Public Policy

Ibe Mbanu, MD, MBA, MPH, became medical director of the adult hospitalist department at Bon Secours St. Mary’s Hospital in Richmond, Va., about six months ago. Since then, he’s been besieged by a torrent of reform-based challenges he says make his job exponentially more difficult than that of medical directors just a few years ago.

Accountable-care organizations (ACOs), value-based purchasing, and discussions about bundled payments for episodic care are changing rapidly, and as a new administrator in a group with 24 hospitalists and three nonphysician providers (NPPs), he felt he needed to attend his first SHM annual meeting to keep up.

“The landscape in health care is rapidly evolving, at a frantic pace,” Dr. Mbanu says. “I essentially came here to just try to get a condensed source of information on how to manage the changes that are coming through the pipeline, and how to effectively run my department.”

Managing a practice is a challenge, and many of the more than 2,700 attendees at HM13 said the four-day confab’s focus on the topic was a major draw. From a rebooted continuing medical education (CME) pre-course appropriately named “What Keeps You Awake at Night? Hot Topics in Hospitalist Practice Management” to dozens of breakout sessions on the topic, it’s clear that successful practice management is a concern for many hospitalists.

“Before, the drivers were pretty clear,” Dr. Mbanu says. “Volume, productivity. Now we’re switching more toward a business model that’s changing from volume to value. Trying to adapt to that change is pretty challenging.

“Now it’s critical to really understand the environment.”

Comanagement Conundrum

One particularly hot topic this year was the trend of hospitalists taking on more comanagement responsibilities for patients previously managed by other specialties, including neurology, surgery, and others. Frank Volpicelli, MD, a first-year hospitalist and instructor at New York University (NYU) Langone Medical Center in New York, was one of three members of his HM group that attended the “Perioperative Medicine: Medical Consultation and Co-Management” pre-course. This summer, his group is going to establish a presence in the preoperative clinic.

“We hope very strongly that we can prevent some complications, identify patients that we should be following when they come into the hospital, and help the surgeons out,” he says. “No. 1, keep them in the [operating room] more, and No. 2, get in front of some of the complications that they are less comfortable managing.”

Ralph Velazquez, MD, senior vice president of care management for OSF Healthcare System in Peoria, Ill., isn’t so sure comanagement of more and more patients is the best practice-management model moving forward. For example, as physician compensation is tied more to how much their care costs to deliver, a hospitalist comanaging a surgical patient’s elective knee replacement could be financially penalized for the cost of that person’s stay, despite having nothing to do with the most expensive portion of the bill.

“You have a financial model that says do more billings, but as you start developing analytics … you may see there is no difference between the model that’s doing more billing, in terms of improving quality, and the one that is doing less,” Dr. Velazquez says. “So if you’re getting the same amount of quality, and the only thing you’re doing is generating more cost by doing more billing, you need to reevaluate your strategy.”

He believes some patients benefit from comanagement, but HM groups have to be diligent in seeking them out.

“We look for simple solutions and one-size-fits-all,” he adds. “Comanagement in complex patients—definitely there’s a need for that. Comanagement in noncomplex patients, elective patients—there’s no need for that. It’s just additional cost. I don’t think it’s going to produce any value.”

Startup Academy

John Colombo, MD, FACP, a 30-year veteran of internal medicine who moved to HM a few years ago when one of the hospitals he worked at asked him to launch a hospitalist group, thinks bundled payments might alleviate that value conundrum. Then again, he’s not quite sure. That’s why attended his first annual meeting.

“I found it difficult starting a new program from scratch,” says Dr. Colombo, of Crozer Keystone Health System in Drexel Hill, Pa. “Even with the materials available, there’s not a lot of ‘how to do it’ out there. There’s no ‘Starting Hospitals for Dummies’ book.”

Dr. Colombo spent much of his meeting focused on recruiting, compensation, bonus structures, and scheduling concerns. He said all are important in the hospital-heavy metropolitan Philadelphia region where he works. Plus, with departures and retirements at other programs in his health system, Dr. Colombo went from no HM experience three years ago to being in charge of four HM programs.

“The biggest thing is, I wanted to make sure I hadn’t stepped in something that I shouldn’t have already,” he adds. “There’s many different ways to do things. So I’ve learned a few different ways. I found value.”

Demonstrate Value

Another way to discover value in running a practice is looking at the business side of the house, says Denice Cora-Bramble, MD, MBA, chief medical officer and executive vice president of Ambulatory & Community Health Services at the Children’s National Medical Center in Washington, D.C.

Dr. Bramble says many hospitalists need to understand that while clinical care is what brought them to medicine, their future paychecks depend on recognizing how to provide that care in a way that demonstrates business value.

“When you finish residency, if you have not intentionally sought out those courses or those seminars, you need to recognize that as a blind spot,” she says. “You need to fill that toolkit as it relates to the business side of medicine.

“You don’t necessarily have to know all the answers, but you need to know the right questions to ask,” she says.

Dr. Bramble adds that hospitalist leaders should take advantage of certificate programs, leadership courses, basic budgeting classes, or anything that gives them added education about the economics of healthcare.

“It all comes down to demonstrating your outcomes, demonstrating the value that you bring to that institution,” she says. “And with health-care reform, I think hospitalists are uniquely positioned to be able to partner with other areas of the hospital to look at this value-based approach.”

Gary Gammon, MD, FHM, the newly named medical director of the Hospitalist Service at FirstHealth Moore Regional Hospital in Pinehurst, N.C., is doing his part to demonstrate value to his administrators. While his group does multidisciplinary rounds on patients, one of his questions for the pre-course faculty was to make sure that system of rounding is an evidence-based practice. He’s also looking for ways to establish more hegemony to his practice to ensure the rounds are effective, regardless of which physicians and others are participating.

The feedback he received was that most people view multidisciplinary rounds as a best practice. Now, Dr. Gammon can feel more authoritative that he and his 32 hospitalists and 12 extenders are practicing HM the way it should be practiced.

“I wanted to hear just what I heard, which is the leaders in the community feel that it’s helping, feel that it’s the right thing to do, feel that there’s objective data,” he says. “This is the stuff that makes me say, ‘OK, I’ve got the same problems everybody else has.’”

Richard Quinn is a freelance writer in New Jersey.

Ibe Mbanu, MD, MBA, MPH, became medical director of the adult hospitalist department at Bon Secours St. Mary’s Hospital in Richmond, Va., about six months ago. Since then, he’s been besieged by a torrent of reform-based challenges he says make his job exponentially more difficult than that of medical directors just a few years ago.

Accountable-care organizations (ACOs), value-based purchasing, and discussions about bundled payments for episodic care are changing rapidly, and as a new administrator in a group with 24 hospitalists and three nonphysician providers (NPPs), he felt he needed to attend his first SHM annual meeting to keep up.

“The landscape in health care is rapidly evolving, at a frantic pace,” Dr. Mbanu says. “I essentially came here to just try to get a condensed source of information on how to manage the changes that are coming through the pipeline, and how to effectively run my department.”

Managing a practice is a challenge, and many of the more than 2,700 attendees at HM13 said the four-day confab’s focus on the topic was a major draw. From a rebooted continuing medical education (CME) pre-course appropriately named “What Keeps You Awake at Night? Hot Topics in Hospitalist Practice Management” to dozens of breakout sessions on the topic, it’s clear that successful practice management is a concern for many hospitalists.

“Before, the drivers were pretty clear,” Dr. Mbanu says. “Volume, productivity. Now we’re switching more toward a business model that’s changing from volume to value. Trying to adapt to that change is pretty challenging.

“Now it’s critical to really understand the environment.”

Comanagement Conundrum

One particularly hot topic this year was the trend of hospitalists taking on more comanagement responsibilities for patients previously managed by other specialties, including neurology, surgery, and others. Frank Volpicelli, MD, a first-year hospitalist and instructor at New York University (NYU) Langone Medical Center in New York, was one of three members of his HM group that attended the “Perioperative Medicine: Medical Consultation and Co-Management” pre-course. This summer, his group is going to establish a presence in the preoperative clinic.

“We hope very strongly that we can prevent some complications, identify patients that we should be following when they come into the hospital, and help the surgeons out,” he says. “No. 1, keep them in the [operating room] more, and No. 2, get in front of some of the complications that they are less comfortable managing.”

Ralph Velazquez, MD, senior vice president of care management for OSF Healthcare System in Peoria, Ill., isn’t so sure comanagement of more and more patients is the best practice-management model moving forward. For example, as physician compensation is tied more to how much their care costs to deliver, a hospitalist comanaging a surgical patient’s elective knee replacement could be financially penalized for the cost of that person’s stay, despite having nothing to do with the most expensive portion of the bill.

“You have a financial model that says do more billings, but as you start developing analytics … you may see there is no difference between the model that’s doing more billing, in terms of improving quality, and the one that is doing less,” Dr. Velazquez says. “So if you’re getting the same amount of quality, and the only thing you’re doing is generating more cost by doing more billing, you need to reevaluate your strategy.”

He believes some patients benefit from comanagement, but HM groups have to be diligent in seeking them out.

“We look for simple solutions and one-size-fits-all,” he adds. “Comanagement in complex patients—definitely there’s a need for that. Comanagement in noncomplex patients, elective patients—there’s no need for that. It’s just additional cost. I don’t think it’s going to produce any value.”

Startup Academy

John Colombo, MD, FACP, a 30-year veteran of internal medicine who moved to HM a few years ago when one of the hospitals he worked at asked him to launch a hospitalist group, thinks bundled payments might alleviate that value conundrum. Then again, he’s not quite sure. That’s why attended his first annual meeting.

“I found it difficult starting a new program from scratch,” says Dr. Colombo, of Crozer Keystone Health System in Drexel Hill, Pa. “Even with the materials available, there’s not a lot of ‘how to do it’ out there. There’s no ‘Starting Hospitals for Dummies’ book.”

Dr. Colombo spent much of his meeting focused on recruiting, compensation, bonus structures, and scheduling concerns. He said all are important in the hospital-heavy metropolitan Philadelphia region where he works. Plus, with departures and retirements at other programs in his health system, Dr. Colombo went from no HM experience three years ago to being in charge of four HM programs.

“The biggest thing is, I wanted to make sure I hadn’t stepped in something that I shouldn’t have already,” he adds. “There’s many different ways to do things. So I’ve learned a few different ways. I found value.”

Demonstrate Value

Another way to discover value in running a practice is looking at the business side of the house, says Denice Cora-Bramble, MD, MBA, chief medical officer and executive vice president of Ambulatory & Community Health Services at the Children’s National Medical Center in Washington, D.C.

Dr. Bramble says many hospitalists need to understand that while clinical care is what brought them to medicine, their future paychecks depend on recognizing how to provide that care in a way that demonstrates business value.

“When you finish residency, if you have not intentionally sought out those courses or those seminars, you need to recognize that as a blind spot,” she says. “You need to fill that toolkit as it relates to the business side of medicine.

“You don’t necessarily have to know all the answers, but you need to know the right questions to ask,” she says.

Dr. Bramble adds that hospitalist leaders should take advantage of certificate programs, leadership courses, basic budgeting classes, or anything that gives them added education about the economics of healthcare.

“It all comes down to demonstrating your outcomes, demonstrating the value that you bring to that institution,” she says. “And with health-care reform, I think hospitalists are uniquely positioned to be able to partner with other areas of the hospital to look at this value-based approach.”

Gary Gammon, MD, FHM, the newly named medical director of the Hospitalist Service at FirstHealth Moore Regional Hospital in Pinehurst, N.C., is doing his part to demonstrate value to his administrators. While his group does multidisciplinary rounds on patients, one of his questions for the pre-course faculty was to make sure that system of rounding is an evidence-based practice. He’s also looking for ways to establish more hegemony to his practice to ensure the rounds are effective, regardless of which physicians and others are participating.

The feedback he received was that most people view multidisciplinary rounds as a best practice. Now, Dr. Gammon can feel more authoritative that he and his 32 hospitalists and 12 extenders are practicing HM the way it should be practiced.

“I wanted to hear just what I heard, which is the leaders in the community feel that it’s helping, feel that it’s the right thing to do, feel that there’s objective data,” he says. “This is the stuff that makes me say, ‘OK, I’ve got the same problems everybody else has.’”

Richard Quinn is a freelance writer in New Jersey.

Ibe Mbanu, MD, MBA, MPH, became medical director of the adult hospitalist department at Bon Secours St. Mary’s Hospital in Richmond, Va., about six months ago. Since then, he’s been besieged by a torrent of reform-based challenges he says make his job exponentially more difficult than that of medical directors just a few years ago.

Accountable-care organizations (ACOs), value-based purchasing, and discussions about bundled payments for episodic care are changing rapidly, and as a new administrator in a group with 24 hospitalists and three nonphysician providers (NPPs), he felt he needed to attend his first SHM annual meeting to keep up.

“The landscape in health care is rapidly evolving, at a frantic pace,” Dr. Mbanu says. “I essentially came here to just try to get a condensed source of information on how to manage the changes that are coming through the pipeline, and how to effectively run my department.”

Managing a practice is a challenge, and many of the more than 2,700 attendees at HM13 said the four-day confab’s focus on the topic was a major draw. From a rebooted continuing medical education (CME) pre-course appropriately named “What Keeps You Awake at Night? Hot Topics in Hospitalist Practice Management” to dozens of breakout sessions on the topic, it’s clear that successful practice management is a concern for many hospitalists.

“Before, the drivers were pretty clear,” Dr. Mbanu says. “Volume, productivity. Now we’re switching more toward a business model that’s changing from volume to value. Trying to adapt to that change is pretty challenging.

“Now it’s critical to really understand the environment.”

Comanagement Conundrum

One particularly hot topic this year was the trend of hospitalists taking on more comanagement responsibilities for patients previously managed by other specialties, including neurology, surgery, and others. Frank Volpicelli, MD, a first-year hospitalist and instructor at New York University (NYU) Langone Medical Center in New York, was one of three members of his HM group that attended the “Perioperative Medicine: Medical Consultation and Co-Management” pre-course. This summer, his group is going to establish a presence in the preoperative clinic.

“We hope very strongly that we can prevent some complications, identify patients that we should be following when they come into the hospital, and help the surgeons out,” he says. “No. 1, keep them in the [operating room] more, and No. 2, get in front of some of the complications that they are less comfortable managing.”

Ralph Velazquez, MD, senior vice president of care management for OSF Healthcare System in Peoria, Ill., isn’t so sure comanagement of more and more patients is the best practice-management model moving forward. For example, as physician compensation is tied more to how much their care costs to deliver, a hospitalist comanaging a surgical patient’s elective knee replacement could be financially penalized for the cost of that person’s stay, despite having nothing to do with the most expensive portion of the bill.

“You have a financial model that says do more billings, but as you start developing analytics … you may see there is no difference between the model that’s doing more billing, in terms of improving quality, and the one that is doing less,” Dr. Velazquez says. “So if you’re getting the same amount of quality, and the only thing you’re doing is generating more cost by doing more billing, you need to reevaluate your strategy.”

He believes some patients benefit from comanagement, but HM groups have to be diligent in seeking them out.

“We look for simple solutions and one-size-fits-all,” he adds. “Comanagement in complex patients—definitely there’s a need for that. Comanagement in noncomplex patients, elective patients—there’s no need for that. It’s just additional cost. I don’t think it’s going to produce any value.”

Startup Academy

John Colombo, MD, FACP, a 30-year veteran of internal medicine who moved to HM a few years ago when one of the hospitals he worked at asked him to launch a hospitalist group, thinks bundled payments might alleviate that value conundrum. Then again, he’s not quite sure. That’s why attended his first annual meeting.

“I found it difficult starting a new program from scratch,” says Dr. Colombo, of Crozer Keystone Health System in Drexel Hill, Pa. “Even with the materials available, there’s not a lot of ‘how to do it’ out there. There’s no ‘Starting Hospitals for Dummies’ book.”

Dr. Colombo spent much of his meeting focused on recruiting, compensation, bonus structures, and scheduling concerns. He said all are important in the hospital-heavy metropolitan Philadelphia region where he works. Plus, with departures and retirements at other programs in his health system, Dr. Colombo went from no HM experience three years ago to being in charge of four HM programs.

“The biggest thing is, I wanted to make sure I hadn’t stepped in something that I shouldn’t have already,” he adds. “There’s many different ways to do things. So I’ve learned a few different ways. I found value.”

Demonstrate Value

Another way to discover value in running a practice is looking at the business side of the house, says Denice Cora-Bramble, MD, MBA, chief medical officer and executive vice president of Ambulatory & Community Health Services at the Children’s National Medical Center in Washington, D.C.

Dr. Bramble says many hospitalists need to understand that while clinical care is what brought them to medicine, their future paychecks depend on recognizing how to provide that care in a way that demonstrates business value.

“When you finish residency, if you have not intentionally sought out those courses or those seminars, you need to recognize that as a blind spot,” she says. “You need to fill that toolkit as it relates to the business side of medicine.

“You don’t necessarily have to know all the answers, but you need to know the right questions to ask,” she says.

Dr. Bramble adds that hospitalist leaders should take advantage of certificate programs, leadership courses, basic budgeting classes, or anything that gives them added education about the economics of healthcare.

“It all comes down to demonstrating your outcomes, demonstrating the value that you bring to that institution,” she says. “And with health-care reform, I think hospitalists are uniquely positioned to be able to partner with other areas of the hospital to look at this value-based approach.”

Gary Gammon, MD, FHM, the newly named medical director of the Hospitalist Service at FirstHealth Moore Regional Hospital in Pinehurst, N.C., is doing his part to demonstrate value to his administrators. While his group does multidisciplinary rounds on patients, one of his questions for the pre-course faculty was to make sure that system of rounding is an evidence-based practice. He’s also looking for ways to establish more hegemony to his practice to ensure the rounds are effective, regardless of which physicians and others are participating.

The feedback he received was that most people view multidisciplinary rounds as a best practice. Now, Dr. Gammon can feel more authoritative that he and his 32 hospitalists and 12 extenders are practicing HM the way it should be practiced.

“I wanted to hear just what I heard, which is the leaders in the community feel that it’s helping, feel that it’s the right thing to do, feel that there’s objective data,” he says. “This is the stuff that makes me say, ‘OK, I’ve got the same problems everybody else has.’”

Richard Quinn is a freelance writer in New Jersey.

To some HM13 attendees, the keynote speakers might have seemed to be talking about different things.

Patrick Conway, MD, MSc, FAAP, SFHM, chief medical officer and director of the Center for Clinical Standards and Quality at the Centers for Medicare & Medicaid Services (CMS), hinted at promising results from the first accountable-care organizations (ACOs) and noted a meaningful reduction in 30-day readmission rates for the first time in years.

David Feinberg, MD, MBA, president of UCLA Health System in Los Angeles, told hospitalists that unless they’re getting patient care right every time, they’re not getting it right enough. And nothing would make him happier than seeing fewer hospitalists at SHM’s annual meeting—because that would mean fewer hospitalized patients.

HM pioneer Bob Wachter, MD, MHM, said it’s time for hospitalists to link their quality-improvement (QI) efforts and safety acumen to projects focused on cutting costs and reducing waste in the health-care system.

So while each made their points in a different way, each plenary speaker left many meeting-goers with a similar thought: Hospitalists are positioned at the nexus of big-picture reform and day-to-day implementation. So if hospitalists as a specialty continue to embrace teamwork, evidence-based practice, quality, safety, and a sense that the patient comes first, they will cement themselves as leaders in the next iteration of health-care delivery.

“There is enormous change going on in the healthcare system,” says SHM CEO Larry Wellikson. “And we are right in the middle of this. We are essential. If we are bad, we are going to sink it. And if we’re great, we are going to take it to another level.”

Needle Movement

Dr. Conway said some of that progress already is evident. He disclosed that initial findings from the first data sets coming from the first ACOs are showing promising results, though he can’t go into detail until the information is publicly released. However, he did boast that after decades of Medicare readmission rates hovering around 19%, data from late 2012 and early 2013 show that figure has dropped to below 18%.

“That is a 1.5% to 2% shift in readmissions nationally,” he said. “It is a credit to the work you and others are doing in the field. That’s hundreds of thousands of Medicare beneficiaries that are not readmitted every year, that stay home healthy. … It’s a tremendous example of moving a national needle.”

He dismissed those who attribute the initial readmission progress solely to penalties instituted on readmissions, though he acknowledged that CMS is using both carrots and sticks to push change.

“It’s a combination of interventions,” he said.

And all of those initiatives must be aimed jointly at improving the patient experience, said Dr. Feinberg, a child psychiatrist by training whose mantra is “patient-centeredness.” Dr. Feinberg’s reputation is that of a physician-administrator who puts patients first. For example, even though his health system (www.uclahealth.org) is in the 99th percentile for patient satisfaction, he is unhappy. That’s because the top ranking means roughly 85 out of every 100 patients served are pretty happy with their experience.

“It means that we’re the cream of the crap,” he said. “Of the last 100 people we took care of, 15 of them—and, by definition, those 15 people are someone’s mom, someone’s brother, someone’s coworker—would not refer us to a friend, or rate us a 9 or 10. So, I think, while we’ve really moved the needle, we’re really not done until we get it right with every patient, every time.”

He added that those who argue against difficult or time-consuming innovations and improvements that better patient care are arguing against the moral high ground of how they would want a family member to be treated in the hospital.

“The pushback I hear is, ‘Some of this stuff is unpreventable,’” Dr. Feinberg said. “Well, maybe it’s unpreventable the way we’re doing it now. But maybe we need to think differently. Maybe it is unpreventable, but if this decreases the prevalence, or makes it better, then to me, it’s important to do.”

Dr. Feinberg, who took over as UCLA Health System’s president in 2011, says he still spends several hours every day talking to patients. For those who say there’s not enough time to stay connected to patients and that all the time spent making sure patients are happy takes away from other activities, he says they’re forgetting what brought them into medicine in the first place: healing. He blames the delivery system for stifling what he believes is a provider’s desire to help people.

“We haven’t allowed the culture to come out,” he said. “I think it’s there.”

Dr. Wachter has a similar faith in the hospitalist culture—although his is based in the pluripotent nature of the specialty. Hospitalists have worked hard to be viewed as “generalists, able to solve all kinds of problems,” and that means the specialty is poised to adapt and thrive.

“We will morph into what is needed,” said Dr. Wachter, a past president of SHM whose titles include chief of the division of hospital medicine at the University of California at San Francisco and chair of the American Board of Internal Medicine. “That will be all sorts of things: comanagement, dealing with the residency limits in teaching hospitals, systems improvement, cost reductions, transitions, working in skilled nursing facilities, all the specialty hospitalists.

“We will fill new niches,” he said.

What Dr. Wachter does not want to see is that the field grows “fat and happy,” as it is now firmly entrenched in the U.S. health-care delivery system. In fact, he urged hospitalists to welcome change, particularly initiatives that improve quality and safety, reduce costs and waste, and, ultimately, improve the patient experience.

But he cautioned against conceptually separating QI and cost reduction. Instead, they should be viewed as equally meaningful parts of his oft-quoted value equation, which, viewed from the health-care consumer’s point of view, is quality divided by cost.

“You can’t survive and thrive in a world with the kinds of pressures that we have to improve performance if you do business the same old way,” he added. “It’s no longer possible to achieve the things you need to achieve handling these as single projects. You need to transform the way you think about care.”

Richard Quinn is a freelance writer in New Jersey.

To some HM13 attendees, the keynote speakers might have seemed to be talking about different things.

Patrick Conway, MD, MSc, FAAP, SFHM, chief medical officer and director of the Center for Clinical Standards and Quality at the Centers for Medicare & Medicaid Services (CMS), hinted at promising results from the first accountable-care organizations (ACOs) and noted a meaningful reduction in 30-day readmission rates for the first time in years.

David Feinberg, MD, MBA, president of UCLA Health System in Los Angeles, told hospitalists that unless they’re getting patient care right every time, they’re not getting it right enough. And nothing would make him happier than seeing fewer hospitalists at SHM’s annual meeting—because that would mean fewer hospitalized patients.

HM pioneer Bob Wachter, MD, MHM, said it’s time for hospitalists to link their quality-improvement (QI) efforts and safety acumen to projects focused on cutting costs and reducing waste in the health-care system.

So while each made their points in a different way, each plenary speaker left many meeting-goers with a similar thought: Hospitalists are positioned at the nexus of big-picture reform and day-to-day implementation. So if hospitalists as a specialty continue to embrace teamwork, evidence-based practice, quality, safety, and a sense that the patient comes first, they will cement themselves as leaders in the next iteration of health-care delivery.

“There is enormous change going on in the healthcare system,” says SHM CEO Larry Wellikson. “And we are right in the middle of this. We are essential. If we are bad, we are going to sink it. And if we’re great, we are going to take it to another level.”

Needle Movement

Dr. Conway said some of that progress already is evident. He disclosed that initial findings from the first data sets coming from the first ACOs are showing promising results, though he can’t go into detail until the information is publicly released. However, he did boast that after decades of Medicare readmission rates hovering around 19%, data from late 2012 and early 2013 show that figure has dropped to below 18%.

“That is a 1.5% to 2% shift in readmissions nationally,” he said. “It is a credit to the work you and others are doing in the field. That’s hundreds of thousands of Medicare beneficiaries that are not readmitted every year, that stay home healthy. … It’s a tremendous example of moving a national needle.”

He dismissed those who attribute the initial readmission progress solely to penalties instituted on readmissions, though he acknowledged that CMS is using both carrots and sticks to push change.

“It’s a combination of interventions,” he said.

And all of those initiatives must be aimed jointly at improving the patient experience, said Dr. Feinberg, a child psychiatrist by training whose mantra is “patient-centeredness.” Dr. Feinberg’s reputation is that of a physician-administrator who puts patients first. For example, even though his health system (www.uclahealth.org) is in the 99th percentile for patient satisfaction, he is unhappy. That’s because the top ranking means roughly 85 out of every 100 patients served are pretty happy with their experience.

“It means that we’re the cream of the crap,” he said. “Of the last 100 people we took care of, 15 of them—and, by definition, those 15 people are someone’s mom, someone’s brother, someone’s coworker—would not refer us to a friend, or rate us a 9 or 10. So, I think, while we’ve really moved the needle, we’re really not done until we get it right with every patient, every time.”

He added that those who argue against difficult or time-consuming innovations and improvements that better patient care are arguing against the moral high ground of how they would want a family member to be treated in the hospital.

“The pushback I hear is, ‘Some of this stuff is unpreventable,’” Dr. Feinberg said. “Well, maybe it’s unpreventable the way we’re doing it now. But maybe we need to think differently. Maybe it is unpreventable, but if this decreases the prevalence, or makes it better, then to me, it’s important to do.”

Dr. Feinberg, who took over as UCLA Health System’s president in 2011, says he still spends several hours every day talking to patients. For those who say there’s not enough time to stay connected to patients and that all the time spent making sure patients are happy takes away from other activities, he says they’re forgetting what brought them into medicine in the first place: healing. He blames the delivery system for stifling what he believes is a provider’s desire to help people.

“We haven’t allowed the culture to come out,” he said. “I think it’s there.”

Dr. Wachter has a similar faith in the hospitalist culture—although his is based in the pluripotent nature of the specialty. Hospitalists have worked hard to be viewed as “generalists, able to solve all kinds of problems,” and that means the specialty is poised to adapt and thrive.

“We will morph into what is needed,” said Dr. Wachter, a past president of SHM whose titles include chief of the division of hospital medicine at the University of California at San Francisco and chair of the American Board of Internal Medicine. “That will be all sorts of things: comanagement, dealing with the residency limits in teaching hospitals, systems improvement, cost reductions, transitions, working in skilled nursing facilities, all the specialty hospitalists.

“We will fill new niches,” he said.

What Dr. Wachter does not want to see is that the field grows “fat and happy,” as it is now firmly entrenched in the U.S. health-care delivery system. In fact, he urged hospitalists to welcome change, particularly initiatives that improve quality and safety, reduce costs and waste, and, ultimately, improve the patient experience.

But he cautioned against conceptually separating QI and cost reduction. Instead, they should be viewed as equally meaningful parts of his oft-quoted value equation, which, viewed from the health-care consumer’s point of view, is quality divided by cost.

“You can’t survive and thrive in a world with the kinds of pressures that we have to improve performance if you do business the same old way,” he added. “It’s no longer possible to achieve the things you need to achieve handling these as single projects. You need to transform the way you think about care.”

Richard Quinn is a freelance writer in New Jersey.

To some HM13 attendees, the keynote speakers might have seemed to be talking about different things.

Patrick Conway, MD, MSc, FAAP, SFHM, chief medical officer and director of the Center for Clinical Standards and Quality at the Centers for Medicare & Medicaid Services (CMS), hinted at promising results from the first accountable-care organizations (ACOs) and noted a meaningful reduction in 30-day readmission rates for the first time in years.

David Feinberg, MD, MBA, president of UCLA Health System in Los Angeles, told hospitalists that unless they’re getting patient care right every time, they’re not getting it right enough. And nothing would make him happier than seeing fewer hospitalists at SHM’s annual meeting—because that would mean fewer hospitalized patients.

HM pioneer Bob Wachter, MD, MHM, said it’s time for hospitalists to link their quality-improvement (QI) efforts and safety acumen to projects focused on cutting costs and reducing waste in the health-care system.

So while each made their points in a different way, each plenary speaker left many meeting-goers with a similar thought: Hospitalists are positioned at the nexus of big-picture reform and day-to-day implementation. So if hospitalists as a specialty continue to embrace teamwork, evidence-based practice, quality, safety, and a sense that the patient comes first, they will cement themselves as leaders in the next iteration of health-care delivery.

“There is enormous change going on in the healthcare system,” says SHM CEO Larry Wellikson. “And we are right in the middle of this. We are essential. If we are bad, we are going to sink it. And if we’re great, we are going to take it to another level.”

Needle Movement

Dr. Conway said some of that progress already is evident. He disclosed that initial findings from the first data sets coming from the first ACOs are showing promising results, though he can’t go into detail until the information is publicly released. However, he did boast that after decades of Medicare readmission rates hovering around 19%, data from late 2012 and early 2013 show that figure has dropped to below 18%.

“That is a 1.5% to 2% shift in readmissions nationally,” he said. “It is a credit to the work you and others are doing in the field. That’s hundreds of thousands of Medicare beneficiaries that are not readmitted every year, that stay home healthy. … It’s a tremendous example of moving a national needle.”

He dismissed those who attribute the initial readmission progress solely to penalties instituted on readmissions, though he acknowledged that CMS is using both carrots and sticks to push change.

“It’s a combination of interventions,” he said.

And all of those initiatives must be aimed jointly at improving the patient experience, said Dr. Feinberg, a child psychiatrist by training whose mantra is “patient-centeredness.” Dr. Feinberg’s reputation is that of a physician-administrator who puts patients first. For example, even though his health system (www.uclahealth.org) is in the 99th percentile for patient satisfaction, he is unhappy. That’s because the top ranking means roughly 85 out of every 100 patients served are pretty happy with their experience.

“It means that we’re the cream of the crap,” he said. “Of the last 100 people we took care of, 15 of them—and, by definition, those 15 people are someone’s mom, someone’s brother, someone’s coworker—would not refer us to a friend, or rate us a 9 or 10. So, I think, while we’ve really moved the needle, we’re really not done until we get it right with every patient, every time.”

He added that those who argue against difficult or time-consuming innovations and improvements that better patient care are arguing against the moral high ground of how they would want a family member to be treated in the hospital.

“The pushback I hear is, ‘Some of this stuff is unpreventable,’” Dr. Feinberg said. “Well, maybe it’s unpreventable the way we’re doing it now. But maybe we need to think differently. Maybe it is unpreventable, but if this decreases the prevalence, or makes it better, then to me, it’s important to do.”

Dr. Feinberg, who took over as UCLA Health System’s president in 2011, says he still spends several hours every day talking to patients. For those who say there’s not enough time to stay connected to patients and that all the time spent making sure patients are happy takes away from other activities, he says they’re forgetting what brought them into medicine in the first place: healing. He blames the delivery system for stifling what he believes is a provider’s desire to help people.

“We haven’t allowed the culture to come out,” he said. “I think it’s there.”

Dr. Wachter has a similar faith in the hospitalist culture—although his is based in the pluripotent nature of the specialty. Hospitalists have worked hard to be viewed as “generalists, able to solve all kinds of problems,” and that means the specialty is poised to adapt and thrive.

“We will morph into what is needed,” said Dr. Wachter, a past president of SHM whose titles include chief of the division of hospital medicine at the University of California at San Francisco and chair of the American Board of Internal Medicine. “That will be all sorts of things: comanagement, dealing with the residency limits in teaching hospitals, systems improvement, cost reductions, transitions, working in skilled nursing facilities, all the specialty hospitalists.

“We will fill new niches,” he said.

What Dr. Wachter does not want to see is that the field grows “fat and happy,” as it is now firmly entrenched in the U.S. health-care delivery system. In fact, he urged hospitalists to welcome change, particularly initiatives that improve quality and safety, reduce costs and waste, and, ultimately, improve the patient experience.

But he cautioned against conceptually separating QI and cost reduction. Instead, they should be viewed as equally meaningful parts of his oft-quoted value equation, which, viewed from the health-care consumer’s point of view, is quality divided by cost.

“You can’t survive and thrive in a world with the kinds of pressures that we have to improve performance if you do business the same old way,” he added. “It’s no longer possible to achieve the things you need to achieve handling these as single projects. You need to transform the way you think about care.”

Richard Quinn is a freelance writer in New Jersey.

The Association of Health Care Journalists, a professional association that includes 1,400 journalists, is tackling some of the barriers consumers and advocates face when trying to access such information as hospital safety records. AHCJ’s www.HospitalInfections.org is a free, searchable news application that went live in March with detailed reports of deficiencies cited in federal inspection visits for acute- and critical-access hospitals nationwide.

Through years of advocacy, AHCJ has filed Freedom of Information Act requests and negotiated with the Centers for Medicare & Medicaid Services (CMS) to get access to hospital safety information in electronic form.

CMS’ Hospital Compare website (www.medicare.gov/hospitalcompare) and the Joint Commission’s Quality Check (www.qualitycheck.org) program both publicly report hospital quality data, but they have significant time lags and data that are difficult for the average consumer to understand, according to AHCJ. The association touts its new site as an “early attempt by an advocacy group to make hospital safety information easier to access and more consumer-driven.”

“Being able to easily review the performance of your local hospital is vital for health-care journalists and for the public,” AHCJ president Charles Ornstein, a senior reporter at ProPublica in New York, said in a statement.

Larry Beresford is a freelance writer in San Francisco

References

1. Weigel C, Suen W, Gupta G. Using Lean methodology to teach quality improvement to internal medicine residents at a safety net hospital. Am J Med Qual. 2013 Feb 4 [Epub ahead of print].
2. Morganti KG, Lovejoy S, Beckjord EB, Haviland AM, Haas AC, Farley DO. A retrospective evaluation of the Perfecting Patient Care University training program for health care organizations. Am J Med Qual. 2013 Apr 9 [Epub ahead of print].
3. Myers JS, Tess A, Glasheen JJ, et al. The Quality and Safety Educators’ Academy: fulfilling an unmet need for faculty development. Am J Med Qual.  2013 Apr 11 [Epub ahead of print].
4. Dong XQ, Simon MA. Elder abuse as a risk factor for hospitalization in older persons. JAMA Intern Med. 2013 Apr 8:1-7. doi: 10.1001/jamainternmed.2013.238 [Epub ahead of print].
5. Cisco mConcierge. 90% American workers use their own smartphones for work. Cisco mConcierge website. Available at: http://www.ciscomcon.com/sw/swchannel/registration/internet/registrationcfm?SWAPPID=91&RegPageID=350200&SWTHEMEID=12949. Accessed

The Association of Health Care Journalists, a professional association that includes 1,400 journalists, is tackling some of the barriers consumers and advocates face when trying to access such information as hospital safety records. AHCJ’s www.HospitalInfections.org is a free, searchable news application that went live in March with detailed reports of deficiencies cited in federal inspection visits for acute- and critical-access hospitals nationwide.

Through years of advocacy, AHCJ has filed Freedom of Information Act requests and negotiated with the Centers for Medicare & Medicaid Services (CMS) to get access to hospital safety information in electronic form.

CMS’ Hospital Compare website (www.medicare.gov/hospitalcompare) and the Joint Commission’s Quality Check (www.qualitycheck.org) program both publicly report hospital quality data, but they have significant time lags and data that are difficult for the average consumer to understand, according to AHCJ. The association touts its new site as an “early attempt by an advocacy group to make hospital safety information easier to access and more consumer-driven.”

“Being able to easily review the performance of your local hospital is vital for health-care journalists and for the public,” AHCJ president Charles Ornstein, a senior reporter at ProPublica in New York, said in a statement.

Larry Beresford is a freelance writer in San Francisco

References

1. Weigel C, Suen W, Gupta G. Using Lean methodology to teach quality improvement to internal medicine residents at a safety net hospital. Am J Med Qual. 2013 Feb 4 [Epub ahead of print].
2. Morganti KG, Lovejoy S, Beckjord EB, Haviland AM, Haas AC, Farley DO. A retrospective evaluation of the Perfecting Patient Care University training program for health care organizations. Am J Med Qual. 2013 Apr 9 [Epub ahead of print].
3. Myers JS, Tess A, Glasheen JJ, et al. The Quality and Safety Educators’ Academy: fulfilling an unmet need for faculty development. Am J Med Qual.  2013 Apr 11 [Epub ahead of print].
4. Dong XQ, Simon MA. Elder abuse as a risk factor for hospitalization in older persons. JAMA Intern Med. 2013 Apr 8:1-7. doi: 10.1001/jamainternmed.2013.238 [Epub ahead of print].
5. Cisco mConcierge. 90% American workers use their own smartphones for work. Cisco mConcierge website. Available at: http://www.ciscomcon.com/sw/swchannel/registration/internet/registrationcfm?SWAPPID=91&RegPageID=350200&SWTHEMEID=12949. Accessed

The Association of Health Care Journalists, a professional association that includes 1,400 journalists, is tackling some of the barriers consumers and advocates face when trying to access such information as hospital safety records. AHCJ’s www.HospitalInfections.org is a free, searchable news application that went live in March with detailed reports of deficiencies cited in federal inspection visits for acute- and critical-access hospitals nationwide.

Through years of advocacy, AHCJ has filed Freedom of Information Act requests and negotiated with the Centers for Medicare & Medicaid Services (CMS) to get access to hospital safety information in electronic form.

CMS’ Hospital Compare website (www.medicare.gov/hospitalcompare) and the Joint Commission’s Quality Check (www.qualitycheck.org) program both publicly report hospital quality data, but they have significant time lags and data that are difficult for the average consumer to understand, according to AHCJ. The association touts its new site as an “early attempt by an advocacy group to make hospital safety information easier to access and more consumer-driven.”

“Being able to easily review the performance of your local hospital is vital for health-care journalists and for the public,” AHCJ president Charles Ornstein, a senior reporter at ProPublica in New York, said in a statement.

Larry Beresford is a freelance writer in San Francisco

References

1. Weigel C, Suen W, Gupta G. Using Lean methodology to teach quality improvement to internal medicine residents at a safety net hospital. Am J Med Qual. 2013 Feb 4 [Epub ahead of print].
2. Morganti KG, Lovejoy S, Beckjord EB, Haviland AM, Haas AC, Farley DO. A retrospective evaluation of the Perfecting Patient Care University training program for health care organizations. Am J Med Qual. 2013 Apr 9 [Epub ahead of print].
3. Myers JS, Tess A, Glasheen JJ, et al. The Quality and Safety Educators’ Academy: fulfilling an unmet need for faculty development. Am J Med Qual.  2013 Apr 11 [Epub ahead of print].
4. Dong XQ, Simon MA. Elder abuse as a risk factor for hospitalization in older persons. JAMA Intern Med. 2013 Apr 8:1-7. doi: 10.1001/jamainternmed.2013.238 [Epub ahead of print].
5. Cisco mConcierge. 90% American workers use their own smartphones for work. Cisco mConcierge website. Available at: http://www.ciscomcon.com/sw/swchannel/registration/internet/registrationcfm?SWAPPID=91&RegPageID=350200&SWTHEMEID=12949. Accessed

A veritable perfect storm of relationships brought hospitalist Jairy Hunter, MD, MBA, SFHM, to “Hospitalists on the Hill 2013,” a daylong advocacy affair that preceded HM13 last month.

First, Dr. Hunter was born and bred—and now lives—in South Carolina, a close-knit state where leaders across industries tend to run in the same circles, or at least have relatives who do. Second, Dr. Hunter’s father, Jairy Hunter Jr., is the longtime president of Charleston Southern University, where Sen. Tim Scott (R-S.C.) earned his undergraduate degree when it was still called Baptist College at Charleston. And three, Dr. Hunter is associate executive medical director of one of the state’s flagship health-care institutions, Medical University of South Carolina in Charleston.

So it was that SHM set Dr. Hunter up in meetings with the offices of Scott, Sen. Lindsey Graham (R-S.C.), and Rep. Jim Clyburn (D-S.C.), and—for the day at least—made Dr. Hunter the voice of hospital medicine.

“It was a little bit demystifying of an experience to be able to know there’s actually people you can talk to and you can develop a relationship with,” says Dr. Hunter, who also serves on Team Hospitalist. “I thought that was very rewarding.”

The connections made by Dr. Hunter are the point of the annual trek made by SHM leaders and members to lobby legislators and federal staffers “on the way policies affect your practice and your patients,” SHM says on its website (www.hospitalmedicine.org/advocacy). This year’s volunteer effort was by far the largest ever, says Public Policy Committee chair Ron Greeno, MD, FCCP, MHM. More than 150 hospitalists participated in training, 113 hospitalists visited Capitol Hill, and scores more had to be turned away. All told, hospitalists held 409 individual meetings with legislators and staff members.

“Quite frankly, if we’d have had the budget, we could have had another 100 to 150 people come,” Dr. Greeno says. “That’s how many people wanted to go.”

Dr. Greeno attributes the interest to two factors. One, having the annual meeting at the Gaylord National Resort & Convention Center, just outside Washington, D.C, makes the Hill trip a natural extension. Two, the current landscape of health-care reform has motivated many physicians to become more involved than they might otherwise be. One challenge of having so many first-timers making this year’s trip was making sure they were properly prepared. To hone the message, SHM gave the group a few hours of education by former legislative staffer Stephanie Vance of Advocacy Associates, a communications firm that helps organizations, such as medical societies, tailor their message to policymakers. Vance told hospitalists a personal visit with a constituent often becomes the most influential type of advocacy.

“That’s why it was easy to make an initial connection, because these staffers are from where I’m from, friends with people that I’m friends with,” Dr. Hunter says.

Unique Approach

SHM CEO Larry Wellikson, MD, SFHM, says the society tries to differentiate itself from other organizations through its grassroots approach to advocacy. More important, the society refrains from giving a long list of legislative requests that are self-serving.

“We’re someone they want to talk to because we’re not coming there to just say, ‘Here’s a power play for hospitalists,’” Dr. Wellikson says. “We come and try to provide solutions.”

To that end, this year’s lobbying effort was targeted to topics important both to HM and the health-care system:

• Repealing the sustainable growth rate (SGR) formula for Medicare payments, specifically via the proposed Medicare Physician Payment Innovation Act of 2013 (H.R. 574);
• Solving the quagmire of observation status time not counting toward the required three consecutive overnights as an inpatient needed to qualify for Medicare benefits at a skilled nursing facility, by supporting the Improving Access to Medicare Coverage Act of 2013 (H.R. 1179, S. 569); and
• Getting the federal government to commit to providing $434 million in funding for the Agency for Healthcare Research and Quality (AHRQ) in fiscal 2014.

“The message that we’re sending resonated with the people we met with on both sides of the aisle,” Dr. Greeno says. “The SGR, for instance, they know there needs to be a fix. We want to serve as a resource for them as they start to figure out the answer to the question: What are we going to replace it with?

“What we want to do is make everybody on the Hill understand that we can be relied upon as a resource when they’re looking for solutions,” he says.

Focused on Follow-Up

And that’s where rank-and-filers, such as Dr. Hunter, have to take charge. So for his Hill Day visits, he tried to stand out. Everyone he met with got a lapel pin in the shape of a South Carolina state flag, which has become a popular fashion statement in recent years. And Scott also got a pin from Charleston Southern University, his alma mater. The gestures were small, but they served as icebreakers and reminders that Dr. Hunter and the people he met are bound by service to the residents of the Palmetto State.

Dr. Hunter also hopes the small token will be that little extra that makes him memorable enough that the next time a Congressional staffer has an SGR question, they’ll ask him and not a doctor from another specialty.

“I’m interested to see how much feedback I get back from them,” he says. “I can feed them all day long, but I don’t want to be that crazy guy bugging them. If they respond back to me, I can hopefully make more inroads.”

He certainly would if Dr. Greeno gets his way. Moving forward, SHM hopes to be able to rely more on local advocates pushing for reform than just a once-a-year major event and formal positions drafted by SHM’s staffers or the Public Policy Committee. Dr. Greeno says the physicians who participated in this year’s Hill trip are likely to find they will be asked to be the first cohort of a grassroots initiative meant to deliver the society’s message more routinely.

“These are not easy things to change because there are not easy solutions,” Dr. Greeno adds. “If you have just one meeting on the Hill, you’ll have no impact at all. You have to follow up. You have to do it consistently. And you have to have a consistent message. And we will.”

Richard Quinn is a freelance writer in New Jersey.

A veritable perfect storm of relationships brought hospitalist Jairy Hunter, MD, MBA, SFHM, to “Hospitalists on the Hill 2013,” a daylong advocacy affair that preceded HM13 last month.

First, Dr. Hunter was born and bred—and now lives—in South Carolina, a close-knit state where leaders across industries tend to run in the same circles, or at least have relatives who do. Second, Dr. Hunter’s father, Jairy Hunter Jr., is the longtime president of Charleston Southern University, where Sen. Tim Scott (R-S.C.) earned his undergraduate degree when it was still called Baptist College at Charleston. And three, Dr. Hunter is associate executive medical director of one of the state’s flagship health-care institutions, Medical University of South Carolina in Charleston.

So it was that SHM set Dr. Hunter up in meetings with the offices of Scott, Sen. Lindsey Graham (R-S.C.), and Rep. Jim Clyburn (D-S.C.), and—for the day at least—made Dr. Hunter the voice of hospital medicine.

“It was a little bit demystifying of an experience to be able to know there’s actually people you can talk to and you can develop a relationship with,” says Dr. Hunter, who also serves on Team Hospitalist. “I thought that was very rewarding.”

The connections made by Dr. Hunter are the point of the annual trek made by SHM leaders and members to lobby legislators and federal staffers “on the way policies affect your practice and your patients,” SHM says on its website (www.hospitalmedicine.org/advocacy). This year’s volunteer effort was by far the largest ever, says Public Policy Committee chair Ron Greeno, MD, FCCP, MHM. More than 150 hospitalists participated in training, 113 hospitalists visited Capitol Hill, and scores more had to be turned away. All told, hospitalists held 409 individual meetings with legislators and staff members.

“Quite frankly, if we’d have had the budget, we could have had another 100 to 150 people come,” Dr. Greeno says. “That’s how many people wanted to go.”

Dr. Greeno attributes the interest to two factors. One, having the annual meeting at the Gaylord National Resort & Convention Center, just outside Washington, D.C, makes the Hill trip a natural extension. Two, the current landscape of health-care reform has motivated many physicians to become more involved than they might otherwise be. One challenge of having so many first-timers making this year’s trip was making sure they were properly prepared. To hone the message, SHM gave the group a few hours of education by former legislative staffer Stephanie Vance of Advocacy Associates, a communications firm that helps organizations, such as medical societies, tailor their message to policymakers. Vance told hospitalists a personal visit with a constituent often becomes the most influential type of advocacy.

“That’s why it was easy to make an initial connection, because these staffers are from where I’m from, friends with people that I’m friends with,” Dr. Hunter says.

Unique Approach

SHM CEO Larry Wellikson, MD, SFHM, says the society tries to differentiate itself from other organizations through its grassroots approach to advocacy. More important, the society refrains from giving a long list of legislative requests that are self-serving.

“We’re someone they want to talk to because we’re not coming there to just say, ‘Here’s a power play for hospitalists,’” Dr. Wellikson says. “We come and try to provide solutions.”

To that end, this year’s lobbying effort was targeted to topics important both to HM and the health-care system:

• Repealing the sustainable growth rate (SGR) formula for Medicare payments, specifically via the proposed Medicare Physician Payment Innovation Act of 2013 (H.R. 574);
• Solving the quagmire of observation status time not counting toward the required three consecutive overnights as an inpatient needed to qualify for Medicare benefits at a skilled nursing facility, by supporting the Improving Access to Medicare Coverage Act of 2013 (H.R. 1179, S. 569); and
• Getting the federal government to commit to providing $434 million in funding for the Agency for Healthcare Research and Quality (AHRQ) in fiscal 2014.

“The message that we’re sending resonated with the people we met with on both sides of the aisle,” Dr. Greeno says. “The SGR, for instance, they know there needs to be a fix. We want to serve as a resource for them as they start to figure out the answer to the question: What are we going to replace it with?

“What we want to do is make everybody on the Hill understand that we can be relied upon as a resource when they’re looking for solutions,” he says.

Focused on Follow-Up

And that’s where rank-and-filers, such as Dr. Hunter, have to take charge. So for his Hill Day visits, he tried to stand out. Everyone he met with got a lapel pin in the shape of a South Carolina state flag, which has become a popular fashion statement in recent years. And Scott also got a pin from Charleston Southern University, his alma mater. The gestures were small, but they served as icebreakers and reminders that Dr. Hunter and the people he met are bound by service to the residents of the Palmetto State.

Dr. Hunter also hopes the small token will be that little extra that makes him memorable enough that the next time a Congressional staffer has an SGR question, they’ll ask him and not a doctor from another specialty.

“I’m interested to see how much feedback I get back from them,” he says. “I can feed them all day long, but I don’t want to be that crazy guy bugging them. If they respond back to me, I can hopefully make more inroads.”

He certainly would if Dr. Greeno gets his way. Moving forward, SHM hopes to be able to rely more on local advocates pushing for reform than just a once-a-year major event and formal positions drafted by SHM’s staffers or the Public Policy Committee. Dr. Greeno says the physicians who participated in this year’s Hill trip are likely to find they will be asked to be the first cohort of a grassroots initiative meant to deliver the society’s message more routinely.

“These are not easy things to change because there are not easy solutions,” Dr. Greeno adds. “If you have just one meeting on the Hill, you’ll have no impact at all. You have to follow up. You have to do it consistently. And you have to have a consistent message. And we will.”

Richard Quinn is a freelance writer in New Jersey.

A veritable perfect storm of relationships brought hospitalist Jairy Hunter, MD, MBA, SFHM, to “Hospitalists on the Hill 2013,” a daylong advocacy affair that preceded HM13 last month.

First, Dr. Hunter was born and bred—and now lives—in South Carolina, a close-knit state where leaders across industries tend to run in the same circles, or at least have relatives who do. Second, Dr. Hunter’s father, Jairy Hunter Jr., is the longtime president of Charleston Southern University, where Sen. Tim Scott (R-S.C.) earned his undergraduate degree when it was still called Baptist College at Charleston. And three, Dr. Hunter is associate executive medical director of one of the state’s flagship health-care institutions, Medical University of South Carolina in Charleston.

So it was that SHM set Dr. Hunter up in meetings with the offices of Scott, Sen. Lindsey Graham (R-S.C.), and Rep. Jim Clyburn (D-S.C.), and—for the day at least—made Dr. Hunter the voice of hospital medicine.

“It was a little bit demystifying of an experience to be able to know there’s actually people you can talk to and you can develop a relationship with,” says Dr. Hunter, who also serves on Team Hospitalist. “I thought that was very rewarding.”

The connections made by Dr. Hunter are the point of the annual trek made by SHM leaders and members to lobby legislators and federal staffers “on the way policies affect your practice and your patients,” SHM says on its website (www.hospitalmedicine.org/advocacy). This year’s volunteer effort was by far the largest ever, says Public Policy Committee chair Ron Greeno, MD, FCCP, MHM. More than 150 hospitalists participated in training, 113 hospitalists visited Capitol Hill, and scores more had to be turned away. All told, hospitalists held 409 individual meetings with legislators and staff members.

“Quite frankly, if we’d have had the budget, we could have had another 100 to 150 people come,” Dr. Greeno says. “That’s how many people wanted to go.”

Dr. Greeno attributes the interest to two factors. One, having the annual meeting at the Gaylord National Resort & Convention Center, just outside Washington, D.C, makes the Hill trip a natural extension. Two, the current landscape of health-care reform has motivated many physicians to become more involved than they might otherwise be. One challenge of having so many first-timers making this year’s trip was making sure they were properly prepared. To hone the message, SHM gave the group a few hours of education by former legislative staffer Stephanie Vance of Advocacy Associates, a communications firm that helps organizations, such as medical societies, tailor their message to policymakers. Vance told hospitalists a personal visit with a constituent often becomes the most influential type of advocacy.

“That’s why it was easy to make an initial connection, because these staffers are from where I’m from, friends with people that I’m friends with,” Dr. Hunter says.

Unique Approach

SHM CEO Larry Wellikson, MD, SFHM, says the society tries to differentiate itself from other organizations through its grassroots approach to advocacy. More important, the society refrains from giving a long list of legislative requests that are self-serving.

“We’re someone they want to talk to because we’re not coming there to just say, ‘Here’s a power play for hospitalists,’” Dr. Wellikson says. “We come and try to provide solutions.”

To that end, this year’s lobbying effort was targeted to topics important both to HM and the health-care system:

• Repealing the sustainable growth rate (SGR) formula for Medicare payments, specifically via the proposed Medicare Physician Payment Innovation Act of 2013 (H.R. 574);
• Solving the quagmire of observation status time not counting toward the required three consecutive overnights as an inpatient needed to qualify for Medicare benefits at a skilled nursing facility, by supporting the Improving Access to Medicare Coverage Act of 2013 (H.R. 1179, S. 569); and
• Getting the federal government to commit to providing $434 million in funding for the Agency for Healthcare Research and Quality (AHRQ) in fiscal 2014.

“The message that we’re sending resonated with the people we met with on both sides of the aisle,” Dr. Greeno says. “The SGR, for instance, they know there needs to be a fix. We want to serve as a resource for them as they start to figure out the answer to the question: What are we going to replace it with?

“What we want to do is make everybody on the Hill understand that we can be relied upon as a resource when they’re looking for solutions,” he says.

Focused on Follow-Up

And that’s where rank-and-filers, such as Dr. Hunter, have to take charge. So for his Hill Day visits, he tried to stand out. Everyone he met with got a lapel pin in the shape of a South Carolina state flag, which has become a popular fashion statement in recent years. And Scott also got a pin from Charleston Southern University, his alma mater. The gestures were small, but they served as icebreakers and reminders that Dr. Hunter and the people he met are bound by service to the residents of the Palmetto State.

Dr. Hunter also hopes the small token will be that little extra that makes him memorable enough that the next time a Congressional staffer has an SGR question, they’ll ask him and not a doctor from another specialty.

“I’m interested to see how much feedback I get back from them,” he says. “I can feed them all day long, but I don’t want to be that crazy guy bugging them. If they respond back to me, I can hopefully make more inroads.”

He certainly would if Dr. Greeno gets his way. Moving forward, SHM hopes to be able to rely more on local advocates pushing for reform than just a once-a-year major event and formal positions drafted by SHM’s staffers or the Public Policy Committee. Dr. Greeno says the physicians who participated in this year’s Hill trip are likely to find they will be asked to be the first cohort of a grassroots initiative meant to deliver the society’s message more routinely.

“These are not easy things to change because there are not easy solutions,” Dr. Greeno adds. “If you have just one meeting on the Hill, you’ll have no impact at all. You have to follow up. You have to do it consistently. And you have to have a consistent message. And we will.”

Richard Quinn is a freelance writer in New Jersey.

Alarms about our nation’s health-care costs have been sounding for well over a decade. According to the Centers for Medicare & Medicaid Services (CMS), spending on U.S. health care doubled between 1999 and 2011, climbing to $2.7 trillion from $1.3 trillion, and now represents 17.9% of the United States’ GDP.¹

“The medical care system is bankrupting the country,” Paul B. Ginsburg, PhD, president of the Center for Studying Health System Change (HSC), based in Washington, D.C., says bluntly. A four-decade-long upward spending trend is “unsustainable,” he wrote in the New England Journal of Medicine with Chapin White, PhD, a senior health researcher at HSC.²

Recent reports suggest that rising premiums and out-of-pocket costs are rendering the price of health care untenable for the average consumer. A 2011 RAND Corp. study found that, for the average American family, the rate of increased costs for health care had outpaced growth in earnings from 1999 to 2009.³ And last year, for the first time, the cost of health care for a typical American family of four surpassed $20,000, the annual Milliman Medical Index reported.⁴

Should hospitalists be concerned, professionally and personally, about these trends? Absolutely, say hospitalist leaders who spoke with The Hospitalist. HM clinicians have much to contribute at both the macro level (addressing systemic causes of overutilization through quality improvement and other initiatives) and at the micro level, by understanding their personal contributions and by engaging patients and their families in shared decision-making.

But getting at and addressing the root causes of rising health-care costs, according to health-care policy analysts and veteran hospitalists, will require major shifts in thinking and processes.

Contributors to Rising Costs

It’s difficult to pinpoint the root causes of the recent surge in health-care costs. Victor Fuchs, emeritus professor of economics and health research and policy at Stanford University, points to the U.S.’ high administrative costs and complicated billing systems.⁵ A fragmented, nontransparent system for negotiating fees between insurers and providers also plays a role, as demonstrated in a Consumer Reports investigation into geographic variations in costs for common tests and procedures. A complete blood count might be as low as $15 or as high as $105; a colonoscopy ranges from $800 to $3,160.⁶

Bradley Flansbaum, DO, MPH, SFHM, an SHM Public Policy Committee member and AMA delegate, says rising costs are a provider-specific issue. He challenges colleagues to take an honest look at their own practice patterns to assess whether they’re contributing to overuse of resources (see “A Lesson in Change,”).

“The culture of practice has developed so that this is not going to change overnight,” says Dr. Flansbaum, director of hospitalist services at Lenox Hill Hospital in New York City. That’s because many physicians fail to view their own decisions as a problem. For example, says Dr. Flansbaum, “an oncologist may not identify a third round of chemotherapy as an embodiment of the problem, or a gastroenterologist might not embody the colonoscopy at Year Four instead of Year Five as the problem. We must come to grips with the usual mindset, look in the mirror, and admit, ‘Maybe we are part of the problem.’”

The culture of practice has developed so that this is not going to change overnight. An oncologist may not identify a third round of chemotherapy as an embodiment of the problem. We must come to grips with the usual mindset, look in the mirror, and admit, 'Maybe we are part of the problem.'

—Bradley Flansbaum, DO, MPH, SFHM

Potential Solutions

Hospitalists, intensivists, and ED clinicians are tasked with finding a balance between being prudent stewards of resources and staying within a comfort zone that promotes patient safety. SHM supports the goals of the ABIM Foundation’s Choosing Wisely campaign, which aims to reduce waste by curtailing duplicative and unnecessary care (see “Better Choices, Better Care,” March 2013). Also included in the campaign (www.ChoosingWisely.org) are the American College of Physicians’ recommendations against low-value testing (e.g. obtaining imaging studies in patients with nonspecific low back pain).

“Those recommendations are not going to solve our health spending problem,” says White, “but they are part of a broader move to give permission to clinicians, based on evidence, to follow more conservative practice patterns.”

Still, counters David I. Auerbach, PhD, a health economist at RAND in Boston and author of the RAND study, “there’s another value to these tests that the cost-effectiveness equations do not always consider, which is, they can bring peace of mind. We’re trying to nudge patients down the pathway that we think is best for them without rationing care. That’s a delicate balance.”

Dr. Flansbaum says SHM’s Public Policy Committee has discussed a variety of issues related to rising costs, although the group has not directly tackled advice in the form of a white paper. He suggests some ways that hospitalists can address cost savings:

• Involve patients in shared decision-making, and discuss the evidence against unnecessary testing;
• Utilize generic medications on discharge, when available, especially if patients are uninsured or have limited drug coverage with their insurance plans;
• Use palliative care whenever appropriate; and
• Adhere to transitional-care standards.

On the macro level, HM has “always been the specialty invited to champion the important discussion relating to resource utilization, and the evidence-based medicine driving that resource utilization,” says Christopher Frost, MD, FHM, medical director of hospital medicine at the Hospital Corporation of America (HCA) in Nashville, Tenn. He points to SHM’s leadership with Project BOOST (www.hospitalmedicine.org/boost) as one example of addressing the utilization of resources in caring for older adults (see “Resources for Improving Transitions in Care,”).

What else can hospitalists do? Going forward, says Dan Fuller, president and co-founder of IN Compass Health in Alpharetta, Ga., it might be a good idea for the SHM Practice Analysis Committee, of which he’s a member, to look at its possible role in the issue.

We need the time to make these calls [to PCPs], to sit down with families. This adds value to our health system and to society at large.

—Dr. Frederickson

Embrace Reality

Whatever the downstream developments around the Affordable Care Act, Dr. Ginsburg is “confident” that Medicare policies will continue in a direction of reduced reimbursements. Thomas Frederickson, MD, FACP, FHM, MBA, medical director of the hospital medicine service at Alegent Health in Omaha, Neb., agrees with such an assessment. He also believes that hospitalists are in a prime position to improve care delivery at less cost. To do so, though, requires deliberate partnership-building with outpatient providers to better bridge the transitions of care.

At his institution, Dr. Frederickson says, hospitalists invite themselves to primary-care physicians’ (PCP) meetings. This facilitates rapport so that calls to PCPs at discharge not only communicate essential clinical information, but also build confidence in the hospitalists’ care of their patients. As hospitalists demonstrate value, they must intentionally put metrics in place so that administrators appreciate the need to keep the census at a certain level, Dr. Frederickson says.

“We need the time to make these calls, to sit down with families,” he says. “This adds value to our health system and to society at large.”

SHM does a good job, says Dr. Frost, of being part of the conversation as the hospital C-suite focuses more on episodes of care.

“The intensity of that discussion is getting dialed up and will be driven more by government and the payors,” he adds. The challenge going forward will be to bridge those arenas just outside the acute episode of care, where hospitalists have ownership of processes, to those where they do not have as much control. If payors apply broader definitions to the episode of care, Dr. Frost says, hospitalists might be “invited to play an increasing role, that of ‘transitionist.’”

And in that context, he says, hospitalists need to look at length of stay with a new lens.

Partnership-building will become more important as the definition of “episode of care” expands beyond the hospital stay to the post-acute setting.

“Including post-acute care in the episode of care is a core aspect of the whole” value-based purchasing approach, Dr. Ginsburg says. “Hospitals [and hospitalists] will be wise to opt for the model with the greatest potential to reduce costs, particularly costs incurred by other providers.”

Gretchen Henkel is a freelance writer in California.

References

1. Centers for Medicare & Medicaid Services. National health expenditures 2011 highlights. Centers for Medicare & Medicaid Services website. Available at: http://www.cms.gov/Research-Statistics-Data-and-Systems/Statistics-Trends-and-Reports/NationalHealthExpendData/Downloads/highlights.pdf. Accessed May 6, 2013. costs how much? Consumer Reports website. Available at: http://www.consumerreports.org/cro/magazine/ 2012/07/that-ct-scan-costs-how-much/index.htm. Accessed Aug. 2, 2012.
2. White C, Ginsburg PB. Slower growth in Medicare spending—is this the new normal? N Engl J Med. 2012;366(12):1073-1075.
3. Auerbach DI, Kellermann AL. A decade of health care cost growth has wiped out real income gains for an average US family. Health Aff (Millwood). 2011;30(9):1630-1636.
4. Milliman Inc. 2012 Milliman Medical Index. Milliman Inc. website. Available at: http://publications.milliman.com/periodicals/mmi/pdfs/milliman-medical-index-2012.pdf. Accessed Aug. 1, 2012.
5. Kolata G. Knotty challenges in health care costs. The New York Times website. Available at: http://www.nytimes.com/2012/03/06/health/policy/an-interview-with-victor-fuchs-on-health-care-costs.html. Accessed March 8, 2012.
6. Consumer Reports. That CT scan costs how much? Consumer Reports website. Available at: http://www.consumerreports.org/cro/magazine/ 2012/07/that-ct-scan-costs-how-much/index.htm.

Alarms about our nation’s health-care costs have been sounding for well over a decade. According to the Centers for Medicare & Medicaid Services (CMS), spending on U.S. health care doubled between 1999 and 2011, climbing to $2.7 trillion from $1.3 trillion, and now represents 17.9% of the United States’ GDP.¹

“The medical care system is bankrupting the country,” Paul B. Ginsburg, PhD, president of the Center for Studying Health System Change (HSC), based in Washington, D.C., says bluntly. A four-decade-long upward spending trend is “unsustainable,” he wrote in the New England Journal of Medicine with Chapin White, PhD, a senior health researcher at HSC.²

Recent reports suggest that rising premiums and out-of-pocket costs are rendering the price of health care untenable for the average consumer. A 2011 RAND Corp. study found that, for the average American family, the rate of increased costs for health care had outpaced growth in earnings from 1999 to 2009.³ And last year, for the first time, the cost of health care for a typical American family of four surpassed $20,000, the annual Milliman Medical Index reported.⁴

Should hospitalists be concerned, professionally and personally, about these trends? Absolutely, say hospitalist leaders who spoke with The Hospitalist. HM clinicians have much to contribute at both the macro level (addressing systemic causes of overutilization through quality improvement and other initiatives) and at the micro level, by understanding their personal contributions and by engaging patients and their families in shared decision-making.

But getting at and addressing the root causes of rising health-care costs, according to health-care policy analysts and veteran hospitalists, will require major shifts in thinking and processes.

Contributors to Rising Costs

It’s difficult to pinpoint the root causes of the recent surge in health-care costs. Victor Fuchs, emeritus professor of economics and health research and policy at Stanford University, points to the U.S.’ high administrative costs and complicated billing systems.⁵ A fragmented, nontransparent system for negotiating fees between insurers and providers also plays a role, as demonstrated in a Consumer Reports investigation into geographic variations in costs for common tests and procedures. A complete blood count might be as low as $15 or as high as $105; a colonoscopy ranges from $800 to $3,160.⁶

Bradley Flansbaum, DO, MPH, SFHM, an SHM Public Policy Committee member and AMA delegate, says rising costs are a provider-specific issue. He challenges colleagues to take an honest look at their own practice patterns to assess whether they’re contributing to overuse of resources (see “A Lesson in Change,”).

“The culture of practice has developed so that this is not going to change overnight,” says Dr. Flansbaum, director of hospitalist services at Lenox Hill Hospital in New York City. That’s because many physicians fail to view their own decisions as a problem. For example, says Dr. Flansbaum, “an oncologist may not identify a third round of chemotherapy as an embodiment of the problem, or a gastroenterologist might not embody the colonoscopy at Year Four instead of Year Five as the problem. We must come to grips with the usual mindset, look in the mirror, and admit, ‘Maybe we are part of the problem.’”

The culture of practice has developed so that this is not going to change overnight. An oncologist may not identify a third round of chemotherapy as an embodiment of the problem. We must come to grips with the usual mindset, look in the mirror, and admit, 'Maybe we are part of the problem.'

—Bradley Flansbaum, DO, MPH, SFHM

Potential Solutions

Hospitalists, intensivists, and ED clinicians are tasked with finding a balance between being prudent stewards of resources and staying within a comfort zone that promotes patient safety. SHM supports the goals of the ABIM Foundation’s Choosing Wisely campaign, which aims to reduce waste by curtailing duplicative and unnecessary care (see “Better Choices, Better Care,” March 2013). Also included in the campaign (www.ChoosingWisely.org) are the American College of Physicians’ recommendations against low-value testing (e.g. obtaining imaging studies in patients with nonspecific low back pain).

“Those recommendations are not going to solve our health spending problem,” says White, “but they are part of a broader move to give permission to clinicians, based on evidence, to follow more conservative practice patterns.”

Still, counters David I. Auerbach, PhD, a health economist at RAND in Boston and author of the RAND study, “there’s another value to these tests that the cost-effectiveness equations do not always consider, which is, they can bring peace of mind. We’re trying to nudge patients down the pathway that we think is best for them without rationing care. That’s a delicate balance.”

Dr. Flansbaum says SHM’s Public Policy Committee has discussed a variety of issues related to rising costs, although the group has not directly tackled advice in the form of a white paper. He suggests some ways that hospitalists can address cost savings:

• Involve patients in shared decision-making, and discuss the evidence against unnecessary testing;
• Utilize generic medications on discharge, when available, especially if patients are uninsured or have limited drug coverage with their insurance plans;
• Use palliative care whenever appropriate; and
• Adhere to transitional-care standards.

On the macro level, HM has “always been the specialty invited to champion the important discussion relating to resource utilization, and the evidence-based medicine driving that resource utilization,” says Christopher Frost, MD, FHM, medical director of hospital medicine at the Hospital Corporation of America (HCA) in Nashville, Tenn. He points to SHM’s leadership with Project BOOST (www.hospitalmedicine.org/boost) as one example of addressing the utilization of resources in caring for older adults (see “Resources for Improving Transitions in Care,”).

What else can hospitalists do? Going forward, says Dan Fuller, president and co-founder of IN Compass Health in Alpharetta, Ga., it might be a good idea for the SHM Practice Analysis Committee, of which he’s a member, to look at its possible role in the issue.

We need the time to make these calls [to PCPs], to sit down with families. This adds value to our health system and to society at large.

—Dr. Frederickson

Embrace Reality

Whatever the downstream developments around the Affordable Care Act, Dr. Ginsburg is “confident” that Medicare policies will continue in a direction of reduced reimbursements. Thomas Frederickson, MD, FACP, FHM, MBA, medical director of the hospital medicine service at Alegent Health in Omaha, Neb., agrees with such an assessment. He also believes that hospitalists are in a prime position to improve care delivery at less cost. To do so, though, requires deliberate partnership-building with outpatient providers to better bridge the transitions of care.

At his institution, Dr. Frederickson says, hospitalists invite themselves to primary-care physicians’ (PCP) meetings. This facilitates rapport so that calls to PCPs at discharge not only communicate essential clinical information, but also build confidence in the hospitalists’ care of their patients. As hospitalists demonstrate value, they must intentionally put metrics in place so that administrators appreciate the need to keep the census at a certain level, Dr. Frederickson says.

“We need the time to make these calls, to sit down with families,” he says. “This adds value to our health system and to society at large.”

SHM does a good job, says Dr. Frost, of being part of the conversation as the hospital C-suite focuses more on episodes of care.

“The intensity of that discussion is getting dialed up and will be driven more by government and the payors,” he adds. The challenge going forward will be to bridge those arenas just outside the acute episode of care, where hospitalists have ownership of processes, to those where they do not have as much control. If payors apply broader definitions to the episode of care, Dr. Frost says, hospitalists might be “invited to play an increasing role, that of ‘transitionist.’”

And in that context, he says, hospitalists need to look at length of stay with a new lens.

Partnership-building will become more important as the definition of “episode of care” expands beyond the hospital stay to the post-acute setting.

“Including post-acute care in the episode of care is a core aspect of the whole” value-based purchasing approach, Dr. Ginsburg says. “Hospitals [and hospitalists] will be wise to opt for the model with the greatest potential to reduce costs, particularly costs incurred by other providers.”

Gretchen Henkel is a freelance writer in California.

References

1. Centers for Medicare & Medicaid Services. National health expenditures 2011 highlights. Centers for Medicare & Medicaid Services website. Available at: http://www.cms.gov/Research-Statistics-Data-and-Systems/Statistics-Trends-and-Reports/NationalHealthExpendData/Downloads/highlights.pdf. Accessed May 6, 2013. costs how much? Consumer Reports website. Available at: http://www.consumerreports.org/cro/magazine/ 2012/07/that-ct-scan-costs-how-much/index.htm. Accessed Aug. 2, 2012.
2. White C, Ginsburg PB. Slower growth in Medicare spending—is this the new normal? N Engl J Med. 2012;366(12):1073-1075.
3. Auerbach DI, Kellermann AL. A decade of health care cost growth has wiped out real income gains for an average US family. Health Aff (Millwood). 2011;30(9):1630-1636.
4. Milliman Inc. 2012 Milliman Medical Index. Milliman Inc. website. Available at: http://publications.milliman.com/periodicals/mmi/pdfs/milliman-medical-index-2012.pdf. Accessed Aug. 1, 2012.
5. Kolata G. Knotty challenges in health care costs. The New York Times website. Available at: http://www.nytimes.com/2012/03/06/health/policy/an-interview-with-victor-fuchs-on-health-care-costs.html. Accessed March 8, 2012.
6. Consumer Reports. That CT scan costs how much? Consumer Reports website. Available at: http://www.consumerreports.org/cro/magazine/ 2012/07/that-ct-scan-costs-how-much/index.htm.

Alarms about our nation’s health-care costs have been sounding for well over a decade. According to the Centers for Medicare & Medicaid Services (CMS), spending on U.S. health care doubled between 1999 and 2011, climbing to $2.7 trillion from $1.3 trillion, and now represents 17.9% of the United States’ GDP.¹

“The medical care system is bankrupting the country,” Paul B. Ginsburg, PhD, president of the Center for Studying Health System Change (HSC), based in Washington, D.C., says bluntly. A four-decade-long upward spending trend is “unsustainable,” he wrote in the New England Journal of Medicine with Chapin White, PhD, a senior health researcher at HSC.²

Recent reports suggest that rising premiums and out-of-pocket costs are rendering the price of health care untenable for the average consumer. A 2011 RAND Corp. study found that, for the average American family, the rate of increased costs for health care had outpaced growth in earnings from 1999 to 2009.³ And last year, for the first time, the cost of health care for a typical American family of four surpassed $20,000, the annual Milliman Medical Index reported.⁴

Should hospitalists be concerned, professionally and personally, about these trends? Absolutely, say hospitalist leaders who spoke with The Hospitalist. HM clinicians have much to contribute at both the macro level (addressing systemic causes of overutilization through quality improvement and other initiatives) and at the micro level, by understanding their personal contributions and by engaging patients and their families in shared decision-making.

But getting at and addressing the root causes of rising health-care costs, according to health-care policy analysts and veteran hospitalists, will require major shifts in thinking and processes.

Contributors to Rising Costs

It’s difficult to pinpoint the root causes of the recent surge in health-care costs. Victor Fuchs, emeritus professor of economics and health research and policy at Stanford University, points to the U.S.’ high administrative costs and complicated billing systems.⁵ A fragmented, nontransparent system for negotiating fees between insurers and providers also plays a role, as demonstrated in a Consumer Reports investigation into geographic variations in costs for common tests and procedures. A complete blood count might be as low as $15 or as high as $105; a colonoscopy ranges from $800 to $3,160.⁶

Bradley Flansbaum, DO, MPH, SFHM, an SHM Public Policy Committee member and AMA delegate, says rising costs are a provider-specific issue. He challenges colleagues to take an honest look at their own practice patterns to assess whether they’re contributing to overuse of resources (see “A Lesson in Change,”).

“The culture of practice has developed so that this is not going to change overnight,” says Dr. Flansbaum, director of hospitalist services at Lenox Hill Hospital in New York City. That’s because many physicians fail to view their own decisions as a problem. For example, says Dr. Flansbaum, “an oncologist may not identify a third round of chemotherapy as an embodiment of the problem, or a gastroenterologist might not embody the colonoscopy at Year Four instead of Year Five as the problem. We must come to grips with the usual mindset, look in the mirror, and admit, ‘Maybe we are part of the problem.’”

The culture of practice has developed so that this is not going to change overnight. An oncologist may not identify a third round of chemotherapy as an embodiment of the problem. We must come to grips with the usual mindset, look in the mirror, and admit, 'Maybe we are part of the problem.'

—Bradley Flansbaum, DO, MPH, SFHM

Potential Solutions

Hospitalists, intensivists, and ED clinicians are tasked with finding a balance between being prudent stewards of resources and staying within a comfort zone that promotes patient safety. SHM supports the goals of the ABIM Foundation’s Choosing Wisely campaign, which aims to reduce waste by curtailing duplicative and unnecessary care (see “Better Choices, Better Care,” March 2013). Also included in the campaign (www.ChoosingWisely.org) are the American College of Physicians’ recommendations against low-value testing (e.g. obtaining imaging studies in patients with nonspecific low back pain).

“Those recommendations are not going to solve our health spending problem,” says White, “but they are part of a broader move to give permission to clinicians, based on evidence, to follow more conservative practice patterns.”

Still, counters David I. Auerbach, PhD, a health economist at RAND in Boston and author of the RAND study, “there’s another value to these tests that the cost-effectiveness equations do not always consider, which is, they can bring peace of mind. We’re trying to nudge patients down the pathway that we think is best for them without rationing care. That’s a delicate balance.”

Dr. Flansbaum says SHM’s Public Policy Committee has discussed a variety of issues related to rising costs, although the group has not directly tackled advice in the form of a white paper. He suggests some ways that hospitalists can address cost savings:

• Involve patients in shared decision-making, and discuss the evidence against unnecessary testing;
• Utilize generic medications on discharge, when available, especially if patients are uninsured or have limited drug coverage with their insurance plans;
• Use palliative care whenever appropriate; and
• Adhere to transitional-care standards.

On the macro level, HM has “always been the specialty invited to champion the important discussion relating to resource utilization, and the evidence-based medicine driving that resource utilization,” says Christopher Frost, MD, FHM, medical director of hospital medicine at the Hospital Corporation of America (HCA) in Nashville, Tenn. He points to SHM’s leadership with Project BOOST (www.hospitalmedicine.org/boost) as one example of addressing the utilization of resources in caring for older adults (see “Resources for Improving Transitions in Care,”).

What else can hospitalists do? Going forward, says Dan Fuller, president and co-founder of IN Compass Health in Alpharetta, Ga., it might be a good idea for the SHM Practice Analysis Committee, of which he’s a member, to look at its possible role in the issue.

We need the time to make these calls [to PCPs], to sit down with families. This adds value to our health system and to society at large.

—Dr. Frederickson

Embrace Reality

Whatever the downstream developments around the Affordable Care Act, Dr. Ginsburg is “confident” that Medicare policies will continue in a direction of reduced reimbursements. Thomas Frederickson, MD, FACP, FHM, MBA, medical director of the hospital medicine service at Alegent Health in Omaha, Neb., agrees with such an assessment. He also believes that hospitalists are in a prime position to improve care delivery at less cost. To do so, though, requires deliberate partnership-building with outpatient providers to better bridge the transitions of care.

At his institution, Dr. Frederickson says, hospitalists invite themselves to primary-care physicians’ (PCP) meetings. This facilitates rapport so that calls to PCPs at discharge not only communicate essential clinical information, but also build confidence in the hospitalists’ care of their patients. As hospitalists demonstrate value, they must intentionally put metrics in place so that administrators appreciate the need to keep the census at a certain level, Dr. Frederickson says.

“We need the time to make these calls, to sit down with families,” he says. “This adds value to our health system and to society at large.”

SHM does a good job, says Dr. Frost, of being part of the conversation as the hospital C-suite focuses more on episodes of care.

“The intensity of that discussion is getting dialed up and will be driven more by government and the payors,” he adds. The challenge going forward will be to bridge those arenas just outside the acute episode of care, where hospitalists have ownership of processes, to those where they do not have as much control. If payors apply broader definitions to the episode of care, Dr. Frost says, hospitalists might be “invited to play an increasing role, that of ‘transitionist.’”

And in that context, he says, hospitalists need to look at length of stay with a new lens.

Partnership-building will become more important as the definition of “episode of care” expands beyond the hospital stay to the post-acute setting.

“Including post-acute care in the episode of care is a core aspect of the whole” value-based purchasing approach, Dr. Ginsburg says. “Hospitals [and hospitalists] will be wise to opt for the model with the greatest potential to reduce costs, particularly costs incurred by other providers.”

Gretchen Henkel is a freelance writer in California.

References

1. Centers for Medicare & Medicaid Services. National health expenditures 2011 highlights. Centers for Medicare & Medicaid Services website. Available at: http://www.cms.gov/Research-Statistics-Data-and-Systems/Statistics-Trends-and-Reports/NationalHealthExpendData/Downloads/highlights.pdf. Accessed May 6, 2013. costs how much? Consumer Reports website. Available at: http://www.consumerreports.org/cro/magazine/ 2012/07/that-ct-scan-costs-how-much/index.htm. Accessed Aug. 2, 2012.
2. White C, Ginsburg PB. Slower growth in Medicare spending—is this the new normal? N Engl J Med. 2012;366(12):1073-1075.
3. Auerbach DI, Kellermann AL. A decade of health care cost growth has wiped out real income gains for an average US family. Health Aff (Millwood). 2011;30(9):1630-1636.
4. Milliman Inc. 2012 Milliman Medical Index. Milliman Inc. website. Available at: http://publications.milliman.com/periodicals/mmi/pdfs/milliman-medical-index-2012.pdf. Accessed Aug. 1, 2012.
5. Kolata G. Knotty challenges in health care costs. The New York Times website. Available at: http://www.nytimes.com/2012/03/06/health/policy/an-interview-with-victor-fuchs-on-health-care-costs.html. Accessed March 8, 2012.
6. Consumer Reports. That CT scan costs how much? Consumer Reports website. Available at: http://www.consumerreports.org/cro/magazine/ 2012/07/that-ct-scan-costs-how-much/index.htm.

I read the article “Call for Transparency in Health-Care Performance Results to Impact Hospitalists” (January 2013, p. 47) by Shaun Frost, MD, SFHM, president of the Society of Hospital Medicine, with interest. I’d like to clarify a key point about Physician Compare. In the article, the statement that the Physician Compare website (www.medicare.gov/find-a-doctor) provides performance information on individual doctors is inaccurate.

The Affordable Care Act (ACA) states that the Centers for Medicare & Medicaid Services (CMS) must have a plan in place by Jan. 1, 2013, to include quality-of-care information on the site. To meet that requirement, CMS has established a plan that initiates a phased approach to public reporting. The 2012 Physician Fee Schedule (PFS) Final Rule was the first step in that phased approach. This rule established that the first measures to be reported on the site would be group-level measures for data collected no sooner than program year 2012. A second critical step is the 2013 PFS Proposed Rule, which outlines a longer-term public reporting plan. According to this plan, we expect the first set of group-level quality measure data to be included on the site in calendar year 2014. We are targeting publishing individual-level quality measures no sooner than 2015 reflecting data collected in program year 2014, if technically feasible.

As you may be aware, Physician Compare is undergoing a redesign to significantly improve the underlying database and thus the information on Physician Compare, as well as the ease of use and functionality of the site. We’ll be unveiling the redesigned site soon. We welcome your feedback and look forward to maintaining a dialogue with you as Physician Compare continues to evolve.

Rashaan Byers, MPH, social science research analyst, Centers forMedicare & Medicaid Services, Center for Clinical Standards & Quality, Quality Measurement & Health Assessment Group

Dr. Frost responds:

I thank Mr. Byers for his clarification regarding the current content on the CMS Physician Compare website, and agree that at the present time the website does not report individual physician clinical performance data.

Physician Compare, however, does currently report if an individual physician participated in the CMS Physician Quality Reporting System (PQRS) by stating “this professional chose to take part in Medicare’s PQRS, and reported quality information satisfactorily for the year 2010.” For those physicians who did not participate in PQRS, their personal website pages do not make reference to the PQRS program.

As the intent of transparency is to educate consumers to make informed choices about where to seek health care, care providers should know that their participation in PQRS is currently publically reported. It is, therefore, possible that patient decisions about whom to seek care from may be influenced by this.

As acknowledged in my January 2013 column in The Hospitalist, Physician Compare currently reports very little information. We should expect this to change, however, as Medicare moves forward with developing a plan to publically report valid and reliable individual physician performance metrics. CMS’ clarification of the timeline by which we can expect to see more detailed information is thus greatly appreciated.

The take-home message for hospitalists is that public reporting of care provider performance will become increasingly comprehensive and transparent in the future. As pointed out, CMS’ present plan targets the publication of individual, physician-level quality measures as soon as 2015, which will reflect actual performance during program year 2014. The measurement period is thus less than one year away, so it behooves us all to focus ever more intently on delivering high-value healthcare.

Shaun Frost, MD, SFHM, past president, SHM

I read the article “Call for Transparency in Health-Care Performance Results to Impact Hospitalists” (January 2013, p. 47) by Shaun Frost, MD, SFHM, president of the Society of Hospital Medicine, with interest. I’d like to clarify a key point about Physician Compare. In the article, the statement that the Physician Compare website (www.medicare.gov/find-a-doctor) provides performance information on individual doctors is inaccurate.

The Affordable Care Act (ACA) states that the Centers for Medicare & Medicaid Services (CMS) must have a plan in place by Jan. 1, 2013, to include quality-of-care information on the site. To meet that requirement, CMS has established a plan that initiates a phased approach to public reporting. The 2012 Physician Fee Schedule (PFS) Final Rule was the first step in that phased approach. This rule established that the first measures to be reported on the site would be group-level measures for data collected no sooner than program year 2012. A second critical step is the 2013 PFS Proposed Rule, which outlines a longer-term public reporting plan. According to this plan, we expect the first set of group-level quality measure data to be included on the site in calendar year 2014. We are targeting publishing individual-level quality measures no sooner than 2015 reflecting data collected in program year 2014, if technically feasible.

As you may be aware, Physician Compare is undergoing a redesign to significantly improve the underlying database and thus the information on Physician Compare, as well as the ease of use and functionality of the site. We’ll be unveiling the redesigned site soon. We welcome your feedback and look forward to maintaining a dialogue with you as Physician Compare continues to evolve.

Rashaan Byers, MPH, social science research analyst, Centers forMedicare & Medicaid Services, Center for Clinical Standards & Quality, Quality Measurement & Health Assessment Group

Dr. Frost responds:

I thank Mr. Byers for his clarification regarding the current content on the CMS Physician Compare website, and agree that at the present time the website does not report individual physician clinical performance data.

Physician Compare, however, does currently report if an individual physician participated in the CMS Physician Quality Reporting System (PQRS) by stating “this professional chose to take part in Medicare’s PQRS, and reported quality information satisfactorily for the year 2010.” For those physicians who did not participate in PQRS, their personal website pages do not make reference to the PQRS program.

As the intent of transparency is to educate consumers to make informed choices about where to seek health care, care providers should know that their participation in PQRS is currently publically reported. It is, therefore, possible that patient decisions about whom to seek care from may be influenced by this.

As acknowledged in my January 2013 column in The Hospitalist, Physician Compare currently reports very little information. We should expect this to change, however, as Medicare moves forward with developing a plan to publically report valid and reliable individual physician performance metrics. CMS’ clarification of the timeline by which we can expect to see more detailed information is thus greatly appreciated.

The take-home message for hospitalists is that public reporting of care provider performance will become increasingly comprehensive and transparent in the future. As pointed out, CMS’ present plan targets the publication of individual, physician-level quality measures as soon as 2015, which will reflect actual performance during program year 2014. The measurement period is thus less than one year away, so it behooves us all to focus ever more intently on delivering high-value healthcare.

Shaun Frost, MD, SFHM, past president, SHM

I read the article “Call for Transparency in Health-Care Performance Results to Impact Hospitalists” (January 2013, p. 47) by Shaun Frost, MD, SFHM, president of the Society of Hospital Medicine, with interest. I’d like to clarify a key point about Physician Compare. In the article, the statement that the Physician Compare website (www.medicare.gov/find-a-doctor) provides performance information on individual doctors is inaccurate.

The Affordable Care Act (ACA) states that the Centers for Medicare & Medicaid Services (CMS) must have a plan in place by Jan. 1, 2013, to include quality-of-care information on the site. To meet that requirement, CMS has established a plan that initiates a phased approach to public reporting. The 2012 Physician Fee Schedule (PFS) Final Rule was the first step in that phased approach. This rule established that the first measures to be reported on the site would be group-level measures for data collected no sooner than program year 2012. A second critical step is the 2013 PFS Proposed Rule, which outlines a longer-term public reporting plan. According to this plan, we expect the first set of group-level quality measure data to be included on the site in calendar year 2014. We are targeting publishing individual-level quality measures no sooner than 2015 reflecting data collected in program year 2014, if technically feasible.

As you may be aware, Physician Compare is undergoing a redesign to significantly improve the underlying database and thus the information on Physician Compare, as well as the ease of use and functionality of the site. We’ll be unveiling the redesigned site soon. We welcome your feedback and look forward to maintaining a dialogue with you as Physician Compare continues to evolve.

Rashaan Byers, MPH, social science research analyst, Centers forMedicare & Medicaid Services, Center for Clinical Standards & Quality, Quality Measurement & Health Assessment Group

Dr. Frost responds:

I thank Mr. Byers for his clarification regarding the current content on the CMS Physician Compare website, and agree that at the present time the website does not report individual physician clinical performance data.

Physician Compare, however, does currently report if an individual physician participated in the CMS Physician Quality Reporting System (PQRS) by stating “this professional chose to take part in Medicare’s PQRS, and reported quality information satisfactorily for the year 2010.” For those physicians who did not participate in PQRS, their personal website pages do not make reference to the PQRS program.

As the intent of transparency is to educate consumers to make informed choices about where to seek health care, care providers should know that their participation in PQRS is currently publically reported. It is, therefore, possible that patient decisions about whom to seek care from may be influenced by this.

As acknowledged in my January 2013 column in The Hospitalist, Physician Compare currently reports very little information. We should expect this to change, however, as Medicare moves forward with developing a plan to publically report valid and reliable individual physician performance metrics. CMS’ clarification of the timeline by which we can expect to see more detailed information is thus greatly appreciated.

The take-home message for hospitalists is that public reporting of care provider performance will become increasingly comprehensive and transparent in the future. As pointed out, CMS’ present plan targets the publication of individual, physician-level quality measures as soon as 2015, which will reflect actual performance during program year 2014. The measurement period is thus less than one year away, so it behooves us all to focus ever more intently on delivering high-value healthcare.

Shaun Frost, MD, SFHM, past president, SHM

Back in the 1980s, I would go by medical records every day or two and find, on the front of the charts of my recently discharged patients, a form listing the diagnoses the hospital was billing to Medicare. Before the hospital could submit a patient’s bill, the attending physician was required to review the form and, by signing it, indicate agreement.

The requirement for this signature by the physician went away a long time ago and in my memory is one of the very few examples of reducing a doctor’s paperwork.

For my first few months in practice, I regularly would seek out the people who completed the form and explain they had misunderstood the patient’s clinical situation. “The main issue was a urinary tract infection,” I would say, “but you listed diabetes as the principal diagnosis.”

I don’t ever remember them changing anything based on my feedback. Instead, they explained to me that, for billing purposes, it was legitimate to list diabetes as the principal diagnosis because it had the additional benefit of resulting in a higher payment to the hospital than having “urinary tract infection” listed first.

Such was my introduction to the world of documentation and coding for hospital billing purposes and how it can sometimes differ significantly from the way a doctor sees the clinical picture. Things have evolved a lot since then, but the way doctors document medical conditions still has a huge influence on hospital reimbursement.

Hospital CDI Programs

About 80% of hospitals have formal clinical documentation improvement (CDI) programs to help ensure all clinical conditions are captured and described in the medical record in ways that are valuable for billing and other recordkeeping purposes. These programs might lead to you receive queries about your documentation. For example, you might be asked to clarify whether your patient’s pneumonia might be on the basis of aspiration.

Within SHM’s Code-H program, Dr. Richard Pinson, a former ED physician who now works with Houston-based HCQ Consulting, has a good presentation explaining these documentation issues. In it, he makes the point that, in addition to influencing how hospitals are paid, the way various conditions are documented also influences quality ratings.

click for large version

Novel Approach

The most common approach to engaging hospitalists in CDI initiatives is to have them attend a presentation on the topic, then put in place documentation specialists who generate queries asking the doctor to clarify diagnoses when it might influence payment, severity of illness determination, etc. Dr. Kenji Asakura, a Seattle hospitalist, and Erik Ordal, MBA, have a company called ClinIntell that analyzes each hospitalist (or other specialty) group’s historical patient mix and trains them on the documentation issues that they see most often. The idea of this focused approach is to make “documentation queries” unnecessary, or at least much less necessary. The benefits of this approach are many, including reducing or eliminating the risk of “leading queries”—that is, queries that seem to encourage the doctor to document a diagnosis because it is an advantage to the hospital rather than a well-considered medical opinion. Leading queries can be regarded as fraudulent and can get a lot of people in trouble.

I asked Kenji and Erik if they could provide me with a list of common documentation issues that most hospitalists need to know more about. Table 1 is what they came up with. I hope it helps you and your practice.

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

Back in the 1980s, I would go by medical records every day or two and find, on the front of the charts of my recently discharged patients, a form listing the diagnoses the hospital was billing to Medicare. Before the hospital could submit a patient’s bill, the attending physician was required to review the form and, by signing it, indicate agreement.

The requirement for this signature by the physician went away a long time ago and in my memory is one of the very few examples of reducing a doctor’s paperwork.

For my first few months in practice, I regularly would seek out the people who completed the form and explain they had misunderstood the patient’s clinical situation. “The main issue was a urinary tract infection,” I would say, “but you listed diabetes as the principal diagnosis.”

I don’t ever remember them changing anything based on my feedback. Instead, they explained to me that, for billing purposes, it was legitimate to list diabetes as the principal diagnosis because it had the additional benefit of resulting in a higher payment to the hospital than having “urinary tract infection” listed first.

Such was my introduction to the world of documentation and coding for hospital billing purposes and how it can sometimes differ significantly from the way a doctor sees the clinical picture. Things have evolved a lot since then, but the way doctors document medical conditions still has a huge influence on hospital reimbursement.

Hospital CDI Programs

About 80% of hospitals have formal clinical documentation improvement (CDI) programs to help ensure all clinical conditions are captured and described in the medical record in ways that are valuable for billing and other recordkeeping purposes. These programs might lead to you receive queries about your documentation. For example, you might be asked to clarify whether your patient’s pneumonia might be on the basis of aspiration.

Within SHM’s Code-H program, Dr. Richard Pinson, a former ED physician who now works with Houston-based HCQ Consulting, has a good presentation explaining these documentation issues. In it, he makes the point that, in addition to influencing how hospitals are paid, the way various conditions are documented also influences quality ratings.

click for large version

Novel Approach

The most common approach to engaging hospitalists in CDI initiatives is to have them attend a presentation on the topic, then put in place documentation specialists who generate queries asking the doctor to clarify diagnoses when it might influence payment, severity of illness determination, etc. Dr. Kenji Asakura, a Seattle hospitalist, and Erik Ordal, MBA, have a company called ClinIntell that analyzes each hospitalist (or other specialty) group’s historical patient mix and trains them on the documentation issues that they see most often. The idea of this focused approach is to make “documentation queries” unnecessary, or at least much less necessary. The benefits of this approach are many, including reducing or eliminating the risk of “leading queries”—that is, queries that seem to encourage the doctor to document a diagnosis because it is an advantage to the hospital rather than a well-considered medical opinion. Leading queries can be regarded as fraudulent and can get a lot of people in trouble.

I asked Kenji and Erik if they could provide me with a list of common documentation issues that most hospitalists need to know more about. Table 1 is what they came up with. I hope it helps you and your practice.

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

Back in the 1980s, I would go by medical records every day or two and find, on the front of the charts of my recently discharged patients, a form listing the diagnoses the hospital was billing to Medicare. Before the hospital could submit a patient’s bill, the attending physician was required to review the form and, by signing it, indicate agreement.

The requirement for this signature by the physician went away a long time ago and in my memory is one of the very few examples of reducing a doctor’s paperwork.

For my first few months in practice, I regularly would seek out the people who completed the form and explain they had misunderstood the patient’s clinical situation. “The main issue was a urinary tract infection,” I would say, “but you listed diabetes as the principal diagnosis.”

I don’t ever remember them changing anything based on my feedback. Instead, they explained to me that, for billing purposes, it was legitimate to list diabetes as the principal diagnosis because it had the additional benefit of resulting in a higher payment to the hospital than having “urinary tract infection” listed first.

Such was my introduction to the world of documentation and coding for hospital billing purposes and how it can sometimes differ significantly from the way a doctor sees the clinical picture. Things have evolved a lot since then, but the way doctors document medical conditions still has a huge influence on hospital reimbursement.

Hospital CDI Programs

About 80% of hospitals have formal clinical documentation improvement (CDI) programs to help ensure all clinical conditions are captured and described in the medical record in ways that are valuable for billing and other recordkeeping purposes. These programs might lead to you receive queries about your documentation. For example, you might be asked to clarify whether your patient’s pneumonia might be on the basis of aspiration.

Within SHM’s Code-H program, Dr. Richard Pinson, a former ED physician who now works with Houston-based HCQ Consulting, has a good presentation explaining these documentation issues. In it, he makes the point that, in addition to influencing how hospitals are paid, the way various conditions are documented also influences quality ratings.

click for large version

Novel Approach

The most common approach to engaging hospitalists in CDI initiatives is to have them attend a presentation on the topic, then put in place documentation specialists who generate queries asking the doctor to clarify diagnoses when it might influence payment, severity of illness determination, etc. Dr. Kenji Asakura, a Seattle hospitalist, and Erik Ordal, MBA, have a company called ClinIntell that analyzes each hospitalist (or other specialty) group’s historical patient mix and trains them on the documentation issues that they see most often. The idea of this focused approach is to make “documentation queries” unnecessary, or at least much less necessary. The benefits of this approach are many, including reducing or eliminating the risk of “leading queries”—that is, queries that seem to encourage the doctor to document a diagnosis because it is an advantage to the hospital rather than a well-considered medical opinion. Leading queries can be regarded as fraudulent and can get a lot of people in trouble.

I asked Kenji and Erik if they could provide me with a list of common documentation issues that most hospitalists need to know more about. Table 1 is what they came up with. I hope it helps you and your practice.

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

Dr. Hospitalist

Refrain from Texting about Your Patients

Can I text my partners patient information?

–Stephen Henry, San Luis Obispo, Calif.

Dr. Hospitalist responds:

Can you? Sure. Do you? Probably. Should you? No.

Texting any patient information falls under the category of ePHI (Electronic Protected Health Information) as part of HIPAA. Technically, such patient-specific information must be protected at all times. Once you send a text, at least three copies are known to exist: one on each of the devices, plus one copy on the network it went through, adding for each network it has to cross. Sure, your phone may be password-protected, but is your partner’s? What about the carrier? How protected is their data?

HIPAA goes into excruciating technical detail about all the safeguards that must be present. You are more than welcome to read it (www.hhs.gov/ocr/privacy/hipaa/administrative/securityrule) to see if you meet all the standards. Or you can take my word for it: You don’t.

So you can see why most health organizations expressly prohibit the texting of patient information. If you rang up your local health-care or hospital lawyer, I’m sure they would tell you to never text patient information. Is that reasonable advice? In 2013, I doubt it.

So what’s the practical advice to follow? For starters, password-protect your phone, if you haven’t already. Nothing worse than losing your phone and having patient information on it. A lot of the OCR (Office for Civil Rights, a branch of Health and Human Services) fines for HIPAA violations stem from folks misplacing unencrypted devices with patient information on them.

Just as important, don’t text anything that you wouldn’t want to see blown up on a lawyer’s display board in court. I’ve seen some really egregious examples of communication between doctors that have no business being preserved electronically. Texting “Mr. X in Room 2101 is a meth-using, narcotic-seeking, half-naked, lunatic troll” is an absolutely stupid thing to do. For that matter, so are remarks that seem less offensive: “And his son is completely unreasonable.” Save your commentary and stick to the facts, because you just generated three copies forever.

If you receive an insensitive text, don’t reply. Simply call the sending physician to discuss any issues. Even being on a “secure” texting network won’t protect you from errors of commission.

If I were to text about a patient (purely hypothetically, mind you), I would limit the information as much as possible. Keep it simple and generic (what HIPAA likes to call “de-identified information”)—for example, “Room 428 is ready for discharge.”

Please, hold the subjective commentary. There is no good reason to have an extended text exchange about a patient; you are creating an electronic trail that has no good reason to exist and never really goes away. It’s just the same as writing in the chart, except that it has the illusion of privacy. And that’s all it is: an illusion.

At the end of the day, I’d probably worry more about the discoverable aspect of your text messages in a lawsuit than the possibility of a HIPAA fine, but neither one sounds like much fun to me.

Dr. Hospitalist

Refrain from Texting about Your Patients

Can I text my partners patient information?

–Stephen Henry, San Luis Obispo, Calif.

Dr. Hospitalist responds:

Can you? Sure. Do you? Probably. Should you? No.

Texting any patient information falls under the category of ePHI (Electronic Protected Health Information) as part of HIPAA. Technically, such patient-specific information must be protected at all times. Once you send a text, at least three copies are known to exist: one on each of the devices, plus one copy on the network it went through, adding for each network it has to cross. Sure, your phone may be password-protected, but is your partner’s? What about the carrier? How protected is their data?

HIPAA goes into excruciating technical detail about all the safeguards that must be present. You are more than welcome to read it (www.hhs.gov/ocr/privacy/hipaa/administrative/securityrule) to see if you meet all the standards. Or you can take my word for it: You don’t.

So you can see why most health organizations expressly prohibit the texting of patient information. If you rang up your local health-care or hospital lawyer, I’m sure they would tell you to never text patient information. Is that reasonable advice? In 2013, I doubt it.

So what’s the practical advice to follow? For starters, password-protect your phone, if you haven’t already. Nothing worse than losing your phone and having patient information on it. A lot of the OCR (Office for Civil Rights, a branch of Health and Human Services) fines for HIPAA violations stem from folks misplacing unencrypted devices with patient information on them.

Just as important, don’t text anything that you wouldn’t want to see blown up on a lawyer’s display board in court. I’ve seen some really egregious examples of communication between doctors that have no business being preserved electronically. Texting “Mr. X in Room 2101 is a meth-using, narcotic-seeking, half-naked, lunatic troll” is an absolutely stupid thing to do. For that matter, so are remarks that seem less offensive: “And his son is completely unreasonable.” Save your commentary and stick to the facts, because you just generated three copies forever.

If you receive an insensitive text, don’t reply. Simply call the sending physician to discuss any issues. Even being on a “secure” texting network won’t protect you from errors of commission.

If I were to text about a patient (purely hypothetically, mind you), I would limit the information as much as possible. Keep it simple and generic (what HIPAA likes to call “de-identified information”)—for example, “Room 428 is ready for discharge.”

Please, hold the subjective commentary. There is no good reason to have an extended text exchange about a patient; you are creating an electronic trail that has no good reason to exist and never really goes away. It’s just the same as writing in the chart, except that it has the illusion of privacy. And that’s all it is: an illusion.

At the end of the day, I’d probably worry more about the discoverable aspect of your text messages in a lawsuit than the possibility of a HIPAA fine, but neither one sounds like much fun to me.

Dr. Hospitalist

Refrain from Texting about Your Patients

Can I text my partners patient information?

–Stephen Henry, San Luis Obispo, Calif.

Dr. Hospitalist responds:

Can you? Sure. Do you? Probably. Should you? No.

Texting any patient information falls under the category of ePHI (Electronic Protected Health Information) as part of HIPAA. Technically, such patient-specific information must be protected at all times. Once you send a text, at least three copies are known to exist: one on each of the devices, plus one copy on the network it went through, adding for each network it has to cross. Sure, your phone may be password-protected, but is your partner’s? What about the carrier? How protected is their data?

HIPAA goes into excruciating technical detail about all the safeguards that must be present. You are more than welcome to read it (www.hhs.gov/ocr/privacy/hipaa/administrative/securityrule) to see if you meet all the standards. Or you can take my word for it: You don’t.

So you can see why most health organizations expressly prohibit the texting of patient information. If you rang up your local health-care or hospital lawyer, I’m sure they would tell you to never text patient information. Is that reasonable advice? In 2013, I doubt it.

So what’s the practical advice to follow? For starters, password-protect your phone, if you haven’t already. Nothing worse than losing your phone and having patient information on it. A lot of the OCR (Office for Civil Rights, a branch of Health and Human Services) fines for HIPAA violations stem from folks misplacing unencrypted devices with patient information on them.

Just as important, don’t text anything that you wouldn’t want to see blown up on a lawyer’s display board in court. I’ve seen some really egregious examples of communication between doctors that have no business being preserved electronically. Texting “Mr. X in Room 2101 is a meth-using, narcotic-seeking, half-naked, lunatic troll” is an absolutely stupid thing to do. For that matter, so are remarks that seem less offensive: “And his son is completely unreasonable.” Save your commentary and stick to the facts, because you just generated three copies forever.

If you receive an insensitive text, don’t reply. Simply call the sending physician to discuss any issues. Even being on a “secure” texting network won’t protect you from errors of commission.

If I were to text about a patient (purely hypothetically, mind you), I would limit the information as much as possible. Keep it simple and generic (what HIPAA likes to call “de-identified information”)—for example, “Room 428 is ready for discharge.”

Please, hold the subjective commentary. There is no good reason to have an extended text exchange about a patient; you are creating an electronic trail that has no good reason to exist and never really goes away. It’s just the same as writing in the chart, except that it has the illusion of privacy. And that’s all it is: an illusion.

At the end of the day, I’d probably worry more about the discoverable aspect of your text messages in a lawsuit than the possibility of a HIPAA fine, but neither one sounds like much fun to me.

Medicare requires beneficiaries to have at least three consecutive days as a hospital inpatient to qualify for Medicare-covered skilled nursing facility (SNF) care. As the use and duration of observation status continues to rise throughout the nation, patients have been getting caught more frequently within a policy trap: Even though they are physically within the hospital and generally receive care that is indistinguishable from the care received by other inpatients, Medicare is not covering their subsequent SNF stays.

Why? Observation status is considered “outpatient” by both the hospital and Medicare and, therefore, is not counted toward Medicare’s three-day rule.

This leaves seniors on the hook for their skilled nursing care costs, which often exceed their ability to pay. Further, this shortsighted policy might actually result in a net greater cost to Medicare and the health-care system. Faced with mounting costs, many seniors truncate or opt out of SNF care altogether, leaving them vulnerable to added health issues (e.g. dehydration, falls). With new conditions that were not present at the time of the original hospital stay, many of these seniors are at risk to return to the hospital and become another readmission statistic.

As key players in hospitals and, increasingly, in skilled nursing facilities, hospitalists are caught squarely in the middle of this policy. Transitions of care both in and out of these institutions should be guided by sound medical decision-making, not whether Medicare will cover the costs incurred. Although the three-day rule—and, indeed, observation status itself—was originally cast as a cost-containment policy, such policies should incorporate broader care process and delivery reforms that do not add burden to patients when they are at their most vulnerable.

SHM affirms that it is sensible for Medicare to provide coverage for skilled nursing care if a clinician recommends it as part of a treatment plan. Coverage determination should not be beholden to a patient status subject to other systemic pressures, but should reflect the best interest of the patient and the care ordered by providers.

The Improving Access to Medicare Coverage Act, sponsored by Rep. Joe Courtney (D-Conn.), Rep. Tom Latham (R-Iowa), and Sen. Sherrod Brown (D-Ohio), would clarify the law to indicate that Medicare beneficiaries in observation status are deemed inpatients in the hospital for the purposes of the three-day requirement for SNF coverage. This simple adjustment would ensure that patients are able to access the skilled nursing care they need and that providers do not have to worry about this systemic barrier to patient care.

SHM is actively supporting this legislation. A letter of support was sent to Courtney and Brown earlier this year, and membership was mobilized to take action through our Legislative Action Center (www.hospitalmedicine.org/advocacy). Hospitalists also plan to voice their support for the legislation during Hospitalists on the Hill, to be held this month in conjunction with HM13.

As one of only a few specialty medical societies that are active on this issue, SHM stands out as a leader on health-care-system reforms that improve access to care for patients and reduce administrative barriers to medically appropriate care.

Joshua Lapps is SHM’s government relations specialist.

Medicare requires beneficiaries to have at least three consecutive days as a hospital inpatient to qualify for Medicare-covered skilled nursing facility (SNF) care. As the use and duration of observation status continues to rise throughout the nation, patients have been getting caught more frequently within a policy trap: Even though they are physically within the hospital and generally receive care that is indistinguishable from the care received by other inpatients, Medicare is not covering their subsequent SNF stays.

Why? Observation status is considered “outpatient” by both the hospital and Medicare and, therefore, is not counted toward Medicare’s three-day rule.

This leaves seniors on the hook for their skilled nursing care costs, which often exceed their ability to pay. Further, this shortsighted policy might actually result in a net greater cost to Medicare and the health-care system. Faced with mounting costs, many seniors truncate or opt out of SNF care altogether, leaving them vulnerable to added health issues (e.g. dehydration, falls). With new conditions that were not present at the time of the original hospital stay, many of these seniors are at risk to return to the hospital and become another readmission statistic.

As key players in hospitals and, increasingly, in skilled nursing facilities, hospitalists are caught squarely in the middle of this policy. Transitions of care both in and out of these institutions should be guided by sound medical decision-making, not whether Medicare will cover the costs incurred. Although the three-day rule—and, indeed, observation status itself—was originally cast as a cost-containment policy, such policies should incorporate broader care process and delivery reforms that do not add burden to patients when they are at their most vulnerable.

SHM affirms that it is sensible for Medicare to provide coverage for skilled nursing care if a clinician recommends it as part of a treatment plan. Coverage determination should not be beholden to a patient status subject to other systemic pressures, but should reflect the best interest of the patient and the care ordered by providers.

The Improving Access to Medicare Coverage Act, sponsored by Rep. Joe Courtney (D-Conn.), Rep. Tom Latham (R-Iowa), and Sen. Sherrod Brown (D-Ohio), would clarify the law to indicate that Medicare beneficiaries in observation status are deemed inpatients in the hospital for the purposes of the three-day requirement for SNF coverage. This simple adjustment would ensure that patients are able to access the skilled nursing care they need and that providers do not have to worry about this systemic barrier to patient care.

SHM is actively supporting this legislation. A letter of support was sent to Courtney and Brown earlier this year, and membership was mobilized to take action through our Legislative Action Center (www.hospitalmedicine.org/advocacy). Hospitalists also plan to voice their support for the legislation during Hospitalists on the Hill, to be held this month in conjunction with HM13.

As one of only a few specialty medical societies that are active on this issue, SHM stands out as a leader on health-care-system reforms that improve access to care for patients and reduce administrative barriers to medically appropriate care.

Joshua Lapps is SHM’s government relations specialist.

Medicare requires beneficiaries to have at least three consecutive days as a hospital inpatient to qualify for Medicare-covered skilled nursing facility (SNF) care. As the use and duration of observation status continues to rise throughout the nation, patients have been getting caught more frequently within a policy trap: Even though they are physically within the hospital and generally receive care that is indistinguishable from the care received by other inpatients, Medicare is not covering their subsequent SNF stays.

Why? Observation status is considered “outpatient” by both the hospital and Medicare and, therefore, is not counted toward Medicare’s three-day rule.

This leaves seniors on the hook for their skilled nursing care costs, which often exceed their ability to pay. Further, this shortsighted policy might actually result in a net greater cost to Medicare and the health-care system. Faced with mounting costs, many seniors truncate or opt out of SNF care altogether, leaving them vulnerable to added health issues (e.g. dehydration, falls). With new conditions that were not present at the time of the original hospital stay, many of these seniors are at risk to return to the hospital and become another readmission statistic.

As key players in hospitals and, increasingly, in skilled nursing facilities, hospitalists are caught squarely in the middle of this policy. Transitions of care both in and out of these institutions should be guided by sound medical decision-making, not whether Medicare will cover the costs incurred. Although the three-day rule—and, indeed, observation status itself—was originally cast as a cost-containment policy, such policies should incorporate broader care process and delivery reforms that do not add burden to patients when they are at their most vulnerable.

SHM affirms that it is sensible for Medicare to provide coverage for skilled nursing care if a clinician recommends it as part of a treatment plan. Coverage determination should not be beholden to a patient status subject to other systemic pressures, but should reflect the best interest of the patient and the care ordered by providers.

The Improving Access to Medicare Coverage Act, sponsored by Rep. Joe Courtney (D-Conn.), Rep. Tom Latham (R-Iowa), and Sen. Sherrod Brown (D-Ohio), would clarify the law to indicate that Medicare beneficiaries in observation status are deemed inpatients in the hospital for the purposes of the three-day requirement for SNF coverage. This simple adjustment would ensure that patients are able to access the skilled nursing care they need and that providers do not have to worry about this systemic barrier to patient care.

SHM is actively supporting this legislation. A letter of support was sent to Courtney and Brown earlier this year, and membership was mobilized to take action through our Legislative Action Center (www.hospitalmedicine.org/advocacy). Hospitalists also plan to voice their support for the legislation during Hospitalists on the Hill, to be held this month in conjunction with HM13.

As one of only a few specialty medical societies that are active on this issue, SHM stands out as a leader on health-care-system reforms that improve access to care for patients and reduce administrative barriers to medically appropriate care.

Joshua Lapps is SHM’s government relations specialist.

What this has done is impose additional administrative requirements that now take time away from our seeing patients or doing clinical activity.

—Joshua Lenchus, DO, RPh, FACP, SFHM

Hospitalist leaders are taking a wait-and-see approach to the Physician Payment Sunshine Act, which requires reporting of payments and gifts from drug and medical device companies. But as wary as many are after publication of the Final Rule 1 in February, SHM and other groups already have claimed at least one victory in tweaking the new rules.

The Sunshine Rule, as it’s known, was included in the Affordable Care Act of 2010. The rule, created by the Centers for Medicaid & Medicare Services (CMS), requires manufacturers to publicly report gifts, payments, or other transfers of value to physicians from pharmaceutical and medical device manufacturers worth more than $10 (see “Dos and Don’ts,” below).¹

One major change to the law sought by SHM and others was tied to the reporting of indirect payments to speakers at accredited continuing medical education (CME) classes or courses. The proposed rule required reporting of those payments even if a particular industry group did not select the speakers or pay them. SHM and three dozen other societies lobbied CMS to change the rule.² The final rule says indirect payments don’t have to be reported if the CME program meets widely accepted accreditation standards and the industry participant is neither directly paid nor selected by the vendor.

CME Coalition, a Washington, D.C.-based advocacy group, said in a statement the caveat recognizes that CMS “is sending a strong message to commercial supporters: Underwriting accredited continuing education programs for health-care providers is to be applauded, not restricted.”

SHM Public Policy Committee member Joshua Lenchus, DO, RPh, FACP, SFHM, said the initial rule was too restrictive and could have reduced physician participation in important CME activities. He said the Accreditation Council for Continuing Medical Education (ACCME) and other industry groups already govern the ethical issue of accepting direct payments that could imply bias to patients.

“I’m not so sure we needed the Sunshine Act as part of the ACA at all because these same things were in effect from the ACCME and other CME accrediting organizations,” said Dr. Lenchus, a Team Hospitalist member and president of the medical staff at Jackson Health System in Miami. “What this has done is impose additional administrative requirements that now take time away from our seeing patients or doing clinical activity.”

Those costs will add up quickly, according to figures from the Federal Register, Dr. Lenchus said. CMS projects the administrative costs of reviewing reports at $1.9 million for teaching hospital staff—the category Dr. Lenchus says is most applicable to hospitalists.

Dr. Lenchus says there was discussion within the Public Policy Committee about how much information needed to be publicly reported in relation to CME. Some members “wanted nothing recorded” and “some people wanted everything recorded.”

“The rule that has been implemented strikes a nice balance between the two,” he said.

Transparent Process

Industry groups and group purchasing organizations (GPOs) currently are working to put in place systems and procedures to begin collecting the data in August. Data will be collected through the end of 2013 and must be reported to CMS by March 31, 2014. CMS will then unveil a public website showcasing the information by Sept. 30, 2014.

Public Policy Committee member Jack Percelay, MD, MPH, FAAP, SFHM, said some hospitalists might feel they are “being picked on again” by having to report the added information. He instead looks at the intended push toward added transparency as “a set of obligations we have as physicians.”

“We have tremendous discretion about how health-care dollars are spent and with that comes a fiduciary responsibility, both to the patient and to the public,” he said. “This does not seem terribly burdensome to me. If I was getting nickel and dimed for every piece of candy I took through the exhibit hall during a meeting, that would be ridiculous. I’m happy to do this in a reasoned way.”

Dr. Percelay noted that the Sunshine Rule does not prevent industry payments to physicians or groups, but simply requires the public reporting and display of the remuneration. In that vein, he likened it to ethical rules that govern those who hold elected office.

“Someone should be able to Google and see that I’ve [received] funds from market research,” he said. “It’s not much different from politicians. It’s then up to the public and the media to do their due diligence.”

Dr. Lenchus said the public database has the potential to be misinterpreted by a public unfamiliar with how health care works. In particular, patients might not be able to discern the differences between the value of lunches, the payments for being on advisory boards, and industry-funded research.

“I really fear the public will look at this website, see there is any financial inducement to any physician, and erroneously conclude that any prescription of that company’s medication means that person is getting a kickback,” he says. “And we know that’s absolutely false.”

Richard Quinn is a freelance writer in New Jersey.

References

1. Centers for Medicare & Medicaid Services. Medicare, Medicaid, Children’s Health Insurance Programs; transparency reports and reporting of physician ownership or investment interests. Federal Register website. Available at: https://www.federalregister.gov/articles/2013/02/08/2013-02572/medicare-mediaid-childrens-health-insurance-programs-transparency-reports-and-reporting-of. Accessed March 24, 2013.
2. Council of Medical Specialty Societies. Letter to CMS. SHM website. Available at: http://www.hospitalmedicine.org/AM/Template.cfm?Section=Letters_to_Congress_ and_Regulatory_Agencies&Template=/CM/ContentDisplay.cfm&ContentID=30674. Accessed March 24, 2013.

What this has done is impose additional administrative requirements that now take time away from our seeing patients or doing clinical activity.

—Joshua Lenchus, DO, RPh, FACP, SFHM

Hospitalist leaders are taking a wait-and-see approach to the Physician Payment Sunshine Act, which requires reporting of payments and gifts from drug and medical device companies. But as wary as many are after publication of the Final Rule 1 in February, SHM and other groups already have claimed at least one victory in tweaking the new rules.

The Sunshine Rule, as it’s known, was included in the Affordable Care Act of 2010. The rule, created by the Centers for Medicaid & Medicare Services (CMS), requires manufacturers to publicly report gifts, payments, or other transfers of value to physicians from pharmaceutical and medical device manufacturers worth more than $10 (see “Dos and Don’ts,” below).¹

One major change to the law sought by SHM and others was tied to the reporting of indirect payments to speakers at accredited continuing medical education (CME) classes or courses. The proposed rule required reporting of those payments even if a particular industry group did not select the speakers or pay them. SHM and three dozen other societies lobbied CMS to change the rule.² The final rule says indirect payments don’t have to be reported if the CME program meets widely accepted accreditation standards and the industry participant is neither directly paid nor selected by the vendor.

CME Coalition, a Washington, D.C.-based advocacy group, said in a statement the caveat recognizes that CMS “is sending a strong message to commercial supporters: Underwriting accredited continuing education programs for health-care providers is to be applauded, not restricted.”

SHM Public Policy Committee member Joshua Lenchus, DO, RPh, FACP, SFHM, said the initial rule was too restrictive and could have reduced physician participation in important CME activities. He said the Accreditation Council for Continuing Medical Education (ACCME) and other industry groups already govern the ethical issue of accepting direct payments that could imply bias to patients.

“I’m not so sure we needed the Sunshine Act as part of the ACA at all because these same things were in effect from the ACCME and other CME accrediting organizations,” said Dr. Lenchus, a Team Hospitalist member and president of the medical staff at Jackson Health System in Miami. “What this has done is impose additional administrative requirements that now take time away from our seeing patients or doing clinical activity.”

Those costs will add up quickly, according to figures from the Federal Register, Dr. Lenchus said. CMS projects the administrative costs of reviewing reports at $1.9 million for teaching hospital staff—the category Dr. Lenchus says is most applicable to hospitalists.

Dr. Lenchus says there was discussion within the Public Policy Committee about how much information needed to be publicly reported in relation to CME. Some members “wanted nothing recorded” and “some people wanted everything recorded.”

“The rule that has been implemented strikes a nice balance between the two,” he said.

Transparent Process

Industry groups and group purchasing organizations (GPOs) currently are working to put in place systems and procedures to begin collecting the data in August. Data will be collected through the end of 2013 and must be reported to CMS by March 31, 2014. CMS will then unveil a public website showcasing the information by Sept. 30, 2014.

Public Policy Committee member Jack Percelay, MD, MPH, FAAP, SFHM, said some hospitalists might feel they are “being picked on again” by having to report the added information. He instead looks at the intended push toward added transparency as “a set of obligations we have as physicians.”

“We have tremendous discretion about how health-care dollars are spent and with that comes a fiduciary responsibility, both to the patient and to the public,” he said. “This does not seem terribly burdensome to me. If I was getting nickel and dimed for every piece of candy I took through the exhibit hall during a meeting, that would be ridiculous. I’m happy to do this in a reasoned way.”

Dr. Percelay noted that the Sunshine Rule does not prevent industry payments to physicians or groups, but simply requires the public reporting and display of the remuneration. In that vein, he likened it to ethical rules that govern those who hold elected office.

“Someone should be able to Google and see that I’ve [received] funds from market research,” he said. “It’s not much different from politicians. It’s then up to the public and the media to do their due diligence.”

Dr. Lenchus said the public database has the potential to be misinterpreted by a public unfamiliar with how health care works. In particular, patients might not be able to discern the differences between the value of lunches, the payments for being on advisory boards, and industry-funded research.

“I really fear the public will look at this website, see there is any financial inducement to any physician, and erroneously conclude that any prescription of that company’s medication means that person is getting a kickback,” he says. “And we know that’s absolutely false.”

Richard Quinn is a freelance writer in New Jersey.

References

1. Centers for Medicare & Medicaid Services. Medicare, Medicaid, Children’s Health Insurance Programs; transparency reports and reporting of physician ownership or investment interests. Federal Register website. Available at: https://www.federalregister.gov/articles/2013/02/08/2013-02572/medicare-mediaid-childrens-health-insurance-programs-transparency-reports-and-reporting-of. Accessed March 24, 2013.
2. Council of Medical Specialty Societies. Letter to CMS. SHM website. Available at: http://www.hospitalmedicine.org/AM/Template.cfm?Section=Letters_to_Congress_ and_Regulatory_Agencies&Template=/CM/ContentDisplay.cfm&ContentID=30674. Accessed March 24, 2013.

What this has done is impose additional administrative requirements that now take time away from our seeing patients or doing clinical activity.

—Joshua Lenchus, DO, RPh, FACP, SFHM

Hospitalist leaders are taking a wait-and-see approach to the Physician Payment Sunshine Act, which requires reporting of payments and gifts from drug and medical device companies. But as wary as many are after publication of the Final Rule 1 in February, SHM and other groups already have claimed at least one victory in tweaking the new rules.

The Sunshine Rule, as it’s known, was included in the Affordable Care Act of 2010. The rule, created by the Centers for Medicaid & Medicare Services (CMS), requires manufacturers to publicly report gifts, payments, or other transfers of value to physicians from pharmaceutical and medical device manufacturers worth more than $10 (see “Dos and Don’ts,” below).¹

One major change to the law sought by SHM and others was tied to the reporting of indirect payments to speakers at accredited continuing medical education (CME) classes or courses. The proposed rule required reporting of those payments even if a particular industry group did not select the speakers or pay them. SHM and three dozen other societies lobbied CMS to change the rule.² The final rule says indirect payments don’t have to be reported if the CME program meets widely accepted accreditation standards and the industry participant is neither directly paid nor selected by the vendor.

CME Coalition, a Washington, D.C.-based advocacy group, said in a statement the caveat recognizes that CMS “is sending a strong message to commercial supporters: Underwriting accredited continuing education programs for health-care providers is to be applauded, not restricted.”

SHM Public Policy Committee member Joshua Lenchus, DO, RPh, FACP, SFHM, said the initial rule was too restrictive and could have reduced physician participation in important CME activities. He said the Accreditation Council for Continuing Medical Education (ACCME) and other industry groups already govern the ethical issue of accepting direct payments that could imply bias to patients.

“I’m not so sure we needed the Sunshine Act as part of the ACA at all because these same things were in effect from the ACCME and other CME accrediting organizations,” said Dr. Lenchus, a Team Hospitalist member and president of the medical staff at Jackson Health System in Miami. “What this has done is impose additional administrative requirements that now take time away from our seeing patients or doing clinical activity.”

Those costs will add up quickly, according to figures from the Federal Register, Dr. Lenchus said. CMS projects the administrative costs of reviewing reports at $1.9 million for teaching hospital staff—the category Dr. Lenchus says is most applicable to hospitalists.

Dr. Lenchus says there was discussion within the Public Policy Committee about how much information needed to be publicly reported in relation to CME. Some members “wanted nothing recorded” and “some people wanted everything recorded.”

“The rule that has been implemented strikes a nice balance between the two,” he said.

Transparent Process

Industry groups and group purchasing organizations (GPOs) currently are working to put in place systems and procedures to begin collecting the data in August. Data will be collected through the end of 2013 and must be reported to CMS by March 31, 2014. CMS will then unveil a public website showcasing the information by Sept. 30, 2014.

Public Policy Committee member Jack Percelay, MD, MPH, FAAP, SFHM, said some hospitalists might feel they are “being picked on again” by having to report the added information. He instead looks at the intended push toward added transparency as “a set of obligations we have as physicians.”

“We have tremendous discretion about how health-care dollars are spent and with that comes a fiduciary responsibility, both to the patient and to the public,” he said. “This does not seem terribly burdensome to me. If I was getting nickel and dimed for every piece of candy I took through the exhibit hall during a meeting, that would be ridiculous. I’m happy to do this in a reasoned way.”

Dr. Percelay noted that the Sunshine Rule does not prevent industry payments to physicians or groups, but simply requires the public reporting and display of the remuneration. In that vein, he likened it to ethical rules that govern those who hold elected office.

“Someone should be able to Google and see that I’ve [received] funds from market research,” he said. “It’s not much different from politicians. It’s then up to the public and the media to do their due diligence.”

Dr. Lenchus said the public database has the potential to be misinterpreted by a public unfamiliar with how health care works. In particular, patients might not be able to discern the differences between the value of lunches, the payments for being on advisory boards, and industry-funded research.

“I really fear the public will look at this website, see there is any financial inducement to any physician, and erroneously conclude that any prescription of that company’s medication means that person is getting a kickback,” he says. “And we know that’s absolutely false.”

Richard Quinn is a freelance writer in New Jersey.

References

1. Centers for Medicare & Medicaid Services. Medicare, Medicaid, Children’s Health Insurance Programs; transparency reports and reporting of physician ownership or investment interests. Federal Register website. Available at: https://www.federalregister.gov/articles/2013/02/08/2013-02572/medicare-mediaid-childrens-health-insurance-programs-transparency-reports-and-reporting-of. Accessed March 24, 2013.
2. Council of Medical Specialty Societies. Letter to CMS. SHM website. Available at: http://www.hospitalmedicine.org/AM/Template.cfm?Section=Letters_to_Congress_ and_Regulatory_Agencies&Template=/CM/ContentDisplay.cfm&ContentID=30674. Accessed March 24, 2013.