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Hospitals will feel the squeeze of DSH payment changes
Earlier this year, the Centers for Medicare and Medicaid Services finalized fundamental changes to how it reimburses hospitals for uncompensated care costs. When first proposed, the move raised alarm among physicians, hospitals, health systems, state health departments, and others around the country, and even prompted a lawsuit in New Hampshire.
In the months since the official adoption by the CMS, it remains unclear how the change will affect hospitals around the country, particularly the safety net hospitals that rely on these payments most.
In its final rule issued in April 2017 and finalized on August 2, 2017, the federal agency said the intent of the change is to more fairly distribute a fixed amount of DSH funds to the hospitals most in need. It also argued the change is a more consistent interpretation of the existing statute [Section 1923(g)], provides clarification around language that has been the subject of inquiry over the last decade, and promotes what it calls “fiscal integrity.”
“These allotments essentially establish a finite pool of available federal DSH funds that states use to pay the federal portion of payments to all qualifying hospitals in each state,” the final rule reads. “As states often use most or all of their federal DSH allotment, in practice, if one hospital gets more DSH funding, other DSH-eligible hospitals in the state may get less.”
This is not, however, the way all parties see it. For instance, in a comment submitted to the CMS in September 2016, the National Association of Urban Hospitals expressed its concern that DSH payments already are inadequate to cover the financial burden associated with providing care in low-income communities, such as translation services and the costs of employing physicians to practice in more challenged settings.2
In a letter to the CMS, the Minnesota Department of Human Services said it agrees with the agency that DSH payments should not be used to “subsidize costs that have been paid by Medicare and other insurers” but disagrees with the agency’s approach. Its argument includes a challenge to the CMS’ statutory authority to change the formula based on existing language.3
“I think the reason it’s contentious is because when you’re dealing with a fixed dollar amount and you’re talking about redistributing dollars, someone is going to lose,” said John McHugh, PhD, professor of health management at the Mailman School of Public Health at Columbia University. “A facility receiving DSH payments is already dealing with high levels of uncompensated care; the hospitals are operating on very thin margins. They are very often getting by because of these payments.”
Despite the CMS’ seemingly good intentions, Bradley Flansbaum, DO, MPH, MHM, a hospitalist at Geisinger Health System and member of the SHM Public Policy Committee, remains skeptical that the hospitals that need and deserve DSH payments will actually see more redistributed in their favor.
If hospitals in need see fewer DSH dollars, Dr. McHugh noted, they will feel the squeeze.
“It’s not easy to operate safety net hospitals,” he said. “And on top of that, hospitals have been operating under a certain assumption and it’s changing, and it takes time to incorporate those changes. There will probably be some fallout for the first couple of years as hospitals are adapting their practices. It could mean loss of services. It could mean the loss of quality physicians and quality staffing, and that can impact patient care.”
How will hospitals adapt?
The CMS did not give hospitals transition time. The reinterpretation became effective in June 2017, just 60 days after the agency issued the final rule. Dr. McHugh said he is not sure why the agency did not build in time for hospitals to adapt, particularly given the uncertainty around the national uninsured rate going forward, with so many potential changes to the American health care system under a new administration.
How any of these changes trickle down to hospitalists remains to be seen, said Dr. Flansbaum. Dr. McHugh believes it could lead to increased patient loads, higher turnover and churn, and fewer experienced physicians in safety net hospitals as younger doctors are hired and burn out. “At the end of the day, that feeds into patient care and patient satisfaction and quality,” he said.
However, hospitals across the country have been living with this “slow burn” for a long time, said Dr. Flansbaum, though not necessarily due to inadequate DSH payments. At least in some areas, reimbursements have gone down, hospital occupancy rates have declined, rural hospitals have closed, hospitals have consolidated, and people have been laid off.
It’s important to ensure the hospitals providing care for high levels of uninsured or underinsured patients receive the help they need, he said, and it’s also important to examine the role hospitals play as a whole in the American health care system.
“It’s an expensive system,” he said. “We have we created a system where, unlike other countries that have developed more vigorous primary or outpatient care, we have created an inpatient health system.”
With the CMS’ change, the government is the only entity that seems to win across the board, Dr. McHugh said. He said he would not be surprised if analysts looked to see how hospitals were affected by it in coming months.
But, he remains optimistic. In fact, the final rule also came with an $800 million increase in the amount of uncompensated care payments for acute care hospitals in fiscal year 2018, the CMS says.4
“Hospitals are adaptable,” Dr. McHugh said. “I think what you’ll see is this will spur some innovation in terms of patient care maybe a few years down the road. It may hit some stumbling blocks in the early going but there may be some positive changes in the future.”
References
1. Medicaid Program; Disproportionate Share Hospital Payments –Treatment of Third Party Payers in Calculating Uncompensated Care Costs. Centers for Medicare and Medicaid Services final rule. Citation 82 FR 16114. Published April 3, 2017. Last accessed August 14, 2017. https://www.federalregister.gov/documents/2017/04/03/2017-06538/medicaid-program-disproportionate-share-hospital-payments-treatment-of-third-party-payers-in
2. Kugler E. 2016-09-14 NAUH Medicaid Program DSH Payments – Treatment of Third Party Payer in Calculating Uncompensated Care Costs. September 14, 2016. Last accessed August 14, 2017. https://www.regulations.gov/document?D=CMS-2016-0144-0020
3. Berg A. Proposed Rule on Disproportionate Share Hospital Payments – Treatment of Third Party Payers in Calculating Uncompensated Care Costs, CMS-2399-P. September 14, 2016. Last accessed August 14, 2017. https://www.regulations.gov/document?D=CMS-2016-0144-0046
4. CMS finalizes 2018 payment and policy updates for Medicare hospital admissions. Published August 2, 2017. Last accessed August 14, 2017. https://www.cms.gov/Newsroom/MediaReleaseDatabase/Press-releases/2017-Press-releases-items/2017-08-02.html
Earlier this year, the Centers for Medicare and Medicaid Services finalized fundamental changes to how it reimburses hospitals for uncompensated care costs. When first proposed, the move raised alarm among physicians, hospitals, health systems, state health departments, and others around the country, and even prompted a lawsuit in New Hampshire.
In the months since the official adoption by the CMS, it remains unclear how the change will affect hospitals around the country, particularly the safety net hospitals that rely on these payments most.
In its final rule issued in April 2017 and finalized on August 2, 2017, the federal agency said the intent of the change is to more fairly distribute a fixed amount of DSH funds to the hospitals most in need. It also argued the change is a more consistent interpretation of the existing statute [Section 1923(g)], provides clarification around language that has been the subject of inquiry over the last decade, and promotes what it calls “fiscal integrity.”
“These allotments essentially establish a finite pool of available federal DSH funds that states use to pay the federal portion of payments to all qualifying hospitals in each state,” the final rule reads. “As states often use most or all of their federal DSH allotment, in practice, if one hospital gets more DSH funding, other DSH-eligible hospitals in the state may get less.”
This is not, however, the way all parties see it. For instance, in a comment submitted to the CMS in September 2016, the National Association of Urban Hospitals expressed its concern that DSH payments already are inadequate to cover the financial burden associated with providing care in low-income communities, such as translation services and the costs of employing physicians to practice in more challenged settings.2
In a letter to the CMS, the Minnesota Department of Human Services said it agrees with the agency that DSH payments should not be used to “subsidize costs that have been paid by Medicare and other insurers” but disagrees with the agency’s approach. Its argument includes a challenge to the CMS’ statutory authority to change the formula based on existing language.3
“I think the reason it’s contentious is because when you’re dealing with a fixed dollar amount and you’re talking about redistributing dollars, someone is going to lose,” said John McHugh, PhD, professor of health management at the Mailman School of Public Health at Columbia University. “A facility receiving DSH payments is already dealing with high levels of uncompensated care; the hospitals are operating on very thin margins. They are very often getting by because of these payments.”
Despite the CMS’ seemingly good intentions, Bradley Flansbaum, DO, MPH, MHM, a hospitalist at Geisinger Health System and member of the SHM Public Policy Committee, remains skeptical that the hospitals that need and deserve DSH payments will actually see more redistributed in their favor.
If hospitals in need see fewer DSH dollars, Dr. McHugh noted, they will feel the squeeze.
“It’s not easy to operate safety net hospitals,” he said. “And on top of that, hospitals have been operating under a certain assumption and it’s changing, and it takes time to incorporate those changes. There will probably be some fallout for the first couple of years as hospitals are adapting their practices. It could mean loss of services. It could mean the loss of quality physicians and quality staffing, and that can impact patient care.”
How will hospitals adapt?
The CMS did not give hospitals transition time. The reinterpretation became effective in June 2017, just 60 days after the agency issued the final rule. Dr. McHugh said he is not sure why the agency did not build in time for hospitals to adapt, particularly given the uncertainty around the national uninsured rate going forward, with so many potential changes to the American health care system under a new administration.
How any of these changes trickle down to hospitalists remains to be seen, said Dr. Flansbaum. Dr. McHugh believes it could lead to increased patient loads, higher turnover and churn, and fewer experienced physicians in safety net hospitals as younger doctors are hired and burn out. “At the end of the day, that feeds into patient care and patient satisfaction and quality,” he said.
However, hospitals across the country have been living with this “slow burn” for a long time, said Dr. Flansbaum, though not necessarily due to inadequate DSH payments. At least in some areas, reimbursements have gone down, hospital occupancy rates have declined, rural hospitals have closed, hospitals have consolidated, and people have been laid off.
It’s important to ensure the hospitals providing care for high levels of uninsured or underinsured patients receive the help they need, he said, and it’s also important to examine the role hospitals play as a whole in the American health care system.
“It’s an expensive system,” he said. “We have we created a system where, unlike other countries that have developed more vigorous primary or outpatient care, we have created an inpatient health system.”
With the CMS’ change, the government is the only entity that seems to win across the board, Dr. McHugh said. He said he would not be surprised if analysts looked to see how hospitals were affected by it in coming months.
But, he remains optimistic. In fact, the final rule also came with an $800 million increase in the amount of uncompensated care payments for acute care hospitals in fiscal year 2018, the CMS says.4
“Hospitals are adaptable,” Dr. McHugh said. “I think what you’ll see is this will spur some innovation in terms of patient care maybe a few years down the road. It may hit some stumbling blocks in the early going but there may be some positive changes in the future.”
References
1. Medicaid Program; Disproportionate Share Hospital Payments –Treatment of Third Party Payers in Calculating Uncompensated Care Costs. Centers for Medicare and Medicaid Services final rule. Citation 82 FR 16114. Published April 3, 2017. Last accessed August 14, 2017. https://www.federalregister.gov/documents/2017/04/03/2017-06538/medicaid-program-disproportionate-share-hospital-payments-treatment-of-third-party-payers-in
2. Kugler E. 2016-09-14 NAUH Medicaid Program DSH Payments – Treatment of Third Party Payer in Calculating Uncompensated Care Costs. September 14, 2016. Last accessed August 14, 2017. https://www.regulations.gov/document?D=CMS-2016-0144-0020
3. Berg A. Proposed Rule on Disproportionate Share Hospital Payments – Treatment of Third Party Payers in Calculating Uncompensated Care Costs, CMS-2399-P. September 14, 2016. Last accessed August 14, 2017. https://www.regulations.gov/document?D=CMS-2016-0144-0046
4. CMS finalizes 2018 payment and policy updates for Medicare hospital admissions. Published August 2, 2017. Last accessed August 14, 2017. https://www.cms.gov/Newsroom/MediaReleaseDatabase/Press-releases/2017-Press-releases-items/2017-08-02.html
Earlier this year, the Centers for Medicare and Medicaid Services finalized fundamental changes to how it reimburses hospitals for uncompensated care costs. When first proposed, the move raised alarm among physicians, hospitals, health systems, state health departments, and others around the country, and even prompted a lawsuit in New Hampshire.
In the months since the official adoption by the CMS, it remains unclear how the change will affect hospitals around the country, particularly the safety net hospitals that rely on these payments most.
In its final rule issued in April 2017 and finalized on August 2, 2017, the federal agency said the intent of the change is to more fairly distribute a fixed amount of DSH funds to the hospitals most in need. It also argued the change is a more consistent interpretation of the existing statute [Section 1923(g)], provides clarification around language that has been the subject of inquiry over the last decade, and promotes what it calls “fiscal integrity.”
“These allotments essentially establish a finite pool of available federal DSH funds that states use to pay the federal portion of payments to all qualifying hospitals in each state,” the final rule reads. “As states often use most or all of their federal DSH allotment, in practice, if one hospital gets more DSH funding, other DSH-eligible hospitals in the state may get less.”
This is not, however, the way all parties see it. For instance, in a comment submitted to the CMS in September 2016, the National Association of Urban Hospitals expressed its concern that DSH payments already are inadequate to cover the financial burden associated with providing care in low-income communities, such as translation services and the costs of employing physicians to practice in more challenged settings.2
In a letter to the CMS, the Minnesota Department of Human Services said it agrees with the agency that DSH payments should not be used to “subsidize costs that have been paid by Medicare and other insurers” but disagrees with the agency’s approach. Its argument includes a challenge to the CMS’ statutory authority to change the formula based on existing language.3
“I think the reason it’s contentious is because when you’re dealing with a fixed dollar amount and you’re talking about redistributing dollars, someone is going to lose,” said John McHugh, PhD, professor of health management at the Mailman School of Public Health at Columbia University. “A facility receiving DSH payments is already dealing with high levels of uncompensated care; the hospitals are operating on very thin margins. They are very often getting by because of these payments.”
Despite the CMS’ seemingly good intentions, Bradley Flansbaum, DO, MPH, MHM, a hospitalist at Geisinger Health System and member of the SHM Public Policy Committee, remains skeptical that the hospitals that need and deserve DSH payments will actually see more redistributed in their favor.
If hospitals in need see fewer DSH dollars, Dr. McHugh noted, they will feel the squeeze.
“It’s not easy to operate safety net hospitals,” he said. “And on top of that, hospitals have been operating under a certain assumption and it’s changing, and it takes time to incorporate those changes. There will probably be some fallout for the first couple of years as hospitals are adapting their practices. It could mean loss of services. It could mean the loss of quality physicians and quality staffing, and that can impact patient care.”
How will hospitals adapt?
The CMS did not give hospitals transition time. The reinterpretation became effective in June 2017, just 60 days after the agency issued the final rule. Dr. McHugh said he is not sure why the agency did not build in time for hospitals to adapt, particularly given the uncertainty around the national uninsured rate going forward, with so many potential changes to the American health care system under a new administration.
How any of these changes trickle down to hospitalists remains to be seen, said Dr. Flansbaum. Dr. McHugh believes it could lead to increased patient loads, higher turnover and churn, and fewer experienced physicians in safety net hospitals as younger doctors are hired and burn out. “At the end of the day, that feeds into patient care and patient satisfaction and quality,” he said.
However, hospitals across the country have been living with this “slow burn” for a long time, said Dr. Flansbaum, though not necessarily due to inadequate DSH payments. At least in some areas, reimbursements have gone down, hospital occupancy rates have declined, rural hospitals have closed, hospitals have consolidated, and people have been laid off.
It’s important to ensure the hospitals providing care for high levels of uninsured or underinsured patients receive the help they need, he said, and it’s also important to examine the role hospitals play as a whole in the American health care system.
“It’s an expensive system,” he said. “We have we created a system where, unlike other countries that have developed more vigorous primary or outpatient care, we have created an inpatient health system.”
With the CMS’ change, the government is the only entity that seems to win across the board, Dr. McHugh said. He said he would not be surprised if analysts looked to see how hospitals were affected by it in coming months.
But, he remains optimistic. In fact, the final rule also came with an $800 million increase in the amount of uncompensated care payments for acute care hospitals in fiscal year 2018, the CMS says.4
“Hospitals are adaptable,” Dr. McHugh said. “I think what you’ll see is this will spur some innovation in terms of patient care maybe a few years down the road. It may hit some stumbling blocks in the early going but there may be some positive changes in the future.”
References
1. Medicaid Program; Disproportionate Share Hospital Payments –Treatment of Third Party Payers in Calculating Uncompensated Care Costs. Centers for Medicare and Medicaid Services final rule. Citation 82 FR 16114. Published April 3, 2017. Last accessed August 14, 2017. https://www.federalregister.gov/documents/2017/04/03/2017-06538/medicaid-program-disproportionate-share-hospital-payments-treatment-of-third-party-payers-in
2. Kugler E. 2016-09-14 NAUH Medicaid Program DSH Payments – Treatment of Third Party Payer in Calculating Uncompensated Care Costs. September 14, 2016. Last accessed August 14, 2017. https://www.regulations.gov/document?D=CMS-2016-0144-0020
3. Berg A. Proposed Rule on Disproportionate Share Hospital Payments – Treatment of Third Party Payers in Calculating Uncompensated Care Costs, CMS-2399-P. September 14, 2016. Last accessed August 14, 2017. https://www.regulations.gov/document?D=CMS-2016-0144-0046
4. CMS finalizes 2018 payment and policy updates for Medicare hospital admissions. Published August 2, 2017. Last accessed August 14, 2017. https://www.cms.gov/Newsroom/MediaReleaseDatabase/Press-releases/2017-Press-releases-items/2017-08-02.html
How hospitalists can focus on health equity
A decade ago, most hospitalists and hospital leaders were not thinking about health equity, let alone discussing it.
“It used to be we could say: ‘We saved your life but everything else is beyond our control,’ ” said Nick Fitterman, MD, FACP, SFHM, vice chair of Hospital Medicine at Northwell Health in New York, and associate professor of medicine at Hofstra Northwell School of Medicine and Long Island Jewish Medical Center.
But today?
”We have a better understanding that what affects the health of most of our patients is what happens outside the four walls of the hospital,” he said. “Now, we can work with case managers and community-based organizations to help address housing and food. We can at least steer our patients to resources and help them with the social determinants of their health.”
A report recently published by the University of California, San Francisco, and the Robert Wood Johnson Foundation (RWJF) takes on the definition of health equity.1 Because, as one of the report’s authors, Paula Braveman, MD, MPH, professor of Family and Community Medicine and director of the Center on Social Disparities in Health at UCSF, argued in a Health Affairs blog post in June 2017: “Clarity is particularly important because pursuing equity often involves engaging diverse audiences and stakeholders, each with their own constituents, beliefs, and agendas. And in an era of data, a sound definition is crucial to shape the benchmarks against which progress can be measured.”
Measurement is an unavoidable aspect of the practice of medicine in the 21st century and both Dr. Fitterman and Dr. Smothers say hospitals must start focusing on the nonmedical factors that influence health to find success.
“Payment reform is forcing delivery reform,” Dr. Fitterman said.
A report from the National Academies of Sciences, Engineering, and Medicine estimates that racial health disparities alone – not including other marginalized groups – could cost health insurers as much as $337 billion between 2009 and 2018.2 “Hospitals and hospitalists have to focus on health disparities in order to address the multitude of chronic medical conditions they treat,” said Dr. Smothers.
For the purposes of measurement, the authors of the RWJF report conclude that “health equity means reducing and ultimately eliminating disparities in health and its determinants that adversely affect excluded or marginalized groups.” The report attempts to define health equity as a means of specifically addressing it.
“Population health means taking care of the wider population, in terms of health and cost,” said Dr. Fitterman. “But if you’re just looking at the average health of a population you could still be missing pockets of disparity, since there will be pockets that excel and pockets of disparity but the average looks good. If we’re not careful how we measure it, we may leave some groups behind.”
Achieving health equity, the RWJF report says, requires removing the “obstacles to health such as poverty, discrimination, and their consequences, including powerlessness and lack of access to good jobs with fair pay, quality education and housing, safe environments, and health care.” Health equity means that everyone must have “a fair and just opportunity to be as healthy as possible.”
It lays out four “key steps” to achieve health equity: 1. Identify important health disparities; 2. Change and implement policies, laws, systems, environments, and practices to reduce inequities in the opportunities and resources needed to be healthier; 3. Evaluate and monitor efforts using short- and long-term measures; and 4. Reassess strategies in light of process and outcomes, plan next steps.
Everyone can be a part of the solutions to address health disparities, Dr. Fitterman said. He was not involved in the report. For hospitalists interested in addressing health equity, Dr. Braveman had two recommendations:
• Choose to practice at a hospital that serves large numbers of socially disadvantaged people;
• Put particular effort into helping the most socially disadvantaged patients in their hospitals.
This should include understanding the conditions that bring disadvantaged people to the hospital in disproportionate numbers, Dr. Braveman said, and getting involved in initiatives intended to address them. For example, after observing that disproportionate numbers of poor kids are hospitalized with asthma, hospitalists might connect with community groups that can help address pest abatement in low-income housing.
Health equity efforts should not just focus on socioeconomically or racially disadvantaged groups either, Dr. Braveman and Dr. Fitterman argue. They must also address others who are marginalized, like patients who are disabled, elderly, obese, non–English speaking, or gender nonconforming.
Dr. Fitterman said his hospital leadership has made health equity a priority and believes successful health equity practices involve good leadership, becoming aware of and addressing unconscious bias, and efforts to address the social determinants that can cut through health disparities.
“The focus of our last leadership retreat was diversity and health disparities,” Dr. Fitterman said. “It starts at the top down. I bring that to our faculty and site directors: everyone takes an online test to raise their awareness of unconscious bias.”
Dr. Smothers serves on the board of the Center for Health Equity and Wellness at Adventist HealthCare, which works to improve access to “culturally appropriate care, and provides community wellness outreach and education.” He said that, in addition to programs at the Center which address disparities, his hospital has also established teams of doctors, nurses, case managers, and transitional care nurses to help redirect patients to “more appropriate, less costly services, such as primary care, urgent care, home care, and subacute care,” when it is in the patient’s best interest.
Not only are Adventist’s hospitalists aware of community resources available to their patients, they are also culturally diverse, Dr. Smothers said, noting that they are “well equipped to manage our diverse patient population, including those who lack adequate health care.”
Additionally, Dr. Smothers said: “We engage our hospitalists in care coordination, encouraging them to make recommendations on alternative treatment locations and/or options at the point of entry.” And all admitted patients with chronic conditions are provided with a month’s supply of medication and schedule transportation for their follow-up appointment upon discharge.
“We need to inquire about social determinants that may prohibit our success with our patients,” said Dr. Fitterman. “You are not always going to be able to fix it, but it doesn’t mean you shouldn’t try.”
References
1. Braveman P, et al. What is health equity? And what difference does a definition make? Robert Wood Johnson Foundation. Published May 2017. Accessed July 15, 2017.
2. Communities in Action: Pathways to Health Equity. National Academies of Sciences, Engineering and Medicine. Published Jan. 11, 2017. Accessed July 15, 2017.
A decade ago, most hospitalists and hospital leaders were not thinking about health equity, let alone discussing it.
“It used to be we could say: ‘We saved your life but everything else is beyond our control,’ ” said Nick Fitterman, MD, FACP, SFHM, vice chair of Hospital Medicine at Northwell Health in New York, and associate professor of medicine at Hofstra Northwell School of Medicine and Long Island Jewish Medical Center.
But today?
”We have a better understanding that what affects the health of most of our patients is what happens outside the four walls of the hospital,” he said. “Now, we can work with case managers and community-based organizations to help address housing and food. We can at least steer our patients to resources and help them with the social determinants of their health.”
A report recently published by the University of California, San Francisco, and the Robert Wood Johnson Foundation (RWJF) takes on the definition of health equity.1 Because, as one of the report’s authors, Paula Braveman, MD, MPH, professor of Family and Community Medicine and director of the Center on Social Disparities in Health at UCSF, argued in a Health Affairs blog post in June 2017: “Clarity is particularly important because pursuing equity often involves engaging diverse audiences and stakeholders, each with their own constituents, beliefs, and agendas. And in an era of data, a sound definition is crucial to shape the benchmarks against which progress can be measured.”
Measurement is an unavoidable aspect of the practice of medicine in the 21st century and both Dr. Fitterman and Dr. Smothers say hospitals must start focusing on the nonmedical factors that influence health to find success.
“Payment reform is forcing delivery reform,” Dr. Fitterman said.
A report from the National Academies of Sciences, Engineering, and Medicine estimates that racial health disparities alone – not including other marginalized groups – could cost health insurers as much as $337 billion between 2009 and 2018.2 “Hospitals and hospitalists have to focus on health disparities in order to address the multitude of chronic medical conditions they treat,” said Dr. Smothers.
For the purposes of measurement, the authors of the RWJF report conclude that “health equity means reducing and ultimately eliminating disparities in health and its determinants that adversely affect excluded or marginalized groups.” The report attempts to define health equity as a means of specifically addressing it.
“Population health means taking care of the wider population, in terms of health and cost,” said Dr. Fitterman. “But if you’re just looking at the average health of a population you could still be missing pockets of disparity, since there will be pockets that excel and pockets of disparity but the average looks good. If we’re not careful how we measure it, we may leave some groups behind.”
Achieving health equity, the RWJF report says, requires removing the “obstacles to health such as poverty, discrimination, and their consequences, including powerlessness and lack of access to good jobs with fair pay, quality education and housing, safe environments, and health care.” Health equity means that everyone must have “a fair and just opportunity to be as healthy as possible.”
It lays out four “key steps” to achieve health equity: 1. Identify important health disparities; 2. Change and implement policies, laws, systems, environments, and practices to reduce inequities in the opportunities and resources needed to be healthier; 3. Evaluate and monitor efforts using short- and long-term measures; and 4. Reassess strategies in light of process and outcomes, plan next steps.
Everyone can be a part of the solutions to address health disparities, Dr. Fitterman said. He was not involved in the report. For hospitalists interested in addressing health equity, Dr. Braveman had two recommendations:
• Choose to practice at a hospital that serves large numbers of socially disadvantaged people;
• Put particular effort into helping the most socially disadvantaged patients in their hospitals.
This should include understanding the conditions that bring disadvantaged people to the hospital in disproportionate numbers, Dr. Braveman said, and getting involved in initiatives intended to address them. For example, after observing that disproportionate numbers of poor kids are hospitalized with asthma, hospitalists might connect with community groups that can help address pest abatement in low-income housing.
Health equity efforts should not just focus on socioeconomically or racially disadvantaged groups either, Dr. Braveman and Dr. Fitterman argue. They must also address others who are marginalized, like patients who are disabled, elderly, obese, non–English speaking, or gender nonconforming.
Dr. Fitterman said his hospital leadership has made health equity a priority and believes successful health equity practices involve good leadership, becoming aware of and addressing unconscious bias, and efforts to address the social determinants that can cut through health disparities.
“The focus of our last leadership retreat was diversity and health disparities,” Dr. Fitterman said. “It starts at the top down. I bring that to our faculty and site directors: everyone takes an online test to raise their awareness of unconscious bias.”
Dr. Smothers serves on the board of the Center for Health Equity and Wellness at Adventist HealthCare, which works to improve access to “culturally appropriate care, and provides community wellness outreach and education.” He said that, in addition to programs at the Center which address disparities, his hospital has also established teams of doctors, nurses, case managers, and transitional care nurses to help redirect patients to “more appropriate, less costly services, such as primary care, urgent care, home care, and subacute care,” when it is in the patient’s best interest.
Not only are Adventist’s hospitalists aware of community resources available to their patients, they are also culturally diverse, Dr. Smothers said, noting that they are “well equipped to manage our diverse patient population, including those who lack adequate health care.”
Additionally, Dr. Smothers said: “We engage our hospitalists in care coordination, encouraging them to make recommendations on alternative treatment locations and/or options at the point of entry.” And all admitted patients with chronic conditions are provided with a month’s supply of medication and schedule transportation for their follow-up appointment upon discharge.
“We need to inquire about social determinants that may prohibit our success with our patients,” said Dr. Fitterman. “You are not always going to be able to fix it, but it doesn’t mean you shouldn’t try.”
References
1. Braveman P, et al. What is health equity? And what difference does a definition make? Robert Wood Johnson Foundation. Published May 2017. Accessed July 15, 2017.
2. Communities in Action: Pathways to Health Equity. National Academies of Sciences, Engineering and Medicine. Published Jan. 11, 2017. Accessed July 15, 2017.
A decade ago, most hospitalists and hospital leaders were not thinking about health equity, let alone discussing it.
“It used to be we could say: ‘We saved your life but everything else is beyond our control,’ ” said Nick Fitterman, MD, FACP, SFHM, vice chair of Hospital Medicine at Northwell Health in New York, and associate professor of medicine at Hofstra Northwell School of Medicine and Long Island Jewish Medical Center.
But today?
”We have a better understanding that what affects the health of most of our patients is what happens outside the four walls of the hospital,” he said. “Now, we can work with case managers and community-based organizations to help address housing and food. We can at least steer our patients to resources and help them with the social determinants of their health.”
A report recently published by the University of California, San Francisco, and the Robert Wood Johnson Foundation (RWJF) takes on the definition of health equity.1 Because, as one of the report’s authors, Paula Braveman, MD, MPH, professor of Family and Community Medicine and director of the Center on Social Disparities in Health at UCSF, argued in a Health Affairs blog post in June 2017: “Clarity is particularly important because pursuing equity often involves engaging diverse audiences and stakeholders, each with their own constituents, beliefs, and agendas. And in an era of data, a sound definition is crucial to shape the benchmarks against which progress can be measured.”
Measurement is an unavoidable aspect of the practice of medicine in the 21st century and both Dr. Fitterman and Dr. Smothers say hospitals must start focusing on the nonmedical factors that influence health to find success.
“Payment reform is forcing delivery reform,” Dr. Fitterman said.
A report from the National Academies of Sciences, Engineering, and Medicine estimates that racial health disparities alone – not including other marginalized groups – could cost health insurers as much as $337 billion between 2009 and 2018.2 “Hospitals and hospitalists have to focus on health disparities in order to address the multitude of chronic medical conditions they treat,” said Dr. Smothers.
For the purposes of measurement, the authors of the RWJF report conclude that “health equity means reducing and ultimately eliminating disparities in health and its determinants that adversely affect excluded or marginalized groups.” The report attempts to define health equity as a means of specifically addressing it.
“Population health means taking care of the wider population, in terms of health and cost,” said Dr. Fitterman. “But if you’re just looking at the average health of a population you could still be missing pockets of disparity, since there will be pockets that excel and pockets of disparity but the average looks good. If we’re not careful how we measure it, we may leave some groups behind.”
Achieving health equity, the RWJF report says, requires removing the “obstacles to health such as poverty, discrimination, and their consequences, including powerlessness and lack of access to good jobs with fair pay, quality education and housing, safe environments, and health care.” Health equity means that everyone must have “a fair and just opportunity to be as healthy as possible.”
It lays out four “key steps” to achieve health equity: 1. Identify important health disparities; 2. Change and implement policies, laws, systems, environments, and practices to reduce inequities in the opportunities and resources needed to be healthier; 3. Evaluate and monitor efforts using short- and long-term measures; and 4. Reassess strategies in light of process and outcomes, plan next steps.
Everyone can be a part of the solutions to address health disparities, Dr. Fitterman said. He was not involved in the report. For hospitalists interested in addressing health equity, Dr. Braveman had two recommendations:
• Choose to practice at a hospital that serves large numbers of socially disadvantaged people;
• Put particular effort into helping the most socially disadvantaged patients in their hospitals.
This should include understanding the conditions that bring disadvantaged people to the hospital in disproportionate numbers, Dr. Braveman said, and getting involved in initiatives intended to address them. For example, after observing that disproportionate numbers of poor kids are hospitalized with asthma, hospitalists might connect with community groups that can help address pest abatement in low-income housing.
Health equity efforts should not just focus on socioeconomically or racially disadvantaged groups either, Dr. Braveman and Dr. Fitterman argue. They must also address others who are marginalized, like patients who are disabled, elderly, obese, non–English speaking, or gender nonconforming.
Dr. Fitterman said his hospital leadership has made health equity a priority and believes successful health equity practices involve good leadership, becoming aware of and addressing unconscious bias, and efforts to address the social determinants that can cut through health disparities.
“The focus of our last leadership retreat was diversity and health disparities,” Dr. Fitterman said. “It starts at the top down. I bring that to our faculty and site directors: everyone takes an online test to raise their awareness of unconscious bias.”
Dr. Smothers serves on the board of the Center for Health Equity and Wellness at Adventist HealthCare, which works to improve access to “culturally appropriate care, and provides community wellness outreach and education.” He said that, in addition to programs at the Center which address disparities, his hospital has also established teams of doctors, nurses, case managers, and transitional care nurses to help redirect patients to “more appropriate, less costly services, such as primary care, urgent care, home care, and subacute care,” when it is in the patient’s best interest.
Not only are Adventist’s hospitalists aware of community resources available to their patients, they are also culturally diverse, Dr. Smothers said, noting that they are “well equipped to manage our diverse patient population, including those who lack adequate health care.”
Additionally, Dr. Smothers said: “We engage our hospitalists in care coordination, encouraging them to make recommendations on alternative treatment locations and/or options at the point of entry.” And all admitted patients with chronic conditions are provided with a month’s supply of medication and schedule transportation for their follow-up appointment upon discharge.
“We need to inquire about social determinants that may prohibit our success with our patients,” said Dr. Fitterman. “You are not always going to be able to fix it, but it doesn’t mean you shouldn’t try.”
References
1. Braveman P, et al. What is health equity? And what difference does a definition make? Robert Wood Johnson Foundation. Published May 2017. Accessed July 15, 2017.
2. Communities in Action: Pathways to Health Equity. National Academies of Sciences, Engineering and Medicine. Published Jan. 11, 2017. Accessed July 15, 2017.
Heart failure readmission penalties linked with rise in deaths
ANAHEIM, CALIF. – Evidence continues to mount that Medicare’s penalization of hospitals with excess heart failure readmissions has cut readmissions but at the apparent price of more deaths.
During the penalty phase of the Hospital Readmission Reduction Program (HRRP), which started in Oct. 2012, 30-day all-cause mortality following a heart failure hospitalization was 18% higher compared with the adjusted rate during 2006-2010, based on Medicare data from 2006-2014 that underwent “extensive” risk adjustment using prospectively-collected clinical data, Gregg C. Fonarow, MD, and his associates reported in a poster at the American Heart Association scientific sessions. During the same 2012-2014 period with imposed penalties, 30-day all-cause readmissions following an index heart failure hospitalization fell by a risk-adjusted 9% compared to the era just before the HRRP. Both the drop in readmissions and rise in deaths were statistically significant.
A similar pattern existed for the risk-adjusted readmissions and mortality rates during the year following the index hospitalization: readmissions fell by 8% compared with the time before the program but deaths rose by a relative 10%, also statistically significant differences.
“This is urgent and alarming. The Centers for Medicare & Medicaid Services needs to revamp the program to exclude heart failure patients and take steps to mitigate the damage,” Dr. Fonarow said in an interview. He estimated that the uptick in mortality following heart failure hospitalizations is causing 5,000-10,000 excess annual deaths among U.S. heart failure patients that are directly attributable to the HRRP. Similar effects have not been seen for patients with an index hospitalization of pneumonia or acute MI, two other targets of the HRRP, he noted.
The HRRP “currently has penalties for readmissions that are 15-fold higher than for mortality. They need to penalize equally, and they need to get at the gaming that hospitals are doing” to shift outcomes away from readmissions even if it means more patients will die. Heart failure patients “who need hospitalization are being denied admission by hospitals out of fear of the readmissions penalty,” said Dr. Fonarow, professor and co-chief of cardiology at the University of California, Los Angeles. “Seeing increased mortality linked with implementation of the penalty is completely unacceptable.”
Although a prior report used similar Medicare data from 2008-2014 to initially find this inverse association, that analysis relied entirely on administrative data collected in Medicare records to perform risk adjustments (JAMA. 2017 July 17;318[3]:270-8). The new analysis reported by Dr. Fonarow and his associates combined the Medicare data with detailed clinical records for the same patients collected by the Get With the Guidelines--Heart Failure program. The extensive clinical data that the researchers used for risk-adjustment allowed for a more reliable attribution to the HRRP of readmission and mortality differences between the two time periods. Despite the extensive risk adjustment “we see exactly the same result” as initially reported, Dr. Fonarow said.
The findings “remind us that it is very important to look at the unintended consequences” of interventions that might initially seem reasonable, commented Lynne Warner Stevenson, MD, professor and director of cardiomyopathy at Vanderbilt University in Nashville, Tenn.
Concurrent with the presentation at the meeting the results also appeared in an article published online (JAMA Cardiol. 2017 Nov 12;doi:10.1001/jamacardio.2017.4265).
A separate analysis of data collected in the Get With the Guidelines--Heart Failure during 2005-2009 showed that within the past decade the 5-year survival of U.S. hospitalized heart failure patients has remained dismally low, and similar regardless of whether patients had heart failure with reduced ejection fraction (HFrEF, 46% of all heart failure patients in the analysis), heart failure with preserved ejection fraction (HFpEF, also 46% of patients), or the in-between patients who had heart failure with borderline ejection fraction (HFbEF, an ejection fraction of 41%-49%, in 8% of patients).
The results, from 39,982 patients, showed a 75% mortality rate during 5-years of follow-up, with similar mortality rates regardless of the patient’s ejection-fraction level, reported Dr. Fonarow and his associates in a separate poster. In every age group examined, patients with heart failure had dramatically reduced life expectancies compared with the general population. For example, among heart failure patients aged 65-69 years in the study, median survival was less than 4 years compared with a 19-year expected median survival for people in the general U.S. population in the same age range.
These very low survival rates of heart failure patients initially hospitalized for heart failure during the relatively recent era of 2005-2009 “is a call to action to prevent heart failure,” said Dr. Fonarow.
The poor prognosis most heart failure patients face should also spur aggressive treatment of HFrEF patients with all proven treatments, Dr. Fonarow said. It should also spur more effort to find effective treatments for HFpEF, which currently has no clearly-proven effective treatment.
These results also appeared in a report simultaneously published online (J Amer Coll Cardiol. 2017 Nov 12;doi: 10.1016/j.jacc.2017.08.074).
[email protected]
On Twitter @mitchelzoler
ANAHEIM, CALIF. – Evidence continues to mount that Medicare’s penalization of hospitals with excess heart failure readmissions has cut readmissions but at the apparent price of more deaths.
During the penalty phase of the Hospital Readmission Reduction Program (HRRP), which started in Oct. 2012, 30-day all-cause mortality following a heart failure hospitalization was 18% higher compared with the adjusted rate during 2006-2010, based on Medicare data from 2006-2014 that underwent “extensive” risk adjustment using prospectively-collected clinical data, Gregg C. Fonarow, MD, and his associates reported in a poster at the American Heart Association scientific sessions. During the same 2012-2014 period with imposed penalties, 30-day all-cause readmissions following an index heart failure hospitalization fell by a risk-adjusted 9% compared to the era just before the HRRP. Both the drop in readmissions and rise in deaths were statistically significant.
A similar pattern existed for the risk-adjusted readmissions and mortality rates during the year following the index hospitalization: readmissions fell by 8% compared with the time before the program but deaths rose by a relative 10%, also statistically significant differences.
“This is urgent and alarming. The Centers for Medicare & Medicaid Services needs to revamp the program to exclude heart failure patients and take steps to mitigate the damage,” Dr. Fonarow said in an interview. He estimated that the uptick in mortality following heart failure hospitalizations is causing 5,000-10,000 excess annual deaths among U.S. heart failure patients that are directly attributable to the HRRP. Similar effects have not been seen for patients with an index hospitalization of pneumonia or acute MI, two other targets of the HRRP, he noted.
The HRRP “currently has penalties for readmissions that are 15-fold higher than for mortality. They need to penalize equally, and they need to get at the gaming that hospitals are doing” to shift outcomes away from readmissions even if it means more patients will die. Heart failure patients “who need hospitalization are being denied admission by hospitals out of fear of the readmissions penalty,” said Dr. Fonarow, professor and co-chief of cardiology at the University of California, Los Angeles. “Seeing increased mortality linked with implementation of the penalty is completely unacceptable.”
Although a prior report used similar Medicare data from 2008-2014 to initially find this inverse association, that analysis relied entirely on administrative data collected in Medicare records to perform risk adjustments (JAMA. 2017 July 17;318[3]:270-8). The new analysis reported by Dr. Fonarow and his associates combined the Medicare data with detailed clinical records for the same patients collected by the Get With the Guidelines--Heart Failure program. The extensive clinical data that the researchers used for risk-adjustment allowed for a more reliable attribution to the HRRP of readmission and mortality differences between the two time periods. Despite the extensive risk adjustment “we see exactly the same result” as initially reported, Dr. Fonarow said.
The findings “remind us that it is very important to look at the unintended consequences” of interventions that might initially seem reasonable, commented Lynne Warner Stevenson, MD, professor and director of cardiomyopathy at Vanderbilt University in Nashville, Tenn.
Concurrent with the presentation at the meeting the results also appeared in an article published online (JAMA Cardiol. 2017 Nov 12;doi:10.1001/jamacardio.2017.4265).
A separate analysis of data collected in the Get With the Guidelines--Heart Failure during 2005-2009 showed that within the past decade the 5-year survival of U.S. hospitalized heart failure patients has remained dismally low, and similar regardless of whether patients had heart failure with reduced ejection fraction (HFrEF, 46% of all heart failure patients in the analysis), heart failure with preserved ejection fraction (HFpEF, also 46% of patients), or the in-between patients who had heart failure with borderline ejection fraction (HFbEF, an ejection fraction of 41%-49%, in 8% of patients).
The results, from 39,982 patients, showed a 75% mortality rate during 5-years of follow-up, with similar mortality rates regardless of the patient’s ejection-fraction level, reported Dr. Fonarow and his associates in a separate poster. In every age group examined, patients with heart failure had dramatically reduced life expectancies compared with the general population. For example, among heart failure patients aged 65-69 years in the study, median survival was less than 4 years compared with a 19-year expected median survival for people in the general U.S. population in the same age range.
These very low survival rates of heart failure patients initially hospitalized for heart failure during the relatively recent era of 2005-2009 “is a call to action to prevent heart failure,” said Dr. Fonarow.
The poor prognosis most heart failure patients face should also spur aggressive treatment of HFrEF patients with all proven treatments, Dr. Fonarow said. It should also spur more effort to find effective treatments for HFpEF, which currently has no clearly-proven effective treatment.
These results also appeared in a report simultaneously published online (J Amer Coll Cardiol. 2017 Nov 12;doi: 10.1016/j.jacc.2017.08.074).
[email protected]
On Twitter @mitchelzoler
ANAHEIM, CALIF. – Evidence continues to mount that Medicare’s penalization of hospitals with excess heart failure readmissions has cut readmissions but at the apparent price of more deaths.
During the penalty phase of the Hospital Readmission Reduction Program (HRRP), which started in Oct. 2012, 30-day all-cause mortality following a heart failure hospitalization was 18% higher compared with the adjusted rate during 2006-2010, based on Medicare data from 2006-2014 that underwent “extensive” risk adjustment using prospectively-collected clinical data, Gregg C. Fonarow, MD, and his associates reported in a poster at the American Heart Association scientific sessions. During the same 2012-2014 period with imposed penalties, 30-day all-cause readmissions following an index heart failure hospitalization fell by a risk-adjusted 9% compared to the era just before the HRRP. Both the drop in readmissions and rise in deaths were statistically significant.
A similar pattern existed for the risk-adjusted readmissions and mortality rates during the year following the index hospitalization: readmissions fell by 8% compared with the time before the program but deaths rose by a relative 10%, also statistically significant differences.
“This is urgent and alarming. The Centers for Medicare & Medicaid Services needs to revamp the program to exclude heart failure patients and take steps to mitigate the damage,” Dr. Fonarow said in an interview. He estimated that the uptick in mortality following heart failure hospitalizations is causing 5,000-10,000 excess annual deaths among U.S. heart failure patients that are directly attributable to the HRRP. Similar effects have not been seen for patients with an index hospitalization of pneumonia or acute MI, two other targets of the HRRP, he noted.
The HRRP “currently has penalties for readmissions that are 15-fold higher than for mortality. They need to penalize equally, and they need to get at the gaming that hospitals are doing” to shift outcomes away from readmissions even if it means more patients will die. Heart failure patients “who need hospitalization are being denied admission by hospitals out of fear of the readmissions penalty,” said Dr. Fonarow, professor and co-chief of cardiology at the University of California, Los Angeles. “Seeing increased mortality linked with implementation of the penalty is completely unacceptable.”
Although a prior report used similar Medicare data from 2008-2014 to initially find this inverse association, that analysis relied entirely on administrative data collected in Medicare records to perform risk adjustments (JAMA. 2017 July 17;318[3]:270-8). The new analysis reported by Dr. Fonarow and his associates combined the Medicare data with detailed clinical records for the same patients collected by the Get With the Guidelines--Heart Failure program. The extensive clinical data that the researchers used for risk-adjustment allowed for a more reliable attribution to the HRRP of readmission and mortality differences between the two time periods. Despite the extensive risk adjustment “we see exactly the same result” as initially reported, Dr. Fonarow said.
The findings “remind us that it is very important to look at the unintended consequences” of interventions that might initially seem reasonable, commented Lynne Warner Stevenson, MD, professor and director of cardiomyopathy at Vanderbilt University in Nashville, Tenn.
Concurrent with the presentation at the meeting the results also appeared in an article published online (JAMA Cardiol. 2017 Nov 12;doi:10.1001/jamacardio.2017.4265).
A separate analysis of data collected in the Get With the Guidelines--Heart Failure during 2005-2009 showed that within the past decade the 5-year survival of U.S. hospitalized heart failure patients has remained dismally low, and similar regardless of whether patients had heart failure with reduced ejection fraction (HFrEF, 46% of all heart failure patients in the analysis), heart failure with preserved ejection fraction (HFpEF, also 46% of patients), or the in-between patients who had heart failure with borderline ejection fraction (HFbEF, an ejection fraction of 41%-49%, in 8% of patients).
The results, from 39,982 patients, showed a 75% mortality rate during 5-years of follow-up, with similar mortality rates regardless of the patient’s ejection-fraction level, reported Dr. Fonarow and his associates in a separate poster. In every age group examined, patients with heart failure had dramatically reduced life expectancies compared with the general population. For example, among heart failure patients aged 65-69 years in the study, median survival was less than 4 years compared with a 19-year expected median survival for people in the general U.S. population in the same age range.
These very low survival rates of heart failure patients initially hospitalized for heart failure during the relatively recent era of 2005-2009 “is a call to action to prevent heart failure,” said Dr. Fonarow.
The poor prognosis most heart failure patients face should also spur aggressive treatment of HFrEF patients with all proven treatments, Dr. Fonarow said. It should also spur more effort to find effective treatments for HFpEF, which currently has no clearly-proven effective treatment.
These results also appeared in a report simultaneously published online (J Amer Coll Cardiol. 2017 Nov 12;doi: 10.1016/j.jacc.2017.08.074).
[email protected]
On Twitter @mitchelzoler
AT THE AHA SCIENTIFIC SESSIONS
Key clinical point:
Major finding: Risk-adjusted 30-day readmissions fell by a relative 9% during the reduction program but relative mortality rose by 18%.
Data source: Review of 115,245 Medicare beneficiaries with heart failure treated at hospitals in the Get With the Guidelines--Heart Failure program.
Disclosures: Dr. Fonarow has been a consultant to Amgen, Janssen, Medtronic, Novartis, and St. Jude. Dr. Stevenson has been a consultant to Abbott, has received travel support from St. Jude, and has received research funding and food from Novartis.
DACA: Time to act
President Trump recently announced his decision to officially end the Deferred Action for Childhood Arrivals program, also known as DACA. The program has been controversial since its inception, almost as controversial as the decision to end it. What impact has DACA had on the medical community, including hospitalists, and what are the implications of ending it?
DACA is a program started in 2012 by an executive action under the Obama administration. The program currently protects approximately 800,000 undocumented immigrants in the United States from being deported. All DACA recipients were brought to this country illegally as children. When the DACA program began, in order to enroll, recipients had to prove that they had arrived to here before age 16, and that they had been living in the United States continuously since 2007. Once enrolled, the protections they receive from the program include the ability to legally work and to go to school, as well as obtain a social security number and driver’s license. These protections are then afforded for renewable 2-year periods of time.1
When Trump was elected, the controversy over continuing the DACA program accelerated. Understandably, the volume of applications rose substantially, with some estimating ~8,000 renewal requests being filed each week since the election. As such, many estimate the number of illegal immigrants affected by DACA has reached almost 1 million.1
One of the reasons the Trump administration feels compelled to dismantle the program is they contend that DACA is unconstitutional, as it was established purely by executive order. In the meantime, Trump is urging Congress to replace DACA with some type of equivalent legislation. According to his staffers, the dismantling of DACA means:
- No new applications will be accepted.
- All existing permits will be honored until they expire.
- All applications in process will continue to be processed.
They contend that no current DACA recipients will be affected before March 2018. Unfortunately for the Trump administration, this has been a very unpopular move, as two-thirds of Americans support allowing the Dreamers to stay in the United States.1
Impact on health care
The concern for the medical industry is that a “dismantling” of DACA could exacerbate an already existing physician shortage in the United States. For example, the Association of American Medical Colleges estimates the physician shortage will rise as the population ages and medical access increases; they currently estimate a physician shortage of approximately 40,000-104,000 by 2030.
But objectively evaluating the impact of the DACA program on the medical industry is difficult. We do know that most of the DACA recipients arrived from Mexico, El Salvador, Guatemala, and Honduras, as well as from Asia (primarily South Korea and the Philippines). We also know they reside in every state, with the largest numbers in California (222,795), Texas (124,300), New York (41,970), Illinois (42,376), and Florida (32,795). Most appear to be using DACA to work and to go to school; in a recent survey, 91% were employed, and 45% were enrolled in school.1
Pertaining specifically to medical school, during the 2016-2017 school year, there were 113 DACA applicants to U.S. medical schools, 65 of which were accepted and enrolled. The AAMC expects the 2017-2018 enrollment to be even higher. Almost half of medical school enrollees attend Loyola University Chicago, Maywood, Ill.; this year alone, Loyola Stritch Medical School enrolled 32 DACA medical students. This is because, in 2013, Loyola was the first medical school nationwide to openly accept students with DACA status. They did this by creating a mechanism for DACA medical students to get student loans.
One of the biggest challenges for DACA students is paying for school, as they are not eligible for federal student loans. To remove this barrier, Loyola created a loan program through the Illinois Finance Authority, which offers interest-free loans to DACA students if they commit to paying back the principal and working after medical school for 4 years in an underserved area in Illinois. It is clear that no medical school in the country will feel the effects of the DACA dismantling more than will Loyola.3
Another unintended issue that the dismantling of DACA can have on the medical industry is the temptation for undocumented immigrants to avoid seeking medical care, for fear of being discovered and deported. Such delays in seeking care can result in these patients presenting with significant and expensive medical issues.
So what are the options for Congress and what is the likely fate of these DACA recipients whose lives have been placed in limbo? Proposals introduced to date include:
- The Bridge Act, which effectively extends the present DACA program by 3 years.
- Recognizing America’s Children Act, which would allow people who meet DACA eligibility criteria to apply for conditional permanent residence with a path toward citizenship.
- The American Hope Act and updated DREAM Act, both of which propose broader eligibility criteria and faster pathways to citizenship.4
There is great hope that some definitive action can be employed by Congress, as most legislators on both sides of the aisle have expressed some support for at least one of the proposed policies (although that certainly does not guarantee sufficient votes to pass). There also is support from many Americans, given that most DACA recipients have been productive members of society, and most Americans believe that DACA recipients should not be held accountable “for the sins of their parents.”4
It appears that the dismantling of DACA would be quite unsettling and certainly would affect some areas of the country more severely than others. Regardless of political stance, everyone can agree that Congress needs to do something, as the ambiguity and uncertainty caused by a million undocumented immigrants living and working in the United States cannot be ignored or indefinitely deferred. Any of the above options that offer a pathway to citizenship would be welcomed by most Americans. Having Dreamers in limbo is bad for everyone; the time to act is now.
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. http://www.npr.org/2017/09/05/548754723/5-things-you-should-know-about-daca
2. https://www.forbes.com/sites/brucejapsen/2017/09/05/how-trumps-move-to-end-daca-worsens-the-doctor-shortage/#5143320d5b06
3. http://www.chicagomag.com/city-life/September-2017/DACA-Stritch-Medical-School/
4. http://www.nejm.org/doi/full/10.1056/NEJMp1711416?query=TOC
President Trump recently announced his decision to officially end the Deferred Action for Childhood Arrivals program, also known as DACA. The program has been controversial since its inception, almost as controversial as the decision to end it. What impact has DACA had on the medical community, including hospitalists, and what are the implications of ending it?
DACA is a program started in 2012 by an executive action under the Obama administration. The program currently protects approximately 800,000 undocumented immigrants in the United States from being deported. All DACA recipients were brought to this country illegally as children. When the DACA program began, in order to enroll, recipients had to prove that they had arrived to here before age 16, and that they had been living in the United States continuously since 2007. Once enrolled, the protections they receive from the program include the ability to legally work and to go to school, as well as obtain a social security number and driver’s license. These protections are then afforded for renewable 2-year periods of time.1
When Trump was elected, the controversy over continuing the DACA program accelerated. Understandably, the volume of applications rose substantially, with some estimating ~8,000 renewal requests being filed each week since the election. As such, many estimate the number of illegal immigrants affected by DACA has reached almost 1 million.1
One of the reasons the Trump administration feels compelled to dismantle the program is they contend that DACA is unconstitutional, as it was established purely by executive order. In the meantime, Trump is urging Congress to replace DACA with some type of equivalent legislation. According to his staffers, the dismantling of DACA means:
- No new applications will be accepted.
- All existing permits will be honored until they expire.
- All applications in process will continue to be processed.
They contend that no current DACA recipients will be affected before March 2018. Unfortunately for the Trump administration, this has been a very unpopular move, as two-thirds of Americans support allowing the Dreamers to stay in the United States.1
Impact on health care
The concern for the medical industry is that a “dismantling” of DACA could exacerbate an already existing physician shortage in the United States. For example, the Association of American Medical Colleges estimates the physician shortage will rise as the population ages and medical access increases; they currently estimate a physician shortage of approximately 40,000-104,000 by 2030.
But objectively evaluating the impact of the DACA program on the medical industry is difficult. We do know that most of the DACA recipients arrived from Mexico, El Salvador, Guatemala, and Honduras, as well as from Asia (primarily South Korea and the Philippines). We also know they reside in every state, with the largest numbers in California (222,795), Texas (124,300), New York (41,970), Illinois (42,376), and Florida (32,795). Most appear to be using DACA to work and to go to school; in a recent survey, 91% were employed, and 45% were enrolled in school.1
Pertaining specifically to medical school, during the 2016-2017 school year, there were 113 DACA applicants to U.S. medical schools, 65 of which were accepted and enrolled. The AAMC expects the 2017-2018 enrollment to be even higher. Almost half of medical school enrollees attend Loyola University Chicago, Maywood, Ill.; this year alone, Loyola Stritch Medical School enrolled 32 DACA medical students. This is because, in 2013, Loyola was the first medical school nationwide to openly accept students with DACA status. They did this by creating a mechanism for DACA medical students to get student loans.
One of the biggest challenges for DACA students is paying for school, as they are not eligible for federal student loans. To remove this barrier, Loyola created a loan program through the Illinois Finance Authority, which offers interest-free loans to DACA students if they commit to paying back the principal and working after medical school for 4 years in an underserved area in Illinois. It is clear that no medical school in the country will feel the effects of the DACA dismantling more than will Loyola.3
Another unintended issue that the dismantling of DACA can have on the medical industry is the temptation for undocumented immigrants to avoid seeking medical care, for fear of being discovered and deported. Such delays in seeking care can result in these patients presenting with significant and expensive medical issues.
So what are the options for Congress and what is the likely fate of these DACA recipients whose lives have been placed in limbo? Proposals introduced to date include:
- The Bridge Act, which effectively extends the present DACA program by 3 years.
- Recognizing America’s Children Act, which would allow people who meet DACA eligibility criteria to apply for conditional permanent residence with a path toward citizenship.
- The American Hope Act and updated DREAM Act, both of which propose broader eligibility criteria and faster pathways to citizenship.4
There is great hope that some definitive action can be employed by Congress, as most legislators on both sides of the aisle have expressed some support for at least one of the proposed policies (although that certainly does not guarantee sufficient votes to pass). There also is support from many Americans, given that most DACA recipients have been productive members of society, and most Americans believe that DACA recipients should not be held accountable “for the sins of their parents.”4
It appears that the dismantling of DACA would be quite unsettling and certainly would affect some areas of the country more severely than others. Regardless of political stance, everyone can agree that Congress needs to do something, as the ambiguity and uncertainty caused by a million undocumented immigrants living and working in the United States cannot be ignored or indefinitely deferred. Any of the above options that offer a pathway to citizenship would be welcomed by most Americans. Having Dreamers in limbo is bad for everyone; the time to act is now.
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. http://www.npr.org/2017/09/05/548754723/5-things-you-should-know-about-daca
2. https://www.forbes.com/sites/brucejapsen/2017/09/05/how-trumps-move-to-end-daca-worsens-the-doctor-shortage/#5143320d5b06
3. http://www.chicagomag.com/city-life/September-2017/DACA-Stritch-Medical-School/
4. http://www.nejm.org/doi/full/10.1056/NEJMp1711416?query=TOC
President Trump recently announced his decision to officially end the Deferred Action for Childhood Arrivals program, also known as DACA. The program has been controversial since its inception, almost as controversial as the decision to end it. What impact has DACA had on the medical community, including hospitalists, and what are the implications of ending it?
DACA is a program started in 2012 by an executive action under the Obama administration. The program currently protects approximately 800,000 undocumented immigrants in the United States from being deported. All DACA recipients were brought to this country illegally as children. When the DACA program began, in order to enroll, recipients had to prove that they had arrived to here before age 16, and that they had been living in the United States continuously since 2007. Once enrolled, the protections they receive from the program include the ability to legally work and to go to school, as well as obtain a social security number and driver’s license. These protections are then afforded for renewable 2-year periods of time.1
When Trump was elected, the controversy over continuing the DACA program accelerated. Understandably, the volume of applications rose substantially, with some estimating ~8,000 renewal requests being filed each week since the election. As such, many estimate the number of illegal immigrants affected by DACA has reached almost 1 million.1
One of the reasons the Trump administration feels compelled to dismantle the program is they contend that DACA is unconstitutional, as it was established purely by executive order. In the meantime, Trump is urging Congress to replace DACA with some type of equivalent legislation. According to his staffers, the dismantling of DACA means:
- No new applications will be accepted.
- All existing permits will be honored until they expire.
- All applications in process will continue to be processed.
They contend that no current DACA recipients will be affected before March 2018. Unfortunately for the Trump administration, this has been a very unpopular move, as two-thirds of Americans support allowing the Dreamers to stay in the United States.1
Impact on health care
The concern for the medical industry is that a “dismantling” of DACA could exacerbate an already existing physician shortage in the United States. For example, the Association of American Medical Colleges estimates the physician shortage will rise as the population ages and medical access increases; they currently estimate a physician shortage of approximately 40,000-104,000 by 2030.
But objectively evaluating the impact of the DACA program on the medical industry is difficult. We do know that most of the DACA recipients arrived from Mexico, El Salvador, Guatemala, and Honduras, as well as from Asia (primarily South Korea and the Philippines). We also know they reside in every state, with the largest numbers in California (222,795), Texas (124,300), New York (41,970), Illinois (42,376), and Florida (32,795). Most appear to be using DACA to work and to go to school; in a recent survey, 91% were employed, and 45% were enrolled in school.1
Pertaining specifically to medical school, during the 2016-2017 school year, there were 113 DACA applicants to U.S. medical schools, 65 of which were accepted and enrolled. The AAMC expects the 2017-2018 enrollment to be even higher. Almost half of medical school enrollees attend Loyola University Chicago, Maywood, Ill.; this year alone, Loyola Stritch Medical School enrolled 32 DACA medical students. This is because, in 2013, Loyola was the first medical school nationwide to openly accept students with DACA status. They did this by creating a mechanism for DACA medical students to get student loans.
One of the biggest challenges for DACA students is paying for school, as they are not eligible for federal student loans. To remove this barrier, Loyola created a loan program through the Illinois Finance Authority, which offers interest-free loans to DACA students if they commit to paying back the principal and working after medical school for 4 years in an underserved area in Illinois. It is clear that no medical school in the country will feel the effects of the DACA dismantling more than will Loyola.3
Another unintended issue that the dismantling of DACA can have on the medical industry is the temptation for undocumented immigrants to avoid seeking medical care, for fear of being discovered and deported. Such delays in seeking care can result in these patients presenting with significant and expensive medical issues.
So what are the options for Congress and what is the likely fate of these DACA recipients whose lives have been placed in limbo? Proposals introduced to date include:
- The Bridge Act, which effectively extends the present DACA program by 3 years.
- Recognizing America’s Children Act, which would allow people who meet DACA eligibility criteria to apply for conditional permanent residence with a path toward citizenship.
- The American Hope Act and updated DREAM Act, both of which propose broader eligibility criteria and faster pathways to citizenship.4
There is great hope that some definitive action can be employed by Congress, as most legislators on both sides of the aisle have expressed some support for at least one of the proposed policies (although that certainly does not guarantee sufficient votes to pass). There also is support from many Americans, given that most DACA recipients have been productive members of society, and most Americans believe that DACA recipients should not be held accountable “for the sins of their parents.”4
It appears that the dismantling of DACA would be quite unsettling and certainly would affect some areas of the country more severely than others. Regardless of political stance, everyone can agree that Congress needs to do something, as the ambiguity and uncertainty caused by a million undocumented immigrants living and working in the United States cannot be ignored or indefinitely deferred. Any of the above options that offer a pathway to citizenship would be welcomed by most Americans. Having Dreamers in limbo is bad for everyone; the time to act is now.
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. http://www.npr.org/2017/09/05/548754723/5-things-you-should-know-about-daca
2. https://www.forbes.com/sites/brucejapsen/2017/09/05/how-trumps-move-to-end-daca-worsens-the-doctor-shortage/#5143320d5b06
3. http://www.chicagomag.com/city-life/September-2017/DACA-Stritch-Medical-School/
4. http://www.nejm.org/doi/full/10.1056/NEJMp1711416?query=TOC
SHM pushes to protect patients from ‘surprise’ out-of-network expenses
Patients entering a hospital should not be on the hook for costs related to out-of-network insurance coverage when that hospital is in-network, according to the Society of Hospital Medicine and other major medical societies, especially if it is an emergency situation and the patient is unable to make an informed choice regarding who is administering care to them.
“We want to see it come to a resolution that does not put patients in jeopardy for paying these extra costs when they are going a hospital that is in-network, and they assume that the physicians are in-network,” Ron Greeno, MD, FCCP, MHM, president of the Society of Hospital Medicine, said in an interview.
Other groups signing onto the resolution include the American College of Emergency Physicians, the American Academy of Orthopedic Surgeons, the American College of Radiology, the American Society of Anesthesiologists, the College of American Pathologists, the American Association of Neurological Surgeons, and the Congress of Neurological Surgeons.
“States are tackling this on a state-by-state basis and creating laws that are meant to protect patients from being placed in legal jeopardy,” Dr. Greeno said. “But you still want to maintain the rights of the health plan and the physicians to negotiate in good faith. That is basically the stance we take.”
According to Dr. Greeno, the joint resolution passed at the AMA meeting was “designed to make recommendations to states who are considering such laws.” The medical societies want to provide guidance on what to include in those laws that will make the process fair. “If you have a law that says ‘out of network doctors cannot balance bill at a hospital that is in-network,’ then the health plans have no reason to negotiate in good faith,” he said. “They will just pay those doctors whatever they feel like paying them.”
Ultimately, though, the resolution was about medical societies affirming their desire to protect patients from burdensome, unexpected bills.
“We want to make sure whatever laws are passed that they actually protect the patients while maintaining the ability of physicians and health plans to negotiate in good faith to a mutual resolution,” Dr. Greeno said.
Patients entering a hospital should not be on the hook for costs related to out-of-network insurance coverage when that hospital is in-network, according to the Society of Hospital Medicine and other major medical societies, especially if it is an emergency situation and the patient is unable to make an informed choice regarding who is administering care to them.
“We want to see it come to a resolution that does not put patients in jeopardy for paying these extra costs when they are going a hospital that is in-network, and they assume that the physicians are in-network,” Ron Greeno, MD, FCCP, MHM, president of the Society of Hospital Medicine, said in an interview.
Other groups signing onto the resolution include the American College of Emergency Physicians, the American Academy of Orthopedic Surgeons, the American College of Radiology, the American Society of Anesthesiologists, the College of American Pathologists, the American Association of Neurological Surgeons, and the Congress of Neurological Surgeons.
“States are tackling this on a state-by-state basis and creating laws that are meant to protect patients from being placed in legal jeopardy,” Dr. Greeno said. “But you still want to maintain the rights of the health plan and the physicians to negotiate in good faith. That is basically the stance we take.”
According to Dr. Greeno, the joint resolution passed at the AMA meeting was “designed to make recommendations to states who are considering such laws.” The medical societies want to provide guidance on what to include in those laws that will make the process fair. “If you have a law that says ‘out of network doctors cannot balance bill at a hospital that is in-network,’ then the health plans have no reason to negotiate in good faith,” he said. “They will just pay those doctors whatever they feel like paying them.”
Ultimately, though, the resolution was about medical societies affirming their desire to protect patients from burdensome, unexpected bills.
“We want to make sure whatever laws are passed that they actually protect the patients while maintaining the ability of physicians and health plans to negotiate in good faith to a mutual resolution,” Dr. Greeno said.
Patients entering a hospital should not be on the hook for costs related to out-of-network insurance coverage when that hospital is in-network, according to the Society of Hospital Medicine and other major medical societies, especially if it is an emergency situation and the patient is unable to make an informed choice regarding who is administering care to them.
“We want to see it come to a resolution that does not put patients in jeopardy for paying these extra costs when they are going a hospital that is in-network, and they assume that the physicians are in-network,” Ron Greeno, MD, FCCP, MHM, president of the Society of Hospital Medicine, said in an interview.
Other groups signing onto the resolution include the American College of Emergency Physicians, the American Academy of Orthopedic Surgeons, the American College of Radiology, the American Society of Anesthesiologists, the College of American Pathologists, the American Association of Neurological Surgeons, and the Congress of Neurological Surgeons.
“States are tackling this on a state-by-state basis and creating laws that are meant to protect patients from being placed in legal jeopardy,” Dr. Greeno said. “But you still want to maintain the rights of the health plan and the physicians to negotiate in good faith. That is basically the stance we take.”
According to Dr. Greeno, the joint resolution passed at the AMA meeting was “designed to make recommendations to states who are considering such laws.” The medical societies want to provide guidance on what to include in those laws that will make the process fair. “If you have a law that says ‘out of network doctors cannot balance bill at a hospital that is in-network,’ then the health plans have no reason to negotiate in good faith,” he said. “They will just pay those doctors whatever they feel like paying them.”
Ultimately, though, the resolution was about medical societies affirming their desire to protect patients from burdensome, unexpected bills.
“We want to make sure whatever laws are passed that they actually protect the patients while maintaining the ability of physicians and health plans to negotiate in good faith to a mutual resolution,” Dr. Greeno said.
Walking the halls of power
Hospital medicine may be a young specialty, but it is already playing a significant role in both front-line patient care and, increasingly, in shaping public policy. Case in point: Two hospitalists serving currently in key roles in the federal government, and two former top civil servants, each of whom are examples of the growing influence of the hospitalist perspective.
“The hospitalist viewpoint of the health care system is a unique one, and it lends itself very well to the challenges of our current delivery system reform. We’re reforming the health care system to deliver care more cost effectively,” said Ron Greeno, MD, FCCP, MHM, SHM president and chair of the SHM Public Policy committee. “Hospitalists are trained to do that – they go to work every day to do that.”
Leading the FDA
“He’s the perfect person for that job and is looking to shake things up,” Dr. Greeno said. “There are a lot of things that can improve in terms of how drugs get to market, including lower cost generic drugs.” That’s an issue Dr. Gottlieb has been championing for years, and his understanding of the issue also makes him well prepared to take this position now, Dr. Greeno said.
“Dr. Gottlieb’s nomination comes at a momentous time for the agency, which Mr. Trump has promised to significantly remake,” the New York Times wrote on March 29, prior to his confirmation. “The next commissioner will be charged with putting into practice a far-reaching law, passed in December, aimed at bringing drugs to market more quickly.”
In addition to his work at the AEI, Dr. Gottlieb served on SHM’s Public Policy committee. He was a clinical assistant professor at New York University School of Medicine and advised the U.S. Department of Health and Human Services as a member of the Federal Health IT Policy committee.
Steering national quality programs
Kate Goodrich’s preparation for her government role included experience with several sides of the health care system: Dr. Goodrich, MD, MHS, was the director of the Division of Hospital Medicine at George Washington University Hospital, one of the first hospitalist programs in the Washington area. She worked at an inpatient rehab facility and has practiced in ambulatory care.
Now, as chief medical officer of CMS and director of the Center for Clinical Standards and Quality (CCSQ), she’s helping drive those policy decisions, overseeing multiple quality measurement and value-based purchasing programs and health and safety standards for hospitals.
Dr. Goodrich still makes rounds at George Washington Hospital on weekends. “It allows me to have a sort of in-your-bones understanding of the challenges of frontline providers,” she said. “I’m able to understand the clinician point of view in our policy decisions.” She’s also able to see first-hand the effects of those policy decisions on clinicians, patients, and health care systems.
As physician leaders within their organizations, hospitalists fit naturally into other leadership positions, she said. “Hospitalists often take leadership roles around quality of care and efficiency and flow and those sorts of thing,” Dr. Goodrich said. “I think it is a very natural progression for hospitalists to get interested in health care and medicine from that viewpoint, which then might allow them to make a leap into another type of field.”
An innovator at CMS
Until very recently, pediatric hospitalist Patrick Conway, MD, FAAP, MHM, served as deputy administrator for Innovation and Quality at the Centers for Medicare & Medicaid Services and director of the Center for Medicare and Medicaid Innovation. On Oct. 1, he took on a new challenge, becoming president and CEO of Blue Cross and Blue Shield of North Carolina (Blue Cross NC).
Dr. Conway was selected as a Master of Hospital Medicine by SHM, and received the HHS Secretary’s Award for Distinguished Service, the Secretary’s highest distinction for excellence. The Patient Safety Movement Foundation gave him their Humanitarian Award, and in February 2017, he received the AMA’s Dr. Nathan Davis Award for Outstanding Government Service. He also was elected to the Health and Medicine Division of the National Academies of Sciences, Engineering, and Medicine in 2014.
Prior to joining CMS, Dr. Conway oversaw clinical operations and research at Cincinnati Children’s Hospital Medical Center as director of hospital medicine, with a focus on improving patient outcomes across the health system.
Improving the country’s health
Obesity, tobacco-related disease, mental illness, and addiction are some of the issues Vivek H. Murthy, MD, MBA, targeted while serving as the 19th U.S. Surgeon General. He was appointed to the position by President Obama in 2014, and was relieved of his duties by President Trump in April 2017.
Dr. Murthy has said that addiction should be seen as a chronic illness, not a character flaw, and last year sent a letter to 2.3 million health care providers nationwide, encouraging them to join a national effort to reform prescribing practices.
According to Dr. Greeno, each of these hospitalists illuminates new paths for others in the field. “I think for young people who are trying to identify what career path they want to pursue, this is something that can’t be anything but good for our specialty – and good for the health system,” he said. “Hospitalists have the perfect clinical background and mindset to help our health care system get to where it needs to go. It’s a huge challenge. It’s going to be a ton of work, and the stakes are very, very high.”
Reference
1. Thomas K. F.D.A. Nominee, Paid Millions by Industry, Says He’ll Recuse Himself if Needed. New York Times. March 29, 2017. https://www.nytimes.com/2017/03/29/health/fda-nominee-scott-gottlieb-recuse-conflicts.html?_r=0. Accessed March 31, 2017.
Hospital medicine may be a young specialty, but it is already playing a significant role in both front-line patient care and, increasingly, in shaping public policy. Case in point: Two hospitalists serving currently in key roles in the federal government, and two former top civil servants, each of whom are examples of the growing influence of the hospitalist perspective.
“The hospitalist viewpoint of the health care system is a unique one, and it lends itself very well to the challenges of our current delivery system reform. We’re reforming the health care system to deliver care more cost effectively,” said Ron Greeno, MD, FCCP, MHM, SHM president and chair of the SHM Public Policy committee. “Hospitalists are trained to do that – they go to work every day to do that.”
Leading the FDA
“He’s the perfect person for that job and is looking to shake things up,” Dr. Greeno said. “There are a lot of things that can improve in terms of how drugs get to market, including lower cost generic drugs.” That’s an issue Dr. Gottlieb has been championing for years, and his understanding of the issue also makes him well prepared to take this position now, Dr. Greeno said.
“Dr. Gottlieb’s nomination comes at a momentous time for the agency, which Mr. Trump has promised to significantly remake,” the New York Times wrote on March 29, prior to his confirmation. “The next commissioner will be charged with putting into practice a far-reaching law, passed in December, aimed at bringing drugs to market more quickly.”
In addition to his work at the AEI, Dr. Gottlieb served on SHM’s Public Policy committee. He was a clinical assistant professor at New York University School of Medicine and advised the U.S. Department of Health and Human Services as a member of the Federal Health IT Policy committee.
Steering national quality programs
Kate Goodrich’s preparation for her government role included experience with several sides of the health care system: Dr. Goodrich, MD, MHS, was the director of the Division of Hospital Medicine at George Washington University Hospital, one of the first hospitalist programs in the Washington area. She worked at an inpatient rehab facility and has practiced in ambulatory care.
Now, as chief medical officer of CMS and director of the Center for Clinical Standards and Quality (CCSQ), she’s helping drive those policy decisions, overseeing multiple quality measurement and value-based purchasing programs and health and safety standards for hospitals.
Dr. Goodrich still makes rounds at George Washington Hospital on weekends. “It allows me to have a sort of in-your-bones understanding of the challenges of frontline providers,” she said. “I’m able to understand the clinician point of view in our policy decisions.” She’s also able to see first-hand the effects of those policy decisions on clinicians, patients, and health care systems.
As physician leaders within their organizations, hospitalists fit naturally into other leadership positions, she said. “Hospitalists often take leadership roles around quality of care and efficiency and flow and those sorts of thing,” Dr. Goodrich said. “I think it is a very natural progression for hospitalists to get interested in health care and medicine from that viewpoint, which then might allow them to make a leap into another type of field.”
An innovator at CMS
Until very recently, pediatric hospitalist Patrick Conway, MD, FAAP, MHM, served as deputy administrator for Innovation and Quality at the Centers for Medicare & Medicaid Services and director of the Center for Medicare and Medicaid Innovation. On Oct. 1, he took on a new challenge, becoming president and CEO of Blue Cross and Blue Shield of North Carolina (Blue Cross NC).
Dr. Conway was selected as a Master of Hospital Medicine by SHM, and received the HHS Secretary’s Award for Distinguished Service, the Secretary’s highest distinction for excellence. The Patient Safety Movement Foundation gave him their Humanitarian Award, and in February 2017, he received the AMA’s Dr. Nathan Davis Award for Outstanding Government Service. He also was elected to the Health and Medicine Division of the National Academies of Sciences, Engineering, and Medicine in 2014.
Prior to joining CMS, Dr. Conway oversaw clinical operations and research at Cincinnati Children’s Hospital Medical Center as director of hospital medicine, with a focus on improving patient outcomes across the health system.
Improving the country’s health
Obesity, tobacco-related disease, mental illness, and addiction are some of the issues Vivek H. Murthy, MD, MBA, targeted while serving as the 19th U.S. Surgeon General. He was appointed to the position by President Obama in 2014, and was relieved of his duties by President Trump in April 2017.
Dr. Murthy has said that addiction should be seen as a chronic illness, not a character flaw, and last year sent a letter to 2.3 million health care providers nationwide, encouraging them to join a national effort to reform prescribing practices.
According to Dr. Greeno, each of these hospitalists illuminates new paths for others in the field. “I think for young people who are trying to identify what career path they want to pursue, this is something that can’t be anything but good for our specialty – and good for the health system,” he said. “Hospitalists have the perfect clinical background and mindset to help our health care system get to where it needs to go. It’s a huge challenge. It’s going to be a ton of work, and the stakes are very, very high.”
Reference
1. Thomas K. F.D.A. Nominee, Paid Millions by Industry, Says He’ll Recuse Himself if Needed. New York Times. March 29, 2017. https://www.nytimes.com/2017/03/29/health/fda-nominee-scott-gottlieb-recuse-conflicts.html?_r=0. Accessed March 31, 2017.
Hospital medicine may be a young specialty, but it is already playing a significant role in both front-line patient care and, increasingly, in shaping public policy. Case in point: Two hospitalists serving currently in key roles in the federal government, and two former top civil servants, each of whom are examples of the growing influence of the hospitalist perspective.
“The hospitalist viewpoint of the health care system is a unique one, and it lends itself very well to the challenges of our current delivery system reform. We’re reforming the health care system to deliver care more cost effectively,” said Ron Greeno, MD, FCCP, MHM, SHM president and chair of the SHM Public Policy committee. “Hospitalists are trained to do that – they go to work every day to do that.”
Leading the FDA
“He’s the perfect person for that job and is looking to shake things up,” Dr. Greeno said. “There are a lot of things that can improve in terms of how drugs get to market, including lower cost generic drugs.” That’s an issue Dr. Gottlieb has been championing for years, and his understanding of the issue also makes him well prepared to take this position now, Dr. Greeno said.
“Dr. Gottlieb’s nomination comes at a momentous time for the agency, which Mr. Trump has promised to significantly remake,” the New York Times wrote on March 29, prior to his confirmation. “The next commissioner will be charged with putting into practice a far-reaching law, passed in December, aimed at bringing drugs to market more quickly.”
In addition to his work at the AEI, Dr. Gottlieb served on SHM’s Public Policy committee. He was a clinical assistant professor at New York University School of Medicine and advised the U.S. Department of Health and Human Services as a member of the Federal Health IT Policy committee.
Steering national quality programs
Kate Goodrich’s preparation for her government role included experience with several sides of the health care system: Dr. Goodrich, MD, MHS, was the director of the Division of Hospital Medicine at George Washington University Hospital, one of the first hospitalist programs in the Washington area. She worked at an inpatient rehab facility and has practiced in ambulatory care.
Now, as chief medical officer of CMS and director of the Center for Clinical Standards and Quality (CCSQ), she’s helping drive those policy decisions, overseeing multiple quality measurement and value-based purchasing programs and health and safety standards for hospitals.
Dr. Goodrich still makes rounds at George Washington Hospital on weekends. “It allows me to have a sort of in-your-bones understanding of the challenges of frontline providers,” she said. “I’m able to understand the clinician point of view in our policy decisions.” She’s also able to see first-hand the effects of those policy decisions on clinicians, patients, and health care systems.
As physician leaders within their organizations, hospitalists fit naturally into other leadership positions, she said. “Hospitalists often take leadership roles around quality of care and efficiency and flow and those sorts of thing,” Dr. Goodrich said. “I think it is a very natural progression for hospitalists to get interested in health care and medicine from that viewpoint, which then might allow them to make a leap into another type of field.”
An innovator at CMS
Until very recently, pediatric hospitalist Patrick Conway, MD, FAAP, MHM, served as deputy administrator for Innovation and Quality at the Centers for Medicare & Medicaid Services and director of the Center for Medicare and Medicaid Innovation. On Oct. 1, he took on a new challenge, becoming president and CEO of Blue Cross and Blue Shield of North Carolina (Blue Cross NC).
Dr. Conway was selected as a Master of Hospital Medicine by SHM, and received the HHS Secretary’s Award for Distinguished Service, the Secretary’s highest distinction for excellence. The Patient Safety Movement Foundation gave him their Humanitarian Award, and in February 2017, he received the AMA’s Dr. Nathan Davis Award for Outstanding Government Service. He also was elected to the Health and Medicine Division of the National Academies of Sciences, Engineering, and Medicine in 2014.
Prior to joining CMS, Dr. Conway oversaw clinical operations and research at Cincinnati Children’s Hospital Medical Center as director of hospital medicine, with a focus on improving patient outcomes across the health system.
Improving the country’s health
Obesity, tobacco-related disease, mental illness, and addiction are some of the issues Vivek H. Murthy, MD, MBA, targeted while serving as the 19th U.S. Surgeon General. He was appointed to the position by President Obama in 2014, and was relieved of his duties by President Trump in April 2017.
Dr. Murthy has said that addiction should be seen as a chronic illness, not a character flaw, and last year sent a letter to 2.3 million health care providers nationwide, encouraging them to join a national effort to reform prescribing practices.
According to Dr. Greeno, each of these hospitalists illuminates new paths for others in the field. “I think for young people who are trying to identify what career path they want to pursue, this is something that can’t be anything but good for our specialty – and good for the health system,” he said. “Hospitalists have the perfect clinical background and mindset to help our health care system get to where it needs to go. It’s a huge challenge. It’s going to be a ton of work, and the stakes are very, very high.”
Reference
1. Thomas K. F.D.A. Nominee, Paid Millions by Industry, Says He’ll Recuse Himself if Needed. New York Times. March 29, 2017. https://www.nytimes.com/2017/03/29/health/fda-nominee-scott-gottlieb-recuse-conflicts.html?_r=0. Accessed March 31, 2017.
SHM suggests tweaks to CMS QPP proposal
The Society of Hospital Medicine approves of the direction the Centers for Medicare & Medicaid Services is heading when it comes to measuring pay-for-performance for hospitalists in its Quality Payment Program (QPP) but is suggesting some tweaks to make it a better system.
The proposed CMS 2018 update to the QPP, the value-based payment scheme developed by the Medicare Access and CHIP Reauthorization Act (MACRA), included an option that would allow all physicians who primarily practice in a hospital setting to report as a unified group under the hospital umbrella – as an alternative to reporting as an individual in the Merit-Based Incentive Payment System (MIPS) track.
He said there is lot to like in that option, although there are things that need to be changed as well.
One key area SHM would like to see changed is how time spent in a hospital is measured. In the CMS proposal, codes related to site of service capture only those in the emergency room and those admitted for in-patient services. Doctors who are seeing patients on an observation basis before they are admitted are not captured and could not be included in the facility payment.
“Observation services are virtually indistinguishable from inpatient care and frequently occur on the same wards of the hospital,” SHM said in Aug. 21, 2017, comments to CMS on the proposed QPP update, noting that observational care is built around the two-midnight rule.
“We disagree with this interpretation,” the SHM letter continues. “While it is true observation is generally time limited for a given patient, practice structures and provider scheduling have a profound [impact] on the proportion of observation care an individual clinician provides.” The letter noted that hospitalists who are on observation service could have a high proportion of observation (outpatient) billing, which could in turn exclude them from qualifying for a facility-based reporting option “despite the fact they are truly hospital-based inpatient providers.”
Dr. Greeno noted that some hospitals have hospitalists that exclusively provide observational care.
The proposal designates physicians who meet a 75% threshold of providing care in an emergency room or in-patient setting as eligible to opt into facility-based reporting.
SHM suggests that if observation services cannot be included in the 75% threshold, those services should be included and “couple the calculation with a cross-check to ensure most other billing is also hospital-based. As a further check, CMS could look at specialty codes – is the provider also enrolled in Medicare as a hospitalist?” SHM also recommends lowering the threshold “to 70% or, ideally, 60%. Due to the wide variation in hospitalist practice, we are uncomfortable with the use of thresholds in general, but lowering this threshold would at least provide a kind of safety net for hospitalists who are caring for high numbers of patients on observation.”
Another key area that needs to be addressed is the quality metrics that are used for scoring, which Dr. Greeno acknowledged is “surprisingly hard to do.”
For the 2018 reporting year, CMS is proposing that the required number of measures for the MIPS program be six, that same is it currently is for 2017. While SHM agrees with this level, “we remind CMS that even six measures may be a challenge for some providers, including hospitalists, to meet. Concerted efforts should be made to ensure that those providers who have fewer than six measures available for reporting are not disadvantaged in any way.”
Two of the six hospitalist-specific quality metrics relate to heart attacks, Dr. Seymann noted.
“Most hospitalists do take care of these patients, but they can only be reported via registry or via an electronic health record, and I don’t know that all hospitalist groups have access to reporting those ways,” Dr. Seymann said. “Most folks are reporting when they submit their billing claims. That takes two measures away from them. That may significantly decrease your score, even if you are trying your best.”
While Dr. Seymann applauded CMS for the slow rollout of the MIPS program in general, “we haven’t seen great progress as far as the growth of available relevant measures for hospitalists, and I am not confident that 2 years down the line we are going to have 12 measures to choose from.”
He did suggest that hospitalists would like a greater variety of measures and want to be measured on the quality of care they provide.
“We truly believe that the majority of hospitalist groups are really heavily invested in improving the quality of care that is provided at their hospitals – that is a big part of the culture of hospital medicine in general,” Dr. Seymann said. “We want to make our ability to succeed and participate in this program as effective as we can. We want to try to minimize barriers to hospitalists hitting this one out of the park.”
SHM also noted that certain measures rarely meet the volume threshold, which could ultimately put hospitalists at a disadvantage when it comes to receiving bonus payments.
“This is not an acceptable outcome, and we strongly urge CMS to develop a solution for providers with low-volume measures, such as removing low-volume measures from the Quality category score,” SHM wrote.
Ultimately, Dr. Greeno believes the facility reporting opt-in will survive when the rule is finalized.
“We fully expect there to be a facility-based option for hospital-based doctors, including hospitalists,” he said. “So rather than reporting on physician metrics, especially metrics through MIPS, they can get rewarded or penalized based on the hospital value-based purchasing metrics for their hospital.”
The Society of Hospital Medicine approves of the direction the Centers for Medicare & Medicaid Services is heading when it comes to measuring pay-for-performance for hospitalists in its Quality Payment Program (QPP) but is suggesting some tweaks to make it a better system.
The proposed CMS 2018 update to the QPP, the value-based payment scheme developed by the Medicare Access and CHIP Reauthorization Act (MACRA), included an option that would allow all physicians who primarily practice in a hospital setting to report as a unified group under the hospital umbrella – as an alternative to reporting as an individual in the Merit-Based Incentive Payment System (MIPS) track.
He said there is lot to like in that option, although there are things that need to be changed as well.
One key area SHM would like to see changed is how time spent in a hospital is measured. In the CMS proposal, codes related to site of service capture only those in the emergency room and those admitted for in-patient services. Doctors who are seeing patients on an observation basis before they are admitted are not captured and could not be included in the facility payment.
“Observation services are virtually indistinguishable from inpatient care and frequently occur on the same wards of the hospital,” SHM said in Aug. 21, 2017, comments to CMS on the proposed QPP update, noting that observational care is built around the two-midnight rule.
“We disagree with this interpretation,” the SHM letter continues. “While it is true observation is generally time limited for a given patient, practice structures and provider scheduling have a profound [impact] on the proportion of observation care an individual clinician provides.” The letter noted that hospitalists who are on observation service could have a high proportion of observation (outpatient) billing, which could in turn exclude them from qualifying for a facility-based reporting option “despite the fact they are truly hospital-based inpatient providers.”
Dr. Greeno noted that some hospitals have hospitalists that exclusively provide observational care.
The proposal designates physicians who meet a 75% threshold of providing care in an emergency room or in-patient setting as eligible to opt into facility-based reporting.
SHM suggests that if observation services cannot be included in the 75% threshold, those services should be included and “couple the calculation with a cross-check to ensure most other billing is also hospital-based. As a further check, CMS could look at specialty codes – is the provider also enrolled in Medicare as a hospitalist?” SHM also recommends lowering the threshold “to 70% or, ideally, 60%. Due to the wide variation in hospitalist practice, we are uncomfortable with the use of thresholds in general, but lowering this threshold would at least provide a kind of safety net for hospitalists who are caring for high numbers of patients on observation.”
Another key area that needs to be addressed is the quality metrics that are used for scoring, which Dr. Greeno acknowledged is “surprisingly hard to do.”
For the 2018 reporting year, CMS is proposing that the required number of measures for the MIPS program be six, that same is it currently is for 2017. While SHM agrees with this level, “we remind CMS that even six measures may be a challenge for some providers, including hospitalists, to meet. Concerted efforts should be made to ensure that those providers who have fewer than six measures available for reporting are not disadvantaged in any way.”
Two of the six hospitalist-specific quality metrics relate to heart attacks, Dr. Seymann noted.
“Most hospitalists do take care of these patients, but they can only be reported via registry or via an electronic health record, and I don’t know that all hospitalist groups have access to reporting those ways,” Dr. Seymann said. “Most folks are reporting when they submit their billing claims. That takes two measures away from them. That may significantly decrease your score, even if you are trying your best.”
While Dr. Seymann applauded CMS for the slow rollout of the MIPS program in general, “we haven’t seen great progress as far as the growth of available relevant measures for hospitalists, and I am not confident that 2 years down the line we are going to have 12 measures to choose from.”
He did suggest that hospitalists would like a greater variety of measures and want to be measured on the quality of care they provide.
“We truly believe that the majority of hospitalist groups are really heavily invested in improving the quality of care that is provided at their hospitals – that is a big part of the culture of hospital medicine in general,” Dr. Seymann said. “We want to make our ability to succeed and participate in this program as effective as we can. We want to try to minimize barriers to hospitalists hitting this one out of the park.”
SHM also noted that certain measures rarely meet the volume threshold, which could ultimately put hospitalists at a disadvantage when it comes to receiving bonus payments.
“This is not an acceptable outcome, and we strongly urge CMS to develop a solution for providers with low-volume measures, such as removing low-volume measures from the Quality category score,” SHM wrote.
Ultimately, Dr. Greeno believes the facility reporting opt-in will survive when the rule is finalized.
“We fully expect there to be a facility-based option for hospital-based doctors, including hospitalists,” he said. “So rather than reporting on physician metrics, especially metrics through MIPS, they can get rewarded or penalized based on the hospital value-based purchasing metrics for their hospital.”
The Society of Hospital Medicine approves of the direction the Centers for Medicare & Medicaid Services is heading when it comes to measuring pay-for-performance for hospitalists in its Quality Payment Program (QPP) but is suggesting some tweaks to make it a better system.
The proposed CMS 2018 update to the QPP, the value-based payment scheme developed by the Medicare Access and CHIP Reauthorization Act (MACRA), included an option that would allow all physicians who primarily practice in a hospital setting to report as a unified group under the hospital umbrella – as an alternative to reporting as an individual in the Merit-Based Incentive Payment System (MIPS) track.
He said there is lot to like in that option, although there are things that need to be changed as well.
One key area SHM would like to see changed is how time spent in a hospital is measured. In the CMS proposal, codes related to site of service capture only those in the emergency room and those admitted for in-patient services. Doctors who are seeing patients on an observation basis before they are admitted are not captured and could not be included in the facility payment.
“Observation services are virtually indistinguishable from inpatient care and frequently occur on the same wards of the hospital,” SHM said in Aug. 21, 2017, comments to CMS on the proposed QPP update, noting that observational care is built around the two-midnight rule.
“We disagree with this interpretation,” the SHM letter continues. “While it is true observation is generally time limited for a given patient, practice structures and provider scheduling have a profound [impact] on the proportion of observation care an individual clinician provides.” The letter noted that hospitalists who are on observation service could have a high proportion of observation (outpatient) billing, which could in turn exclude them from qualifying for a facility-based reporting option “despite the fact they are truly hospital-based inpatient providers.”
Dr. Greeno noted that some hospitals have hospitalists that exclusively provide observational care.
The proposal designates physicians who meet a 75% threshold of providing care in an emergency room or in-patient setting as eligible to opt into facility-based reporting.
SHM suggests that if observation services cannot be included in the 75% threshold, those services should be included and “couple the calculation with a cross-check to ensure most other billing is also hospital-based. As a further check, CMS could look at specialty codes – is the provider also enrolled in Medicare as a hospitalist?” SHM also recommends lowering the threshold “to 70% or, ideally, 60%. Due to the wide variation in hospitalist practice, we are uncomfortable with the use of thresholds in general, but lowering this threshold would at least provide a kind of safety net for hospitalists who are caring for high numbers of patients on observation.”
Another key area that needs to be addressed is the quality metrics that are used for scoring, which Dr. Greeno acknowledged is “surprisingly hard to do.”
For the 2018 reporting year, CMS is proposing that the required number of measures for the MIPS program be six, that same is it currently is for 2017. While SHM agrees with this level, “we remind CMS that even six measures may be a challenge for some providers, including hospitalists, to meet. Concerted efforts should be made to ensure that those providers who have fewer than six measures available for reporting are not disadvantaged in any way.”
Two of the six hospitalist-specific quality metrics relate to heart attacks, Dr. Seymann noted.
“Most hospitalists do take care of these patients, but they can only be reported via registry or via an electronic health record, and I don’t know that all hospitalist groups have access to reporting those ways,” Dr. Seymann said. “Most folks are reporting when they submit their billing claims. That takes two measures away from them. That may significantly decrease your score, even if you are trying your best.”
While Dr. Seymann applauded CMS for the slow rollout of the MIPS program in general, “we haven’t seen great progress as far as the growth of available relevant measures for hospitalists, and I am not confident that 2 years down the line we are going to have 12 measures to choose from.”
He did suggest that hospitalists would like a greater variety of measures and want to be measured on the quality of care they provide.
“We truly believe that the majority of hospitalist groups are really heavily invested in improving the quality of care that is provided at their hospitals – that is a big part of the culture of hospital medicine in general,” Dr. Seymann said. “We want to make our ability to succeed and participate in this program as effective as we can. We want to try to minimize barriers to hospitalists hitting this one out of the park.”
SHM also noted that certain measures rarely meet the volume threshold, which could ultimately put hospitalists at a disadvantage when it comes to receiving bonus payments.
“This is not an acceptable outcome, and we strongly urge CMS to develop a solution for providers with low-volume measures, such as removing low-volume measures from the Quality category score,” SHM wrote.
Ultimately, Dr. Greeno believes the facility reporting opt-in will survive when the rule is finalized.
“We fully expect there to be a facility-based option for hospital-based doctors, including hospitalists,” he said. “So rather than reporting on physician metrics, especially metrics through MIPS, they can get rewarded or penalized based on the hospital value-based purchasing metrics for their hospital.”
More studies show Medicaid expansion has benefited hospitals
In 2016, a series of studies showed the impact of Medicaid expansion on hospitals.1 The news was good: Hospitals in states that accepted Medicaid expansion through the Affordable Care Act saw dramatic reductions in their uninsured patient populations, increases in their Medicaid stays, and reductions in uncompensated care costs.1,2
In 2017, additional data continue to show that Medicaid expansion has been a boon to hospitals, including an April 2017 report published by the Urban Institute and a May 2017 analysis from The Commonwealth Fund.3,4 Both show that some of the hospitals that need it most are reaping the greatest benefits of expansion.
At the same time, Craig Garthwaite, PhD, MPP, lead author of The Commonwealth Fund report, said Medicaid expansion “wiped out roughly half of the uncompensated care faced by hospitals, with relatively little or no decline in nonexpansion states.” To date, 19 states have not expanded Medicaid.
With Medicaid facing an uncertain future, Dr. Blavin said some experts are concerned about what could happen to vulnerable hospitals if Medicaid expansion is repealed or scaled back. Indeed, President Trump and Congressional Republicans have proposed significantly altering Medicaid by either transitioning it to block grants or by capping federal funding for the entitlement.6,7
“We wanted to give people a sense of the stakes of what you’re talking about with repeal of the Affordable Care Act and go back to a system where patients are able to get emergency care at the hospital but not the complete care they get if they’re insured. We’re not going to be paying hospitals for that care, so the hospital has that coming out of their profit margin,” said Dr. Garthwaite, professor of strategy and codirector of the Health Enterprise Management Program in the Kellogg School of Management at Northwestern University, Evanston, Ill.
The Commonwealth Fund report used data from the Centers for Medicare & Medicaid Services (CMS) Hospital Cost Reports to examine 1,154 hospitals in expansion and nonexpansion states. It built on a Health Affairs study Dr. Garthwaite and his coauthors published in 2016.2 The analysis found that between 2013 and 2014, uncompensated care costs declined dramatically in expansion states and continued into 2015, falling from 3.9% to 2.3% of operating costs. Meanwhile, hospitals in nonexpansion states saw uncompensated care costs drop just 0.3-0.4 percentage points. The largest reductions were seen by hospitals providing the highest proportion of care to low-income and uninsured patients and overall savings to hospitals in expansion states amounted to $6.2 billion.
“Any contraction of the Medicaid expansion will reduce overall health insurance coverage and could have important financial implications for hospitals,” Dr. Blavin said. “We are likely to see large increases in expenses attributable to uninsured patients, declines in Medicaid revenue, and increases in uncompensated care burdens that can be a significant financial strain to hospitals.”
As part of a project supported by the Robert Wood Johnson Foundation, the Urban Institute in May 2011 began to track and study the impact of health reform. The report Dr. Blavin authored is part of this endeavor and utilized data from the American Hospital Association Annual Survey and the CMS Health Care Cost Reports to update the 2016 JAMA study. It compared hospitals in expansion states to those in nonexpansion states between fiscal years 2011 and 2015, excluding hospitals in states that expanded before January 2014. It examined hospital-reported data on uncompensated care, uncompensated care as a percentage of total hospital expenses, Medicaid revenue, Medicaid as a percentage of total revenue, operating margins, and excess margins.
The analysis found that Medicaid expansion resulted in a $3.2 million reduction in uncompensated care and a $5.0 million increase in mean annual Medicaid revenue per hospital. Expansion-state hospitals also saw improvements in excess and operating margins relative to nonexpansion state hospitals.
In Connecticut, Medicaid reimbursement rates are among the lowest in the country.8 The state uses a provider tax to finance Medicaid but, facing a budget deficit, state leaders have dramatically reduced the amount of money returned to hospitals in recent years.9
“Our Medicaid patient volume has gone up but our margins have declined because the return on investment is so low,” added Dr. Kumar, a practicing hospitalist and member of the SHM Public Policy Committee. He is concerned about what happens if Medicaid is capped or transitioned to a block grant, since “block grants have not been favorable so far … It would further squeeze us.”
In Arizona, Steve Narang, MD, MHCM, a hospitalist and CEO of Banner–University Medical Center Phoenix (B-UMCP), already knows what it’s like when Medicaid funding expands and then contracts. In 2001, the state expanded Medicaid to 100% of the federal poverty level for childless adults but then in 2011, in the throes of recession, the state froze its match on federal dollars. Prior to the freeze, charity care and bad debt made up 9% of B-UMCP’s net revenue. After the state cut to Medicaid, the hospital’s uncompensated care doubled; charity care and bad debt spiked to 20% of net revenue. Once the freeze was lifted and the state expanded Medicaid through the ACA in 2014, bad debt and charity care plummeted to 7% of revenue and remains in the single digits, Dr. Narang said.
“You hear a lot, especially in debates, about Medicaid being bad coverage … From a hospital perspective, if you’re taking care of a patient who is uninsured versus a patient with Medicaid coverage, that hospital is likely better off financially treating the patient with Medicaid coverage,” said Dr. Blavin.
“From a basic commitment to our fellow human beings, are we doing the right thing as a country?” he asked, noting that states and the federal government must address the economic realities of health care while also providing safety nets for patients. “We have to do both. But I have faith that the state and federal government will find a model and we will continue to focus on what we can control.”
References
1. Tyrrell K. Benefits of Medicaid Expansion for Hospitalists. The Hospitalist. 2016 March;2016(3). http://www.the-hospitalist.org/hospitalist/article/121832/benefits-medicaid-expansion-hospitalists. Accessed May 25, 2017.
2. Dranove D., Garthwaite C., Ody C. Uncompensated Care Decreased at Hospitals in Medicaid Expansion States but Not at Hospitals in Nonexpansion States. Health Affairs, Aug. 2016 35(8):1471-9. http://content.healthaffairs.org/content/35/8/1471.abstract. Accessed May 25, 2017.
3. Blavin F. How Has the ACA Changed Finances for Different Types of Hospitals? Updated Insights from 2015 Cost Report Data. Urban Institute. Published April 2017. Accessed May 25, 2017. http://www.urban.org/sites/default/files/publication/89446/2001215-how-has-the-aca-changed-finances-for-different-types-of-hospitals.pdf.
4. Dranove D., Garthwaite C., Ody C. The Impact of the ACA’s Medicaid Expansion on Hospitals’ Uncompensated Care Burden and the Potential Effects of Repeal. Published May 3, 2017. Accessed May 25, 2017. http://www.commonwealthfund.org/publications/issue-briefs/2017/may/aca-medicaid-expansion-hospital-uncompensated-care.
5. Blavin F. Association Between the 2014 Medicaid Expansion and US Hospital Finances. http://jamanetwork.com/journals/jama/fullarticle/2565750. JAMA 2016;316(14):1475-1483. doi:10.1001/jama.2016.14765
6. President Trump’s 2018 Budget Proposal Reduces Federal Funding for Coverage of Children in Medicaid and CHIP. Kaiser Family Foundation. Published March 23, 2017. Accessed May 25, 2017. http://kff.org/medicaid/fact-sheet/presidents-2018-budget-proposal-reduces-federal-funding-for-coverage-of-children-in-medicaid-and-chip/
7. Paradise J. Restructuring Medicaid in the American Health Care Act: Five Key Considerations. Kaiser Family Foundation. Published March 15, 2017. Accessed May 25, 2017. http://kff.org/medicaid/issue-brief/restructuring-medicaid-in-the-american-health-care-act-five-key-considerations/
8. Medicaid Hospital Payment: A comparison across states and to Medicare. MACPAC Issue Brief. Published April 2017.
9. Levin Becker A. Hospitals blast Malloy’s proposal to subject them to property taxes. Published Feb. 8, 2017. Accessed May 25, 2017. https://ctmirror.org/2017/02/08/hospitals-blast-malloys-proposal-to-subject-them-to-property-taxes/
In 2016, a series of studies showed the impact of Medicaid expansion on hospitals.1 The news was good: Hospitals in states that accepted Medicaid expansion through the Affordable Care Act saw dramatic reductions in their uninsured patient populations, increases in their Medicaid stays, and reductions in uncompensated care costs.1,2
In 2017, additional data continue to show that Medicaid expansion has been a boon to hospitals, including an April 2017 report published by the Urban Institute and a May 2017 analysis from The Commonwealth Fund.3,4 Both show that some of the hospitals that need it most are reaping the greatest benefits of expansion.
At the same time, Craig Garthwaite, PhD, MPP, lead author of The Commonwealth Fund report, said Medicaid expansion “wiped out roughly half of the uncompensated care faced by hospitals, with relatively little or no decline in nonexpansion states.” To date, 19 states have not expanded Medicaid.
With Medicaid facing an uncertain future, Dr. Blavin said some experts are concerned about what could happen to vulnerable hospitals if Medicaid expansion is repealed or scaled back. Indeed, President Trump and Congressional Republicans have proposed significantly altering Medicaid by either transitioning it to block grants or by capping federal funding for the entitlement.6,7
“We wanted to give people a sense of the stakes of what you’re talking about with repeal of the Affordable Care Act and go back to a system where patients are able to get emergency care at the hospital but not the complete care they get if they’re insured. We’re not going to be paying hospitals for that care, so the hospital has that coming out of their profit margin,” said Dr. Garthwaite, professor of strategy and codirector of the Health Enterprise Management Program in the Kellogg School of Management at Northwestern University, Evanston, Ill.
The Commonwealth Fund report used data from the Centers for Medicare & Medicaid Services (CMS) Hospital Cost Reports to examine 1,154 hospitals in expansion and nonexpansion states. It built on a Health Affairs study Dr. Garthwaite and his coauthors published in 2016.2 The analysis found that between 2013 and 2014, uncompensated care costs declined dramatically in expansion states and continued into 2015, falling from 3.9% to 2.3% of operating costs. Meanwhile, hospitals in nonexpansion states saw uncompensated care costs drop just 0.3-0.4 percentage points. The largest reductions were seen by hospitals providing the highest proportion of care to low-income and uninsured patients and overall savings to hospitals in expansion states amounted to $6.2 billion.
“Any contraction of the Medicaid expansion will reduce overall health insurance coverage and could have important financial implications for hospitals,” Dr. Blavin said. “We are likely to see large increases in expenses attributable to uninsured patients, declines in Medicaid revenue, and increases in uncompensated care burdens that can be a significant financial strain to hospitals.”
As part of a project supported by the Robert Wood Johnson Foundation, the Urban Institute in May 2011 began to track and study the impact of health reform. The report Dr. Blavin authored is part of this endeavor and utilized data from the American Hospital Association Annual Survey and the CMS Health Care Cost Reports to update the 2016 JAMA study. It compared hospitals in expansion states to those in nonexpansion states between fiscal years 2011 and 2015, excluding hospitals in states that expanded before January 2014. It examined hospital-reported data on uncompensated care, uncompensated care as a percentage of total hospital expenses, Medicaid revenue, Medicaid as a percentage of total revenue, operating margins, and excess margins.
The analysis found that Medicaid expansion resulted in a $3.2 million reduction in uncompensated care and a $5.0 million increase in mean annual Medicaid revenue per hospital. Expansion-state hospitals also saw improvements in excess and operating margins relative to nonexpansion state hospitals.
In Connecticut, Medicaid reimbursement rates are among the lowest in the country.8 The state uses a provider tax to finance Medicaid but, facing a budget deficit, state leaders have dramatically reduced the amount of money returned to hospitals in recent years.9
“Our Medicaid patient volume has gone up but our margins have declined because the return on investment is so low,” added Dr. Kumar, a practicing hospitalist and member of the SHM Public Policy Committee. He is concerned about what happens if Medicaid is capped or transitioned to a block grant, since “block grants have not been favorable so far … It would further squeeze us.”
In Arizona, Steve Narang, MD, MHCM, a hospitalist and CEO of Banner–University Medical Center Phoenix (B-UMCP), already knows what it’s like when Medicaid funding expands and then contracts. In 2001, the state expanded Medicaid to 100% of the federal poverty level for childless adults but then in 2011, in the throes of recession, the state froze its match on federal dollars. Prior to the freeze, charity care and bad debt made up 9% of B-UMCP’s net revenue. After the state cut to Medicaid, the hospital’s uncompensated care doubled; charity care and bad debt spiked to 20% of net revenue. Once the freeze was lifted and the state expanded Medicaid through the ACA in 2014, bad debt and charity care plummeted to 7% of revenue and remains in the single digits, Dr. Narang said.
“You hear a lot, especially in debates, about Medicaid being bad coverage … From a hospital perspective, if you’re taking care of a patient who is uninsured versus a patient with Medicaid coverage, that hospital is likely better off financially treating the patient with Medicaid coverage,” said Dr. Blavin.
“From a basic commitment to our fellow human beings, are we doing the right thing as a country?” he asked, noting that states and the federal government must address the economic realities of health care while also providing safety nets for patients. “We have to do both. But I have faith that the state and federal government will find a model and we will continue to focus on what we can control.”
References
1. Tyrrell K. Benefits of Medicaid Expansion for Hospitalists. The Hospitalist. 2016 March;2016(3). http://www.the-hospitalist.org/hospitalist/article/121832/benefits-medicaid-expansion-hospitalists. Accessed May 25, 2017.
2. Dranove D., Garthwaite C., Ody C. Uncompensated Care Decreased at Hospitals in Medicaid Expansion States but Not at Hospitals in Nonexpansion States. Health Affairs, Aug. 2016 35(8):1471-9. http://content.healthaffairs.org/content/35/8/1471.abstract. Accessed May 25, 2017.
3. Blavin F. How Has the ACA Changed Finances for Different Types of Hospitals? Updated Insights from 2015 Cost Report Data. Urban Institute. Published April 2017. Accessed May 25, 2017. http://www.urban.org/sites/default/files/publication/89446/2001215-how-has-the-aca-changed-finances-for-different-types-of-hospitals.pdf.
4. Dranove D., Garthwaite C., Ody C. The Impact of the ACA’s Medicaid Expansion on Hospitals’ Uncompensated Care Burden and the Potential Effects of Repeal. Published May 3, 2017. Accessed May 25, 2017. http://www.commonwealthfund.org/publications/issue-briefs/2017/may/aca-medicaid-expansion-hospital-uncompensated-care.
5. Blavin F. Association Between the 2014 Medicaid Expansion and US Hospital Finances. http://jamanetwork.com/journals/jama/fullarticle/2565750. JAMA 2016;316(14):1475-1483. doi:10.1001/jama.2016.14765
6. President Trump’s 2018 Budget Proposal Reduces Federal Funding for Coverage of Children in Medicaid and CHIP. Kaiser Family Foundation. Published March 23, 2017. Accessed May 25, 2017. http://kff.org/medicaid/fact-sheet/presidents-2018-budget-proposal-reduces-federal-funding-for-coverage-of-children-in-medicaid-and-chip/
7. Paradise J. Restructuring Medicaid in the American Health Care Act: Five Key Considerations. Kaiser Family Foundation. Published March 15, 2017. Accessed May 25, 2017. http://kff.org/medicaid/issue-brief/restructuring-medicaid-in-the-american-health-care-act-five-key-considerations/
8. Medicaid Hospital Payment: A comparison across states and to Medicare. MACPAC Issue Brief. Published April 2017.
9. Levin Becker A. Hospitals blast Malloy’s proposal to subject them to property taxes. Published Feb. 8, 2017. Accessed May 25, 2017. https://ctmirror.org/2017/02/08/hospitals-blast-malloys-proposal-to-subject-them-to-property-taxes/
In 2016, a series of studies showed the impact of Medicaid expansion on hospitals.1 The news was good: Hospitals in states that accepted Medicaid expansion through the Affordable Care Act saw dramatic reductions in their uninsured patient populations, increases in their Medicaid stays, and reductions in uncompensated care costs.1,2
In 2017, additional data continue to show that Medicaid expansion has been a boon to hospitals, including an April 2017 report published by the Urban Institute and a May 2017 analysis from The Commonwealth Fund.3,4 Both show that some of the hospitals that need it most are reaping the greatest benefits of expansion.
At the same time, Craig Garthwaite, PhD, MPP, lead author of The Commonwealth Fund report, said Medicaid expansion “wiped out roughly half of the uncompensated care faced by hospitals, with relatively little or no decline in nonexpansion states.” To date, 19 states have not expanded Medicaid.
With Medicaid facing an uncertain future, Dr. Blavin said some experts are concerned about what could happen to vulnerable hospitals if Medicaid expansion is repealed or scaled back. Indeed, President Trump and Congressional Republicans have proposed significantly altering Medicaid by either transitioning it to block grants or by capping federal funding for the entitlement.6,7
“We wanted to give people a sense of the stakes of what you’re talking about with repeal of the Affordable Care Act and go back to a system where patients are able to get emergency care at the hospital but not the complete care they get if they’re insured. We’re not going to be paying hospitals for that care, so the hospital has that coming out of their profit margin,” said Dr. Garthwaite, professor of strategy and codirector of the Health Enterprise Management Program in the Kellogg School of Management at Northwestern University, Evanston, Ill.
The Commonwealth Fund report used data from the Centers for Medicare & Medicaid Services (CMS) Hospital Cost Reports to examine 1,154 hospitals in expansion and nonexpansion states. It built on a Health Affairs study Dr. Garthwaite and his coauthors published in 2016.2 The analysis found that between 2013 and 2014, uncompensated care costs declined dramatically in expansion states and continued into 2015, falling from 3.9% to 2.3% of operating costs. Meanwhile, hospitals in nonexpansion states saw uncompensated care costs drop just 0.3-0.4 percentage points. The largest reductions were seen by hospitals providing the highest proportion of care to low-income and uninsured patients and overall savings to hospitals in expansion states amounted to $6.2 billion.
“Any contraction of the Medicaid expansion will reduce overall health insurance coverage and could have important financial implications for hospitals,” Dr. Blavin said. “We are likely to see large increases in expenses attributable to uninsured patients, declines in Medicaid revenue, and increases in uncompensated care burdens that can be a significant financial strain to hospitals.”
As part of a project supported by the Robert Wood Johnson Foundation, the Urban Institute in May 2011 began to track and study the impact of health reform. The report Dr. Blavin authored is part of this endeavor and utilized data from the American Hospital Association Annual Survey and the CMS Health Care Cost Reports to update the 2016 JAMA study. It compared hospitals in expansion states to those in nonexpansion states between fiscal years 2011 and 2015, excluding hospitals in states that expanded before January 2014. It examined hospital-reported data on uncompensated care, uncompensated care as a percentage of total hospital expenses, Medicaid revenue, Medicaid as a percentage of total revenue, operating margins, and excess margins.
The analysis found that Medicaid expansion resulted in a $3.2 million reduction in uncompensated care and a $5.0 million increase in mean annual Medicaid revenue per hospital. Expansion-state hospitals also saw improvements in excess and operating margins relative to nonexpansion state hospitals.
In Connecticut, Medicaid reimbursement rates are among the lowest in the country.8 The state uses a provider tax to finance Medicaid but, facing a budget deficit, state leaders have dramatically reduced the amount of money returned to hospitals in recent years.9
“Our Medicaid patient volume has gone up but our margins have declined because the return on investment is so low,” added Dr. Kumar, a practicing hospitalist and member of the SHM Public Policy Committee. He is concerned about what happens if Medicaid is capped or transitioned to a block grant, since “block grants have not been favorable so far … It would further squeeze us.”
In Arizona, Steve Narang, MD, MHCM, a hospitalist and CEO of Banner–University Medical Center Phoenix (B-UMCP), already knows what it’s like when Medicaid funding expands and then contracts. In 2001, the state expanded Medicaid to 100% of the federal poverty level for childless adults but then in 2011, in the throes of recession, the state froze its match on federal dollars. Prior to the freeze, charity care and bad debt made up 9% of B-UMCP’s net revenue. After the state cut to Medicaid, the hospital’s uncompensated care doubled; charity care and bad debt spiked to 20% of net revenue. Once the freeze was lifted and the state expanded Medicaid through the ACA in 2014, bad debt and charity care plummeted to 7% of revenue and remains in the single digits, Dr. Narang said.
“You hear a lot, especially in debates, about Medicaid being bad coverage … From a hospital perspective, if you’re taking care of a patient who is uninsured versus a patient with Medicaid coverage, that hospital is likely better off financially treating the patient with Medicaid coverage,” said Dr. Blavin.
“From a basic commitment to our fellow human beings, are we doing the right thing as a country?” he asked, noting that states and the federal government must address the economic realities of health care while also providing safety nets for patients. “We have to do both. But I have faith that the state and federal government will find a model and we will continue to focus on what we can control.”
References
1. Tyrrell K. Benefits of Medicaid Expansion for Hospitalists. The Hospitalist. 2016 March;2016(3). http://www.the-hospitalist.org/hospitalist/article/121832/benefits-medicaid-expansion-hospitalists. Accessed May 25, 2017.
2. Dranove D., Garthwaite C., Ody C. Uncompensated Care Decreased at Hospitals in Medicaid Expansion States but Not at Hospitals in Nonexpansion States. Health Affairs, Aug. 2016 35(8):1471-9. http://content.healthaffairs.org/content/35/8/1471.abstract. Accessed May 25, 2017.
3. Blavin F. How Has the ACA Changed Finances for Different Types of Hospitals? Updated Insights from 2015 Cost Report Data. Urban Institute. Published April 2017. Accessed May 25, 2017. http://www.urban.org/sites/default/files/publication/89446/2001215-how-has-the-aca-changed-finances-for-different-types-of-hospitals.pdf.
4. Dranove D., Garthwaite C., Ody C. The Impact of the ACA’s Medicaid Expansion on Hospitals’ Uncompensated Care Burden and the Potential Effects of Repeal. Published May 3, 2017. Accessed May 25, 2017. http://www.commonwealthfund.org/publications/issue-briefs/2017/may/aca-medicaid-expansion-hospital-uncompensated-care.
5. Blavin F. Association Between the 2014 Medicaid Expansion and US Hospital Finances. http://jamanetwork.com/journals/jama/fullarticle/2565750. JAMA 2016;316(14):1475-1483. doi:10.1001/jama.2016.14765
6. President Trump’s 2018 Budget Proposal Reduces Federal Funding for Coverage of Children in Medicaid and CHIP. Kaiser Family Foundation. Published March 23, 2017. Accessed May 25, 2017. http://kff.org/medicaid/fact-sheet/presidents-2018-budget-proposal-reduces-federal-funding-for-coverage-of-children-in-medicaid-and-chip/
7. Paradise J. Restructuring Medicaid in the American Health Care Act: Five Key Considerations. Kaiser Family Foundation. Published March 15, 2017. Accessed May 25, 2017. http://kff.org/medicaid/issue-brief/restructuring-medicaid-in-the-american-health-care-act-five-key-considerations/
8. Medicaid Hospital Payment: A comparison across states and to Medicare. MACPAC Issue Brief. Published April 2017.
9. Levin Becker A. Hospitals blast Malloy’s proposal to subject them to property taxes. Published Feb. 8, 2017. Accessed May 25, 2017. https://ctmirror.org/2017/02/08/hospitals-blast-malloys-proposal-to-subject-them-to-property-taxes/
Immigration reforms: Repercussions for hospitalists and the health care industry
International medical graduates (IMGs) have been playing a crucial role in clinician staffing needs for U.S. hospitals, especially in hospital medicine and internal medicine. According to a study, IMGs comprise 25% of the total U.S. physician workforce and 36% of internists.1,2 According to data from the 2008 Today’s Hospitalist Compensation & Career Survey, 32% of practicing hospitalists are IMGs.3
Many IMGs come to work in the U.S. via one of three paths. Just like all roads lead to Rome, all visas lead to a permanent residency pathway, eventually based on the country of origin and number of years waiting. The first path is a green card – cases where IMGs were on a visa and within a certain amount of time they received a green card. The second path is J-1 visa waivers for physicians who trained in the U.S. under a J-1 Visa. Typically, physicians on J-1 Visa waivers need to provide their services for a minimum of 3 years working in underserved areas – where there’s a shortage of health professionals – before they can apply for permanent residency.
The third and most popular path is the H-1B visa, which hospitalists traditionally use as a springboard to apply for permanent residency. Studies have shown that IMGs are more likely to practice medicine in rural and underserved areas. In many instances, physicians end up working in these areas for long periods of time.4
The Department of Homeland Security has considered creating another visa pathway for the technology industry, whereby an alien graduating from a U.S. university with an advanced degree in a STEM (Science, Technology, Engineering, and Math) course of study would receive a new visa and pathway to permanent residency. We believe hospitalists and other physicians should also have an expedited pathway to permanent residency. This step benefits both the U.S. health care system and hospitalists in many ways. It increases hospitalists’ portability and flexibility with schedules. With a traditional H-1B visa, hospitalists are bound to work with the one hospital/system that sponsors the H-1B, and would not be able to work at any other hospital without another extension/addendum to current visa status, even in cases where a physician had time off and would like to offer services at another facility. It is a well-known fact that hospitalist teams are understaffed and try to bring on per-diem staff to fill holes in schedules. The majority of hospitalists are working week-on/week-off schedules, and with an expedited pathway to a green card they would be able to work in different hospitals. They would also be able to move to remote places, or “doctor deserts,” and offer their services, helping to ensure the quality and safety of patient care to which all Americans are entitled.
In 2016 alone, around 1,500 H-1B visas were filed for hospitalist physicians.7 Each hospitalist has an average of 15 patient encounters per day, and for 1,500 physicians that amounts to about 4 million patient encounters annually.8 These data account for only new 2016 visa-holding physicians, and do not account for already approved or renewed visas. It would be very challenging to count the number of patient encounters by hospitalists who are on a visa, but 1 billion patient encounters is not overestimating. Recent studies show that quality of care provided by IMGs is not inferior to that of U.S. medical graduates. The study showed that patients cared for by IMGs have lesser mortality, compared with those cared by U.S. medical graduates.9
In this era of hospital medicine, hospitalists are focusing not only on clinical aspects of patient care but also on efficacy, quality of care, and patient safety and satisfaction, and they are working with the Centers for Medicare & Medicaid Services to develop cost-cutting programs to save billions of dollars in health care expenses. This is the primary reason a majority of hospitals are focused on developing a hospitalist track, and encouraging hospitalists to pursue leadership roles in managing hospitals effectively.
The U.S. health care system is starved for hospitalists and primary care physicians, and IMGs will continue to play a pivotal role. Yet IMGs must deal with shifting trends in immigration policy, and in some recent instances immigrant physicians have been asked to leave the U.S. because of immigration reforms.10,11 We would like the Society of Hospital Medicine to take a stand on behalf of IMG hospitalists and ask the U.S. Department of Labor and Homeland Security for an expedited permanent residency pathway for IMG hospitalists. We are certain that our request will get a fair hearing, as the former U.S. surgeon general was a hospitalist and, indeed, an immigrant.
Dr. Medarametla is medical director, Intermediate Care Unit, Baystate Medical Center, Springfield, Mass., and assistant professor of medicine, University of Massachusetts Medical School. Dr. Pamerla is a hospitalist at Wilson Medical Center, Wilson, N.C.
References
1. Educational Commission for Foreign Medical Graduates; ECFMG 2015 Annual Report. April 2016 http://www.ecfmg.org/resources/ECFMG-2015-annual-report.pdf.
2. Pinsky WW. The Importance of International Medical Graduates in the United States. Ann Intern Med. 2017. doi: 10.7326/M17-0505.
3. Hart LG, Skillman SM, Fordyce M, et al. International medical graduate physicians in the United States: changes since 1981. Health Aff. 2007 July/August;26(4):1159-69.
4. Goodfellow A1, Ulloa JG, Dowling PT, et al. Predictors of Primary Care Physician Practice Location in Underserved Urban or Rural Areas in the United States: A Systematic Literature Review. Acad Med. 2016 Sep;91(9):1313-21.
5. https://www.uscis.gov/working-united-states/temporary-workers/h-1b-specialty-occupations-and-fashion-models/h-1b-fiscal-year-fy-2018-cap-season#count
6. https://www.graphiq.com/vlp/bCIqXCpVqF7
7. http://www.myvisajobs.com/Reports/2017-H1B-Visa-Category.aspx?T=JT&P=2
8. Steven M Harris: http://www.the-hospitalist.org/hospitalist/article/125455/appropriate-patient-census-hospital-medicines-holy-grail
9. Tsugawa Y, Jena AB, Orav EJ, Jha AK. Quality of care delivered by general internists in US hospitals who graduated from foreign versus US medical schools: observational study. BMJ. 2017;356:j273.
10. https://www.propublica.org/article/cleveland-clinic-doctor-forced-to-leave-country-after-trump-order
11. http://www.houstonchronicle.com/news/houston-texas/houston/article/Houston-immigrant-doctors-given-24-hours-to-leave-11040259.php
International medical graduates (IMGs) have been playing a crucial role in clinician staffing needs for U.S. hospitals, especially in hospital medicine and internal medicine. According to a study, IMGs comprise 25% of the total U.S. physician workforce and 36% of internists.1,2 According to data from the 2008 Today’s Hospitalist Compensation & Career Survey, 32% of practicing hospitalists are IMGs.3
Many IMGs come to work in the U.S. via one of three paths. Just like all roads lead to Rome, all visas lead to a permanent residency pathway, eventually based on the country of origin and number of years waiting. The first path is a green card – cases where IMGs were on a visa and within a certain amount of time they received a green card. The second path is J-1 visa waivers for physicians who trained in the U.S. under a J-1 Visa. Typically, physicians on J-1 Visa waivers need to provide their services for a minimum of 3 years working in underserved areas – where there’s a shortage of health professionals – before they can apply for permanent residency.
The third and most popular path is the H-1B visa, which hospitalists traditionally use as a springboard to apply for permanent residency. Studies have shown that IMGs are more likely to practice medicine in rural and underserved areas. In many instances, physicians end up working in these areas for long periods of time.4
The Department of Homeland Security has considered creating another visa pathway for the technology industry, whereby an alien graduating from a U.S. university with an advanced degree in a STEM (Science, Technology, Engineering, and Math) course of study would receive a new visa and pathway to permanent residency. We believe hospitalists and other physicians should also have an expedited pathway to permanent residency. This step benefits both the U.S. health care system and hospitalists in many ways. It increases hospitalists’ portability and flexibility with schedules. With a traditional H-1B visa, hospitalists are bound to work with the one hospital/system that sponsors the H-1B, and would not be able to work at any other hospital without another extension/addendum to current visa status, even in cases where a physician had time off and would like to offer services at another facility. It is a well-known fact that hospitalist teams are understaffed and try to bring on per-diem staff to fill holes in schedules. The majority of hospitalists are working week-on/week-off schedules, and with an expedited pathway to a green card they would be able to work in different hospitals. They would also be able to move to remote places, or “doctor deserts,” and offer their services, helping to ensure the quality and safety of patient care to which all Americans are entitled.
In 2016 alone, around 1,500 H-1B visas were filed for hospitalist physicians.7 Each hospitalist has an average of 15 patient encounters per day, and for 1,500 physicians that amounts to about 4 million patient encounters annually.8 These data account for only new 2016 visa-holding physicians, and do not account for already approved or renewed visas. It would be very challenging to count the number of patient encounters by hospitalists who are on a visa, but 1 billion patient encounters is not overestimating. Recent studies show that quality of care provided by IMGs is not inferior to that of U.S. medical graduates. The study showed that patients cared for by IMGs have lesser mortality, compared with those cared by U.S. medical graduates.9
In this era of hospital medicine, hospitalists are focusing not only on clinical aspects of patient care but also on efficacy, quality of care, and patient safety and satisfaction, and they are working with the Centers for Medicare & Medicaid Services to develop cost-cutting programs to save billions of dollars in health care expenses. This is the primary reason a majority of hospitals are focused on developing a hospitalist track, and encouraging hospitalists to pursue leadership roles in managing hospitals effectively.
The U.S. health care system is starved for hospitalists and primary care physicians, and IMGs will continue to play a pivotal role. Yet IMGs must deal with shifting trends in immigration policy, and in some recent instances immigrant physicians have been asked to leave the U.S. because of immigration reforms.10,11 We would like the Society of Hospital Medicine to take a stand on behalf of IMG hospitalists and ask the U.S. Department of Labor and Homeland Security for an expedited permanent residency pathway for IMG hospitalists. We are certain that our request will get a fair hearing, as the former U.S. surgeon general was a hospitalist and, indeed, an immigrant.
Dr. Medarametla is medical director, Intermediate Care Unit, Baystate Medical Center, Springfield, Mass., and assistant professor of medicine, University of Massachusetts Medical School. Dr. Pamerla is a hospitalist at Wilson Medical Center, Wilson, N.C.
References
1. Educational Commission for Foreign Medical Graduates; ECFMG 2015 Annual Report. April 2016 http://www.ecfmg.org/resources/ECFMG-2015-annual-report.pdf.
2. Pinsky WW. The Importance of International Medical Graduates in the United States. Ann Intern Med. 2017. doi: 10.7326/M17-0505.
3. Hart LG, Skillman SM, Fordyce M, et al. International medical graduate physicians in the United States: changes since 1981. Health Aff. 2007 July/August;26(4):1159-69.
4. Goodfellow A1, Ulloa JG, Dowling PT, et al. Predictors of Primary Care Physician Practice Location in Underserved Urban or Rural Areas in the United States: A Systematic Literature Review. Acad Med. 2016 Sep;91(9):1313-21.
5. https://www.uscis.gov/working-united-states/temporary-workers/h-1b-specialty-occupations-and-fashion-models/h-1b-fiscal-year-fy-2018-cap-season#count
6. https://www.graphiq.com/vlp/bCIqXCpVqF7
7. http://www.myvisajobs.com/Reports/2017-H1B-Visa-Category.aspx?T=JT&P=2
8. Steven M Harris: http://www.the-hospitalist.org/hospitalist/article/125455/appropriate-patient-census-hospital-medicines-holy-grail
9. Tsugawa Y, Jena AB, Orav EJ, Jha AK. Quality of care delivered by general internists in US hospitals who graduated from foreign versus US medical schools: observational study. BMJ. 2017;356:j273.
10. https://www.propublica.org/article/cleveland-clinic-doctor-forced-to-leave-country-after-trump-order
11. http://www.houstonchronicle.com/news/houston-texas/houston/article/Houston-immigrant-doctors-given-24-hours-to-leave-11040259.php
International medical graduates (IMGs) have been playing a crucial role in clinician staffing needs for U.S. hospitals, especially in hospital medicine and internal medicine. According to a study, IMGs comprise 25% of the total U.S. physician workforce and 36% of internists.1,2 According to data from the 2008 Today’s Hospitalist Compensation & Career Survey, 32% of practicing hospitalists are IMGs.3
Many IMGs come to work in the U.S. via one of three paths. Just like all roads lead to Rome, all visas lead to a permanent residency pathway, eventually based on the country of origin and number of years waiting. The first path is a green card – cases where IMGs were on a visa and within a certain amount of time they received a green card. The second path is J-1 visa waivers for physicians who trained in the U.S. under a J-1 Visa. Typically, physicians on J-1 Visa waivers need to provide their services for a minimum of 3 years working in underserved areas – where there’s a shortage of health professionals – before they can apply for permanent residency.
The third and most popular path is the H-1B visa, which hospitalists traditionally use as a springboard to apply for permanent residency. Studies have shown that IMGs are more likely to practice medicine in rural and underserved areas. In many instances, physicians end up working in these areas for long periods of time.4
The Department of Homeland Security has considered creating another visa pathway for the technology industry, whereby an alien graduating from a U.S. university with an advanced degree in a STEM (Science, Technology, Engineering, and Math) course of study would receive a new visa and pathway to permanent residency. We believe hospitalists and other physicians should also have an expedited pathway to permanent residency. This step benefits both the U.S. health care system and hospitalists in many ways. It increases hospitalists’ portability and flexibility with schedules. With a traditional H-1B visa, hospitalists are bound to work with the one hospital/system that sponsors the H-1B, and would not be able to work at any other hospital without another extension/addendum to current visa status, even in cases where a physician had time off and would like to offer services at another facility. It is a well-known fact that hospitalist teams are understaffed and try to bring on per-diem staff to fill holes in schedules. The majority of hospitalists are working week-on/week-off schedules, and with an expedited pathway to a green card they would be able to work in different hospitals. They would also be able to move to remote places, or “doctor deserts,” and offer their services, helping to ensure the quality and safety of patient care to which all Americans are entitled.
In 2016 alone, around 1,500 H-1B visas were filed for hospitalist physicians.7 Each hospitalist has an average of 15 patient encounters per day, and for 1,500 physicians that amounts to about 4 million patient encounters annually.8 These data account for only new 2016 visa-holding physicians, and do not account for already approved or renewed visas. It would be very challenging to count the number of patient encounters by hospitalists who are on a visa, but 1 billion patient encounters is not overestimating. Recent studies show that quality of care provided by IMGs is not inferior to that of U.S. medical graduates. The study showed that patients cared for by IMGs have lesser mortality, compared with those cared by U.S. medical graduates.9
In this era of hospital medicine, hospitalists are focusing not only on clinical aspects of patient care but also on efficacy, quality of care, and patient safety and satisfaction, and they are working with the Centers for Medicare & Medicaid Services to develop cost-cutting programs to save billions of dollars in health care expenses. This is the primary reason a majority of hospitals are focused on developing a hospitalist track, and encouraging hospitalists to pursue leadership roles in managing hospitals effectively.
The U.S. health care system is starved for hospitalists and primary care physicians, and IMGs will continue to play a pivotal role. Yet IMGs must deal with shifting trends in immigration policy, and in some recent instances immigrant physicians have been asked to leave the U.S. because of immigration reforms.10,11 We would like the Society of Hospital Medicine to take a stand on behalf of IMG hospitalists and ask the U.S. Department of Labor and Homeland Security for an expedited permanent residency pathway for IMG hospitalists. We are certain that our request will get a fair hearing, as the former U.S. surgeon general was a hospitalist and, indeed, an immigrant.
Dr. Medarametla is medical director, Intermediate Care Unit, Baystate Medical Center, Springfield, Mass., and assistant professor of medicine, University of Massachusetts Medical School. Dr. Pamerla is a hospitalist at Wilson Medical Center, Wilson, N.C.
References
1. Educational Commission for Foreign Medical Graduates; ECFMG 2015 Annual Report. April 2016 http://www.ecfmg.org/resources/ECFMG-2015-annual-report.pdf.
2. Pinsky WW. The Importance of International Medical Graduates in the United States. Ann Intern Med. 2017. doi: 10.7326/M17-0505.
3. Hart LG, Skillman SM, Fordyce M, et al. International medical graduate physicians in the United States: changes since 1981. Health Aff. 2007 July/August;26(4):1159-69.
4. Goodfellow A1, Ulloa JG, Dowling PT, et al. Predictors of Primary Care Physician Practice Location in Underserved Urban or Rural Areas in the United States: A Systematic Literature Review. Acad Med. 2016 Sep;91(9):1313-21.
5. https://www.uscis.gov/working-united-states/temporary-workers/h-1b-specialty-occupations-and-fashion-models/h-1b-fiscal-year-fy-2018-cap-season#count
6. https://www.graphiq.com/vlp/bCIqXCpVqF7
7. http://www.myvisajobs.com/Reports/2017-H1B-Visa-Category.aspx?T=JT&P=2
8. Steven M Harris: http://www.the-hospitalist.org/hospitalist/article/125455/appropriate-patient-census-hospital-medicines-holy-grail
9. Tsugawa Y, Jena AB, Orav EJ, Jha AK. Quality of care delivered by general internists in US hospitals who graduated from foreign versus US medical schools: observational study. BMJ. 2017;356:j273.
10. https://www.propublica.org/article/cleveland-clinic-doctor-forced-to-leave-country-after-trump-order
11. http://www.houstonchronicle.com/news/houston-texas/houston/article/Houston-immigrant-doctors-given-24-hours-to-leave-11040259.php
New telehealth legislation would provide for testing, expansion
A bipartisan bill introduced in the U.S. Senate in late March 2017 would authorize the Center for Medicare & Medicaid Innovation (CMMI) to test expanded telehealth services provided to Medicare beneficiaries.
The Telehealth Innovation and Improvement Act (S.787), currently in the Senate Finance Committee, was introduced by Sen. Gary Peters (D-Mich.) and Sen. Cory Gardner (R-Colo.). A similar bill they introduced in 2015 was never enacted.
However, there are physicians hoping to see this bill or others like it granted consideration. Currently, the Centers for Medicare & Medicaid Services reimburses only for certain telemedicine services provided in rural or underserved geographic areas, but the new bill would apply in suburban and urban areas as well, based on pilot testing of models and evaluating them for cost, quality, and effectiveness. Successful models would be covered by Medicare.
“Medicare has made some provisions for specific rural sites and niche areas, but writ large, there’s no prescribed way for people to just open a telemedicine shop and begin to bill,” said Bradley Flansbaum, DO, MPH, MHM, a member of the SHM Public Policy Committee.
With the exception of telestroke and critical care, “evidence is needed for the type of setting and type of clinical problems addressed by telemedicine. It’s not been tested enough,” added Dr. Flansbaum, who holds a dual appointment in hospital medicine and population health at Geisinger Medical Center in Danville, Penn. “How does it work for routine inpatient problems and how do hospitalists use it? We haven’t seen data there and that’s where a pilot comes in.”
Dr. Mac believes it inconsistent that, in many circumstances, physicians providing services via telemedicine technology are not reimbursed by Medicare and other payers.
“The expansion and ability to provide care in more unique ways – more specialties and in more environments – has expanded more quickly than the systems of reimbursement for professional fees have and it really is a bit of a hodgepodge now,” he said. “We certainly are pleased that this is getting attention and that we have leaders pushing for this in Congress. We don’t know for sure how the final legislation (on this bill) may look but hopefully there will be some form of this that will come to fruition.”
Whether telemedicine can reduce costs while improving outcomes, or improve outcomes without increasing costs, remains unsettled. A study published in Health Affairs in March 2017 indicates that while telehealth can improve access to care, it results in greater utilization, thereby increasing costs.1
The study relied on claims data for more than 300,000 patients in the California Public Employees’ Retirement System during 2011-2013. It looked at utilization of direct-to-consumer telehealth and spending for acute respiratory illness, one of the most common reasons patients seek telehealth services. While, per episode, telehealth visits cost 50% less than did an outpatient visit and less than 5% of an emergency department visit, annual spending per individual for acute respiratory illness went up $45 because, as the authors estimated, 88% of direct-to-consumer telehealth visits represented new utilization.
Whether this would be the case for hospitalist patients remains to be tested.
“It gets back to whether or not you’re adding a necessary service or substituting a less expensive one for a more expensive one,” said Dr. Flansbaum. “Are physicians providing a needed service or adding unnecessary visits to the system?”
Jayne Lee, MD, has been a hospitalist with Eagle for nearly a decade. Before making the transition from an in-hospital physician to one treating patients from behind a robot – with assistance at the point of service from a nurse – she was working 10 shifts in a row at her home in the United States before traveling to her home in Paris. Dr. Mac offered her the opportunity to practice full time as a telehospitalist from overseas. Today, she is also the company’s chief medical officer and estimates she’s had more than 7,000 patient encounters using telemedicine technology.
Dr. Lee is licensed in multiple states – a barrier that plagues many would-be telehealth providers, but which Eagle has solved with its licensing and credentialing staff – and because she is often providing services at night to urban and rural areas, she sees a broad range of patients.
“We see things from coronary artery disease, COPD [chronic obstructive pulmonary disease] exacerbations, and diabetes-related conditions to drug overdoses and alcohol abuse,” she said. “I enjoy seeing the variety of patients I encounter every night.”
Dr. Lee has to navigate each health system’s electronic medical records and triage systems but, she says, patient care has remained the same. And she’s providing services for hospitals that may not have another hospitalist to assign.
“Our practices keep growing, a sign that hospitals are needing our services now more than ever, given that there is a physician shortage and given the financial constraints we’re seeing in the healthcare system.” she said.
References
1. Ashwood JS, Mehrota A, Cowling D, et al. Direct-to-consumer telehealth may increase access to care but does not decrease spending. Health Affairs. 2017; 36(3):485-491. doi: 10.1377/hlthaff.2016.1130.
A bipartisan bill introduced in the U.S. Senate in late March 2017 would authorize the Center for Medicare & Medicaid Innovation (CMMI) to test expanded telehealth services provided to Medicare beneficiaries.
The Telehealth Innovation and Improvement Act (S.787), currently in the Senate Finance Committee, was introduced by Sen. Gary Peters (D-Mich.) and Sen. Cory Gardner (R-Colo.). A similar bill they introduced in 2015 was never enacted.
However, there are physicians hoping to see this bill or others like it granted consideration. Currently, the Centers for Medicare & Medicaid Services reimburses only for certain telemedicine services provided in rural or underserved geographic areas, but the new bill would apply in suburban and urban areas as well, based on pilot testing of models and evaluating them for cost, quality, and effectiveness. Successful models would be covered by Medicare.
“Medicare has made some provisions for specific rural sites and niche areas, but writ large, there’s no prescribed way for people to just open a telemedicine shop and begin to bill,” said Bradley Flansbaum, DO, MPH, MHM, a member of the SHM Public Policy Committee.
With the exception of telestroke and critical care, “evidence is needed for the type of setting and type of clinical problems addressed by telemedicine. It’s not been tested enough,” added Dr. Flansbaum, who holds a dual appointment in hospital medicine and population health at Geisinger Medical Center in Danville, Penn. “How does it work for routine inpatient problems and how do hospitalists use it? We haven’t seen data there and that’s where a pilot comes in.”
Dr. Mac believes it inconsistent that, in many circumstances, physicians providing services via telemedicine technology are not reimbursed by Medicare and other payers.
“The expansion and ability to provide care in more unique ways – more specialties and in more environments – has expanded more quickly than the systems of reimbursement for professional fees have and it really is a bit of a hodgepodge now,” he said. “We certainly are pleased that this is getting attention and that we have leaders pushing for this in Congress. We don’t know for sure how the final legislation (on this bill) may look but hopefully there will be some form of this that will come to fruition.”
Whether telemedicine can reduce costs while improving outcomes, or improve outcomes without increasing costs, remains unsettled. A study published in Health Affairs in March 2017 indicates that while telehealth can improve access to care, it results in greater utilization, thereby increasing costs.1
The study relied on claims data for more than 300,000 patients in the California Public Employees’ Retirement System during 2011-2013. It looked at utilization of direct-to-consumer telehealth and spending for acute respiratory illness, one of the most common reasons patients seek telehealth services. While, per episode, telehealth visits cost 50% less than did an outpatient visit and less than 5% of an emergency department visit, annual spending per individual for acute respiratory illness went up $45 because, as the authors estimated, 88% of direct-to-consumer telehealth visits represented new utilization.
Whether this would be the case for hospitalist patients remains to be tested.
“It gets back to whether or not you’re adding a necessary service or substituting a less expensive one for a more expensive one,” said Dr. Flansbaum. “Are physicians providing a needed service or adding unnecessary visits to the system?”
Jayne Lee, MD, has been a hospitalist with Eagle for nearly a decade. Before making the transition from an in-hospital physician to one treating patients from behind a robot – with assistance at the point of service from a nurse – she was working 10 shifts in a row at her home in the United States before traveling to her home in Paris. Dr. Mac offered her the opportunity to practice full time as a telehospitalist from overseas. Today, she is also the company’s chief medical officer and estimates she’s had more than 7,000 patient encounters using telemedicine technology.
Dr. Lee is licensed in multiple states – a barrier that plagues many would-be telehealth providers, but which Eagle has solved with its licensing and credentialing staff – and because she is often providing services at night to urban and rural areas, she sees a broad range of patients.
“We see things from coronary artery disease, COPD [chronic obstructive pulmonary disease] exacerbations, and diabetes-related conditions to drug overdoses and alcohol abuse,” she said. “I enjoy seeing the variety of patients I encounter every night.”
Dr. Lee has to navigate each health system’s electronic medical records and triage systems but, she says, patient care has remained the same. And she’s providing services for hospitals that may not have another hospitalist to assign.
“Our practices keep growing, a sign that hospitals are needing our services now more than ever, given that there is a physician shortage and given the financial constraints we’re seeing in the healthcare system.” she said.
References
1. Ashwood JS, Mehrota A, Cowling D, et al. Direct-to-consumer telehealth may increase access to care but does not decrease spending. Health Affairs. 2017; 36(3):485-491. doi: 10.1377/hlthaff.2016.1130.
A bipartisan bill introduced in the U.S. Senate in late March 2017 would authorize the Center for Medicare & Medicaid Innovation (CMMI) to test expanded telehealth services provided to Medicare beneficiaries.
The Telehealth Innovation and Improvement Act (S.787), currently in the Senate Finance Committee, was introduced by Sen. Gary Peters (D-Mich.) and Sen. Cory Gardner (R-Colo.). A similar bill they introduced in 2015 was never enacted.
However, there are physicians hoping to see this bill or others like it granted consideration. Currently, the Centers for Medicare & Medicaid Services reimburses only for certain telemedicine services provided in rural or underserved geographic areas, but the new bill would apply in suburban and urban areas as well, based on pilot testing of models and evaluating them for cost, quality, and effectiveness. Successful models would be covered by Medicare.
“Medicare has made some provisions for specific rural sites and niche areas, but writ large, there’s no prescribed way for people to just open a telemedicine shop and begin to bill,” said Bradley Flansbaum, DO, MPH, MHM, a member of the SHM Public Policy Committee.
With the exception of telestroke and critical care, “evidence is needed for the type of setting and type of clinical problems addressed by telemedicine. It’s not been tested enough,” added Dr. Flansbaum, who holds a dual appointment in hospital medicine and population health at Geisinger Medical Center in Danville, Penn. “How does it work for routine inpatient problems and how do hospitalists use it? We haven’t seen data there and that’s where a pilot comes in.”
Dr. Mac believes it inconsistent that, in many circumstances, physicians providing services via telemedicine technology are not reimbursed by Medicare and other payers.
“The expansion and ability to provide care in more unique ways – more specialties and in more environments – has expanded more quickly than the systems of reimbursement for professional fees have and it really is a bit of a hodgepodge now,” he said. “We certainly are pleased that this is getting attention and that we have leaders pushing for this in Congress. We don’t know for sure how the final legislation (on this bill) may look but hopefully there will be some form of this that will come to fruition.”
Whether telemedicine can reduce costs while improving outcomes, or improve outcomes without increasing costs, remains unsettled. A study published in Health Affairs in March 2017 indicates that while telehealth can improve access to care, it results in greater utilization, thereby increasing costs.1
The study relied on claims data for more than 300,000 patients in the California Public Employees’ Retirement System during 2011-2013. It looked at utilization of direct-to-consumer telehealth and spending for acute respiratory illness, one of the most common reasons patients seek telehealth services. While, per episode, telehealth visits cost 50% less than did an outpatient visit and less than 5% of an emergency department visit, annual spending per individual for acute respiratory illness went up $45 because, as the authors estimated, 88% of direct-to-consumer telehealth visits represented new utilization.
Whether this would be the case for hospitalist patients remains to be tested.
“It gets back to whether or not you’re adding a necessary service or substituting a less expensive one for a more expensive one,” said Dr. Flansbaum. “Are physicians providing a needed service or adding unnecessary visits to the system?”
Jayne Lee, MD, has been a hospitalist with Eagle for nearly a decade. Before making the transition from an in-hospital physician to one treating patients from behind a robot – with assistance at the point of service from a nurse – she was working 10 shifts in a row at her home in the United States before traveling to her home in Paris. Dr. Mac offered her the opportunity to practice full time as a telehospitalist from overseas. Today, she is also the company’s chief medical officer and estimates she’s had more than 7,000 patient encounters using telemedicine technology.
Dr. Lee is licensed in multiple states – a barrier that plagues many would-be telehealth providers, but which Eagle has solved with its licensing and credentialing staff – and because she is often providing services at night to urban and rural areas, she sees a broad range of patients.
“We see things from coronary artery disease, COPD [chronic obstructive pulmonary disease] exacerbations, and diabetes-related conditions to drug overdoses and alcohol abuse,” she said. “I enjoy seeing the variety of patients I encounter every night.”
Dr. Lee has to navigate each health system’s electronic medical records and triage systems but, she says, patient care has remained the same. And she’s providing services for hospitals that may not have another hospitalist to assign.
“Our practices keep growing, a sign that hospitals are needing our services now more than ever, given that there is a physician shortage and given the financial constraints we’re seeing in the healthcare system.” she said.
References
1. Ashwood JS, Mehrota A, Cowling D, et al. Direct-to-consumer telehealth may increase access to care but does not decrease spending. Health Affairs. 2017; 36(3):485-491. doi: 10.1377/hlthaff.2016.1130.