growth Rate and it promises to continue to fundamentally alter the way providers are paid. This year determines reimbursement in 2019.

Under the law, physicians must report performance under one of two pathways: MIPS, the Merit-based Incentive Payment System, or participation in a qualified Advanced Alternative Payment Model, or Advanced APM. The first, MIPS, replaces the Physician Quality Reporting System, Meaningful Use and the Physician Value-Based Payment Modifier and is the track most providers can expect to follow, at least initially, because most will not meet the requirements for Advanced APMs.^1,2

This is especially true for hospitalists, most of whom are not yet participating in qualifying alternative payment models.²

The MIPS track is budget neutral, which means for every physician or physician group that receives a boost in reimbursement, another will receive a cut. Others will receive a neutral adjustment. All physicians see an annual 0.5% increase in payment between 2016 and 2019 and MIPS clinicians receive a 0.25% annual boost starting in 2026. Providers participating in Advanced APMs will also receive an annual 5% payment bonus between 2019 and 2024, and a 0.75% annual increase in payments beginning in 2026.¹

Both pathways are complex and will affect different clinicians in unique ways, particularly hospitalists.

MIPS

All providers who receive Medicare Physician Fee Schedule payments and do not participate in an Advanced APM will fall into MIPS, and reporting applies to all patients, not just Medicare beneficiaries.³ There are, however, exemptions: providers in their first year of Medicare, those billing Medicare Part B less than $30,000 annually, and those who see 100 or fewer Medicare patients.⁴

Under MIPS, physicians are scored on a scale of 1 to 100 based on performance across four weighted categories: Quality (60%), Advancing Care Information (25%), Improvement Activities (15%), and Cost (not included for 2017). Hospitalists who provide 75% or more of their services in hospital inpatient or outpatient settings, or in the emergency department, are exempt from Advancing Care Information, which replaced meaningful use. As a result, the Quality category will make up 85% of the overall score in 2017.

The CMS also announced added flexibility for 2017 with regard to reporting under MIPS, intended to give providers who need it extra time to prepare.⁵ Physicians and physician groups can report for a full year, starting January 1, 2017, or report for just 90 days, to be eligible for a positive payment adjustment. To avoid a negative adjustment, they can simply submit more than one quality measure, improvement activity, or advancing care information measure (for those not exempt). Or, providers can choose to report nothing and incur a negative 4% payment.

The approach to MIPS in 2017 will vary widely among SHM members, said Joshua Boswell, SHM’s director of government relations.

“Some are looking to do just the bare minimum, not because of their lack of readiness, but for at least this year, to avoid the time, resources, and cost associated with reporting.” he said. “Other groups are considering jumping in with both feet and fully reporting, their thinking being that they can’t lose, and if there is money on the table for high performers, they might as well go for it.”

For 2017, providers who score 70 or more points are eligible for a performance bonus, drawn from a $500 million pool set aside by CMS. The minimum point threshold defined by CMS is three, which a clinician can earn by submitting just one of the six required quality measures.⁴

Advanced APMs

Physicians who participate in Advanced APMs are exempt from MIPS. Advanced APMs must use Certified Electronic Health Record Technology (CEHRT) and take on a minimum amount of risk. For 2017 and 2018, providers must risk losing the lesser of 3% of their total Medicare expenditures or 8% of their revenue.⁹ They are paid based on the parameters of their particular model.

Additionally, for the 2019 payment year, 25% of a provider’s or group’s Medicare payments or 20% of their patients must be through the Advanced APM. This increases to 50% of payments and 35% of patients for 2021 and 2022, and in 2023, to 75% of payments and 50% of patients.

In 2017, APMs that meet the criteria for Advanced include: Comprehensive End-Stage Renal Disease Care, Comprehensive Primary Care Plus, Next Generation ACO Model, Shared Savings Program Tracks 2 and 3, Comprehensive Joint Replacement Payment Model Track 1, the Vermont Medicare ACO Initiative, and the Oncology Care Model. (APMs that do not qualify must report under MIPS.)⁵

The CMS also says that services provided at critical access hospitals, rural health clinics, and federally qualified health centers may qualify using patient counts, and medical home models and the Medicaid Medical Home Model may also be considered Advanced APMs using financial criteria.⁴

At this time, SHM is unable to quantify the number of hospitalists participating in Advanced APMs, and some, Dr. Greeno said, may not know whether they are part of an Advanced APM.

Currently, BPCI (Bundled Payments for Care Improvement) is the only alternative payment model in which hospitalists can directly take risk, Dr. Greeno says, but it does not yet qualify as an Advanced APM. However, that could change.

Prior to the passage of MACRA, Brandeis University worked with CMS to create the Episode Grouper for Medicare (EGM), software that converts claims data into episodes of care based on a patient’s condition or conditions or procedures. The American College of Surgeons (ACS) has since proposed an alternative payment model, called ACS-Brandeis, that would use the diagnostic grouper to take into account all of the work done by every provider on any episode admitted to the hospital and use algorithms to decide who affected a particular patient’s care.

“Anyone who takes care of the patient can take risk or gain share if the episode initiator allows them,” said Dr. Greeno.

For example, if a patient is admitted for surgery, but has an internist on their case because they have diabetes and heart failure, and they also have an anesthesiologist and an infectious disease specialist, everybody has an impact on their care and makes decisions about the resources used on the case. The risk associated with the case is effectively divided.

The ACS submitted the proposal to PTAC (the Physician-Focused Payment Model Technical Advisory Committee) in 2016 and SHM submitted a letter of support.

“In this model, everybody’s taking risk and everybody has the opportunity to gain share if the patient is managed well,” said Dr. Greeno. “It’s a very complicated, very complex model... Theoretically, everybody on that case should be optimally engaged – that’s the beauty of it – but we don’t know if it will work.”

The SHM got involved at the request of ACS, because it would not apply solely to surgical patients. Dr. Greeno says ACS asked SHM to look at common surgical diagnoses and review every medical scenario that could come to pass, from heart failure and pneumonia to infection.

“There’s bundles within bundles, medical bundles within surgical bundles,” he said. “It’s fascinating and it’s daunting but it is truly a big data approach to episodes of care. We’re thrilled to be invited and ACS was very enthusiastic about our involvement.”

Dr. Patel, who sits on PTAC, is heartened by the amount of physician-led innovation taking place. “Proposals are coming directly from doctors; they are telling us what they want,” she said.

For Dr. Greeno, this captures the intent of MACRA: “There is going to be a continual increase in the sophistication of models, and hopefully toward ones that are better and better and create the right incentives for everyone involved in the health care system.”


References

1. S. Findlay. Medicare’s new physician payment system. http://www.healthaffairs.org/healthpolicybriefs/brief.php?brief_id=156. Published April 21, 2016. Accessed March 6, 2017.

2. The Society of Hospital Medicine. Medicare physician payments are changing. http://www.macraforhm.org/. Accessed March 6, 2017.

3. A. Maciejowski. MACRA: What’s really in the final rule. http://blog.ncqa.org/macra-whats-really-in-the-final-rule/. Blog post published November 15, 2016. Accessed March 6, 2017.

4. Department of Health and Human Services, Centers for Medicare and Medicaid Services. Quality Payment Program executive summary. https://qpp.cms.gov/docs/QPP_Executive_Summary_of_Final_Rule.pdf. Published Oct. 14, 2016. Accessed March 6, 2017.

5. Department of Health and Human Services, Centers for Medicare and Medicaid Services. Quality Payment Program: Modernizing Medicare to provide better care and smarter spending for a healthier America. https://qpp.cms.gov/. Accessed March 6, 2017.

6. D. Barkholz. Potential MACRA byproduct: physician consolidation. http://www.modernhealthcare.com/article/20160630/NEWS/160639995. Published June 30, 2016. Accessed March 6, 2017.

7. United States Department of Health and Human Services. Better, smarter, healthier: In historic announcement, HHS sets clear goals and timeline for shifting Medicare reimbursement from volume to value. http://wayback.archive-it.org/3926/20170127185400/https://www.hhs.gov/about/news/2015/01/26/better-smarter-healthier-in-historic-announcement-hhs-sets-clear-goals-and-timeline-for-shifting-medicare-reimbursements-from-volume-to-value.html. Published January 26, 2015. Accessed March 6, 2017.

8. B. Wynne. MACRA Final Rule: CMS strikes a balance; will docs hang on? http://healthaffairs.org/blog/2016/10/17/macra-final-rule-cms-strikes-a-balance-will-docs-hang-on/. Published October 17, 2016. Accessed March 6, 2017.

9. United States Department of Health and Human Services, Office of the Assistant Secretary for Planning and Evaluation. Documents for Public Comment: Physician-Focused Payment Model Technical Advisory Committee. Proposal for a Physician-Focused Payment Model: CAS-Brandeis Advanced Alternative Payment Model, American College of Surgeons. https://aspe.hhs.gov/system/files/pdf/253406/TheACSBrandeisAdvancedAPM-ACS.pdf. Published December 13, 2016. Accessed March 6, 2017.

Several months into 2017, physicians around the country are preparing for the first benchmark year of MACRA, the Medicare Access and CHIP Reauthorization Act. Passed in 2015, MACRA is the bipartisan health care law responsible for eliminating the Sustainable Growth Rate and it promises to continue to fundamentally alter the way providers are paid. This year determines reimbursement in 2019.

Under the law, physicians must report performance under one of two pathways: MIPS, the Merit-based Incentive Payment System, or participation in a qualified Advanced Alternative Payment Model, or Advanced APM. The first, MIPS, replaces the Physician Quality Reporting System, Meaningful Use and the Physician Value-Based Payment Modifier and is the track most providers can expect to follow, at least initially, because most will not meet the requirements for Advanced APMs.^1,2

This is especially true for hospitalists, most of whom are not yet participating in qualifying alternative payment models.²

The MIPS track is budget neutral, which means for every physician or physician group that receives a boost in reimbursement, another will receive a cut. Others will receive a neutral adjustment. All physicians see an annual 0.5% increase in payment between 2016 and 2019 and MIPS clinicians receive a 0.25% annual boost starting in 2026. Providers participating in Advanced APMs will also receive an annual 5% payment bonus between 2019 and 2024, and a 0.75% annual increase in payments beginning in 2026.¹

Both pathways are complex and will affect different clinicians in unique ways, particularly hospitalists.

MIPS

All providers who receive Medicare Physician Fee Schedule payments and do not participate in an Advanced APM will fall into MIPS, and reporting applies to all patients, not just Medicare beneficiaries.³ There are, however, exemptions: providers in their first year of Medicare, those billing Medicare Part B less than $30,000 annually, and those who see 100 or fewer Medicare patients.⁴

Under MIPS, physicians are scored on a scale of 1 to 100 based on performance across four weighted categories: Quality (60%), Advancing Care Information (25%), Improvement Activities (15%), and Cost (not included for 2017). Hospitalists who provide 75% or more of their services in hospital inpatient or outpatient settings, or in the emergency department, are exempt from Advancing Care Information, which replaced meaningful use. As a result, the Quality category will make up 85% of the overall score in 2017.

The CMS also announced added flexibility for 2017 with regard to reporting under MIPS, intended to give providers who need it extra time to prepare.⁵ Physicians and physician groups can report for a full year, starting January 1, 2017, or report for just 90 days, to be eligible for a positive payment adjustment. To avoid a negative adjustment, they can simply submit more than one quality measure, improvement activity, or advancing care information measure (for those not exempt). Or, providers can choose to report nothing and incur a negative 4% payment.

The approach to MIPS in 2017 will vary widely among SHM members, said Joshua Boswell, SHM’s director of government relations.

“Some are looking to do just the bare minimum, not because of their lack of readiness, but for at least this year, to avoid the time, resources, and cost associated with reporting.” he said. “Other groups are considering jumping in with both feet and fully reporting, their thinking being that they can’t lose, and if there is money on the table for high performers, they might as well go for it.”

For 2017, providers who score 70 or more points are eligible for a performance bonus, drawn from a $500 million pool set aside by CMS. The minimum point threshold defined by CMS is three, which a clinician can earn by submitting just one of the six required quality measures.⁴

Advanced APMs

Physicians who participate in Advanced APMs are exempt from MIPS. Advanced APMs must use Certified Electronic Health Record Technology (CEHRT) and take on a minimum amount of risk. For 2017 and 2018, providers must risk losing the lesser of 3% of their total Medicare expenditures or 8% of their revenue.⁹ They are paid based on the parameters of their particular model.

Additionally, for the 2019 payment year, 25% of a provider’s or group’s Medicare payments or 20% of their patients must be through the Advanced APM. This increases to 50% of payments and 35% of patients for 2021 and 2022, and in 2023, to 75% of payments and 50% of patients.

In 2017, APMs that meet the criteria for Advanced include: Comprehensive End-Stage Renal Disease Care, Comprehensive Primary Care Plus, Next Generation ACO Model, Shared Savings Program Tracks 2 and 3, Comprehensive Joint Replacement Payment Model Track 1, the Vermont Medicare ACO Initiative, and the Oncology Care Model. (APMs that do not qualify must report under MIPS.)⁵

The CMS also says that services provided at critical access hospitals, rural health clinics, and federally qualified health centers may qualify using patient counts, and medical home models and the Medicaid Medical Home Model may also be considered Advanced APMs using financial criteria.⁴

At this time, SHM is unable to quantify the number of hospitalists participating in Advanced APMs, and some, Dr. Greeno said, may not know whether they are part of an Advanced APM.

Currently, BPCI (Bundled Payments for Care Improvement) is the only alternative payment model in which hospitalists can directly take risk, Dr. Greeno says, but it does not yet qualify as an Advanced APM. However, that could change.

Prior to the passage of MACRA, Brandeis University worked with CMS to create the Episode Grouper for Medicare (EGM), software that converts claims data into episodes of care based on a patient’s condition or conditions or procedures. The American College of Surgeons (ACS) has since proposed an alternative payment model, called ACS-Brandeis, that would use the diagnostic grouper to take into account all of the work done by every provider on any episode admitted to the hospital and use algorithms to decide who affected a particular patient’s care.

“Anyone who takes care of the patient can take risk or gain share if the episode initiator allows them,” said Dr. Greeno.

For example, if a patient is admitted for surgery, but has an internist on their case because they have diabetes and heart failure, and they also have an anesthesiologist and an infectious disease specialist, everybody has an impact on their care and makes decisions about the resources used on the case. The risk associated with the case is effectively divided.

The ACS submitted the proposal to PTAC (the Physician-Focused Payment Model Technical Advisory Committee) in 2016 and SHM submitted a letter of support.

“In this model, everybody’s taking risk and everybody has the opportunity to gain share if the patient is managed well,” said Dr. Greeno. “It’s a very complicated, very complex model... Theoretically, everybody on that case should be optimally engaged – that’s the beauty of it – but we don’t know if it will work.”

The SHM got involved at the request of ACS, because it would not apply solely to surgical patients. Dr. Greeno says ACS asked SHM to look at common surgical diagnoses and review every medical scenario that could come to pass, from heart failure and pneumonia to infection.

“There’s bundles within bundles, medical bundles within surgical bundles,” he said. “It’s fascinating and it’s daunting but it is truly a big data approach to episodes of care. We’re thrilled to be invited and ACS was very enthusiastic about our involvement.”

Dr. Patel, who sits on PTAC, is heartened by the amount of physician-led innovation taking place. “Proposals are coming directly from doctors; they are telling us what they want,” she said.

For Dr. Greeno, this captures the intent of MACRA: “There is going to be a continual increase in the sophistication of models, and hopefully toward ones that are better and better and create the right incentives for everyone involved in the health care system.”


References

1. S. Findlay. Medicare’s new physician payment system. http://www.healthaffairs.org/healthpolicybriefs/brief.php?brief_id=156. Published April 21, 2016. Accessed March 6, 2017.

2. The Society of Hospital Medicine. Medicare physician payments are changing. http://www.macraforhm.org/. Accessed March 6, 2017.

3. A. Maciejowski. MACRA: What’s really in the final rule. http://blog.ncqa.org/macra-whats-really-in-the-final-rule/. Blog post published November 15, 2016. Accessed March 6, 2017.

4. Department of Health and Human Services, Centers for Medicare and Medicaid Services. Quality Payment Program executive summary. https://qpp.cms.gov/docs/QPP_Executive_Summary_of_Final_Rule.pdf. Published Oct. 14, 2016. Accessed March 6, 2017.

5. Department of Health and Human Services, Centers for Medicare and Medicaid Services. Quality Payment Program: Modernizing Medicare to provide better care and smarter spending for a healthier America. https://qpp.cms.gov/. Accessed March 6, 2017.

6. D. Barkholz. Potential MACRA byproduct: physician consolidation. http://www.modernhealthcare.com/article/20160630/NEWS/160639995. Published June 30, 2016. Accessed March 6, 2017.

7. United States Department of Health and Human Services. Better, smarter, healthier: In historic announcement, HHS sets clear goals and timeline for shifting Medicare reimbursement from volume to value. http://wayback.archive-it.org/3926/20170127185400/https://www.hhs.gov/about/news/2015/01/26/better-smarter-healthier-in-historic-announcement-hhs-sets-clear-goals-and-timeline-for-shifting-medicare-reimbursements-from-volume-to-value.html. Published January 26, 2015. Accessed March 6, 2017.

8. B. Wynne. MACRA Final Rule: CMS strikes a balance; will docs hang on? http://healthaffairs.org/blog/2016/10/17/macra-final-rule-cms-strikes-a-balance-will-docs-hang-on/. Published October 17, 2016. Accessed March 6, 2017.

9. United States Department of Health and Human Services, Office of the Assistant Secretary for Planning and Evaluation. Documents for Public Comment: Physician-Focused Payment Model Technical Advisory Committee. Proposal for a Physician-Focused Payment Model: CAS-Brandeis Advanced Alternative Payment Model, American College of Surgeons. https://aspe.hhs.gov/system/files/pdf/253406/TheACSBrandeisAdvancedAPM-ACS.pdf. Published December 13, 2016. Accessed March 6, 2017.

LAS VEGAS – Babatunde Akinsete, MD, took a new job about 18 months ago as a lead hospitalist within Adventist Health System of Florida. The role has the expected leadership responsibilities, but those folks he’s now partly supervising are the same ones who used to be his peers.

The same people he spent time “in the trenches” with, complaining about the problems they saw – issues that are now partly his job to help fix.

“It’s tough,” Dr. Akinsete said at the annual meeting of the Society of Hospital Medicine. “How do you motivate people?”

Welcome to managing a practice, circa 2017. The day-to-day doings of an HM group – recruiting, retention, compensation, scheduling and more – are the backbone of the specialty. And SHM’s annual meeting makes the topics a principal point, from a dedicated precourse to dozens of presentations to networking opportunities introducing experienced leaders to nascent ones.

The subject is more relevant than ever these days as the maturing specialty now has three generations of hospitalists practicing side by side, including those who founded the society and laid the groundwork for the specialty some 20 years ago and those who will now infuse it with new blood for the next 20 years, said Jerome Siy, MD, SFHM, an HM17 faculty member and chair of SHM’s Practice Management Committee.

“We’re heading into a cycle of a lot of change,” he said. “Being able to manage change is going to be pretty key.”

The first step in building or bettering a “healthy practice” is building a “culture of ownership,” Dr. Siy said.

“You must have the right culture first if you’re going to tackle any of these issues, whether it’s things like schedules to finances to negotiations,” he added. “Second is this openness and innovation to think outside the box and to allow yourself to hear things that might not work for you. Be open to it because whether you hear something that doesn’t work or not, it may inspire you to figure out … what is the key element you were missing before.”

That’s what Liza Rodriguez Jimenez, MD, is taking away from the meeting. She is moving into a codirector position for her medical group at St. Luke’s in Boise, Idaho. A crash course in alternative-payment models, full-time equivalents (FTEs), relative value units (RVUs) and scheduling was an eye-opener for her.

But to Dr. Siy’s point, it wasn’t the specific examples of how other people do what they do that intrigued Dr. Rodriguez Jimenez. It was more so that people just did it differently.

“It’s just helpful to know that there are other choices,” Dr. Rodriguez Jimenez said. “In other words, why do we do 7 on, 7 off? I don’t know. We just do. If you don’t know that you don’t know, then how do you know to change it? You get exposed to so much stuff here now that you can theoretically go back and say, ‘why do we do 7 on, 7 off? … And then let the group say we want 5 on, 10 off, 4 on, 3 off. Whatever people decide.”

Nasim Afsar, MD, SFHM, chief quality officer of the department of medicine at UCLA Health in Los Angeles, said that idea of just framing the question differently is a big deal, and a leadership skill in and of itself. For example, say a hospital medicine group’s leaders are trying to discuss whether the practice should continue its comanagement focus.

“If you frame a decision as, ‘We are going to lose this comanagement,’ there’s just something, like a gut feeling, you don’t want to lose stuff,” she said. “As opposed to, if you say, ‘Gosh, think about the gains. That we will have all this free time that we now have where we can develop other aspects of our hospital medicine group.’ So when you frame the same exact thing in terms of loss, it becomes so much more difficult for us to actually let go of that.”

Leadership is more than just framing, of course. Dr. Afsar and former SHM president Eric Howell, MD, MHM, said that leadership traits include using standardized processes to make decisions, as well as getting group members involved in those decisions when necessary and using feedback and motivation properly.

But, at day’s end, practice management is managing the needs of your practice.

For Abdul-Hady Kheder, MD, of Hamilton Hospitalists LLC in Central New Jersey, the meeting opened his eyes to techniques he could use to deal with lower reimbursement figures and less patients.

“What can help my situation will be increasing the volume of the practice,” he said. “Right now, we admit 30%-40% of the patients admitted into the hospital. National average is 60%-90% of total hospital admissions. I think that most probably will balance my financial dilemma.”

For Rodney Hollis, practice administrator for Eskenazi Health of Indianapolis, the meeting was a way to glean tips on improving his practice. One nugget he’s excited about: pairing an experienced hospitalist with a new hire for a year. As a nonclinical administrator, Hollis said he views his role as helping clinicians work on the things they are best at, while he handle the rest.

“The more clinical time that the clinical directors can spend, that’s more advantageous to the group,” Hollis said. “Allowing the nonclinical activities to be done by an administrator helps. We want more responsibility and if there’s something that our clinical is doing that I can do, why not have me do it?”

For Dr. Rodriguez Jimenez, open-ended questions like that one are among the most “insightful” takeaways from the meeting.

“There is no right or wrong way, so maybe we’ve been doing it this way ‘just because,’ ” she said. “Now we need to look at it and say, ‘Can we do it a different way? Can we adapt it? Can we change it?’”

She’s starting to sound like a practice manager already.

LAS VEGAS – Babatunde Akinsete, MD, took a new job about 18 months ago as a lead hospitalist within Adventist Health System of Florida. The role has the expected leadership responsibilities, but those folks he’s now partly supervising are the same ones who used to be his peers.

The same people he spent time “in the trenches” with, complaining about the problems they saw – issues that are now partly his job to help fix.

“It’s tough,” Dr. Akinsete said at the annual meeting of the Society of Hospital Medicine. “How do you motivate people?”

Welcome to managing a practice, circa 2017. The day-to-day doings of an HM group – recruiting, retention, compensation, scheduling and more – are the backbone of the specialty. And SHM’s annual meeting makes the topics a principal point, from a dedicated precourse to dozens of presentations to networking opportunities introducing experienced leaders to nascent ones.

The subject is more relevant than ever these days as the maturing specialty now has three generations of hospitalists practicing side by side, including those who founded the society and laid the groundwork for the specialty some 20 years ago and those who will now infuse it with new blood for the next 20 years, said Jerome Siy, MD, SFHM, an HM17 faculty member and chair of SHM’s Practice Management Committee.

“We’re heading into a cycle of a lot of change,” he said. “Being able to manage change is going to be pretty key.”

The first step in building or bettering a “healthy practice” is building a “culture of ownership,” Dr. Siy said.

“You must have the right culture first if you’re going to tackle any of these issues, whether it’s things like schedules to finances to negotiations,” he added. “Second is this openness and innovation to think outside the box and to allow yourself to hear things that might not work for you. Be open to it because whether you hear something that doesn’t work or not, it may inspire you to figure out … what is the key element you were missing before.”

That’s what Liza Rodriguez Jimenez, MD, is taking away from the meeting. She is moving into a codirector position for her medical group at St. Luke’s in Boise, Idaho. A crash course in alternative-payment models, full-time equivalents (FTEs), relative value units (RVUs) and scheduling was an eye-opener for her.

But to Dr. Siy’s point, it wasn’t the specific examples of how other people do what they do that intrigued Dr. Rodriguez Jimenez. It was more so that people just did it differently.

“It’s just helpful to know that there are other choices,” Dr. Rodriguez Jimenez said. “In other words, why do we do 7 on, 7 off? I don’t know. We just do. If you don’t know that you don’t know, then how do you know to change it? You get exposed to so much stuff here now that you can theoretically go back and say, ‘why do we do 7 on, 7 off? … And then let the group say we want 5 on, 10 off, 4 on, 3 off. Whatever people decide.”

Nasim Afsar, MD, SFHM, chief quality officer of the department of medicine at UCLA Health in Los Angeles, said that idea of just framing the question differently is a big deal, and a leadership skill in and of itself. For example, say a hospital medicine group’s leaders are trying to discuss whether the practice should continue its comanagement focus.

“If you frame a decision as, ‘We are going to lose this comanagement,’ there’s just something, like a gut feeling, you don’t want to lose stuff,” she said. “As opposed to, if you say, ‘Gosh, think about the gains. That we will have all this free time that we now have where we can develop other aspects of our hospital medicine group.’ So when you frame the same exact thing in terms of loss, it becomes so much more difficult for us to actually let go of that.”

Leadership is more than just framing, of course. Dr. Afsar and former SHM president Eric Howell, MD, MHM, said that leadership traits include using standardized processes to make decisions, as well as getting group members involved in those decisions when necessary and using feedback and motivation properly.

But, at day’s end, practice management is managing the needs of your practice.

For Abdul-Hady Kheder, MD, of Hamilton Hospitalists LLC in Central New Jersey, the meeting opened his eyes to techniques he could use to deal with lower reimbursement figures and less patients.

“What can help my situation will be increasing the volume of the practice,” he said. “Right now, we admit 30%-40% of the patients admitted into the hospital. National average is 60%-90% of total hospital admissions. I think that most probably will balance my financial dilemma.”

For Rodney Hollis, practice administrator for Eskenazi Health of Indianapolis, the meeting was a way to glean tips on improving his practice. One nugget he’s excited about: pairing an experienced hospitalist with a new hire for a year. As a nonclinical administrator, Hollis said he views his role as helping clinicians work on the things they are best at, while he handle the rest.

“The more clinical time that the clinical directors can spend, that’s more advantageous to the group,” Hollis said. “Allowing the nonclinical activities to be done by an administrator helps. We want more responsibility and if there’s something that our clinical is doing that I can do, why not have me do it?”

For Dr. Rodriguez Jimenez, open-ended questions like that one are among the most “insightful” takeaways from the meeting.

“There is no right or wrong way, so maybe we’ve been doing it this way ‘just because,’ ” she said. “Now we need to look at it and say, ‘Can we do it a different way? Can we adapt it? Can we change it?’”

She’s starting to sound like a practice manager already.

LAS VEGAS – Babatunde Akinsete, MD, took a new job about 18 months ago as a lead hospitalist within Adventist Health System of Florida. The role has the expected leadership responsibilities, but those folks he’s now partly supervising are the same ones who used to be his peers.

The same people he spent time “in the trenches” with, complaining about the problems they saw – issues that are now partly his job to help fix.

“It’s tough,” Dr. Akinsete said at the annual meeting of the Society of Hospital Medicine. “How do you motivate people?”

Welcome to managing a practice, circa 2017. The day-to-day doings of an HM group – recruiting, retention, compensation, scheduling and more – are the backbone of the specialty. And SHM’s annual meeting makes the topics a principal point, from a dedicated precourse to dozens of presentations to networking opportunities introducing experienced leaders to nascent ones.

The subject is more relevant than ever these days as the maturing specialty now has three generations of hospitalists practicing side by side, including those who founded the society and laid the groundwork for the specialty some 20 years ago and those who will now infuse it with new blood for the next 20 years, said Jerome Siy, MD, SFHM, an HM17 faculty member and chair of SHM’s Practice Management Committee.

“We’re heading into a cycle of a lot of change,” he said. “Being able to manage change is going to be pretty key.”

The first step in building or bettering a “healthy practice” is building a “culture of ownership,” Dr. Siy said.

“You must have the right culture first if you’re going to tackle any of these issues, whether it’s things like schedules to finances to negotiations,” he added. “Second is this openness and innovation to think outside the box and to allow yourself to hear things that might not work for you. Be open to it because whether you hear something that doesn’t work or not, it may inspire you to figure out … what is the key element you were missing before.”

That’s what Liza Rodriguez Jimenez, MD, is taking away from the meeting. She is moving into a codirector position for her medical group at St. Luke’s in Boise, Idaho. A crash course in alternative-payment models, full-time equivalents (FTEs), relative value units (RVUs) and scheduling was an eye-opener for her.

But to Dr. Siy’s point, it wasn’t the specific examples of how other people do what they do that intrigued Dr. Rodriguez Jimenez. It was more so that people just did it differently.

“It’s just helpful to know that there are other choices,” Dr. Rodriguez Jimenez said. “In other words, why do we do 7 on, 7 off? I don’t know. We just do. If you don’t know that you don’t know, then how do you know to change it? You get exposed to so much stuff here now that you can theoretically go back and say, ‘why do we do 7 on, 7 off? … And then let the group say we want 5 on, 10 off, 4 on, 3 off. Whatever people decide.”

Nasim Afsar, MD, SFHM, chief quality officer of the department of medicine at UCLA Health in Los Angeles, said that idea of just framing the question differently is a big deal, and a leadership skill in and of itself. For example, say a hospital medicine group’s leaders are trying to discuss whether the practice should continue its comanagement focus.

“If you frame a decision as, ‘We are going to lose this comanagement,’ there’s just something, like a gut feeling, you don’t want to lose stuff,” she said. “As opposed to, if you say, ‘Gosh, think about the gains. That we will have all this free time that we now have where we can develop other aspects of our hospital medicine group.’ So when you frame the same exact thing in terms of loss, it becomes so much more difficult for us to actually let go of that.”

Leadership is more than just framing, of course. Dr. Afsar and former SHM president Eric Howell, MD, MHM, said that leadership traits include using standardized processes to make decisions, as well as getting group members involved in those decisions when necessary and using feedback and motivation properly.

But, at day’s end, practice management is managing the needs of your practice.

For Abdul-Hady Kheder, MD, of Hamilton Hospitalists LLC in Central New Jersey, the meeting opened his eyes to techniques he could use to deal with lower reimbursement figures and less patients.

“What can help my situation will be increasing the volume of the practice,” he said. “Right now, we admit 30%-40% of the patients admitted into the hospital. National average is 60%-90% of total hospital admissions. I think that most probably will balance my financial dilemma.”

For Rodney Hollis, practice administrator for Eskenazi Health of Indianapolis, the meeting was a way to glean tips on improving his practice. One nugget he’s excited about: pairing an experienced hospitalist with a new hire for a year. As a nonclinical administrator, Hollis said he views his role as helping clinicians work on the things they are best at, while he handle the rest.

“The more clinical time that the clinical directors can spend, that’s more advantageous to the group,” Hollis said. “Allowing the nonclinical activities to be done by an administrator helps. We want more responsibility and if there’s something that our clinical is doing that I can do, why not have me do it?”

For Dr. Rodriguez Jimenez, open-ended questions like that one are among the most “insightful” takeaways from the meeting.

“There is no right or wrong way, so maybe we’ve been doing it this way ‘just because,’ ” she said. “Now we need to look at it and say, ‘Can we do it a different way? Can we adapt it? Can we change it?’”

She’s starting to sound like a practice manager already.

Presenters

Roberta Himebaugh MBA, SHM; John Nelson, MD, FACP, MHM; Jerome Siy, MD, SFHM

Session summary

Creating a “culture of ownership” by recruiting the right people, promoting physician leadership, and improving structural elements such as compensation model and schedule were topics discussed in this practice management precourse at HM17.

The presenters said leaders must reduce hierarchy and promote shared decision making among the group, while instilling a “thank you culture” that recognizes motivations such as autonomy, mastery, and purpose.

Key takeaways for HM

• Create a culture of ownership to promote engagement and job satisfaction.

• Make adjustments to schedule and workflow to improve efficiency.

• Prepare for evolving pay-for-performance programs.

• Demonstrate the value of the group by setting expectations with key stakeholders, developing a practice score, and providing effective feedback to providers.
 

Dr. Villagra is a chief hospitalist in Batesville, Ark., and an editorial board member of The Hospitalist.

Presenters

Roberta Himebaugh MBA, SHM; John Nelson, MD, FACP, MHM; Jerome Siy, MD, SFHM

Session summary

Creating a “culture of ownership” by recruiting the right people, promoting physician leadership, and improving structural elements such as compensation model and schedule were topics discussed in this practice management precourse at HM17.

The presenters said leaders must reduce hierarchy and promote shared decision making among the group, while instilling a “thank you culture” that recognizes motivations such as autonomy, mastery, and purpose.

Key takeaways for HM

• Create a culture of ownership to promote engagement and job satisfaction.

• Make adjustments to schedule and workflow to improve efficiency.

• Prepare for evolving pay-for-performance programs.

• Demonstrate the value of the group by setting expectations with key stakeholders, developing a practice score, and providing effective feedback to providers.
 

Dr. Villagra is a chief hospitalist in Batesville, Ark., and an editorial board member of The Hospitalist.

Presenters

Roberta Himebaugh MBA, SHM; John Nelson, MD, FACP, MHM; Jerome Siy, MD, SFHM

Session summary

Creating a “culture of ownership” by recruiting the right people, promoting physician leadership, and improving structural elements such as compensation model and schedule were topics discussed in this practice management precourse at HM17.

The presenters said leaders must reduce hierarchy and promote shared decision making among the group, while instilling a “thank you culture” that recognizes motivations such as autonomy, mastery, and purpose.

Key takeaways for HM

• Create a culture of ownership to promote engagement and job satisfaction.

• Make adjustments to schedule and workflow to improve efficiency.

• Prepare for evolving pay-for-performance programs.

• Demonstrate the value of the group by setting expectations with key stakeholders, developing a practice score, and providing effective feedback to providers.
 

Dr. Villagra is a chief hospitalist in Batesville, Ark., and an editorial board member of The Hospitalist.

Within hospital medicine, there has been a recent increase in programs that provide virtual or telehealth hospitalists, primarily to hospitals that are small, remote, and/or understaffed. According to a 2013 Cisco health care customer experience report, the number of telehealth consumers will likely markedly increase to at least 7 million by 2018.¹

Since telehospitalist programs are still relatively new, there are many questions about why and how they exist and how they are (and can be) funded. Questions also remain about some limitations of telehospitalist programs for both the “givers” and the “receivers” of the services. I tackle some of these questions in this article.

What is a telehospitalist?

What are the drivers of telehospitalist programs?

One primary driver of telehealth (and specifically telehospitalist) programs is an ongoing shortage of hospitalists, especially in remote areas and critical access hospitals where coverage issues are especially prominent at night and/or on weekends. In many hospitals, there is also a growing unwillingness on the part of physicians to be routinely on call at night. Although working on call used to be on par with being a physician, many younger-generation physicians are less willing to blur “work and life.” This increases the need for dedicated night coverage in many hospitals.

Another driver for some programs (especially at tertiary care medical centers) is a desire to more thoroughly assess patients prior to transfer to their respective centers (the alternative being a phone conversation with the transferring center about the patient’s status). There is also a growing desire to keep patients local if possible, which is usually better for the patient and the family and can decrease the total cost of their care.

Another catalyst to telehospitalist program growth is the growing cultural comfort level with two-way video interactions, such as Skype and FaceTime. Since videoconferencing has permeated most of our professional and personal lives, telehealth seems familiar and comfortable for both providers and patients. In a recent consumer survey, three out of every four consumers responded that they are very comfortable communicating with providers via technology, as opposed to seeing them in person.¹

Another driver for some programs is financial. Depending on the way the program is structured, it can be not only financially feasible but financially beneficial, especially if the program can consolidate coverage across multiple sites (more on this later).

One other driver for some health care systems is the need to cover areas with on-site nurse practitioners and physician assistants. Using a telehospitalist makes it easier to get appropriate and required oversight for this coverage model across time and space.

What are the advantages of being a telehospitalist?

Some of the career advantages of being a telehospitalist include the shift flexibility and convenience. This work allows a hospitalist to serve a shift from anywhere in the world and from the convenience of their home. Some telehospitalists can easily work local night shifts when they live many time zones away (and therefore, don’t actually have to work a night shift). Many programs are designed to have a single hospitalist cover many hospitals over a wide geography, which would be logistically impossible to do in person. This is especially appealing for multihospital systems that cannot afford to have a hospitalist on site at each location.

The earning potential can also be appealing, depending on the number of shifts a hospitalist is willing to work.

What are the limitations of being a telehospitalist?

There are limits to what a telehospitalist can perform, many of which depend on the manner in which the program and the technology are arranged. Telehealth can vary from a cart-based videoconferencing system that is transported into a patient’s room to an independent robot that travels throughout sites. The primary limitation is the need to rely on someone in the patient’s room to act as virtual hands. This usually falls to the bedside nurse and requires a good working relationship and patience on their part. The bedside nurses have to “buy into” the program in advance and may need to have scripting for how to explain the process to the patients.

Another major challenge is interacting with different electronic health record systems. Becoming agile with a single EHR is challenging enough, but maneuvering several of them in a single shift can be extremely trying. Telehospitalists can also be challenged by technology glitches or failures that need troubleshooting both on their end and on-site. Although these problems are rare, there will always be a concern that the patient will not get his or her needs met if the technology fails.

How does the financing work?

Although this is a rapidly changing landscape, telehospitalists are not currently able to generate much revenue from professional billing. Unlike in-person visits, Medicare will not reimburse professional fees for telehospitalist visits. Although each payer is unique, most other (nonMedicare) payers are also not willing to reimburse for televisits. This may change in the future, however, as Medicare does pay for virtual specialty services such as telestroke. In addition, many states have enacted telemedicine parity laws, which require private payers to pay for all health care services equally, regardless of modality (audio, video, or in person).

For now, the financial case for employing telehospitalists for most programs has to be made using benfits other than the generation of professional fees. For telehospitalist programs that can cover several sites, the cost is substantially less than employing individual on-site hospitalists to do low-volume work. Telehospitalist programs are also, likely, less costly than is locum tenens staffing. For programs that evaluate the need for transfers, a case can be made that keeping a patient in a smaller, low-cost venue, rather than transferring them to a larger, higher-cost venue, can also reduce overall cost for a health care system.

What about licensing and credentialing?

Telehospitalists can be hindered by the need to have a license in several states and to be credentialed in several systems. This can be cumbersome, time-consuming, and expensive. To ease the multistate licensing burden, the Interstate Medical Licensure Compact has been established.² This is an accelerated licensure process for eligible physicians that improves license portability across states. There are currently 18 states that participate, and the number continues to increase.

For credentialing, most hospitals require initial credentialing and full recredentialing every 2 years. Maintaining credentials at several sites can be extremely time consuming. To ease this burden, some hospitals with telehealth programs have adopted “credentialing by proxy,” which means that one hospital will accept the credentialing process of another facility.

What next?

In summary, there has been and will likely continue to be explosive growth of telehospitalist programs and providers for all the reasons outlined above. Although some barriers to efficient and effective practice do exist, many of those barriers are being overcome quite rapidly. I expect this growth to continue for the betterment of hospitalists, our patients, and the systems in which we work. For a more in-depth look into telemedicine in hospital medicine, view a report created by a work group of SHM's Practice Management Committee.

Dr. Scheurer is a hospitalist and chief quality officer at the Medical University of South Carolina in Charleston. She is physician editor of The Hospitalist. Email her at [email protected].

References

1.Cisco. (2013 March 4). Cisco Study Reveals 74 Percent of Consumers Open to Virtual Doctor Visit. Cisco: The Network. Retrieved from https://newsroom.cisco.com/press-release-content?type=webcontent&articleId=1148539.

2. Interstate Medical Licensure Compact Commission. (2017). Interstate Medical Licensure Compact. Retrieved from http://www.licenseportability.org/index.html.

Within hospital medicine, there has been a recent increase in programs that provide virtual or telehealth hospitalists, primarily to hospitals that are small, remote, and/or understaffed. According to a 2013 Cisco health care customer experience report, the number of telehealth consumers will likely markedly increase to at least 7 million by 2018.¹

Since telehospitalist programs are still relatively new, there are many questions about why and how they exist and how they are (and can be) funded. Questions also remain about some limitations of telehospitalist programs for both the “givers” and the “receivers” of the services. I tackle some of these questions in this article.

What is a telehospitalist?

What are the drivers of telehospitalist programs?

One primary driver of telehealth (and specifically telehospitalist) programs is an ongoing shortage of hospitalists, especially in remote areas and critical access hospitals where coverage issues are especially prominent at night and/or on weekends. In many hospitals, there is also a growing unwillingness on the part of physicians to be routinely on call at night. Although working on call used to be on par with being a physician, many younger-generation physicians are less willing to blur “work and life.” This increases the need for dedicated night coverage in many hospitals.

Another driver for some programs (especially at tertiary care medical centers) is a desire to more thoroughly assess patients prior to transfer to their respective centers (the alternative being a phone conversation with the transferring center about the patient’s status). There is also a growing desire to keep patients local if possible, which is usually better for the patient and the family and can decrease the total cost of their care.

Another catalyst to telehospitalist program growth is the growing cultural comfort level with two-way video interactions, such as Skype and FaceTime. Since videoconferencing has permeated most of our professional and personal lives, telehealth seems familiar and comfortable for both providers and patients. In a recent consumer survey, three out of every four consumers responded that they are very comfortable communicating with providers via technology, as opposed to seeing them in person.¹

Another driver for some programs is financial. Depending on the way the program is structured, it can be not only financially feasible but financially beneficial, especially if the program can consolidate coverage across multiple sites (more on this later).

One other driver for some health care systems is the need to cover areas with on-site nurse practitioners and physician assistants. Using a telehospitalist makes it easier to get appropriate and required oversight for this coverage model across time and space.

What are the advantages of being a telehospitalist?

Some of the career advantages of being a telehospitalist include the shift flexibility and convenience. This work allows a hospitalist to serve a shift from anywhere in the world and from the convenience of their home. Some telehospitalists can easily work local night shifts when they live many time zones away (and therefore, don’t actually have to work a night shift). Many programs are designed to have a single hospitalist cover many hospitals over a wide geography, which would be logistically impossible to do in person. This is especially appealing for multihospital systems that cannot afford to have a hospitalist on site at each location.

The earning potential can also be appealing, depending on the number of shifts a hospitalist is willing to work.

What are the limitations of being a telehospitalist?

There are limits to what a telehospitalist can perform, many of which depend on the manner in which the program and the technology are arranged. Telehealth can vary from a cart-based videoconferencing system that is transported into a patient’s room to an independent robot that travels throughout sites. The primary limitation is the need to rely on someone in the patient’s room to act as virtual hands. This usually falls to the bedside nurse and requires a good working relationship and patience on their part. The bedside nurses have to “buy into” the program in advance and may need to have scripting for how to explain the process to the patients.

Another major challenge is interacting with different electronic health record systems. Becoming agile with a single EHR is challenging enough, but maneuvering several of them in a single shift can be extremely trying. Telehospitalists can also be challenged by technology glitches or failures that need troubleshooting both on their end and on-site. Although these problems are rare, there will always be a concern that the patient will not get his or her needs met if the technology fails.

How does the financing work?

Although this is a rapidly changing landscape, telehospitalists are not currently able to generate much revenue from professional billing. Unlike in-person visits, Medicare will not reimburse professional fees for telehospitalist visits. Although each payer is unique, most other (nonMedicare) payers are also not willing to reimburse for televisits. This may change in the future, however, as Medicare does pay for virtual specialty services such as telestroke. In addition, many states have enacted telemedicine parity laws, which require private payers to pay for all health care services equally, regardless of modality (audio, video, or in person).

For now, the financial case for employing telehospitalists for most programs has to be made using benfits other than the generation of professional fees. For telehospitalist programs that can cover several sites, the cost is substantially less than employing individual on-site hospitalists to do low-volume work. Telehospitalist programs are also, likely, less costly than is locum tenens staffing. For programs that evaluate the need for transfers, a case can be made that keeping a patient in a smaller, low-cost venue, rather than transferring them to a larger, higher-cost venue, can also reduce overall cost for a health care system.

What about licensing and credentialing?

Telehospitalists can be hindered by the need to have a license in several states and to be credentialed in several systems. This can be cumbersome, time-consuming, and expensive. To ease the multistate licensing burden, the Interstate Medical Licensure Compact has been established.² This is an accelerated licensure process for eligible physicians that improves license portability across states. There are currently 18 states that participate, and the number continues to increase.

For credentialing, most hospitals require initial credentialing and full recredentialing every 2 years. Maintaining credentials at several sites can be extremely time consuming. To ease this burden, some hospitals with telehealth programs have adopted “credentialing by proxy,” which means that one hospital will accept the credentialing process of another facility.

What next?

In summary, there has been and will likely continue to be explosive growth of telehospitalist programs and providers for all the reasons outlined above. Although some barriers to efficient and effective practice do exist, many of those barriers are being overcome quite rapidly. I expect this growth to continue for the betterment of hospitalists, our patients, and the systems in which we work. For a more in-depth look into telemedicine in hospital medicine, view a report created by a work group of SHM's Practice Management Committee.

Dr. Scheurer is a hospitalist and chief quality officer at the Medical University of South Carolina in Charleston. She is physician editor of The Hospitalist. Email her at [email protected].

References

1.Cisco. (2013 March 4). Cisco Study Reveals 74 Percent of Consumers Open to Virtual Doctor Visit. Cisco: The Network. Retrieved from https://newsroom.cisco.com/press-release-content?type=webcontent&articleId=1148539.

2. Interstate Medical Licensure Compact Commission. (2017). Interstate Medical Licensure Compact. Retrieved from http://www.licenseportability.org/index.html.

Within hospital medicine, there has been a recent increase in programs that provide virtual or telehealth hospitalists, primarily to hospitals that are small, remote, and/or understaffed. According to a 2013 Cisco health care customer experience report, the number of telehealth consumers will likely markedly increase to at least 7 million by 2018.¹

Since telehospitalist programs are still relatively new, there are many questions about why and how they exist and how they are (and can be) funded. Questions also remain about some limitations of telehospitalist programs for both the “givers” and the “receivers” of the services. I tackle some of these questions in this article.

What is a telehospitalist?

What are the drivers of telehospitalist programs?

One primary driver of telehealth (and specifically telehospitalist) programs is an ongoing shortage of hospitalists, especially in remote areas and critical access hospitals where coverage issues are especially prominent at night and/or on weekends. In many hospitals, there is also a growing unwillingness on the part of physicians to be routinely on call at night. Although working on call used to be on par with being a physician, many younger-generation physicians are less willing to blur “work and life.” This increases the need for dedicated night coverage in many hospitals.

Another driver for some programs (especially at tertiary care medical centers) is a desire to more thoroughly assess patients prior to transfer to their respective centers (the alternative being a phone conversation with the transferring center about the patient’s status). There is also a growing desire to keep patients local if possible, which is usually better for the patient and the family and can decrease the total cost of their care.

Another catalyst to telehospitalist program growth is the growing cultural comfort level with two-way video interactions, such as Skype and FaceTime. Since videoconferencing has permeated most of our professional and personal lives, telehealth seems familiar and comfortable for both providers and patients. In a recent consumer survey, three out of every four consumers responded that they are very comfortable communicating with providers via technology, as opposed to seeing them in person.¹

Another driver for some programs is financial. Depending on the way the program is structured, it can be not only financially feasible but financially beneficial, especially if the program can consolidate coverage across multiple sites (more on this later).

One other driver for some health care systems is the need to cover areas with on-site nurse practitioners and physician assistants. Using a telehospitalist makes it easier to get appropriate and required oversight for this coverage model across time and space.

What are the advantages of being a telehospitalist?

Some of the career advantages of being a telehospitalist include the shift flexibility and convenience. This work allows a hospitalist to serve a shift from anywhere in the world and from the convenience of their home. Some telehospitalists can easily work local night shifts when they live many time zones away (and therefore, don’t actually have to work a night shift). Many programs are designed to have a single hospitalist cover many hospitals over a wide geography, which would be logistically impossible to do in person. This is especially appealing for multihospital systems that cannot afford to have a hospitalist on site at each location.

The earning potential can also be appealing, depending on the number of shifts a hospitalist is willing to work.

What are the limitations of being a telehospitalist?

There are limits to what a telehospitalist can perform, many of which depend on the manner in which the program and the technology are arranged. Telehealth can vary from a cart-based videoconferencing system that is transported into a patient’s room to an independent robot that travels throughout sites. The primary limitation is the need to rely on someone in the patient’s room to act as virtual hands. This usually falls to the bedside nurse and requires a good working relationship and patience on their part. The bedside nurses have to “buy into” the program in advance and may need to have scripting for how to explain the process to the patients.

Another major challenge is interacting with different electronic health record systems. Becoming agile with a single EHR is challenging enough, but maneuvering several of them in a single shift can be extremely trying. Telehospitalists can also be challenged by technology glitches or failures that need troubleshooting both on their end and on-site. Although these problems are rare, there will always be a concern that the patient will not get his or her needs met if the technology fails.

How does the financing work?

Although this is a rapidly changing landscape, telehospitalists are not currently able to generate much revenue from professional billing. Unlike in-person visits, Medicare will not reimburse professional fees for telehospitalist visits. Although each payer is unique, most other (nonMedicare) payers are also not willing to reimburse for televisits. This may change in the future, however, as Medicare does pay for virtual specialty services such as telestroke. In addition, many states have enacted telemedicine parity laws, which require private payers to pay for all health care services equally, regardless of modality (audio, video, or in person).

For now, the financial case for employing telehospitalists for most programs has to be made using benfits other than the generation of professional fees. For telehospitalist programs that can cover several sites, the cost is substantially less than employing individual on-site hospitalists to do low-volume work. Telehospitalist programs are also, likely, less costly than is locum tenens staffing. For programs that evaluate the need for transfers, a case can be made that keeping a patient in a smaller, low-cost venue, rather than transferring them to a larger, higher-cost venue, can also reduce overall cost for a health care system.

What about licensing and credentialing?

Telehospitalists can be hindered by the need to have a license in several states and to be credentialed in several systems. This can be cumbersome, time-consuming, and expensive. To ease the multistate licensing burden, the Interstate Medical Licensure Compact has been established.² This is an accelerated licensure process for eligible physicians that improves license portability across states. There are currently 18 states that participate, and the number continues to increase.

For credentialing, most hospitals require initial credentialing and full recredentialing every 2 years. Maintaining credentials at several sites can be extremely time consuming. To ease this burden, some hospitals with telehealth programs have adopted “credentialing by proxy,” which means that one hospital will accept the credentialing process of another facility.

What next?

In summary, there has been and will likely continue to be explosive growth of telehospitalist programs and providers for all the reasons outlined above. Although some barriers to efficient and effective practice do exist, many of those barriers are being overcome quite rapidly. I expect this growth to continue for the betterment of hospitalists, our patients, and the systems in which we work. For a more in-depth look into telemedicine in hospital medicine, view a report created by a work group of SHM's Practice Management Committee.

Dr. Scheurer is a hospitalist and chief quality officer at the Medical University of South Carolina in Charleston. She is physician editor of The Hospitalist. Email her at [email protected].

References

1.Cisco. (2013 March 4). Cisco Study Reveals 74 Percent of Consumers Open to Virtual Doctor Visit. Cisco: The Network. Retrieved from https://newsroom.cisco.com/press-release-content?type=webcontent&articleId=1148539.

2. Interstate Medical Licensure Compact Commission. (2017). Interstate Medical Licensure Compact. Retrieved from http://www.licenseportability.org/index.html.

LAS VEGAS – Ronald Schaefer, MD, a hospitalist with Hawaii Pacific Health who also works on creating digital templates for his hospital, can’t input hemoglobin A1c levels from three different labs into his electronic medical records (EMR) system the same way.

Hospitalist George Dimitriou, MD, FHM, who splits his time at Allegheny Health Network in Pittsburgh between clinical work and medical informatics, worries there are so many fields in his EMR that physicians can get distracted.

Yevgeniy “Eugene” Gitelman, MD, a clinical informatics manager at the Perelman School of Medicine at University of Pennsylvania Health in Philadelphia, wonders how good any systems can be with the privacy concerns related to HIPAA.

This was the nexus of IT and HM17, a time when hospitalists said they are stymied and frustrated by continuing issues of interoperability, functionality, and access. The meeting highlighted new smartphone and tablet applications, as well as medical devices available to hospitalists, but tech-focused physicians say the biggest issue remains the day-to-day workings of EMR.

“If you build something really good, people will use it. If you build something that makes their documentation process a lot easier and a lot faster and a lot better, they’ll use it,” said Dr. Schaefer. “The tools aren’t there yet. I don’t think the technology is mature enough.”

If the tech hasn’t yet come of full age, the concerns surely have. SHM unveiled a white paper at HM17 that codified hospitalists’ worries about the current state of IT. The report, “Hospitalist Perspectives on Electronic Medical Records,” found that “a staggering” 85% of providers said they spend more time interacting with their inpatient EMR than their actual inpatients.

Rupesh Prasad, MD, MPH, SFHM, chair of SHM’s Health IT Committee, says the report is meant to foster discussion about the issues surrounding EMRs. The data points, generated from 462 respondents, are stark. Just 40% said they were happy with their EMR. Some 52% would change vendors if they could. One-quarter of respondents would revert to using paper if given the option.

“By sharing these results, we hope to raise awareness of the unacceptable performance of existing systems,” the report states. “This continues to contribute to our slower than desired improvement in quality and safety, as well as increasing provider frustration. We strongly believe that we need a renewed focus on initial goals of technology adoption in health care.”

Dr. Prasad said that he hopes hospitalists heed that call to action and use the report in discussions with various stakeholders, including vendors, public policy officials, and their own bosses.

“We want to give hospitalists ammunition to go back to their systems and talk to their administrators to see if they can influence [it],” he said.

Dr. Prasad is pleased that the society is sensitive to the issues surrounding technology. He encourages hospitalists to actively participate in HMX, SHM’s online portal to discuss health IT issues and crowd-source potential solutions. Patrick Vulgamore, MPH, SHM’s director of governance and practice management, said the society is formulating a potential special-interest working group to further seek to solve problems.

Hospitalists were also urged to apply for American Board of Medical Specialties (ABMS) certification in clinical informatics. Physicians can grandfather into eligibility via the “practice pathway” through the end of the year, if they’ve been working in informatics professionally for at least 25% of their time during any three of the previous five years. Next year, only graduates of two-year Accreditation Council for Graduate Medical Education–accredited fellowships will be board eligible.

“As end users of technology, we understand the problems better than anybody else,” Dr. Prasad said. “Obviously, the next step would be try to solve the problems. And what better way then to get involved and become experts in what you do?”

While much of the meeting’s tech talk was frustration, both former National Coordinator for Health IT Karen DeSalvo, MD, MPH, MSc, and HM Dean Robert Wachter, MD, MHM, forecast a future when artificial intelligence and intuitive computers work alongside physicians. Imagine the user-friendliness of Apple’s Siri or Google’s Alexa married to the existing functionalities provided by firms such as Epic or Cerner.

But that’s years away, and hospitalists like Dr. Dimitriou want help now.

“The speed of medicine, the speed of what’s happening in real time, is still faster than what our electronic tools seem to be able to keep up with,” he said. “There are encouraging signs that we’ve definitely moved in the right direction. We’ve come a long way ... but again, the speed at which things are moving? We aren’t keeping up. We’ve got to do more.”

LAS VEGAS – Ronald Schaefer, MD, a hospitalist with Hawaii Pacific Health who also works on creating digital templates for his hospital, can’t input hemoglobin A1c levels from three different labs into his electronic medical records (EMR) system the same way.

Hospitalist George Dimitriou, MD, FHM, who splits his time at Allegheny Health Network in Pittsburgh between clinical work and medical informatics, worries there are so many fields in his EMR that physicians can get distracted.

Yevgeniy “Eugene” Gitelman, MD, a clinical informatics manager at the Perelman School of Medicine at University of Pennsylvania Health in Philadelphia, wonders how good any systems can be with the privacy concerns related to HIPAA.

This was the nexus of IT and HM17, a time when hospitalists said they are stymied and frustrated by continuing issues of interoperability, functionality, and access. The meeting highlighted new smartphone and tablet applications, as well as medical devices available to hospitalists, but tech-focused physicians say the biggest issue remains the day-to-day workings of EMR.

“If you build something really good, people will use it. If you build something that makes their documentation process a lot easier and a lot faster and a lot better, they’ll use it,” said Dr. Schaefer. “The tools aren’t there yet. I don’t think the technology is mature enough.”

If the tech hasn’t yet come of full age, the concerns surely have. SHM unveiled a white paper at HM17 that codified hospitalists’ worries about the current state of IT. The report, “Hospitalist Perspectives on Electronic Medical Records,” found that “a staggering” 85% of providers said they spend more time interacting with their inpatient EMR than their actual inpatients.

Rupesh Prasad, MD, MPH, SFHM, chair of SHM’s Health IT Committee, says the report is meant to foster discussion about the issues surrounding EMRs. The data points, generated from 462 respondents, are stark. Just 40% said they were happy with their EMR. Some 52% would change vendors if they could. One-quarter of respondents would revert to using paper if given the option.

“By sharing these results, we hope to raise awareness of the unacceptable performance of existing systems,” the report states. “This continues to contribute to our slower than desired improvement in quality and safety, as well as increasing provider frustration. We strongly believe that we need a renewed focus on initial goals of technology adoption in health care.”

Dr. Prasad said that he hopes hospitalists heed that call to action and use the report in discussions with various stakeholders, including vendors, public policy officials, and their own bosses.

“We want to give hospitalists ammunition to go back to their systems and talk to their administrators to see if they can influence [it],” he said.

Dr. Prasad is pleased that the society is sensitive to the issues surrounding technology. He encourages hospitalists to actively participate in HMX, SHM’s online portal to discuss health IT issues and crowd-source potential solutions. Patrick Vulgamore, MPH, SHM’s director of governance and practice management, said the society is formulating a potential special-interest working group to further seek to solve problems.

Hospitalists were also urged to apply for American Board of Medical Specialties (ABMS) certification in clinical informatics. Physicians can grandfather into eligibility via the “practice pathway” through the end of the year, if they’ve been working in informatics professionally for at least 25% of their time during any three of the previous five years. Next year, only graduates of two-year Accreditation Council for Graduate Medical Education–accredited fellowships will be board eligible.

“As end users of technology, we understand the problems better than anybody else,” Dr. Prasad said. “Obviously, the next step would be try to solve the problems. And what better way then to get involved and become experts in what you do?”

While much of the meeting’s tech talk was frustration, both former National Coordinator for Health IT Karen DeSalvo, MD, MPH, MSc, and HM Dean Robert Wachter, MD, MHM, forecast a future when artificial intelligence and intuitive computers work alongside physicians. Imagine the user-friendliness of Apple’s Siri or Google’s Alexa married to the existing functionalities provided by firms such as Epic or Cerner.

But that’s years away, and hospitalists like Dr. Dimitriou want help now.

“The speed of medicine, the speed of what’s happening in real time, is still faster than what our electronic tools seem to be able to keep up with,” he said. “There are encouraging signs that we’ve definitely moved in the right direction. We’ve come a long way ... but again, the speed at which things are moving? We aren’t keeping up. We’ve got to do more.”

LAS VEGAS – Ronald Schaefer, MD, a hospitalist with Hawaii Pacific Health who also works on creating digital templates for his hospital, can’t input hemoglobin A1c levels from three different labs into his electronic medical records (EMR) system the same way.

Hospitalist George Dimitriou, MD, FHM, who splits his time at Allegheny Health Network in Pittsburgh between clinical work and medical informatics, worries there are so many fields in his EMR that physicians can get distracted.

Yevgeniy “Eugene” Gitelman, MD, a clinical informatics manager at the Perelman School of Medicine at University of Pennsylvania Health in Philadelphia, wonders how good any systems can be with the privacy concerns related to HIPAA.

This was the nexus of IT and HM17, a time when hospitalists said they are stymied and frustrated by continuing issues of interoperability, functionality, and access. The meeting highlighted new smartphone and tablet applications, as well as medical devices available to hospitalists, but tech-focused physicians say the biggest issue remains the day-to-day workings of EMR.

“If you build something really good, people will use it. If you build something that makes their documentation process a lot easier and a lot faster and a lot better, they’ll use it,” said Dr. Schaefer. “The tools aren’t there yet. I don’t think the technology is mature enough.”

If the tech hasn’t yet come of full age, the concerns surely have. SHM unveiled a white paper at HM17 that codified hospitalists’ worries about the current state of IT. The report, “Hospitalist Perspectives on Electronic Medical Records,” found that “a staggering” 85% of providers said they spend more time interacting with their inpatient EMR than their actual inpatients.

Rupesh Prasad, MD, MPH, SFHM, chair of SHM’s Health IT Committee, says the report is meant to foster discussion about the issues surrounding EMRs. The data points, generated from 462 respondents, are stark. Just 40% said they were happy with their EMR. Some 52% would change vendors if they could. One-quarter of respondents would revert to using paper if given the option.

“By sharing these results, we hope to raise awareness of the unacceptable performance of existing systems,” the report states. “This continues to contribute to our slower than desired improvement in quality and safety, as well as increasing provider frustration. We strongly believe that we need a renewed focus on initial goals of technology adoption in health care.”

Dr. Prasad said that he hopes hospitalists heed that call to action and use the report in discussions with various stakeholders, including vendors, public policy officials, and their own bosses.

“We want to give hospitalists ammunition to go back to their systems and talk to their administrators to see if they can influence [it],” he said.

Dr. Prasad is pleased that the society is sensitive to the issues surrounding technology. He encourages hospitalists to actively participate in HMX, SHM’s online portal to discuss health IT issues and crowd-source potential solutions. Patrick Vulgamore, MPH, SHM’s director of governance and practice management, said the society is formulating a potential special-interest working group to further seek to solve problems.

Hospitalists were also urged to apply for American Board of Medical Specialties (ABMS) certification in clinical informatics. Physicians can grandfather into eligibility via the “practice pathway” through the end of the year, if they’ve been working in informatics professionally for at least 25% of their time during any three of the previous five years. Next year, only graduates of two-year Accreditation Council for Graduate Medical Education–accredited fellowships will be board eligible.

“As end users of technology, we understand the problems better than anybody else,” Dr. Prasad said. “Obviously, the next step would be try to solve the problems. And what better way then to get involved and become experts in what you do?”

While much of the meeting’s tech talk was frustration, both former National Coordinator for Health IT Karen DeSalvo, MD, MPH, MSc, and HM Dean Robert Wachter, MD, MHM, forecast a future when artificial intelligence and intuitive computers work alongside physicians. Imagine the user-friendliness of Apple’s Siri or Google’s Alexa married to the existing functionalities provided by firms such as Epic or Cerner.

But that’s years away, and hospitalists like Dr. Dimitriou want help now.

“The speed of medicine, the speed of what’s happening in real time, is still faster than what our electronic tools seem to be able to keep up with,” he said. “There are encouraging signs that we’ve definitely moved in the right direction. We’ve come a long way ... but again, the speed at which things are moving? We aren’t keeping up. We’ve got to do more.”

“We heard you and will continue listening.”

Those were the words that Andrew Slavitt, then-acting administrator of the Centers for Medicare and Medicaid Services, used in a blog post on Oct. 14, 2016.¹ (Slavitt no longer maintains that title since the new federal administration took office on Jan. 20, 2017.)

• Heart failure: ACE inhibitor/angiotensin receptor blocker for left ventricular systolic dysfunction
• Heart failure: Beta-blocker for LVSD
• Stroke: DC on antithrombotic therapy
• Advance Care Plan
• Prevention of catheter-related bloodstream infection: CVC (central venous catheter) Insertion Protocol
• Documentation of current medications
• Appropriate treatment of methicillin-susceptible Staphylococcus aureus bacteremia

“Of the seven available, not all will be reportable because hospitalist practices have a lot of variation, both in their practices and in their patient mix,” Dr. Greeno said. “Most hospitalists will only be able to successfully report on four measures, but we are seeking clarification on what they call a validation test and how that will function.”

In the final rule, CMS said that it will perform that “validation test” to evaluate physicians who cannot report the minimum number of measures to ensure they are not penalized for it.

In addition to Quality, the other reporting categories under the umbrella of MIPS include Advancing Care Information, Cost, and Improvement Activities. For 2017, CMS gave physicians the option to “pick your pace.”⁴ As long as doctors report just one quality measure, one improvement activity, or the required advancing care information measures (most hospitalists will be exempt from this category), they will avoid a penalty.^1,5 Cost will not be included for 2017, the first performance year for MIPS. This year’s reporting will be used to determine payments in 2019, though all physicians will see a 0.5 percent fee increase between now and 2019.

Additionally, just for this year, physicians can choose to report for either a full or partial year (90 days). They will not be subject to the penalty and may be eligible for a positive payment adjustment. However, those who submit nothing are subject to a negative 4% adjustment penalty.

Alternative payment models

While MIPS is the pathway most physicians expect to find themselves on in 2017, the other option is the Alternative Payment Models (APMs) pathway, which moves away from the pay-for-performance, semi-fee-for-service structure of MIPS and, instead, follows the rules established by the models themselves, which include select qualified accountable care organizations and patient-centered medical homes.⁷ Participating physicians are eligible for a 5% incentive payment in 2019. Many health experts say that it’s clear CMS would like to ultimately steer most physicians from MIPS to APMs.

However, very few – if any – hospitalists will find themselves on an APM track. This is, in part, because models considered APMs require the use of Certified Electronic Health Record Technology (CEHRT) and must present “more than nominal risk” to providers.

“Right now, the only alternative payment model where hospitalists can directly take risk is BPCI [Bundled Payments for Care Improvement], but it does not qualify as an APM,” Dr. Greeno said.

It will also be difficult because CMS requires patient and payer thresholds under APMs that hospitalists simply are not poised to meet. In 2019, this means 25% of Medicare payments must come from an Advanced APM in 2017, or 20% of providers’ Medicare patients must be seen through an Advanced APM.⁸

Advanced APMs are those with which, at least in 2019 and 2020, providers face the risk of losing the lesser of 8% of their revenue or repaying CMS up to 3% of their total Medicare expenditures, if expenditures are higher than expected.^8,9

“It is going to be very difficult for hospitalists to qualify for APMs because we’re not in the position to hit the thresholds,” said Dr. Dutta.

However, SHM has urged CMS to consider other BPCI models for qualification as APMs, and Dr. Greeno said that CMS is currently looking into developing bundles that may be appropriate for hospitalists. For instance, Dr. Dutta said, “What we do often in medicine is chronic disease management, and the time is coming to get into chronic disease bundles, such as [those for] management of heart failure or kidney disease.”

In December, SHM submitted a letter to PTAC (the Physician-Focused Payment Model Technical Advisory Committee) to show support for a model created by the American College of Surgeons, called ACS-Brandeis, which they hope will be considered as an Advanced Alternative Payment Model. In the proposal that ACS submitted, the authors noted, “The core model is focused on procedure episodes but can easily be expanded to include acute and chronic conditions.”

The SHM notes in its letter that, while the initial proposal is intended for surgical patients, the term-based nature of surgical care provides a platform for expanding the model more broadly to hospitalists and other specialties.
 

Some skepticism remains

Even if BPCI or other models are accepted as APMs, hospitalists may still be challenged to meet the required payment or patient thresholds, Dr. Greeno said. Additionally, Dr. Berenson is skeptical of bundled payments, particularly for hospitalists.

“Are hospitalists the right organization to be held accountable for the total cost of care for 90 days of spending, any more than oncologists under Oncology Care Models should be accountable for the total cost of cancer where some patients are getting palliative care and that’s not a driver of healthcare costs?” he asked. “I could see that as problematic for hospitalists.”

While he believes there are many positive aspects to MACRA, in general, Dr. Berenson considers it bad policy. While he does not want to see the Sustainable Growth Rate return, he believes many physicians would have seen reimbursement reductions sooner without MACRA (under the prior quality measurement programs) and that the law provides some perverse incentives.

For one thing, the Quality Payment Program is budget neutral, which means that, for every winner, there is also a loser. Before CMS expanded exemptions for smaller and rural practices, Dr. Berenson said that some larger groups – which are often better equipped to pursue APMs – were planning to stay in MIPS because they figured they were more likely to be the winners when compared with smaller physician practices. And MIPS comes with a 9% payment boost by 2022 (or 9% penalty), plus the possibility of an extra bonus for top performers, compared with the 5% incentive of APMs that same year.⁷

“There were literally groups saying they were going to go for the MIPS pathway because it’s a bigger upside,” Dr. Berenson said. “When CMS said it was exempting those [smaller, rural] groups, the [larger] groups turned around and said [that the smaller, rural groups] were the downside. ... That kind of game theory is bad public policy.”

Dr. Berenson also believes MACRA will be detrimental to some small and independent practices. Others may decide not to bill Medicare altogether, though that is not an option open to most hospitalists who care to stay in practice. It could, however, drive more hospitalists to consolidate or to become employees of their hospitals.¹⁰

“I don’t think there is any doubt this is going to drive consolidation,” Dr. Greeno said, citing numbers released by CMS that show an inverse relationship between practice size and the negative impact of MACRA.¹¹ “I think it’s going to be pretty tough unless you’re big enough to commit the resources you need to do it right.”

At TeamHealth, where Dr. Greeno is senior advisor of medical affairs, he said that they have invested in information technology compliance, developed systems and trained providers to ensure the creation of favorable metrics for the organization’ and built the infrastructure to gather, report, and validate data. These are steps that may be out of reach for most smaller practices.

As Dr. Greeno said, no one expected this to be easy. “You’re trying to get doctors to change the way they practice. Anybody who has ever worked with doctors knows that’s not an easy things to do,” he said. “CMS is changing things to create enough incentive so the pain of not changing becomes greater than the pain of changing.”

While hospitalists may bear more of the pressure than other physician specialties, by virtue of their role in improving the quality of care in hospitals, they were born from reform efforts of the past, Dr. Greeno adds.

“If there had never been an attempt to change the way that physicians were paid, hospitalists wouldn’t exist,” he said. “We were created by physician groups who took capitated payments from HMOs, who had to find more efficient ways to treat patients in the hospital or go out of business.”

“Hospitalists are a delivery system reform and people look to us to lead. We can create a tremendous amount of value for whomever we work for,” Dr. Greeno said.

This is also why SHM continues to work with CMS to advocate for all its members. Dr. Greeno is in Washington at least once a month, participating in critical meetings and helping to guide decisions.

“The Public Policy Committee has to get into the weeds and get involved in advocating for measures that truly get at the work we do and push back on metrics and categories that do not relate to the care we are delivering for our patients,” said Dr. Dutta. “The group worked hard to push back on having to comply with Meaningful Use standards for hospitalists, and now we’re exempt from that category. CMS does listen. It sometimes just takes a while.”
 

References

1. Slavitt A. (2016 Oct 14). A letter from CMS to Medicare clinicians in the Quality Payment Program: We heard you and will continue listening. The CMS Blog (archived). Retrieved from http://wayback.archive-it.org/2744/20161109123921/https://blog.cms.gov/2016/10/14/a-letter-from-cms-to-medicare-clinicians-in-the-quality-payment-program/.

2. Department of Health & Human Services and Centers for Medicare & Medicaid Services. (2016 Oct 14). Quality Payment Program executive summary. Retrieved from https://qpp.cms.gov/docs/QPP_Executive_Summary_of_Final_Rule.pdf.

3. American Medical Association. (2016 Oct 19). Medicare Access and CHIP Reauthorization Act (MACRA) Quality Payment Program final rule AMA summary. Retrieved from https://www.ama-assn.org/sites/default/files/media-browser/public/physicians/macra/macra-qpp-summary.pdf.

4. Slavitt A. (2016 Sept 8). Plans for the Quality Payment Program in 2017: Pick your pace. The CMS Blog (archived). Retrieved from http://wayback.archive-it.org/2744/20161109123909/https://blog.cms.gov/2016/09/08/qualitypaymentprogram-pickyourpace/.

5. The Society of Hospital Medicine. Medicare physician payments are changing. Retrieved from http://www.macraforhm.org/.

6. Department of Health & Human Services and Centers for Medicare & Medicaid Services. (2016 Oct 14). Quality Payment Program fact sheet. Retrieved from https://qpp.cms.gov/docs/QPP_Small_Practice.pdf.

7. The Society of Hospital Medicine. (2017). MACRA and the Quality Payment Program. Retrieved from http://www.macraforhm.org/MACRA_FAQ_m1_final.pdf.

8. Department of Health & Human Services and Centers for Medicare & Medicaid Services. Quality Payment Program: Modernizing Medicare to provide better care and smarter spending for a healthier America. Retrieved from https://qpp.cms.gov/.

9. Wynne B. (2016 Oct 17). MACRA Final Rule: CMS strikes a balance; will docs hang on? Retrieved from http://healthaffairs.org/blog/2016/10/17/macra-final-rule-cms-strikes-a-balance-will-docs-hang-on/.

10. Quinn R. (2015 Aug). TeamHealth-IPC Deal Latest in consolidation trend. The Hospitalist. 2015(8). Retrieved from http://www.the-hospitalist.org/hospitalist/article/122210/teamhealth-ipc-deal-latest-consolidation-trend

11. Barkholz D. (2016 Jun 30). Potential MACRA byproduct: physician consolidation. Retrieved from http://www.modernhealthcare.com/article/20160630/NEWS/160639995.

“We heard you and will continue listening.”

Those were the words that Andrew Slavitt, then-acting administrator of the Centers for Medicare and Medicaid Services, used in a blog post on Oct. 14, 2016.¹ (Slavitt no longer maintains that title since the new federal administration took office on Jan. 20, 2017.)

• Heart failure: ACE inhibitor/angiotensin receptor blocker for left ventricular systolic dysfunction
• Heart failure: Beta-blocker for LVSD
• Stroke: DC on antithrombotic therapy
• Advance Care Plan
• Prevention of catheter-related bloodstream infection: CVC (central venous catheter) Insertion Protocol
• Documentation of current medications
• Appropriate treatment of methicillin-susceptible Staphylococcus aureus bacteremia

“Of the seven available, not all will be reportable because hospitalist practices have a lot of variation, both in their practices and in their patient mix,” Dr. Greeno said. “Most hospitalists will only be able to successfully report on four measures, but we are seeking clarification on what they call a validation test and how that will function.”

In the final rule, CMS said that it will perform that “validation test” to evaluate physicians who cannot report the minimum number of measures to ensure they are not penalized for it.

In addition to Quality, the other reporting categories under the umbrella of MIPS include Advancing Care Information, Cost, and Improvement Activities. For 2017, CMS gave physicians the option to “pick your pace.”⁴ As long as doctors report just one quality measure, one improvement activity, or the required advancing care information measures (most hospitalists will be exempt from this category), they will avoid a penalty.^1,5 Cost will not be included for 2017, the first performance year for MIPS. This year’s reporting will be used to determine payments in 2019, though all physicians will see a 0.5 percent fee increase between now and 2019.

Additionally, just for this year, physicians can choose to report for either a full or partial year (90 days). They will not be subject to the penalty and may be eligible for a positive payment adjustment. However, those who submit nothing are subject to a negative 4% adjustment penalty.

Alternative payment models

While MIPS is the pathway most physicians expect to find themselves on in 2017, the other option is the Alternative Payment Models (APMs) pathway, which moves away from the pay-for-performance, semi-fee-for-service structure of MIPS and, instead, follows the rules established by the models themselves, which include select qualified accountable care organizations and patient-centered medical homes.⁷ Participating physicians are eligible for a 5% incentive payment in 2019. Many health experts say that it’s clear CMS would like to ultimately steer most physicians from MIPS to APMs.

However, very few – if any – hospitalists will find themselves on an APM track. This is, in part, because models considered APMs require the use of Certified Electronic Health Record Technology (CEHRT) and must present “more than nominal risk” to providers.

“Right now, the only alternative payment model where hospitalists can directly take risk is BPCI [Bundled Payments for Care Improvement], but it does not qualify as an APM,” Dr. Greeno said.

It will also be difficult because CMS requires patient and payer thresholds under APMs that hospitalists simply are not poised to meet. In 2019, this means 25% of Medicare payments must come from an Advanced APM in 2017, or 20% of providers’ Medicare patients must be seen through an Advanced APM.⁸

Advanced APMs are those with which, at least in 2019 and 2020, providers face the risk of losing the lesser of 8% of their revenue or repaying CMS up to 3% of their total Medicare expenditures, if expenditures are higher than expected.^8,9

“It is going to be very difficult for hospitalists to qualify for APMs because we’re not in the position to hit the thresholds,” said Dr. Dutta.

However, SHM has urged CMS to consider other BPCI models for qualification as APMs, and Dr. Greeno said that CMS is currently looking into developing bundles that may be appropriate for hospitalists. For instance, Dr. Dutta said, “What we do often in medicine is chronic disease management, and the time is coming to get into chronic disease bundles, such as [those for] management of heart failure or kidney disease.”

In December, SHM submitted a letter to PTAC (the Physician-Focused Payment Model Technical Advisory Committee) to show support for a model created by the American College of Surgeons, called ACS-Brandeis, which they hope will be considered as an Advanced Alternative Payment Model. In the proposal that ACS submitted, the authors noted, “The core model is focused on procedure episodes but can easily be expanded to include acute and chronic conditions.”

The SHM notes in its letter that, while the initial proposal is intended for surgical patients, the term-based nature of surgical care provides a platform for expanding the model more broadly to hospitalists and other specialties.
 

Some skepticism remains

Even if BPCI or other models are accepted as APMs, hospitalists may still be challenged to meet the required payment or patient thresholds, Dr. Greeno said. Additionally, Dr. Berenson is skeptical of bundled payments, particularly for hospitalists.

“Are hospitalists the right organization to be held accountable for the total cost of care for 90 days of spending, any more than oncologists under Oncology Care Models should be accountable for the total cost of cancer where some patients are getting palliative care and that’s not a driver of healthcare costs?” he asked. “I could see that as problematic for hospitalists.”

While he believes there are many positive aspects to MACRA, in general, Dr. Berenson considers it bad policy. While he does not want to see the Sustainable Growth Rate return, he believes many physicians would have seen reimbursement reductions sooner without MACRA (under the prior quality measurement programs) and that the law provides some perverse incentives.

For one thing, the Quality Payment Program is budget neutral, which means that, for every winner, there is also a loser. Before CMS expanded exemptions for smaller and rural practices, Dr. Berenson said that some larger groups – which are often better equipped to pursue APMs – were planning to stay in MIPS because they figured they were more likely to be the winners when compared with smaller physician practices. And MIPS comes with a 9% payment boost by 2022 (or 9% penalty), plus the possibility of an extra bonus for top performers, compared with the 5% incentive of APMs that same year.⁷

“There were literally groups saying they were going to go for the MIPS pathway because it’s a bigger upside,” Dr. Berenson said. “When CMS said it was exempting those [smaller, rural] groups, the [larger] groups turned around and said [that the smaller, rural groups] were the downside. ... That kind of game theory is bad public policy.”

Dr. Berenson also believes MACRA will be detrimental to some small and independent practices. Others may decide not to bill Medicare altogether, though that is not an option open to most hospitalists who care to stay in practice. It could, however, drive more hospitalists to consolidate or to become employees of their hospitals.¹⁰

“I don’t think there is any doubt this is going to drive consolidation,” Dr. Greeno said, citing numbers released by CMS that show an inverse relationship between practice size and the negative impact of MACRA.¹¹ “I think it’s going to be pretty tough unless you’re big enough to commit the resources you need to do it right.”

At TeamHealth, where Dr. Greeno is senior advisor of medical affairs, he said that they have invested in information technology compliance, developed systems and trained providers to ensure the creation of favorable metrics for the organization’ and built the infrastructure to gather, report, and validate data. These are steps that may be out of reach for most smaller practices.

As Dr. Greeno said, no one expected this to be easy. “You’re trying to get doctors to change the way they practice. Anybody who has ever worked with doctors knows that’s not an easy things to do,” he said. “CMS is changing things to create enough incentive so the pain of not changing becomes greater than the pain of changing.”

While hospitalists may bear more of the pressure than other physician specialties, by virtue of their role in improving the quality of care in hospitals, they were born from reform efforts of the past, Dr. Greeno adds.

“If there had never been an attempt to change the way that physicians were paid, hospitalists wouldn’t exist,” he said. “We were created by physician groups who took capitated payments from HMOs, who had to find more efficient ways to treat patients in the hospital or go out of business.”

“Hospitalists are a delivery system reform and people look to us to lead. We can create a tremendous amount of value for whomever we work for,” Dr. Greeno said.

This is also why SHM continues to work with CMS to advocate for all its members. Dr. Greeno is in Washington at least once a month, participating in critical meetings and helping to guide decisions.

“The Public Policy Committee has to get into the weeds and get involved in advocating for measures that truly get at the work we do and push back on metrics and categories that do not relate to the care we are delivering for our patients,” said Dr. Dutta. “The group worked hard to push back on having to comply with Meaningful Use standards for hospitalists, and now we’re exempt from that category. CMS does listen. It sometimes just takes a while.”
 

References

1. Slavitt A. (2016 Oct 14). A letter from CMS to Medicare clinicians in the Quality Payment Program: We heard you and will continue listening. The CMS Blog (archived). Retrieved from http://wayback.archive-it.org/2744/20161109123921/https://blog.cms.gov/2016/10/14/a-letter-from-cms-to-medicare-clinicians-in-the-quality-payment-program/.

2. Department of Health & Human Services and Centers for Medicare & Medicaid Services. (2016 Oct 14). Quality Payment Program executive summary. Retrieved from https://qpp.cms.gov/docs/QPP_Executive_Summary_of_Final_Rule.pdf.

3. American Medical Association. (2016 Oct 19). Medicare Access and CHIP Reauthorization Act (MACRA) Quality Payment Program final rule AMA summary. Retrieved from https://www.ama-assn.org/sites/default/files/media-browser/public/physicians/macra/macra-qpp-summary.pdf.

4. Slavitt A. (2016 Sept 8). Plans for the Quality Payment Program in 2017: Pick your pace. The CMS Blog (archived). Retrieved from http://wayback.archive-it.org/2744/20161109123909/https://blog.cms.gov/2016/09/08/qualitypaymentprogram-pickyourpace/.

5. The Society of Hospital Medicine. Medicare physician payments are changing. Retrieved from http://www.macraforhm.org/.

6. Department of Health & Human Services and Centers for Medicare & Medicaid Services. (2016 Oct 14). Quality Payment Program fact sheet. Retrieved from https://qpp.cms.gov/docs/QPP_Small_Practice.pdf.

7. The Society of Hospital Medicine. (2017). MACRA and the Quality Payment Program. Retrieved from http://www.macraforhm.org/MACRA_FAQ_m1_final.pdf.

8. Department of Health & Human Services and Centers for Medicare & Medicaid Services. Quality Payment Program: Modernizing Medicare to provide better care and smarter spending for a healthier America. Retrieved from https://qpp.cms.gov/.

9. Wynne B. (2016 Oct 17). MACRA Final Rule: CMS strikes a balance; will docs hang on? Retrieved from http://healthaffairs.org/blog/2016/10/17/macra-final-rule-cms-strikes-a-balance-will-docs-hang-on/.

10. Quinn R. (2015 Aug). TeamHealth-IPC Deal Latest in consolidation trend. The Hospitalist. 2015(8). Retrieved from http://www.the-hospitalist.org/hospitalist/article/122210/teamhealth-ipc-deal-latest-consolidation-trend

11. Barkholz D. (2016 Jun 30). Potential MACRA byproduct: physician consolidation. Retrieved from http://www.modernhealthcare.com/article/20160630/NEWS/160639995.

“We heard you and will continue listening.”

Those were the words that Andrew Slavitt, then-acting administrator of the Centers for Medicare and Medicaid Services, used in a blog post on Oct. 14, 2016.¹ (Slavitt no longer maintains that title since the new federal administration took office on Jan. 20, 2017.)

• Heart failure: ACE inhibitor/angiotensin receptor blocker for left ventricular systolic dysfunction
• Heart failure: Beta-blocker for LVSD
• Stroke: DC on antithrombotic therapy
• Advance Care Plan
• Prevention of catheter-related bloodstream infection: CVC (central venous catheter) Insertion Protocol
• Documentation of current medications
• Appropriate treatment of methicillin-susceptible Staphylococcus aureus bacteremia

“Of the seven available, not all will be reportable because hospitalist practices have a lot of variation, both in their practices and in their patient mix,” Dr. Greeno said. “Most hospitalists will only be able to successfully report on four measures, but we are seeking clarification on what they call a validation test and how that will function.”

In the final rule, CMS said that it will perform that “validation test” to evaluate physicians who cannot report the minimum number of measures to ensure they are not penalized for it.

In addition to Quality, the other reporting categories under the umbrella of MIPS include Advancing Care Information, Cost, and Improvement Activities. For 2017, CMS gave physicians the option to “pick your pace.”⁴ As long as doctors report just one quality measure, one improvement activity, or the required advancing care information measures (most hospitalists will be exempt from this category), they will avoid a penalty.^1,5 Cost will not be included for 2017, the first performance year for MIPS. This year’s reporting will be used to determine payments in 2019, though all physicians will see a 0.5 percent fee increase between now and 2019.

Additionally, just for this year, physicians can choose to report for either a full or partial year (90 days). They will not be subject to the penalty and may be eligible for a positive payment adjustment. However, those who submit nothing are subject to a negative 4% adjustment penalty.

Alternative payment models

While MIPS is the pathway most physicians expect to find themselves on in 2017, the other option is the Alternative Payment Models (APMs) pathway, which moves away from the pay-for-performance, semi-fee-for-service structure of MIPS and, instead, follows the rules established by the models themselves, which include select qualified accountable care organizations and patient-centered medical homes.⁷ Participating physicians are eligible for a 5% incentive payment in 2019. Many health experts say that it’s clear CMS would like to ultimately steer most physicians from MIPS to APMs.

However, very few – if any – hospitalists will find themselves on an APM track. This is, in part, because models considered APMs require the use of Certified Electronic Health Record Technology (CEHRT) and must present “more than nominal risk” to providers.

“Right now, the only alternative payment model where hospitalists can directly take risk is BPCI [Bundled Payments for Care Improvement], but it does not qualify as an APM,” Dr. Greeno said.

It will also be difficult because CMS requires patient and payer thresholds under APMs that hospitalists simply are not poised to meet. In 2019, this means 25% of Medicare payments must come from an Advanced APM in 2017, or 20% of providers’ Medicare patients must be seen through an Advanced APM.⁸

Advanced APMs are those with which, at least in 2019 and 2020, providers face the risk of losing the lesser of 8% of their revenue or repaying CMS up to 3% of their total Medicare expenditures, if expenditures are higher than expected.^8,9

“It is going to be very difficult for hospitalists to qualify for APMs because we’re not in the position to hit the thresholds,” said Dr. Dutta.

However, SHM has urged CMS to consider other BPCI models for qualification as APMs, and Dr. Greeno said that CMS is currently looking into developing bundles that may be appropriate for hospitalists. For instance, Dr. Dutta said, “What we do often in medicine is chronic disease management, and the time is coming to get into chronic disease bundles, such as [those for] management of heart failure or kidney disease.”

In December, SHM submitted a letter to PTAC (the Physician-Focused Payment Model Technical Advisory Committee) to show support for a model created by the American College of Surgeons, called ACS-Brandeis, which they hope will be considered as an Advanced Alternative Payment Model. In the proposal that ACS submitted, the authors noted, “The core model is focused on procedure episodes but can easily be expanded to include acute and chronic conditions.”

The SHM notes in its letter that, while the initial proposal is intended for surgical patients, the term-based nature of surgical care provides a platform for expanding the model more broadly to hospitalists and other specialties.
 

Some skepticism remains

Even if BPCI or other models are accepted as APMs, hospitalists may still be challenged to meet the required payment or patient thresholds, Dr. Greeno said. Additionally, Dr. Berenson is skeptical of bundled payments, particularly for hospitalists.

“Are hospitalists the right organization to be held accountable for the total cost of care for 90 days of spending, any more than oncologists under Oncology Care Models should be accountable for the total cost of cancer where some patients are getting palliative care and that’s not a driver of healthcare costs?” he asked. “I could see that as problematic for hospitalists.”

While he believes there are many positive aspects to MACRA, in general, Dr. Berenson considers it bad policy. While he does not want to see the Sustainable Growth Rate return, he believes many physicians would have seen reimbursement reductions sooner without MACRA (under the prior quality measurement programs) and that the law provides some perverse incentives.

For one thing, the Quality Payment Program is budget neutral, which means that, for every winner, there is also a loser. Before CMS expanded exemptions for smaller and rural practices, Dr. Berenson said that some larger groups – which are often better equipped to pursue APMs – were planning to stay in MIPS because they figured they were more likely to be the winners when compared with smaller physician practices. And MIPS comes with a 9% payment boost by 2022 (or 9% penalty), plus the possibility of an extra bonus for top performers, compared with the 5% incentive of APMs that same year.⁷

“There were literally groups saying they were going to go for the MIPS pathway because it’s a bigger upside,” Dr. Berenson said. “When CMS said it was exempting those [smaller, rural] groups, the [larger] groups turned around and said [that the smaller, rural groups] were the downside. ... That kind of game theory is bad public policy.”

Dr. Berenson also believes MACRA will be detrimental to some small and independent practices. Others may decide not to bill Medicare altogether, though that is not an option open to most hospitalists who care to stay in practice. It could, however, drive more hospitalists to consolidate or to become employees of their hospitals.¹⁰

“I don’t think there is any doubt this is going to drive consolidation,” Dr. Greeno said, citing numbers released by CMS that show an inverse relationship between practice size and the negative impact of MACRA.¹¹ “I think it’s going to be pretty tough unless you’re big enough to commit the resources you need to do it right.”

At TeamHealth, where Dr. Greeno is senior advisor of medical affairs, he said that they have invested in information technology compliance, developed systems and trained providers to ensure the creation of favorable metrics for the organization’ and built the infrastructure to gather, report, and validate data. These are steps that may be out of reach for most smaller practices.

As Dr. Greeno said, no one expected this to be easy. “You’re trying to get doctors to change the way they practice. Anybody who has ever worked with doctors knows that’s not an easy things to do,” he said. “CMS is changing things to create enough incentive so the pain of not changing becomes greater than the pain of changing.”

While hospitalists may bear more of the pressure than other physician specialties, by virtue of their role in improving the quality of care in hospitals, they were born from reform efforts of the past, Dr. Greeno adds.

“If there had never been an attempt to change the way that physicians were paid, hospitalists wouldn’t exist,” he said. “We were created by physician groups who took capitated payments from HMOs, who had to find more efficient ways to treat patients in the hospital or go out of business.”

“Hospitalists are a delivery system reform and people look to us to lead. We can create a tremendous amount of value for whomever we work for,” Dr. Greeno said.

This is also why SHM continues to work with CMS to advocate for all its members. Dr. Greeno is in Washington at least once a month, participating in critical meetings and helping to guide decisions.

“The Public Policy Committee has to get into the weeds and get involved in advocating for measures that truly get at the work we do and push back on metrics and categories that do not relate to the care we are delivering for our patients,” said Dr. Dutta. “The group worked hard to push back on having to comply with Meaningful Use standards for hospitalists, and now we’re exempt from that category. CMS does listen. It sometimes just takes a while.”
 

References

1. Slavitt A. (2016 Oct 14). A letter from CMS to Medicare clinicians in the Quality Payment Program: We heard you and will continue listening. The CMS Blog (archived). Retrieved from http://wayback.archive-it.org/2744/20161109123921/https://blog.cms.gov/2016/10/14/a-letter-from-cms-to-medicare-clinicians-in-the-quality-payment-program/.

2. Department of Health & Human Services and Centers for Medicare & Medicaid Services. (2016 Oct 14). Quality Payment Program executive summary. Retrieved from https://qpp.cms.gov/docs/QPP_Executive_Summary_of_Final_Rule.pdf.

3. American Medical Association. (2016 Oct 19). Medicare Access and CHIP Reauthorization Act (MACRA) Quality Payment Program final rule AMA summary. Retrieved from https://www.ama-assn.org/sites/default/files/media-browser/public/physicians/macra/macra-qpp-summary.pdf.

4. Slavitt A. (2016 Sept 8). Plans for the Quality Payment Program in 2017: Pick your pace. The CMS Blog (archived). Retrieved from http://wayback.archive-it.org/2744/20161109123909/https://blog.cms.gov/2016/09/08/qualitypaymentprogram-pickyourpace/.

5. The Society of Hospital Medicine. Medicare physician payments are changing. Retrieved from http://www.macraforhm.org/.

6. Department of Health & Human Services and Centers for Medicare & Medicaid Services. (2016 Oct 14). Quality Payment Program fact sheet. Retrieved from https://qpp.cms.gov/docs/QPP_Small_Practice.pdf.

7. The Society of Hospital Medicine. (2017). MACRA and the Quality Payment Program. Retrieved from http://www.macraforhm.org/MACRA_FAQ_m1_final.pdf.

8. Department of Health & Human Services and Centers for Medicare & Medicaid Services. Quality Payment Program: Modernizing Medicare to provide better care and smarter spending for a healthier America. Retrieved from https://qpp.cms.gov/.

9. Wynne B. (2016 Oct 17). MACRA Final Rule: CMS strikes a balance; will docs hang on? Retrieved from http://healthaffairs.org/blog/2016/10/17/macra-final-rule-cms-strikes-a-balance-will-docs-hang-on/.

10. Quinn R. (2015 Aug). TeamHealth-IPC Deal Latest in consolidation trend. The Hospitalist. 2015(8). Retrieved from http://www.the-hospitalist.org/hospitalist/article/122210/teamhealth-ipc-deal-latest-consolidation-trend

11. Barkholz D. (2016 Jun 30). Potential MACRA byproduct: physician consolidation. Retrieved from http://www.modernhealthcare.com/article/20160630/NEWS/160639995.

The long wait for the introduction of the C6 hospitalist specialty code has ended. If you are a provider, hospital, or hospitalist administrator, this new specialty designation is important.

The Centers for Medicare & Medicaid Services tracks specialty utilization and compares providers across the country using codes attached to medical specialties, such as cardiology, emergency medicine, pediatrics, etc. Until the CMS designated hospital medicine as a unique specialty, hospitalists were grouped together with office-based internal medicine physicians and general practitioners. This lack of recognition of the hospitalist specialty created two issues.

• Paper: Initial enrollment in the Medicare program on form CMS-855I or CMS 855O (https://www.cms.gov/Medicare/CMS-Forms/CMS-Forms/CMS-Forms-List.html).

• Electronically: Utilizing the PECOS system, provider credentialing offices can update existing specialty codes to C6 (https://pecos.cms.hhs.gov/PECOSWebMaintenance.htm).

This major milestone for hospital medicine demonstrates the continued growth and impact of the specialty. Ensure your self-election in the PECOS system reflects “C6,” your specialty as a hospitalist and your commitment to the hospital medicine movement.

For more information, visit www.hospitalmedicine.org/C6.
 

Dea Robinson is a member of SHM’s Practice Management Committee, Cultural Competency Workgroup and Physician Burnout Workgroup.

Reference: MLN Matters Number: MM9716 ( https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/MM9716.pdf)

The long wait for the introduction of the C6 hospitalist specialty code has ended. If you are a provider, hospital, or hospitalist administrator, this new specialty designation is important.

The Centers for Medicare & Medicaid Services tracks specialty utilization and compares providers across the country using codes attached to medical specialties, such as cardiology, emergency medicine, pediatrics, etc. Until the CMS designated hospital medicine as a unique specialty, hospitalists were grouped together with office-based internal medicine physicians and general practitioners. This lack of recognition of the hospitalist specialty created two issues.

• Paper: Initial enrollment in the Medicare program on form CMS-855I or CMS 855O (https://www.cms.gov/Medicare/CMS-Forms/CMS-Forms/CMS-Forms-List.html).

• Electronically: Utilizing the PECOS system, provider credentialing offices can update existing specialty codes to C6 (https://pecos.cms.hhs.gov/PECOSWebMaintenance.htm).

This major milestone for hospital medicine demonstrates the continued growth and impact of the specialty. Ensure your self-election in the PECOS system reflects “C6,” your specialty as a hospitalist and your commitment to the hospital medicine movement.

For more information, visit www.hospitalmedicine.org/C6.
 

Dea Robinson is a member of SHM’s Practice Management Committee, Cultural Competency Workgroup and Physician Burnout Workgroup.

Reference: MLN Matters Number: MM9716 ( https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/MM9716.pdf)

The long wait for the introduction of the C6 hospitalist specialty code has ended. If you are a provider, hospital, or hospitalist administrator, this new specialty designation is important.

The Centers for Medicare & Medicaid Services tracks specialty utilization and compares providers across the country using codes attached to medical specialties, such as cardiology, emergency medicine, pediatrics, etc. Until the CMS designated hospital medicine as a unique specialty, hospitalists were grouped together with office-based internal medicine physicians and general practitioners. This lack of recognition of the hospitalist specialty created two issues.

• Paper: Initial enrollment in the Medicare program on form CMS-855I or CMS 855O (https://www.cms.gov/Medicare/CMS-Forms/CMS-Forms/CMS-Forms-List.html).

• Electronically: Utilizing the PECOS system, provider credentialing offices can update existing specialty codes to C6 (https://pecos.cms.hhs.gov/PECOSWebMaintenance.htm).

This major milestone for hospital medicine demonstrates the continued growth and impact of the specialty. Ensure your self-election in the PECOS system reflects “C6,” your specialty as a hospitalist and your commitment to the hospital medicine movement.

For more information, visit www.hospitalmedicine.org/C6.
 

Dea Robinson is a member of SHM’s Practice Management Committee, Cultural Competency Workgroup and Physician Burnout Workgroup.

Reference: MLN Matters Number: MM9716 ( https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/MM9716.pdf)

I was rounding on the inpatient general medicine teaching service last weekend and offered to meet my team of students and residents in the “resident library” on Saturday morning. (Although it holds the name “library,” there were no books or periodicals to be seen.) I had not been in the library for many months and was struck by a few things as I entered.

It is a dimly lit space, lined on three of the four walls with rickety desks and desktop computers all facing the walls. The walls are painted an off-white color with innumerable dings and nicks, presumably accumulated over the course of years. There was a string of garland in the shape of a Christmas tree pinned to the wall (P.S. It is March), the entire left side of which was sagging and misshapen. There were various tattered and coffee-stained papers scattered haphazardly throughout the room, including what appeared to be progress notes and test results printed from the EHR; a few worn ECGs; a telemetry strip; even a few (REALLY old, no doubt) chest x-ray films. Lining the fourth wall was a large foldable table, topped with crumbs and food scraps, a half-eaten chocolate Bundt cake, and scattered napkins and utensils, some of which appeared to be used. The one exterior-facing wall had a row of windows with crinkled blinds, some completely closed, others opened at awkward angles and seemingly stuck in place. There was a cadre of chairs in the room, none matching, all in various stages of disrepair, with one completely missing an armrest and another tucked in the corner, probably needing the addition of a handwritten sign “BRokEn.”

This library is a place where the students, interns, and residents go for a bit of a safe haven. They can take their coats off, sit down, have their own computer space, answer pages, and complain about their woes. They can bounce questions off each other, vent frustrations, find the humor in a situation, and just be themselves. So,But what struck me about their sanctuary is that it is totally and utterly depressing. And it was as if they didn’t even notice the chaos and filth laying everywhere around them. I find it impossible to believe that it does not have an effect on their mood and outlook. Although we are all social animals, and we have a real need to congregate and connect with one another, is this really the best environment to do that?

Read the full text of this blog post at hospitalleader.org.
 

Dr. Scheurer is a clinical hospitalist and the medical director of quality and safety at the Medical University of South Carolina in Charleston.

Also on The Hospital Leader…

• Should Overuse Be Considered an Adverse Event By Chris Moriates, MD
• Pulling the Welcome Mat Out from Under Our Colleagues By Brett Hendel-Paterson, MD
• The Upside of Anger By Tracy Cardin, ACNP-BC, SFHM
• Does Your Onboarding Process Really Get Folks on Board? By Leslie Flores, MH, SFHM
• A GIF Is Worth 3000 Words: Introducing #Visual Abstract for #JHMChat By Charlie Wray, DO

I was rounding on the inpatient general medicine teaching service last weekend and offered to meet my team of students and residents in the “resident library” on Saturday morning. (Although it holds the name “library,” there were no books or periodicals to be seen.) I had not been in the library for many months and was struck by a few things as I entered.

It is a dimly lit space, lined on three of the four walls with rickety desks and desktop computers all facing the walls. The walls are painted an off-white color with innumerable dings and nicks, presumably accumulated over the course of years. There was a string of garland in the shape of a Christmas tree pinned to the wall (P.S. It is March), the entire left side of which was sagging and misshapen. There were various tattered and coffee-stained papers scattered haphazardly throughout the room, including what appeared to be progress notes and test results printed from the EHR; a few worn ECGs; a telemetry strip; even a few (REALLY old, no doubt) chest x-ray films. Lining the fourth wall was a large foldable table, topped with crumbs and food scraps, a half-eaten chocolate Bundt cake, and scattered napkins and utensils, some of which appeared to be used. The one exterior-facing wall had a row of windows with crinkled blinds, some completely closed, others opened at awkward angles and seemingly stuck in place. There was a cadre of chairs in the room, none matching, all in various stages of disrepair, with one completely missing an armrest and another tucked in the corner, probably needing the addition of a handwritten sign “BRokEn.”

This library is a place where the students, interns, and residents go for a bit of a safe haven. They can take their coats off, sit down, have their own computer space, answer pages, and complain about their woes. They can bounce questions off each other, vent frustrations, find the humor in a situation, and just be themselves. So,But what struck me about their sanctuary is that it is totally and utterly depressing. And it was as if they didn’t even notice the chaos and filth laying everywhere around them. I find it impossible to believe that it does not have an effect on their mood and outlook. Although we are all social animals, and we have a real need to congregate and connect with one another, is this really the best environment to do that?

Read the full text of this blog post at hospitalleader.org.
 

Dr. Scheurer is a clinical hospitalist and the medical director of quality and safety at the Medical University of South Carolina in Charleston.

Also on The Hospital Leader…

• Should Overuse Be Considered an Adverse Event By Chris Moriates, MD
• Pulling the Welcome Mat Out from Under Our Colleagues By Brett Hendel-Paterson, MD
• The Upside of Anger By Tracy Cardin, ACNP-BC, SFHM
• Does Your Onboarding Process Really Get Folks on Board? By Leslie Flores, MH, SFHM
• A GIF Is Worth 3000 Words: Introducing #Visual Abstract for #JHMChat By Charlie Wray, DO

I was rounding on the inpatient general medicine teaching service last weekend and offered to meet my team of students and residents in the “resident library” on Saturday morning. (Although it holds the name “library,” there were no books or periodicals to be seen.) I had not been in the library for many months and was struck by a few things as I entered.

It is a dimly lit space, lined on three of the four walls with rickety desks and desktop computers all facing the walls. The walls are painted an off-white color with innumerable dings and nicks, presumably accumulated over the course of years. There was a string of garland in the shape of a Christmas tree pinned to the wall (P.S. It is March), the entire left side of which was sagging and misshapen. There were various tattered and coffee-stained papers scattered haphazardly throughout the room, including what appeared to be progress notes and test results printed from the EHR; a few worn ECGs; a telemetry strip; even a few (REALLY old, no doubt) chest x-ray films. Lining the fourth wall was a large foldable table, topped with crumbs and food scraps, a half-eaten chocolate Bundt cake, and scattered napkins and utensils, some of which appeared to be used. The one exterior-facing wall had a row of windows with crinkled blinds, some completely closed, others opened at awkward angles and seemingly stuck in place. There was a cadre of chairs in the room, none matching, all in various stages of disrepair, with one completely missing an armrest and another tucked in the corner, probably needing the addition of a handwritten sign “BRokEn.”

This library is a place where the students, interns, and residents go for a bit of a safe haven. They can take their coats off, sit down, have their own computer space, answer pages, and complain about their woes. They can bounce questions off each other, vent frustrations, find the humor in a situation, and just be themselves. So,But what struck me about their sanctuary is that it is totally and utterly depressing. And it was as if they didn’t even notice the chaos and filth laying everywhere around them. I find it impossible to believe that it does not have an effect on their mood and outlook. Although we are all social animals, and we have a real need to congregate and connect with one another, is this really the best environment to do that?

Read the full text of this blog post at hospitalleader.org.
 

Dr. Scheurer is a clinical hospitalist and the medical director of quality and safety at the Medical University of South Carolina in Charleston.

Also on The Hospital Leader…

• Should Overuse Be Considered an Adverse Event By Chris Moriates, MD
• Pulling the Welcome Mat Out from Under Our Colleagues By Brett Hendel-Paterson, MD
• The Upside of Anger By Tracy Cardin, ACNP-BC, SFHM
• Does Your Onboarding Process Really Get Folks on Board? By Leslie Flores, MH, SFHM
• A GIF Is Worth 3000 Words: Introducing #Visual Abstract for #JHMChat By Charlie Wray, DO