Public Policy

Let’s be honest. How many times in the past (insert any timeline here; month, week, day, minute) have you heard a disparaging comment about a hospital regulatory agency? They usually sound something like, “Well, I’ll be darned if I am going to let CMS tell me how to practice medicine” or “So is this another Joint Commission thing?”

I understand the frustration. The healthcare industry is incredibly regulated. So much so that I, and countless others in hospital administration offices around the country, relinquish an inordinate amount of time figuring out what it is we are supposed to be complying with, then figuring how we are actually going to do it. It often has been equated to Whac-a-Mole, a game that requires more eyeballs and arm strength than an extraterrestrial possesses. There are many reasons that underlie the frustration and lead to the disparaging comments:

• Some requirements are not perfectly evidence-based. Not all process measures actually correlate with any outcomes; just because someone checks an oxygen saturation on every pneumonia patient doesn’t mean anything else improves for the patient.
• Some requirements are poorly implemented. I think we can all agree that counseling patients to stop smoking is a laudable goal. However, “smoking cessation counseling” is often relegated to uttering a short phrase (“you know you should really quit smoking”) while holding the exit-door handle, then checking the box for documentation. This “counseling session” is probably as effective as declaring every day a Great American Smokeout.
• Some regulations result in unintended consequences when implemented into large, complicated organizations. An obvious example is the time to first antibiotic in pneumonia patients, which resulted in frequent and unnecessary antibiotic utilization in patients who did not have pneumonia.
• Some are just extremely difficult to accomplish with high reliability. An example here is time to PCI for heart attacks. It’s clearly the right thing to do, and clearly very difficult to get it completed, on time, on every single patient. And 99% compliance is just not good enough, because the 1% matters.

And as a result of these imperfections, “noncompliance” leads to lots of emails, rework, restructuring, and at times downright bickering—hence, the disparaging comments.

Regulatory Origins and Missions

But let’s back up for a minute and think about why healthcare regulations exist: Many local, state, and federal agencies have enhanced the scrutiny of healthcare over time because, quite frankly, the healthcare industry did not regulate itself very well. We insisted for decades that patients were each too unique to be “cook-booked,” that medicine was an art as much as it was a science, and that “it’s just complicated.”

It took a few (too many) high-profile deaths and a few common-sense publications to incense the public, our payors, and our regulators. Who is not familiar with the 98,000-preventable-deaths-a-year statistic? Not only is that figure sobering, but it also is quite difficult to untether from our reputation. Henceforth, over the course of decades, a multitude of moles have emerged, littering the landscape and sparing no area of the healthcare industry.

So let’s back up another minute and think about what these agencies are trying to do: Could it be that most regulatory agencies really do want to leverage large-scale improvements in patient outcomes, at the best value?

 

Take this vision statement, as an example: “All people always experience the safest, highest-quality, best-value healthcare across all settings.”

Sounds like the kind of healthcare I want for my kids and my mom. That is the vision statement of the Joint Commission.

How about this vision statement: “CMS is a major force and a trustworthy partner for the continual improvement of health and healthcare for all Americans.”

Not too shabby.

So why do we view regulators like moles? Why do we arm ourselves with big, black mallets ready to strike when we see them emerge from the corner of our eye?

HM-Mole Alliance

Whac-a-Mole is an unwinnable game. No player has ever whacked all the moles. If you have not been to your local arcade lately, the game starts out slow, such that most players can keep pace; it then accelerates, such that several moles are outside the holes simultaneously, and their time above ground becomes consecutively shorter. You can add mallets, even add players, but generally they end up getting in each other’s way, communication breaks down, and one mole gets whacked twice, while another exits unscathed, only to break the soil elsewhere.

Danielle Scheurer, MD, MSCR, SFHM

Maybe a better strategy is to have a strategy—to work with our “trustworthy partners” to align our vision statements, anticipate the vermin’s approach, and fill the holes (or chasms) before anything has a chance to squeeze through. Maybe we should tell them where the moles are, because we actually already know what they look like and where they dwell. Why don’t we tell them which moles are the most dangerous, the most annoying, or are the most likely to tear up the topsoil into an irreparable state?

What about all the issues that no one is telling us we have to comply with—for example, a universal allergy list across the spectrum of care, or a perfectly reliable system to ensure that a patient with an epidural catheter cannot be anticoagulated? Such a list is endless, and no one is telling us we have to address the majority of the items on the list.

It comes down to this: What kind of healthcare do you want for yourself, your family, and the patients who trust you? I’d rather not have a reactive, frantic race to obliterate the next torrid creature that has arisen. I suggest a proactive, strategic pathway of tilling the soil.

In anticipation of a universal vote for the latter, join me in congratulating the healthcare industry in holding ourselves accountable, embracing a new era of transparency and collaboration, and routinely going beyond the expectations of our regulators. And leaving the mallet in the arcade.

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

Let’s be honest. How many times in the past (insert any timeline here; month, week, day, minute) have you heard a disparaging comment about a hospital regulatory agency? They usually sound something like, “Well, I’ll be darned if I am going to let CMS tell me how to practice medicine” or “So is this another Joint Commission thing?”

I understand the frustration. The healthcare industry is incredibly regulated. So much so that I, and countless others in hospital administration offices around the country, relinquish an inordinate amount of time figuring out what it is we are supposed to be complying with, then figuring how we are actually going to do it. It often has been equated to Whac-a-Mole, a game that requires more eyeballs and arm strength than an extraterrestrial possesses. There are many reasons that underlie the frustration and lead to the disparaging comments:

• Some requirements are not perfectly evidence-based. Not all process measures actually correlate with any outcomes; just because someone checks an oxygen saturation on every pneumonia patient doesn’t mean anything else improves for the patient.
• Some requirements are poorly implemented. I think we can all agree that counseling patients to stop smoking is a laudable goal. However, “smoking cessation counseling” is often relegated to uttering a short phrase (“you know you should really quit smoking”) while holding the exit-door handle, then checking the box for documentation. This “counseling session” is probably as effective as declaring every day a Great American Smokeout.
• Some regulations result in unintended consequences when implemented into large, complicated organizations. An obvious example is the time to first antibiotic in pneumonia patients, which resulted in frequent and unnecessary antibiotic utilization in patients who did not have pneumonia.
• Some are just extremely difficult to accomplish with high reliability. An example here is time to PCI for heart attacks. It’s clearly the right thing to do, and clearly very difficult to get it completed, on time, on every single patient. And 99% compliance is just not good enough, because the 1% matters.

And as a result of these imperfections, “noncompliance” leads to lots of emails, rework, restructuring, and at times downright bickering—hence, the disparaging comments.

Regulatory Origins and Missions

But let’s back up for a minute and think about why healthcare regulations exist: Many local, state, and federal agencies have enhanced the scrutiny of healthcare over time because, quite frankly, the healthcare industry did not regulate itself very well. We insisted for decades that patients were each too unique to be “cook-booked,” that medicine was an art as much as it was a science, and that “it’s just complicated.”

It took a few (too many) high-profile deaths and a few common-sense publications to incense the public, our payors, and our regulators. Who is not familiar with the 98,000-preventable-deaths-a-year statistic? Not only is that figure sobering, but it also is quite difficult to untether from our reputation. Henceforth, over the course of decades, a multitude of moles have emerged, littering the landscape and sparing no area of the healthcare industry.

So let’s back up another minute and think about what these agencies are trying to do: Could it be that most regulatory agencies really do want to leverage large-scale improvements in patient outcomes, at the best value?

 

Take this vision statement, as an example: “All people always experience the safest, highest-quality, best-value healthcare across all settings.”

Sounds like the kind of healthcare I want for my kids and my mom. That is the vision statement of the Joint Commission.

How about this vision statement: “CMS is a major force and a trustworthy partner for the continual improvement of health and healthcare for all Americans.”

Not too shabby.

So why do we view regulators like moles? Why do we arm ourselves with big, black mallets ready to strike when we see them emerge from the corner of our eye?

HM-Mole Alliance

Whac-a-Mole is an unwinnable game. No player has ever whacked all the moles. If you have not been to your local arcade lately, the game starts out slow, such that most players can keep pace; it then accelerates, such that several moles are outside the holes simultaneously, and their time above ground becomes consecutively shorter. You can add mallets, even add players, but generally they end up getting in each other’s way, communication breaks down, and one mole gets whacked twice, while another exits unscathed, only to break the soil elsewhere.

Danielle Scheurer, MD, MSCR, SFHM

Maybe a better strategy is to have a strategy—to work with our “trustworthy partners” to align our vision statements, anticipate the vermin’s approach, and fill the holes (or chasms) before anything has a chance to squeeze through. Maybe we should tell them where the moles are, because we actually already know what they look like and where they dwell. Why don’t we tell them which moles are the most dangerous, the most annoying, or are the most likely to tear up the topsoil into an irreparable state?

What about all the issues that no one is telling us we have to comply with—for example, a universal allergy list across the spectrum of care, or a perfectly reliable system to ensure that a patient with an epidural catheter cannot be anticoagulated? Such a list is endless, and no one is telling us we have to address the majority of the items on the list.

It comes down to this: What kind of healthcare do you want for yourself, your family, and the patients who trust you? I’d rather not have a reactive, frantic race to obliterate the next torrid creature that has arisen. I suggest a proactive, strategic pathway of tilling the soil.

In anticipation of a universal vote for the latter, join me in congratulating the healthcare industry in holding ourselves accountable, embracing a new era of transparency and collaboration, and routinely going beyond the expectations of our regulators. And leaving the mallet in the arcade.

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

Let’s be honest. How many times in the past (insert any timeline here; month, week, day, minute) have you heard a disparaging comment about a hospital regulatory agency? They usually sound something like, “Well, I’ll be darned if I am going to let CMS tell me how to practice medicine” or “So is this another Joint Commission thing?”

I understand the frustration. The healthcare industry is incredibly regulated. So much so that I, and countless others in hospital administration offices around the country, relinquish an inordinate amount of time figuring out what it is we are supposed to be complying with, then figuring how we are actually going to do it. It often has been equated to Whac-a-Mole, a game that requires more eyeballs and arm strength than an extraterrestrial possesses. There are many reasons that underlie the frustration and lead to the disparaging comments:

• Some requirements are not perfectly evidence-based. Not all process measures actually correlate with any outcomes; just because someone checks an oxygen saturation on every pneumonia patient doesn’t mean anything else improves for the patient.
• Some requirements are poorly implemented. I think we can all agree that counseling patients to stop smoking is a laudable goal. However, “smoking cessation counseling” is often relegated to uttering a short phrase (“you know you should really quit smoking”) while holding the exit-door handle, then checking the box for documentation. This “counseling session” is probably as effective as declaring every day a Great American Smokeout.
• Some regulations result in unintended consequences when implemented into large, complicated organizations. An obvious example is the time to first antibiotic in pneumonia patients, which resulted in frequent and unnecessary antibiotic utilization in patients who did not have pneumonia.
• Some are just extremely difficult to accomplish with high reliability. An example here is time to PCI for heart attacks. It’s clearly the right thing to do, and clearly very difficult to get it completed, on time, on every single patient. And 99% compliance is just not good enough, because the 1% matters.

And as a result of these imperfections, “noncompliance” leads to lots of emails, rework, restructuring, and at times downright bickering—hence, the disparaging comments.

Regulatory Origins and Missions

But let’s back up for a minute and think about why healthcare regulations exist: Many local, state, and federal agencies have enhanced the scrutiny of healthcare over time because, quite frankly, the healthcare industry did not regulate itself very well. We insisted for decades that patients were each too unique to be “cook-booked,” that medicine was an art as much as it was a science, and that “it’s just complicated.”

It took a few (too many) high-profile deaths and a few common-sense publications to incense the public, our payors, and our regulators. Who is not familiar with the 98,000-preventable-deaths-a-year statistic? Not only is that figure sobering, but it also is quite difficult to untether from our reputation. Henceforth, over the course of decades, a multitude of moles have emerged, littering the landscape and sparing no area of the healthcare industry.

So let’s back up another minute and think about what these agencies are trying to do: Could it be that most regulatory agencies really do want to leverage large-scale improvements in patient outcomes, at the best value?

 

Take this vision statement, as an example: “All people always experience the safest, highest-quality, best-value healthcare across all settings.”

Sounds like the kind of healthcare I want for my kids and my mom. That is the vision statement of the Joint Commission.

How about this vision statement: “CMS is a major force and a trustworthy partner for the continual improvement of health and healthcare for all Americans.”

Not too shabby.

So why do we view regulators like moles? Why do we arm ourselves with big, black mallets ready to strike when we see them emerge from the corner of our eye?

HM-Mole Alliance

Whac-a-Mole is an unwinnable game. No player has ever whacked all the moles. If you have not been to your local arcade lately, the game starts out slow, such that most players can keep pace; it then accelerates, such that several moles are outside the holes simultaneously, and their time above ground becomes consecutively shorter. You can add mallets, even add players, but generally they end up getting in each other’s way, communication breaks down, and one mole gets whacked twice, while another exits unscathed, only to break the soil elsewhere.

Danielle Scheurer, MD, MSCR, SFHM

Maybe a better strategy is to have a strategy—to work with our “trustworthy partners” to align our vision statements, anticipate the vermin’s approach, and fill the holes (or chasms) before anything has a chance to squeeze through. Maybe we should tell them where the moles are, because we actually already know what they look like and where they dwell. Why don’t we tell them which moles are the most dangerous, the most annoying, or are the most likely to tear up the topsoil into an irreparable state?

What about all the issues that no one is telling us we have to comply with—for example, a universal allergy list across the spectrum of care, or a perfectly reliable system to ensure that a patient with an epidural catheter cannot be anticoagulated? Such a list is endless, and no one is telling us we have to address the majority of the items on the list.

It comes down to this: What kind of healthcare do you want for yourself, your family, and the patients who trust you? I’d rather not have a reactive, frantic race to obliterate the next torrid creature that has arisen. I suggest a proactive, strategic pathway of tilling the soil.

In anticipation of a universal vote for the latter, join me in congratulating the healthcare industry in holding ourselves accountable, embracing a new era of transparency and collaboration, and routinely going beyond the expectations of our regulators. And leaving the mallet in the arcade.

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

The term “patient-centered medical home” has a nice ring to it, but what does it really mean? And how does it function in the real world? The model is evolving, but here are the main components of the PCMH and how they’ve been implemented in real practice, at least so far:

“PERSONAL” PHYSICIAN: This is the doctor, usually a family or general practice physician, who shepherds patients through the medical system. In practice, this means things like encouraging patient questions about their care, extra efforts to educate patients on their health, and nurses making detailed follow-up calls with patients to make sure they’ve gotten their medications and know how to take them, and communicating any other steps the patient should be taking.

“Whole-person orientation”: The personal physician is responsible for taking care of all of the patient’s medical needs, either himself or by arranging care with specialists. The care ranges from preventive to chronic to end-of-life. In practice, this often means having appointments made with another doctor, if necessary, before the patient leaves the primary-care doctor, or seeing several doctors of different specialties during the same appointment.

Coordinated or integrated care: Care in the PCMH spans all aspects of the healthcare system, from subspecialists to the hospital to the nursing home. In practice, this means the use of electronic registries and health information exchange systems to make sure every health professional has all the information they should have about the patient.

Quality and safety: In practice, it means the development of a care plan that is bolstered by close relationships between patients, doctors, and family members. Plus, a good PCMH will have a more collegial atmosphere, with regular meetings among doctors of varying specialties. Evidence-based medicine is the guide. And feedback from the patient is sought more aggressively. Practices also can undergo a voluntary recognition process by a non-government-related healthcare quality organization, such as the National Committee for Quality Assurance.

Enhanced access: So that patients get the care when they need it, same-day scheduling is often offered. There are expanded hours, and phone and email communication is used more often.

Payment: The payment system in a PCMH encourages better primary care and prevention of illness. Still, most PCMH practices currently use a blend of fee-for-service, a monthly “care coordination” fee, and incentives for quality care.

Source: Adapted from 2007’s Joint Statement on Patient-Centered Medical Home, Agency for Healthcare Research and Quality

The term “patient-centered medical home” has a nice ring to it, but what does it really mean? And how does it function in the real world? The model is evolving, but here are the main components of the PCMH and how they’ve been implemented in real practice, at least so far:

“PERSONAL” PHYSICIAN: This is the doctor, usually a family or general practice physician, who shepherds patients through the medical system. In practice, this means things like encouraging patient questions about their care, extra efforts to educate patients on their health, and nurses making detailed follow-up calls with patients to make sure they’ve gotten their medications and know how to take them, and communicating any other steps the patient should be taking.

“Whole-person orientation”: The personal physician is responsible for taking care of all of the patient’s medical needs, either himself or by arranging care with specialists. The care ranges from preventive to chronic to end-of-life. In practice, this often means having appointments made with another doctor, if necessary, before the patient leaves the primary-care doctor, or seeing several doctors of different specialties during the same appointment.

Coordinated or integrated care: Care in the PCMH spans all aspects of the healthcare system, from subspecialists to the hospital to the nursing home. In practice, this means the use of electronic registries and health information exchange systems to make sure every health professional has all the information they should have about the patient.

Quality and safety: In practice, it means the development of a care plan that is bolstered by close relationships between patients, doctors, and family members. Plus, a good PCMH will have a more collegial atmosphere, with regular meetings among doctors of varying specialties. Evidence-based medicine is the guide. And feedback from the patient is sought more aggressively. Practices also can undergo a voluntary recognition process by a non-government-related healthcare quality organization, such as the National Committee for Quality Assurance.

Enhanced access: So that patients get the care when they need it, same-day scheduling is often offered. There are expanded hours, and phone and email communication is used more often.

Payment: The payment system in a PCMH encourages better primary care and prevention of illness. Still, most PCMH practices currently use a blend of fee-for-service, a monthly “care coordination” fee, and incentives for quality care.

Source: Adapted from 2007’s Joint Statement on Patient-Centered Medical Home, Agency for Healthcare Research and Quality

The term “patient-centered medical home” has a nice ring to it, but what does it really mean? And how does it function in the real world? The model is evolving, but here are the main components of the PCMH and how they’ve been implemented in real practice, at least so far:

“PERSONAL” PHYSICIAN: This is the doctor, usually a family or general practice physician, who shepherds patients through the medical system. In practice, this means things like encouraging patient questions about their care, extra efforts to educate patients on their health, and nurses making detailed follow-up calls with patients to make sure they’ve gotten their medications and know how to take them, and communicating any other steps the patient should be taking.

“Whole-person orientation”: The personal physician is responsible for taking care of all of the patient’s medical needs, either himself or by arranging care with specialists. The care ranges from preventive to chronic to end-of-life. In practice, this often means having appointments made with another doctor, if necessary, before the patient leaves the primary-care doctor, or seeing several doctors of different specialties during the same appointment.

Coordinated or integrated care: Care in the PCMH spans all aspects of the healthcare system, from subspecialists to the hospital to the nursing home. In practice, this means the use of electronic registries and health information exchange systems to make sure every health professional has all the information they should have about the patient.

Quality and safety: In practice, it means the development of a care plan that is bolstered by close relationships between patients, doctors, and family members. Plus, a good PCMH will have a more collegial atmosphere, with regular meetings among doctors of varying specialties. Evidence-based medicine is the guide. And feedback from the patient is sought more aggressively. Practices also can undergo a voluntary recognition process by a non-government-related healthcare quality organization, such as the National Committee for Quality Assurance.

Enhanced access: So that patients get the care when they need it, same-day scheduling is often offered. There are expanded hours, and phone and email communication is used more often.

Payment: The payment system in a PCMH encourages better primary care and prevention of illness. Still, most PCMH practices currently use a blend of fee-for-service, a monthly “care coordination” fee, and incentives for quality care.

Source: Adapted from 2007’s Joint Statement on Patient-Centered Medical Home, Agency for Healthcare Research and Quality

If the “patient-centered medical home” model does what it intends to do—makes people healthier and limits preventable illness—fewer people will likely be hospitalized. Should hospitalists be worried? Will that mean less work for hospitalists?

“That clearly is one potential implication of many of the different healthcare reform models, including the development of primary-care medical homes and folks out there who are participating in accountable-care organizations [ACOs], all of which are designed to provide better access to patients on an outpatient setting,” SHM immediate past president Joseph Ming Wah Li, MD, SFHM, says. “The rationale is that it should ultimately lead to fewer hospitalizations.”

Most hospitalists, Dr. Li adds, will say that’s a good thing.

“You’re never going to argue against” fewer hospitalizations, he says. “I think what hospitalists will have to do is they will have to adapt.”

Ultimately, patients who are hospitalized will be sicker, and hospitalists likely will end up seeing those patients several times a day rather than just once or twice, Dr. Li says.

Dr. Meyers, of AHRQ, says inpatient care in the future could become more meaningful, because while there may be fewer patients, those who are hospitalized will need more complex care management.

“I think America’s a big enough country, though, where with an aging population—and we still have lots of chronic disease—there’s going to be no shortage of work, meaningful work, for hospitalists moving forward,” he says.

Dr. Eichhorn, who works in an already up-and-running PCMH system, says patient census shouldn’t be a concern.

“Most hospitalists would probably say that they have plenty of work,” Dr. Eichhorn says. “I think anything that we can do to prevent a hospital stay certainly promotes health and allows us to be better stewards of healthcare resources. And I think it’s a win for everyone.”

If the “patient-centered medical home” model does what it intends to do—makes people healthier and limits preventable illness—fewer people will likely be hospitalized. Should hospitalists be worried? Will that mean less work for hospitalists?

“That clearly is one potential implication of many of the different healthcare reform models, including the development of primary-care medical homes and folks out there who are participating in accountable-care organizations [ACOs], all of which are designed to provide better access to patients on an outpatient setting,” SHM immediate past president Joseph Ming Wah Li, MD, SFHM, says. “The rationale is that it should ultimately lead to fewer hospitalizations.”

Most hospitalists, Dr. Li adds, will say that’s a good thing.

“You’re never going to argue against” fewer hospitalizations, he says. “I think what hospitalists will have to do is they will have to adapt.”

Ultimately, patients who are hospitalized will be sicker, and hospitalists likely will end up seeing those patients several times a day rather than just once or twice, Dr. Li says.

Dr. Meyers, of AHRQ, says inpatient care in the future could become more meaningful, because while there may be fewer patients, those who are hospitalized will need more complex care management.

“I think America’s a big enough country, though, where with an aging population—and we still have lots of chronic disease—there’s going to be no shortage of work, meaningful work, for hospitalists moving forward,” he says.

Dr. Eichhorn, who works in an already up-and-running PCMH system, says patient census shouldn’t be a concern.

“Most hospitalists would probably say that they have plenty of work,” Dr. Eichhorn says. “I think anything that we can do to prevent a hospital stay certainly promotes health and allows us to be better stewards of healthcare resources. And I think it’s a win for everyone.”

If the “patient-centered medical home” model does what it intends to do—makes people healthier and limits preventable illness—fewer people will likely be hospitalized. Should hospitalists be worried? Will that mean less work for hospitalists?

“That clearly is one potential implication of many of the different healthcare reform models, including the development of primary-care medical homes and folks out there who are participating in accountable-care organizations [ACOs], all of which are designed to provide better access to patients on an outpatient setting,” SHM immediate past president Joseph Ming Wah Li, MD, SFHM, says. “The rationale is that it should ultimately lead to fewer hospitalizations.”

Most hospitalists, Dr. Li adds, will say that’s a good thing.

“You’re never going to argue against” fewer hospitalizations, he says. “I think what hospitalists will have to do is they will have to adapt.”

Ultimately, patients who are hospitalized will be sicker, and hospitalists likely will end up seeing those patients several times a day rather than just once or twice, Dr. Li says.

Dr. Meyers, of AHRQ, says inpatient care in the future could become more meaningful, because while there may be fewer patients, those who are hospitalized will need more complex care management.

“I think America’s a big enough country, though, where with an aging population—and we still have lots of chronic disease—there’s going to be no shortage of work, meaningful work, for hospitalists moving forward,” he says.

Dr. Eichhorn, who works in an already up-and-running PCMH system, says patient census shouldn’t be a concern.

“Most hospitalists would probably say that they have plenty of work,” Dr. Eichhorn says. “I think anything that we can do to prevent a hospital stay certainly promotes health and allows us to be better stewards of healthcare resources. And I think it’s a win for everyone.”

Medicine in the past 10-20 years has seen major changes driven by changes in payment systems, lifestyle changes, and changes in training patterns. One such change is the hospitalist model of medicine. The advent of hospitalist practice has turned work-life balance on its head, as far as medicine is concerned.

All along, professionalism required that we pay unquestionable attention to the patient, the profession, and the organization—reporting early to work, staying until the work is done, taking work home, and answering the phone on the nights when we were on call. On weekends, finishing pending dictation was normal. The 20-minute mill of outpatient practice has driven primary medicine to a breaking point.

As the pressures of the primary-care job got worse, there came an exit in the form of the hospitalist model. HM provided shift work that could be adjusted to the needs of the physician.

This new kind of job, however, has its own problems. Physicians choosing the normalcy of shift work did not realize that they would give up professional independence. Hospitalists now are governed by the laws of shift work, and at the same time remain governed by the laws of their profession. It is likely when in need they will stay behind and get the work done. And it has been seen that hospitalists do visit the doctors’ lounge, have professional interests outside of direct patient care, and sometimes leave the hospital when their admits and discharges are complete.

And so the shift-work model has, at times, resulted in friction between hospital administration and hospitalists. It could be understood that, from an employer’s perspective, hospitals are paying on an hourly basis and thus expect the hospitalist group to be on site 24/7, sticking around even if there is no work. However, the argument from the hospitalist perspective is that when needed, I stay extra. It should be OK that on low-census days we should be able to leave for a cup of coffee and still be reachable, ready to come in if need arises.

So how do hospitalist-physician professionalism and shift work co-exist? It’s a big question, one that organizations around the country will be looking to solve in the next few years. How this question is answered is going to impact quality of care, recruitment, and staff satisfaction. Each answer will impact the staff and patients.

Keeping in mind outcomes that both parties are looking for, I think a proper plan can be worked out. I suggest hospital administrators adopt the following value-based measurements to evaluate hospitalist clinicians, and establish a compensation system where a minimum amount of production must be met.

Work relative value units (wRVUs). Work RVUs provide a consistent method to measure physician productivity. If one HM clinician’s numbers are below the group average, they might need a lesson in billing, along with a report of their productivity numbers and group expectations.

Patient encounters per day. The average number of patients seen per day (patients seen divided by number of shifts worked) should be measured on a quarterly basis. This metric should provide a measure of the work done by the physician; however, it needs to be offset by your group’s turnover rate (as discussed below).

Length of stay (LOS). Most HM groups are measuring LOS. It is the reason hospitalists exist. Not much more needs to be said about this measure of work performance.

Percentage of patient turnover. A good hospitalist will have a high patient turnover figure (total discharges divided by total encounters per day). This is important to know; it’s even better if accompanied by a short LOS.

 

New admissions per shift. Again, if there is an outlier, that metric should be detected rather easily.

Patient satisfaction. More and more, this is becoming an important measure of physician quality and is essential for competitive marketplaces. Of course, the quality of medical care will have its own parameters. And it is best left to use the existing, longstanding parameters that are used for the rest of the doctors in your system. There is no need to create an alternative system for the hospitalist.

If all of the above measures are better than the average hospitalist in the locality, then no one should worry about the hospitalist’s other activities, be it involvement in committee work, research, or browsing a newspaper or a cup of coffee in the doctors’ lounge. After all, one of the main reasons physicians opted for HM practice was to have the ability to control their workday.

This will, in my opinion, improve workforce satisfaction and improve productivity. It only makes common sense. It may be a hard pill to swallow for the administrators, but it is the right medicine for the doctor.

Rwoof Reshi, MD, hospitalist, St. Joe’s Hospital, St. Paul, Minn.

Medicine in the past 10-20 years has seen major changes driven by changes in payment systems, lifestyle changes, and changes in training patterns. One such change is the hospitalist model of medicine. The advent of hospitalist practice has turned work-life balance on its head, as far as medicine is concerned.

All along, professionalism required that we pay unquestionable attention to the patient, the profession, and the organization—reporting early to work, staying until the work is done, taking work home, and answering the phone on the nights when we were on call. On weekends, finishing pending dictation was normal. The 20-minute mill of outpatient practice has driven primary medicine to a breaking point.

As the pressures of the primary-care job got worse, there came an exit in the form of the hospitalist model. HM provided shift work that could be adjusted to the needs of the physician.

This new kind of job, however, has its own problems. Physicians choosing the normalcy of shift work did not realize that they would give up professional independence. Hospitalists now are governed by the laws of shift work, and at the same time remain governed by the laws of their profession. It is likely when in need they will stay behind and get the work done. And it has been seen that hospitalists do visit the doctors’ lounge, have professional interests outside of direct patient care, and sometimes leave the hospital when their admits and discharges are complete.

And so the shift-work model has, at times, resulted in friction between hospital administration and hospitalists. It could be understood that, from an employer’s perspective, hospitals are paying on an hourly basis and thus expect the hospitalist group to be on site 24/7, sticking around even if there is no work. However, the argument from the hospitalist perspective is that when needed, I stay extra. It should be OK that on low-census days we should be able to leave for a cup of coffee and still be reachable, ready to come in if need arises.

So how do hospitalist-physician professionalism and shift work co-exist? It’s a big question, one that organizations around the country will be looking to solve in the next few years. How this question is answered is going to impact quality of care, recruitment, and staff satisfaction. Each answer will impact the staff and patients.

Keeping in mind outcomes that both parties are looking for, I think a proper plan can be worked out. I suggest hospital administrators adopt the following value-based measurements to evaluate hospitalist clinicians, and establish a compensation system where a minimum amount of production must be met.

Work relative value units (wRVUs). Work RVUs provide a consistent method to measure physician productivity. If one HM clinician’s numbers are below the group average, they might need a lesson in billing, along with a report of their productivity numbers and group expectations.

Patient encounters per day. The average number of patients seen per day (patients seen divided by number of shifts worked) should be measured on a quarterly basis. This metric should provide a measure of the work done by the physician; however, it needs to be offset by your group’s turnover rate (as discussed below).

Length of stay (LOS). Most HM groups are measuring LOS. It is the reason hospitalists exist. Not much more needs to be said about this measure of work performance.

Percentage of patient turnover. A good hospitalist will have a high patient turnover figure (total discharges divided by total encounters per day). This is important to know; it’s even better if accompanied by a short LOS.

 

New admissions per shift. Again, if there is an outlier, that metric should be detected rather easily.

Patient satisfaction. More and more, this is becoming an important measure of physician quality and is essential for competitive marketplaces. Of course, the quality of medical care will have its own parameters. And it is best left to use the existing, longstanding parameters that are used for the rest of the doctors in your system. There is no need to create an alternative system for the hospitalist.

If all of the above measures are better than the average hospitalist in the locality, then no one should worry about the hospitalist’s other activities, be it involvement in committee work, research, or browsing a newspaper or a cup of coffee in the doctors’ lounge. After all, one of the main reasons physicians opted for HM practice was to have the ability to control their workday.

This will, in my opinion, improve workforce satisfaction and improve productivity. It only makes common sense. It may be a hard pill to swallow for the administrators, but it is the right medicine for the doctor.

Rwoof Reshi, MD, hospitalist, St. Joe’s Hospital, St. Paul, Minn.

Medicine in the past 10-20 years has seen major changes driven by changes in payment systems, lifestyle changes, and changes in training patterns. One such change is the hospitalist model of medicine. The advent of hospitalist practice has turned work-life balance on its head, as far as medicine is concerned.

All along, professionalism required that we pay unquestionable attention to the patient, the profession, and the organization—reporting early to work, staying until the work is done, taking work home, and answering the phone on the nights when we were on call. On weekends, finishing pending dictation was normal. The 20-minute mill of outpatient practice has driven primary medicine to a breaking point.

As the pressures of the primary-care job got worse, there came an exit in the form of the hospitalist model. HM provided shift work that could be adjusted to the needs of the physician.

This new kind of job, however, has its own problems. Physicians choosing the normalcy of shift work did not realize that they would give up professional independence. Hospitalists now are governed by the laws of shift work, and at the same time remain governed by the laws of their profession. It is likely when in need they will stay behind and get the work done. And it has been seen that hospitalists do visit the doctors’ lounge, have professional interests outside of direct patient care, and sometimes leave the hospital when their admits and discharges are complete.

And so the shift-work model has, at times, resulted in friction between hospital administration and hospitalists. It could be understood that, from an employer’s perspective, hospitals are paying on an hourly basis and thus expect the hospitalist group to be on site 24/7, sticking around even if there is no work. However, the argument from the hospitalist perspective is that when needed, I stay extra. It should be OK that on low-census days we should be able to leave for a cup of coffee and still be reachable, ready to come in if need arises.

So how do hospitalist-physician professionalism and shift work co-exist? It’s a big question, one that organizations around the country will be looking to solve in the next few years. How this question is answered is going to impact quality of care, recruitment, and staff satisfaction. Each answer will impact the staff and patients.

Keeping in mind outcomes that both parties are looking for, I think a proper plan can be worked out. I suggest hospital administrators adopt the following value-based measurements to evaluate hospitalist clinicians, and establish a compensation system where a minimum amount of production must be met.

Work relative value units (wRVUs). Work RVUs provide a consistent method to measure physician productivity. If one HM clinician’s numbers are below the group average, they might need a lesson in billing, along with a report of their productivity numbers and group expectations.

Patient encounters per day. The average number of patients seen per day (patients seen divided by number of shifts worked) should be measured on a quarterly basis. This metric should provide a measure of the work done by the physician; however, it needs to be offset by your group’s turnover rate (as discussed below).

Length of stay (LOS). Most HM groups are measuring LOS. It is the reason hospitalists exist. Not much more needs to be said about this measure of work performance.

Percentage of patient turnover. A good hospitalist will have a high patient turnover figure (total discharges divided by total encounters per day). This is important to know; it’s even better if accompanied by a short LOS.

 

New admissions per shift. Again, if there is an outlier, that metric should be detected rather easily.

Patient satisfaction. More and more, this is becoming an important measure of physician quality and is essential for competitive marketplaces. Of course, the quality of medical care will have its own parameters. And it is best left to use the existing, longstanding parameters that are used for the rest of the doctors in your system. There is no need to create an alternative system for the hospitalist.

If all of the above measures are better than the average hospitalist in the locality, then no one should worry about the hospitalist’s other activities, be it involvement in committee work, research, or browsing a newspaper or a cup of coffee in the doctors’ lounge. After all, one of the main reasons physicians opted for HM practice was to have the ability to control their workday.

This will, in my opinion, improve workforce satisfaction and improve productivity. It only makes common sense. It may be a hard pill to swallow for the administrators, but it is the right medicine for the doctor.

Rwoof Reshi, MD, hospitalist, St. Joe’s Hospital, St. Paul, Minn.

An evaluation of the Pennsylvania-based Geisinger Health System’s ProvenHealth Navigator, a patient-centered medical home (PCMH) model, found that hospitalizations have been reduced by 18% for all patients.¹

The National Institutes on Aging-sponsored project Geriatric Resources for Assessment and Care of Elders (GRACE), which also functioned according to several PCMH principles, reduced hospitalizations by 40% and 44% in its second and third years, another evaluation showed.^2,3

And in the Veterans Affairs-managed Home-Based Primary Care project, another PCMH-based effort, readmissions were reduced by 22% in the first six months, but the reduction wasn’t sustained for the rest of the year.⁴

Those findings are among the most definitive so far on the effects of the PCMH on hospitalization rates, according to an Agency for Healthcare Research and Quality (AHRQ) report published in February.

The report concluded that among the statistically significant findings in the biggest PCMH evaluations, favorable results far outnumbered unfavorable results—on outcomes, ED use, and patient experience.

But AHRQ also found that most studies have been inconclusive due to problems with their methodologies. For instance, many studies don’t factor in “clustering,” in which patient outcomes within a practice can be expected to be similar to that of other patients at that practice. AHRQ’s report evaluated the results only from studies it determined had methodologies that were sufficiently rigorous.

The evaluation of the GRACE project was the only evaluation that found any evidence of savings, according to the report. But that study was one of only four on the topic that were deemed worth consideration.

David Meyers, MD, director of the Center for Primary Care, Prevention, and Clinical Partnerships at AHRQ, points out that the systems that have been evaluated are the very earliest adopters of PCMH principles. Researchers estimate that it could take 10 years to get reliable results.

“The good news,” Dr. Meyers says, “is that there are a lot more demonstrations happening now, so we soon will have a lot more guidance about how to make this model work.”

Tom Collins is a freelance writer in South Florida.

References

1. Gilfillan RJ, Tomcavage J, Rosenthal MB, et al. Value and the medical home: Effects of transformed primary care. Am J Manag Care. 2010;16(8):607-614.

2. Bielaszka-DuVernay, et al. The “GRACE” model: in-home assessments lead to better care for dual eligibles. Health Aff (Millwood). 2011;30(3):431-434.

3. Counsell SR, Callahan CM, Tu W, Stump TE, Arling GW. Cost analysis of the Geriatric Resources for Assessment and Care of Elders care management intervention. J Am Geriatr Soc. 2009;57(8):1420-1426.

4. Hughes SL, Weaver FM, Giobbie-Hurder A, et al. Effectiveness of team-managed home-based primary care: a randomized multicenter trial. JAMA. 2000;284(22):2877-2885.

 

An evaluation of the Pennsylvania-based Geisinger Health System’s ProvenHealth Navigator, a patient-centered medical home (PCMH) model, found that hospitalizations have been reduced by 18% for all patients.¹

The National Institutes on Aging-sponsored project Geriatric Resources for Assessment and Care of Elders (GRACE), which also functioned according to several PCMH principles, reduced hospitalizations by 40% and 44% in its second and third years, another evaluation showed.^2,3

And in the Veterans Affairs-managed Home-Based Primary Care project, another PCMH-based effort, readmissions were reduced by 22% in the first six months, but the reduction wasn’t sustained for the rest of the year.⁴

Those findings are among the most definitive so far on the effects of the PCMH on hospitalization rates, according to an Agency for Healthcare Research and Quality (AHRQ) report published in February.

The report concluded that among the statistically significant findings in the biggest PCMH evaluations, favorable results far outnumbered unfavorable results—on outcomes, ED use, and patient experience.

But AHRQ also found that most studies have been inconclusive due to problems with their methodologies. For instance, many studies don’t factor in “clustering,” in which patient outcomes within a practice can be expected to be similar to that of other patients at that practice. AHRQ’s report evaluated the results only from studies it determined had methodologies that were sufficiently rigorous.

The evaluation of the GRACE project was the only evaluation that found any evidence of savings, according to the report. But that study was one of only four on the topic that were deemed worth consideration.

David Meyers, MD, director of the Center for Primary Care, Prevention, and Clinical Partnerships at AHRQ, points out that the systems that have been evaluated are the very earliest adopters of PCMH principles. Researchers estimate that it could take 10 years to get reliable results.

“The good news,” Dr. Meyers says, “is that there are a lot more demonstrations happening now, so we soon will have a lot more guidance about how to make this model work.”

Tom Collins is a freelance writer in South Florida.

References

1. Gilfillan RJ, Tomcavage J, Rosenthal MB, et al. Value and the medical home: Effects of transformed primary care. Am J Manag Care. 2010;16(8):607-614.

2. Bielaszka-DuVernay, et al. The “GRACE” model: in-home assessments lead to better care for dual eligibles. Health Aff (Millwood). 2011;30(3):431-434.

3. Counsell SR, Callahan CM, Tu W, Stump TE, Arling GW. Cost analysis of the Geriatric Resources for Assessment and Care of Elders care management intervention. J Am Geriatr Soc. 2009;57(8):1420-1426.

4. Hughes SL, Weaver FM, Giobbie-Hurder A, et al. Effectiveness of team-managed home-based primary care: a randomized multicenter trial. JAMA. 2000;284(22):2877-2885.

 

An evaluation of the Pennsylvania-based Geisinger Health System’s ProvenHealth Navigator, a patient-centered medical home (PCMH) model, found that hospitalizations have been reduced by 18% for all patients.¹

The National Institutes on Aging-sponsored project Geriatric Resources for Assessment and Care of Elders (GRACE), which also functioned according to several PCMH principles, reduced hospitalizations by 40% and 44% in its second and third years, another evaluation showed.^2,3

And in the Veterans Affairs-managed Home-Based Primary Care project, another PCMH-based effort, readmissions were reduced by 22% in the first six months, but the reduction wasn’t sustained for the rest of the year.⁴

Those findings are among the most definitive so far on the effects of the PCMH on hospitalization rates, according to an Agency for Healthcare Research and Quality (AHRQ) report published in February.

The report concluded that among the statistically significant findings in the biggest PCMH evaluations, favorable results far outnumbered unfavorable results—on outcomes, ED use, and patient experience.

But AHRQ also found that most studies have been inconclusive due to problems with their methodologies. For instance, many studies don’t factor in “clustering,” in which patient outcomes within a practice can be expected to be similar to that of other patients at that practice. AHRQ’s report evaluated the results only from studies it determined had methodologies that were sufficiently rigorous.

The evaluation of the GRACE project was the only evaluation that found any evidence of savings, according to the report. But that study was one of only four on the topic that were deemed worth consideration.

David Meyers, MD, director of the Center for Primary Care, Prevention, and Clinical Partnerships at AHRQ, points out that the systems that have been evaluated are the very earliest adopters of PCMH principles. Researchers estimate that it could take 10 years to get reliable results.

“The good news,” Dr. Meyers says, “is that there are a lot more demonstrations happening now, so we soon will have a lot more guidance about how to make this model work.”

Tom Collins is a freelance writer in South Florida.

References

1. Gilfillan RJ, Tomcavage J, Rosenthal MB, et al. Value and the medical home: Effects of transformed primary care. Am J Manag Care. 2010;16(8):607-614.

2. Bielaszka-DuVernay, et al. The “GRACE” model: in-home assessments lead to better care for dual eligibles. Health Aff (Millwood). 2011;30(3):431-434.

3. Counsell SR, Callahan CM, Tu W, Stump TE, Arling GW. Cost analysis of the Geriatric Resources for Assessment and Care of Elders care management intervention. J Am Geriatr Soc. 2009;57(8):1420-1426.

4. Hughes SL, Weaver FM, Giobbie-Hurder A, et al. Effectiveness of team-managed home-based primary care: a randomized multicenter trial. JAMA. 2000;284(22):2877-2885.

 

Click here to listen to Dr. Eichhorn

Click here to listen to Dr. Eichhorn

Click here to listen to Dr. Eichhorn

Click here to listen to the state officials

Click here to listen to the state officials

Click here to listen to the state officials

Click here to listen to

Dr. Maynard and others at the public hearing

Click here to listen to

Dr. Maynard and others at the public hearing

Click here to listen to

Dr. Maynard and others at the public hearing

Several years ago, Presbyterian Medical Group in Albuquerque, N.M., decided to integrate three elements of its healthcare system: its health plan, the employed medical group, and the hospital delivery system. Knitting those parts into a cohesive whole helped the group realize that “lowering the cost of care by improving efficiency, by improving coordination, and by enhancing collaboration between payor and physicians made a lot of sense,” executive medical director David Arredondo, MD, says.

When the accountable care organization (ACO) concept came along, Dr. Arredondo says, “it really was just a natural extension of what we were doing.”

The ACO model, championed as a way to prevent the fragmentation of care and rein in costs by getting providers to assume joint responsibility for specific patient populations, received a major boost through 2010’s Affordable Care Act. Last year’s ACO rule-making process by the Centers for Medicare & Medicaid Services (CMS), however, was anything but smooth. Cautious optimism by such organizations as SHM gave way to loud complaints over the initial rules for a voluntary initiative called the Shared Savings Program. Critics asserted that participants would be forced to assume too much financial risk while being swamped with paperwork requirements.

By year’s end, though, the final rules had assuaged many of the biggest concerns, and the April 10 announcement of 27 participants for the program’s first round—more than half of which are physician-led organizations—has rekindled much of the enthusiasm. According to CMS officials, the agency is reviewing more than 150 applications for the program’s next round, which will begin in July.

Keys to Success

In December, CMS selected 32 organizations to participate in an even more ambitious initiative called the Pioneer ACO Model. That separate but related experiment in shared accountability launched Jan. 1, and it may be months before enrolled organizations can say whether the rewards outweigh the risks. Interviews with Presbyterian’s Dr. Arredondo and two other Pioneer participants about why they took the plunge, however, have highlighted some potential keys to success.

All three agree that the ACO model offers a better match for their long-term, patient-centered goals and that the fee-for-service model is gradually becoming a thing of the past.

“In some ways, it was actually kind of a relief that the system was going this way because we, probably like many systems, were beginning to be caught between the budgeted model and a fee-for-service model,” Dr. Arredondo says. “When you’re heavily one way or heavily the other way, then it makes things a little easier to manage and understand. When you’re right in the middle, it becomes a little uncomfortable.”

Penny Wheeler, MD, chief clinical officer for Minneapolis-based Allina Hospitals & Clinics, says organizations in that precarious position need to carefully examine their capabilities and consider how best to pace their transition. Otherwise, they might prematurely give up too much revenue that could be used to reinvest in care improvements.

“We can tolerate it if we shoot ourselves in one foot, but we can’t tolerate it if we shoot ourselves in both feet, in this new world,” Dr. Wheeler says.

If caution is warranted, she says, the ACO model still aligns well with a strategy of building toward outcome-based healthcare. Despite the likelihood of “lumps and bumps and warts along the way,” Dr. Wheeler says, “we really wanted to be part of the shaping of that outcome-based delivery, and receive market rewards for what we were creating for our community.”

 

Austin, Texas-based Seton Health Alliance, a third Pioneer participant, is a collaborative effort between a hospital delivery system known as Seton Health Care Family and a multispecialty physician group called Austin Regional Clinic. Greg Sheff, MD, president and chief medical officer of the ACO, says the partnering organizations were separately moving toward more population health initiatives and more proactive, coordinated, and accountable care.

“The Pioneer ACO, for us, really provided an opportunity to light the fire and motivate the organizations to put the entity together and start doing the work,” he says, adding PCPs and hospitalists will be critical to his organization’s ongoing integration efforts.

“The areas where there are opportunities to be more efficient are largely under the care of the hospitalists,” he says, citing in-house utilization as well as care transitions, comprehensive post-acute placement, and readmission prevention efforts. To support those providers, Pioneer participants say well-designed electronic medical records are paramount, while separate efforts, such as patient-centered medical homes and unit-based rounding, might offer timely assists. (Click here to listen to more of The Hospitalist’s interview with Dr. Sheff.)

No one’s expecting the next few years to be seamless, but Dr. Sheff views his newly formed ACO as a long-term endeavor in which success isn’t necessarily defined by whether the group achieves shared cost savings.

“We define success by whether we are able to move our delivery system to a place where we’ll be much more adept at going forward, continuing to manage populations,” he says. “We really see this as a strategic organizational decision more than, ‘Boy, that contract looks like something that we can leverage in the short term.’”

Bryn Nelson is a freelance medical writer in Seattle.

 

Several years ago, Presbyterian Medical Group in Albuquerque, N.M., decided to integrate three elements of its healthcare system: its health plan, the employed medical group, and the hospital delivery system. Knitting those parts into a cohesive whole helped the group realize that “lowering the cost of care by improving efficiency, by improving coordination, and by enhancing collaboration between payor and physicians made a lot of sense,” executive medical director David Arredondo, MD, says.

When the accountable care organization (ACO) concept came along, Dr. Arredondo says, “it really was just a natural extension of what we were doing.”

The ACO model, championed as a way to prevent the fragmentation of care and rein in costs by getting providers to assume joint responsibility for specific patient populations, received a major boost through 2010’s Affordable Care Act. Last year’s ACO rule-making process by the Centers for Medicare & Medicaid Services (CMS), however, was anything but smooth. Cautious optimism by such organizations as SHM gave way to loud complaints over the initial rules for a voluntary initiative called the Shared Savings Program. Critics asserted that participants would be forced to assume too much financial risk while being swamped with paperwork requirements.

By year’s end, though, the final rules had assuaged many of the biggest concerns, and the April 10 announcement of 27 participants for the program’s first round—more than half of which are physician-led organizations—has rekindled much of the enthusiasm. According to CMS officials, the agency is reviewing more than 150 applications for the program’s next round, which will begin in July.

Keys to Success

In December, CMS selected 32 organizations to participate in an even more ambitious initiative called the Pioneer ACO Model. That separate but related experiment in shared accountability launched Jan. 1, and it may be months before enrolled organizations can say whether the rewards outweigh the risks. Interviews with Presbyterian’s Dr. Arredondo and two other Pioneer participants about why they took the plunge, however, have highlighted some potential keys to success.

All three agree that the ACO model offers a better match for their long-term, patient-centered goals and that the fee-for-service model is gradually becoming a thing of the past.

“In some ways, it was actually kind of a relief that the system was going this way because we, probably like many systems, were beginning to be caught between the budgeted model and a fee-for-service model,” Dr. Arredondo says. “When you’re heavily one way or heavily the other way, then it makes things a little easier to manage and understand. When you’re right in the middle, it becomes a little uncomfortable.”

Penny Wheeler, MD, chief clinical officer for Minneapolis-based Allina Hospitals & Clinics, says organizations in that precarious position need to carefully examine their capabilities and consider how best to pace their transition. Otherwise, they might prematurely give up too much revenue that could be used to reinvest in care improvements.

“We can tolerate it if we shoot ourselves in one foot, but we can’t tolerate it if we shoot ourselves in both feet, in this new world,” Dr. Wheeler says.

If caution is warranted, she says, the ACO model still aligns well with a strategy of building toward outcome-based healthcare. Despite the likelihood of “lumps and bumps and warts along the way,” Dr. Wheeler says, “we really wanted to be part of the shaping of that outcome-based delivery, and receive market rewards for what we were creating for our community.”

 

Austin, Texas-based Seton Health Alliance, a third Pioneer participant, is a collaborative effort between a hospital delivery system known as Seton Health Care Family and a multispecialty physician group called Austin Regional Clinic. Greg Sheff, MD, president and chief medical officer of the ACO, says the partnering organizations were separately moving toward more population health initiatives and more proactive, coordinated, and accountable care.

“The Pioneer ACO, for us, really provided an opportunity to light the fire and motivate the organizations to put the entity together and start doing the work,” he says, adding PCPs and hospitalists will be critical to his organization’s ongoing integration efforts.

“The areas where there are opportunities to be more efficient are largely under the care of the hospitalists,” he says, citing in-house utilization as well as care transitions, comprehensive post-acute placement, and readmission prevention efforts. To support those providers, Pioneer participants say well-designed electronic medical records are paramount, while separate efforts, such as patient-centered medical homes and unit-based rounding, might offer timely assists. (Click here to listen to more of The Hospitalist’s interview with Dr. Sheff.)

No one’s expecting the next few years to be seamless, but Dr. Sheff views his newly formed ACO as a long-term endeavor in which success isn’t necessarily defined by whether the group achieves shared cost savings.

“We define success by whether we are able to move our delivery system to a place where we’ll be much more adept at going forward, continuing to manage populations,” he says. “We really see this as a strategic organizational decision more than, ‘Boy, that contract looks like something that we can leverage in the short term.’”

Bryn Nelson is a freelance medical writer in Seattle.

 

Several years ago, Presbyterian Medical Group in Albuquerque, N.M., decided to integrate three elements of its healthcare system: its health plan, the employed medical group, and the hospital delivery system. Knitting those parts into a cohesive whole helped the group realize that “lowering the cost of care by improving efficiency, by improving coordination, and by enhancing collaboration between payor and physicians made a lot of sense,” executive medical director David Arredondo, MD, says.

When the accountable care organization (ACO) concept came along, Dr. Arredondo says, “it really was just a natural extension of what we were doing.”

The ACO model, championed as a way to prevent the fragmentation of care and rein in costs by getting providers to assume joint responsibility for specific patient populations, received a major boost through 2010’s Affordable Care Act. Last year’s ACO rule-making process by the Centers for Medicare & Medicaid Services (CMS), however, was anything but smooth. Cautious optimism by such organizations as SHM gave way to loud complaints over the initial rules for a voluntary initiative called the Shared Savings Program. Critics asserted that participants would be forced to assume too much financial risk while being swamped with paperwork requirements.

By year’s end, though, the final rules had assuaged many of the biggest concerns, and the April 10 announcement of 27 participants for the program’s first round—more than half of which are physician-led organizations—has rekindled much of the enthusiasm. According to CMS officials, the agency is reviewing more than 150 applications for the program’s next round, which will begin in July.

Keys to Success

In December, CMS selected 32 organizations to participate in an even more ambitious initiative called the Pioneer ACO Model. That separate but related experiment in shared accountability launched Jan. 1, and it may be months before enrolled organizations can say whether the rewards outweigh the risks. Interviews with Presbyterian’s Dr. Arredondo and two other Pioneer participants about why they took the plunge, however, have highlighted some potential keys to success.

All three agree that the ACO model offers a better match for their long-term, patient-centered goals and that the fee-for-service model is gradually becoming a thing of the past.

“In some ways, it was actually kind of a relief that the system was going this way because we, probably like many systems, were beginning to be caught between the budgeted model and a fee-for-service model,” Dr. Arredondo says. “When you’re heavily one way or heavily the other way, then it makes things a little easier to manage and understand. When you’re right in the middle, it becomes a little uncomfortable.”

Penny Wheeler, MD, chief clinical officer for Minneapolis-based Allina Hospitals & Clinics, says organizations in that precarious position need to carefully examine their capabilities and consider how best to pace their transition. Otherwise, they might prematurely give up too much revenue that could be used to reinvest in care improvements.

“We can tolerate it if we shoot ourselves in one foot, but we can’t tolerate it if we shoot ourselves in both feet, in this new world,” Dr. Wheeler says.

If caution is warranted, she says, the ACO model still aligns well with a strategy of building toward outcome-based healthcare. Despite the likelihood of “lumps and bumps and warts along the way,” Dr. Wheeler says, “we really wanted to be part of the shaping of that outcome-based delivery, and receive market rewards for what we were creating for our community.”

 

Austin, Texas-based Seton Health Alliance, a third Pioneer participant, is a collaborative effort between a hospital delivery system known as Seton Health Care Family and a multispecialty physician group called Austin Regional Clinic. Greg Sheff, MD, president and chief medical officer of the ACO, says the partnering organizations were separately moving toward more population health initiatives and more proactive, coordinated, and accountable care.

“The Pioneer ACO, for us, really provided an opportunity to light the fire and motivate the organizations to put the entity together and start doing the work,” he says, adding PCPs and hospitalists will be critical to his organization’s ongoing integration efforts.

“The areas where there are opportunities to be more efficient are largely under the care of the hospitalists,” he says, citing in-house utilization as well as care transitions, comprehensive post-acute placement, and readmission prevention efforts. To support those providers, Pioneer participants say well-designed electronic medical records are paramount, while separate efforts, such as patient-centered medical homes and unit-based rounding, might offer timely assists. (Click here to listen to more of The Hospitalist’s interview with Dr. Sheff.)

No one’s expecting the next few years to be seamless, but Dr. Sheff views his newly formed ACO as a long-term endeavor in which success isn’t necessarily defined by whether the group achieves shared cost savings.

“We define success by whether we are able to move our delivery system to a place where we’ll be much more adept at going forward, continuing to manage populations,” he says. “We really see this as a strategic organizational decision more than, ‘Boy, that contract looks like something that we can leverage in the short term.’”

Bryn Nelson is a freelance medical writer in Seattle.

 

In early November, the Institute of Medicine (IOM) released a report on the current status of health information technology (HIT). Although the report was developed at the request of the Office of the National Coordinator (ONC), the arm within the Department of Health and Human Services (HHS) responsible for promoting the use of HIT, not everything in the report was positive—and could leave the impression that HIT is not quite as successful as some think.

The report recommends that the ONC should work with the private and public sectors to make comparative user experiences across vendors publicly available.

Many hospitalists have developed significant expertise with HIT, played significant roles in its effective implementation and use, and are acutely aware of implementation pitfalls. This practical experience could be very helpful in working with the ONC to develop solutions. It is for this reason that hospitalists should reach out to the ONC and offer their expertise instead of waiting for the ONC to act.

The report, “Patient Safety and Health IT: Building Safer Systems for Better Care,” did praise HIT’s potential for eventual cost savings and increased patient safety but stopped short of being a ringing endorsement of the pace HM is taking toward implementation initiatives, such as meaningful use. An overall theme of the report is that greater oversight of HIT is needed to protect patients from potential medical errors associated with its use.

A few of the recommendations given by the IOM to achieve a greater level of safety range from the establishment of a mechanism for vendors and users to report health IT-related deaths, injuries, or unsafe conditions to possible FDA regulation of the systems themselves.

Information-sharing and reporting in a nonpunitive environment, as recommended by the IOM, would go a long way when it comes to remedying or avoiding IT-related problems, and hospitalists probably have some ideas about how this could be done.

Unfortunately, IT vendor contracts often prevent the open sharing of information, so working toward doing away with such contract terms might be a worthy step before making a push toward overall FDA regulation and the unintended consequences that may come with it.

At first glance, FDA regulation seems like the easiest solution because the FDA can theoretically control every aspect of what might go wrong with HIT, but at what cost would such regulation come? FDA approval can be long, complicated and expensive. The whole process could result in cutting-edge technology becoming outdated by the time approval is granted or innovations being overlooked entirely because of a negative cost-benefit analysis. Furthermore, the expense associated with FDA approval could in turn increase the cost of already costly electronic health records (EHR).

Despite the myriad problems that can arise if implementation moves too fast, HIT holds promise and has shown success when done well.

SHM is currently working to position hospitalists as a resource for the ONC, so hospitalists with expertise in this area should not hesitate to come forward with ideas on how to make HIT work better and more safely. HIT is not going to go away, so the best option is to help make it better.

In early November, the Institute of Medicine (IOM) released a report on the current status of health information technology (HIT). Although the report was developed at the request of the Office of the National Coordinator (ONC), the arm within the Department of Health and Human Services (HHS) responsible for promoting the use of HIT, not everything in the report was positive—and could leave the impression that HIT is not quite as successful as some think.

The report recommends that the ONC should work with the private and public sectors to make comparative user experiences across vendors publicly available.

Many hospitalists have developed significant expertise with HIT, played significant roles in its effective implementation and use, and are acutely aware of implementation pitfalls. This practical experience could be very helpful in working with the ONC to develop solutions. It is for this reason that hospitalists should reach out to the ONC and offer their expertise instead of waiting for the ONC to act.

The report, “Patient Safety and Health IT: Building Safer Systems for Better Care,” did praise HIT’s potential for eventual cost savings and increased patient safety but stopped short of being a ringing endorsement of the pace HM is taking toward implementation initiatives, such as meaningful use. An overall theme of the report is that greater oversight of HIT is needed to protect patients from potential medical errors associated with its use.

A few of the recommendations given by the IOM to achieve a greater level of safety range from the establishment of a mechanism for vendors and users to report health IT-related deaths, injuries, or unsafe conditions to possible FDA regulation of the systems themselves.

Information-sharing and reporting in a nonpunitive environment, as recommended by the IOM, would go a long way when it comes to remedying or avoiding IT-related problems, and hospitalists probably have some ideas about how this could be done.

Unfortunately, IT vendor contracts often prevent the open sharing of information, so working toward doing away with such contract terms might be a worthy step before making a push toward overall FDA regulation and the unintended consequences that may come with it.

At first glance, FDA regulation seems like the easiest solution because the FDA can theoretically control every aspect of what might go wrong with HIT, but at what cost would such regulation come? FDA approval can be long, complicated and expensive. The whole process could result in cutting-edge technology becoming outdated by the time approval is granted or innovations being overlooked entirely because of a negative cost-benefit analysis. Furthermore, the expense associated with FDA approval could in turn increase the cost of already costly electronic health records (EHR).

Despite the myriad problems that can arise if implementation moves too fast, HIT holds promise and has shown success when done well.

SHM is currently working to position hospitalists as a resource for the ONC, so hospitalists with expertise in this area should not hesitate to come forward with ideas on how to make HIT work better and more safely. HIT is not going to go away, so the best option is to help make it better.

In early November, the Institute of Medicine (IOM) released a report on the current status of health information technology (HIT). Although the report was developed at the request of the Office of the National Coordinator (ONC), the arm within the Department of Health and Human Services (HHS) responsible for promoting the use of HIT, not everything in the report was positive—and could leave the impression that HIT is not quite as successful as some think.

The report recommends that the ONC should work with the private and public sectors to make comparative user experiences across vendors publicly available.

Many hospitalists have developed significant expertise with HIT, played significant roles in its effective implementation and use, and are acutely aware of implementation pitfalls. This practical experience could be very helpful in working with the ONC to develop solutions. It is for this reason that hospitalists should reach out to the ONC and offer their expertise instead of waiting for the ONC to act.

The report, “Patient Safety and Health IT: Building Safer Systems for Better Care,” did praise HIT’s potential for eventual cost savings and increased patient safety but stopped short of being a ringing endorsement of the pace HM is taking toward implementation initiatives, such as meaningful use. An overall theme of the report is that greater oversight of HIT is needed to protect patients from potential medical errors associated with its use.

A few of the recommendations given by the IOM to achieve a greater level of safety range from the establishment of a mechanism for vendors and users to report health IT-related deaths, injuries, or unsafe conditions to possible FDA regulation of the systems themselves.

Information-sharing and reporting in a nonpunitive environment, as recommended by the IOM, would go a long way when it comes to remedying or avoiding IT-related problems, and hospitalists probably have some ideas about how this could be done.

Unfortunately, IT vendor contracts often prevent the open sharing of information, so working toward doing away with such contract terms might be a worthy step before making a push toward overall FDA regulation and the unintended consequences that may come with it.

At first glance, FDA regulation seems like the easiest solution because the FDA can theoretically control every aspect of what might go wrong with HIT, but at what cost would such regulation come? FDA approval can be long, complicated and expensive. The whole process could result in cutting-edge technology becoming outdated by the time approval is granted or innovations being overlooked entirely because of a negative cost-benefit analysis. Furthermore, the expense associated with FDA approval could in turn increase the cost of already costly electronic health records (EHR).

Despite the myriad problems that can arise if implementation moves too fast, HIT holds promise and has shown success when done well.

SHM is currently working to position hospitalists as a resource for the ONC, so hospitalists with expertise in this area should not hesitate to come forward with ideas on how to make HIT work better and more safely. HIT is not going to go away, so the best option is to help make it better.