Public Policy

As reported in the Los Angeles Times, Glendale Adventist Medical Center in Glendale, Calif., has agreed to pay $700,000 in civil penalties to settle a lawsuit brought against it by the Los Angeles City Attorney. A hospital spokesperson said the medical center denies the charges but has agreed to pay the fine to avoid the cost of fighting the allegations.

"We have to be able to recognize that just writing a discharge order is not meeting any of our patients' needs," says Gregory Misky, MD, hospitalist and associate professor of medicine at the University of Colorado (UC) Hospital in Denver. "It's hard to expect we can fix their COPD or manage their diabetes when there are all these layers of social and behavioral health needs."

Dr. Misky says he gradually became interested in issues affecting indigent patients while researching ways to help patients transition from hospital to home.

"Some patients are dealing with financial issues," he says. "Some have acute family crises they're dealing with. Some have homelessness issues or housing issues. All those things interfere with their health and ability to prioritize health needs over these other things."

One of Dr. Misky's current research projects involves performing qualitative interviews with patients who are readmitted within 30 days to learn what challenges they dealt with after being discharged.

As for "patient dumping," Dr. Misky says that, in his experience, hospitals typically do the opposite: hospitalize patients for indefinite periods of time when they seem to have no family to turn to, for example, or are dealing with cognitive issues.

Here are Dr. Misky's tips for providing better discharges:

• Be aware: Not all patients are equal. It's important to realize patients may not recuperate from pneumonia if they are living on the street;
• Rely on case managers: Hospitalists at the UC Hospital perform discharge rounds with a team that includes a case manager, who is usually a registered nurse or social worker. Let the case manager know about your patients’ needs; and
• Form partnerships: Learn about how you can match up your patients with resources for homeless people available in your community.

As reported in the Los Angeles Times, Glendale Adventist Medical Center in Glendale, Calif., has agreed to pay $700,000 in civil penalties to settle a lawsuit brought against it by the Los Angeles City Attorney. A hospital spokesperson said the medical center denies the charges but has agreed to pay the fine to avoid the cost of fighting the allegations.

"We have to be able to recognize that just writing a discharge order is not meeting any of our patients' needs," says Gregory Misky, MD, hospitalist and associate professor of medicine at the University of Colorado (UC) Hospital in Denver. "It's hard to expect we can fix their COPD or manage their diabetes when there are all these layers of social and behavioral health needs."

Dr. Misky says he gradually became interested in issues affecting indigent patients while researching ways to help patients transition from hospital to home.

"Some patients are dealing with financial issues," he says. "Some have acute family crises they're dealing with. Some have homelessness issues or housing issues. All those things interfere with their health and ability to prioritize health needs over these other things."

One of Dr. Misky's current research projects involves performing qualitative interviews with patients who are readmitted within 30 days to learn what challenges they dealt with after being discharged.

As for "patient dumping," Dr. Misky says that, in his experience, hospitals typically do the opposite: hospitalize patients for indefinite periods of time when they seem to have no family to turn to, for example, or are dealing with cognitive issues.

Here are Dr. Misky's tips for providing better discharges:

• Be aware: Not all patients are equal. It's important to realize patients may not recuperate from pneumonia if they are living on the street;
• Rely on case managers: Hospitalists at the UC Hospital perform discharge rounds with a team that includes a case manager, who is usually a registered nurse or social worker. Let the case manager know about your patients’ needs; and
• Form partnerships: Learn about how you can match up your patients with resources for homeless people available in your community.

As reported in the Los Angeles Times, Glendale Adventist Medical Center in Glendale, Calif., has agreed to pay $700,000 in civil penalties to settle a lawsuit brought against it by the Los Angeles City Attorney. A hospital spokesperson said the medical center denies the charges but has agreed to pay the fine to avoid the cost of fighting the allegations.

"We have to be able to recognize that just writing a discharge order is not meeting any of our patients' needs," says Gregory Misky, MD, hospitalist and associate professor of medicine at the University of Colorado (UC) Hospital in Denver. "It's hard to expect we can fix their COPD or manage their diabetes when there are all these layers of social and behavioral health needs."

Dr. Misky says he gradually became interested in issues affecting indigent patients while researching ways to help patients transition from hospital to home.

"Some patients are dealing with financial issues," he says. "Some have acute family crises they're dealing with. Some have homelessness issues or housing issues. All those things interfere with their health and ability to prioritize health needs over these other things."

One of Dr. Misky's current research projects involves performing qualitative interviews with patients who are readmitted within 30 days to learn what challenges they dealt with after being discharged.

As for "patient dumping," Dr. Misky says that, in his experience, hospitals typically do the opposite: hospitalize patients for indefinite periods of time when they seem to have no family to turn to, for example, or are dealing with cognitive issues.

Here are Dr. Misky's tips for providing better discharges:

• Be aware: Not all patients are equal. It's important to realize patients may not recuperate from pneumonia if they are living on the street;
• Rely on case managers: Hospitalists at the UC Hospital perform discharge rounds with a team that includes a case manager, who is usually a registered nurse or social worker. Let the case manager know about your patients’ needs; and
• Form partnerships: Learn about how you can match up your patients with resources for homeless people available in your community.

Committee member Bradley Flansbaum, DO, MPH, SFHM, says he expects the amount of funding going to hospitalists to decrease in the coming years as healthcare reform focuses on keeping patients out of the hospital.

"The slice that's going to be dedicated to inpatient medicine in hospitals is going to shrink," says Dr. Flansbaum, a hospitalist at Lenox Hill Hospital in New York City. "From a hospitalist standpoint, I don't think it's kick back, flip open the beer lid, and turn the game on. Things are really going to change."

A report in this month's Health Affairs shows that spending growth in 2013 fell to 3.6%, down from 7.2% annually on average between 1990 and 2008. The decreased rate is attributed to a "sluggish economic recovery, the effects of sequestration, and continued increases in private health insurance cost-sharing requirements," according to the report.

However, the combination of money being pumped into healthcare reform and a growing economy is projected to push up spending by 5.6% this year and 6% annually each year from 2015 to 2023, according to the report. How much of that money will flow into HM depends, in part, on how well the specialty improves patient care and hospital bottom lines, Dr. Flansbaum says. "And teasing out that effect is tough," he says. "Mainly, is it that we're ordering less tests or are the prices going down or neither, and [are] other forces contributing to efficiency gains? Those are very different variables."

Committee member Bradley Flansbaum, DO, MPH, SFHM, says he expects the amount of funding going to hospitalists to decrease in the coming years as healthcare reform focuses on keeping patients out of the hospital.

"The slice that's going to be dedicated to inpatient medicine in hospitals is going to shrink," says Dr. Flansbaum, a hospitalist at Lenox Hill Hospital in New York City. "From a hospitalist standpoint, I don't think it's kick back, flip open the beer lid, and turn the game on. Things are really going to change."

A report in this month's Health Affairs shows that spending growth in 2013 fell to 3.6%, down from 7.2% annually on average between 1990 and 2008. The decreased rate is attributed to a "sluggish economic recovery, the effects of sequestration, and continued increases in private health insurance cost-sharing requirements," according to the report.

However, the combination of money being pumped into healthcare reform and a growing economy is projected to push up spending by 5.6% this year and 6% annually each year from 2015 to 2023, according to the report. How much of that money will flow into HM depends, in part, on how well the specialty improves patient care and hospital bottom lines, Dr. Flansbaum says. "And teasing out that effect is tough," he says. "Mainly, is it that we're ordering less tests or are the prices going down or neither, and [are] other forces contributing to efficiency gains? Those are very different variables."

Committee member Bradley Flansbaum, DO, MPH, SFHM, says he expects the amount of funding going to hospitalists to decrease in the coming years as healthcare reform focuses on keeping patients out of the hospital.

"The slice that's going to be dedicated to inpatient medicine in hospitals is going to shrink," says Dr. Flansbaum, a hospitalist at Lenox Hill Hospital in New York City. "From a hospitalist standpoint, I don't think it's kick back, flip open the beer lid, and turn the game on. Things are really going to change."

A report in this month's Health Affairs shows that spending growth in 2013 fell to 3.6%, down from 7.2% annually on average between 1990 and 2008. The decreased rate is attributed to a "sluggish economic recovery, the effects of sequestration, and continued increases in private health insurance cost-sharing requirements," according to the report.

However, the combination of money being pumped into healthcare reform and a growing economy is projected to push up spending by 5.6% this year and 6% annually each year from 2015 to 2023, according to the report. How much of that money will flow into HM depends, in part, on how well the specialty improves patient care and hospital bottom lines, Dr. Flansbaum says. "And teasing out that effect is tough," he says. "Mainly, is it that we're ordering less tests or are the prices going down or neither, and [are] other forces contributing to efficiency gains? Those are very different variables."

Where there is variation, there is room for improvement. The Institute of Medicine’s report on geographic variation in Medicare spending concluded that the largest contributor to overall spending variation is spending for post-acute care services.1 Furthermore, we know that a significant amount of overall spending is devoted to post-acute care. For example, for patients hospitalized with a flare-up of a chronic condition like COPD or heart failure, Medicare spends nearly as much on post-acute care and readmissions in the first 30 days after discharge as it does on the initial admission.¹

What does this mean for hospitalists?

Numerous research articles and quality improvement projects have focused on what makes a good hospital discharge or hand off to the ‘next provider of care’; however, hospitalists are increasingly participating in value-based payment programs like accountable care organizations (ACOs), risk contracts, and bundled payments. This means they must begin to pay attention to the cost side of the value equation (quality divided by cost) as it relates to hospital discharge.

A day of home care represents a more cost-effective alternative than a day of care in a skilled nursing facility (SNF). Hospitalists who can identify those patients who are appropriate to send home with home health services—and who otherwise would have gone to a SNF—will serve the dual goals of improving patient experience and decreasing costs.

Hospitalists will need to develop a decision-making process that determines the appropriate level of care for the patient after discharge. The decision-making process should address questions like:

• What skilled services lead a patient to go to a SNF instead of home with home health?
• Which patients go to a SNF instead of home simply because they don’t have family or a caregiver to help them with activities of daily living?
• Are there services requiring a nurse or a therapist that can’t be delivered in the home?

Hospitalists also will need to develop a more intimate understanding of the following levels of care:

• Skilled nursing includes management of a nursing care plan, assessment of a patient’s changing condition, and services like wound care, infusion therapy, and management of medications, feeding or drainage tubes, and pain.
• Skilled rehabilitation refers to the array of services provided by physical, occupational, speech, and respiratory therapists.
• Custodial care, usually supplied by a home health aid or family member, includes help with activities of daily living (feeding, dressing, bathing, grooming, personal hygiene, and toileting).

It should be noted that most skilled nursing or therapy services can be delivered in the home setting if the patient’s custodial care needs are met—a big ‘if’ in some cases. Some patients go to a SNF because they require three or more skilled nursing or therapy services, and it is therefore impractical for them to go home.

Here are my suggestions to hospitalists seeking to reengineer the discharge process with the goals of “right-sizing” the number of patients who go to SNFs and optimizing the utilization of home healthcare services:

• Become familiar with the range of post-acute care providers and care coordination services in your community.
• Refer any patient who wishes to go home, either directly or after a SNF stay, for a home care evaluation. Home care agencies are experts in determining if and how patients can return home.
• If a need for help with activities of daily living is the major barrier to having a patient discharged to home, create a system in which case management develops a custodial care plan with the patient and caregivers during the inpatient stay. Currently, this step is delayed until well into the SNF stay and may prolong that stay. Such a plan includes a financial analysis, screening for Medicaid eligibility, and evaluating whether a family member can assume some or all of the custodial care needs.
• If a patient is being discharged to a SNF, review the list of needed services leading to the SNF transfer. Ask the case manager if these services can be provided in the home. If not, then why?
• Bed capacity permitting, consider keeping patients who are functionally improving in the hospital an extra day so they can be discharged directly home instead of to a SNF.²

In his seminal work, The Innovator’s Dilemma, Clayton Christensen describes “disruptive innovation” as that which gives rise to products or services that are cheaper, simpler, and more convenient to use. Even though home care has been around for a while, there is a sizeable group of patients, especially in geographic areas of high SNF spending, who might be better served in the home environment. As we create better systems under value-based payment, we should see an increase in the use of home healthcare as a disruptive innovation when applied to appropriate patients transitioning out of the hospital or a SNF.

Dr. Whitcomb is Chief Medical Officer of Remedy Partners. He is co-founder and past president of SHM. Email him at [email protected].

References

1. Newhouse JP, Garber AM. Geographic variation in Medicare services. N Engl J Med. 2013;368:1465-1468.
2. Mechanic R. Post-acute care—The next frontier for controlling Medicare spending. N Engl J Med. 2014;370(8):692-694.

Where there is variation, there is room for improvement. The Institute of Medicine’s report on geographic variation in Medicare spending concluded that the largest contributor to overall spending variation is spending for post-acute care services.1 Furthermore, we know that a significant amount of overall spending is devoted to post-acute care. For example, for patients hospitalized with a flare-up of a chronic condition like COPD or heart failure, Medicare spends nearly as much on post-acute care and readmissions in the first 30 days after discharge as it does on the initial admission.¹

What does this mean for hospitalists?

Numerous research articles and quality improvement projects have focused on what makes a good hospital discharge or hand off to the ‘next provider of care’; however, hospitalists are increasingly participating in value-based payment programs like accountable care organizations (ACOs), risk contracts, and bundled payments. This means they must begin to pay attention to the cost side of the value equation (quality divided by cost) as it relates to hospital discharge.

A day of home care represents a more cost-effective alternative than a day of care in a skilled nursing facility (SNF). Hospitalists who can identify those patients who are appropriate to send home with home health services—and who otherwise would have gone to a SNF—will serve the dual goals of improving patient experience and decreasing costs.

Hospitalists will need to develop a decision-making process that determines the appropriate level of care for the patient after discharge. The decision-making process should address questions like:

• What skilled services lead a patient to go to a SNF instead of home with home health?
• Which patients go to a SNF instead of home simply because they don’t have family or a caregiver to help them with activities of daily living?
• Are there services requiring a nurse or a therapist that can’t be delivered in the home?

Hospitalists also will need to develop a more intimate understanding of the following levels of care:

• Skilled nursing includes management of a nursing care plan, assessment of a patient’s changing condition, and services like wound care, infusion therapy, and management of medications, feeding or drainage tubes, and pain.
• Skilled rehabilitation refers to the array of services provided by physical, occupational, speech, and respiratory therapists.
• Custodial care, usually supplied by a home health aid or family member, includes help with activities of daily living (feeding, dressing, bathing, grooming, personal hygiene, and toileting).

It should be noted that most skilled nursing or therapy services can be delivered in the home setting if the patient’s custodial care needs are met—a big ‘if’ in some cases. Some patients go to a SNF because they require three or more skilled nursing or therapy services, and it is therefore impractical for them to go home.

Here are my suggestions to hospitalists seeking to reengineer the discharge process with the goals of “right-sizing” the number of patients who go to SNFs and optimizing the utilization of home healthcare services:

• Become familiar with the range of post-acute care providers and care coordination services in your community.
• Refer any patient who wishes to go home, either directly or after a SNF stay, for a home care evaluation. Home care agencies are experts in determining if and how patients can return home.
• If a need for help with activities of daily living is the major barrier to having a patient discharged to home, create a system in which case management develops a custodial care plan with the patient and caregivers during the inpatient stay. Currently, this step is delayed until well into the SNF stay and may prolong that stay. Such a plan includes a financial analysis, screening for Medicaid eligibility, and evaluating whether a family member can assume some or all of the custodial care needs.
• If a patient is being discharged to a SNF, review the list of needed services leading to the SNF transfer. Ask the case manager if these services can be provided in the home. If not, then why?
• Bed capacity permitting, consider keeping patients who are functionally improving in the hospital an extra day so they can be discharged directly home instead of to a SNF.²

In his seminal work, The Innovator’s Dilemma, Clayton Christensen describes “disruptive innovation” as that which gives rise to products or services that are cheaper, simpler, and more convenient to use. Even though home care has been around for a while, there is a sizeable group of patients, especially in geographic areas of high SNF spending, who might be better served in the home environment. As we create better systems under value-based payment, we should see an increase in the use of home healthcare as a disruptive innovation when applied to appropriate patients transitioning out of the hospital or a SNF.

Dr. Whitcomb is Chief Medical Officer of Remedy Partners. He is co-founder and past president of SHM. Email him at [email protected].

References

1. Newhouse JP, Garber AM. Geographic variation in Medicare services. N Engl J Med. 2013;368:1465-1468.
2. Mechanic R. Post-acute care—The next frontier for controlling Medicare spending. N Engl J Med. 2014;370(8):692-694.

Where there is variation, there is room for improvement. The Institute of Medicine’s report on geographic variation in Medicare spending concluded that the largest contributor to overall spending variation is spending for post-acute care services.1 Furthermore, we know that a significant amount of overall spending is devoted to post-acute care. For example, for patients hospitalized with a flare-up of a chronic condition like COPD or heart failure, Medicare spends nearly as much on post-acute care and readmissions in the first 30 days after discharge as it does on the initial admission.¹

What does this mean for hospitalists?

Numerous research articles and quality improvement projects have focused on what makes a good hospital discharge or hand off to the ‘next provider of care’; however, hospitalists are increasingly participating in value-based payment programs like accountable care organizations (ACOs), risk contracts, and bundled payments. This means they must begin to pay attention to the cost side of the value equation (quality divided by cost) as it relates to hospital discharge.

A day of home care represents a more cost-effective alternative than a day of care in a skilled nursing facility (SNF). Hospitalists who can identify those patients who are appropriate to send home with home health services—and who otherwise would have gone to a SNF—will serve the dual goals of improving patient experience and decreasing costs.

Hospitalists will need to develop a decision-making process that determines the appropriate level of care for the patient after discharge. The decision-making process should address questions like:

• What skilled services lead a patient to go to a SNF instead of home with home health?
• Which patients go to a SNF instead of home simply because they don’t have family or a caregiver to help them with activities of daily living?
• Are there services requiring a nurse or a therapist that can’t be delivered in the home?

Hospitalists also will need to develop a more intimate understanding of the following levels of care:

• Skilled nursing includes management of a nursing care plan, assessment of a patient’s changing condition, and services like wound care, infusion therapy, and management of medications, feeding or drainage tubes, and pain.
• Skilled rehabilitation refers to the array of services provided by physical, occupational, speech, and respiratory therapists.
• Custodial care, usually supplied by a home health aid or family member, includes help with activities of daily living (feeding, dressing, bathing, grooming, personal hygiene, and toileting).

It should be noted that most skilled nursing or therapy services can be delivered in the home setting if the patient’s custodial care needs are met—a big ‘if’ in some cases. Some patients go to a SNF because they require three or more skilled nursing or therapy services, and it is therefore impractical for them to go home.

Here are my suggestions to hospitalists seeking to reengineer the discharge process with the goals of “right-sizing” the number of patients who go to SNFs and optimizing the utilization of home healthcare services:

• Become familiar with the range of post-acute care providers and care coordination services in your community.
• Refer any patient who wishes to go home, either directly or after a SNF stay, for a home care evaluation. Home care agencies are experts in determining if and how patients can return home.
• If a need for help with activities of daily living is the major barrier to having a patient discharged to home, create a system in which case management develops a custodial care plan with the patient and caregivers during the inpatient stay. Currently, this step is delayed until well into the SNF stay and may prolong that stay. Such a plan includes a financial analysis, screening for Medicaid eligibility, and evaluating whether a family member can assume some or all of the custodial care needs.
• If a patient is being discharged to a SNF, review the list of needed services leading to the SNF transfer. Ask the case manager if these services can be provided in the home. If not, then why?
• Bed capacity permitting, consider keeping patients who are functionally improving in the hospital an extra day so they can be discharged directly home instead of to a SNF.²

In his seminal work, The Innovator’s Dilemma, Clayton Christensen describes “disruptive innovation” as that which gives rise to products or services that are cheaper, simpler, and more convenient to use. Even though home care has been around for a while, there is a sizeable group of patients, especially in geographic areas of high SNF spending, who might be better served in the home environment. As we create better systems under value-based payment, we should see an increase in the use of home healthcare as a disruptive innovation when applied to appropriate patients transitioning out of the hospital or a SNF.

Dr. Whitcomb is Chief Medical Officer of Remedy Partners. He is co-founder and past president of SHM. Email him at [email protected].

References

1. Newhouse JP, Garber AM. Geographic variation in Medicare services. N Engl J Med. 2013;368:1465-1468.
2. Mechanic R. Post-acute care—The next frontier for controlling Medicare spending. N Engl J Med. 2014;370(8):692-694.

The role of nonclinical factors in shaping rates of rehospitalization has been explored in several recent studies—and targeted through new legislation endorsed by the Society of Hospital Medicine. A study in Health Affairs compared hospital performance on 30-day readmissions for the first three diagnoses included in penalty calculations for CMS’ Hospital Readmissions Reduction Program (HRRP) and found that adjusting for patients’ socioeconomic status significantly reduced the rates of variation in readmissions between hospitals across the state of Missouri.¹

For patients discharged between 2009 and 2012, analysis using a model enriched with census tract socioeconomic data found that the range of variation in readmissions between hospitals decreased to 1.8% from 6.5% for patients with acute myocardial infarction; to 7.4% from 14.0% for congestive heart failure; and to 3.7% from 7.4% for pneumonia, compared with rates unadjusted for these socioeconomic factors. Another study in the same journal by researchers at an urban teaching hospital found that patients living in high-poverty neighborhoods were 24% more likely to be readmitted to the hospital within 30 days, after adjusting for demographic and clinical characteristics.²

For a factor that may be more amenable to intervention by hospitalists, a standardized rehabilitation medicine test measuring patients’ ability to perform everyday tasks of living, such as the ability to move independently from bed to chair, wheelchair, or toilet was found to be a good predictor of readmissions.³ Few hospitals currently require assessment of their patients’ functional ability, notes the study’s lead author Erik Hoyer, MD, assistant professor in the department of physical medicine and rehabilitation at the Johns Hopkins University School of Medicine in Baltimore. But the score “is a direct reflection of the patient’s ability to heal [outside of the hospital].”

The Functional Independence Measure used in this study and in inpatient rehabilitation facilities nationwide is probably not the right tool for hospitalists because of its length and the training required to administer it, Dr. Hoyer says.

“There are other, easier tools that are available or in development that may also serve a similar purpose,” he says. “The main point is that routine functional assessment is important in the hospital setting, and developing strategies to improve patient function is likely an important way to improve outcomes such as hospital readmissions.”

The documented role of socioeconomic status in determining readmissions also is addressed by legislation introduced by Rep. Jim Renacci (R-Ohio) and supported by both the Society of Hospital Medicine and the American Hospital Association. The Establishing Beneficiary Equity in the Hospital Readmission Program Act (HR-4188) would adjust HRRP readmissions penalties to reflect “certain socioeconomic and health factors that increase the patient’s risk of readmissions.”

Larry Beresford is a freelance writer in Alameda, Calif.

The role of nonclinical factors in shaping rates of rehospitalization has been explored in several recent studies—and targeted through new legislation endorsed by the Society of Hospital Medicine. A study in Health Affairs compared hospital performance on 30-day readmissions for the first three diagnoses included in penalty calculations for CMS’ Hospital Readmissions Reduction Program (HRRP) and found that adjusting for patients’ socioeconomic status significantly reduced the rates of variation in readmissions between hospitals across the state of Missouri.¹

For patients discharged between 2009 and 2012, analysis using a model enriched with census tract socioeconomic data found that the range of variation in readmissions between hospitals decreased to 1.8% from 6.5% for patients with acute myocardial infarction; to 7.4% from 14.0% for congestive heart failure; and to 3.7% from 7.4% for pneumonia, compared with rates unadjusted for these socioeconomic factors. Another study in the same journal by researchers at an urban teaching hospital found that patients living in high-poverty neighborhoods were 24% more likely to be readmitted to the hospital within 30 days, after adjusting for demographic and clinical characteristics.²

For a factor that may be more amenable to intervention by hospitalists, a standardized rehabilitation medicine test measuring patients’ ability to perform everyday tasks of living, such as the ability to move independently from bed to chair, wheelchair, or toilet was found to be a good predictor of readmissions.³ Few hospitals currently require assessment of their patients’ functional ability, notes the study’s lead author Erik Hoyer, MD, assistant professor in the department of physical medicine and rehabilitation at the Johns Hopkins University School of Medicine in Baltimore. But the score “is a direct reflection of the patient’s ability to heal [outside of the hospital].”

The Functional Independence Measure used in this study and in inpatient rehabilitation facilities nationwide is probably not the right tool for hospitalists because of its length and the training required to administer it, Dr. Hoyer says.

“There are other, easier tools that are available or in development that may also serve a similar purpose,” he says. “The main point is that routine functional assessment is important in the hospital setting, and developing strategies to improve patient function is likely an important way to improve outcomes such as hospital readmissions.”

The documented role of socioeconomic status in determining readmissions also is addressed by legislation introduced by Rep. Jim Renacci (R-Ohio) and supported by both the Society of Hospital Medicine and the American Hospital Association. The Establishing Beneficiary Equity in the Hospital Readmission Program Act (HR-4188) would adjust HRRP readmissions penalties to reflect “certain socioeconomic and health factors that increase the patient’s risk of readmissions.”

Larry Beresford is a freelance writer in Alameda, Calif.

The role of nonclinical factors in shaping rates of rehospitalization has been explored in several recent studies—and targeted through new legislation endorsed by the Society of Hospital Medicine. A study in Health Affairs compared hospital performance on 30-day readmissions for the first three diagnoses included in penalty calculations for CMS’ Hospital Readmissions Reduction Program (HRRP) and found that adjusting for patients’ socioeconomic status significantly reduced the rates of variation in readmissions between hospitals across the state of Missouri.¹

For patients discharged between 2009 and 2012, analysis using a model enriched with census tract socioeconomic data found that the range of variation in readmissions between hospitals decreased to 1.8% from 6.5% for patients with acute myocardial infarction; to 7.4% from 14.0% for congestive heart failure; and to 3.7% from 7.4% for pneumonia, compared with rates unadjusted for these socioeconomic factors. Another study in the same journal by researchers at an urban teaching hospital found that patients living in high-poverty neighborhoods were 24% more likely to be readmitted to the hospital within 30 days, after adjusting for demographic and clinical characteristics.²

For a factor that may be more amenable to intervention by hospitalists, a standardized rehabilitation medicine test measuring patients’ ability to perform everyday tasks of living, such as the ability to move independently from bed to chair, wheelchair, or toilet was found to be a good predictor of readmissions.³ Few hospitals currently require assessment of their patients’ functional ability, notes the study’s lead author Erik Hoyer, MD, assistant professor in the department of physical medicine and rehabilitation at the Johns Hopkins University School of Medicine in Baltimore. But the score “is a direct reflection of the patient’s ability to heal [outside of the hospital].”

The Functional Independence Measure used in this study and in inpatient rehabilitation facilities nationwide is probably not the right tool for hospitalists because of its length and the training required to administer it, Dr. Hoyer says.

“There are other, easier tools that are available or in development that may also serve a similar purpose,” he says. “The main point is that routine functional assessment is important in the hospital setting, and developing strategies to improve patient function is likely an important way to improve outcomes such as hospital readmissions.”

The documented role of socioeconomic status in determining readmissions also is addressed by legislation introduced by Rep. Jim Renacci (R-Ohio) and supported by both the Society of Hospital Medicine and the American Hospital Association. The Establishing Beneficiary Equity in the Hospital Readmission Program Act (HR-4188) would adjust HRRP readmissions penalties to reflect “certain socioeconomic and health factors that increase the patient’s risk of readmissions.”

Larry Beresford is a freelance writer in Alameda, Calif.

Overuse of antibiotics is fueling antimicrobial resistance, posing a threat to people around the world and prompting increased attention to antibiotic stewardship practices. Good stewardship requires hospitals and clinicians to adopt coordinated interventions that focus on reducing inappropriate antibiotic prescribing while remaining focused on the health of patients.

Although it can seem overwhelming to physicians with busy workloads and sick patients to engage in these practices, not addressing the issue of responsible antibiotic prescribing is putting patients at risk.

“We know development of resistance is complicated,” says Arjun Srinivasan, MD, FSHEA, associate director for the CDC’s Healthcare Associated Infection Prevention Program and medical director of Get Smart for Healthcare in the CDC’s division of Healthcare Quality Promotion. Dr. Srinivasan is one of the authors of a recent CDC report on antibiotic prescribing practices across the U.S. “Nonetheless, we know that overuse of antibiotics leads to increases in resistance. We also know that if we can improve the way we prescribe them, we can reduce antibiotic resistance.”

The CDC recommends that hospitals adopt, at a minimum, the following antibiotic stewardship checklist:

• Commit leadership: Dedicate necessary human, financial, and information technology resources.
• Create accountability: Appoint a single leader responsible for program outcomes. Physicians have proven successful in this role.
• Provide drug expertise: Appoint a single pharmacist leader to support improved prescribing.
• Act: Take at least one prescribing improvement action, such as requiring reassessment within 48 hours to check drug choice, dose, and duration.
• Track: Monitor prescribing and antibiotic resistance patterns.
• Report: Regularly report to staff on prescribing and resistance patterns, as well as steps to improve.
• Educate: Offer education about antibiotic resistance and improving prescribing practices.
• Work with other healthcare facilities to prevent infections, transmission, and resistance.

These practices are not just the domain of infectious disease clinicians, either, says Neil Fishman, MD, chief patient safety officer and associate chief medical officer at the University of Pennsylvania Health System and past president of the Society for Healthcare Epidemiology of America. In 1992, Dr. Fishman helped establish an antibiotic stewardship program at Penn, working with infectious disease staff to identify and adopt best practices tailored to their needs.

Their efforts have shown promise in improving the health of their patients, he says, and many institutions that adopt stewardship programs typically see cost savings, too.

“These programs do usually end up decreasing drug costs but also increasing the quality of care,”

Dr. Fishman says. “If you can cut out 30% of unnecessary drugs, you cut drug costs. To me, that meets the true definition of value in healthcare.”

In one study that looked at stewardship-related cost reduction, primarily among larger healthcare settings, the average annual savings from reduced inappropriate antibiotic prescribing ranged from $200,000 to $900,000.

The recent CDC report, to which Dr. Srinivasan contributed, was published March 4 in Vital Signs. The study found that as many as a third of antibiotics prescribed are done so inappropriately. According to experts, hospitals and other healthcare institutions need to develop processes and standards to assist physicians in efforts to be responsible antibiotic prescribers.

“Sometimes, when you’re focusing on other issues, antibiotics are a bit of an afterthought,” says Scott Flanders, MD, FACP, MHM, professor of internal medicine and director of hospital medicine at University of Michigan Medical School in Ann Arbor.

“If there is not a checklist of processes [and] things are not accounted for in a systematic way, it doesn’t happen.”

Dr. Flanders and colleague Sanjay Saint, MD, MPH, the University of Michigan George Dock Collegiate professor of internal medicine and associate chief of medicine at the VA Ann Arbor Healthcare System, recently published an article in the Journal of the American Medical Association Internal Medicine in which they recommend the following:

• Antimicrobial stewardship programs, which aim to develop guidelines and implement programs that help optimize antibiotic use among hospitalized patients, should partner with front-line clinicians to tackle the problem.
• Clinicians should better document aspects of antibiotic use that can be shared with other providers caring for the same patient throughout his or her hospital stay and after discharge.
• Clinicians should take an “antibiotic time-out” after 48-72 hours of a patient’s use of antibiotics to reassess the use of these drugs.
• Treatment and its duration should be in line with evidence-based guidelines, and institutions should work to clearly identify appropriate treatment duration.
• Improved diagnostic tests should be available to physicians.
• Target diagnostic error by working to improve how physicians think when considering whether to provide antibiotics.
• Develop performance measures that highlight common conditions in which antibiotics are overprescribed, to shine a brighter light on the problem.

“I think we can make a lot of progress,” Dr. Flanders says. “The problem is complex; it developed over decades, and any solutions are unlikely to solve the problem immediately. But there are several examples of institutions and hospitals making significant inroads in a short period of time.” —KAT

Overuse of antibiotics is fueling antimicrobial resistance, posing a threat to people around the world and prompting increased attention to antibiotic stewardship practices. Good stewardship requires hospitals and clinicians to adopt coordinated interventions that focus on reducing inappropriate antibiotic prescribing while remaining focused on the health of patients.

Although it can seem overwhelming to physicians with busy workloads and sick patients to engage in these practices, not addressing the issue of responsible antibiotic prescribing is putting patients at risk.

“We know development of resistance is complicated,” says Arjun Srinivasan, MD, FSHEA, associate director for the CDC’s Healthcare Associated Infection Prevention Program and medical director of Get Smart for Healthcare in the CDC’s division of Healthcare Quality Promotion. Dr. Srinivasan is one of the authors of a recent CDC report on antibiotic prescribing practices across the U.S. “Nonetheless, we know that overuse of antibiotics leads to increases in resistance. We also know that if we can improve the way we prescribe them, we can reduce antibiotic resistance.”

The CDC recommends that hospitals adopt, at a minimum, the following antibiotic stewardship checklist:

• Commit leadership: Dedicate necessary human, financial, and information technology resources.
• Create accountability: Appoint a single leader responsible for program outcomes. Physicians have proven successful in this role.
• Provide drug expertise: Appoint a single pharmacist leader to support improved prescribing.
• Act: Take at least one prescribing improvement action, such as requiring reassessment within 48 hours to check drug choice, dose, and duration.
• Track: Monitor prescribing and antibiotic resistance patterns.
• Report: Regularly report to staff on prescribing and resistance patterns, as well as steps to improve.
• Educate: Offer education about antibiotic resistance and improving prescribing practices.
• Work with other healthcare facilities to prevent infections, transmission, and resistance.

These practices are not just the domain of infectious disease clinicians, either, says Neil Fishman, MD, chief patient safety officer and associate chief medical officer at the University of Pennsylvania Health System and past president of the Society for Healthcare Epidemiology of America. In 1992, Dr. Fishman helped establish an antibiotic stewardship program at Penn, working with infectious disease staff to identify and adopt best practices tailored to their needs.

Their efforts have shown promise in improving the health of their patients, he says, and many institutions that adopt stewardship programs typically see cost savings, too.

“These programs do usually end up decreasing drug costs but also increasing the quality of care,”

Dr. Fishman says. “If you can cut out 30% of unnecessary drugs, you cut drug costs. To me, that meets the true definition of value in healthcare.”

In one study that looked at stewardship-related cost reduction, primarily among larger healthcare settings, the average annual savings from reduced inappropriate antibiotic prescribing ranged from $200,000 to $900,000.

The recent CDC report, to which Dr. Srinivasan contributed, was published March 4 in Vital Signs. The study found that as many as a third of antibiotics prescribed are done so inappropriately. According to experts, hospitals and other healthcare institutions need to develop processes and standards to assist physicians in efforts to be responsible antibiotic prescribers.

“Sometimes, when you’re focusing on other issues, antibiotics are a bit of an afterthought,” says Scott Flanders, MD, FACP, MHM, professor of internal medicine and director of hospital medicine at University of Michigan Medical School in Ann Arbor.

“If there is not a checklist of processes [and] things are not accounted for in a systematic way, it doesn’t happen.”

Dr. Flanders and colleague Sanjay Saint, MD, MPH, the University of Michigan George Dock Collegiate professor of internal medicine and associate chief of medicine at the VA Ann Arbor Healthcare System, recently published an article in the Journal of the American Medical Association Internal Medicine in which they recommend the following:

• Antimicrobial stewardship programs, which aim to develop guidelines and implement programs that help optimize antibiotic use among hospitalized patients, should partner with front-line clinicians to tackle the problem.
• Clinicians should better document aspects of antibiotic use that can be shared with other providers caring for the same patient throughout his or her hospital stay and after discharge.
• Clinicians should take an “antibiotic time-out” after 48-72 hours of a patient’s use of antibiotics to reassess the use of these drugs.
• Treatment and its duration should be in line with evidence-based guidelines, and institutions should work to clearly identify appropriate treatment duration.
• Improved diagnostic tests should be available to physicians.
• Target diagnostic error by working to improve how physicians think when considering whether to provide antibiotics.
• Develop performance measures that highlight common conditions in which antibiotics are overprescribed, to shine a brighter light on the problem.

“I think we can make a lot of progress,” Dr. Flanders says. “The problem is complex; it developed over decades, and any solutions are unlikely to solve the problem immediately. But there are several examples of institutions and hospitals making significant inroads in a short period of time.” —KAT

Overuse of antibiotics is fueling antimicrobial resistance, posing a threat to people around the world and prompting increased attention to antibiotic stewardship practices. Good stewardship requires hospitals and clinicians to adopt coordinated interventions that focus on reducing inappropriate antibiotic prescribing while remaining focused on the health of patients.

Although it can seem overwhelming to physicians with busy workloads and sick patients to engage in these practices, not addressing the issue of responsible antibiotic prescribing is putting patients at risk.

“We know development of resistance is complicated,” says Arjun Srinivasan, MD, FSHEA, associate director for the CDC’s Healthcare Associated Infection Prevention Program and medical director of Get Smart for Healthcare in the CDC’s division of Healthcare Quality Promotion. Dr. Srinivasan is one of the authors of a recent CDC report on antibiotic prescribing practices across the U.S. “Nonetheless, we know that overuse of antibiotics leads to increases in resistance. We also know that if we can improve the way we prescribe them, we can reduce antibiotic resistance.”

The CDC recommends that hospitals adopt, at a minimum, the following antibiotic stewardship checklist:

• Commit leadership: Dedicate necessary human, financial, and information technology resources.
• Create accountability: Appoint a single leader responsible for program outcomes. Physicians have proven successful in this role.
• Provide drug expertise: Appoint a single pharmacist leader to support improved prescribing.
• Act: Take at least one prescribing improvement action, such as requiring reassessment within 48 hours to check drug choice, dose, and duration.
• Track: Monitor prescribing and antibiotic resistance patterns.
• Report: Regularly report to staff on prescribing and resistance patterns, as well as steps to improve.
• Educate: Offer education about antibiotic resistance and improving prescribing practices.
• Work with other healthcare facilities to prevent infections, transmission, and resistance.

These practices are not just the domain of infectious disease clinicians, either, says Neil Fishman, MD, chief patient safety officer and associate chief medical officer at the University of Pennsylvania Health System and past president of the Society for Healthcare Epidemiology of America. In 1992, Dr. Fishman helped establish an antibiotic stewardship program at Penn, working with infectious disease staff to identify and adopt best practices tailored to their needs.

Their efforts have shown promise in improving the health of their patients, he says, and many institutions that adopt stewardship programs typically see cost savings, too.

“These programs do usually end up decreasing drug costs but also increasing the quality of care,”

Dr. Fishman says. “If you can cut out 30% of unnecessary drugs, you cut drug costs. To me, that meets the true definition of value in healthcare.”

In one study that looked at stewardship-related cost reduction, primarily among larger healthcare settings, the average annual savings from reduced inappropriate antibiotic prescribing ranged from $200,000 to $900,000.

The recent CDC report, to which Dr. Srinivasan contributed, was published March 4 in Vital Signs. The study found that as many as a third of antibiotics prescribed are done so inappropriately. According to experts, hospitals and other healthcare institutions need to develop processes and standards to assist physicians in efforts to be responsible antibiotic prescribers.

“Sometimes, when you’re focusing on other issues, antibiotics are a bit of an afterthought,” says Scott Flanders, MD, FACP, MHM, professor of internal medicine and director of hospital medicine at University of Michigan Medical School in Ann Arbor.

“If there is not a checklist of processes [and] things are not accounted for in a systematic way, it doesn’t happen.”

Dr. Flanders and colleague Sanjay Saint, MD, MPH, the University of Michigan George Dock Collegiate professor of internal medicine and associate chief of medicine at the VA Ann Arbor Healthcare System, recently published an article in the Journal of the American Medical Association Internal Medicine in which they recommend the following:

• Antimicrobial stewardship programs, which aim to develop guidelines and implement programs that help optimize antibiotic use among hospitalized patients, should partner with front-line clinicians to tackle the problem.
• Clinicians should better document aspects of antibiotic use that can be shared with other providers caring for the same patient throughout his or her hospital stay and after discharge.
• Clinicians should take an “antibiotic time-out” after 48-72 hours of a patient’s use of antibiotics to reassess the use of these drugs.
• Treatment and its duration should be in line with evidence-based guidelines, and institutions should work to clearly identify appropriate treatment duration.
• Improved diagnostic tests should be available to physicians.
• Target diagnostic error by working to improve how physicians think when considering whether to provide antibiotics.
• Develop performance measures that highlight common conditions in which antibiotics are overprescribed, to shine a brighter light on the problem.

“I think we can make a lot of progress,” Dr. Flanders says. “The problem is complex; it developed over decades, and any solutions are unlikely to solve the problem immediately. But there are several examples of institutions and hospitals making significant inroads in a short period of time.” —KAT

A recent CDC study found that nearly a third of antibiotics might be inappropriately prescribed.¹ The report also found wide variation in antibiotic prescribing practices for patients in similar treatment areas in hospitals across the country.

Across the globe, antibiotic resistance has become a daunting threat. Some public health officials have labeled it a crisis, and improper prescribing and use of antibiotics is at least partly to blame, experts say.

“We’re dangerously close to a pre-antibiotic era where we don’t have antibiotics to treat common infections,” says Neil Fishman, MD, chief patient safety officer and associate chief medical officer at the University of Pennsylvania Health System and past president of the Society for Healthcare Epidemiology of America. “We are seeing more and more infections, usually hospital-based, caused by bacterial resistance to most, if not all, of the antibiotics that we have.”

It’s an issue hospitalists around the country are championing.

“I think for a long time there’s been a misperception that antibiotic stewardship is at odds with hospitalists, who are managing very busy patient loads and managing inpatient prescribing,” says Arjun Srinivasan, MD, FSHEA, associate director for the CDC’s Healthcare Associated Infection Prevention Program and medical director of Get Smart for Healthcare in the division of Healthcare Quality Promotion at the CDC. Dr. Srinivasan is one of the authors of the new CDC study.

But “they have taken that ball and run with it,” says Dr. Srinivasan, who has worked with the Society of Hospital Medicine to address antibiotic resistance issues.

The goals of the study, published in the CDC’s Vital Signs on March 4, 2014, were to evaluate the extent and rationale for the prescribing of antibiotics in U.S. hospitals, while demonstrating opportunities for improvement in prescribing practices.

Study authors analyzed data from the Truven Health MarketScan Hospital Drug Database and the CDC’s Emerging Infection Program and, using a model based on the data, demonstrated that a 30% reduction in broad-spectrum antibiotics use would decrease Clostridium difficile infection (CDI) by 26%. Overall antibiotic use would drop by 5%.

According to the CDC, antibiotics are among the most frequent causes of adverse drug events among hospitalized patients in the U.S., and complications like CDI can be deadly. In fact, 250,000 hospitalized patients are infected with CDI each year, resulting in 14,000 deaths.

“We’re really at a critical juncture in healthcare now,” Dr. Fishman says. “The field of stewardship has evolved mainly in academic tertiary care settings. The CDC report is timely because it highlights the necessity of making sure antibiotics are used appropriately in all healthcare settings.”

Take a Break

One of the ways in which hospitalists have addressed the need for more appropriate antibiotic prescribing in their institutions is the practice of an “antibiotic time-out.”

“After some point, when the dust settles at about 48-72 hours, you can evaluate the patient’s progress, evaluate their studies, [and] you may have culture results,” says Scott Flanders, MD, FACP, MHM, professor of internal medicine and director of hospital medicine at the University of Michigan Medical School in Ann Arbor. At that point, physicians can decide whether to maintain a patient on the original antibiotic, alter the duration of treatment, or take them off the treatment altogether.

Dr. Flanders and a colleague published an editorial in the Journal of the American Medical Association Internal Medicine that coincided with the CDC report.² A 2007 study published in Clinical Infectious Diseases found that the choice of antibiotic agent or duration of treatment can be incorrect in as many as half of all cases in which antibiotics are prescribed.³

Dr. Flanders, a past president of SHM who has worked extensively with the CDC and the Institute for Healthcare Improvement, was behind the development of the time-out strategy. Dr. Srinivasan says the clinical utility of the method was “eye-opening.”

The strategy, which has taken hold among hospital groups the CDC has worked with, has demonstrated that stewardship and patient management are not at odds, Dr. Srinivasan says. Despite patient sign-outs and hand-offs, the time-out strategy allows any clinician to track a patient’s antibiotic status and reevaluate the treatment plan.

Having a process is critical to more responsible prescribing practices, Dr. Flanders says. He attributes much of the variability in antibiotics prescribing among similar departments at hospitals across the country to a lack of standards, though he noted that variability in patient populations undoubtedly plays a role.

Lack of Stats

The CDC report showed up to a threefold difference in the number of antibiotics prescribed to patients in similar hospital settings at hospitals across the country. The reasons for this are not known, Dr. Fishman says.

“The main reason we don’t know is we don’t have a good mechanism in the U.S. right now to monitor antibiotics use,” he explains. “We don’t have a way for healthcare facilities to benchmark their use.”

Without good strategies to monitor and develop more responsible antibiotics prescription practices, Dr. Flanders believes many physicians find themselves trapped by the “chagrin” of not prescribing.

“Patients often enter the hospital without a clear diagnosis,” he says. “They are quite ill. They may have a serious bacterial infection, and, in diagnosing them, we can’t guess wrong and make the decision to withhold antibiotics, only to find out later the patient is infected.

“We know delays increase mortality, and that’s not an acceptable option.”

Patients often enter the hospital without a clear diagnosis. They are quite ill. They may have a serious bacterial infection, and, in diagnosing them, we can’t guess wrong and make the decision to withhold antibiotics, only to find out later the patient is infected.

 

—Scott Flanders, MD, FACP, MHM, professor of internal medicine, director of hospital medicine, University of Michigan Medical School, Ann Arbor, past president, SHM

Beyond the Bedside

Many physicians fail to consider the bigger societal implications when prescribing antibiotics for sick patients in their charge, because their responsibility is, first and foremost, to that individual. But, Dr. Srinivasan says, “good antibiotic stewardship is beneficial to the patient lying in the bed in front of you, because every day we are confronted with C. diff. infections, adverse drug events, all of these issues.”

Strategies and processes help hospitalists make the best decision for their patients at the time they require care, while providing room for adaptation and the improvements that serve all patients.

Some institutions use interventions like prospective audit and feedback monitoring to help physicians become more responsible antibiotic prescribers, says Dr. Fishman, who worked with infectious disease specialists at the University of Pennsylvania in the early 1990s to develop a stewardship program there.

“In our institution, we see better outcomes—lower complications—usually associated with a decreased length of stay, at least in the ICU for critically ill patients—and increased cure rates,” he says.

Stewardship efforts take investment on the part of the hospital. Dr. Fishman cited a recent study at the Children’s Hospital of Pennsylvania that looked at whether a particular education strategy the hospital implemented actually led to improvements.⁴

“It was successful in intervening in this problem [of inappropriate prescribing] in pediatricians, but it did take ongoing education of both healthcare providers and patients,” he says, noting that large financial and time investments are necessary for the ongoing training and follow-up that is necessary.

And patients need to be educated, too.

“It takes a minute to write that prescription and probably 15 or 20 minutes not to write it,” Dr. Fishman says. “We need to educate patients about potential complications of antibiotics use, as well as the signs and symptoms of infection.”

The CDC report is a call to action for all healthcare providers to consider how they can become better antibiotic stewards. There are very few new antibiotics on the market and little in the pipeline. All providers must do what they can to preserve the antibiotics we currently have, Dr. Fishman says.

“There is opportunity, and I think hospitalists are up to the challenge,” Dr. Flanders says. “They are doing lots of work to improve quality across lots of domains in their hospitals. I think this is an area where attention is deserved.”

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

References

1. Centers for Disease Control and Prevention. Morbidity and Mortality Weekly Report. Vital signs: improving antibiotic use among hospitalized patients. Available at: www.cdc.gov/mmwr/preview/mmwrhtml/mm6309a4.htm?s_cid=mm6309a4_w. Accessed August 31, 2014.
2. Flanders SA, Saint S. Why does antrimicrobial overuse in hospitalized patients persist? JAMA Internal Medicine online. Available at: http://archinte.jamanetwork.com/article.aspx?articleid=1838720. Accessed August 31, 2014.
3. Dellit TH, Owens RC, McGowan JE, et al. Clinical Infectious Diseases online. Available at: http://cid.oxfordjournals.org/content/44/2/159.full. Accessed August 31, 2014.
4. Gerber JS, Prasad PA, Fiks A, et al. Effect of an outpatient antimicrobial stewardship intervention on broad-spectrum antibiotic prescribing by primary care pediatricians. JAMA. 2013;309(22):2345-2352.

A recent CDC study found that nearly a third of antibiotics might be inappropriately prescribed.¹ The report also found wide variation in antibiotic prescribing practices for patients in similar treatment areas in hospitals across the country.

Across the globe, antibiotic resistance has become a daunting threat. Some public health officials have labeled it a crisis, and improper prescribing and use of antibiotics is at least partly to blame, experts say.

“We’re dangerously close to a pre-antibiotic era where we don’t have antibiotics to treat common infections,” says Neil Fishman, MD, chief patient safety officer and associate chief medical officer at the University of Pennsylvania Health System and past president of the Society for Healthcare Epidemiology of America. “We are seeing more and more infections, usually hospital-based, caused by bacterial resistance to most, if not all, of the antibiotics that we have.”

It’s an issue hospitalists around the country are championing.

“I think for a long time there’s been a misperception that antibiotic stewardship is at odds with hospitalists, who are managing very busy patient loads and managing inpatient prescribing,” says Arjun Srinivasan, MD, FSHEA, associate director for the CDC’s Healthcare Associated Infection Prevention Program and medical director of Get Smart for Healthcare in the division of Healthcare Quality Promotion at the CDC. Dr. Srinivasan is one of the authors of the new CDC study.

But “they have taken that ball and run with it,” says Dr. Srinivasan, who has worked with the Society of Hospital Medicine to address antibiotic resistance issues.

The goals of the study, published in the CDC’s Vital Signs on March 4, 2014, were to evaluate the extent and rationale for the prescribing of antibiotics in U.S. hospitals, while demonstrating opportunities for improvement in prescribing practices.

Study authors analyzed data from the Truven Health MarketScan Hospital Drug Database and the CDC’s Emerging Infection Program and, using a model based on the data, demonstrated that a 30% reduction in broad-spectrum antibiotics use would decrease Clostridium difficile infection (CDI) by 26%. Overall antibiotic use would drop by 5%.

According to the CDC, antibiotics are among the most frequent causes of adverse drug events among hospitalized patients in the U.S., and complications like CDI can be deadly. In fact, 250,000 hospitalized patients are infected with CDI each year, resulting in 14,000 deaths.

“We’re really at a critical juncture in healthcare now,” Dr. Fishman says. “The field of stewardship has evolved mainly in academic tertiary care settings. The CDC report is timely because it highlights the necessity of making sure antibiotics are used appropriately in all healthcare settings.”

Take a Break

One of the ways in which hospitalists have addressed the need for more appropriate antibiotic prescribing in their institutions is the practice of an “antibiotic time-out.”

“After some point, when the dust settles at about 48-72 hours, you can evaluate the patient’s progress, evaluate their studies, [and] you may have culture results,” says Scott Flanders, MD, FACP, MHM, professor of internal medicine and director of hospital medicine at the University of Michigan Medical School in Ann Arbor. At that point, physicians can decide whether to maintain a patient on the original antibiotic, alter the duration of treatment, or take them off the treatment altogether.

Dr. Flanders and a colleague published an editorial in the Journal of the American Medical Association Internal Medicine that coincided with the CDC report.² A 2007 study published in Clinical Infectious Diseases found that the choice of antibiotic agent or duration of treatment can be incorrect in as many as half of all cases in which antibiotics are prescribed.³

Dr. Flanders, a past president of SHM who has worked extensively with the CDC and the Institute for Healthcare Improvement, was behind the development of the time-out strategy. Dr. Srinivasan says the clinical utility of the method was “eye-opening.”

The strategy, which has taken hold among hospital groups the CDC has worked with, has demonstrated that stewardship and patient management are not at odds, Dr. Srinivasan says. Despite patient sign-outs and hand-offs, the time-out strategy allows any clinician to track a patient’s antibiotic status and reevaluate the treatment plan.

Having a process is critical to more responsible prescribing practices, Dr. Flanders says. He attributes much of the variability in antibiotics prescribing among similar departments at hospitals across the country to a lack of standards, though he noted that variability in patient populations undoubtedly plays a role.

Lack of Stats

The CDC report showed up to a threefold difference in the number of antibiotics prescribed to patients in similar hospital settings at hospitals across the country. The reasons for this are not known, Dr. Fishman says.

“The main reason we don’t know is we don’t have a good mechanism in the U.S. right now to monitor antibiotics use,” he explains. “We don’t have a way for healthcare facilities to benchmark their use.”

Without good strategies to monitor and develop more responsible antibiotics prescription practices, Dr. Flanders believes many physicians find themselves trapped by the “chagrin” of not prescribing.

“Patients often enter the hospital without a clear diagnosis,” he says. “They are quite ill. They may have a serious bacterial infection, and, in diagnosing them, we can’t guess wrong and make the decision to withhold antibiotics, only to find out later the patient is infected.

“We know delays increase mortality, and that’s not an acceptable option.”

Patients often enter the hospital without a clear diagnosis. They are quite ill. They may have a serious bacterial infection, and, in diagnosing them, we can’t guess wrong and make the decision to withhold antibiotics, only to find out later the patient is infected.

 

—Scott Flanders, MD, FACP, MHM, professor of internal medicine, director of hospital medicine, University of Michigan Medical School, Ann Arbor, past president, SHM

Beyond the Bedside

Many physicians fail to consider the bigger societal implications when prescribing antibiotics for sick patients in their charge, because their responsibility is, first and foremost, to that individual. But, Dr. Srinivasan says, “good antibiotic stewardship is beneficial to the patient lying in the bed in front of you, because every day we are confronted with C. diff. infections, adverse drug events, all of these issues.”

Strategies and processes help hospitalists make the best decision for their patients at the time they require care, while providing room for adaptation and the improvements that serve all patients.

Some institutions use interventions like prospective audit and feedback monitoring to help physicians become more responsible antibiotic prescribers, says Dr. Fishman, who worked with infectious disease specialists at the University of Pennsylvania in the early 1990s to develop a stewardship program there.

“In our institution, we see better outcomes—lower complications—usually associated with a decreased length of stay, at least in the ICU for critically ill patients—and increased cure rates,” he says.

Stewardship efforts take investment on the part of the hospital. Dr. Fishman cited a recent study at the Children’s Hospital of Pennsylvania that looked at whether a particular education strategy the hospital implemented actually led to improvements.⁴

“It was successful in intervening in this problem [of inappropriate prescribing] in pediatricians, but it did take ongoing education of both healthcare providers and patients,” he says, noting that large financial and time investments are necessary for the ongoing training and follow-up that is necessary.

And patients need to be educated, too.

“It takes a minute to write that prescription and probably 15 or 20 minutes not to write it,” Dr. Fishman says. “We need to educate patients about potential complications of antibiotics use, as well as the signs and symptoms of infection.”

The CDC report is a call to action for all healthcare providers to consider how they can become better antibiotic stewards. There are very few new antibiotics on the market and little in the pipeline. All providers must do what they can to preserve the antibiotics we currently have, Dr. Fishman says.

“There is opportunity, and I think hospitalists are up to the challenge,” Dr. Flanders says. “They are doing lots of work to improve quality across lots of domains in their hospitals. I think this is an area where attention is deserved.”

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

References

1. Centers for Disease Control and Prevention. Morbidity and Mortality Weekly Report. Vital signs: improving antibiotic use among hospitalized patients. Available at: www.cdc.gov/mmwr/preview/mmwrhtml/mm6309a4.htm?s_cid=mm6309a4_w. Accessed August 31, 2014.
2. Flanders SA, Saint S. Why does antrimicrobial overuse in hospitalized patients persist? JAMA Internal Medicine online. Available at: http://archinte.jamanetwork.com/article.aspx?articleid=1838720. Accessed August 31, 2014.
3. Dellit TH, Owens RC, McGowan JE, et al. Clinical Infectious Diseases online. Available at: http://cid.oxfordjournals.org/content/44/2/159.full. Accessed August 31, 2014.
4. Gerber JS, Prasad PA, Fiks A, et al. Effect of an outpatient antimicrobial stewardship intervention on broad-spectrum antibiotic prescribing by primary care pediatricians. JAMA. 2013;309(22):2345-2352.

A recent CDC study found that nearly a third of antibiotics might be inappropriately prescribed.¹ The report also found wide variation in antibiotic prescribing practices for patients in similar treatment areas in hospitals across the country.

Across the globe, antibiotic resistance has become a daunting threat. Some public health officials have labeled it a crisis, and improper prescribing and use of antibiotics is at least partly to blame, experts say.

“We’re dangerously close to a pre-antibiotic era where we don’t have antibiotics to treat common infections,” says Neil Fishman, MD, chief patient safety officer and associate chief medical officer at the University of Pennsylvania Health System and past president of the Society for Healthcare Epidemiology of America. “We are seeing more and more infections, usually hospital-based, caused by bacterial resistance to most, if not all, of the antibiotics that we have.”

It’s an issue hospitalists around the country are championing.

“I think for a long time there’s been a misperception that antibiotic stewardship is at odds with hospitalists, who are managing very busy patient loads and managing inpatient prescribing,” says Arjun Srinivasan, MD, FSHEA, associate director for the CDC’s Healthcare Associated Infection Prevention Program and medical director of Get Smart for Healthcare in the division of Healthcare Quality Promotion at the CDC. Dr. Srinivasan is one of the authors of the new CDC study.

But “they have taken that ball and run with it,” says Dr. Srinivasan, who has worked with the Society of Hospital Medicine to address antibiotic resistance issues.

The goals of the study, published in the CDC’s Vital Signs on March 4, 2014, were to evaluate the extent and rationale for the prescribing of antibiotics in U.S. hospitals, while demonstrating opportunities for improvement in prescribing practices.

Study authors analyzed data from the Truven Health MarketScan Hospital Drug Database and the CDC’s Emerging Infection Program and, using a model based on the data, demonstrated that a 30% reduction in broad-spectrum antibiotics use would decrease Clostridium difficile infection (CDI) by 26%. Overall antibiotic use would drop by 5%.

According to the CDC, antibiotics are among the most frequent causes of adverse drug events among hospitalized patients in the U.S., and complications like CDI can be deadly. In fact, 250,000 hospitalized patients are infected with CDI each year, resulting in 14,000 deaths.

“We’re really at a critical juncture in healthcare now,” Dr. Fishman says. “The field of stewardship has evolved mainly in academic tertiary care settings. The CDC report is timely because it highlights the necessity of making sure antibiotics are used appropriately in all healthcare settings.”

Take a Break

One of the ways in which hospitalists have addressed the need for more appropriate antibiotic prescribing in their institutions is the practice of an “antibiotic time-out.”

“After some point, when the dust settles at about 48-72 hours, you can evaluate the patient’s progress, evaluate their studies, [and] you may have culture results,” says Scott Flanders, MD, FACP, MHM, professor of internal medicine and director of hospital medicine at the University of Michigan Medical School in Ann Arbor. At that point, physicians can decide whether to maintain a patient on the original antibiotic, alter the duration of treatment, or take them off the treatment altogether.

Dr. Flanders and a colleague published an editorial in the Journal of the American Medical Association Internal Medicine that coincided with the CDC report.² A 2007 study published in Clinical Infectious Diseases found that the choice of antibiotic agent or duration of treatment can be incorrect in as many as half of all cases in which antibiotics are prescribed.³

Dr. Flanders, a past president of SHM who has worked extensively with the CDC and the Institute for Healthcare Improvement, was behind the development of the time-out strategy. Dr. Srinivasan says the clinical utility of the method was “eye-opening.”

The strategy, which has taken hold among hospital groups the CDC has worked with, has demonstrated that stewardship and patient management are not at odds, Dr. Srinivasan says. Despite patient sign-outs and hand-offs, the time-out strategy allows any clinician to track a patient’s antibiotic status and reevaluate the treatment plan.

Having a process is critical to more responsible prescribing practices, Dr. Flanders says. He attributes much of the variability in antibiotics prescribing among similar departments at hospitals across the country to a lack of standards, though he noted that variability in patient populations undoubtedly plays a role.

Lack of Stats

The CDC report showed up to a threefold difference in the number of antibiotics prescribed to patients in similar hospital settings at hospitals across the country. The reasons for this are not known, Dr. Fishman says.

“The main reason we don’t know is we don’t have a good mechanism in the U.S. right now to monitor antibiotics use,” he explains. “We don’t have a way for healthcare facilities to benchmark their use.”

Without good strategies to monitor and develop more responsible antibiotics prescription practices, Dr. Flanders believes many physicians find themselves trapped by the “chagrin” of not prescribing.

“Patients often enter the hospital without a clear diagnosis,” he says. “They are quite ill. They may have a serious bacterial infection, and, in diagnosing them, we can’t guess wrong and make the decision to withhold antibiotics, only to find out later the patient is infected.

“We know delays increase mortality, and that’s not an acceptable option.”

Patients often enter the hospital without a clear diagnosis. They are quite ill. They may have a serious bacterial infection, and, in diagnosing them, we can’t guess wrong and make the decision to withhold antibiotics, only to find out later the patient is infected.

 

—Scott Flanders, MD, FACP, MHM, professor of internal medicine, director of hospital medicine, University of Michigan Medical School, Ann Arbor, past president, SHM

Beyond the Bedside

Many physicians fail to consider the bigger societal implications when prescribing antibiotics for sick patients in their charge, because their responsibility is, first and foremost, to that individual. But, Dr. Srinivasan says, “good antibiotic stewardship is beneficial to the patient lying in the bed in front of you, because every day we are confronted with C. diff. infections, adverse drug events, all of these issues.”

Strategies and processes help hospitalists make the best decision for their patients at the time they require care, while providing room for adaptation and the improvements that serve all patients.

Some institutions use interventions like prospective audit and feedback monitoring to help physicians become more responsible antibiotic prescribers, says Dr. Fishman, who worked with infectious disease specialists at the University of Pennsylvania in the early 1990s to develop a stewardship program there.

“In our institution, we see better outcomes—lower complications—usually associated with a decreased length of stay, at least in the ICU for critically ill patients—and increased cure rates,” he says.

Stewardship efforts take investment on the part of the hospital. Dr. Fishman cited a recent study at the Children’s Hospital of Pennsylvania that looked at whether a particular education strategy the hospital implemented actually led to improvements.⁴

“It was successful in intervening in this problem [of inappropriate prescribing] in pediatricians, but it did take ongoing education of both healthcare providers and patients,” he says, noting that large financial and time investments are necessary for the ongoing training and follow-up that is necessary.

And patients need to be educated, too.

“It takes a minute to write that prescription and probably 15 or 20 minutes not to write it,” Dr. Fishman says. “We need to educate patients about potential complications of antibiotics use, as well as the signs and symptoms of infection.”

The CDC report is a call to action for all healthcare providers to consider how they can become better antibiotic stewards. There are very few new antibiotics on the market and little in the pipeline. All providers must do what they can to preserve the antibiotics we currently have, Dr. Fishman says.

“There is opportunity, and I think hospitalists are up to the challenge,” Dr. Flanders says. “They are doing lots of work to improve quality across lots of domains in their hospitals. I think this is an area where attention is deserved.”

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

References

1. Centers for Disease Control and Prevention. Morbidity and Mortality Weekly Report. Vital signs: improving antibiotic use among hospitalized patients. Available at: www.cdc.gov/mmwr/preview/mmwrhtml/mm6309a4.htm?s_cid=mm6309a4_w. Accessed August 31, 2014.
2. Flanders SA, Saint S. Why does antrimicrobial overuse in hospitalized patients persist? JAMA Internal Medicine online. Available at: http://archinte.jamanetwork.com/article.aspx?articleid=1838720. Accessed August 31, 2014.
3. Dellit TH, Owens RC, McGowan JE, et al. Clinical Infectious Diseases online. Available at: http://cid.oxfordjournals.org/content/44/2/159.full. Accessed August 31, 2014.
4. Gerber JS, Prasad PA, Fiks A, et al. Effect of an outpatient antimicrobial stewardship intervention on broad-spectrum antibiotic prescribing by primary care pediatricians. JAMA. 2013;309(22):2345-2352.

Twice in the past four months, Society of Hospital Medicine (SHM) member Ann Sheehy, MD, MS, FHM, found herself on Capitol Hill, testifying before Congressional committees focused on the U.S. healthcare system.

A physician at the University of Wisconsin (UW) School of Medicine and Public Health and a member of SHM’s Public Policy Committee, Dr. Sheehy was invited to speak about issues related to Medicare’s two-midnight rule, patient observation status, and the Recovery Audit Contractor (RAC) program.

These issues are “so important, and I am passionate about it,” Dr. Sheehy says. “I saw what was happening to patients and it just did not make any sense at all.”

Medicare’s two-midnight rule classifies most patients who stay in the hospital fewer than two midnights as outpatient or under observation. Observation status leaves patients on the hook for the costs of any chronic condition medications they receive in the hospital; additionally, patients under observation or considered outpatient are not eligible for skilled nursing facility (SNF) coverage.

SHM actively supports the Improving Access to Medicare Coverage Act, a bipartisan bill sponsored by Rep. Joe Courtney (D-CT) aimed at ensuring Medicare beneficiaries classified as under observation are considered inpatient for the purposes of accessing SNF care, even if their stay spanned fewer than two midnights.

At the Congressional hearings (watch video of the testimony at www.c-span.org/video/?319488-1/medicare-hospital-coverage committee and http://www.aging.senate.gov/hearings/admitted-or-not-the-impact-of-medicare-observation-status-on-seniors), Dr. Sheehy used her experience at UW Hospital and findings she and colleagues published in JAMA Internal Medicine to build a backstory around the issues. Based on the transcript of the testimony, Dr. Sheehy told the House Ways and Means Subcommittee on Health: “Because of our clinical work and extensive experience in the hospital setting, hospitalists have a firsthand view of what observation care looks like to patients, physicians, and hospitals.”

She argues in her testimony that observation status harms the patient-physician relationship and does not make clinical sense.

For instance, the time of day a patient gets sick can impact their designation under the two-midnight rule. In one 2013 JAMA Internal Medicine publication [http://archinte.jamanetwork.com/article.aspx?articleid=1731964], Dr. Sheehy and colleagues found nearly half of UW Hospital patients would have been assigned observation status rather than inpatient under the two-midnight rule by virtue of the time they arrived at the hospital.

Additionally, Dr. Sheehy addressed the issue of the private contractors, or RACs, which were established under the Tax Relief and Health Care Act of 2006 to audit patient records for appropriate hospital status. Dr. Sheehy, in her testimony, said the RACs are aggressive and nontransparent in their audits. Additionally, the RACs are paid a percentage of the money they recover on Medicare’s behalf but are not held financially accountable for decisions that are subsequently appealed and overturned.

Nationally, roughly 40% of RAC audits are appealed, and 70% of these are overturned. Dr. Sheehy told the Congressional committee that at UW Hospital from Oct. 1, 2012 through Sept. 30, 2013, RAC audits determined that 21% of 299 patient charts had received improper payments. The hospital appealed 58 of the 63 audit decisions and had won each of them as of mid-May 2014.

Dr. Sheehy believes changes to the auditing programs enforcing observation rule compliance are necessary for the success of any observation reform, whether it comes through legislation or regulation. In her testimony closing, Dr. Sheehy told the House committee the two-midnight rule is not the answer to the need for observation status change. Medicare policy, she said, “should be aligned with clinical realities and should also be rooted in allowing physicians to provide the care patients need.”

In addition to addressing the arbitrary time cutoff, Dr. Sheehy made the case that the two-midnight rule puts short-stay, acutely ill patients at a disadvantage, may add cost and waste to the healthcare system, and is challenging for providers, who must estimate patient time of stay upon patient hospitalization.

But, Dr. Sheehy believes meaningful change is possible and hopes her testimony is helpful in the endeavor.

“Our understanding is that [Ways and Means committee members] were going to draft legislation out of the hearing, and we hope we have comprehensively addressed [patient] observation and the auditing programs that enforce it,” she says. “Hopefully, we provided the backstory and evidence for a comprehensive bill everyone can get behind.”

For SHM, Dr. Sheehy’s testimony demonstrates that hospitalists are taking leadership when it comes to critical issues that impact patients, physicians, and hospitals.

“The hearings shows the strength of hospital medicine as a specialty and a movement in healthcare: Hospitalists and SHM are not standing on the sidelines when it comes to flawed Medicare policies such as the two-midnight rule and observation care in general,” says SHM President Burke Kealey, MD, SFHM, medical director of hospital specialties at HealthPartners Medical Group in St. Paul, Minn. “These policy discussions are critical to the care our patients receive. Congress is clearly interested in listening to the hospitalist perspective. Dr. Sheehy represented the nation’s 44,000 hospitalists with the expertise, confidence, and compassion that are hallmarks of the specialty.”

Kelly April Tyrrell is a freelance writer in Wisconsin.

Twice in the past four months, Society of Hospital Medicine (SHM) member Ann Sheehy, MD, MS, FHM, found herself on Capitol Hill, testifying before Congressional committees focused on the U.S. healthcare system.

A physician at the University of Wisconsin (UW) School of Medicine and Public Health and a member of SHM’s Public Policy Committee, Dr. Sheehy was invited to speak about issues related to Medicare’s two-midnight rule, patient observation status, and the Recovery Audit Contractor (RAC) program.

These issues are “so important, and I am passionate about it,” Dr. Sheehy says. “I saw what was happening to patients and it just did not make any sense at all.”

Medicare’s two-midnight rule classifies most patients who stay in the hospital fewer than two midnights as outpatient or under observation. Observation status leaves patients on the hook for the costs of any chronic condition medications they receive in the hospital; additionally, patients under observation or considered outpatient are not eligible for skilled nursing facility (SNF) coverage.

SHM actively supports the Improving Access to Medicare Coverage Act, a bipartisan bill sponsored by Rep. Joe Courtney (D-CT) aimed at ensuring Medicare beneficiaries classified as under observation are considered inpatient for the purposes of accessing SNF care, even if their stay spanned fewer than two midnights.

At the Congressional hearings (watch video of the testimony at www.c-span.org/video/?319488-1/medicare-hospital-coverage committee and http://www.aging.senate.gov/hearings/admitted-or-not-the-impact-of-medicare-observation-status-on-seniors), Dr. Sheehy used her experience at UW Hospital and findings she and colleagues published in JAMA Internal Medicine to build a backstory around the issues. Based on the transcript of the testimony, Dr. Sheehy told the House Ways and Means Subcommittee on Health: “Because of our clinical work and extensive experience in the hospital setting, hospitalists have a firsthand view of what observation care looks like to patients, physicians, and hospitals.”

She argues in her testimony that observation status harms the patient-physician relationship and does not make clinical sense.

For instance, the time of day a patient gets sick can impact their designation under the two-midnight rule. In one 2013 JAMA Internal Medicine publication [http://archinte.jamanetwork.com/article.aspx?articleid=1731964], Dr. Sheehy and colleagues found nearly half of UW Hospital patients would have been assigned observation status rather than inpatient under the two-midnight rule by virtue of the time they arrived at the hospital.

Additionally, Dr. Sheehy addressed the issue of the private contractors, or RACs, which were established under the Tax Relief and Health Care Act of 2006 to audit patient records for appropriate hospital status. Dr. Sheehy, in her testimony, said the RACs are aggressive and nontransparent in their audits. Additionally, the RACs are paid a percentage of the money they recover on Medicare’s behalf but are not held financially accountable for decisions that are subsequently appealed and overturned.

Nationally, roughly 40% of RAC audits are appealed, and 70% of these are overturned. Dr. Sheehy told the Congressional committee that at UW Hospital from Oct. 1, 2012 through Sept. 30, 2013, RAC audits determined that 21% of 299 patient charts had received improper payments. The hospital appealed 58 of the 63 audit decisions and had won each of them as of mid-May 2014.

Dr. Sheehy believes changes to the auditing programs enforcing observation rule compliance are necessary for the success of any observation reform, whether it comes through legislation or regulation. In her testimony closing, Dr. Sheehy told the House committee the two-midnight rule is not the answer to the need for observation status change. Medicare policy, she said, “should be aligned with clinical realities and should also be rooted in allowing physicians to provide the care patients need.”

In addition to addressing the arbitrary time cutoff, Dr. Sheehy made the case that the two-midnight rule puts short-stay, acutely ill patients at a disadvantage, may add cost and waste to the healthcare system, and is challenging for providers, who must estimate patient time of stay upon patient hospitalization.

But, Dr. Sheehy believes meaningful change is possible and hopes her testimony is helpful in the endeavor.

“Our understanding is that [Ways and Means committee members] were going to draft legislation out of the hearing, and we hope we have comprehensively addressed [patient] observation and the auditing programs that enforce it,” she says. “Hopefully, we provided the backstory and evidence for a comprehensive bill everyone can get behind.”

For SHM, Dr. Sheehy’s testimony demonstrates that hospitalists are taking leadership when it comes to critical issues that impact patients, physicians, and hospitals.

“The hearings shows the strength of hospital medicine as a specialty and a movement in healthcare: Hospitalists and SHM are not standing on the sidelines when it comes to flawed Medicare policies such as the two-midnight rule and observation care in general,” says SHM President Burke Kealey, MD, SFHM, medical director of hospital specialties at HealthPartners Medical Group in St. Paul, Minn. “These policy discussions are critical to the care our patients receive. Congress is clearly interested in listening to the hospitalist perspective. Dr. Sheehy represented the nation’s 44,000 hospitalists with the expertise, confidence, and compassion that are hallmarks of the specialty.”

Kelly April Tyrrell is a freelance writer in Wisconsin.

Twice in the past four months, Society of Hospital Medicine (SHM) member Ann Sheehy, MD, MS, FHM, found herself on Capitol Hill, testifying before Congressional committees focused on the U.S. healthcare system.

A physician at the University of Wisconsin (UW) School of Medicine and Public Health and a member of SHM’s Public Policy Committee, Dr. Sheehy was invited to speak about issues related to Medicare’s two-midnight rule, patient observation status, and the Recovery Audit Contractor (RAC) program.

These issues are “so important, and I am passionate about it,” Dr. Sheehy says. “I saw what was happening to patients and it just did not make any sense at all.”

Medicare’s two-midnight rule classifies most patients who stay in the hospital fewer than two midnights as outpatient or under observation. Observation status leaves patients on the hook for the costs of any chronic condition medications they receive in the hospital; additionally, patients under observation or considered outpatient are not eligible for skilled nursing facility (SNF) coverage.

SHM actively supports the Improving Access to Medicare Coverage Act, a bipartisan bill sponsored by Rep. Joe Courtney (D-CT) aimed at ensuring Medicare beneficiaries classified as under observation are considered inpatient for the purposes of accessing SNF care, even if their stay spanned fewer than two midnights.

At the Congressional hearings (watch video of the testimony at www.c-span.org/video/?319488-1/medicare-hospital-coverage committee and http://www.aging.senate.gov/hearings/admitted-or-not-the-impact-of-medicare-observation-status-on-seniors), Dr. Sheehy used her experience at UW Hospital and findings she and colleagues published in JAMA Internal Medicine to build a backstory around the issues. Based on the transcript of the testimony, Dr. Sheehy told the House Ways and Means Subcommittee on Health: “Because of our clinical work and extensive experience in the hospital setting, hospitalists have a firsthand view of what observation care looks like to patients, physicians, and hospitals.”

She argues in her testimony that observation status harms the patient-physician relationship and does not make clinical sense.

For instance, the time of day a patient gets sick can impact their designation under the two-midnight rule. In one 2013 JAMA Internal Medicine publication [http://archinte.jamanetwork.com/article.aspx?articleid=1731964], Dr. Sheehy and colleagues found nearly half of UW Hospital patients would have been assigned observation status rather than inpatient under the two-midnight rule by virtue of the time they arrived at the hospital.

Additionally, Dr. Sheehy addressed the issue of the private contractors, or RACs, which were established under the Tax Relief and Health Care Act of 2006 to audit patient records for appropriate hospital status. Dr. Sheehy, in her testimony, said the RACs are aggressive and nontransparent in their audits. Additionally, the RACs are paid a percentage of the money they recover on Medicare’s behalf but are not held financially accountable for decisions that are subsequently appealed and overturned.

Nationally, roughly 40% of RAC audits are appealed, and 70% of these are overturned. Dr. Sheehy told the Congressional committee that at UW Hospital from Oct. 1, 2012 through Sept. 30, 2013, RAC audits determined that 21% of 299 patient charts had received improper payments. The hospital appealed 58 of the 63 audit decisions and had won each of them as of mid-May 2014.

Dr. Sheehy believes changes to the auditing programs enforcing observation rule compliance are necessary for the success of any observation reform, whether it comes through legislation or regulation. In her testimony closing, Dr. Sheehy told the House committee the two-midnight rule is not the answer to the need for observation status change. Medicare policy, she said, “should be aligned with clinical realities and should also be rooted in allowing physicians to provide the care patients need.”

In addition to addressing the arbitrary time cutoff, Dr. Sheehy made the case that the two-midnight rule puts short-stay, acutely ill patients at a disadvantage, may add cost and waste to the healthcare system, and is challenging for providers, who must estimate patient time of stay upon patient hospitalization.

But, Dr. Sheehy believes meaningful change is possible and hopes her testimony is helpful in the endeavor.

“Our understanding is that [Ways and Means committee members] were going to draft legislation out of the hearing, and we hope we have comprehensively addressed [patient] observation and the auditing programs that enforce it,” she says. “Hopefully, we provided the backstory and evidence for a comprehensive bill everyone can get behind.”

For SHM, Dr. Sheehy’s testimony demonstrates that hospitalists are taking leadership when it comes to critical issues that impact patients, physicians, and hospitals.

“The hearings shows the strength of hospital medicine as a specialty and a movement in healthcare: Hospitalists and SHM are not standing on the sidelines when it comes to flawed Medicare policies such as the two-midnight rule and observation care in general,” says SHM President Burke Kealey, MD, SFHM, medical director of hospital specialties at HealthPartners Medical Group in St. Paul, Minn. “These policy discussions are critical to the care our patients receive. Congress is clearly interested in listening to the hospitalist perspective. Dr. Sheehy represented the nation’s 44,000 hospitalists with the expertise, confidence, and compassion that are hallmarks of the specialty.”

Kelly April Tyrrell is a freelance writer in Wisconsin.

In recent months, numerous articles have come out targeting high-billing physicians—looking for smoking guns in recently released 2012 Medicare fee-for-service physician claims data. These data include both the amount each individual physician billed and the amount Medicare paid on average for services performed by all physicians treating Medicare beneficiaries.

Many physician groups, including the AMA, criticized the data release as having significant limitations, including clinical and billing practice realities that confound the layperson’s understanding of the data’s implications. Still, there is much physicians can learn by exploring this information, particularly those in a still-growing field like hospital medicine (HM).

There is no clear method to identify hospitalists within these data. Hospitalists are dispersed throughout their respective board certifications—internal medicine, family practice, pediatrics. The designations come directly from the Medicare specialty billing code; the code associated with the largest number of services becomes that provider’s de facto specialty. For the majority of providers, this will correspond with their board certification and their professional identity. A hospitalist’s unique practice is lost within these general identifiers.

However, the contours of that unique practice may provide some tools to identify hospitalists, albeit roughly, within the data and in the absence of a specialty billing code. Things like practice location and commonly billed Healthcare Common Procedure Coding System (HCPCS) codes can help sketch the boundaries of the field. Certainly, any classification methodology will have its share of imperfections and may exclude individuals who would otherwise identify as hospitalists. Regardless, such an exercise could identify trends in hospital medicine while providing a better understanding of the field as a whole.

HM does not have the traditional hallmark signifiers—board certification and Medicare specialty billing code—used by many specialties and subspecialties to frame their fields and to classify and compare physicians. The Medicare specialty billing code is a unique code applied to Medicare billing claims that tells Medicare exactly how the provider would like to be identified.

Because of its relative specificity and ready accessibility, the Centers for Medicare and Medicaid Services (CMS) uses the specialty billing code to create specialty comparison groups in pay-for-performance programs. Under the value-based payment modifier, hospitalists are compared against outpatient internal medicine or family medicine physicians, which makes them seem all the more expensive and less efficient.

SHM has been attuned to this particular issue since the early days of the physician value-based payment modifier. For nearly two years, SHM has repeatedly admonished CMS to compare hospitalists against other hospitalists in order for a pay-for-performance scheme to fairly and reasonably evaluate quality and efficiency. CMS acknowledged that many specialties and subspecialties may be masked within the current listing of Medicare specialty billing codes but yielded only so far as to say that aggrieved specialties can apply for their own code. SHM, for its part, applied for a specialty billing code for hospitalists in May 2014.

SHM has been actively exploring the data and looking at ways to identify hospitalists within this Medicare data. There’s an inherent value to this sort of self-reflection—it explains who we are and where we have been.

More importantly, it helps inform where we are going.

Joshua Lapps is SHM’s government relations manager.

In recent months, numerous articles have come out targeting high-billing physicians—looking for smoking guns in recently released 2012 Medicare fee-for-service physician claims data. These data include both the amount each individual physician billed and the amount Medicare paid on average for services performed by all physicians treating Medicare beneficiaries.

Many physician groups, including the AMA, criticized the data release as having significant limitations, including clinical and billing practice realities that confound the layperson’s understanding of the data’s implications. Still, there is much physicians can learn by exploring this information, particularly those in a still-growing field like hospital medicine (HM).

There is no clear method to identify hospitalists within these data. Hospitalists are dispersed throughout their respective board certifications—internal medicine, family practice, pediatrics. The designations come directly from the Medicare specialty billing code; the code associated with the largest number of services becomes that provider’s de facto specialty. For the majority of providers, this will correspond with their board certification and their professional identity. A hospitalist’s unique practice is lost within these general identifiers.

However, the contours of that unique practice may provide some tools to identify hospitalists, albeit roughly, within the data and in the absence of a specialty billing code. Things like practice location and commonly billed Healthcare Common Procedure Coding System (HCPCS) codes can help sketch the boundaries of the field. Certainly, any classification methodology will have its share of imperfections and may exclude individuals who would otherwise identify as hospitalists. Regardless, such an exercise could identify trends in hospital medicine while providing a better understanding of the field as a whole.

HM does not have the traditional hallmark signifiers—board certification and Medicare specialty billing code—used by many specialties and subspecialties to frame their fields and to classify and compare physicians. The Medicare specialty billing code is a unique code applied to Medicare billing claims that tells Medicare exactly how the provider would like to be identified.

Because of its relative specificity and ready accessibility, the Centers for Medicare and Medicaid Services (CMS) uses the specialty billing code to create specialty comparison groups in pay-for-performance programs. Under the value-based payment modifier, hospitalists are compared against outpatient internal medicine or family medicine physicians, which makes them seem all the more expensive and less efficient.

SHM has been attuned to this particular issue since the early days of the physician value-based payment modifier. For nearly two years, SHM has repeatedly admonished CMS to compare hospitalists against other hospitalists in order for a pay-for-performance scheme to fairly and reasonably evaluate quality and efficiency. CMS acknowledged that many specialties and subspecialties may be masked within the current listing of Medicare specialty billing codes but yielded only so far as to say that aggrieved specialties can apply for their own code. SHM, for its part, applied for a specialty billing code for hospitalists in May 2014.

SHM has been actively exploring the data and looking at ways to identify hospitalists within this Medicare data. There’s an inherent value to this sort of self-reflection—it explains who we are and where we have been.

More importantly, it helps inform where we are going.

Joshua Lapps is SHM’s government relations manager.

In recent months, numerous articles have come out targeting high-billing physicians—looking for smoking guns in recently released 2012 Medicare fee-for-service physician claims data. These data include both the amount each individual physician billed and the amount Medicare paid on average for services performed by all physicians treating Medicare beneficiaries.

Many physician groups, including the AMA, criticized the data release as having significant limitations, including clinical and billing practice realities that confound the layperson’s understanding of the data’s implications. Still, there is much physicians can learn by exploring this information, particularly those in a still-growing field like hospital medicine (HM).

There is no clear method to identify hospitalists within these data. Hospitalists are dispersed throughout their respective board certifications—internal medicine, family practice, pediatrics. The designations come directly from the Medicare specialty billing code; the code associated with the largest number of services becomes that provider’s de facto specialty. For the majority of providers, this will correspond with their board certification and their professional identity. A hospitalist’s unique practice is lost within these general identifiers.

However, the contours of that unique practice may provide some tools to identify hospitalists, albeit roughly, within the data and in the absence of a specialty billing code. Things like practice location and commonly billed Healthcare Common Procedure Coding System (HCPCS) codes can help sketch the boundaries of the field. Certainly, any classification methodology will have its share of imperfections and may exclude individuals who would otherwise identify as hospitalists. Regardless, such an exercise could identify trends in hospital medicine while providing a better understanding of the field as a whole.

HM does not have the traditional hallmark signifiers—board certification and Medicare specialty billing code—used by many specialties and subspecialties to frame their fields and to classify and compare physicians. The Medicare specialty billing code is a unique code applied to Medicare billing claims that tells Medicare exactly how the provider would like to be identified.

Because of its relative specificity and ready accessibility, the Centers for Medicare and Medicaid Services (CMS) uses the specialty billing code to create specialty comparison groups in pay-for-performance programs. Under the value-based payment modifier, hospitalists are compared against outpatient internal medicine or family medicine physicians, which makes them seem all the more expensive and less efficient.

SHM has been attuned to this particular issue since the early days of the physician value-based payment modifier. For nearly two years, SHM has repeatedly admonished CMS to compare hospitalists against other hospitalists in order for a pay-for-performance scheme to fairly and reasonably evaluate quality and efficiency. CMS acknowledged that many specialties and subspecialties may be masked within the current listing of Medicare specialty billing codes but yielded only so far as to say that aggrieved specialties can apply for their own code. SHM, for its part, applied for a specialty billing code for hospitalists in May 2014.

SHM has been actively exploring the data and looking at ways to identify hospitalists within this Medicare data. There’s an inherent value to this sort of self-reflection—it explains who we are and where we have been.

More importantly, it helps inform where we are going.

Joshua Lapps is SHM’s government relations manager.

Dr. Scheurer

The U.S. Department of Health and Human Services (HHS) is putting forth stricter interventions and penalties aimed at curbing acts of careless billing by physicians it refers to as “recalcitrant providers.” Webster’s defines recalcitrant as “obstinately defiant of authority or restraint…difficult to manage or operate.” According to Medicare, these “recalcitrants” are providers who routinely and repeatedly overcharge for services billed through Medicare, despite proper training on how to bill appropriately for these services.¹

Medicare has long battled the issue of finding and curbing overcharging and overpayment. CMS estimates that such defiance accounts for up to $6 billion a year in unnecessary Medicare costs, which makes up about 10% of all physician fee payments, given the fact that total Medicare Part B payments are about $65 billion a year.²

Medicare has systems in place to prevent, detect, and/or mitigate improper payments, whether they result from mistakes or from intentional fraud. In 2011, CMS’ Center for Program Integrity implemented sophisticated technology, called the Fraud Prevention System (FPS), which uses predictive analytics to detect provider irregularities warranting further inspection. According to their 2012 report, the FPS generated 536 new investigations, assisted in providing additional information for 511 active investigations, and initiated thousands of verification interviews of beneficiaries and providers to validate the legitimate receipt of services and items. The center estimates that in the first year of this program, FPS prevented about $115 million in payments.³

So what is Medicare’s response to providers who are identified as outliers? For overpayments from mistakes, CMS generally aims to recover the overpayments and educate the providers. Tactics range from educational letters and phone calls to on-site reviews and “prepayment medical reviews.” For fraud, on the other hand, Medicare (obviously) pursues more disciplinary sanctions, including criminal or civil penalties.

A New Paradigm

Now CMS is stepping up its expectations of provider accountability, adding heftier penalties for infractions, including higher financial penalties and even expulsion from Medicare, Medicaid, and other federal programs. In addition to these disciplinary actions, the agency plans to utilize recently changed laws to maximize public transparency around provider billing practices.

As of March 2014, Medicare will be able to publicly report all federal payments that have been paid out to individual providers. Although it has not yet disclosed how or when these will be reported, CMS now has the authority, for the first time since 1979, to display this information publicly. The history on this topic is that a federal district judge in Florida in 1979 prohibited the disclosure of individual payments to physicians, based on the contention that such disclosure would be an invasion of physician privacy. This longstanding mandate, which was reversed in May 2012, now allows Medicare to weigh the risks and benefits of individual requests for information on charges/payments by individual physicians. According to a New York Times article, Medicare is now being pressured by advocacy groups (insurers, employers, consumers) to release as much of the data as possible, to aid in data dissection and analysis and prompt early identification of abusive providers.⁴

Understandably, many physician advocacy groups, such as the American Medical Association, are concerned that such unfiltered access to this raw data may lead to inaccurate and unnecessary conclusions about physician practice and billing patterns.

The good news is that the federal government currently estimates that the recalcitrant provider list comprises a relatively small group of providers, roughly 300 or so. Some of these providers have received up to $3 million in Medicare payments a year. They estimate that, overall, about 2% of total Medicare licensed providers charged 25% of total payments, and that the total volume of these high-charging outliers increased by 78% between the years 2008 to 2011. A 2009 audit found that more than half of these recalcitrants were internists; other “high offenders” were ophthalmology and radiation oncology.

The list of these particular high-outlier offenders will be turned over to the Office of the Inspector General (OIG) at HHS to impose the appropriate degree of penalty. Then the federal government will determine an appropriate process of “screening” for providers that may meet the criteria for penalties and will start with those at the highest levels of cumulative payments. The OIG acknowledges that high payments do not necessarily imply fraud or abuse but believes it is reasonable to start there when analyzing and investigating potential areas of fraud or abuse.

Transparency Is Coming

So, while it is not exactly clear when or how the data will be released, what is clear is that the federal government has been granted the authority to dissect and release the data as it sees fit, opening up a new era of transparency in pricing, cost, charges, billing, and payments.

This change should affect all types of providers that bill Medicare part B, including hospitalists and other physicians, as well as nurse practitioners and physical therapists.⁵ While this is likely to cause some degree of discomfort and generate many questions from the public, hospitalists should be willing to embrace such transparency and engage in the dialogue needed to help the lay public understand the data. Most hospitalists work in practices that routinely share their data about billing, at least among the group, if not with a larger audience.

This is just one of many examples of how transparency can and should identify those providers considered “recalcitrant” in a number of realms, including patient satisfaction, quality, utilization, or cost. And, similar to other publicly reported “metrics,” release of this data will likely generate more questions than answers in the short run. In the long run, we should all be prepared for the release of data that is coming, one that will usher us into a whole new era of transparency.

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

References

1. Department of Health and Human Services. Centers for Medicare and Medicaid Services. CMS Manual System. Pub 100-08 Medicare program integrity. December 13, 2013. Available at: https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/Downloads/R495PI.pdf. Accessed April 6, 2014.
2. Levinson DR. Department of Health and Human Services. Office of Inspector General. Reviews of clinicians associated with high cumulative payments could improve Medicare program integrity efforts. December 2013. Available at: http://oig.hhs.gov/oas/reports/region1/11100511.pdf. Accessed April 6, 2014.
3. Department of Health and Human Services. Centers for Medicare and Medicaid Services. Report to Congress: fraud prevention system—first implementation year, 2012. Available at: http://www.stopmedicarefraud.gov/fraud-rtc12142012.pdf. Accessed April 6, 2014.
4. Pear R. Doctors abusing Medicare face fines and expulsion. January 25, 2014. The New York Times website. Available at: http://www.nytimes.com/2014/01/26/us/doctors-abusing-medicare-to-face-fines.html. Accessed April 6, 2014.
5. Steinbrook R. Public disclosure of Medicare payments to individual physicians. The Journal of the American Medical Association website. April 2, 2014. Available at: http://jama.jamanetwork.com/article.aspx?articleID=1832217&utm_source=Silverchair%20Information%20Systems&utm_medium=email&utm_campaign=JAMA%3AOnlineFirst02%2F17%2F2014. Accessed April 6,

2014.

Dr. Scheurer

The U.S. Department of Health and Human Services (HHS) is putting forth stricter interventions and penalties aimed at curbing acts of careless billing by physicians it refers to as “recalcitrant providers.” Webster’s defines recalcitrant as “obstinately defiant of authority or restraint…difficult to manage or operate.” According to Medicare, these “recalcitrants” are providers who routinely and repeatedly overcharge for services billed through Medicare, despite proper training on how to bill appropriately for these services.¹

Medicare has long battled the issue of finding and curbing overcharging and overpayment. CMS estimates that such defiance accounts for up to $6 billion a year in unnecessary Medicare costs, which makes up about 10% of all physician fee payments, given the fact that total Medicare Part B payments are about $65 billion a year.²

Medicare has systems in place to prevent, detect, and/or mitigate improper payments, whether they result from mistakes or from intentional fraud. In 2011, CMS’ Center for Program Integrity implemented sophisticated technology, called the Fraud Prevention System (FPS), which uses predictive analytics to detect provider irregularities warranting further inspection. According to their 2012 report, the FPS generated 536 new investigations, assisted in providing additional information for 511 active investigations, and initiated thousands of verification interviews of beneficiaries and providers to validate the legitimate receipt of services and items. The center estimates that in the first year of this program, FPS prevented about $115 million in payments.³

So what is Medicare’s response to providers who are identified as outliers? For overpayments from mistakes, CMS generally aims to recover the overpayments and educate the providers. Tactics range from educational letters and phone calls to on-site reviews and “prepayment medical reviews.” For fraud, on the other hand, Medicare (obviously) pursues more disciplinary sanctions, including criminal or civil penalties.

A New Paradigm

Now CMS is stepping up its expectations of provider accountability, adding heftier penalties for infractions, including higher financial penalties and even expulsion from Medicare, Medicaid, and other federal programs. In addition to these disciplinary actions, the agency plans to utilize recently changed laws to maximize public transparency around provider billing practices.

As of March 2014, Medicare will be able to publicly report all federal payments that have been paid out to individual providers. Although it has not yet disclosed how or when these will be reported, CMS now has the authority, for the first time since 1979, to display this information publicly. The history on this topic is that a federal district judge in Florida in 1979 prohibited the disclosure of individual payments to physicians, based on the contention that such disclosure would be an invasion of physician privacy. This longstanding mandate, which was reversed in May 2012, now allows Medicare to weigh the risks and benefits of individual requests for information on charges/payments by individual physicians. According to a New York Times article, Medicare is now being pressured by advocacy groups (insurers, employers, consumers) to release as much of the data as possible, to aid in data dissection and analysis and prompt early identification of abusive providers.⁴

Understandably, many physician advocacy groups, such as the American Medical Association, are concerned that such unfiltered access to this raw data may lead to inaccurate and unnecessary conclusions about physician practice and billing patterns.

The good news is that the federal government currently estimates that the recalcitrant provider list comprises a relatively small group of providers, roughly 300 or so. Some of these providers have received up to $3 million in Medicare payments a year. They estimate that, overall, about 2% of total Medicare licensed providers charged 25% of total payments, and that the total volume of these high-charging outliers increased by 78% between the years 2008 to 2011. A 2009 audit found that more than half of these recalcitrants were internists; other “high offenders” were ophthalmology and radiation oncology.

The list of these particular high-outlier offenders will be turned over to the Office of the Inspector General (OIG) at HHS to impose the appropriate degree of penalty. Then the federal government will determine an appropriate process of “screening” for providers that may meet the criteria for penalties and will start with those at the highest levels of cumulative payments. The OIG acknowledges that high payments do not necessarily imply fraud or abuse but believes it is reasonable to start there when analyzing and investigating potential areas of fraud or abuse.

Transparency Is Coming

So, while it is not exactly clear when or how the data will be released, what is clear is that the federal government has been granted the authority to dissect and release the data as it sees fit, opening up a new era of transparency in pricing, cost, charges, billing, and payments.

This change should affect all types of providers that bill Medicare part B, including hospitalists and other physicians, as well as nurse practitioners and physical therapists.⁵ While this is likely to cause some degree of discomfort and generate many questions from the public, hospitalists should be willing to embrace such transparency and engage in the dialogue needed to help the lay public understand the data. Most hospitalists work in practices that routinely share their data about billing, at least among the group, if not with a larger audience.

This is just one of many examples of how transparency can and should identify those providers considered “recalcitrant” in a number of realms, including patient satisfaction, quality, utilization, or cost. And, similar to other publicly reported “metrics,” release of this data will likely generate more questions than answers in the short run. In the long run, we should all be prepared for the release of data that is coming, one that will usher us into a whole new era of transparency.

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

References

1. Department of Health and Human Services. Centers for Medicare and Medicaid Services. CMS Manual System. Pub 100-08 Medicare program integrity. December 13, 2013. Available at: https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/Downloads/R495PI.pdf. Accessed April 6, 2014.
2. Levinson DR. Department of Health and Human Services. Office of Inspector General. Reviews of clinicians associated with high cumulative payments could improve Medicare program integrity efforts. December 2013. Available at: http://oig.hhs.gov/oas/reports/region1/11100511.pdf. Accessed April 6, 2014.
3. Department of Health and Human Services. Centers for Medicare and Medicaid Services. Report to Congress: fraud prevention system—first implementation year, 2012. Available at: http://www.stopmedicarefraud.gov/fraud-rtc12142012.pdf. Accessed April 6, 2014.
4. Pear R. Doctors abusing Medicare face fines and expulsion. January 25, 2014. The New York Times website. Available at: http://www.nytimes.com/2014/01/26/us/doctors-abusing-medicare-to-face-fines.html. Accessed April 6, 2014.
5. Steinbrook R. Public disclosure of Medicare payments to individual physicians. The Journal of the American Medical Association website. April 2, 2014. Available at: http://jama.jamanetwork.com/article.aspx?articleID=1832217&utm_source=Silverchair%20Information%20Systems&utm_medium=email&utm_campaign=JAMA%3AOnlineFirst02%2F17%2F2014. Accessed April 6,

2014.

Dr. Scheurer

The U.S. Department of Health and Human Services (HHS) is putting forth stricter interventions and penalties aimed at curbing acts of careless billing by physicians it refers to as “recalcitrant providers.” Webster’s defines recalcitrant as “obstinately defiant of authority or restraint…difficult to manage or operate.” According to Medicare, these “recalcitrants” are providers who routinely and repeatedly overcharge for services billed through Medicare, despite proper training on how to bill appropriately for these services.¹

Medicare has long battled the issue of finding and curbing overcharging and overpayment. CMS estimates that such defiance accounts for up to $6 billion a year in unnecessary Medicare costs, which makes up about 10% of all physician fee payments, given the fact that total Medicare Part B payments are about $65 billion a year.²

Medicare has systems in place to prevent, detect, and/or mitigate improper payments, whether they result from mistakes or from intentional fraud. In 2011, CMS’ Center for Program Integrity implemented sophisticated technology, called the Fraud Prevention System (FPS), which uses predictive analytics to detect provider irregularities warranting further inspection. According to their 2012 report, the FPS generated 536 new investigations, assisted in providing additional information for 511 active investigations, and initiated thousands of verification interviews of beneficiaries and providers to validate the legitimate receipt of services and items. The center estimates that in the first year of this program, FPS prevented about $115 million in payments.³

So what is Medicare’s response to providers who are identified as outliers? For overpayments from mistakes, CMS generally aims to recover the overpayments and educate the providers. Tactics range from educational letters and phone calls to on-site reviews and “prepayment medical reviews.” For fraud, on the other hand, Medicare (obviously) pursues more disciplinary sanctions, including criminal or civil penalties.

A New Paradigm

Now CMS is stepping up its expectations of provider accountability, adding heftier penalties for infractions, including higher financial penalties and even expulsion from Medicare, Medicaid, and other federal programs. In addition to these disciplinary actions, the agency plans to utilize recently changed laws to maximize public transparency around provider billing practices.

As of March 2014, Medicare will be able to publicly report all federal payments that have been paid out to individual providers. Although it has not yet disclosed how or when these will be reported, CMS now has the authority, for the first time since 1979, to display this information publicly. The history on this topic is that a federal district judge in Florida in 1979 prohibited the disclosure of individual payments to physicians, based on the contention that such disclosure would be an invasion of physician privacy. This longstanding mandate, which was reversed in May 2012, now allows Medicare to weigh the risks and benefits of individual requests for information on charges/payments by individual physicians. According to a New York Times article, Medicare is now being pressured by advocacy groups (insurers, employers, consumers) to release as much of the data as possible, to aid in data dissection and analysis and prompt early identification of abusive providers.⁴

Understandably, many physician advocacy groups, such as the American Medical Association, are concerned that such unfiltered access to this raw data may lead to inaccurate and unnecessary conclusions about physician practice and billing patterns.

The good news is that the federal government currently estimates that the recalcitrant provider list comprises a relatively small group of providers, roughly 300 or so. Some of these providers have received up to $3 million in Medicare payments a year. They estimate that, overall, about 2% of total Medicare licensed providers charged 25% of total payments, and that the total volume of these high-charging outliers increased by 78% between the years 2008 to 2011. A 2009 audit found that more than half of these recalcitrants were internists; other “high offenders” were ophthalmology and radiation oncology.

The list of these particular high-outlier offenders will be turned over to the Office of the Inspector General (OIG) at HHS to impose the appropriate degree of penalty. Then the federal government will determine an appropriate process of “screening” for providers that may meet the criteria for penalties and will start with those at the highest levels of cumulative payments. The OIG acknowledges that high payments do not necessarily imply fraud or abuse but believes it is reasonable to start there when analyzing and investigating potential areas of fraud or abuse.

Transparency Is Coming

So, while it is not exactly clear when or how the data will be released, what is clear is that the federal government has been granted the authority to dissect and release the data as it sees fit, opening up a new era of transparency in pricing, cost, charges, billing, and payments.

This change should affect all types of providers that bill Medicare part B, including hospitalists and other physicians, as well as nurse practitioners and physical therapists.⁵ While this is likely to cause some degree of discomfort and generate many questions from the public, hospitalists should be willing to embrace such transparency and engage in the dialogue needed to help the lay public understand the data. Most hospitalists work in practices that routinely share their data about billing, at least among the group, if not with a larger audience.

This is just one of many examples of how transparency can and should identify those providers considered “recalcitrant” in a number of realms, including patient satisfaction, quality, utilization, or cost. And, similar to other publicly reported “metrics,” release of this data will likely generate more questions than answers in the short run. In the long run, we should all be prepared for the release of data that is coming, one that will usher us into a whole new era of transparency.

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

References

1. Department of Health and Human Services. Centers for Medicare and Medicaid Services. CMS Manual System. Pub 100-08 Medicare program integrity. December 13, 2013. Available at: https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/Downloads/R495PI.pdf. Accessed April 6, 2014.
2. Levinson DR. Department of Health and Human Services. Office of Inspector General. Reviews of clinicians associated with high cumulative payments could improve Medicare program integrity efforts. December 2013. Available at: http://oig.hhs.gov/oas/reports/region1/11100511.pdf. Accessed April 6, 2014.
3. Department of Health and Human Services. Centers for Medicare and Medicaid Services. Report to Congress: fraud prevention system—first implementation year, 2012. Available at: http://www.stopmedicarefraud.gov/fraud-rtc12142012.pdf. Accessed April 6, 2014.
4. Pear R. Doctors abusing Medicare face fines and expulsion. January 25, 2014. The New York Times website. Available at: http://www.nytimes.com/2014/01/26/us/doctors-abusing-medicare-to-face-fines.html. Accessed April 6, 2014.
5. Steinbrook R. Public disclosure of Medicare payments to individual physicians. The Journal of the American Medical Association website. April 2, 2014. Available at: http://jama.jamanetwork.com/article.aspx?articleID=1832217&utm_source=Silverchair%20Information%20Systems&utm_medium=email&utm_campaign=JAMA%3AOnlineFirst02%2F17%2F2014. Accessed April 6,

2014.

Several years ago we sent a CPT coding auditor 15 chart notes generated by each doctor in our group. Among each doctors’ 15 notes were at least one or two billed as initial hospital care, follow up, discharge, critical care, and so on. This coding expert returned a report showing that, out of all the notes reviewed, a significant portion were not billed at the correct level. Most of the incorrectly billed notes were judged to reflect “up-coding,” and a few were seen as “down-coded.”

This was distressing and hard to believe.

So I took the same set of notes and paid a second coding expert for an independent review. She didn’t know about the first audit but returned a report that showed a nearly identical portion of incorrectly coded notes.

Two independent audits showing nearly the same portion of notes coded incorrectly was alarming. But it was difficult for my partners and me to address, because the auditors didn’t agree on the correct code for many of the notes. In some cases, both flagged a note as incorrectly coded but didn’t agree on the correct code. For a number of the notes, one auditor said the visit was “up-coded,” while the other said it was “down-coded.” There was so little agreement between the two of them that we had a hard time coming up with any firm conclusions about what we should do to improve our performance.

If experts who think about coding all the time can’t agree on the right code for a given note, how can hospitalists be expected to code nearly all of our visits accurately?

RAC: Recovery Audit Contractor

Despite what I believe is poor inter-rater reliability among coding auditors, we need to work diligently to comply with coding guidelines. A 2003 Federal law mandated a program of Recovery Audit Contractors, or RAC for short, to find cases of “up-coding” or other overbilling and require the provider to repay any resulting loss.

A number of companies are in the business of conducting RAC audits (one of them, CGI, is the Canadian company blamed for the failed “Obamacare” exchange websites), and there is a reasonable chance one of these companies has reviewed some of your charges—or those of your hospitalist colleagues.

The RAC auditors review information about your charges, and if they determine that you up-coded or overbilled, they send a “demand letter” summarizing their findings, along with the amount of money they have determined you should pay back. (Theoretically, they could notify you of “under-coding,” so that you can be paid more for past work, but I haven’t yet come across an example of that.)

It is common to appeal the RAC findings, but that can be a long process, and many organizations decide to pay back all the money requested by the RAC as quickly as possible to avoid paying interest on a delayed payment if the appeal is unsuccessful. In the case of a successful appeal, the money previously refunded by the doctor would be returned.

Page 338 of the CMS Fiscal Year 2015 “Justification of Estimates for Appropriations Committees” says that “…about 50 percent of the estimated 43,000 appeals [of adverse RAC audit findings] were fully or partially overturned…” This could mean the RACs are a sort of loose cannon, accusing many providers of overbilling while knowing that some won’t bother to appeal because they don’t understand the process or because the dollar amount involved for a single provider is too small to justify the time and expense of conducting the appeal. In this way, a RAC audit is like the $15 rebate on the last electronic gadget you bought. The seller knows that many people, including me, will fail to do the work required to claim the rebate.

Accuracy Strategies

There are a number of ways to help your group ensure appropriate CPT coding and reduce the chance a RAC will ask for money back.

Education. There are many ways to help providers in your practice understand the elements of documentation and coding. Periodic training classes (e.g. during orientation and annually thereafter) are useful but may not be enough. For me, this is a little like learning a foreign language by going to a couple of classes. Instead, I think “immersion training” is more effective. That might mean a doctor spends a few minutes with a certified coder on most working days for a few weeks. For example, they could meet for 15 minutes near lunchtime and review how the doctor plans to bill visits made that morning. Lastly, consider targeted education for each doctor, based on any problems found in an audit of his/her coding.

Review coding patterns. As I wrote in my August 2007 column, there is value in ensuring that each doctor in the group can see how her coding pattern differs from the group as a whole or any individual in the group. That is, what portion of follow-up visits was billed at the lowest, middle, and highest levels? What about admissions, discharges, and so on? I provided a sample report in that same column.

It also is worth taking the time to compare each doctor’s coding pattern to both the CMS Internal Medicine data and SHM’s State of Hospital Medicine report. The accompanying figure shows the most current data sets available.

Keep in mind that the goal is not to simply ensure that your coding pattern matches these external data sets; knowing where yours differs from these sets can suggest where you might want to investigate further or seek additional education.

Coding audits. Having a certified coder audit your performance at least annually is a good idea. It can help uncover areas in which you’d benefit from further review and training, and if, heaven forbid, questions are ever raised about whether you’re intentionally up-coding (fraud), showing that you’re audited regularly could help demonstrate your efforts to code correctly. In the latter case, it is probably more valuable if the audit is done independently of your employer.

Dr. Nelson has been a practicing hospitalist since 1988. He is co-founder and past president of SHM, and principal in Nelson Flores Hospital Medicine Consultants. He is co-director for SHM’s “Best Practices in Managing a Hospital Medicine Program” course. Write to him at [email protected].

Several years ago we sent a CPT coding auditor 15 chart notes generated by each doctor in our group. Among each doctors’ 15 notes were at least one or two billed as initial hospital care, follow up, discharge, critical care, and so on. This coding expert returned a report showing that, out of all the notes reviewed, a significant portion were not billed at the correct level. Most of the incorrectly billed notes were judged to reflect “up-coding,” and a few were seen as “down-coded.”

This was distressing and hard to believe.

So I took the same set of notes and paid a second coding expert for an independent review. She didn’t know about the first audit but returned a report that showed a nearly identical portion of incorrectly coded notes.

Two independent audits showing nearly the same portion of notes coded incorrectly was alarming. But it was difficult for my partners and me to address, because the auditors didn’t agree on the correct code for many of the notes. In some cases, both flagged a note as incorrectly coded but didn’t agree on the correct code. For a number of the notes, one auditor said the visit was “up-coded,” while the other said it was “down-coded.” There was so little agreement between the two of them that we had a hard time coming up with any firm conclusions about what we should do to improve our performance.

If experts who think about coding all the time can’t agree on the right code for a given note, how can hospitalists be expected to code nearly all of our visits accurately?

RAC: Recovery Audit Contractor

Despite what I believe is poor inter-rater reliability among coding auditors, we need to work diligently to comply with coding guidelines. A 2003 Federal law mandated a program of Recovery Audit Contractors, or RAC for short, to find cases of “up-coding” or other overbilling and require the provider to repay any resulting loss.

A number of companies are in the business of conducting RAC audits (one of them, CGI, is the Canadian company blamed for the failed “Obamacare” exchange websites), and there is a reasonable chance one of these companies has reviewed some of your charges—or those of your hospitalist colleagues.

The RAC auditors review information about your charges, and if they determine that you up-coded or overbilled, they send a “demand letter” summarizing their findings, along with the amount of money they have determined you should pay back. (Theoretically, they could notify you of “under-coding,” so that you can be paid more for past work, but I haven’t yet come across an example of that.)

It is common to appeal the RAC findings, but that can be a long process, and many organizations decide to pay back all the money requested by the RAC as quickly as possible to avoid paying interest on a delayed payment if the appeal is unsuccessful. In the case of a successful appeal, the money previously refunded by the doctor would be returned.

Page 338 of the CMS Fiscal Year 2015 “Justification of Estimates for Appropriations Committees” says that “…about 50 percent of the estimated 43,000 appeals [of adverse RAC audit findings] were fully or partially overturned…” This could mean the RACs are a sort of loose cannon, accusing many providers of overbilling while knowing that some won’t bother to appeal because they don’t understand the process or because the dollar amount involved for a single provider is too small to justify the time and expense of conducting the appeal. In this way, a RAC audit is like the $15 rebate on the last electronic gadget you bought. The seller knows that many people, including me, will fail to do the work required to claim the rebate.

Accuracy Strategies

There are a number of ways to help your group ensure appropriate CPT coding and reduce the chance a RAC will ask for money back.

Education. There are many ways to help providers in your practice understand the elements of documentation and coding. Periodic training classes (e.g. during orientation and annually thereafter) are useful but may not be enough. For me, this is a little like learning a foreign language by going to a couple of classes. Instead, I think “immersion training” is more effective. That might mean a doctor spends a few minutes with a certified coder on most working days for a few weeks. For example, they could meet for 15 minutes near lunchtime and review how the doctor plans to bill visits made that morning. Lastly, consider targeted education for each doctor, based on any problems found in an audit of his/her coding.

Review coding patterns. As I wrote in my August 2007 column, there is value in ensuring that each doctor in the group can see how her coding pattern differs from the group as a whole or any individual in the group. That is, what portion of follow-up visits was billed at the lowest, middle, and highest levels? What about admissions, discharges, and so on? I provided a sample report in that same column.

It also is worth taking the time to compare each doctor’s coding pattern to both the CMS Internal Medicine data and SHM’s State of Hospital Medicine report. The accompanying figure shows the most current data sets available.

Keep in mind that the goal is not to simply ensure that your coding pattern matches these external data sets; knowing where yours differs from these sets can suggest where you might want to investigate further or seek additional education.

Coding audits. Having a certified coder audit your performance at least annually is a good idea. It can help uncover areas in which you’d benefit from further review and training, and if, heaven forbid, questions are ever raised about whether you’re intentionally up-coding (fraud), showing that you’re audited regularly could help demonstrate your efforts to code correctly. In the latter case, it is probably more valuable if the audit is done independently of your employer.

Dr. Nelson has been a practicing hospitalist since 1988. He is co-founder and past president of SHM, and principal in Nelson Flores Hospital Medicine Consultants. He is co-director for SHM’s “Best Practices in Managing a Hospital Medicine Program” course. Write to him at [email protected].

Several years ago we sent a CPT coding auditor 15 chart notes generated by each doctor in our group. Among each doctors’ 15 notes were at least one or two billed as initial hospital care, follow up, discharge, critical care, and so on. This coding expert returned a report showing that, out of all the notes reviewed, a significant portion were not billed at the correct level. Most of the incorrectly billed notes were judged to reflect “up-coding,” and a few were seen as “down-coded.”

This was distressing and hard to believe.

So I took the same set of notes and paid a second coding expert for an independent review. She didn’t know about the first audit but returned a report that showed a nearly identical portion of incorrectly coded notes.

Two independent audits showing nearly the same portion of notes coded incorrectly was alarming. But it was difficult for my partners and me to address, because the auditors didn’t agree on the correct code for many of the notes. In some cases, both flagged a note as incorrectly coded but didn’t agree on the correct code. For a number of the notes, one auditor said the visit was “up-coded,” while the other said it was “down-coded.” There was so little agreement between the two of them that we had a hard time coming up with any firm conclusions about what we should do to improve our performance.

If experts who think about coding all the time can’t agree on the right code for a given note, how can hospitalists be expected to code nearly all of our visits accurately?

RAC: Recovery Audit Contractor

Despite what I believe is poor inter-rater reliability among coding auditors, we need to work diligently to comply with coding guidelines. A 2003 Federal law mandated a program of Recovery Audit Contractors, or RAC for short, to find cases of “up-coding” or other overbilling and require the provider to repay any resulting loss.

A number of companies are in the business of conducting RAC audits (one of them, CGI, is the Canadian company blamed for the failed “Obamacare” exchange websites), and there is a reasonable chance one of these companies has reviewed some of your charges—or those of your hospitalist colleagues.

The RAC auditors review information about your charges, and if they determine that you up-coded or overbilled, they send a “demand letter” summarizing their findings, along with the amount of money they have determined you should pay back. (Theoretically, they could notify you of “under-coding,” so that you can be paid more for past work, but I haven’t yet come across an example of that.)

It is common to appeal the RAC findings, but that can be a long process, and many organizations decide to pay back all the money requested by the RAC as quickly as possible to avoid paying interest on a delayed payment if the appeal is unsuccessful. In the case of a successful appeal, the money previously refunded by the doctor would be returned.

Page 338 of the CMS Fiscal Year 2015 “Justification of Estimates for Appropriations Committees” says that “…about 50 percent of the estimated 43,000 appeals [of adverse RAC audit findings] were fully or partially overturned…” This could mean the RACs are a sort of loose cannon, accusing many providers of overbilling while knowing that some won’t bother to appeal because they don’t understand the process or because the dollar amount involved for a single provider is too small to justify the time and expense of conducting the appeal. In this way, a RAC audit is like the $15 rebate on the last electronic gadget you bought. The seller knows that many people, including me, will fail to do the work required to claim the rebate.

Accuracy Strategies

There are a number of ways to help your group ensure appropriate CPT coding and reduce the chance a RAC will ask for money back.

Education. There are many ways to help providers in your practice understand the elements of documentation and coding. Periodic training classes (e.g. during orientation and annually thereafter) are useful but may not be enough. For me, this is a little like learning a foreign language by going to a couple of classes. Instead, I think “immersion training” is more effective. That might mean a doctor spends a few minutes with a certified coder on most working days for a few weeks. For example, they could meet for 15 minutes near lunchtime and review how the doctor plans to bill visits made that morning. Lastly, consider targeted education for each doctor, based on any problems found in an audit of his/her coding.

Review coding patterns. As I wrote in my August 2007 column, there is value in ensuring that each doctor in the group can see how her coding pattern differs from the group as a whole or any individual in the group. That is, what portion of follow-up visits was billed at the lowest, middle, and highest levels? What about admissions, discharges, and so on? I provided a sample report in that same column.

It also is worth taking the time to compare each doctor’s coding pattern to both the CMS Internal Medicine data and SHM’s State of Hospital Medicine report. The accompanying figure shows the most current data sets available.

Keep in mind that the goal is not to simply ensure that your coding pattern matches these external data sets; knowing where yours differs from these sets can suggest where you might want to investigate further or seek additional education.

Coding audits. Having a certified coder audit your performance at least annually is a good idea. It can help uncover areas in which you’d benefit from further review and training, and if, heaven forbid, questions are ever raised about whether you’re intentionally up-coding (fraud), showing that you’re audited regularly could help demonstrate your efforts to code correctly. In the latter case, it is probably more valuable if the audit is done independently of your employer.

Dr. Nelson has been a practicing hospitalist since 1988. He is co-founder and past president of SHM, and principal in Nelson Flores Hospital Medicine Consultants. He is co-director for SHM’s “Best Practices in Managing a Hospital Medicine Program” course. Write to him at [email protected].