Public Policy

Last year, Congress passed legislation to permanently eliminate the Sustainable Growth Rate (SGR) formula, created in 1997 and designed to hold Medicare Part B or outpatient spending under control. Allowing the SGR to go into effect would have severely cut physician reimbursements in recent years, but Congress passed legislation each year to temporarily avert these cuts (also known annually as the “doc fix”). In search of a permanent solution, the passage of bipartisan legislation permanently repealing the SGR in 2015 was hailed as a way to ensure more certainty around the future of Medicare payments for physicians.

This legislation (H.R. 2, 114th Congress), sponsored by Rep. Michael C. Burgess (R-Texas) and entitled “Medicare Access and CHIP Reauthorization Act of 2015,” or MACRA, does much more than simply remove the SGR’s threat of broader Medicare payment cuts. The law changes the ways physicians are reimbursed by Medicare and continues to shift our healthcare system away from volume-based reimbursements and toward a value-based payment system.

What Is MIPS?

MACRA creates two value-based payment tracks for physicians. The first, the Merit-Based Incentive Payment System (MIPS), is closer to the old fee-for-service model of reimbursement. However, MIPS takes into account both volume and quality (i.e., payment is adjusted based on physician-quality scores). These physician-specific scores broaden the scope of quality measurement by including new measures related to resource utilization, electronic health record (EHR) use, and clinical improvement practices, along with the traditional clinical quality markers.

Under MIPS, the current Physician Quality Reporting System (PQRS), EHR Incentive Program, and Physician Value-Based Modifier all will be integrated into this single-payment adjustment.

The range of potential payment adjustments based on a physician’s MIPS score grows each year through 2022 (in 2022, adjustments can range from +9% to -9%). The program is budget neutral, which means that increases in payments to high-scoring providers will be offset by decreases in payments to low-scoring providers. For 2019 to 2024, there also will be an additional payment adjustment given to the highest MIPS performers for exceptional performance.

A benefit of MIPS is that it will streamline the various quality-reporting programs currently in place into one single program and does not ask physicians to assume any additional financial risk related to outcomes when taking care of patients. However, the particulars of how the MIPS score will be calculated are yet to be determined, and much of the utility and palatability of this score will depend on the chosen metrics. The goal of these metrics should be that they are meaningful, valid, and attributable to specific providers.

What Are APMs?

The other payment option MACRA provides for physicians allows them to opt out of MIPS and participate in the Alternative Payment Models (APMs) track. To incentivize physicians to take part in this riskier track, providers taking part in APMs will receive some extra money for their participation: a 5% annual lump sum bonus on reimbursement payments. To clarify, qualifying APMs are those where providers take on “more than nominal” financial risk, report on their quality measures, and use certified EHR technology.

To qualify as a participant in an APM (for example, the Medicare Shared Savings Program), providers must hit a threshold for percentage of total revenue received or percentage of patients from qualifying APMs. This threshold will increase over time. For example, from 2019 to 2020, providers must obtain at least 25% of their Medicare revenue or patients via APMs, whereas in 2023, 75% of their Medicare revenue or \ patients will need to come from APMs.

Providers will benefit from the increased reimbursement offered if they participate in APMs. There also is funding allocated in MACRA to help develop quality measures, with a call for physician leads to develop quality standards. This payment model, however, does come with increased financial risk for the provider contingent on patient outcomes. In addition, it may be difficult for all providers to hit the thresholds for participation.

Stick with MIPS? Or Take the Plunge with APM?

How MACRA affects you will depend a lot on the practice environment. As described above, MACRA is designed to move physicians into risk-based payment structures if possible. If possible, or otherwise, to simplify the current fee-for-service mechanism of payment by consolidating various Medicare pay-for-performance programs.

Let’s look at a few scenarios:

Hospitalist A works for a physician group that assumes risk for patients in a MACRA-approved APM and sees only those inpatients as opposed to unassigned patients. Therefore, almost all of hospitalist A’s patients are covered by risk-based contracts, and hospitalist A might be well positioned for the new APM structure.

Hospitalist B works for a group, or a university, and sees whatever patients are admitted to the hospital. Hospitalist B’s eligibility to participate in the APM will depend on the percentage of patients in alternative payment models in their market. If hospitalist B’s market has many Medicare accountable care organizations, and Medicaid and the commercial insurers compensate through a risk-sharing model, hospitalist B might reach the threshold. This is more accidental than planned, however, and hospitalist B might not be able to consistently hit this threshold year after year.

In addition, just working within the model will probably not be enough to qualify. Hospitalist B will need to also take on “more than nominal risk” as a participant in the model. In an employed academic setting, where the hospital is taking on risk as part of an APM, it is unlikely hospitalist B will qualify just by virtue of hospital employment. Hospitalist B must also meet/exceed the patient or payment thresholds under the model.

Bottom line: Given the current situation, we expect many hospitalists will likely be required to participate in MIPS and not qualify for APMs. Understanding the details and expectations now will help them be successful in the future.

Is MACRA Good for Hospitalists?

Most of organized medicine is happy to be free from the annual threat of reimbursement cuts. In addition, the new law might streamline quality reporting. But the specific upside depends on your perspective.

With APMs, a hospitalist might enjoy more upside potential, particularly for high-quality work and EHR use. However, whether it is realistic for most hospitalists to even participate in the model depends on many factors, as described previously, and SHM is advocating for the law to be implemented in ways that will more readily accommodate hospitalist practice and employment structures.

For example, the SHM Public Policy Committee has provided the Centers for Medicare & Medicaid Services (CMS) with realistic options for implementing the APM framework that would allow hospitalist B in the above example to qualify as an APM participant.

With MIPS, the benefit to hospitalists depends a fair amount on the way the law is implemented: how quality reporting happens, what metrics will count as quality improvement efforts, and how utilization of EHRs is measured.

What Issues Should Hospitalists Be Aware Of?

As MACRA is further developed, the main issue for hospitalists will be to ensure fairness in assessing quality and incentive payments. As previously encountered with quality reporting, hospitalists are not differentiated clearly from outpatient providers. As a result, they could suffer from the comparison of their quality outcomes for their sicker hospitalized patients to the patients cared for in a typical primary-care internal medicine practice. This inaccurate comparison poses problems in both models.

A potential solution would be a hospitalist-specific billing code, which would make it easier to identify hospitalists. SHM applied for and advocated for the approval of such a billing code and the request was recently approved by CMS.

In addition, as hospitalists mostly work in groups with shift-based schedules, thus sharing care of patients, individual identifiers may not be as significant as possibly looking at hospital, system, or team-based metrics. Using facility performance measures for both clinical quality and performance improvement—where hospitalists can opt to align with their hospital, which is already reporting quality outcomes—might be one way out of this conundrum. It would take into account the type of facility-level quality improvement work many hospitalists participate in. This also would decrease reporting burden for hospitalist groups.

SHM has advocated for this solution and was able to ensure this concept was included in the law; however, it is unclear when or how CMS will implement it.

To summarize, looking good in quality reporting will continue to be a challenge for hospitalists. It will be critical to keep pressure on CMS to implement solutions that account for the unique situation of our specialty.

Another issue to be aware of is the ability of hospitalists to participate in APMs. As with other facility-based providers, hospitalists have little control over whether their facility participates in an APM. Ways to ensure hospitalists can reach thresholds for participation could include allowing the various APMs that hospitalist patients are aligned with count toward an individual hospitalists’ APM participation total—a solution that SHM is advocating for Medicare to include in the APM framework.

What’s Next?

Much remains to be solidified regarding implementation of MACRA, despite the fact it goes live in a few short years (see Figure 1). CMS has asked for comments and stakeholder input regarding MIPS and APMs, and it will be releasing the first round of rules around MACRA this year.

SHM is actively working with CMS to ensure this legislation will reflect the work we are doing as hospitalists to provide high-quality clinical care for our patients and enhance the performance of our hospitals and health system. TH

Dr. Doctoroff is a hospitalist at Beth Israel Deaconess Medical Center and an instructor of medicine at Harvard Medical School in Boston. Dr. Dutta is a hospitalist at Rush University Medical Center and an assistant professor of medicine at Rush Medical College in Chicago. Both are members of the SHM Public Policy Committee.

Last year, Congress passed legislation to permanently eliminate the Sustainable Growth Rate (SGR) formula, created in 1997 and designed to hold Medicare Part B or outpatient spending under control. Allowing the SGR to go into effect would have severely cut physician reimbursements in recent years, but Congress passed legislation each year to temporarily avert these cuts (also known annually as the “doc fix”). In search of a permanent solution, the passage of bipartisan legislation permanently repealing the SGR in 2015 was hailed as a way to ensure more certainty around the future of Medicare payments for physicians.

This legislation (H.R. 2, 114th Congress), sponsored by Rep. Michael C. Burgess (R-Texas) and entitled “Medicare Access and CHIP Reauthorization Act of 2015,” or MACRA, does much more than simply remove the SGR’s threat of broader Medicare payment cuts. The law changes the ways physicians are reimbursed by Medicare and continues to shift our healthcare system away from volume-based reimbursements and toward a value-based payment system.

What Is MIPS?

MACRA creates two value-based payment tracks for physicians. The first, the Merit-Based Incentive Payment System (MIPS), is closer to the old fee-for-service model of reimbursement. However, MIPS takes into account both volume and quality (i.e., payment is adjusted based on physician-quality scores). These physician-specific scores broaden the scope of quality measurement by including new measures related to resource utilization, electronic health record (EHR) use, and clinical improvement practices, along with the traditional clinical quality markers.

Under MIPS, the current Physician Quality Reporting System (PQRS), EHR Incentive Program, and Physician Value-Based Modifier all will be integrated into this single-payment adjustment.

The range of potential payment adjustments based on a physician’s MIPS score grows each year through 2022 (in 2022, adjustments can range from +9% to -9%). The program is budget neutral, which means that increases in payments to high-scoring providers will be offset by decreases in payments to low-scoring providers. For 2019 to 2024, there also will be an additional payment adjustment given to the highest MIPS performers for exceptional performance.

A benefit of MIPS is that it will streamline the various quality-reporting programs currently in place into one single program and does not ask physicians to assume any additional financial risk related to outcomes when taking care of patients. However, the particulars of how the MIPS score will be calculated are yet to be determined, and much of the utility and palatability of this score will depend on the chosen metrics. The goal of these metrics should be that they are meaningful, valid, and attributable to specific providers.

What Are APMs?

The other payment option MACRA provides for physicians allows them to opt out of MIPS and participate in the Alternative Payment Models (APMs) track. To incentivize physicians to take part in this riskier track, providers taking part in APMs will receive some extra money for their participation: a 5% annual lump sum bonus on reimbursement payments. To clarify, qualifying APMs are those where providers take on “more than nominal” financial risk, report on their quality measures, and use certified EHR technology.

To qualify as a participant in an APM (for example, the Medicare Shared Savings Program), providers must hit a threshold for percentage of total revenue received or percentage of patients from qualifying APMs. This threshold will increase over time. For example, from 2019 to 2020, providers must obtain at least 25% of their Medicare revenue or patients via APMs, whereas in 2023, 75% of their Medicare revenue or \ patients will need to come from APMs.

Providers will benefit from the increased reimbursement offered if they participate in APMs. There also is funding allocated in MACRA to help develop quality measures, with a call for physician leads to develop quality standards. This payment model, however, does come with increased financial risk for the provider contingent on patient outcomes. In addition, it may be difficult for all providers to hit the thresholds for participation.

Stick with MIPS? Or Take the Plunge with APM?

How MACRA affects you will depend a lot on the practice environment. As described above, MACRA is designed to move physicians into risk-based payment structures if possible. If possible, or otherwise, to simplify the current fee-for-service mechanism of payment by consolidating various Medicare pay-for-performance programs.

Let’s look at a few scenarios:

Hospitalist A works for a physician group that assumes risk for patients in a MACRA-approved APM and sees only those inpatients as opposed to unassigned patients. Therefore, almost all of hospitalist A’s patients are covered by risk-based contracts, and hospitalist A might be well positioned for the new APM structure.

Hospitalist B works for a group, or a university, and sees whatever patients are admitted to the hospital. Hospitalist B’s eligibility to participate in the APM will depend on the percentage of patients in alternative payment models in their market. If hospitalist B’s market has many Medicare accountable care organizations, and Medicaid and the commercial insurers compensate through a risk-sharing model, hospitalist B might reach the threshold. This is more accidental than planned, however, and hospitalist B might not be able to consistently hit this threshold year after year.

In addition, just working within the model will probably not be enough to qualify. Hospitalist B will need to also take on “more than nominal risk” as a participant in the model. In an employed academic setting, where the hospital is taking on risk as part of an APM, it is unlikely hospitalist B will qualify just by virtue of hospital employment. Hospitalist B must also meet/exceed the patient or payment thresholds under the model.

Bottom line: Given the current situation, we expect many hospitalists will likely be required to participate in MIPS and not qualify for APMs. Understanding the details and expectations now will help them be successful in the future.

Is MACRA Good for Hospitalists?

Most of organized medicine is happy to be free from the annual threat of reimbursement cuts. In addition, the new law might streamline quality reporting. But the specific upside depends on your perspective.

With APMs, a hospitalist might enjoy more upside potential, particularly for high-quality work and EHR use. However, whether it is realistic for most hospitalists to even participate in the model depends on many factors, as described previously, and SHM is advocating for the law to be implemented in ways that will more readily accommodate hospitalist practice and employment structures.

For example, the SHM Public Policy Committee has provided the Centers for Medicare & Medicaid Services (CMS) with realistic options for implementing the APM framework that would allow hospitalist B in the above example to qualify as an APM participant.

With MIPS, the benefit to hospitalists depends a fair amount on the way the law is implemented: how quality reporting happens, what metrics will count as quality improvement efforts, and how utilization of EHRs is measured.

What Issues Should Hospitalists Be Aware Of?

As MACRA is further developed, the main issue for hospitalists will be to ensure fairness in assessing quality and incentive payments. As previously encountered with quality reporting, hospitalists are not differentiated clearly from outpatient providers. As a result, they could suffer from the comparison of their quality outcomes for their sicker hospitalized patients to the patients cared for in a typical primary-care internal medicine practice. This inaccurate comparison poses problems in both models.

A potential solution would be a hospitalist-specific billing code, which would make it easier to identify hospitalists. SHM applied for and advocated for the approval of such a billing code and the request was recently approved by CMS.

In addition, as hospitalists mostly work in groups with shift-based schedules, thus sharing care of patients, individual identifiers may not be as significant as possibly looking at hospital, system, or team-based metrics. Using facility performance measures for both clinical quality and performance improvement—where hospitalists can opt to align with their hospital, which is already reporting quality outcomes—might be one way out of this conundrum. It would take into account the type of facility-level quality improvement work many hospitalists participate in. This also would decrease reporting burden for hospitalist groups.

SHM has advocated for this solution and was able to ensure this concept was included in the law; however, it is unclear when or how CMS will implement it.

To summarize, looking good in quality reporting will continue to be a challenge for hospitalists. It will be critical to keep pressure on CMS to implement solutions that account for the unique situation of our specialty.

Another issue to be aware of is the ability of hospitalists to participate in APMs. As with other facility-based providers, hospitalists have little control over whether their facility participates in an APM. Ways to ensure hospitalists can reach thresholds for participation could include allowing the various APMs that hospitalist patients are aligned with count toward an individual hospitalists’ APM participation total—a solution that SHM is advocating for Medicare to include in the APM framework.

What’s Next?

Much remains to be solidified regarding implementation of MACRA, despite the fact it goes live in a few short years (see Figure 1). CMS has asked for comments and stakeholder input regarding MIPS and APMs, and it will be releasing the first round of rules around MACRA this year.

SHM is actively working with CMS to ensure this legislation will reflect the work we are doing as hospitalists to provide high-quality clinical care for our patients and enhance the performance of our hospitals and health system. TH

Dr. Doctoroff is a hospitalist at Beth Israel Deaconess Medical Center and an instructor of medicine at Harvard Medical School in Boston. Dr. Dutta is a hospitalist at Rush University Medical Center and an assistant professor of medicine at Rush Medical College in Chicago. Both are members of the SHM Public Policy Committee.

Last year, Congress passed legislation to permanently eliminate the Sustainable Growth Rate (SGR) formula, created in 1997 and designed to hold Medicare Part B or outpatient spending under control. Allowing the SGR to go into effect would have severely cut physician reimbursements in recent years, but Congress passed legislation each year to temporarily avert these cuts (also known annually as the “doc fix”). In search of a permanent solution, the passage of bipartisan legislation permanently repealing the SGR in 2015 was hailed as a way to ensure more certainty around the future of Medicare payments for physicians.

This legislation (H.R. 2, 114th Congress), sponsored by Rep. Michael C. Burgess (R-Texas) and entitled “Medicare Access and CHIP Reauthorization Act of 2015,” or MACRA, does much more than simply remove the SGR’s threat of broader Medicare payment cuts. The law changes the ways physicians are reimbursed by Medicare and continues to shift our healthcare system away from volume-based reimbursements and toward a value-based payment system.

What Is MIPS?

MACRA creates two value-based payment tracks for physicians. The first, the Merit-Based Incentive Payment System (MIPS), is closer to the old fee-for-service model of reimbursement. However, MIPS takes into account both volume and quality (i.e., payment is adjusted based on physician-quality scores). These physician-specific scores broaden the scope of quality measurement by including new measures related to resource utilization, electronic health record (EHR) use, and clinical improvement practices, along with the traditional clinical quality markers.

Under MIPS, the current Physician Quality Reporting System (PQRS), EHR Incentive Program, and Physician Value-Based Modifier all will be integrated into this single-payment adjustment.

The range of potential payment adjustments based on a physician’s MIPS score grows each year through 2022 (in 2022, adjustments can range from +9% to -9%). The program is budget neutral, which means that increases in payments to high-scoring providers will be offset by decreases in payments to low-scoring providers. For 2019 to 2024, there also will be an additional payment adjustment given to the highest MIPS performers for exceptional performance.

A benefit of MIPS is that it will streamline the various quality-reporting programs currently in place into one single program and does not ask physicians to assume any additional financial risk related to outcomes when taking care of patients. However, the particulars of how the MIPS score will be calculated are yet to be determined, and much of the utility and palatability of this score will depend on the chosen metrics. The goal of these metrics should be that they are meaningful, valid, and attributable to specific providers.

What Are APMs?

The other payment option MACRA provides for physicians allows them to opt out of MIPS and participate in the Alternative Payment Models (APMs) track. To incentivize physicians to take part in this riskier track, providers taking part in APMs will receive some extra money for their participation: a 5% annual lump sum bonus on reimbursement payments. To clarify, qualifying APMs are those where providers take on “more than nominal” financial risk, report on their quality measures, and use certified EHR technology.

To qualify as a participant in an APM (for example, the Medicare Shared Savings Program), providers must hit a threshold for percentage of total revenue received or percentage of patients from qualifying APMs. This threshold will increase over time. For example, from 2019 to 2020, providers must obtain at least 25% of their Medicare revenue or patients via APMs, whereas in 2023, 75% of their Medicare revenue or \ patients will need to come from APMs.

Providers will benefit from the increased reimbursement offered if they participate in APMs. There also is funding allocated in MACRA to help develop quality measures, with a call for physician leads to develop quality standards. This payment model, however, does come with increased financial risk for the provider contingent on patient outcomes. In addition, it may be difficult for all providers to hit the thresholds for participation.

Stick with MIPS? Or Take the Plunge with APM?

How MACRA affects you will depend a lot on the practice environment. As described above, MACRA is designed to move physicians into risk-based payment structures if possible. If possible, or otherwise, to simplify the current fee-for-service mechanism of payment by consolidating various Medicare pay-for-performance programs.

Let’s look at a few scenarios:

Hospitalist A works for a physician group that assumes risk for patients in a MACRA-approved APM and sees only those inpatients as opposed to unassigned patients. Therefore, almost all of hospitalist A’s patients are covered by risk-based contracts, and hospitalist A might be well positioned for the new APM structure.

Hospitalist B works for a group, or a university, and sees whatever patients are admitted to the hospital. Hospitalist B’s eligibility to participate in the APM will depend on the percentage of patients in alternative payment models in their market. If hospitalist B’s market has many Medicare accountable care organizations, and Medicaid and the commercial insurers compensate through a risk-sharing model, hospitalist B might reach the threshold. This is more accidental than planned, however, and hospitalist B might not be able to consistently hit this threshold year after year.

In addition, just working within the model will probably not be enough to qualify. Hospitalist B will need to also take on “more than nominal risk” as a participant in the model. In an employed academic setting, where the hospital is taking on risk as part of an APM, it is unlikely hospitalist B will qualify just by virtue of hospital employment. Hospitalist B must also meet/exceed the patient or payment thresholds under the model.

Bottom line: Given the current situation, we expect many hospitalists will likely be required to participate in MIPS and not qualify for APMs. Understanding the details and expectations now will help them be successful in the future.

Is MACRA Good for Hospitalists?

Most of organized medicine is happy to be free from the annual threat of reimbursement cuts. In addition, the new law might streamline quality reporting. But the specific upside depends on your perspective.

With APMs, a hospitalist might enjoy more upside potential, particularly for high-quality work and EHR use. However, whether it is realistic for most hospitalists to even participate in the model depends on many factors, as described previously, and SHM is advocating for the law to be implemented in ways that will more readily accommodate hospitalist practice and employment structures.

For example, the SHM Public Policy Committee has provided the Centers for Medicare & Medicaid Services (CMS) with realistic options for implementing the APM framework that would allow hospitalist B in the above example to qualify as an APM participant.

With MIPS, the benefit to hospitalists depends a fair amount on the way the law is implemented: how quality reporting happens, what metrics will count as quality improvement efforts, and how utilization of EHRs is measured.

What Issues Should Hospitalists Be Aware Of?

As MACRA is further developed, the main issue for hospitalists will be to ensure fairness in assessing quality and incentive payments. As previously encountered with quality reporting, hospitalists are not differentiated clearly from outpatient providers. As a result, they could suffer from the comparison of their quality outcomes for their sicker hospitalized patients to the patients cared for in a typical primary-care internal medicine practice. This inaccurate comparison poses problems in both models.

A potential solution would be a hospitalist-specific billing code, which would make it easier to identify hospitalists. SHM applied for and advocated for the approval of such a billing code and the request was recently approved by CMS.

In addition, as hospitalists mostly work in groups with shift-based schedules, thus sharing care of patients, individual identifiers may not be as significant as possibly looking at hospital, system, or team-based metrics. Using facility performance measures for both clinical quality and performance improvement—where hospitalists can opt to align with their hospital, which is already reporting quality outcomes—might be one way out of this conundrum. It would take into account the type of facility-level quality improvement work many hospitalists participate in. This also would decrease reporting burden for hospitalist groups.

SHM has advocated for this solution and was able to ensure this concept was included in the law; however, it is unclear when or how CMS will implement it.

To summarize, looking good in quality reporting will continue to be a challenge for hospitalists. It will be critical to keep pressure on CMS to implement solutions that account for the unique situation of our specialty.

Another issue to be aware of is the ability of hospitalists to participate in APMs. As with other facility-based providers, hospitalists have little control over whether their facility participates in an APM. Ways to ensure hospitalists can reach thresholds for participation could include allowing the various APMs that hospitalist patients are aligned with count toward an individual hospitalists’ APM participation total—a solution that SHM is advocating for Medicare to include in the APM framework.

What’s Next?

Much remains to be solidified regarding implementation of MACRA, despite the fact it goes live in a few short years (see Figure 1). CMS has asked for comments and stakeholder input regarding MIPS and APMs, and it will be releasing the first round of rules around MACRA this year.

SHM is actively working with CMS to ensure this legislation will reflect the work we are doing as hospitalists to provide high-quality clinical care for our patients and enhance the performance of our hospitals and health system. TH

Dr. Doctoroff is a hospitalist at Beth Israel Deaconess Medical Center and an instructor of medicine at Harvard Medical School in Boston. Dr. Dutta is a hospitalist at Rush University Medical Center and an assistant professor of medicine at Rush Medical College in Chicago. Both are members of the SHM Public Policy Committee.

The Centers for Medicare & Medicaid Services (CMS) recently announced the approval of a dedicated specialty billing code for hospitalists that will soon be ready for official use. This is a monumental step for hospital medicine, which continues to be the fastest growing medical specialty in the U.S., with more than 48,000 practitioners identifying as hospitalists.

The Hospitalist recently discussed the implications of this decision with Ron Greeno, MD, MHM, chief strategy officer for IPC Healthcare and chair of SHM’s Public Policy Committee (PPC), and Josh Boswell, director of government relations at SHM, to answer questions raised by SHM members.

Question: What are the benefits to hospitalists using the code?

Dr. Greeno: As we transition from fee-for-service to quality-based payment models, using this code will become critical to ensure hospitalists are reimbursed and evaluated fairly. Under the current code structure, hospitalists are missing opportunities to be rewarded and may be penalized unnecessarily because they are required to identify with internal medicine, family medicine, or another specialty that most closely resembles their daily practice. What current measures do not account for is that hospitalists’ patients are inherently more complex than those seen by practitioners in these other—most often outpatient—specialties. We as hospitalists face unique challenges and work with patients from all demographics, often with severe illnesses, making it nearly impossible to rely on benchmarks used for these other specialties.

There are a few prime examples of this that illustrate the need for the new code. Under the current system, some quality-based patient satisfaction measures under MACRA, on which hospitalists are being evaluated, pertain to the outpatient setting, including waiting room quality and office staff–irrelevant measurements for hospitalists. Hospitalists are also often incorrectly penalized under meaningful use due to complications brought on by observation status and its classification as an outpatient stay. This can cause both quality and cost measures to be extremely flawed and can misrepresent the performance and cost of hospitalists and hospital medicine groups. In the current billing structure, there is no way to accurately identify hospitalists and enable a definite fix to these problems.

To get what we want (fair measurement using relevant metrics), we must be able to identify as a separate group, and fortunately, now we can. There will be benefits we don’t even know about yet. We have to wait and see how healthcare policy continues to evolve and change moving forward. What we do know is that having this code will help us shape MACRA and future healthcare policy so that it works better for hospitalists as the specialty continues to grow in scope and impact.

Q: When will the new code go into effect?

Boswell: While there is not a set date at this time, CMS has reported that it can take up to a year, mostly due to technical changes that need to be made within their own systems. The code has already been officially approved; we just need to wait a bit longer to actually use it.

Q: What happens to hospitalists if they do not use the code?

Dr. Greeno: Some hospitalists might be nervous about the change after having billed a certain way for so long. While there is no absolute requirement for hospitalists to use the new code, the bottom line is that if hospitalists do not adopt the new code, they risk not receiving fair evaluations. Using this code should provide hospitalists with greater insight into their own performance—the data will be much more accurate and meaningful. This will allow hospitalists to hone in on areas needing improvement and provide them with more confidence that they are being compared using accurate benchmarks.

I want to stress that hospitalists, or in some cases their hospital medicine groups, will need to physically change their specialty affiliation when the code becomes effective. Otherwise, they risk not reaping the benefits associated with the new code and will continue to be evaluated using less-than-optimal benchmarks. The ball is in their court to make the change when the code is available, and SHM will serve as a resource to help ensure they know what to do and when.

Q: Where can someone go to find the code? Will it be available on the CMS website?

Boswell: When the code does become available for use, it will be communicated through various channels at SHM and also through the Medicare Learning Network, the site that houses education, information, and resources for healthcare professionals. It will also likely be distributed through additional Medicare circulars and newsletters.

As more details from CMS become available, we will have more specific information to share with members, including information on our website, webinars with billing and coding experts, email communication, and more. Continue to watch your email and social media channels for the latest updates and information.

 Q: What role did SHM play in bringing this code to fruition?

Boswell: We can say with confidence that this effort was driven entirely by SHM. To start, a formal application needs to be filed in order for a code to even be considered. After determining that the benefits associated with this code far outweighed the costs and then receiving the support of our board of directors, SHM’s staff and PPC members collaborated to draft a brief and made the argument for the addition of a hospitalist billing code based on the individual elements CMS requires for consideration.

Due to the fact hospital medicine doesn’t have a board certification, while solid, our argument was far from a slam dunk. After submitting the application, SHM continuously followed up with and pressured CMS through various channels and utilized our grassroots network of hospitalists on the Hill to put this code on legislators’ radars—the result was pressure getting applied from interested members of Congress as well. If it weren’t for the persistent advocacy efforts of SHM and its members over the past several years, this code would not have even been considered, let alone approved.

This is a significant development—to our knowledge, this is the first medical specialty to be granted a code without also having a board certification. We’re thrilled that what we have been advocating for on behalf of our members is now a reality!

For the latest information on the new hospitalist billing code and other important healthcare policy updates, continue to check for SHM emails and follow SHM’s social media channels, including @SHMLive and @SHMAdvocacy on Twitter.

Sign up for the network to get the latest news in healthcare policy and discover opportunities to advocate for yourself and fellow hospitalists. TH

Brett Radler is SHM’s communications coordinator.

The Centers for Medicare & Medicaid Services (CMS) recently announced the approval of a dedicated specialty billing code for hospitalists that will soon be ready for official use. This is a monumental step for hospital medicine, which continues to be the fastest growing medical specialty in the U.S., with more than 48,000 practitioners identifying as hospitalists.

The Hospitalist recently discussed the implications of this decision with Ron Greeno, MD, MHM, chief strategy officer for IPC Healthcare and chair of SHM’s Public Policy Committee (PPC), and Josh Boswell, director of government relations at SHM, to answer questions raised by SHM members.

Question: What are the benefits to hospitalists using the code?

Dr. Greeno: As we transition from fee-for-service to quality-based payment models, using this code will become critical to ensure hospitalists are reimbursed and evaluated fairly. Under the current code structure, hospitalists are missing opportunities to be rewarded and may be penalized unnecessarily because they are required to identify with internal medicine, family medicine, or another specialty that most closely resembles their daily practice. What current measures do not account for is that hospitalists’ patients are inherently more complex than those seen by practitioners in these other—most often outpatient—specialties. We as hospitalists face unique challenges and work with patients from all demographics, often with severe illnesses, making it nearly impossible to rely on benchmarks used for these other specialties.

There are a few prime examples of this that illustrate the need for the new code. Under the current system, some quality-based patient satisfaction measures under MACRA, on which hospitalists are being evaluated, pertain to the outpatient setting, including waiting room quality and office staff–irrelevant measurements for hospitalists. Hospitalists are also often incorrectly penalized under meaningful use due to complications brought on by observation status and its classification as an outpatient stay. This can cause both quality and cost measures to be extremely flawed and can misrepresent the performance and cost of hospitalists and hospital medicine groups. In the current billing structure, there is no way to accurately identify hospitalists and enable a definite fix to these problems.

To get what we want (fair measurement using relevant metrics), we must be able to identify as a separate group, and fortunately, now we can. There will be benefits we don’t even know about yet. We have to wait and see how healthcare policy continues to evolve and change moving forward. What we do know is that having this code will help us shape MACRA and future healthcare policy so that it works better for hospitalists as the specialty continues to grow in scope and impact.

Q: When will the new code go into effect?

Boswell: While there is not a set date at this time, CMS has reported that it can take up to a year, mostly due to technical changes that need to be made within their own systems. The code has already been officially approved; we just need to wait a bit longer to actually use it.

Q: What happens to hospitalists if they do not use the code?

Dr. Greeno: Some hospitalists might be nervous about the change after having billed a certain way for so long. While there is no absolute requirement for hospitalists to use the new code, the bottom line is that if hospitalists do not adopt the new code, they risk not receiving fair evaluations. Using this code should provide hospitalists with greater insight into their own performance—the data will be much more accurate and meaningful. This will allow hospitalists to hone in on areas needing improvement and provide them with more confidence that they are being compared using accurate benchmarks.

I want to stress that hospitalists, or in some cases their hospital medicine groups, will need to physically change their specialty affiliation when the code becomes effective. Otherwise, they risk not reaping the benefits associated with the new code and will continue to be evaluated using less-than-optimal benchmarks. The ball is in their court to make the change when the code is available, and SHM will serve as a resource to help ensure they know what to do and when.

Q: Where can someone go to find the code? Will it be available on the CMS website?

Boswell: When the code does become available for use, it will be communicated through various channels at SHM and also through the Medicare Learning Network, the site that houses education, information, and resources for healthcare professionals. It will also likely be distributed through additional Medicare circulars and newsletters.

As more details from CMS become available, we will have more specific information to share with members, including information on our website, webinars with billing and coding experts, email communication, and more. Continue to watch your email and social media channels for the latest updates and information.

 Q: What role did SHM play in bringing this code to fruition?

Boswell: We can say with confidence that this effort was driven entirely by SHM. To start, a formal application needs to be filed in order for a code to even be considered. After determining that the benefits associated with this code far outweighed the costs and then receiving the support of our board of directors, SHM’s staff and PPC members collaborated to draft a brief and made the argument for the addition of a hospitalist billing code based on the individual elements CMS requires for consideration.

Due to the fact hospital medicine doesn’t have a board certification, while solid, our argument was far from a slam dunk. After submitting the application, SHM continuously followed up with and pressured CMS through various channels and utilized our grassroots network of hospitalists on the Hill to put this code on legislators’ radars—the result was pressure getting applied from interested members of Congress as well. If it weren’t for the persistent advocacy efforts of SHM and its members over the past several years, this code would not have even been considered, let alone approved.

This is a significant development—to our knowledge, this is the first medical specialty to be granted a code without also having a board certification. We’re thrilled that what we have been advocating for on behalf of our members is now a reality!

For the latest information on the new hospitalist billing code and other important healthcare policy updates, continue to check for SHM emails and follow SHM’s social media channels, including @SHMLive and @SHMAdvocacy on Twitter.

Sign up for the network to get the latest news in healthcare policy and discover opportunities to advocate for yourself and fellow hospitalists. TH

Brett Radler is SHM’s communications coordinator.

The Centers for Medicare & Medicaid Services (CMS) recently announced the approval of a dedicated specialty billing code for hospitalists that will soon be ready for official use. This is a monumental step for hospital medicine, which continues to be the fastest growing medical specialty in the U.S., with more than 48,000 practitioners identifying as hospitalists.

The Hospitalist recently discussed the implications of this decision with Ron Greeno, MD, MHM, chief strategy officer for IPC Healthcare and chair of SHM’s Public Policy Committee (PPC), and Josh Boswell, director of government relations at SHM, to answer questions raised by SHM members.

Question: What are the benefits to hospitalists using the code?

Dr. Greeno: As we transition from fee-for-service to quality-based payment models, using this code will become critical to ensure hospitalists are reimbursed and evaluated fairly. Under the current code structure, hospitalists are missing opportunities to be rewarded and may be penalized unnecessarily because they are required to identify with internal medicine, family medicine, or another specialty that most closely resembles their daily practice. What current measures do not account for is that hospitalists’ patients are inherently more complex than those seen by practitioners in these other—most often outpatient—specialties. We as hospitalists face unique challenges and work with patients from all demographics, often with severe illnesses, making it nearly impossible to rely on benchmarks used for these other specialties.

There are a few prime examples of this that illustrate the need for the new code. Under the current system, some quality-based patient satisfaction measures under MACRA, on which hospitalists are being evaluated, pertain to the outpatient setting, including waiting room quality and office staff–irrelevant measurements for hospitalists. Hospitalists are also often incorrectly penalized under meaningful use due to complications brought on by observation status and its classification as an outpatient stay. This can cause both quality and cost measures to be extremely flawed and can misrepresent the performance and cost of hospitalists and hospital medicine groups. In the current billing structure, there is no way to accurately identify hospitalists and enable a definite fix to these problems.

To get what we want (fair measurement using relevant metrics), we must be able to identify as a separate group, and fortunately, now we can. There will be benefits we don’t even know about yet. We have to wait and see how healthcare policy continues to evolve and change moving forward. What we do know is that having this code will help us shape MACRA and future healthcare policy so that it works better for hospitalists as the specialty continues to grow in scope and impact.

Q: When will the new code go into effect?

Boswell: While there is not a set date at this time, CMS has reported that it can take up to a year, mostly due to technical changes that need to be made within their own systems. The code has already been officially approved; we just need to wait a bit longer to actually use it.

Q: What happens to hospitalists if they do not use the code?

Dr. Greeno: Some hospitalists might be nervous about the change after having billed a certain way for so long. While there is no absolute requirement for hospitalists to use the new code, the bottom line is that if hospitalists do not adopt the new code, they risk not receiving fair evaluations. Using this code should provide hospitalists with greater insight into their own performance—the data will be much more accurate and meaningful. This will allow hospitalists to hone in on areas needing improvement and provide them with more confidence that they are being compared using accurate benchmarks.

I want to stress that hospitalists, or in some cases their hospital medicine groups, will need to physically change their specialty affiliation when the code becomes effective. Otherwise, they risk not reaping the benefits associated with the new code and will continue to be evaluated using less-than-optimal benchmarks. The ball is in their court to make the change when the code is available, and SHM will serve as a resource to help ensure they know what to do and when.

Q: Where can someone go to find the code? Will it be available on the CMS website?

Boswell: When the code does become available for use, it will be communicated through various channels at SHM and also through the Medicare Learning Network, the site that houses education, information, and resources for healthcare professionals. It will also likely be distributed through additional Medicare circulars and newsletters.

As more details from CMS become available, we will have more specific information to share with members, including information on our website, webinars with billing and coding experts, email communication, and more. Continue to watch your email and social media channels for the latest updates and information.

 Q: What role did SHM play in bringing this code to fruition?

Boswell: We can say with confidence that this effort was driven entirely by SHM. To start, a formal application needs to be filed in order for a code to even be considered. After determining that the benefits associated with this code far outweighed the costs and then receiving the support of our board of directors, SHM’s staff and PPC members collaborated to draft a brief and made the argument for the addition of a hospitalist billing code based on the individual elements CMS requires for consideration.

Due to the fact hospital medicine doesn’t have a board certification, while solid, our argument was far from a slam dunk. After submitting the application, SHM continuously followed up with and pressured CMS through various channels and utilized our grassroots network of hospitalists on the Hill to put this code on legislators’ radars—the result was pressure getting applied from interested members of Congress as well. If it weren’t for the persistent advocacy efforts of SHM and its members over the past several years, this code would not have even been considered, let alone approved.

This is a significant development—to our knowledge, this is the first medical specialty to be granted a code without also having a board certification. We’re thrilled that what we have been advocating for on behalf of our members is now a reality!

For the latest information on the new hospitalist billing code and other important healthcare policy updates, continue to check for SHM emails and follow SHM’s social media channels, including @SHMLive and @SHMAdvocacy on Twitter.

Sign up for the network to get the latest news in healthcare policy and discover opportunities to advocate for yourself and fellow hospitalists. TH

Brett Radler is SHM’s communications coordinator.

As the long 2016 presidential election season draws on, Republican hopefuls strive to stand out among their fellow party candidates; however, many in the running remain tacit about specific policies on issues ranging from immigration to gun control and healthcare.

“Many of these candidates … do not feel like getting involved in an extensive policy discussion will influence whether they win Iowa and New Hampshire,” says Robert Blendon, ScD, professor of health policy and political analysis at the Harvard School of Public Health and Harvard Kennedy School of Government in Cambridge, Mass. “They see it as a distraction, because the people voting are not asking them.”

For physicians and others passionate about healthcare, “it’s very frustrating,” Dr. Blendon says. “People who are on the Republican side want a replacement [for the Affordable Care Act], but they are not driven—I have seen the surveys—to want to really know the details of that replacement.”

GOP candidates share many common ideas about the U.S. health system. Most say they want to allow people under age 26 to remain on their parents’ health plans and believe people with preexisting conditions should have access to coverage, generally through the creation of state-based, high-risk insurance pools. They believe expanded health savings accounts will give patients more skin in the game, and, across the board, they have vowed to “repeal and replace Obamacare.”

Listen to more of our interview with Robert Blendon, ScD

However, “with more than 10 candidates, there is going to be variation,” Dr. Blendon adds.

For instance, former Florida Governor Jeb Bush has proposed the Conservative Plan for 21st Century Health, which aims to “lower costs,” “promote innovation,” and “return power to states.”

Neurosurgeon Ben Carson originally suggested he would “abolish” Medicare and instead provide seniors with a $2,000-a-year federal subsidy to purchase private insurance. He has backtracked that idea and, in December 2015, issued a report highlighting the pillars of his health plan, which include creating “health empowerment accounts” and raising the Medicare age to 70.

New Jersey Governor Chris Christie’s plan suggests a priority for veterans, including the formation of a federal Secretary of Veterans Affairs, while Carly Fiorina says that “every healthcare provider “ought to publish its costs, its prices, its outcomes” so patients know what they are buying.

“As the field on the Republican side narrows, I think we will start to see more pressure on them to flesh those principles out a little bit more,” says Joshua Lenchus, DO, RPh, FACP, SFHM, a hospitalist at the University of Miami (Fla.) Jackson Memorial Hospital and a member of SHM’s Public Policy Committee.

Some GOP candidates, like Kentucky Senator and ophthalmologist Rand Paul, have proposed reforming medical malpractice. Some wish to make insurance portable from one job to the next, like former Arkansas Governor Mike Huckabee, or across state lines, as Ohio Governor John Kasich has proposed.

Some of these ideas, says hospitalist and SHM Public Policy Committee member Bradley Flansbaum, DO, MPH, MHM, “have been adequately dismembered, and they’re not going to carry weight.

“Buying insurance across state lines, fixing malpractice—that is not going to fix the healthcare system,” says Dr. Flansbaum, clinical professor of medicine at NYU School of Medicine in New York City.

Overall, a Republican-sponsored healthcare system will not guarantee the same level of comprehensive benefits patients have now under the ACA, Dr. Blendon says, and, in general, subsidies and tax credits will be less generous than they are today, in turn reducing federal expenditures.

Most Republican candidates are in favor of some version of free market healthcare, but Dr. Flansbaum points out that “there are so many imperfections in the market, everything from people having asymmetric information—a physician knows a lot more than a patient does—to opaque pricing,” he says. “It’s not exchanging goods like we are used to.”

Republicans are generally committed to “less federal government, less expenditures, more choices, and less expensive benefits,” in healthcare, but Dr. Blendon says the system “would not go back to 2009.”

For hospitalists interested in election-year or other healthcare policy issues, Dr. Flansbaum suggests getting involved in the SHM committee, visiting the advocacy section of the SHM website, and reaching out to local representatives and others who write and vote on laws.

“How do you affect change?” he asks. “It’s not sitting in the breakfast lounge at the hospital bellyaching to your colleagues.” TH

Editor's note: update Jan. 4, 2016.

Kelly April Tyrrell is a freelance writer in Madison, Wis.

As the long 2016 presidential election season draws on, Republican hopefuls strive to stand out among their fellow party candidates; however, many in the running remain tacit about specific policies on issues ranging from immigration to gun control and healthcare.

“Many of these candidates … do not feel like getting involved in an extensive policy discussion will influence whether they win Iowa and New Hampshire,” says Robert Blendon, ScD, professor of health policy and political analysis at the Harvard School of Public Health and Harvard Kennedy School of Government in Cambridge, Mass. “They see it as a distraction, because the people voting are not asking them.”

For physicians and others passionate about healthcare, “it’s very frustrating,” Dr. Blendon says. “People who are on the Republican side want a replacement [for the Affordable Care Act], but they are not driven—I have seen the surveys—to want to really know the details of that replacement.”

GOP candidates share many common ideas about the U.S. health system. Most say they want to allow people under age 26 to remain on their parents’ health plans and believe people with preexisting conditions should have access to coverage, generally through the creation of state-based, high-risk insurance pools. They believe expanded health savings accounts will give patients more skin in the game, and, across the board, they have vowed to “repeal and replace Obamacare.”

Listen to more of our interview with Robert Blendon, ScD

However, “with more than 10 candidates, there is going to be variation,” Dr. Blendon adds.

For instance, former Florida Governor Jeb Bush has proposed the Conservative Plan for 21st Century Health, which aims to “lower costs,” “promote innovation,” and “return power to states.”

Neurosurgeon Ben Carson originally suggested he would “abolish” Medicare and instead provide seniors with a $2,000-a-year federal subsidy to purchase private insurance. He has backtracked that idea and, in December 2015, issued a report highlighting the pillars of his health plan, which include creating “health empowerment accounts” and raising the Medicare age to 70.

New Jersey Governor Chris Christie’s plan suggests a priority for veterans, including the formation of a federal Secretary of Veterans Affairs, while Carly Fiorina says that “every healthcare provider “ought to publish its costs, its prices, its outcomes” so patients know what they are buying.

“As the field on the Republican side narrows, I think we will start to see more pressure on them to flesh those principles out a little bit more,” says Joshua Lenchus, DO, RPh, FACP, SFHM, a hospitalist at the University of Miami (Fla.) Jackson Memorial Hospital and a member of SHM’s Public Policy Committee.

Some GOP candidates, like Kentucky Senator and ophthalmologist Rand Paul, have proposed reforming medical malpractice. Some wish to make insurance portable from one job to the next, like former Arkansas Governor Mike Huckabee, or across state lines, as Ohio Governor John Kasich has proposed.

Some of these ideas, says hospitalist and SHM Public Policy Committee member Bradley Flansbaum, DO, MPH, MHM, “have been adequately dismembered, and they’re not going to carry weight.

“Buying insurance across state lines, fixing malpractice—that is not going to fix the healthcare system,” says Dr. Flansbaum, clinical professor of medicine at NYU School of Medicine in New York City.

Overall, a Republican-sponsored healthcare system will not guarantee the same level of comprehensive benefits patients have now under the ACA, Dr. Blendon says, and, in general, subsidies and tax credits will be less generous than they are today, in turn reducing federal expenditures.

Most Republican candidates are in favor of some version of free market healthcare, but Dr. Flansbaum points out that “there are so many imperfections in the market, everything from people having asymmetric information—a physician knows a lot more than a patient does—to opaque pricing,” he says. “It’s not exchanging goods like we are used to.”

Republicans are generally committed to “less federal government, less expenditures, more choices, and less expensive benefits,” in healthcare, but Dr. Blendon says the system “would not go back to 2009.”

For hospitalists interested in election-year or other healthcare policy issues, Dr. Flansbaum suggests getting involved in the SHM committee, visiting the advocacy section of the SHM website, and reaching out to local representatives and others who write and vote on laws.

“How do you affect change?” he asks. “It’s not sitting in the breakfast lounge at the hospital bellyaching to your colleagues.” TH

Editor's note: update Jan. 4, 2016.

Kelly April Tyrrell is a freelance writer in Madison, Wis.

As the long 2016 presidential election season draws on, Republican hopefuls strive to stand out among their fellow party candidates; however, many in the running remain tacit about specific policies on issues ranging from immigration to gun control and healthcare.

“Many of these candidates … do not feel like getting involved in an extensive policy discussion will influence whether they win Iowa and New Hampshire,” says Robert Blendon, ScD, professor of health policy and political analysis at the Harvard School of Public Health and Harvard Kennedy School of Government in Cambridge, Mass. “They see it as a distraction, because the people voting are not asking them.”

For physicians and others passionate about healthcare, “it’s very frustrating,” Dr. Blendon says. “People who are on the Republican side want a replacement [for the Affordable Care Act], but they are not driven—I have seen the surveys—to want to really know the details of that replacement.”

GOP candidates share many common ideas about the U.S. health system. Most say they want to allow people under age 26 to remain on their parents’ health plans and believe people with preexisting conditions should have access to coverage, generally through the creation of state-based, high-risk insurance pools. They believe expanded health savings accounts will give patients more skin in the game, and, across the board, they have vowed to “repeal and replace Obamacare.”

Listen to more of our interview with Robert Blendon, ScD

However, “with more than 10 candidates, there is going to be variation,” Dr. Blendon adds.

For instance, former Florida Governor Jeb Bush has proposed the Conservative Plan for 21st Century Health, which aims to “lower costs,” “promote innovation,” and “return power to states.”

Neurosurgeon Ben Carson originally suggested he would “abolish” Medicare and instead provide seniors with a $2,000-a-year federal subsidy to purchase private insurance. He has backtracked that idea and, in December 2015, issued a report highlighting the pillars of his health plan, which include creating “health empowerment accounts” and raising the Medicare age to 70.

New Jersey Governor Chris Christie’s plan suggests a priority for veterans, including the formation of a federal Secretary of Veterans Affairs, while Carly Fiorina says that “every healthcare provider “ought to publish its costs, its prices, its outcomes” so patients know what they are buying.

“As the field on the Republican side narrows, I think we will start to see more pressure on them to flesh those principles out a little bit more,” says Joshua Lenchus, DO, RPh, FACP, SFHM, a hospitalist at the University of Miami (Fla.) Jackson Memorial Hospital and a member of SHM’s Public Policy Committee.

Some GOP candidates, like Kentucky Senator and ophthalmologist Rand Paul, have proposed reforming medical malpractice. Some wish to make insurance portable from one job to the next, like former Arkansas Governor Mike Huckabee, or across state lines, as Ohio Governor John Kasich has proposed.

Some of these ideas, says hospitalist and SHM Public Policy Committee member Bradley Flansbaum, DO, MPH, MHM, “have been adequately dismembered, and they’re not going to carry weight.

“Buying insurance across state lines, fixing malpractice—that is not going to fix the healthcare system,” says Dr. Flansbaum, clinical professor of medicine at NYU School of Medicine in New York City.

Overall, a Republican-sponsored healthcare system will not guarantee the same level of comprehensive benefits patients have now under the ACA, Dr. Blendon says, and, in general, subsidies and tax credits will be less generous than they are today, in turn reducing federal expenditures.

Most Republican candidates are in favor of some version of free market healthcare, but Dr. Flansbaum points out that “there are so many imperfections in the market, everything from people having asymmetric information—a physician knows a lot more than a patient does—to opaque pricing,” he says. “It’s not exchanging goods like we are used to.”

Republicans are generally committed to “less federal government, less expenditures, more choices, and less expensive benefits,” in healthcare, but Dr. Blendon says the system “would not go back to 2009.”

For hospitalists interested in election-year or other healthcare policy issues, Dr. Flansbaum suggests getting involved in the SHM committee, visiting the advocacy section of the SHM website, and reaching out to local representatives and others who write and vote on laws.

“How do you affect change?” he asks. “It’s not sitting in the breakfast lounge at the hospital bellyaching to your colleagues.” TH

Editor's note: update Jan. 4, 2016.

Kelly April Tyrrell is a freelance writer in Madison, Wis.

Hospitalists care for patients with the most serious, chronic, and complex illnesses. As a result, they are often faced with the daunting task of counseling their patients to help them clearly define their end-of-life wishes. The mere subject of death is met with apprehension and avoidance, but its inevitability warrants an early discussion.

End-of-life care, also known as Advance Care Planning (ACP), enables patients to formulate advanced directives: a living will, the designation of a healthcare proxy, Medical Orders for Life-Sustaining Treatment (MOLST), and the preparation for hospice care, among others. Patients should start thinking about their healthcare options and share such important decisions with their physicians and family before the need for hospitalization.

On October 30, 2015, the Centers for Medicare and Medicaid Services (CMS) released the final payment rules for Medicare reimbursement of physicians who consult with their patients on advance care planning. This separate payment system under the 2016 Physician Fee Schedule will impact the almost 55 million Medicare beneficiaries and their healthcare providers.

Effective January 1, 2016, Medicare will pay $86 for 30 minutes of ACP in a physician’s office and will pay $80 for the same service in a hospital (CPT billing code 99497). In both settings, Medicare will pay up to $75 for 30 additional minutes of consultation (add-on CPT billing code 99498). Such counseling can take place during a senior’s annual wellness visit or during a routine office visit and at various stages of health, always “at the discretion of the beneficiary.”

Six years ago, proposed legislation on Medicare reimbursement for ACP under the Accountable Care Act (ACA) sparked political debate over fears that the implementation of so-called “death panels” could influence decisions to avoid medical care. The goal was to reduce healthcare costs, but these controversial provisions were dropped with the passage of the ACA. This time, there was less resistance.

Proponents of this new legislation, such as the American Medical Association and the American Academy of Palliative and Hospice Medicine, say that this rule will encourage physicians to make time for these lengthy discussions and facilitate patient choices while improving quality of care for seniors. Opponents, including the Association of American Physicians and Surgeons, contend that such payments will “create financial incentives to persuade patients to consent to the denial of care.”

Patrick Conway, MD, CMS' chief medical officer, told the New York Times, "We received overwhelmingly positive comments about the importance of these conversations between physicians and patients. We know that many patients and families want to have these discussions."

Future endeavors should focus on efforts to improve the quality of delivering end-of-life care that honors and upholds a patient’s wishes. Strengthening the clinical training of physicians in palliative care, developing quality metrics and standards, and educating the public should remain a top priority.

Will tying a financial incentive to these services have an impact on the cost and quality of care delivered? Hospitalists can begin billing for valuable services they are already providing on a daily basis, and can better coordinate inpatient medical care when more seniors have clear advanced directives. TH

Dr. Zeitoun is a member of Team Hospitalist.

Hospitalists care for patients with the most serious, chronic, and complex illnesses. As a result, they are often faced with the daunting task of counseling their patients to help them clearly define their end-of-life wishes. The mere subject of death is met with apprehension and avoidance, but its inevitability warrants an early discussion.

End-of-life care, also known as Advance Care Planning (ACP), enables patients to formulate advanced directives: a living will, the designation of a healthcare proxy, Medical Orders for Life-Sustaining Treatment (MOLST), and the preparation for hospice care, among others. Patients should start thinking about their healthcare options and share such important decisions with their physicians and family before the need for hospitalization.

On October 30, 2015, the Centers for Medicare and Medicaid Services (CMS) released the final payment rules for Medicare reimbursement of physicians who consult with their patients on advance care planning. This separate payment system under the 2016 Physician Fee Schedule will impact the almost 55 million Medicare beneficiaries and their healthcare providers.

Effective January 1, 2016, Medicare will pay $86 for 30 minutes of ACP in a physician’s office and will pay $80 for the same service in a hospital (CPT billing code 99497). In both settings, Medicare will pay up to $75 for 30 additional minutes of consultation (add-on CPT billing code 99498). Such counseling can take place during a senior’s annual wellness visit or during a routine office visit and at various stages of health, always “at the discretion of the beneficiary.”

Six years ago, proposed legislation on Medicare reimbursement for ACP under the Accountable Care Act (ACA) sparked political debate over fears that the implementation of so-called “death panels” could influence decisions to avoid medical care. The goal was to reduce healthcare costs, but these controversial provisions were dropped with the passage of the ACA. This time, there was less resistance.

Proponents of this new legislation, such as the American Medical Association and the American Academy of Palliative and Hospice Medicine, say that this rule will encourage physicians to make time for these lengthy discussions and facilitate patient choices while improving quality of care for seniors. Opponents, including the Association of American Physicians and Surgeons, contend that such payments will “create financial incentives to persuade patients to consent to the denial of care.”

Patrick Conway, MD, CMS' chief medical officer, told the New York Times, "We received overwhelmingly positive comments about the importance of these conversations between physicians and patients. We know that many patients and families want to have these discussions."

Future endeavors should focus on efforts to improve the quality of delivering end-of-life care that honors and upholds a patient’s wishes. Strengthening the clinical training of physicians in palliative care, developing quality metrics and standards, and educating the public should remain a top priority.

Will tying a financial incentive to these services have an impact on the cost and quality of care delivered? Hospitalists can begin billing for valuable services they are already providing on a daily basis, and can better coordinate inpatient medical care when more seniors have clear advanced directives. TH

Dr. Zeitoun is a member of Team Hospitalist.

Hospitalists care for patients with the most serious, chronic, and complex illnesses. As a result, they are often faced with the daunting task of counseling their patients to help them clearly define their end-of-life wishes. The mere subject of death is met with apprehension and avoidance, but its inevitability warrants an early discussion.

End-of-life care, also known as Advance Care Planning (ACP), enables patients to formulate advanced directives: a living will, the designation of a healthcare proxy, Medical Orders for Life-Sustaining Treatment (MOLST), and the preparation for hospice care, among others. Patients should start thinking about their healthcare options and share such important decisions with their physicians and family before the need for hospitalization.

On October 30, 2015, the Centers for Medicare and Medicaid Services (CMS) released the final payment rules for Medicare reimbursement of physicians who consult with their patients on advance care planning. This separate payment system under the 2016 Physician Fee Schedule will impact the almost 55 million Medicare beneficiaries and their healthcare providers.

Effective January 1, 2016, Medicare will pay $86 for 30 minutes of ACP in a physician’s office and will pay $80 for the same service in a hospital (CPT billing code 99497). In both settings, Medicare will pay up to $75 for 30 additional minutes of consultation (add-on CPT billing code 99498). Such counseling can take place during a senior’s annual wellness visit or during a routine office visit and at various stages of health, always “at the discretion of the beneficiary.”

Six years ago, proposed legislation on Medicare reimbursement for ACP under the Accountable Care Act (ACA) sparked political debate over fears that the implementation of so-called “death panels” could influence decisions to avoid medical care. The goal was to reduce healthcare costs, but these controversial provisions were dropped with the passage of the ACA. This time, there was less resistance.

Proponents of this new legislation, such as the American Medical Association and the American Academy of Palliative and Hospice Medicine, say that this rule will encourage physicians to make time for these lengthy discussions and facilitate patient choices while improving quality of care for seniors. Opponents, including the Association of American Physicians and Surgeons, contend that such payments will “create financial incentives to persuade patients to consent to the denial of care.”

Patrick Conway, MD, CMS' chief medical officer, told the New York Times, "We received overwhelmingly positive comments about the importance of these conversations between physicians and patients. We know that many patients and families want to have these discussions."

Future endeavors should focus on efforts to improve the quality of delivering end-of-life care that honors and upholds a patient’s wishes. Strengthening the clinical training of physicians in palliative care, developing quality metrics and standards, and educating the public should remain a top priority.

Will tying a financial incentive to these services have an impact on the cost and quality of care delivered? Hospitalists can begin billing for valuable services they are already providing on a daily basis, and can better coordinate inpatient medical care when more seniors have clear advanced directives. TH

Dr. Zeitoun is a member of Team Hospitalist.

The year 2015 brought the repeal of the sustainable growth rate (SGR) and new rules for advanced care planning reimbursement. It saw hospitalists take the lead on improving the two-midnight rule and respond to a global infectious disease scare.

The Hospitalist caught up with Dr. Greeno, chief strategy officer at North Hollywood, Calif.-based IPC Healthcare, to ask him about what he sees for the year ahead in policy.

Question: What are the biggest changes in store for 2016 that stand to impact hospitalists?

Answer: Much of it is just a magnification of the things that most hospitalists are already feeling or sensing. Clearly, there is a very solid movement toward alternative payment methodologies. BPCI (the Bundled Payments for Care Improvement initiative) has been embraced by hospitalists and other physicians all over the country at a scale that has surprised everybody.

There is also more consolidation in the healthcare industry as a whole. Hospital organizations are getting bigger, and we’re seeing consolidation of hospitalist groups. We will see cross-integration in the healthcare system that occurs at a rapid pace: hospitals buying physician groups, health systems and providers starting health plans, health plans acquiring hospital systems. In the not-too-distant future, we are all going to be in the population health business. This is a complete realignment of the healthcare system, and we haven’t seen the half of it yet. We have to be prepared to do it all, or a very big piece of it. The good news is, we are an absolute necessity for success in the future.

Q: It’s a presidential election year. How much weight should physicians put on claims made by candidates?

A: I encourage people to be politically engaged, but I don’t think the majority of what’s happening in healthcare is being driven by politics. It’s being driven by dispassionate economic forces that aren’t going to go away, no matter who is president. We have to figure out how to care for our population more cost-effectively. The ACA (Affordable Care Act) has driven a lot of the political environment in D.C. since its passage, including a big divide between the two parties, but it’s about three things: insurance reform, expanded access, and, particularly, delivery system reform. That’s the part we really care about and can influence the most, I think. Both parties feel like the delivery system needs to be reformed. I don’t think the election will have a major impact on hospitalists and what we do.

The ACA created an environment where things moved faster, created the (CMS) Innovation Center that drives alternative payment methodologies. It created a burning platform for things that already needed to happen.

Q: Is there anything new for meaningful use/EHR in 2016?

A: There are implications of meaningful use for hospitalists. Last year was the first that meaningful use penalties for physician groups came into effect. The way it was written, there was an exception to meaningful use requirements for hospital-based physicians, but a majority of SHM’s membership does not qualify for exemption and are subject to penalties. It’s not small: $2,500 to $5,000 per doctor. The Public Policy Committee at SHM has been working in Washington the last couple of years. We were able to get a one-year exemption, and now they’ve given us a second year, but we can only do five years according to law, and we have to apply every year. We have applied to CMS for a specialty code for hospitalists, and if that gets approved, it will be used to identify who is a hospitalist and who is not. If we submit under that code, then we’re not subject to penalty.

My lesson is to embrace the changes; don’t fight it. As a hospitalist, your job is going to be different a year from now. We might as well get ready for the change, because there’s going to be a lot of change in the system.

–Dr. Greeno

Q: What is the future of the two-midnight rule?

A: The committee and SHM took that on several years ago at my urging because it didn’t seem like other specialties were leading that issue. It doesn’t affect hospitalists in terms of how we’re paid, but it does affect the patients we care for. I think we’ll have a better solution in the coming years.

Q: What should hospitalists be thinking about heading into 2016?

A: They should be starting to prepare for a world where they no longer get paid with fee-for-service. Hospitalists are in the post-acute setting, where a lot of the action takes place, and it’s the high-cost action. My lesson is to embrace the changes; don’t fight it. As a hospitalist, your job is going to be different a year from now. We might as well get ready for the change, because there’s going to be a lot of change in the system.

Kelly April Tyrrell is a freelance writer in Madison, Wis.

The year 2015 brought the repeal of the sustainable growth rate (SGR) and new rules for advanced care planning reimbursement. It saw hospitalists take the lead on improving the two-midnight rule and respond to a global infectious disease scare.

The Hospitalist caught up with Dr. Greeno, chief strategy officer at North Hollywood, Calif.-based IPC Healthcare, to ask him about what he sees for the year ahead in policy.

Question: What are the biggest changes in store for 2016 that stand to impact hospitalists?

Answer: Much of it is just a magnification of the things that most hospitalists are already feeling or sensing. Clearly, there is a very solid movement toward alternative payment methodologies. BPCI (the Bundled Payments for Care Improvement initiative) has been embraced by hospitalists and other physicians all over the country at a scale that has surprised everybody.

There is also more consolidation in the healthcare industry as a whole. Hospital organizations are getting bigger, and we’re seeing consolidation of hospitalist groups. We will see cross-integration in the healthcare system that occurs at a rapid pace: hospitals buying physician groups, health systems and providers starting health plans, health plans acquiring hospital systems. In the not-too-distant future, we are all going to be in the population health business. This is a complete realignment of the healthcare system, and we haven’t seen the half of it yet. We have to be prepared to do it all, or a very big piece of it. The good news is, we are an absolute necessity for success in the future.

Q: It’s a presidential election year. How much weight should physicians put on claims made by candidates?

A: I encourage people to be politically engaged, but I don’t think the majority of what’s happening in healthcare is being driven by politics. It’s being driven by dispassionate economic forces that aren’t going to go away, no matter who is president. We have to figure out how to care for our population more cost-effectively. The ACA (Affordable Care Act) has driven a lot of the political environment in D.C. since its passage, including a big divide between the two parties, but it’s about three things: insurance reform, expanded access, and, particularly, delivery system reform. That’s the part we really care about and can influence the most, I think. Both parties feel like the delivery system needs to be reformed. I don’t think the election will have a major impact on hospitalists and what we do.

The ACA created an environment where things moved faster, created the (CMS) Innovation Center that drives alternative payment methodologies. It created a burning platform for things that already needed to happen.

Q: Is there anything new for meaningful use/EHR in 2016?

A: There are implications of meaningful use for hospitalists. Last year was the first that meaningful use penalties for physician groups came into effect. The way it was written, there was an exception to meaningful use requirements for hospital-based physicians, but a majority of SHM’s membership does not qualify for exemption and are subject to penalties. It’s not small: $2,500 to $5,000 per doctor. The Public Policy Committee at SHM has been working in Washington the last couple of years. We were able to get a one-year exemption, and now they’ve given us a second year, but we can only do five years according to law, and we have to apply every year. We have applied to CMS for a specialty code for hospitalists, and if that gets approved, it will be used to identify who is a hospitalist and who is not. If we submit under that code, then we’re not subject to penalty.

My lesson is to embrace the changes; don’t fight it. As a hospitalist, your job is going to be different a year from now. We might as well get ready for the change, because there’s going to be a lot of change in the system.

–Dr. Greeno

Q: What is the future of the two-midnight rule?

A: The committee and SHM took that on several years ago at my urging because it didn’t seem like other specialties were leading that issue. It doesn’t affect hospitalists in terms of how we’re paid, but it does affect the patients we care for. I think we’ll have a better solution in the coming years.

Q: What should hospitalists be thinking about heading into 2016?

A: They should be starting to prepare for a world where they no longer get paid with fee-for-service. Hospitalists are in the post-acute setting, where a lot of the action takes place, and it’s the high-cost action. My lesson is to embrace the changes; don’t fight it. As a hospitalist, your job is going to be different a year from now. We might as well get ready for the change, because there’s going to be a lot of change in the system.

Kelly April Tyrrell is a freelance writer in Madison, Wis.

The year 2015 brought the repeal of the sustainable growth rate (SGR) and new rules for advanced care planning reimbursement. It saw hospitalists take the lead on improving the two-midnight rule and respond to a global infectious disease scare.

The Hospitalist caught up with Dr. Greeno, chief strategy officer at North Hollywood, Calif.-based IPC Healthcare, to ask him about what he sees for the year ahead in policy.

Question: What are the biggest changes in store for 2016 that stand to impact hospitalists?

Answer: Much of it is just a magnification of the things that most hospitalists are already feeling or sensing. Clearly, there is a very solid movement toward alternative payment methodologies. BPCI (the Bundled Payments for Care Improvement initiative) has been embraced by hospitalists and other physicians all over the country at a scale that has surprised everybody.

There is also more consolidation in the healthcare industry as a whole. Hospital organizations are getting bigger, and we’re seeing consolidation of hospitalist groups. We will see cross-integration in the healthcare system that occurs at a rapid pace: hospitals buying physician groups, health systems and providers starting health plans, health plans acquiring hospital systems. In the not-too-distant future, we are all going to be in the population health business. This is a complete realignment of the healthcare system, and we haven’t seen the half of it yet. We have to be prepared to do it all, or a very big piece of it. The good news is, we are an absolute necessity for success in the future.

Q: It’s a presidential election year. How much weight should physicians put on claims made by candidates?

A: I encourage people to be politically engaged, but I don’t think the majority of what’s happening in healthcare is being driven by politics. It’s being driven by dispassionate economic forces that aren’t going to go away, no matter who is president. We have to figure out how to care for our population more cost-effectively. The ACA (Affordable Care Act) has driven a lot of the political environment in D.C. since its passage, including a big divide between the two parties, but it’s about three things: insurance reform, expanded access, and, particularly, delivery system reform. That’s the part we really care about and can influence the most, I think. Both parties feel like the delivery system needs to be reformed. I don’t think the election will have a major impact on hospitalists and what we do.

The ACA created an environment where things moved faster, created the (CMS) Innovation Center that drives alternative payment methodologies. It created a burning platform for things that already needed to happen.

Q: Is there anything new for meaningful use/EHR in 2016?

A: There are implications of meaningful use for hospitalists. Last year was the first that meaningful use penalties for physician groups came into effect. The way it was written, there was an exception to meaningful use requirements for hospital-based physicians, but a majority of SHM’s membership does not qualify for exemption and are subject to penalties. It’s not small: $2,500 to $5,000 per doctor. The Public Policy Committee at SHM has been working in Washington the last couple of years. We were able to get a one-year exemption, and now they’ve given us a second year, but we can only do five years according to law, and we have to apply every year. We have applied to CMS for a specialty code for hospitalists, and if that gets approved, it will be used to identify who is a hospitalist and who is not. If we submit under that code, then we’re not subject to penalty.

My lesson is to embrace the changes; don’t fight it. As a hospitalist, your job is going to be different a year from now. We might as well get ready for the change, because there’s going to be a lot of change in the system.

–Dr. Greeno

Q: What is the future of the two-midnight rule?

A: The committee and SHM took that on several years ago at my urging because it didn’t seem like other specialties were leading that issue. It doesn’t affect hospitalists in terms of how we’re paid, but it does affect the patients we care for. I think we’ll have a better solution in the coming years.

Q: What should hospitalists be thinking about heading into 2016?

A: They should be starting to prepare for a world where they no longer get paid with fee-for-service. Hospitalists are in the post-acute setting, where a lot of the action takes place, and it’s the high-cost action. My lesson is to embrace the changes; don’t fight it. As a hospitalist, your job is going to be different a year from now. We might as well get ready for the change, because there’s going to be a lot of change in the system.

Kelly April Tyrrell is a freelance writer in Madison, Wis.

As the senior physician advisor to SHM’s Center for Hospital Innovation and Improvement, Eric Howell, MD, SFHM, bridges the gap between clinical expertise and project support and development. The Hospitalist recently had a conversation with Dr. Howell, a past president of SHM, to learn more about his role and how the Center for Hospital Innovation and Improvement is revolutionizing quality improvement (QI) in hospital medicine.

Question: What is your role as the senior physician advisor to The Center for Hospital Innovation and Improvement?

Answer: I see my role as the intersection of a Venn diagram; one circle involves my clinical know-how, and the other includes the proposals brought to the Center for Hospital Innovation and Improvement by hospitalists and healthcare professionals. Where those two circles intersect is where I am able to use my experience from the front line of patient care to validate potential projects.

In addition to project assessment, I monitor the pulse of healthcare professionals and hospital leadership to ensure we are meeting their needs, including our efforts of convening a recent summit, where hospitalist clinicians … weighed in on how our team could help them improve. I plan to share this feedback in an upcoming feature, centered on emerging topics in hospital medicine, including care transitions, high-risk medications, advance care planning, and others.

Q: Given your clinical experience and involvement with SHM, how would you say hospitalists are positioned to improve quality, safety, and patient outcomes?

After attending the related White House forum earlier this year, SHM committed to cultivating initiatives that emphasize

appropriate prescribing practices, which will aid in slowing the emergence of antibiotic-resistant bacteria and prevent the spread of resistant infections.

—Dr. Howell

A: We possess the necessary ingredients to develop a recipe for success in QI from both a clinical and an operational perspective. Hospital medicine is still a young, innovative field that is extremely open to change. Anyone who knows QI knows that it is all about effectively managing and responding to change. Hospitalists also are aware of how to operate in a highly matrixed environment and to collaborate as part of an interdisciplinary team, which are invaluable assets to implementing QI initiatives successfully and proactively monitoring their impact.

Q: What are the biggest assets the Center for Hospital Innovation and Improvement can offer hospitalists in their mission to improve patient care?

A: Our team has resources to help hospitalists improve their skills at whatever stage they are in their careers. If you are just beginning or trying to learn new things independently, you can explore the web-based materials and resource rooms. They are publicly accessible resources that can assist in informing quality improvement efforts in the hospital. For those looking to expand their skills in a more hands-on way, we offer a mentored implementation program, where hospitalists can receive guidance from expert mentors in a number of different clinical areas.

Q: How can the Center for Hospital Innovation and Improvement help hospitalists address emerging challenges in hospital medicine?

A: You cannot talk about the Center for Hospital Innovation and Improvement without mentioning signature mentored implementation programs like Project BOOST, focused on effective care transitions, and glycemic control—they are juggernauts for SHM’s portfolio because of their proven track records and sustainable frameworks for driving positive change. These two alone have already been implemented at over 400 facilities, with more inquiries each day.

With support from The Milbank Foundation, The Hastings Center and SHM have joined forces and will create new skills-based training resources and a QI framework to improve end-of-life care in the hospital. Our goal is to equip hospital clinicians with the requisite tools to provide adequate palliative care, especially given the policy landscape related to advance care planning discussions.

As antibiotic resistance emerges as a global issue, antibiotic stewardship has continued to be a high priority for hospitalists. After attending the related White House forum earlier this year, SHM committed to cultivating initiatives that emphasize appropriate prescribing practices, which will aid in slowing the emergence of antibiotic-resistant bacteria and prevent the spread of resistant infections. SHM looks forward to making noteworthy contributions to this initiative, promoting awareness and behavior change through the “Fight the Resistance” campaign.

Q: What is one major takeaway about The Center for Hospital Innovation and Improvement hospitalists should know?

A: The Center for Hospital Innovation and Improvement is not an exclusive club—rather, it is like an open farmers’ market. Anyone with any amount of expertise can get resources through collaboration and partnership. Whether it is residents trying to improve the house staff or professors at major academic centers looking for research partners, The Center for Hospital Innovation and Improvement will welcome you to collaborate and link you to valuable resources.

Brett Radler is SHM’s communications coordinator.

As the senior physician advisor to SHM’s Center for Hospital Innovation and Improvement, Eric Howell, MD, SFHM, bridges the gap between clinical expertise and project support and development. The Hospitalist recently had a conversation with Dr. Howell, a past president of SHM, to learn more about his role and how the Center for Hospital Innovation and Improvement is revolutionizing quality improvement (QI) in hospital medicine.

Question: What is your role as the senior physician advisor to The Center for Hospital Innovation and Improvement?

Answer: I see my role as the intersection of a Venn diagram; one circle involves my clinical know-how, and the other includes the proposals brought to the Center for Hospital Innovation and Improvement by hospitalists and healthcare professionals. Where those two circles intersect is where I am able to use my experience from the front line of patient care to validate potential projects.

In addition to project assessment, I monitor the pulse of healthcare professionals and hospital leadership to ensure we are meeting their needs, including our efforts of convening a recent summit, where hospitalist clinicians … weighed in on how our team could help them improve. I plan to share this feedback in an upcoming feature, centered on emerging topics in hospital medicine, including care transitions, high-risk medications, advance care planning, and others.

Q: Given your clinical experience and involvement with SHM, how would you say hospitalists are positioned to improve quality, safety, and patient outcomes?

After attending the related White House forum earlier this year, SHM committed to cultivating initiatives that emphasize

appropriate prescribing practices, which will aid in slowing the emergence of antibiotic-resistant bacteria and prevent the spread of resistant infections.

—Dr. Howell

A: We possess the necessary ingredients to develop a recipe for success in QI from both a clinical and an operational perspective. Hospital medicine is still a young, innovative field that is extremely open to change. Anyone who knows QI knows that it is all about effectively managing and responding to change. Hospitalists also are aware of how to operate in a highly matrixed environment and to collaborate as part of an interdisciplinary team, which are invaluable assets to implementing QI initiatives successfully and proactively monitoring their impact.

Q: What are the biggest assets the Center for Hospital Innovation and Improvement can offer hospitalists in their mission to improve patient care?

A: Our team has resources to help hospitalists improve their skills at whatever stage they are in their careers. If you are just beginning or trying to learn new things independently, you can explore the web-based materials and resource rooms. They are publicly accessible resources that can assist in informing quality improvement efforts in the hospital. For those looking to expand their skills in a more hands-on way, we offer a mentored implementation program, where hospitalists can receive guidance from expert mentors in a number of different clinical areas.

Q: How can the Center for Hospital Innovation and Improvement help hospitalists address emerging challenges in hospital medicine?

A: You cannot talk about the Center for Hospital Innovation and Improvement without mentioning signature mentored implementation programs like Project BOOST, focused on effective care transitions, and glycemic control—they are juggernauts for SHM’s portfolio because of their proven track records and sustainable frameworks for driving positive change. These two alone have already been implemented at over 400 facilities, with more inquiries each day.

With support from The Milbank Foundation, The Hastings Center and SHM have joined forces and will create new skills-based training resources and a QI framework to improve end-of-life care in the hospital. Our goal is to equip hospital clinicians with the requisite tools to provide adequate palliative care, especially given the policy landscape related to advance care planning discussions.

As antibiotic resistance emerges as a global issue, antibiotic stewardship has continued to be a high priority for hospitalists. After attending the related White House forum earlier this year, SHM committed to cultivating initiatives that emphasize appropriate prescribing practices, which will aid in slowing the emergence of antibiotic-resistant bacteria and prevent the spread of resistant infections. SHM looks forward to making noteworthy contributions to this initiative, promoting awareness and behavior change through the “Fight the Resistance” campaign.

Q: What is one major takeaway about The Center for Hospital Innovation and Improvement hospitalists should know?

A: The Center for Hospital Innovation and Improvement is not an exclusive club—rather, it is like an open farmers’ market. Anyone with any amount of expertise can get resources through collaboration and partnership. Whether it is residents trying to improve the house staff or professors at major academic centers looking for research partners, The Center for Hospital Innovation and Improvement will welcome you to collaborate and link you to valuable resources.

Brett Radler is SHM’s communications coordinator.

As the senior physician advisor to SHM’s Center for Hospital Innovation and Improvement, Eric Howell, MD, SFHM, bridges the gap between clinical expertise and project support and development. The Hospitalist recently had a conversation with Dr. Howell, a past president of SHM, to learn more about his role and how the Center for Hospital Innovation and Improvement is revolutionizing quality improvement (QI) in hospital medicine.

Question: What is your role as the senior physician advisor to The Center for Hospital Innovation and Improvement?

Answer: I see my role as the intersection of a Venn diagram; one circle involves my clinical know-how, and the other includes the proposals brought to the Center for Hospital Innovation and Improvement by hospitalists and healthcare professionals. Where those two circles intersect is where I am able to use my experience from the front line of patient care to validate potential projects.

In addition to project assessment, I monitor the pulse of healthcare professionals and hospital leadership to ensure we are meeting their needs, including our efforts of convening a recent summit, where hospitalist clinicians … weighed in on how our team could help them improve. I plan to share this feedback in an upcoming feature, centered on emerging topics in hospital medicine, including care transitions, high-risk medications, advance care planning, and others.

Q: Given your clinical experience and involvement with SHM, how would you say hospitalists are positioned to improve quality, safety, and patient outcomes?

After attending the related White House forum earlier this year, SHM committed to cultivating initiatives that emphasize

appropriate prescribing practices, which will aid in slowing the emergence of antibiotic-resistant bacteria and prevent the spread of resistant infections.

—Dr. Howell

A: We possess the necessary ingredients to develop a recipe for success in QI from both a clinical and an operational perspective. Hospital medicine is still a young, innovative field that is extremely open to change. Anyone who knows QI knows that it is all about effectively managing and responding to change. Hospitalists also are aware of how to operate in a highly matrixed environment and to collaborate as part of an interdisciplinary team, which are invaluable assets to implementing QI initiatives successfully and proactively monitoring their impact.

Q: What are the biggest assets the Center for Hospital Innovation and Improvement can offer hospitalists in their mission to improve patient care?

A: Our team has resources to help hospitalists improve their skills at whatever stage they are in their careers. If you are just beginning or trying to learn new things independently, you can explore the web-based materials and resource rooms. They are publicly accessible resources that can assist in informing quality improvement efforts in the hospital. For those looking to expand their skills in a more hands-on way, we offer a mentored implementation program, where hospitalists can receive guidance from expert mentors in a number of different clinical areas.

Q: How can the Center for Hospital Innovation and Improvement help hospitalists address emerging challenges in hospital medicine?

A: You cannot talk about the Center for Hospital Innovation and Improvement without mentioning signature mentored implementation programs like Project BOOST, focused on effective care transitions, and glycemic control—they are juggernauts for SHM’s portfolio because of their proven track records and sustainable frameworks for driving positive change. These two alone have already been implemented at over 400 facilities, with more inquiries each day.

With support from The Milbank Foundation, The Hastings Center and SHM have joined forces and will create new skills-based training resources and a QI framework to improve end-of-life care in the hospital. Our goal is to equip hospital clinicians with the requisite tools to provide adequate palliative care, especially given the policy landscape related to advance care planning discussions.

As antibiotic resistance emerges as a global issue, antibiotic stewardship has continued to be a high priority for hospitalists. After attending the related White House forum earlier this year, SHM committed to cultivating initiatives that emphasize appropriate prescribing practices, which will aid in slowing the emergence of antibiotic-resistant bacteria and prevent the spread of resistant infections. SHM looks forward to making noteworthy contributions to this initiative, promoting awareness and behavior change through the “Fight the Resistance” campaign.

Q: What is one major takeaway about The Center for Hospital Innovation and Improvement hospitalists should know?

A: The Center for Hospital Innovation and Improvement is not an exclusive club—rather, it is like an open farmers’ market. Anyone with any amount of expertise can get resources through collaboration and partnership. Whether it is residents trying to improve the house staff or professors at major academic centers looking for research partners, The Center for Hospital Innovation and Improvement will welcome you to collaborate and link you to valuable resources.

Brett Radler is SHM’s communications coordinator.

Nearly three-quarters of hospitals will be receiving penalties from the Centers for Medicare and Medicaid Services (CMS) in 2016 for excess readmissions, having failed to prevent enough patients from returning to the hospital 30 days post-discharge. With so many hospitals impacted by penalties, it is understandable that the underlying methodology of the Hospital Readmissions Reduction Program (HRRP) is coming under intense scrutiny.

Research published in JAMA Internal Medicine in September hit upon many of the myriad factors—often outside of the hospital or providers’ control—that influence whether a patient is readmitted to the hospital. This information adds weight to criticism of the measures included in the HRRP and asserts the need to refine or reform the measures to better account for readmissions preventable through the interventions of the healthcare system. The behavior these measures are meant to curb, including poor quality care, inadequate access to follow-up or medications, and gaps in transitions of care, are not identifiable within broad-based, all-cause readmission measures. Instead, hospitals are being penalized for all readmissions, a majority of which may be attributable to community or patient-related factors, such as sociodemographic or housing status, among other variables.

A growing consensus on two fronts asserts that these measures, as currently structured, might not be appropriate for use in pay-for-performance programs. Measure developers, bolstered by a recent decision by the National Quality Forum to institute a trial run of risk adjusting measures for sociodemographic status, are exploring the impact of using different available variables to enhance risk adjusting their measures. Measures for readmissions are at the front of the line of these efforts. Although it is only in the beginning stages, this work could change the foundation of all quality measures used in pay-for-performance programs.

In Congress, legislation has been introduced in both the House of Representatives and the Senate aiming to refine the HRRP through additional risk adjustments. The Establishing Beneficiary Equity in the Hospital Readmission Program Act of 2015 (H.R. 1343 and S. 688), introduced by Rep. Jim Renacci (R-Ohio) and Sen. Joe Manchin (D-W.V.), would create immediate relief for hospitals by implementing risk adjustment for dual-eligible patients and the socioeconomic status of the hospital’s patients. At the same time, when reports that are currently in progress about risk adjustment in readmission measures and the use of a 30-day window for categorizing readmissions are completed, CMS would be required to incorporate their findings into the risk adjustment in the HRRP in the future.

SHM is supporting both of these pathways toward improving risk adjustment in readmissions measures. By engaging in the measure process and advocating for the passage of legislation to refine risk adjustment, SHM has taken a stand. The goal of reducing preventable readmissions is too important to use imprecise metrics that seem to penalize the hospitals serving the nation’s neediest patients.

As hospitalists on the front line, you can join SHM in advocating for these common sense, and necessary, changes to the HRRP.

Visit SHM’s Legislative Action Center to send a message to Congress in support of the Establishing Beneficiary Equity in the Hospital Readmission Program Act of 2015.

Joshua Lapps is SHM’s government relations manager.

Nearly three-quarters of hospitals will be receiving penalties from the Centers for Medicare and Medicaid Services (CMS) in 2016 for excess readmissions, having failed to prevent enough patients from returning to the hospital 30 days post-discharge. With so many hospitals impacted by penalties, it is understandable that the underlying methodology of the Hospital Readmissions Reduction Program (HRRP) is coming under intense scrutiny.

Research published in JAMA Internal Medicine in September hit upon many of the myriad factors—often outside of the hospital or providers’ control—that influence whether a patient is readmitted to the hospital. This information adds weight to criticism of the measures included in the HRRP and asserts the need to refine or reform the measures to better account for readmissions preventable through the interventions of the healthcare system. The behavior these measures are meant to curb, including poor quality care, inadequate access to follow-up or medications, and gaps in transitions of care, are not identifiable within broad-based, all-cause readmission measures. Instead, hospitals are being penalized for all readmissions, a majority of which may be attributable to community or patient-related factors, such as sociodemographic or housing status, among other variables.

A growing consensus on two fronts asserts that these measures, as currently structured, might not be appropriate for use in pay-for-performance programs. Measure developers, bolstered by a recent decision by the National Quality Forum to institute a trial run of risk adjusting measures for sociodemographic status, are exploring the impact of using different available variables to enhance risk adjusting their measures. Measures for readmissions are at the front of the line of these efforts. Although it is only in the beginning stages, this work could change the foundation of all quality measures used in pay-for-performance programs.

In Congress, legislation has been introduced in both the House of Representatives and the Senate aiming to refine the HRRP through additional risk adjustments. The Establishing Beneficiary Equity in the Hospital Readmission Program Act of 2015 (H.R. 1343 and S. 688), introduced by Rep. Jim Renacci (R-Ohio) and Sen. Joe Manchin (D-W.V.), would create immediate relief for hospitals by implementing risk adjustment for dual-eligible patients and the socioeconomic status of the hospital’s patients. At the same time, when reports that are currently in progress about risk adjustment in readmission measures and the use of a 30-day window for categorizing readmissions are completed, CMS would be required to incorporate their findings into the risk adjustment in the HRRP in the future.

SHM is supporting both of these pathways toward improving risk adjustment in readmissions measures. By engaging in the measure process and advocating for the passage of legislation to refine risk adjustment, SHM has taken a stand. The goal of reducing preventable readmissions is too important to use imprecise metrics that seem to penalize the hospitals serving the nation’s neediest patients.

As hospitalists on the front line, you can join SHM in advocating for these common sense, and necessary, changes to the HRRP.

Visit SHM’s Legislative Action Center to send a message to Congress in support of the Establishing Beneficiary Equity in the Hospital Readmission Program Act of 2015.

Joshua Lapps is SHM’s government relations manager.

Nearly three-quarters of hospitals will be receiving penalties from the Centers for Medicare and Medicaid Services (CMS) in 2016 for excess readmissions, having failed to prevent enough patients from returning to the hospital 30 days post-discharge. With so many hospitals impacted by penalties, it is understandable that the underlying methodology of the Hospital Readmissions Reduction Program (HRRP) is coming under intense scrutiny.

Research published in JAMA Internal Medicine in September hit upon many of the myriad factors—often outside of the hospital or providers’ control—that influence whether a patient is readmitted to the hospital. This information adds weight to criticism of the measures included in the HRRP and asserts the need to refine or reform the measures to better account for readmissions preventable through the interventions of the healthcare system. The behavior these measures are meant to curb, including poor quality care, inadequate access to follow-up or medications, and gaps in transitions of care, are not identifiable within broad-based, all-cause readmission measures. Instead, hospitals are being penalized for all readmissions, a majority of which may be attributable to community or patient-related factors, such as sociodemographic or housing status, among other variables.

A growing consensus on two fronts asserts that these measures, as currently structured, might not be appropriate for use in pay-for-performance programs. Measure developers, bolstered by a recent decision by the National Quality Forum to institute a trial run of risk adjusting measures for sociodemographic status, are exploring the impact of using different available variables to enhance risk adjusting their measures. Measures for readmissions are at the front of the line of these efforts. Although it is only in the beginning stages, this work could change the foundation of all quality measures used in pay-for-performance programs.

In Congress, legislation has been introduced in both the House of Representatives and the Senate aiming to refine the HRRP through additional risk adjustments. The Establishing Beneficiary Equity in the Hospital Readmission Program Act of 2015 (H.R. 1343 and S. 688), introduced by Rep. Jim Renacci (R-Ohio) and Sen. Joe Manchin (D-W.V.), would create immediate relief for hospitals by implementing risk adjustment for dual-eligible patients and the socioeconomic status of the hospital’s patients. At the same time, when reports that are currently in progress about risk adjustment in readmission measures and the use of a 30-day window for categorizing readmissions are completed, CMS would be required to incorporate their findings into the risk adjustment in the HRRP in the future.

SHM is supporting both of these pathways toward improving risk adjustment in readmissions measures. By engaging in the measure process and advocating for the passage of legislation to refine risk adjustment, SHM has taken a stand. The goal of reducing preventable readmissions is too important to use imprecise metrics that seem to penalize the hospitals serving the nation’s neediest patients.

As hospitalists on the front line, you can join SHM in advocating for these common sense, and necessary, changes to the HRRP.

Visit SHM’s Legislative Action Center to send a message to Congress in support of the Establishing Beneficiary Equity in the Hospital Readmission Program Act of 2015.

Joshua Lapps is SHM’s government relations manager.