Public Policy

The Centers for Medicare & Medicaid Services (CMS) recently issued a Final Rule for the Inpatient Prospective Payment System, which guides payment and programs associated with inpatient hospitalizations. In this year’s rule, CMS adjusted the criteria for inpatient admissions in an attempt to simplify and clarify the decision-making process.

The policy would allow physicians to admit a patient if they reasonably expect and document in the medical record that a beneficiary will need to stay in the hospital for more than two midnights. Admissions based on this time-limited expectation will be presumed to be appropriate for Medicare Part A payment. CMS cited concerns about the growing trend of longer observation stays to support this change.

With observation stays, there are two major financial concerns for patients: whether the hospital stay is paid under Medicare Part A or Part B, and whether Medicare will pay for post-acute care in a skilled-nursing facility (SNF). Medicare Part A reimburses for inpatient admissions, with a one-time deductible for the benefit period. Outpatient services, such as observation care and physician services, are covered under Medicare Part B, which has copays and co-insurance that greatly increase the costs for beneficiaries. In addition, SNF coverage through Medicare Part A is determined by the three-day rule; a patient must be an inpatient for three days to qualify for coverage.

While the long-term impacts of this regulatory change to the admission criteria remain to be seen, SHM is concerned that the rule does not adequately address the broader problems associated with inpatient and observation status. As we note in our comments to CMS on the new rule:¹

Even with these changes, the central tension created by the bifurcation in admission status still remains.…Other policies and programs, such as the attempts to reduce admissions, may inadvertently add pressure to the admission decision.

Indeed, for beneficiaries, the barrier to SNF coverage remains. CMS takes care to note that, while time under emergency care and observation care count toward the two-midnight presumption for inpatient admission, it does not count toward the three-day rule for SNF coverage. This is particularly problematic; as advances in medicine allow for the treatment of higher-acuity and -severity conditions with observation stays or shorter inpatient stays, patients might not be getting the follow-up care they need. This puts them at risk for additional complications and, ultimately, readmissions to the hospital.

In an era of seeking value in the healthcare system, it seems like an opportunity lost to streamline and coordinate care across settings and to ensure that patients are getting the follow-up care they require. It is for this reason that hospitalists continue to push for passage of the Improving Access to Medicare Coverage Act, a bill sponsored by Rep. Joe Courtney (D-Conn.), Rep. Tom Latham (R-Iowa), and Sen. Sherrod Brown (D-Ohio) that would count observation status as time toward the three-day requirement for SNF coverage.

A recent Office of Inspector General (OIG) report for the U.S. Department of Health and Human Services on observation status sums up the problem succinctly.2 The OIG states that “CMS should consider how to ensure that beneficiaries with similar post-hospital care needs have the same access and cost-sharing for SNF services.”²

SHM concurs.

Joshua Lapps is SHM’s government relations specialist.

References

1. Society of Hospital Medicine. SHM submits comments in response to FY2014 inpatient prospective payment system proposed rule. Society of Hospital Medicine website. Available at: http://www.hospitalmedicine.org/AM/Template.cfm?Section=Letters_to_Congress_and_Regulatory_Agencies&Template=/CM/ContentDisplay.cfm&ContentID=34044. Accessed Sept. 9, 2013.
2. Office of Inspector General. Memorandum report: Hospitals’ use of observations stays and short inpatient stays for Medicare beneficiaries, OEI-02-12-00040. U.S. Department of Health and Human Services website. Available at: http://oig.hhs.gov/oei/reports/oei-02-12-00040.pdf. Accessed Sept. 9, 2013.

The Centers for Medicare & Medicaid Services (CMS) recently issued a Final Rule for the Inpatient Prospective Payment System, which guides payment and programs associated with inpatient hospitalizations. In this year’s rule, CMS adjusted the criteria for inpatient admissions in an attempt to simplify and clarify the decision-making process.

The policy would allow physicians to admit a patient if they reasonably expect and document in the medical record that a beneficiary will need to stay in the hospital for more than two midnights. Admissions based on this time-limited expectation will be presumed to be appropriate for Medicare Part A payment. CMS cited concerns about the growing trend of longer observation stays to support this change.

With observation stays, there are two major financial concerns for patients: whether the hospital stay is paid under Medicare Part A or Part B, and whether Medicare will pay for post-acute care in a skilled-nursing facility (SNF). Medicare Part A reimburses for inpatient admissions, with a one-time deductible for the benefit period. Outpatient services, such as observation care and physician services, are covered under Medicare Part B, which has copays and co-insurance that greatly increase the costs for beneficiaries. In addition, SNF coverage through Medicare Part A is determined by the three-day rule; a patient must be an inpatient for three days to qualify for coverage.

While the long-term impacts of this regulatory change to the admission criteria remain to be seen, SHM is concerned that the rule does not adequately address the broader problems associated with inpatient and observation status. As we note in our comments to CMS on the new rule:¹

Even with these changes, the central tension created by the bifurcation in admission status still remains.…Other policies and programs, such as the attempts to reduce admissions, may inadvertently add pressure to the admission decision.

Indeed, for beneficiaries, the barrier to SNF coverage remains. CMS takes care to note that, while time under emergency care and observation care count toward the two-midnight presumption for inpatient admission, it does not count toward the three-day rule for SNF coverage. This is particularly problematic; as advances in medicine allow for the treatment of higher-acuity and -severity conditions with observation stays or shorter inpatient stays, patients might not be getting the follow-up care they need. This puts them at risk for additional complications and, ultimately, readmissions to the hospital.

In an era of seeking value in the healthcare system, it seems like an opportunity lost to streamline and coordinate care across settings and to ensure that patients are getting the follow-up care they require. It is for this reason that hospitalists continue to push for passage of the Improving Access to Medicare Coverage Act, a bill sponsored by Rep. Joe Courtney (D-Conn.), Rep. Tom Latham (R-Iowa), and Sen. Sherrod Brown (D-Ohio) that would count observation status as time toward the three-day requirement for SNF coverage.

A recent Office of Inspector General (OIG) report for the U.S. Department of Health and Human Services on observation status sums up the problem succinctly.2 The OIG states that “CMS should consider how to ensure that beneficiaries with similar post-hospital care needs have the same access and cost-sharing for SNF services.”²

SHM concurs.

Joshua Lapps is SHM’s government relations specialist.

References

1. Society of Hospital Medicine. SHM submits comments in response to FY2014 inpatient prospective payment system proposed rule. Society of Hospital Medicine website. Available at: http://www.hospitalmedicine.org/AM/Template.cfm?Section=Letters_to_Congress_and_Regulatory_Agencies&Template=/CM/ContentDisplay.cfm&ContentID=34044. Accessed Sept. 9, 2013.
2. Office of Inspector General. Memorandum report: Hospitals’ use of observations stays and short inpatient stays for Medicare beneficiaries, OEI-02-12-00040. U.S. Department of Health and Human Services website. Available at: http://oig.hhs.gov/oei/reports/oei-02-12-00040.pdf. Accessed Sept. 9, 2013.

The Centers for Medicare & Medicaid Services (CMS) recently issued a Final Rule for the Inpatient Prospective Payment System, which guides payment and programs associated with inpatient hospitalizations. In this year’s rule, CMS adjusted the criteria for inpatient admissions in an attempt to simplify and clarify the decision-making process.

The policy would allow physicians to admit a patient if they reasonably expect and document in the medical record that a beneficiary will need to stay in the hospital for more than two midnights. Admissions based on this time-limited expectation will be presumed to be appropriate for Medicare Part A payment. CMS cited concerns about the growing trend of longer observation stays to support this change.

With observation stays, there are two major financial concerns for patients: whether the hospital stay is paid under Medicare Part A or Part B, and whether Medicare will pay for post-acute care in a skilled-nursing facility (SNF). Medicare Part A reimburses for inpatient admissions, with a one-time deductible for the benefit period. Outpatient services, such as observation care and physician services, are covered under Medicare Part B, which has copays and co-insurance that greatly increase the costs for beneficiaries. In addition, SNF coverage through Medicare Part A is determined by the three-day rule; a patient must be an inpatient for three days to qualify for coverage.

While the long-term impacts of this regulatory change to the admission criteria remain to be seen, SHM is concerned that the rule does not adequately address the broader problems associated with inpatient and observation status. As we note in our comments to CMS on the new rule:¹

Even with these changes, the central tension created by the bifurcation in admission status still remains.…Other policies and programs, such as the attempts to reduce admissions, may inadvertently add pressure to the admission decision.

Indeed, for beneficiaries, the barrier to SNF coverage remains. CMS takes care to note that, while time under emergency care and observation care count toward the two-midnight presumption for inpatient admission, it does not count toward the three-day rule for SNF coverage. This is particularly problematic; as advances in medicine allow for the treatment of higher-acuity and -severity conditions with observation stays or shorter inpatient stays, patients might not be getting the follow-up care they need. This puts them at risk for additional complications and, ultimately, readmissions to the hospital.

In an era of seeking value in the healthcare system, it seems like an opportunity lost to streamline and coordinate care across settings and to ensure that patients are getting the follow-up care they require. It is for this reason that hospitalists continue to push for passage of the Improving Access to Medicare Coverage Act, a bill sponsored by Rep. Joe Courtney (D-Conn.), Rep. Tom Latham (R-Iowa), and Sen. Sherrod Brown (D-Ohio) that would count observation status as time toward the three-day requirement for SNF coverage.

A recent Office of Inspector General (OIG) report for the U.S. Department of Health and Human Services on observation status sums up the problem succinctly.2 The OIG states that “CMS should consider how to ensure that beneficiaries with similar post-hospital care needs have the same access and cost-sharing for SNF services.”²

SHM concurs.

Joshua Lapps is SHM’s government relations specialist.

References

1. Society of Hospital Medicine. SHM submits comments in response to FY2014 inpatient prospective payment system proposed rule. Society of Hospital Medicine website. Available at: http://www.hospitalmedicine.org/AM/Template.cfm?Section=Letters_to_Congress_and_Regulatory_Agencies&Template=/CM/ContentDisplay.cfm&ContentID=34044. Accessed Sept. 9, 2013.
2. Office of Inspector General. Memorandum report: Hospitals’ use of observations stays and short inpatient stays for Medicare beneficiaries, OEI-02-12-00040. U.S. Department of Health and Human Services website. Available at: http://oig.hhs.gov/oei/reports/oei-02-12-00040.pdf. Accessed Sept. 9, 2013.

First, SHM’s new Learning Portal was the one-stop shop for free and discounted continuing medical education (CME) credits online. Now, the Learning Portal can help hospitalists report into the physician quality reporting system (PQRS) at a discounted individual rate.

And the time to start reporting measures in PQRS is now.

The PQRS was developed by the Centers for Medicare & Medicaid Services (CMS) in 2007 as a voluntary reporting program that provides a financial incentive to physicians and other eligible professionals who report data on quality measures for covered services furnished to Medicare beneficiaries. Starting in 2013, reporting in PQRS becomes mandatory for all eligible professionals.

SHM has encouraged its members to participate in the PQRS since the system’s inception in 2007. With the exciting launch of the SHM Learning Portal, it is easier than ever to get started. If you or your group are not currently reporting, there are still incentive payments available in 2013 and 2014. Beginning in 2015, there will be a penalty for not reporting quality measures based on 2013 performance.

Access the PQRIwizard through the SHM Learning Portal

SHM has secured a significant discount for members to report PQRS through the PQRIwizard. Located within the SHM Learning Portal, this online tool is a fast, convenient, and cost-effective solution to help collect and report quality measures data for the PQRS program. Similar to online tax-preparation software, the PQRIwizard guides you through a few easy steps to help rapidly collect, validate, report, and submit your results to CMS. The tool is powered by the CECity Registry, a CMS-qualified registry for PQRS reporting.

What Measures Are Available?

The SHM PQRIwizard features six individual quality measures in the areas of stroke and stroke rehabilitation, including measures on screening for dysphagia and thrombolytic therapy. To report on any of these measures, simply select three measures and report on 80 percent of your Medicare Part B fee-for-services patients who apply to the measures you selected.

PQRIwizard has a built-in progress monitor that validates your report by checking for missing data. The monitor also tracks your data to provide you with continuous feedback regarding valid patients. The system even calculates your measures and provides a printable report of your measure results in real time.

First, SHM’s new Learning Portal was the one-stop shop for free and discounted continuing medical education (CME) credits online. Now, the Learning Portal can help hospitalists report into the physician quality reporting system (PQRS) at a discounted individual rate.

And the time to start reporting measures in PQRS is now.

The PQRS was developed by the Centers for Medicare & Medicaid Services (CMS) in 2007 as a voluntary reporting program that provides a financial incentive to physicians and other eligible professionals who report data on quality measures for covered services furnished to Medicare beneficiaries. Starting in 2013, reporting in PQRS becomes mandatory for all eligible professionals.

SHM has encouraged its members to participate in the PQRS since the system’s inception in 2007. With the exciting launch of the SHM Learning Portal, it is easier than ever to get started. If you or your group are not currently reporting, there are still incentive payments available in 2013 and 2014. Beginning in 2015, there will be a penalty for not reporting quality measures based on 2013 performance.

Access the PQRIwizard through the SHM Learning Portal

SHM has secured a significant discount for members to report PQRS through the PQRIwizard. Located within the SHM Learning Portal, this online tool is a fast, convenient, and cost-effective solution to help collect and report quality measures data for the PQRS program. Similar to online tax-preparation software, the PQRIwizard guides you through a few easy steps to help rapidly collect, validate, report, and submit your results to CMS. The tool is powered by the CECity Registry, a CMS-qualified registry for PQRS reporting.

What Measures Are Available?

The SHM PQRIwizard features six individual quality measures in the areas of stroke and stroke rehabilitation, including measures on screening for dysphagia and thrombolytic therapy. To report on any of these measures, simply select three measures and report on 80 percent of your Medicare Part B fee-for-services patients who apply to the measures you selected.

PQRIwizard has a built-in progress monitor that validates your report by checking for missing data. The monitor also tracks your data to provide you with continuous feedback regarding valid patients. The system even calculates your measures and provides a printable report of your measure results in real time.

First, SHM’s new Learning Portal was the one-stop shop for free and discounted continuing medical education (CME) credits online. Now, the Learning Portal can help hospitalists report into the physician quality reporting system (PQRS) at a discounted individual rate.

And the time to start reporting measures in PQRS is now.

The PQRS was developed by the Centers for Medicare & Medicaid Services (CMS) in 2007 as a voluntary reporting program that provides a financial incentive to physicians and other eligible professionals who report data on quality measures for covered services furnished to Medicare beneficiaries. Starting in 2013, reporting in PQRS becomes mandatory for all eligible professionals.

SHM has encouraged its members to participate in the PQRS since the system’s inception in 2007. With the exciting launch of the SHM Learning Portal, it is easier than ever to get started. If you or your group are not currently reporting, there are still incentive payments available in 2013 and 2014. Beginning in 2015, there will be a penalty for not reporting quality measures based on 2013 performance.

Access the PQRIwizard through the SHM Learning Portal

SHM has secured a significant discount for members to report PQRS through the PQRIwizard. Located within the SHM Learning Portal, this online tool is a fast, convenient, and cost-effective solution to help collect and report quality measures data for the PQRS program. Similar to online tax-preparation software, the PQRIwizard guides you through a few easy steps to help rapidly collect, validate, report, and submit your results to CMS. The tool is powered by the CECity Registry, a CMS-qualified registry for PQRS reporting.

What Measures Are Available?

The SHM PQRIwizard features six individual quality measures in the areas of stroke and stroke rehabilitation, including measures on screening for dysphagia and thrombolytic therapy. To report on any of these measures, simply select three measures and report on 80 percent of your Medicare Part B fee-for-services patients who apply to the measures you selected.

PQRIwizard has a built-in progress monitor that validates your report by checking for missing data. The monitor also tracks your data to provide you with continuous feedback regarding valid patients. The system even calculates your measures and provides a printable report of your measure results in real time.

As we enter a new era of health-care and payment reform, we are all keenly aware of the need to limit unnecessary readmissions. We have been given tools and tips on how to most efficiently and effectively transition patients from the hospital setting to the outpatient world in order to limit the chances that they will “bounce back” to us, resulting in penalties to our hospital or health-care system. Tools such as Project BOOST and others help us to educate patients, transfer information effectively, follow up on patients post-discharge, and reconcile medications safely across the continuum of care. But without a competent and committed provider of care to “catch” the patient on the other side, we might just be dropping the ball yet again.

It is imperative as we look to safely transition patients into the next level of care that we, as hospitalists, get outside the box and begin to engage the community of care providers outside our walls, and yes, even outside of our control. We have been down this road before with other quality initiatives, which at first glance appeared to be outside our sphere of influence—such projects as post-operative antibiotic use and hospitalwide DVT prophylaxis. Given the right hospitalist leader, with the right set of leadership tools, these quality-improvement (QI) projects have been widely successful in many environments.

I would suggest that the issue of safe transitions for our patients is no different, and maybe more important, to the health and safety of our patients.

Solving the readmission problem on a local level requires an analytical approach, much like a “root-cause analysis.” We need to begin to examine the sources of our readmitted patients, as well as the routes of our discharged patients, and we need to ask ourselves if we are continuing to feed patients into the vicious circle that results in readmissions. Are there post-acute-care facilities in your area that are responsible for more than their fair share of patients returning to your service? If so, why do we continue to discharge patients to their care? Is it because we are pressured to lower length of stay, and any bed at the next level of care is better than another day in the acute-care hospital? At some point, this reasoning fails, and given the penalties coming soon, it may be better to begin to more discriminately discharge patients to facilities that provide higher-quality care and assist us in our goals to reduce unnecessary readmissions. Leading the charge in this endeavor also necessitates that we begin to engage those providers on the other side, making them aware of the quality data related to their facility and providing education and resources to assist them in improving their performance.

Realities of the Care Continuum

Several options pertaining to hospitalist groups are available. The first, already a large movement in our current marketplace, is to extend the current hospitalist group across the chasm and begin to deliver care in those post-acute facilities. Long-term acute care (LTAC) and skilled nursing facilities (SNF) are prime examples of this movement; the obvious advantage lies in the effective control of quality and efficient transfer of information that a single group can achieve when it extends to these facilities. Obviously, manpower issues and financial support are drawbacks in a model such as this.

More realistically, a group might consider taking a less aggressive approach to this problem. Educating care providers and assisting these facilities with QI projects would require fewer resources and might provide a higher return on investment (ROI) for your group and hospital. Engaging these physicians, nonphysician providers, and facility administrators is key to our ability to impact this problem. Demanding quality care for our discharged patients in terms of timeliness of follow-up, adherence to care paths, and responsiveness to changes in condition should be non-negotiable and factored into our development of referral patterns.

As our population of patients continues to be more acutely ill, and the level of care provided at post-acute care facilities continues to rise, our current reality is that a majority of these patients, at any given time, meet hospital admissions criteria. Preventing readmissions requires that post-acute care providers have mechanisms in place to stop the “knee-jerk” transfer to the emergency department, rather than attempt to evaluate and treat the patient in the facility. Interact II (http://interact2.net/index.aspx) is a resource that provides tools for post-acute-care facilities to use in monitoring their own internal data around acute-care transfers. It also provides tracking tools, communication strategies, advanced-care-planning tools, and clinical pathways for limiting the number of acute-care transfers. The reality is, once these patients end up in the emergency department, they are likely to be referred to us for consideration of readmission. The best way to stop this is to stop the transfer before it happens.

Demand Better

We, as hospitalists, need to begin to leverage our own “buying power” as it relates to the care of our patients post-discharge. We can start by educating and assisting care providers on a local level to improve compliance with well-known standards of care that prevent unnecessary readmissions. We need to be prepared to wield our collective weight as a specialty to demand from our post-acute care colleagues what has been demanded of us over the last several years: quality and value. Make no mistake—hospitalists have to get outside the box.

Dr. Harrington is an SHM board member and chief medical officer of Locum Leaders in Alpharetta, Ga.

As we enter a new era of health-care and payment reform, we are all keenly aware of the need to limit unnecessary readmissions. We have been given tools and tips on how to most efficiently and effectively transition patients from the hospital setting to the outpatient world in order to limit the chances that they will “bounce back” to us, resulting in penalties to our hospital or health-care system. Tools such as Project BOOST and others help us to educate patients, transfer information effectively, follow up on patients post-discharge, and reconcile medications safely across the continuum of care. But without a competent and committed provider of care to “catch” the patient on the other side, we might just be dropping the ball yet again.

It is imperative as we look to safely transition patients into the next level of care that we, as hospitalists, get outside the box and begin to engage the community of care providers outside our walls, and yes, even outside of our control. We have been down this road before with other quality initiatives, which at first glance appeared to be outside our sphere of influence—such projects as post-operative antibiotic use and hospitalwide DVT prophylaxis. Given the right hospitalist leader, with the right set of leadership tools, these quality-improvement (QI) projects have been widely successful in many environments.

I would suggest that the issue of safe transitions for our patients is no different, and maybe more important, to the health and safety of our patients.

Solving the readmission problem on a local level requires an analytical approach, much like a “root-cause analysis.” We need to begin to examine the sources of our readmitted patients, as well as the routes of our discharged patients, and we need to ask ourselves if we are continuing to feed patients into the vicious circle that results in readmissions. Are there post-acute-care facilities in your area that are responsible for more than their fair share of patients returning to your service? If so, why do we continue to discharge patients to their care? Is it because we are pressured to lower length of stay, and any bed at the next level of care is better than another day in the acute-care hospital? At some point, this reasoning fails, and given the penalties coming soon, it may be better to begin to more discriminately discharge patients to facilities that provide higher-quality care and assist us in our goals to reduce unnecessary readmissions. Leading the charge in this endeavor also necessitates that we begin to engage those providers on the other side, making them aware of the quality data related to their facility and providing education and resources to assist them in improving their performance.

Realities of the Care Continuum

Several options pertaining to hospitalist groups are available. The first, already a large movement in our current marketplace, is to extend the current hospitalist group across the chasm and begin to deliver care in those post-acute facilities. Long-term acute care (LTAC) and skilled nursing facilities (SNF) are prime examples of this movement; the obvious advantage lies in the effective control of quality and efficient transfer of information that a single group can achieve when it extends to these facilities. Obviously, manpower issues and financial support are drawbacks in a model such as this.

More realistically, a group might consider taking a less aggressive approach to this problem. Educating care providers and assisting these facilities with QI projects would require fewer resources and might provide a higher return on investment (ROI) for your group and hospital. Engaging these physicians, nonphysician providers, and facility administrators is key to our ability to impact this problem. Demanding quality care for our discharged patients in terms of timeliness of follow-up, adherence to care paths, and responsiveness to changes in condition should be non-negotiable and factored into our development of referral patterns.

As our population of patients continues to be more acutely ill, and the level of care provided at post-acute care facilities continues to rise, our current reality is that a majority of these patients, at any given time, meet hospital admissions criteria. Preventing readmissions requires that post-acute care providers have mechanisms in place to stop the “knee-jerk” transfer to the emergency department, rather than attempt to evaluate and treat the patient in the facility. Interact II (http://interact2.net/index.aspx) is a resource that provides tools for post-acute-care facilities to use in monitoring their own internal data around acute-care transfers. It also provides tracking tools, communication strategies, advanced-care-planning tools, and clinical pathways for limiting the number of acute-care transfers. The reality is, once these patients end up in the emergency department, they are likely to be referred to us for consideration of readmission. The best way to stop this is to stop the transfer before it happens.

Demand Better

We, as hospitalists, need to begin to leverage our own “buying power” as it relates to the care of our patients post-discharge. We can start by educating and assisting care providers on a local level to improve compliance with well-known standards of care that prevent unnecessary readmissions. We need to be prepared to wield our collective weight as a specialty to demand from our post-acute care colleagues what has been demanded of us over the last several years: quality and value. Make no mistake—hospitalists have to get outside the box.

Dr. Harrington is an SHM board member and chief medical officer of Locum Leaders in Alpharetta, Ga.

As we enter a new era of health-care and payment reform, we are all keenly aware of the need to limit unnecessary readmissions. We have been given tools and tips on how to most efficiently and effectively transition patients from the hospital setting to the outpatient world in order to limit the chances that they will “bounce back” to us, resulting in penalties to our hospital or health-care system. Tools such as Project BOOST and others help us to educate patients, transfer information effectively, follow up on patients post-discharge, and reconcile medications safely across the continuum of care. But without a competent and committed provider of care to “catch” the patient on the other side, we might just be dropping the ball yet again.

It is imperative as we look to safely transition patients into the next level of care that we, as hospitalists, get outside the box and begin to engage the community of care providers outside our walls, and yes, even outside of our control. We have been down this road before with other quality initiatives, which at first glance appeared to be outside our sphere of influence—such projects as post-operative antibiotic use and hospitalwide DVT prophylaxis. Given the right hospitalist leader, with the right set of leadership tools, these quality-improvement (QI) projects have been widely successful in many environments.

I would suggest that the issue of safe transitions for our patients is no different, and maybe more important, to the health and safety of our patients.

Solving the readmission problem on a local level requires an analytical approach, much like a “root-cause analysis.” We need to begin to examine the sources of our readmitted patients, as well as the routes of our discharged patients, and we need to ask ourselves if we are continuing to feed patients into the vicious circle that results in readmissions. Are there post-acute-care facilities in your area that are responsible for more than their fair share of patients returning to your service? If so, why do we continue to discharge patients to their care? Is it because we are pressured to lower length of stay, and any bed at the next level of care is better than another day in the acute-care hospital? At some point, this reasoning fails, and given the penalties coming soon, it may be better to begin to more discriminately discharge patients to facilities that provide higher-quality care and assist us in our goals to reduce unnecessary readmissions. Leading the charge in this endeavor also necessitates that we begin to engage those providers on the other side, making them aware of the quality data related to their facility and providing education and resources to assist them in improving their performance.

Realities of the Care Continuum

Several options pertaining to hospitalist groups are available. The first, already a large movement in our current marketplace, is to extend the current hospitalist group across the chasm and begin to deliver care in those post-acute facilities. Long-term acute care (LTAC) and skilled nursing facilities (SNF) are prime examples of this movement; the obvious advantage lies in the effective control of quality and efficient transfer of information that a single group can achieve when it extends to these facilities. Obviously, manpower issues and financial support are drawbacks in a model such as this.

More realistically, a group might consider taking a less aggressive approach to this problem. Educating care providers and assisting these facilities with QI projects would require fewer resources and might provide a higher return on investment (ROI) for your group and hospital. Engaging these physicians, nonphysician providers, and facility administrators is key to our ability to impact this problem. Demanding quality care for our discharged patients in terms of timeliness of follow-up, adherence to care paths, and responsiveness to changes in condition should be non-negotiable and factored into our development of referral patterns.

As our population of patients continues to be more acutely ill, and the level of care provided at post-acute care facilities continues to rise, our current reality is that a majority of these patients, at any given time, meet hospital admissions criteria. Preventing readmissions requires that post-acute care providers have mechanisms in place to stop the “knee-jerk” transfer to the emergency department, rather than attempt to evaluate and treat the patient in the facility. Interact II (http://interact2.net/index.aspx) is a resource that provides tools for post-acute-care facilities to use in monitoring their own internal data around acute-care transfers. It also provides tracking tools, communication strategies, advanced-care-planning tools, and clinical pathways for limiting the number of acute-care transfers. The reality is, once these patients end up in the emergency department, they are likely to be referred to us for consideration of readmission. The best way to stop this is to stop the transfer before it happens.

Demand Better

We, as hospitalists, need to begin to leverage our own “buying power” as it relates to the care of our patients post-discharge. We can start by educating and assisting care providers on a local level to improve compliance with well-known standards of care that prevent unnecessary readmissions. We need to be prepared to wield our collective weight as a specialty to demand from our post-acute care colleagues what has been demanded of us over the last several years: quality and value. Make no mistake—hospitalists have to get outside the box.

Dr. Harrington is an SHM board member and chief medical officer of Locum Leaders in Alpharetta, Ga.

Initial research on outcomes following Project BOOST (Better Outcomes for Older Adults through Safe Transitions) implementation shows modest improvement in rehospitalization rates. Moreover, some experts suggest the real problem might lie in using 30-day hospital readmissions, now a target for Medicare reimbursement penalties, as the quality metric for care transitions out of the hospital.

Study data showed a 2% absolute reduction in all-patient, 30-day readmission rates at 11 of the original 30 BOOST sites (to 12.7% from 14.7%), according to an article in the August issue of the Journal of Hospital Medicine.¹

“Everybody has talked about readmissions as the quality target, but really it should be about improving transitions of care for the patient going home,” says Ashish Jha, MD, MPH, of the Harvard School of Public Health, Health Policy and Management. “If we’re going to use readmissions as our quality measure, maybe we’re set up to fail. Can we do care transitions better? Yes, we can. Can we do better quality measures? Yes. My take-home message is that we should get clearer on what we are trying to achieve.”

Project BOOST (www.hospitalmedicine.org/boost) has been a major quality initiative for SHM since 2008 and one of several national programs aimed at helping hospitals improve care-transitions processes and patient outcomes. BOOST offers participating sites an online toolkit of strategies and interventions, along with the support of an expert mentor.

“Participation in Project BOOST appeared to be associated with a decrease in readmission rates,” the authors conclude. But two accompanying editorials in the journal expressed disappointment with a lack of “robustness” to these results and lack of participation by BOOST sites.^2,3 The editorials also acknowledge the challenges of multisite, voluntary research on a topic that, so far, has largely resisted validated, generalizable research outcomes demonstrating what really works in preventing readmissions.

“I think people want a silver bullet on this issue,” says lead author Luke Hansen, MD, MHS, of the division of hospital medicine at Northwestern University Feinberg School of Medicine in Chicago. “They want to be able to define an intervention to take care of all of the avoidable fraction of rehospitalizations. But I don’t think that’s possible. The disappointment may come from the fact that this is a more complicated issue than we thought.”

Dr. Hansen says data reporting was voluntary and uncompensated, and the BOOST research team is trying to facilitate better reporting from subsequent cohorts. He says one of BOOST’s unique aspects—tailoring interventions to local circumstances—could be a drawback to outcomes research. “We have to incorporate the diversity of experience into our research methods and our expectations,” he says.

Hospitalist Bradley Flansbaum, DO, MPH, FACP, SFHM, of Lenox Hill Hospital in New York City says BOOST reinforces many of things hospitalists should be doing to provide optimal discharges and transitions

.

“Like appropriate teaching and patient education, medication reconciliation, and setting up follow-up appointments,” says Dr. Flansbaum, a member of SHM’s Public Policy Committee and regular contributor to SHM’s Practice Management blog. “But if there was one thing I’d like hospitalists to take home from this research, it’s the cognitive dissonance—the challenge of matching the evidence with what the regulatory bodies expect from us and knowing that the evidence is falling short.

“As much as we might be held accountable for outcomes like readmissions, the reality is that we can’t control them. What we’re learning is that this is really hard to do.”

Amy Boutwell, MD, MPP, a hospitalist in Newton, Mass., and founder of Collaborative Healthcare Strategies, agrees transitions of care are difficult. However, she also thinks hospitals and hospitalists cannot wait for conclusive research that proves what works in preventing readmissions.

“The BOOST results reflect my own experience working with more than a hundred STAAR [State Action on Avoidable Readmissions] hospitals. We haven’t yet been able to sufficiently extract the data about readmissions from the field—and we need to figure out how to do that,” she says. “But when you look at the issue from a patient’s perspective and their desire for a safe transition, why would you not do the things recommended by Project BOOST and similar initiatives?”

Primary-care physicians (PCPs) need to know about major changes in a discharged patient’s plan of care in a timely manner, along with any results from pending lab tests, Dr. Boutwell explains. She emphasizes that patients and their caregivers need to be given clear discharge instructions when they leave the hospital.

“We have an obligation to do what we know to be best practices and standards of care. The BOOST toolkit of recommendations is very comprehensive and gives hospitals a lot of options to improve their internal processes,” Dr. Boutwell says. “It’s hard to argue against any of them, even if it’s hard to draw clear links between them and readmissions rates. These are the self-evident, basic tasks that I would want done for myself or my child or my parent, if we were in the hospital.”

Larry Beresford is a freelance writer in San Francisco.

References

1. Hansen L, Greenwald J, Budnitz T, et al. Project BOOST: Effectiveness of a multihospital effort to reduce rehospitalization. J Hosp Med. 2013;8(8):421-427. doi: 10.1002/jhm.2054. Epub 2013 Jul 22.
2. Auerbach A, Fang M, Glasheen J, Brotman D, O’Leary KJ, Horwitz LJ. BOOST: Evidence needing a lift. J Hosp Med. 2013;8(8):468-469. doi: 10.1002/jhm.2065. Epub 2013 Jul 22.
3. Jha A. BOOST and readmissions: Thinking beyond the walls of the hospital. J Hosp Med. 2013;8(8):470-471. doi: 10.1002/jhm.2069. Epub 2013 Jul 22.

Initial research on outcomes following Project BOOST (Better Outcomes for Older Adults through Safe Transitions) implementation shows modest improvement in rehospitalization rates. Moreover, some experts suggest the real problem might lie in using 30-day hospital readmissions, now a target for Medicare reimbursement penalties, as the quality metric for care transitions out of the hospital.

Study data showed a 2% absolute reduction in all-patient, 30-day readmission rates at 11 of the original 30 BOOST sites (to 12.7% from 14.7%), according to an article in the August issue of the Journal of Hospital Medicine.¹

“Everybody has talked about readmissions as the quality target, but really it should be about improving transitions of care for the patient going home,” says Ashish Jha, MD, MPH, of the Harvard School of Public Health, Health Policy and Management. “If we’re going to use readmissions as our quality measure, maybe we’re set up to fail. Can we do care transitions better? Yes, we can. Can we do better quality measures? Yes. My take-home message is that we should get clearer on what we are trying to achieve.”

Project BOOST (www.hospitalmedicine.org/boost) has been a major quality initiative for SHM since 2008 and one of several national programs aimed at helping hospitals improve care-transitions processes and patient outcomes. BOOST offers participating sites an online toolkit of strategies and interventions, along with the support of an expert mentor.

“Participation in Project BOOST appeared to be associated with a decrease in readmission rates,” the authors conclude. But two accompanying editorials in the journal expressed disappointment with a lack of “robustness” to these results and lack of participation by BOOST sites.^2,3 The editorials also acknowledge the challenges of multisite, voluntary research on a topic that, so far, has largely resisted validated, generalizable research outcomes demonstrating what really works in preventing readmissions.

“I think people want a silver bullet on this issue,” says lead author Luke Hansen, MD, MHS, of the division of hospital medicine at Northwestern University Feinberg School of Medicine in Chicago. “They want to be able to define an intervention to take care of all of the avoidable fraction of rehospitalizations. But I don’t think that’s possible. The disappointment may come from the fact that this is a more complicated issue than we thought.”

Dr. Hansen says data reporting was voluntary and uncompensated, and the BOOST research team is trying to facilitate better reporting from subsequent cohorts. He says one of BOOST’s unique aspects—tailoring interventions to local circumstances—could be a drawback to outcomes research. “We have to incorporate the diversity of experience into our research methods and our expectations,” he says.

Hospitalist Bradley Flansbaum, DO, MPH, FACP, SFHM, of Lenox Hill Hospital in New York City says BOOST reinforces many of things hospitalists should be doing to provide optimal discharges and transitions

.

“Like appropriate teaching and patient education, medication reconciliation, and setting up follow-up appointments,” says Dr. Flansbaum, a member of SHM’s Public Policy Committee and regular contributor to SHM’s Practice Management blog. “But if there was one thing I’d like hospitalists to take home from this research, it’s the cognitive dissonance—the challenge of matching the evidence with what the regulatory bodies expect from us and knowing that the evidence is falling short.

“As much as we might be held accountable for outcomes like readmissions, the reality is that we can’t control them. What we’re learning is that this is really hard to do.”

Amy Boutwell, MD, MPP, a hospitalist in Newton, Mass., and founder of Collaborative Healthcare Strategies, agrees transitions of care are difficult. However, she also thinks hospitals and hospitalists cannot wait for conclusive research that proves what works in preventing readmissions.

“The BOOST results reflect my own experience working with more than a hundred STAAR [State Action on Avoidable Readmissions] hospitals. We haven’t yet been able to sufficiently extract the data about readmissions from the field—and we need to figure out how to do that,” she says. “But when you look at the issue from a patient’s perspective and their desire for a safe transition, why would you not do the things recommended by Project BOOST and similar initiatives?”

Primary-care physicians (PCPs) need to know about major changes in a discharged patient’s plan of care in a timely manner, along with any results from pending lab tests, Dr. Boutwell explains. She emphasizes that patients and their caregivers need to be given clear discharge instructions when they leave the hospital.

“We have an obligation to do what we know to be best practices and standards of care. The BOOST toolkit of recommendations is very comprehensive and gives hospitals a lot of options to improve their internal processes,” Dr. Boutwell says. “It’s hard to argue against any of them, even if it’s hard to draw clear links between them and readmissions rates. These are the self-evident, basic tasks that I would want done for myself or my child or my parent, if we were in the hospital.”

Larry Beresford is a freelance writer in San Francisco.

References

1. Hansen L, Greenwald J, Budnitz T, et al. Project BOOST: Effectiveness of a multihospital effort to reduce rehospitalization. J Hosp Med. 2013;8(8):421-427. doi: 10.1002/jhm.2054. Epub 2013 Jul 22.
2. Auerbach A, Fang M, Glasheen J, Brotman D, O’Leary KJ, Horwitz LJ. BOOST: Evidence needing a lift. J Hosp Med. 2013;8(8):468-469. doi: 10.1002/jhm.2065. Epub 2013 Jul 22.
3. Jha A. BOOST and readmissions: Thinking beyond the walls of the hospital. J Hosp Med. 2013;8(8):470-471. doi: 10.1002/jhm.2069. Epub 2013 Jul 22.

Initial research on outcomes following Project BOOST (Better Outcomes for Older Adults through Safe Transitions) implementation shows modest improvement in rehospitalization rates. Moreover, some experts suggest the real problem might lie in using 30-day hospital readmissions, now a target for Medicare reimbursement penalties, as the quality metric for care transitions out of the hospital.

Study data showed a 2% absolute reduction in all-patient, 30-day readmission rates at 11 of the original 30 BOOST sites (to 12.7% from 14.7%), according to an article in the August issue of the Journal of Hospital Medicine.¹

“Everybody has talked about readmissions as the quality target, but really it should be about improving transitions of care for the patient going home,” says Ashish Jha, MD, MPH, of the Harvard School of Public Health, Health Policy and Management. “If we’re going to use readmissions as our quality measure, maybe we’re set up to fail. Can we do care transitions better? Yes, we can. Can we do better quality measures? Yes. My take-home message is that we should get clearer on what we are trying to achieve.”

Project BOOST (www.hospitalmedicine.org/boost) has been a major quality initiative for SHM since 2008 and one of several national programs aimed at helping hospitals improve care-transitions processes and patient outcomes. BOOST offers participating sites an online toolkit of strategies and interventions, along with the support of an expert mentor.

“Participation in Project BOOST appeared to be associated with a decrease in readmission rates,” the authors conclude. But two accompanying editorials in the journal expressed disappointment with a lack of “robustness” to these results and lack of participation by BOOST sites.^2,3 The editorials also acknowledge the challenges of multisite, voluntary research on a topic that, so far, has largely resisted validated, generalizable research outcomes demonstrating what really works in preventing readmissions.

“I think people want a silver bullet on this issue,” says lead author Luke Hansen, MD, MHS, of the division of hospital medicine at Northwestern University Feinberg School of Medicine in Chicago. “They want to be able to define an intervention to take care of all of the avoidable fraction of rehospitalizations. But I don’t think that’s possible. The disappointment may come from the fact that this is a more complicated issue than we thought.”

Dr. Hansen says data reporting was voluntary and uncompensated, and the BOOST research team is trying to facilitate better reporting from subsequent cohorts. He says one of BOOST’s unique aspects—tailoring interventions to local circumstances—could be a drawback to outcomes research. “We have to incorporate the diversity of experience into our research methods and our expectations,” he says.

Hospitalist Bradley Flansbaum, DO, MPH, FACP, SFHM, of Lenox Hill Hospital in New York City says BOOST reinforces many of things hospitalists should be doing to provide optimal discharges and transitions

.

“Like appropriate teaching and patient education, medication reconciliation, and setting up follow-up appointments,” says Dr. Flansbaum, a member of SHM’s Public Policy Committee and regular contributor to SHM’s Practice Management blog. “But if there was one thing I’d like hospitalists to take home from this research, it’s the cognitive dissonance—the challenge of matching the evidence with what the regulatory bodies expect from us and knowing that the evidence is falling short.

“As much as we might be held accountable for outcomes like readmissions, the reality is that we can’t control them. What we’re learning is that this is really hard to do.”

Amy Boutwell, MD, MPP, a hospitalist in Newton, Mass., and founder of Collaborative Healthcare Strategies, agrees transitions of care are difficult. However, she also thinks hospitals and hospitalists cannot wait for conclusive research that proves what works in preventing readmissions.

“The BOOST results reflect my own experience working with more than a hundred STAAR [State Action on Avoidable Readmissions] hospitals. We haven’t yet been able to sufficiently extract the data about readmissions from the field—and we need to figure out how to do that,” she says. “But when you look at the issue from a patient’s perspective and their desire for a safe transition, why would you not do the things recommended by Project BOOST and similar initiatives?”

Primary-care physicians (PCPs) need to know about major changes in a discharged patient’s plan of care in a timely manner, along with any results from pending lab tests, Dr. Boutwell explains. She emphasizes that patients and their caregivers need to be given clear discharge instructions when they leave the hospital.

“We have an obligation to do what we know to be best practices and standards of care. The BOOST toolkit of recommendations is very comprehensive and gives hospitals a lot of options to improve their internal processes,” Dr. Boutwell says. “It’s hard to argue against any of them, even if it’s hard to draw clear links between them and readmissions rates. These are the self-evident, basic tasks that I would want done for myself or my child or my parent, if we were in the hospital.”

Larry Beresford is a freelance writer in San Francisco.

References

1. Hansen L, Greenwald J, Budnitz T, et al. Project BOOST: Effectiveness of a multihospital effort to reduce rehospitalization. J Hosp Med. 2013;8(8):421-427. doi: 10.1002/jhm.2054. Epub 2013 Jul 22.
2. Auerbach A, Fang M, Glasheen J, Brotman D, O’Leary KJ, Horwitz LJ. BOOST: Evidence needing a lift. J Hosp Med. 2013;8(8):468-469. doi: 10.1002/jhm.2065. Epub 2013 Jul 22.
3. Jha A. BOOST and readmissions: Thinking beyond the walls of the hospital. J Hosp Med. 2013;8(8):470-471. doi: 10.1002/jhm.2069. Epub 2013 Jul 22.

Feeling frustrated with your group’s patient-satisfaction performance? Wondering why your chief (fill in the blank) officer glazes over when you try to explain why your hospitalist group’s Hospital Consumer Assessment of Healthcare Providers and System (HCAHPS) scores for doctor communication are in a percentile rivaling the numeric age of your children?

It is likely that the C-suite administrator overseeing your hospitalist group has a portion of their pay based on HCAHPS or other patient-satisfaction (also called patient experience) scores. And for good reason: The Centers for Medicare & Medicaid Services (CMS) Hospital Value-Based Purchasing (HVBP) program that started Oct. 1, 2012, has placed your hospital’s Medicare reimbursement at risk based on its HCAHPS scores.

HVBP and Patient Satisfaction

Patient satisfaction will remain an important part of HVBP in the coming years. Table 1 (below) shows the domains that will be included in fiscal years 2014 (which starts Oct. 1, 2013), 2015, and 2016. Table 2 (below) depicts the percent weighting the patient-satisfaction domain will receive through 2016. You may recall that HVBP is a program in which all hospitals place 1% to 2% (2013 through 2017, starting at 1% and increasing each year by 0.25% so that by 2017%, it is 2%) of their CMS inpatient payments in a withhold pool and, based on performance, can make back some, all, or an amount in excess of the amount placed in the withhold pool.

click for large version

click for large version

End In Itself

A colleague of mine recently asked, “Is an increase in patient satisfaction associated with higher quality of care and better patient safety?” The point here: It doesn’t matter. Patient satisfaction is an end in itself, and we should strive to maximize it, or at least put ourselves in the place of the patient and design care accordingly.

For Hospitalists: A Starting Point

There is a conundrum for hospitalists vis-à-vis patient satisfaction. Follow this chain of logic: The hospitals at which we work are incented to perform well on the HCAHPS domains. Hospitals pay a lot for hospitalists. Hospitalists can impact many of the HCAHPS domains. So shouldn’t hospitalists be judged according to HCAHPS scores?

Yes and no.

HCAHPS as a survey is intended to measure a patient’s overall experience of receiving care in the hospital. For example, from the “Doctor Communication” domain, we have questions like “how often did doctors treat you with courtesy and respect?” And “how often did doctors explain things in a way you could understand?”

These questions, like all in HCAHPS, are not designed to get at individual doctor performance, or even performance of a group of doctors, such as hospitalists. Instead, they are designed to measure a patient’s overall experience with the hospitalization, and “Doctor Communication” questions are designed to assess satisfaction with “doctors” collectively.

The Need for Hospitalist-Specific Satisfaction Surveys

So while HCAHPS is not designed to measure hospitalist performance with regard to patient satisfaction, it is a reasonable interim step for hospitals to judge hospitalists according to HCAHPS. However, this should be a bridge to a strategy that adopts hospitalist-specific patient-satisfaction questionnaires in the future and not an end in itself.

Why? Perhaps the biggest reason is that HCAHPS scores are neither specific nor timely enough to form the basis of improvement efforts for hospitalists. If a hospitalist receives a low score on the “Doctor Communication” domain, the scores are likely to be three to nine months old. How can we legitimately assign (and then modify) behaviors based on those scores?

Further, because the survey is not built to measure patient satisfaction specifically with hospitalists, the results are unlikely to engender meaningful and sustained behavior change. Hospitalists I talk to are generally bewildered and confused by HCAHPS scores attributed to them or their groups. Even if they understand the scores, I almost never see true quality improvement (plan-do-study-act) based on specific HCAHPS results. Instead, I see hospitalists trying to adhere to “best practices,” with no adjustments made along the way based on performance.

Nearly all the prominent patient satisfaction vendors have developed a survey instrument specifically designed for hospitalists. Each has an approach to appropriately attribute performance to the hospitalist in question, and each has a battery of questions that is designed to capture patient satisfaction with the hospitalist. Although use of these surveys involves an added financial commitment, I submit that because hospitalists have an unparalleled proximity to hospitalized patients, such an investment is worthy of consideration and has an accompanying business case, thanks to HVBP. The results of these surveys may form the basis of legitimate, targeted feedback to hospitalists, who may then adjust their approach to patient interactions. Such performance improvement should result in improved HCAHPS scores.

In sum, hospitalists should pay close attention to patient satisfaction and embrace HCAHPS. However, we should be looking beyond HCAHPS to survey instruments that fairly and accurately measure our performance. Such surveys will be more widely accepted by the hospitalists they are measuring, and will allow hospitalists to perform meaningful quality improvement based on the results. Although hospitalist-specific surveys will require an investment, the increased patient satisfaction that results should be the basis of a favorable return on that investment.

Dr. Whitcomb is medical director of healthcare quality at Baystate Medical Center in Springfield, Mass. He is co-founder and past president of SHM. Email him at [email protected].

Feeling frustrated with your group’s patient-satisfaction performance? Wondering why your chief (fill in the blank) officer glazes over when you try to explain why your hospitalist group’s Hospital Consumer Assessment of Healthcare Providers and System (HCAHPS) scores for doctor communication are in a percentile rivaling the numeric age of your children?

It is likely that the C-suite administrator overseeing your hospitalist group has a portion of their pay based on HCAHPS or other patient-satisfaction (also called patient experience) scores. And for good reason: The Centers for Medicare & Medicaid Services (CMS) Hospital Value-Based Purchasing (HVBP) program that started Oct. 1, 2012, has placed your hospital’s Medicare reimbursement at risk based on its HCAHPS scores.

HVBP and Patient Satisfaction

Patient satisfaction will remain an important part of HVBP in the coming years. Table 1 (below) shows the domains that will be included in fiscal years 2014 (which starts Oct. 1, 2013), 2015, and 2016. Table 2 (below) depicts the percent weighting the patient-satisfaction domain will receive through 2016. You may recall that HVBP is a program in which all hospitals place 1% to 2% (2013 through 2017, starting at 1% and increasing each year by 0.25% so that by 2017%, it is 2%) of their CMS inpatient payments in a withhold pool and, based on performance, can make back some, all, or an amount in excess of the amount placed in the withhold pool.

click for large version

click for large version

End In Itself

A colleague of mine recently asked, “Is an increase in patient satisfaction associated with higher quality of care and better patient safety?” The point here: It doesn’t matter. Patient satisfaction is an end in itself, and we should strive to maximize it, or at least put ourselves in the place of the patient and design care accordingly.

For Hospitalists: A Starting Point

There is a conundrum for hospitalists vis-à-vis patient satisfaction. Follow this chain of logic: The hospitals at which we work are incented to perform well on the HCAHPS domains. Hospitals pay a lot for hospitalists. Hospitalists can impact many of the HCAHPS domains. So shouldn’t hospitalists be judged according to HCAHPS scores?

Yes and no.

HCAHPS as a survey is intended to measure a patient’s overall experience of receiving care in the hospital. For example, from the “Doctor Communication” domain, we have questions like “how often did doctors treat you with courtesy and respect?” And “how often did doctors explain things in a way you could understand?”

These questions, like all in HCAHPS, are not designed to get at individual doctor performance, or even performance of a group of doctors, such as hospitalists. Instead, they are designed to measure a patient’s overall experience with the hospitalization, and “Doctor Communication” questions are designed to assess satisfaction with “doctors” collectively.

The Need for Hospitalist-Specific Satisfaction Surveys

So while HCAHPS is not designed to measure hospitalist performance with regard to patient satisfaction, it is a reasonable interim step for hospitals to judge hospitalists according to HCAHPS. However, this should be a bridge to a strategy that adopts hospitalist-specific patient-satisfaction questionnaires in the future and not an end in itself.

Why? Perhaps the biggest reason is that HCAHPS scores are neither specific nor timely enough to form the basis of improvement efforts for hospitalists. If a hospitalist receives a low score on the “Doctor Communication” domain, the scores are likely to be three to nine months old. How can we legitimately assign (and then modify) behaviors based on those scores?

Further, because the survey is not built to measure patient satisfaction specifically with hospitalists, the results are unlikely to engender meaningful and sustained behavior change. Hospitalists I talk to are generally bewildered and confused by HCAHPS scores attributed to them or their groups. Even if they understand the scores, I almost never see true quality improvement (plan-do-study-act) based on specific HCAHPS results. Instead, I see hospitalists trying to adhere to “best practices,” with no adjustments made along the way based on performance.

Nearly all the prominent patient satisfaction vendors have developed a survey instrument specifically designed for hospitalists. Each has an approach to appropriately attribute performance to the hospitalist in question, and each has a battery of questions that is designed to capture patient satisfaction with the hospitalist. Although use of these surveys involves an added financial commitment, I submit that because hospitalists have an unparalleled proximity to hospitalized patients, such an investment is worthy of consideration and has an accompanying business case, thanks to HVBP. The results of these surveys may form the basis of legitimate, targeted feedback to hospitalists, who may then adjust their approach to patient interactions. Such performance improvement should result in improved HCAHPS scores.

In sum, hospitalists should pay close attention to patient satisfaction and embrace HCAHPS. However, we should be looking beyond HCAHPS to survey instruments that fairly and accurately measure our performance. Such surveys will be more widely accepted by the hospitalists they are measuring, and will allow hospitalists to perform meaningful quality improvement based on the results. Although hospitalist-specific surveys will require an investment, the increased patient satisfaction that results should be the basis of a favorable return on that investment.

Dr. Whitcomb is medical director of healthcare quality at Baystate Medical Center in Springfield, Mass. He is co-founder and past president of SHM. Email him at [email protected].

Feeling frustrated with your group’s patient-satisfaction performance? Wondering why your chief (fill in the blank) officer glazes over when you try to explain why your hospitalist group’s Hospital Consumer Assessment of Healthcare Providers and System (HCAHPS) scores for doctor communication are in a percentile rivaling the numeric age of your children?

It is likely that the C-suite administrator overseeing your hospitalist group has a portion of their pay based on HCAHPS or other patient-satisfaction (also called patient experience) scores. And for good reason: The Centers for Medicare & Medicaid Services (CMS) Hospital Value-Based Purchasing (HVBP) program that started Oct. 1, 2012, has placed your hospital’s Medicare reimbursement at risk based on its HCAHPS scores.

HVBP and Patient Satisfaction

Patient satisfaction will remain an important part of HVBP in the coming years. Table 1 (below) shows the domains that will be included in fiscal years 2014 (which starts Oct. 1, 2013), 2015, and 2016. Table 2 (below) depicts the percent weighting the patient-satisfaction domain will receive through 2016. You may recall that HVBP is a program in which all hospitals place 1% to 2% (2013 through 2017, starting at 1% and increasing each year by 0.25% so that by 2017%, it is 2%) of their CMS inpatient payments in a withhold pool and, based on performance, can make back some, all, or an amount in excess of the amount placed in the withhold pool.

click for large version

click for large version

End In Itself

A colleague of mine recently asked, “Is an increase in patient satisfaction associated with higher quality of care and better patient safety?” The point here: It doesn’t matter. Patient satisfaction is an end in itself, and we should strive to maximize it, or at least put ourselves in the place of the patient and design care accordingly.

For Hospitalists: A Starting Point

There is a conundrum for hospitalists vis-à-vis patient satisfaction. Follow this chain of logic: The hospitals at which we work are incented to perform well on the HCAHPS domains. Hospitals pay a lot for hospitalists. Hospitalists can impact many of the HCAHPS domains. So shouldn’t hospitalists be judged according to HCAHPS scores?

Yes and no.

HCAHPS as a survey is intended to measure a patient’s overall experience of receiving care in the hospital. For example, from the “Doctor Communication” domain, we have questions like “how often did doctors treat you with courtesy and respect?” And “how often did doctors explain things in a way you could understand?”

These questions, like all in HCAHPS, are not designed to get at individual doctor performance, or even performance of a group of doctors, such as hospitalists. Instead, they are designed to measure a patient’s overall experience with the hospitalization, and “Doctor Communication” questions are designed to assess satisfaction with “doctors” collectively.

The Need for Hospitalist-Specific Satisfaction Surveys

So while HCAHPS is not designed to measure hospitalist performance with regard to patient satisfaction, it is a reasonable interim step for hospitals to judge hospitalists according to HCAHPS. However, this should be a bridge to a strategy that adopts hospitalist-specific patient-satisfaction questionnaires in the future and not an end in itself.

Why? Perhaps the biggest reason is that HCAHPS scores are neither specific nor timely enough to form the basis of improvement efforts for hospitalists. If a hospitalist receives a low score on the “Doctor Communication” domain, the scores are likely to be three to nine months old. How can we legitimately assign (and then modify) behaviors based on those scores?

Further, because the survey is not built to measure patient satisfaction specifically with hospitalists, the results are unlikely to engender meaningful and sustained behavior change. Hospitalists I talk to are generally bewildered and confused by HCAHPS scores attributed to them or their groups. Even if they understand the scores, I almost never see true quality improvement (plan-do-study-act) based on specific HCAHPS results. Instead, I see hospitalists trying to adhere to “best practices,” with no adjustments made along the way based on performance.

Nearly all the prominent patient satisfaction vendors have developed a survey instrument specifically designed for hospitalists. Each has an approach to appropriately attribute performance to the hospitalist in question, and each has a battery of questions that is designed to capture patient satisfaction with the hospitalist. Although use of these surveys involves an added financial commitment, I submit that because hospitalists have an unparalleled proximity to hospitalized patients, such an investment is worthy of consideration and has an accompanying business case, thanks to HVBP. The results of these surveys may form the basis of legitimate, targeted feedback to hospitalists, who may then adjust their approach to patient interactions. Such performance improvement should result in improved HCAHPS scores.

In sum, hospitalists should pay close attention to patient satisfaction and embrace HCAHPS. However, we should be looking beyond HCAHPS to survey instruments that fairly and accurately measure our performance. Such surveys will be more widely accepted by the hospitalists they are measuring, and will allow hospitalists to perform meaningful quality improvement based on the results. Although hospitalist-specific surveys will require an investment, the increased patient satisfaction that results should be the basis of a favorable return on that investment.

Dr. Whitcomb is medical director of healthcare quality at Baystate Medical Center in Springfield, Mass. He is co-founder and past president of SHM. Email him at [email protected].

On May 12, 113 hospitalists descended on Capitol Hill for “Hospitalists on the Hill 2013,” the public-advocacy highlight of SHM’s annual meeting. Hospitalists from all parts of the country engaged with congressional representatives in a daylong series of meet-and-greets that may seem to some people useless in the face of political obstinacy in Washington. But the trip worked.

Josh Boswell, SHM’s senior manager of government relations, reports many Hill Day objectives were achieved:

• The number of legislators co-sponsoring a bill regarding the “three-day observation rule” more than tripled in the House of Representatives and doubled in the Senate. SHM officials note that the added support has come from both political parties.
• A Congressional Budget Office (CBO) review of the bill has been formally requested by those legislators.
• A congressman from Washington state asked for—and received—a letter of support for a proposed measure, the Improved Health Care at a Lower Cost Act of 2013 (H.R. 1487).
• Multiple reports of continued dialogue between congressional staffers and SHM members nationwide. When planning the advocacy day, SHM officials noted that one of the most valuable results is creating relationships at the local level.

Observation Legislation

One of the three talking points hospitalists took into their legislative meetings was solving the dilemmas surrounding observation status. Currently, time spent on observation status does not count toward the required three consecutive overnights an inpatient needs to qualify for Medicare benefits at a skilled nursing facility (SNF).

Hospitalists have been pushing to change that rule, in large part by supporting the Improving Access to Medicare Coverage Act of 2013 (H.R. 1179, S. 569), sponsored by Rep. Joe Courtney (D-Conn.), Rep. Tom Latham (R-Iowa), and Sen. Sherrod Brown (D-Ohio).¹ In addition to the status reclassification, the proposal would establish a 90-day appeal period for those who have been denied the benefit.

The issue is important to hospitalists because of the penalties hospitals face for readmissions—and also in part because hospitalists increasingly are providing care at SNFs and other post-acute-care facilities. SHM says that after the Hill visits—and the ensuing follow-up communications—the number of co-sponsors in the House jumped to 70 from 22. The Senate version doubled its list of co-sponsors.

And, perhaps more important, a CBO analysis has been requested for the observation bills. That review, known as a CBO score, weighs the financial impacts of proposed laws and is considered a necessary precursor to successfully passing any legislation.

All in all, SHM was pleased with the progress on the observation-status bill and will continue to push for its passage, whether it is in this congressional session or the next.

“Rep. Courtney’s bill is now getting significant traction,” Boswell says. “Hospitalists should be proud to know this is in no small part due to their advocacy efforts.”

Political Networking

Hospitalist David Ramenofsky, MD, who works at Northwest Hospital and Medical Center in Seattle, wasn’t sure how much traction he was going to be able to generate at his first Hill Day. SHM had arranged meetings with the offices of three local politicians: Rep. Jim McDermott (D-Wash.), Sen. Patty Murray (D-Wash.), and Sen. Maria Cantwell (D-Wash.).

Dr. Ramenofsky sat with two of McDermott’s staffers, one of whom sounded knowledgeable and enthused about health-care-policy issues. Although the congressman couldn’t sit in on the meeting, he knew Dr. Ramenofsky’s name and took the time to say hello.

“It was really interesting to me that these staffers wanted to hear what I had to say and learn about my experience,” Dr. Ramenofsky adds. “My views may affect how they work with their bosses to make policy changes. It was surprising to me how much my opinions mattered to them.”

After the meeting and another briefing SHM arranged with another local hospitalist, McDermott reached out to SHM. He asked for support for his proposed bill to expand protections from anti-kickback laws and regulations, to provide safe harbor protection for gainsharing, and other incentive-payment systems.

SHM responded in July with a letter of support that thanked the congressman for his efforts.²

“We look forward to working with you,” the letter ended.

Dr. Ramenofsky says he’s proud his efforts led to a working relationship between his professional society and his local legislator. He says he’s looking forward to participating in future Hill Day activities and acting as a local liaison for SHM.

He laments that he has not received much post-meeting feedback from his discussions with the senators’ offices, but says he understands how busy politicians are. And a 1-for-3 showing is pretty good, given his status as a political novice.

“Given overall public perception of Congress, I’m amazed that my visits caused one of three offices to engage in further policy discussions with SHM,” he says. “I’m encouraged to remain engaged in political activities through SHM.”

Richard Quinn is a freelance writer in New Jersey.

References

1. Society of Hospital Medicine. Letter to Congress members. Society of Hospital Medicine website. Available at: http://www.hospitalmedicine.org/AM/Template.cfm?Section=Letters_to_Congress_and_ Regulatory_Agencies&Template=/CM/ContentDisplay.cfm&ContentID=33169. Accessed July 15, 2013.
2. Society of Hospital Medicine. Letter to Congressman Jim McDermott. Society of Hospital Medicine website. Available at: http://www.hospitalmedicine.org/AM/Template.cfm?Section=Letters_to_Congress_and_Regulatory_Agencies&Template=/CM/ContentDisplay.cfm&ContentID=34169. Accessed July 15, 2013.

On May 12, 113 hospitalists descended on Capitol Hill for “Hospitalists on the Hill 2013,” the public-advocacy highlight of SHM’s annual meeting. Hospitalists from all parts of the country engaged with congressional representatives in a daylong series of meet-and-greets that may seem to some people useless in the face of political obstinacy in Washington. But the trip worked.

Josh Boswell, SHM’s senior manager of government relations, reports many Hill Day objectives were achieved:

• The number of legislators co-sponsoring a bill regarding the “three-day observation rule” more than tripled in the House of Representatives and doubled in the Senate. SHM officials note that the added support has come from both political parties.
• A Congressional Budget Office (CBO) review of the bill has been formally requested by those legislators.
• A congressman from Washington state asked for—and received—a letter of support for a proposed measure, the Improved Health Care at a Lower Cost Act of 2013 (H.R. 1487).
• Multiple reports of continued dialogue between congressional staffers and SHM members nationwide. When planning the advocacy day, SHM officials noted that one of the most valuable results is creating relationships at the local level.

Observation Legislation

One of the three talking points hospitalists took into their legislative meetings was solving the dilemmas surrounding observation status. Currently, time spent on observation status does not count toward the required three consecutive overnights an inpatient needs to qualify for Medicare benefits at a skilled nursing facility (SNF).

Hospitalists have been pushing to change that rule, in large part by supporting the Improving Access to Medicare Coverage Act of 2013 (H.R. 1179, S. 569), sponsored by Rep. Joe Courtney (D-Conn.), Rep. Tom Latham (R-Iowa), and Sen. Sherrod Brown (D-Ohio).¹ In addition to the status reclassification, the proposal would establish a 90-day appeal period for those who have been denied the benefit.

The issue is important to hospitalists because of the penalties hospitals face for readmissions—and also in part because hospitalists increasingly are providing care at SNFs and other post-acute-care facilities. SHM says that after the Hill visits—and the ensuing follow-up communications—the number of co-sponsors in the House jumped to 70 from 22. The Senate version doubled its list of co-sponsors.

And, perhaps more important, a CBO analysis has been requested for the observation bills. That review, known as a CBO score, weighs the financial impacts of proposed laws and is considered a necessary precursor to successfully passing any legislation.

All in all, SHM was pleased with the progress on the observation-status bill and will continue to push for its passage, whether it is in this congressional session or the next.

“Rep. Courtney’s bill is now getting significant traction,” Boswell says. “Hospitalists should be proud to know this is in no small part due to their advocacy efforts.”

Political Networking

Hospitalist David Ramenofsky, MD, who works at Northwest Hospital and Medical Center in Seattle, wasn’t sure how much traction he was going to be able to generate at his first Hill Day. SHM had arranged meetings with the offices of three local politicians: Rep. Jim McDermott (D-Wash.), Sen. Patty Murray (D-Wash.), and Sen. Maria Cantwell (D-Wash.).

Dr. Ramenofsky sat with two of McDermott’s staffers, one of whom sounded knowledgeable and enthused about health-care-policy issues. Although the congressman couldn’t sit in on the meeting, he knew Dr. Ramenofsky’s name and took the time to say hello.

“It was really interesting to me that these staffers wanted to hear what I had to say and learn about my experience,” Dr. Ramenofsky adds. “My views may affect how they work with their bosses to make policy changes. It was surprising to me how much my opinions mattered to them.”

After the meeting and another briefing SHM arranged with another local hospitalist, McDermott reached out to SHM. He asked for support for his proposed bill to expand protections from anti-kickback laws and regulations, to provide safe harbor protection for gainsharing, and other incentive-payment systems.

SHM responded in July with a letter of support that thanked the congressman for his efforts.²

“We look forward to working with you,” the letter ended.

Dr. Ramenofsky says he’s proud his efforts led to a working relationship between his professional society and his local legislator. He says he’s looking forward to participating in future Hill Day activities and acting as a local liaison for SHM.

He laments that he has not received much post-meeting feedback from his discussions with the senators’ offices, but says he understands how busy politicians are. And a 1-for-3 showing is pretty good, given his status as a political novice.

“Given overall public perception of Congress, I’m amazed that my visits caused one of three offices to engage in further policy discussions with SHM,” he says. “I’m encouraged to remain engaged in political activities through SHM.”

Richard Quinn is a freelance writer in New Jersey.

References

1. Society of Hospital Medicine. Letter to Congress members. Society of Hospital Medicine website. Available at: http://www.hospitalmedicine.org/AM/Template.cfm?Section=Letters_to_Congress_and_ Regulatory_Agencies&Template=/CM/ContentDisplay.cfm&ContentID=33169. Accessed July 15, 2013.
2. Society of Hospital Medicine. Letter to Congressman Jim McDermott. Society of Hospital Medicine website. Available at: http://www.hospitalmedicine.org/AM/Template.cfm?Section=Letters_to_Congress_and_Regulatory_Agencies&Template=/CM/ContentDisplay.cfm&ContentID=34169. Accessed July 15, 2013.

On May 12, 113 hospitalists descended on Capitol Hill for “Hospitalists on the Hill 2013,” the public-advocacy highlight of SHM’s annual meeting. Hospitalists from all parts of the country engaged with congressional representatives in a daylong series of meet-and-greets that may seem to some people useless in the face of political obstinacy in Washington. But the trip worked.

Josh Boswell, SHM’s senior manager of government relations, reports many Hill Day objectives were achieved:

• The number of legislators co-sponsoring a bill regarding the “three-day observation rule” more than tripled in the House of Representatives and doubled in the Senate. SHM officials note that the added support has come from both political parties.
• A Congressional Budget Office (CBO) review of the bill has been formally requested by those legislators.
• A congressman from Washington state asked for—and received—a letter of support for a proposed measure, the Improved Health Care at a Lower Cost Act of 2013 (H.R. 1487).
• Multiple reports of continued dialogue between congressional staffers and SHM members nationwide. When planning the advocacy day, SHM officials noted that one of the most valuable results is creating relationships at the local level.

Observation Legislation

One of the three talking points hospitalists took into their legislative meetings was solving the dilemmas surrounding observation status. Currently, time spent on observation status does not count toward the required three consecutive overnights an inpatient needs to qualify for Medicare benefits at a skilled nursing facility (SNF).

Hospitalists have been pushing to change that rule, in large part by supporting the Improving Access to Medicare Coverage Act of 2013 (H.R. 1179, S. 569), sponsored by Rep. Joe Courtney (D-Conn.), Rep. Tom Latham (R-Iowa), and Sen. Sherrod Brown (D-Ohio).¹ In addition to the status reclassification, the proposal would establish a 90-day appeal period for those who have been denied the benefit.

The issue is important to hospitalists because of the penalties hospitals face for readmissions—and also in part because hospitalists increasingly are providing care at SNFs and other post-acute-care facilities. SHM says that after the Hill visits—and the ensuing follow-up communications—the number of co-sponsors in the House jumped to 70 from 22. The Senate version doubled its list of co-sponsors.

And, perhaps more important, a CBO analysis has been requested for the observation bills. That review, known as a CBO score, weighs the financial impacts of proposed laws and is considered a necessary precursor to successfully passing any legislation.

All in all, SHM was pleased with the progress on the observation-status bill and will continue to push for its passage, whether it is in this congressional session or the next.

“Rep. Courtney’s bill is now getting significant traction,” Boswell says. “Hospitalists should be proud to know this is in no small part due to their advocacy efforts.”

Political Networking

Hospitalist David Ramenofsky, MD, who works at Northwest Hospital and Medical Center in Seattle, wasn’t sure how much traction he was going to be able to generate at his first Hill Day. SHM had arranged meetings with the offices of three local politicians: Rep. Jim McDermott (D-Wash.), Sen. Patty Murray (D-Wash.), and Sen. Maria Cantwell (D-Wash.).

Dr. Ramenofsky sat with two of McDermott’s staffers, one of whom sounded knowledgeable and enthused about health-care-policy issues. Although the congressman couldn’t sit in on the meeting, he knew Dr. Ramenofsky’s name and took the time to say hello.

“It was really interesting to me that these staffers wanted to hear what I had to say and learn about my experience,” Dr. Ramenofsky adds. “My views may affect how they work with their bosses to make policy changes. It was surprising to me how much my opinions mattered to them.”

After the meeting and another briefing SHM arranged with another local hospitalist, McDermott reached out to SHM. He asked for support for his proposed bill to expand protections from anti-kickback laws and regulations, to provide safe harbor protection for gainsharing, and other incentive-payment systems.

SHM responded in July with a letter of support that thanked the congressman for his efforts.²

“We look forward to working with you,” the letter ended.

Dr. Ramenofsky says he’s proud his efforts led to a working relationship between his professional society and his local legislator. He says he’s looking forward to participating in future Hill Day activities and acting as a local liaison for SHM.

He laments that he has not received much post-meeting feedback from his discussions with the senators’ offices, but says he understands how busy politicians are. And a 1-for-3 showing is pretty good, given his status as a political novice.

“Given overall public perception of Congress, I’m amazed that my visits caused one of three offices to engage in further policy discussions with SHM,” he says. “I’m encouraged to remain engaged in political activities through SHM.”

Richard Quinn is a freelance writer in New Jersey.

References

1. Society of Hospital Medicine. Letter to Congress members. Society of Hospital Medicine website. Available at: http://www.hospitalmedicine.org/AM/Template.cfm?Section=Letters_to_Congress_and_ Regulatory_Agencies&Template=/CM/ContentDisplay.cfm&ContentID=33169. Accessed July 15, 2013.
2. Society of Hospital Medicine. Letter to Congressman Jim McDermott. Society of Hospital Medicine website. Available at: http://www.hospitalmedicine.org/AM/Template.cfm?Section=Letters_to_Congress_and_Regulatory_Agencies&Template=/CM/ContentDisplay.cfm&ContentID=34169. Accessed July 15, 2013.

There is little dispute in the potential for cost savings when gainsharing arrangements incentivize things like product standardization, substitution of lower-cost products, and, most notably for hospitalists, medically appropriate decreases in length of stay. However, well-meaning but overly inclusive federal law makes the legal risk of establishing these arrangements so great that providers recoil at the prospect.

This doesn’t mean that gainsharing isn’t occurring. Currently, Medicare accountable-care organizations (ACOs) have been granted official waivers to establish such arrangements; smaller-scale pilot projects implemented by Medicare also have been granted similar waivers in the past. As availability is limited to participants within officially sanctioned programs, most providers are not able to tap into these cost-saving efforts, though this has not been for lack of trying.

Hospitals and physicians are engaging in a number of clinical joint ventures that have spurred them to seek their own gainsharing waivers by approaching the Office of the Inspector General (OIG). The OIG is the arm of the U.S. Department of Health and Human Services charged with enforcing the applicable laws affecting gainsharing. The OIG responded by cautioning that gainsharing arrangements violate the Social Security Act’s “Civil Monetary Penalty” prohibition against limitation of services to publicly insured patients, in addition to violating the federal Anti-Kickback Law and possibly the “Stark” law. Nonetheless, the OIG concluded it would not impose sanctions for the violations. In short, the OIG declared the proposals illegal but gave the go-ahead. The caveat, of course, is that these opinions are nonbinding, so providers remain understandably timid.

As a result, gainsharing currently remains more or less out of reach for those not participating in a Medicare ACO. This makes little sense at a time when Medicare and the entire health-care system are focusing on how to deliver high-quality, cost-conscious care. For example, if hospitalists are capable of reducing length of stay without detriment to the patient, they should not be legally prohibited from sharing any of the resulting cost savings. Fortunately, U.S. Rep. Jim McDermott (D-Wash.) agrees with this sentiment and has introduced legislation to address the problem.

McDermott introduced the Improved Health Care at Lower Cost Act of 2013 (H.R. 1487) in April. It seeks to exempt monetary incentive payments made by hospitals to physicians from federal anti-kickback and other sanctions. Such exemptions, or safe harbors, would be automatically granted to gainsharing arrangements that meet a pre-determined set of requirements. This means no formal application process or participation in a specific federal program would be required.

Passage of the bill would be a major step in the right direction for providers lacking the resources to navigate legal minefields or establish a full-scale ACO. If well-implemented, it could also generate significant cost savings for Medicare.

It is for these reasons that SHM supports H.R. 1487 and looks forward to working with McDermott in securing its passage.

In the coming months, members of SHM’s Grassroots Network will be encouraging Congress to make this important change to facilitate practice arrangements that provide high-value coordinated care for patients. Stay informed and take action when SHM issues Legislative Action Alerts by signing up for the Grassroots Network at www.hospitalmedicine.org/grassroots.

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

There is little dispute in the potential for cost savings when gainsharing arrangements incentivize things like product standardization, substitution of lower-cost products, and, most notably for hospitalists, medically appropriate decreases in length of stay. However, well-meaning but overly inclusive federal law makes the legal risk of establishing these arrangements so great that providers recoil at the prospect.

This doesn’t mean that gainsharing isn’t occurring. Currently, Medicare accountable-care organizations (ACOs) have been granted official waivers to establish such arrangements; smaller-scale pilot projects implemented by Medicare also have been granted similar waivers in the past. As availability is limited to participants within officially sanctioned programs, most providers are not able to tap into these cost-saving efforts, though this has not been for lack of trying.

Hospitals and physicians are engaging in a number of clinical joint ventures that have spurred them to seek their own gainsharing waivers by approaching the Office of the Inspector General (OIG). The OIG is the arm of the U.S. Department of Health and Human Services charged with enforcing the applicable laws affecting gainsharing. The OIG responded by cautioning that gainsharing arrangements violate the Social Security Act’s “Civil Monetary Penalty” prohibition against limitation of services to publicly insured patients, in addition to violating the federal Anti-Kickback Law and possibly the “Stark” law. Nonetheless, the OIG concluded it would not impose sanctions for the violations. In short, the OIG declared the proposals illegal but gave the go-ahead. The caveat, of course, is that these opinions are nonbinding, so providers remain understandably timid.

As a result, gainsharing currently remains more or less out of reach for those not participating in a Medicare ACO. This makes little sense at a time when Medicare and the entire health-care system are focusing on how to deliver high-quality, cost-conscious care. For example, if hospitalists are capable of reducing length of stay without detriment to the patient, they should not be legally prohibited from sharing any of the resulting cost savings. Fortunately, U.S. Rep. Jim McDermott (D-Wash.) agrees with this sentiment and has introduced legislation to address the problem.

McDermott introduced the Improved Health Care at Lower Cost Act of 2013 (H.R. 1487) in April. It seeks to exempt monetary incentive payments made by hospitals to physicians from federal anti-kickback and other sanctions. Such exemptions, or safe harbors, would be automatically granted to gainsharing arrangements that meet a pre-determined set of requirements. This means no formal application process or participation in a specific federal program would be required.

Passage of the bill would be a major step in the right direction for providers lacking the resources to navigate legal minefields or establish a full-scale ACO. If well-implemented, it could also generate significant cost savings for Medicare.

It is for these reasons that SHM supports H.R. 1487 and looks forward to working with McDermott in securing its passage.

In the coming months, members of SHM’s Grassroots Network will be encouraging Congress to make this important change to facilitate practice arrangements that provide high-value coordinated care for patients. Stay informed and take action when SHM issues Legislative Action Alerts by signing up for the Grassroots Network at www.hospitalmedicine.org/grassroots.

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

There is little dispute in the potential for cost savings when gainsharing arrangements incentivize things like product standardization, substitution of lower-cost products, and, most notably for hospitalists, medically appropriate decreases in length of stay. However, well-meaning but overly inclusive federal law makes the legal risk of establishing these arrangements so great that providers recoil at the prospect.

This doesn’t mean that gainsharing isn’t occurring. Currently, Medicare accountable-care organizations (ACOs) have been granted official waivers to establish such arrangements; smaller-scale pilot projects implemented by Medicare also have been granted similar waivers in the past. As availability is limited to participants within officially sanctioned programs, most providers are not able to tap into these cost-saving efforts, though this has not been for lack of trying.

Hospitals and physicians are engaging in a number of clinical joint ventures that have spurred them to seek their own gainsharing waivers by approaching the Office of the Inspector General (OIG). The OIG is the arm of the U.S. Department of Health and Human Services charged with enforcing the applicable laws affecting gainsharing. The OIG responded by cautioning that gainsharing arrangements violate the Social Security Act’s “Civil Monetary Penalty” prohibition against limitation of services to publicly insured patients, in addition to violating the federal Anti-Kickback Law and possibly the “Stark” law. Nonetheless, the OIG concluded it would not impose sanctions for the violations. In short, the OIG declared the proposals illegal but gave the go-ahead. The caveat, of course, is that these opinions are nonbinding, so providers remain understandably timid.

As a result, gainsharing currently remains more or less out of reach for those not participating in a Medicare ACO. This makes little sense at a time when Medicare and the entire health-care system are focusing on how to deliver high-quality, cost-conscious care. For example, if hospitalists are capable of reducing length of stay without detriment to the patient, they should not be legally prohibited from sharing any of the resulting cost savings. Fortunately, U.S. Rep. Jim McDermott (D-Wash.) agrees with this sentiment and has introduced legislation to address the problem.

McDermott introduced the Improved Health Care at Lower Cost Act of 2013 (H.R. 1487) in April. It seeks to exempt monetary incentive payments made by hospitals to physicians from federal anti-kickback and other sanctions. Such exemptions, or safe harbors, would be automatically granted to gainsharing arrangements that meet a pre-determined set of requirements. This means no formal application process or participation in a specific federal program would be required.

Passage of the bill would be a major step in the right direction for providers lacking the resources to navigate legal minefields or establish a full-scale ACO. If well-implemented, it could also generate significant cost savings for Medicare.

It is for these reasons that SHM supports H.R. 1487 and looks forward to working with McDermott in securing its passage.

In the coming months, members of SHM’s Grassroots Network will be encouraging Congress to make this important change to facilitate practice arrangements that provide high-value coordinated care for patients. Stay informed and take action when SHM issues Legislative Action Alerts by signing up for the Grassroots Network at www.hospitalmedicine.org/grassroots.

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

click for large version

A shift in governmental regulations regarding reimbursement for hospital-acquired infections (HAIs) is forcing hospitals to take a closer look at how to reduce them. A recent study in Infection Control and Hospital Epidemiology shows that copper-alloy surfaces may be one such solution.³ According to the study, although only 9% of the touch surfaces in each ICU were replaced with copper components, there were 58% fewer HAI cases.¹

“Before these regulations, hospitals didn’t necessarily want technology to decrease HAI rates, because the more infections and complications, the longer the length of patient stay, the greater the reimbursement, and the better the bottom line,” says Archelle Georgiou, MD, president of Georgiou Consulting LLC in Minneapolis and an advisor to the Copper Development Association.

Three regulations that have resulted in reimbursements to hospitals getting cut include:

1. The Deficit Reduction Act of 2005, which was implemented on Oct. 1, 2008, which states that Medicare will not reimburse for certain types of HAIs;
2. Section 3025 of the Affordable Care Act (signed into law in 2010), which incentivizes hospitals to decrease their readmission rates, which frequently are caused by HAIs. Beginning this fall, hospitals are getting reduced reimbursement when their readmission rates exceed a certain threshold. The maximum penalty in 2013 is 1% and will increase to 3% by 2015; and
3. Section 1886 of the Affordable Care Act, which describes value-based purchasing and makes hospitals eligible to receive incentive payments for achieving better care on certain quality metrics. Funding for the program comes from withholding payment from poor-performing hospitals. The financial impact to hospitals started this year. In 2014, urinary tract infections and vascular-catheter-associated infections will be among the targeted conditions measured by CMS to calculate incentives and penalties.

“Hospitals are now feeling a direct impact from all of this,” Dr. Georgiou says. “Back in 2008, hospitals were noticing, but it was hard to get their attention since only one program was impacting their bottom line. But, pretty soon, hospitals risk losing upwards of 5% of their Medicare reimbursement for decreased quality.

“Reducing HAIs is clearly on the priority list of chief operating officers. They are very aware of the impact to their bottom line. They are looking to their vendors and suppliers to develop strategies to work with their hospitals to improve performance around these metrics.”

Karen Appold is a freelance writer in Pennsylvania.

click for large version

A shift in governmental regulations regarding reimbursement for hospital-acquired infections (HAIs) is forcing hospitals to take a closer look at how to reduce them. A recent study in Infection Control and Hospital Epidemiology shows that copper-alloy surfaces may be one such solution.³ According to the study, although only 9% of the touch surfaces in each ICU were replaced with copper components, there were 58% fewer HAI cases.¹

“Before these regulations, hospitals didn’t necessarily want technology to decrease HAI rates, because the more infections and complications, the longer the length of patient stay, the greater the reimbursement, and the better the bottom line,” says Archelle Georgiou, MD, president of Georgiou Consulting LLC in Minneapolis and an advisor to the Copper Development Association.

Three regulations that have resulted in reimbursements to hospitals getting cut include:

1. The Deficit Reduction Act of 2005, which was implemented on Oct. 1, 2008, which states that Medicare will not reimburse for certain types of HAIs;
2. Section 3025 of the Affordable Care Act (signed into law in 2010), which incentivizes hospitals to decrease their readmission rates, which frequently are caused by HAIs. Beginning this fall, hospitals are getting reduced reimbursement when their readmission rates exceed a certain threshold. The maximum penalty in 2013 is 1% and will increase to 3% by 2015; and
3. Section 1886 of the Affordable Care Act, which describes value-based purchasing and makes hospitals eligible to receive incentive payments for achieving better care on certain quality metrics. Funding for the program comes from withholding payment from poor-performing hospitals. The financial impact to hospitals started this year. In 2014, urinary tract infections and vascular-catheter-associated infections will be among the targeted conditions measured by CMS to calculate incentives and penalties.

“Hospitals are now feeling a direct impact from all of this,” Dr. Georgiou says. “Back in 2008, hospitals were noticing, but it was hard to get their attention since only one program was impacting their bottom line. But, pretty soon, hospitals risk losing upwards of 5% of their Medicare reimbursement for decreased quality.

“Reducing HAIs is clearly on the priority list of chief operating officers. They are very aware of the impact to their bottom line. They are looking to their vendors and suppliers to develop strategies to work with their hospitals to improve performance around these metrics.”

Karen Appold is a freelance writer in Pennsylvania.

click for large version

A shift in governmental regulations regarding reimbursement for hospital-acquired infections (HAIs) is forcing hospitals to take a closer look at how to reduce them. A recent study in Infection Control and Hospital Epidemiology shows that copper-alloy surfaces may be one such solution.³ According to the study, although only 9% of the touch surfaces in each ICU were replaced with copper components, there were 58% fewer HAI cases.¹

“Before these regulations, hospitals didn’t necessarily want technology to decrease HAI rates, because the more infections and complications, the longer the length of patient stay, the greater the reimbursement, and the better the bottom line,” says Archelle Georgiou, MD, president of Georgiou Consulting LLC in Minneapolis and an advisor to the Copper Development Association.

Three regulations that have resulted in reimbursements to hospitals getting cut include:

1. The Deficit Reduction Act of 2005, which was implemented on Oct. 1, 2008, which states that Medicare will not reimburse for certain types of HAIs;
2. Section 3025 of the Affordable Care Act (signed into law in 2010), which incentivizes hospitals to decrease their readmission rates, which frequently are caused by HAIs. Beginning this fall, hospitals are getting reduced reimbursement when their readmission rates exceed a certain threshold. The maximum penalty in 2013 is 1% and will increase to 3% by 2015; and
3. Section 1886 of the Affordable Care Act, which describes value-based purchasing and makes hospitals eligible to receive incentive payments for achieving better care on certain quality metrics. Funding for the program comes from withholding payment from poor-performing hospitals. The financial impact to hospitals started this year. In 2014, urinary tract infections and vascular-catheter-associated infections will be among the targeted conditions measured by CMS to calculate incentives and penalties.

“Hospitals are now feeling a direct impact from all of this,” Dr. Georgiou says. “Back in 2008, hospitals were noticing, but it was hard to get their attention since only one program was impacting their bottom line. But, pretty soon, hospitals risk losing upwards of 5% of their Medicare reimbursement for decreased quality.

“Reducing HAIs is clearly on the priority list of chief operating officers. They are very aware of the impact to their bottom line. They are looking to their vendors and suppliers to develop strategies to work with their hospitals to improve performance around these metrics.”

Karen Appold is a freelance writer in Pennsylvania.

Can quality measurement and comparisons serve as the backbone for a major shift in the Medicare payment system to reward value instead of volume? That is the question being explored over the next few years as the Physician Quality Reporting System (PQRS) and, by extension, the physician value-based payment modifier (VBPM) come fully into effect for all physicians.

There seems to be a consensus in the policy community that the fee-for-service model of payment is past its prime and needs to be replaced with a more dynamic and responsive payment system. Medicare hopes that PQRS and the VBPM will enable adjustments to physician payments to reward high-quality and low-cost care. Although these programs currently are add-ons to the fee-for-service system, they likely will serve as stepping stones to more radical departures from the existing payment system.

SHM advocates refinements to policies for PQRS and similar programs to make them more meaningful and productive for both hospitalists and the broader health-care system. Each year, SHM submits comments on the Physician Fee Schedule Rule, which creates and updates the regulatory framework for PQRS and the VBPM. SHM also provided feedback on Quality and Resource Use Reports (QRURs), the report cards for the modifier that were being tested over the past year.

From a practical standpoint, SHM engages with measure development and endorsement processes to ensure there are reportable quality measures in PQRS that fit hospitalist practice. In addition, SHM is helping to increase accessibility to PQRS reporting by offering members reduced fare access to registry reporting through the PQRI Wizard.

The comments range from the technical aspects of individual quality measures in PQRS to how hospitalists appear to be performing in these programs. SHM firmly believes that the unique positioning of hospitalists within the health-care system presents challenges for their identification and evaluation in Medicare programs. In some sense, hospitalists exist on the line between the inpatient and outpatient worlds, a location not adequately captured in pay-for-performance programs.

It’s imperative that pay-for-performance programs have reasonable and actionable outcomes for providers. If quality measures are not clinically meaningful and do not capture a plurality of the care provided by an individual hospitalist, it is difficult for the program to meet its stated aims. If payment is to be influenced by performance on quality measures, it follows that those measures should be relevant to the care provided.

There is a long way to go toward creating quality measurement and evaluation programs that are relevant and actionable for clinical quality improvement (QI). By becoming involved in SHM’s policy efforts, members are able to share their experiences and impressions of programs with SHM and lawmakers. This partnership helps create more responsive and intuitive programs, which in turn leads to greater participation and, hopefully, improved patient outcomes. As these programs continue to evolve and more health professionals are required to participate, SHM will be looking to its membership for their perspectives.

Join the grassroots network to stay involved and up to date by registering at www.hospitalmedicine.org/grassroots.

Joshua Lapps is SHM’s government relations specialist.

Can quality measurement and comparisons serve as the backbone for a major shift in the Medicare payment system to reward value instead of volume? That is the question being explored over the next few years as the Physician Quality Reporting System (PQRS) and, by extension, the physician value-based payment modifier (VBPM) come fully into effect for all physicians.

There seems to be a consensus in the policy community that the fee-for-service model of payment is past its prime and needs to be replaced with a more dynamic and responsive payment system. Medicare hopes that PQRS and the VBPM will enable adjustments to physician payments to reward high-quality and low-cost care. Although these programs currently are add-ons to the fee-for-service system, they likely will serve as stepping stones to more radical departures from the existing payment system.

SHM advocates refinements to policies for PQRS and similar programs to make them more meaningful and productive for both hospitalists and the broader health-care system. Each year, SHM submits comments on the Physician Fee Schedule Rule, which creates and updates the regulatory framework for PQRS and the VBPM. SHM also provided feedback on Quality and Resource Use Reports (QRURs), the report cards for the modifier that were being tested over the past year.

From a practical standpoint, SHM engages with measure development and endorsement processes to ensure there are reportable quality measures in PQRS that fit hospitalist practice. In addition, SHM is helping to increase accessibility to PQRS reporting by offering members reduced fare access to registry reporting through the PQRI Wizard.

The comments range from the technical aspects of individual quality measures in PQRS to how hospitalists appear to be performing in these programs. SHM firmly believes that the unique positioning of hospitalists within the health-care system presents challenges for their identification and evaluation in Medicare programs. In some sense, hospitalists exist on the line between the inpatient and outpatient worlds, a location not adequately captured in pay-for-performance programs.

It’s imperative that pay-for-performance programs have reasonable and actionable outcomes for providers. If quality measures are not clinically meaningful and do not capture a plurality of the care provided by an individual hospitalist, it is difficult for the program to meet its stated aims. If payment is to be influenced by performance on quality measures, it follows that those measures should be relevant to the care provided.

There is a long way to go toward creating quality measurement and evaluation programs that are relevant and actionable for clinical quality improvement (QI). By becoming involved in SHM’s policy efforts, members are able to share their experiences and impressions of programs with SHM and lawmakers. This partnership helps create more responsive and intuitive programs, which in turn leads to greater participation and, hopefully, improved patient outcomes. As these programs continue to evolve and more health professionals are required to participate, SHM will be looking to its membership for their perspectives.

Join the grassroots network to stay involved and up to date by registering at www.hospitalmedicine.org/grassroots.

Joshua Lapps is SHM’s government relations specialist.

Can quality measurement and comparisons serve as the backbone for a major shift in the Medicare payment system to reward value instead of volume? That is the question being explored over the next few years as the Physician Quality Reporting System (PQRS) and, by extension, the physician value-based payment modifier (VBPM) come fully into effect for all physicians.

There seems to be a consensus in the policy community that the fee-for-service model of payment is past its prime and needs to be replaced with a more dynamic and responsive payment system. Medicare hopes that PQRS and the VBPM will enable adjustments to physician payments to reward high-quality and low-cost care. Although these programs currently are add-ons to the fee-for-service system, they likely will serve as stepping stones to more radical departures from the existing payment system.

SHM advocates refinements to policies for PQRS and similar programs to make them more meaningful and productive for both hospitalists and the broader health-care system. Each year, SHM submits comments on the Physician Fee Schedule Rule, which creates and updates the regulatory framework for PQRS and the VBPM. SHM also provided feedback on Quality and Resource Use Reports (QRURs), the report cards for the modifier that were being tested over the past year.

From a practical standpoint, SHM engages with measure development and endorsement processes to ensure there are reportable quality measures in PQRS that fit hospitalist practice. In addition, SHM is helping to increase accessibility to PQRS reporting by offering members reduced fare access to registry reporting through the PQRI Wizard.

The comments range from the technical aspects of individual quality measures in PQRS to how hospitalists appear to be performing in these programs. SHM firmly believes that the unique positioning of hospitalists within the health-care system presents challenges for their identification and evaluation in Medicare programs. In some sense, hospitalists exist on the line between the inpatient and outpatient worlds, a location not adequately captured in pay-for-performance programs.

It’s imperative that pay-for-performance programs have reasonable and actionable outcomes for providers. If quality measures are not clinically meaningful and do not capture a plurality of the care provided by an individual hospitalist, it is difficult for the program to meet its stated aims. If payment is to be influenced by performance on quality measures, it follows that those measures should be relevant to the care provided.

There is a long way to go toward creating quality measurement and evaluation programs that are relevant and actionable for clinical quality improvement (QI). By becoming involved in SHM’s policy efforts, members are able to share their experiences and impressions of programs with SHM and lawmakers. This partnership helps create more responsive and intuitive programs, which in turn leads to greater participation and, hopefully, improved patient outcomes. As these programs continue to evolve and more health professionals are required to participate, SHM will be looking to its membership for their perspectives.

Join the grassroots network to stay involved and up to date by registering at www.hospitalmedicine.org/grassroots.

Joshua Lapps is SHM’s government relations specialist.

An electronic health record (EHR)—sometimes called an electronic medical record (EMR)—allows health-care providers to record patient information electronically instead of using paper records.¹ It also has the capability to perform various tasks that can assist in health-care delivery while maintaining standards of practice. The Health Information Technology for Economic and Clinical Health (HITECH) Act, enacted under the American Recovery and Reinvestment Act of 2009 (Recovery Act), established a provision for incentive payments for eligible professionals (EPs), critical-access hospitals (CAHs), and eligible hospitals if they can demonstrate meaningful use of certified EHR technology:²

• The use of a certified EHR in a meaningful manner (e.g. e-prescribing);
• The use of certified EHR technology for electronic exchange of health information to improve quality of health care; and
• The use of certified EHR technology to submit clinical quality and other measures.

Eligible professionals must satisfy 20 of 25 meaningful-use objectives (15 required core objectives and five objectives chosen from a list of 10 menu-set objectives).³ Eligible hospitals and CAHs must achieve 19 of 24 objectives (14 required core objectives and five objectives chosen from a list of 10 menu-set objectives).³

It seems that any program implementation with the potential to generate new or additional payment also has the potential to generate new or additional scrutiny of its application to ensure the generated payment is appropriate.⁵ Issues with EHR that recently have been highlighted include copy-and-paste, pulling notes forward, and upcoding based on volume instead of necessity.

Consider the Case

A patient is admitted to the hospital for pain, warmth, and swelling in the left lower extremity; r/o deep vein thrombosis (DVT) versus cellulitis. The patient’s history includes peripheral vascular disease (PVD), chronic renal insufficiency (CRI), and allergic rhinitis (AR). Testing confirms DVT, and the patient begins anticoagulation therapy. To achieve a therapeutic balance and prevent adverse reactions, the hospitalist orders INR monitoring.

On admission, the complexity of the patient’s condition may be considered high given the nature of the presenting problem.⁴ The hospitalist receives extensive credit for developing a care plan involving differential diagnoses with additional testing in anticipation of confirming a diagnosis. The patient’s presenting problem elevates the risk of morbidity/mortality, while the determined course of anticoagulation therapy places the patient at increased (i.e. “high”) risk for bleeding and requires intensive monitoring for toxicity. In this instance, 99223 may be warranted if the documentation requirements corresponding to this visit level have been satisfied.

As subsequent hospital days ensue, the complexity of the patient’s condition may not be as high. Even though the risk of anticoagulation remains high, the number of diagnoses and/or data ordered/reviewed may be less extensive than the initial encounter. Therefore, without any new or additional factors, the overall complexity of decision-making may be more appropriately categorized as moderate or low (e.g. 99232 or 99231, respectively).⁴

Do not fall victim to shortcuts that may falsely ease the workload of the overburdened physician. For example, the patient’s co-existing conditions of PVD, CRI, and AR likely were addressed during the initial encounter for DVT with inclusion in the plan of care. When using an electronic documentation system, it might be possible to copy the previously entered information from the initial encounter into the current encounter to save time. However, the previously entered information could include elements that do not need to be re-addressed during a subsequent encounter (e.g., AR) or yield information involving care for conditions that are being managed concurrently by another specialist (e.g. CRI being managed by the nephrologist).

Leaving the pasted information unaltered, without modification, can misrepresent the patient’s condition or the care provided by the hospitalist during the subsequent encounter.

Preventative Measures

Documentation should support the service provided on a given date, and the information included in the entry should reflect the content that was rendered and/or considered for assessment and management. Information that is pulled forward or copied and pasted from a previous entry should be modified to demonstrate updated content and nonoverlapping care with relevance for that date.

Do not use coding tools, or EHR “service calculators,” that override medical decision-making to determine the service level. Determining the service level for a particular CPT code category depends upon the key components of history, exam, and medical decision-making (MDM).⁴ For some code categories, each of the three key components must meet the documentation guidelines for the corresponding visit level (i.e. initial hospital care, initial observation care, and consultations). If all three components do not satisfy the requirements for a particular visit level, code selection is determined by the lowest component. For example, the physician must select 99221 when documenting a detailed history despite having also documented a comprehensive exam and high complexity decision-making. In other code categories, coding principles require that only two key components need to meet the documentation guidelines (i.e. subsequent hospital care and subsequent observation care) for code selection.

More specifically, code selection is determined by the second-lowest component. For example, the physician may appropriately select 99233 when only documenting a brief history after having also documented a detailed exam and high complexity decision-making. Based on this “two of three” stipulation, 99233 is acceptable. Service calculators that override MDM as one of the two supporting components in subsequent care services could generate 99233 for a service involving a detailed history and a detailed exam but only low complexity decision-making. Such coding practice can leave the hospitalist vulnerable to external inquiries involving medical necessity and upcoding. Despite this “two component” technicality with subsequent services (99231-99233 and 99224-99226), MDM always should be one of the two key components considered during subsequent visit level selection as it most clearly conveys the medical necessity of the encounter.

References

1. Centers for Medicare & Medicaid Services. The official web site for the Medicare and Medicaid electronic health records (EHR) incentive programs. Centers for Medicare & Medicaid Services website. Available at: http://www.cms.gov/Regulations-and-Guidance/Legislation/EHRIncentivePrograms/index.html?redirect=/ehrincentiveprograms/. Accessed March 10, 2013.
2. Centers for Medicare & Medicaid Services. Frequently asked questions (FAQs). Centers for Medicare & Medicaid Services website. Available at: http://www.cms.gov/Regulations-and-Guidance/Legislation/EHRIncentivePrograms/FAQ.html. Accessed March 10, 2013.
3. Centers for Medicare & Medicaid Services. Meaningful use. Centers for Medicare & Medicaid Services website. Available at: http://www.cms.gov/Regulations-and-Guidance/Legislation/EHRIncentivePrograms/Meaningful_Use.html. Accessed March 10, 2013.
4. Abraham M, Ahlman J, Anderson C, Boudreau A, Connelly J. Current Procedural Terminology 2012 Professional Edition. Chicago: American Medical Association Press; 2011:13-17.
5. U.S. Department of Health and Human Services. Office of Inspector General work plan fiscal year 2013. U.S. Department of Health and Human Services website. Available at: http://oig.hhs.gov/reports-and-publications/archives/workplan/2013/Work-Plan-2013.pdf. Accessed March 11, 2013.

An electronic health record (EHR)—sometimes called an electronic medical record (EMR)—allows health-care providers to record patient information electronically instead of using paper records.¹ It also has the capability to perform various tasks that can assist in health-care delivery while maintaining standards of practice. The Health Information Technology for Economic and Clinical Health (HITECH) Act, enacted under the American Recovery and Reinvestment Act of 2009 (Recovery Act), established a provision for incentive payments for eligible professionals (EPs), critical-access hospitals (CAHs), and eligible hospitals if they can demonstrate meaningful use of certified EHR technology:²

• The use of a certified EHR in a meaningful manner (e.g. e-prescribing);
• The use of certified EHR technology for electronic exchange of health information to improve quality of health care; and
• The use of certified EHR technology to submit clinical quality and other measures.

Eligible professionals must satisfy 20 of 25 meaningful-use objectives (15 required core objectives and five objectives chosen from a list of 10 menu-set objectives).³ Eligible hospitals and CAHs must achieve 19 of 24 objectives (14 required core objectives and five objectives chosen from a list of 10 menu-set objectives).³

It seems that any program implementation with the potential to generate new or additional payment also has the potential to generate new or additional scrutiny of its application to ensure the generated payment is appropriate.⁵ Issues with EHR that recently have been highlighted include copy-and-paste, pulling notes forward, and upcoding based on volume instead of necessity.

Consider the Case

A patient is admitted to the hospital for pain, warmth, and swelling in the left lower extremity; r/o deep vein thrombosis (DVT) versus cellulitis. The patient’s history includes peripheral vascular disease (PVD), chronic renal insufficiency (CRI), and allergic rhinitis (AR). Testing confirms DVT, and the patient begins anticoagulation therapy. To achieve a therapeutic balance and prevent adverse reactions, the hospitalist orders INR monitoring.

On admission, the complexity of the patient’s condition may be considered high given the nature of the presenting problem.⁴ The hospitalist receives extensive credit for developing a care plan involving differential diagnoses with additional testing in anticipation of confirming a diagnosis. The patient’s presenting problem elevates the risk of morbidity/mortality, while the determined course of anticoagulation therapy places the patient at increased (i.e. “high”) risk for bleeding and requires intensive monitoring for toxicity. In this instance, 99223 may be warranted if the documentation requirements corresponding to this visit level have been satisfied.

As subsequent hospital days ensue, the complexity of the patient’s condition may not be as high. Even though the risk of anticoagulation remains high, the number of diagnoses and/or data ordered/reviewed may be less extensive than the initial encounter. Therefore, without any new or additional factors, the overall complexity of decision-making may be more appropriately categorized as moderate or low (e.g. 99232 or 99231, respectively).⁴

Do not fall victim to shortcuts that may falsely ease the workload of the overburdened physician. For example, the patient’s co-existing conditions of PVD, CRI, and AR likely were addressed during the initial encounter for DVT with inclusion in the plan of care. When using an electronic documentation system, it might be possible to copy the previously entered information from the initial encounter into the current encounter to save time. However, the previously entered information could include elements that do not need to be re-addressed during a subsequent encounter (e.g., AR) or yield information involving care for conditions that are being managed concurrently by another specialist (e.g. CRI being managed by the nephrologist).

Leaving the pasted information unaltered, without modification, can misrepresent the patient’s condition or the care provided by the hospitalist during the subsequent encounter.

Preventative Measures

Documentation should support the service provided on a given date, and the information included in the entry should reflect the content that was rendered and/or considered for assessment and management. Information that is pulled forward or copied and pasted from a previous entry should be modified to demonstrate updated content and nonoverlapping care with relevance for that date.

Do not use coding tools, or EHR “service calculators,” that override medical decision-making to determine the service level. Determining the service level for a particular CPT code category depends upon the key components of history, exam, and medical decision-making (MDM).⁴ For some code categories, each of the three key components must meet the documentation guidelines for the corresponding visit level (i.e. initial hospital care, initial observation care, and consultations). If all three components do not satisfy the requirements for a particular visit level, code selection is determined by the lowest component. For example, the physician must select 99221 when documenting a detailed history despite having also documented a comprehensive exam and high complexity decision-making. In other code categories, coding principles require that only two key components need to meet the documentation guidelines (i.e. subsequent hospital care and subsequent observation care) for code selection.

More specifically, code selection is determined by the second-lowest component. For example, the physician may appropriately select 99233 when only documenting a brief history after having also documented a detailed exam and high complexity decision-making. Based on this “two of three” stipulation, 99233 is acceptable. Service calculators that override MDM as one of the two supporting components in subsequent care services could generate 99233 for a service involving a detailed history and a detailed exam but only low complexity decision-making. Such coding practice can leave the hospitalist vulnerable to external inquiries involving medical necessity and upcoding. Despite this “two component” technicality with subsequent services (99231-99233 and 99224-99226), MDM always should be one of the two key components considered during subsequent visit level selection as it most clearly conveys the medical necessity of the encounter.

References

1. Centers for Medicare & Medicaid Services. The official web site for the Medicare and Medicaid electronic health records (EHR) incentive programs. Centers for Medicare & Medicaid Services website. Available at: http://www.cms.gov/Regulations-and-Guidance/Legislation/EHRIncentivePrograms/index.html?redirect=/ehrincentiveprograms/. Accessed March 10, 2013.
2. Centers for Medicare & Medicaid Services. Frequently asked questions (FAQs). Centers for Medicare & Medicaid Services website. Available at: http://www.cms.gov/Regulations-and-Guidance/Legislation/EHRIncentivePrograms/FAQ.html. Accessed March 10, 2013.
3. Centers for Medicare & Medicaid Services. Meaningful use. Centers for Medicare & Medicaid Services website. Available at: http://www.cms.gov/Regulations-and-Guidance/Legislation/EHRIncentivePrograms/Meaningful_Use.html. Accessed March 10, 2013.
4. Abraham M, Ahlman J, Anderson C, Boudreau A, Connelly J. Current Procedural Terminology 2012 Professional Edition. Chicago: American Medical Association Press; 2011:13-17.
5. U.S. Department of Health and Human Services. Office of Inspector General work plan fiscal year 2013. U.S. Department of Health and Human Services website. Available at: http://oig.hhs.gov/reports-and-publications/archives/workplan/2013/Work-Plan-2013.pdf. Accessed March 11, 2013.

An electronic health record (EHR)—sometimes called an electronic medical record (EMR)—allows health-care providers to record patient information electronically instead of using paper records.¹ It also has the capability to perform various tasks that can assist in health-care delivery while maintaining standards of practice. The Health Information Technology for Economic and Clinical Health (HITECH) Act, enacted under the American Recovery and Reinvestment Act of 2009 (Recovery Act), established a provision for incentive payments for eligible professionals (EPs), critical-access hospitals (CAHs), and eligible hospitals if they can demonstrate meaningful use of certified EHR technology:²

• The use of a certified EHR in a meaningful manner (e.g. e-prescribing);
• The use of certified EHR technology for electronic exchange of health information to improve quality of health care; and
• The use of certified EHR technology to submit clinical quality and other measures.

Eligible professionals must satisfy 20 of 25 meaningful-use objectives (15 required core objectives and five objectives chosen from a list of 10 menu-set objectives).³ Eligible hospitals and CAHs must achieve 19 of 24 objectives (14 required core objectives and five objectives chosen from a list of 10 menu-set objectives).³

It seems that any program implementation with the potential to generate new or additional payment also has the potential to generate new or additional scrutiny of its application to ensure the generated payment is appropriate.⁵ Issues with EHR that recently have been highlighted include copy-and-paste, pulling notes forward, and upcoding based on volume instead of necessity.

Consider the Case

A patient is admitted to the hospital for pain, warmth, and swelling in the left lower extremity; r/o deep vein thrombosis (DVT) versus cellulitis. The patient’s history includes peripheral vascular disease (PVD), chronic renal insufficiency (CRI), and allergic rhinitis (AR). Testing confirms DVT, and the patient begins anticoagulation therapy. To achieve a therapeutic balance and prevent adverse reactions, the hospitalist orders INR monitoring.

On admission, the complexity of the patient’s condition may be considered high given the nature of the presenting problem.⁴ The hospitalist receives extensive credit for developing a care plan involving differential diagnoses with additional testing in anticipation of confirming a diagnosis. The patient’s presenting problem elevates the risk of morbidity/mortality, while the determined course of anticoagulation therapy places the patient at increased (i.e. “high”) risk for bleeding and requires intensive monitoring for toxicity. In this instance, 99223 may be warranted if the documentation requirements corresponding to this visit level have been satisfied.

As subsequent hospital days ensue, the complexity of the patient’s condition may not be as high. Even though the risk of anticoagulation remains high, the number of diagnoses and/or data ordered/reviewed may be less extensive than the initial encounter. Therefore, without any new or additional factors, the overall complexity of decision-making may be more appropriately categorized as moderate or low (e.g. 99232 or 99231, respectively).⁴

Do not fall victim to shortcuts that may falsely ease the workload of the overburdened physician. For example, the patient’s co-existing conditions of PVD, CRI, and AR likely were addressed during the initial encounter for DVT with inclusion in the plan of care. When using an electronic documentation system, it might be possible to copy the previously entered information from the initial encounter into the current encounter to save time. However, the previously entered information could include elements that do not need to be re-addressed during a subsequent encounter (e.g., AR) or yield information involving care for conditions that are being managed concurrently by another specialist (e.g. CRI being managed by the nephrologist).

Leaving the pasted information unaltered, without modification, can misrepresent the patient’s condition or the care provided by the hospitalist during the subsequent encounter.

Preventative Measures

Documentation should support the service provided on a given date, and the information included in the entry should reflect the content that was rendered and/or considered for assessment and management. Information that is pulled forward or copied and pasted from a previous entry should be modified to demonstrate updated content and nonoverlapping care with relevance for that date.

Do not use coding tools, or EHR “service calculators,” that override medical decision-making to determine the service level. Determining the service level for a particular CPT code category depends upon the key components of history, exam, and medical decision-making (MDM).⁴ For some code categories, each of the three key components must meet the documentation guidelines for the corresponding visit level (i.e. initial hospital care, initial observation care, and consultations). If all three components do not satisfy the requirements for a particular visit level, code selection is determined by the lowest component. For example, the physician must select 99221 when documenting a detailed history despite having also documented a comprehensive exam and high complexity decision-making. In other code categories, coding principles require that only two key components need to meet the documentation guidelines (i.e. subsequent hospital care and subsequent observation care) for code selection.

More specifically, code selection is determined by the second-lowest component. For example, the physician may appropriately select 99233 when only documenting a brief history after having also documented a detailed exam and high complexity decision-making. Based on this “two of three” stipulation, 99233 is acceptable. Service calculators that override MDM as one of the two supporting components in subsequent care services could generate 99233 for a service involving a detailed history and a detailed exam but only low complexity decision-making. Such coding practice can leave the hospitalist vulnerable to external inquiries involving medical necessity and upcoding. Despite this “two component” technicality with subsequent services (99231-99233 and 99224-99226), MDM always should be one of the two key components considered during subsequent visit level selection as it most clearly conveys the medical necessity of the encounter.

References

1. Centers for Medicare & Medicaid Services. The official web site for the Medicare and Medicaid electronic health records (EHR) incentive programs. Centers for Medicare & Medicaid Services website. Available at: http://www.cms.gov/Regulations-and-Guidance/Legislation/EHRIncentivePrograms/index.html?redirect=/ehrincentiveprograms/. Accessed March 10, 2013.
2. Centers for Medicare & Medicaid Services. Frequently asked questions (FAQs). Centers for Medicare & Medicaid Services website. Available at: http://www.cms.gov/Regulations-and-Guidance/Legislation/EHRIncentivePrograms/FAQ.html. Accessed March 10, 2013.
3. Centers for Medicare & Medicaid Services. Meaningful use. Centers for Medicare & Medicaid Services website. Available at: http://www.cms.gov/Regulations-and-Guidance/Legislation/EHRIncentivePrograms/Meaningful_Use.html. Accessed March 10, 2013.
4. Abraham M, Ahlman J, Anderson C, Boudreau A, Connelly J. Current Procedural Terminology 2012 Professional Edition. Chicago: American Medical Association Press; 2011:13-17.
5. U.S. Department of Health and Human Services. Office of Inspector General work plan fiscal year 2013. U.S. Department of Health and Human Services website. Available at: http://oig.hhs.gov/reports-and-publications/archives/workplan/2013/Work-Plan-2013.pdf. Accessed March 11, 2013.