Public Policy

Section 10332 of the Affordable Care Act (ACA) allows the Centers for Medicare & Medicaid Services (CMS) to provide Medicare claims data to “qualified” private organizations for the purpose of reporting provider performance information. On June 8, CMS issued a proposed rule that includes tight parameters on who qualifies to receive the data, beneficiary privacy protections, and the rights of providers to correct errors before reports are made public. CMS also included estimates of the fees to receive the claims data: $275,000.

The fees are not a price as much as an effort to recoup the expense associated with providing the data. CMS has interpreted expenses to include the cost of providing technical assistance, processing qualified entities’ applications, and monitoring of qualified entities to ensure appropriate use of the data and appropriate adherence to data privacy and security standards.

For hospitalists, the opportunity to access this data presents both positives and negatives. On the positive side, research and QI data sources will be greatly expanded. Currently, it is not unheard of to receive multiple, sometimes contradictory, reports from different sources because they are based on different data from piecemeal claims or measures. This initiative grants the ability to combine private sector data with the enormous amount of data at CMS, which should result in the more useful quality reports. This broad pool of data also will allow for a new level of accuracy when it comes to analyzing quality, efficiency, and resource use.

On the negative side, the expense of obtaining this data could be cost-prohibitive for smaller organizations, and access could end up being limited to those with deeper pockets. Additionally, it will be critical to identify errors and inaccuracies in reports. As a result, hospitalists could be forced to spend time and resources reviewing privately produced performance reports before they are made public.

There is potential in this initiative to change the quality measurement landscape. If done well, the opportunity to combine claims data from both Medicare and the private sector will produce a wealth of information related to how providers and suppliers are performing.

SHM will be voicing support for the concept because it serves to increase performance transparency, not just for hospitalists but for all stakeholders.

Ready to Lead Hospital Medicine?

Join an SHM Committee

Dr. Li

When Kim Dickinson, MD, joined SHM’s Administrators Committee, it expanded her network of HM professionals. It also gave her an opportunity to take some of the best practices in the specialty to others within her company.

For other hospitalists interested in flexing leadership muscles and growing their network of hospitalists, now is the time to apply for positions on more than 30 of SHM’s committees and task forces. Potential applicants are encouraged to apply before January 2012.

Committee information and applications are available at www.hospitalmedicine.org/committees.

“SHM’s committees and task forces are the engines that drive SHM toward a vision of transforming healthcare and revolutionizing patient care in the hospital,” says SHM president Joseph Li, MD, SFHM. “And the broad span of issues covered by our committees gives every aspiring hospitalist an opportunity to channel their energy into something meaningful.”

Dr. Dickinson sees committee participation as a way to learn and grow.

“I always tell people about being on committees,” she says. “It’s a good learning experience for people, and it exposes you to a wide variety of people and different perspectives. What applies to a four-member group is very different than what applies to 40-member group.

“A lot of learning that can come from that.”

SHM’s Atchley Leadership Fund Supports the Next Generation of Hospitalist Leaders

Dr. Atchley

Hospitalist Bill Atchley, MD, SFHM, was there at the beginning of SHM’s Leadership Academy. Now, he’s helping it to endure.

After participating in the first Leadership Academy, he was hooked on the concept and later became a course facilitator.

As much as Bill has been a fixture at Leadership Academy, so has his wife, Anne. There, she saw firsthand her husband’s passion not only for the specialty, but also his passion for helping groom the next generation of hospitalist leaders. The academies also were the place where many got to see Bill and Anne together after hours, a scene that reminds hospitalists that leadership is not a solitary journey, but one to embark on with both colleagues and those closest to us.

When Anne passed in December 2009, following a valiant fight against cancer, Bill worked with SHM to create the Atchley Leadership Fund. The fund honors Anne’s memory by providing partial scholarships for Leadership Academy participants.

Hospitalists can join Bill in paying tribute to Anne and paving the way for new hospitalist leaders in healthcare by making a tax-free donation to the Atchley Leadership Fund. For more information, visit www.hospitalmedicine.org/atchley.

Section 10332 of the Affordable Care Act (ACA) allows the Centers for Medicare & Medicaid Services (CMS) to provide Medicare claims data to “qualified” private organizations for the purpose of reporting provider performance information. On June 8, CMS issued a proposed rule that includes tight parameters on who qualifies to receive the data, beneficiary privacy protections, and the rights of providers to correct errors before reports are made public. CMS also included estimates of the fees to receive the claims data: $275,000.

The fees are not a price as much as an effort to recoup the expense associated with providing the data. CMS has interpreted expenses to include the cost of providing technical assistance, processing qualified entities’ applications, and monitoring of qualified entities to ensure appropriate use of the data and appropriate adherence to data privacy and security standards.

For hospitalists, the opportunity to access this data presents both positives and negatives. On the positive side, research and QI data sources will be greatly expanded. Currently, it is not unheard of to receive multiple, sometimes contradictory, reports from different sources because they are based on different data from piecemeal claims or measures. This initiative grants the ability to combine private sector data with the enormous amount of data at CMS, which should result in the more useful quality reports. This broad pool of data also will allow for a new level of accuracy when it comes to analyzing quality, efficiency, and resource use.

On the negative side, the expense of obtaining this data could be cost-prohibitive for smaller organizations, and access could end up being limited to those with deeper pockets. Additionally, it will be critical to identify errors and inaccuracies in reports. As a result, hospitalists could be forced to spend time and resources reviewing privately produced performance reports before they are made public.

There is potential in this initiative to change the quality measurement landscape. If done well, the opportunity to combine claims data from both Medicare and the private sector will produce a wealth of information related to how providers and suppliers are performing.

SHM will be voicing support for the concept because it serves to increase performance transparency, not just for hospitalists but for all stakeholders.

Ready to Lead Hospital Medicine?

Join an SHM Committee

Dr. Li

When Kim Dickinson, MD, joined SHM’s Administrators Committee, it expanded her network of HM professionals. It also gave her an opportunity to take some of the best practices in the specialty to others within her company.

For other hospitalists interested in flexing leadership muscles and growing their network of hospitalists, now is the time to apply for positions on more than 30 of SHM’s committees and task forces. Potential applicants are encouraged to apply before January 2012.

Committee information and applications are available at www.hospitalmedicine.org/committees.

“SHM’s committees and task forces are the engines that drive SHM toward a vision of transforming healthcare and revolutionizing patient care in the hospital,” says SHM president Joseph Li, MD, SFHM. “And the broad span of issues covered by our committees gives every aspiring hospitalist an opportunity to channel their energy into something meaningful.”

Dr. Dickinson sees committee participation as a way to learn and grow.

“I always tell people about being on committees,” she says. “It’s a good learning experience for people, and it exposes you to a wide variety of people and different perspectives. What applies to a four-member group is very different than what applies to 40-member group.

“A lot of learning that can come from that.”

SHM’s Atchley Leadership Fund Supports the Next Generation of Hospitalist Leaders

Dr. Atchley

Hospitalist Bill Atchley, MD, SFHM, was there at the beginning of SHM’s Leadership Academy. Now, he’s helping it to endure.

After participating in the first Leadership Academy, he was hooked on the concept and later became a course facilitator.

As much as Bill has been a fixture at Leadership Academy, so has his wife, Anne. There, she saw firsthand her husband’s passion not only for the specialty, but also his passion for helping groom the next generation of hospitalist leaders. The academies also were the place where many got to see Bill and Anne together after hours, a scene that reminds hospitalists that leadership is not a solitary journey, but one to embark on with both colleagues and those closest to us.

When Anne passed in December 2009, following a valiant fight against cancer, Bill worked with SHM to create the Atchley Leadership Fund. The fund honors Anne’s memory by providing partial scholarships for Leadership Academy participants.

Hospitalists can join Bill in paying tribute to Anne and paving the way for new hospitalist leaders in healthcare by making a tax-free donation to the Atchley Leadership Fund. For more information, visit www.hospitalmedicine.org/atchley.

Section 10332 of the Affordable Care Act (ACA) allows the Centers for Medicare & Medicaid Services (CMS) to provide Medicare claims data to “qualified” private organizations for the purpose of reporting provider performance information. On June 8, CMS issued a proposed rule that includes tight parameters on who qualifies to receive the data, beneficiary privacy protections, and the rights of providers to correct errors before reports are made public. CMS also included estimates of the fees to receive the claims data: $275,000.

The fees are not a price as much as an effort to recoup the expense associated with providing the data. CMS has interpreted expenses to include the cost of providing technical assistance, processing qualified entities’ applications, and monitoring of qualified entities to ensure appropriate use of the data and appropriate adherence to data privacy and security standards.

For hospitalists, the opportunity to access this data presents both positives and negatives. On the positive side, research and QI data sources will be greatly expanded. Currently, it is not unheard of to receive multiple, sometimes contradictory, reports from different sources because they are based on different data from piecemeal claims or measures. This initiative grants the ability to combine private sector data with the enormous amount of data at CMS, which should result in the more useful quality reports. This broad pool of data also will allow for a new level of accuracy when it comes to analyzing quality, efficiency, and resource use.

On the negative side, the expense of obtaining this data could be cost-prohibitive for smaller organizations, and access could end up being limited to those with deeper pockets. Additionally, it will be critical to identify errors and inaccuracies in reports. As a result, hospitalists could be forced to spend time and resources reviewing privately produced performance reports before they are made public.

There is potential in this initiative to change the quality measurement landscape. If done well, the opportunity to combine claims data from both Medicare and the private sector will produce a wealth of information related to how providers and suppliers are performing.

SHM will be voicing support for the concept because it serves to increase performance transparency, not just for hospitalists but for all stakeholders.

Ready to Lead Hospital Medicine?

Join an SHM Committee

Dr. Li

When Kim Dickinson, MD, joined SHM’s Administrators Committee, it expanded her network of HM professionals. It also gave her an opportunity to take some of the best practices in the specialty to others within her company.

For other hospitalists interested in flexing leadership muscles and growing their network of hospitalists, now is the time to apply for positions on more than 30 of SHM’s committees and task forces. Potential applicants are encouraged to apply before January 2012.

Committee information and applications are available at www.hospitalmedicine.org/committees.

“SHM’s committees and task forces are the engines that drive SHM toward a vision of transforming healthcare and revolutionizing patient care in the hospital,” says SHM president Joseph Li, MD, SFHM. “And the broad span of issues covered by our committees gives every aspiring hospitalist an opportunity to channel their energy into something meaningful.”

Dr. Dickinson sees committee participation as a way to learn and grow.

“I always tell people about being on committees,” she says. “It’s a good learning experience for people, and it exposes you to a wide variety of people and different perspectives. What applies to a four-member group is very different than what applies to 40-member group.

“A lot of learning that can come from that.”

SHM’s Atchley Leadership Fund Supports the Next Generation of Hospitalist Leaders

Dr. Atchley

Hospitalist Bill Atchley, MD, SFHM, was there at the beginning of SHM’s Leadership Academy. Now, he’s helping it to endure.

After participating in the first Leadership Academy, he was hooked on the concept and later became a course facilitator.

As much as Bill has been a fixture at Leadership Academy, so has his wife, Anne. There, she saw firsthand her husband’s passion not only for the specialty, but also his passion for helping groom the next generation of hospitalist leaders. The academies also were the place where many got to see Bill and Anne together after hours, a scene that reminds hospitalists that leadership is not a solitary journey, but one to embark on with both colleagues and those closest to us.

When Anne passed in December 2009, following a valiant fight against cancer, Bill worked with SHM to create the Atchley Leadership Fund. The fund honors Anne’s memory by providing partial scholarships for Leadership Academy participants.

Hospitalists can join Bill in paying tribute to Anne and paving the way for new hospitalist leaders in healthcare by making a tax-free donation to the Atchley Leadership Fund. For more information, visit www.hospitalmedicine.org/atchley.

The reviews are in, and most healthcare provider groups are finding little to their liking in the proposed rules for the Centers for Medicare & Medicaid Services’ (CMS) voluntary Accountable Care Organization (ACO) program. Organizations like SHM have publically supported the concept of an ACO, but details in the 128 pages of proposed rules released March 31 apparently were not what they had in mind. The problem, as many provider groups detailed in a flurry of letters sent before the June 6 deadline for comments, is too much stick and not enough carrot.

The Patient Protection and Affordable Care Act of 2010, which authorized the program, stipulates that any Medicare savings deriving from ACOs must be divided between CMS and participating organizations. Organizations can choose between two financial models: One track allows participants to retain 60% of overall savings but also requires them to assume financial risk from the start; a second track delays any risk until the third year and offers 50% savings. In exchange, ACOs must achieve an average savings of 2% per patient, as well as meet or beat thresholds for 65 measures of quality.

Organizational Uproar

Critics contend that the recommended rules are so onerous and bureaucratic that the program is likely to attract few takers. In its comment letter, SHM expressed an opinion shared by many: "Although the ACO concept holds much promise, the proposed rule as written presents many barriers to successful ACO development and operations. Establishing an ACO will require an enormous upfront investment from participating providers, but the proposed rule does not allow for enough flexibility to ensure a reasonable return on investment." (Read SHM’s response letter at www.hospital medicine.org/advocacy.)

The American College of Physicians similarly warned that the proposed rules set the bar too high for many would-be participants. "The required administrative, infrastructure, service delivery, and financial resources and the need to accept risk will effectively limit participation to those few large entities already organized under an ACO-like structure; that already have ready access to capital, substantial infrastructure development, and experience operating under an integrative service/payment model (e.g. Medicare Advantage)," the ACP wrote in its response letter (www.acponline.org/run ning_practice/aco/acp_comments.pdf).

The tone was markedly different in letters from consumer and advocacy groups, including one by the Campaign for Better Care, signed by more than 40 organizations (www.national­partnership.org). "Overall we believe you are moving in the right direction with the proposed rule, and we applaud your commitment to ensuring ACOs deliver truly patient-centered care," the letter stated. Acknowledging the negative feedback, the letter continued, "While some are concerned about asking too much of ACOs, we cannot expect genuine transformation to be easy, and we know that these new models must be held to standards that ensure they deliver on the promise of better care, better health, and lower cost."

Accountability Gap

Michael W. Painter, JD, MD, senior program officer at the Robert Wood Johnson Foundation in Princeton, N.J., helped research and write the foundation’s own comment letter, which he says tried to bridge the divide between provider and patient groups.

"We did get behind the notion of ratcheting up the accountability for quality and cost, including the risk, as soon as it makes sense to do it," he says. "Not dragging our feet, recognizing that we have to do it rapidly, but it has to be balanced by being reasonable to help move from where we are."

Given the mandate for change, Dr. Painter says, the negative tone of many letters from provider organizations shouldn’t be surprising. "What we’re asking the hospital, the health professionals, to do is to change fairly radically and embrace this accountability. So as you just walk through the door of this conversation, it’s not surprising that they would balk," he says. "Nobody wants to take on all of this new responsibility. It’s no fault of theirs; they’ve just been following the rules of the road of the current system and the payment schemes to try to be successful in that environment."

Success, of course, depends on financial stability, and Dr. Painter says the worry that participating ACOs could open themselves up to financial risk too soon is "absolutely a legitimate concern." CMS, he says, should give providers clear guidance and assistance, as well as assurance that the regulations won’t change on them once they’ve enrolled.

So far, at least, CMS has not swayed some of the very institutions that government officials have lauded as examples of how ACOs should be run. In June, the Mayo Clinic in Rochester, Minn., announced that it would not participate. As reported by the Minneapolis Star Tribune, clinic officials said the proposed regulations clashed with Mayo’s existing Medicare operations. One of the clinic’s chief complaints is the proposed requirement that patients be added to oversight boards charged with assessing performance, something that Mayo argues is unnecessary to deliver patient-centered care. Antitrust rules represent another major concern for Mayo and others that argue their dominant position as healthcare providers in rural communities could run afoul of the regulations.

Cleveland Clinic likewise blasted the proposed ACO rules in a letter. "Rather than providing a broad framework that focuses on results as the key criteria of success, the Proposed Rule is replete with (1) prescriptive requirements that have little to do with outcomes, and (2) many detailed governance and reporting requirements that create significant administrative burdens," stated Delos Cosgrove, MD, the clinic’s CEO and president.

Furthermore, Cosgrove’s letter concluded that the shared-savings component "is structured in such a way that creates real uncertainty about whether applicants will be able to achieve success."

The American Medical Group Association went so far as to include in its letter the results of a member survey, which showed 93% would not enroll under the current ACO rules.

No Turning Back

Dr. Painter says the pushback is to be expected. Although the country has no choice but to move toward more accountability, he says, it’s impossible for the first attempt at a proposed rule to be the "magic bullet" that gets it exactly right. "One, this is a radical departure, and two, when you get into the nitty-gritty of the proposed rule and people crunch the numbers, if it’s not going to work for them or it’s simply not enticing enough for them, they [CMS] need to go back to the table and make it that way," he says.

Organizations like the American Medical Association have been particularly vocal about asking CMS to delay issuing its final rule, slated for January. So far, Dr. Painter says, CMS officials have indicated that the timeline will proceed according to schedule, though he notes that providers have raised plenty of valid concerns that should be addressed.

"Would I be surprised if there’s a delay? No. This is a big deal," he says.

Along with some expected rule changes, he says the newly formed Center for Medicare and Medicaid Innovation could play a key role in offering assistance and developing alternative ACO models and pilot programs.

Regardless of whether the voluntary CMS program ultimately pleases both providers and patients, though, one thing seems certain: The accountable-care concept is here to stay.

Bryn Nelson is a freelance medical writer based in Seattle

The reviews are in, and most healthcare provider groups are finding little to their liking in the proposed rules for the Centers for Medicare & Medicaid Services’ (CMS) voluntary Accountable Care Organization (ACO) program. Organizations like SHM have publically supported the concept of an ACO, but details in the 128 pages of proposed rules released March 31 apparently were not what they had in mind. The problem, as many provider groups detailed in a flurry of letters sent before the June 6 deadline for comments, is too much stick and not enough carrot.

The Patient Protection and Affordable Care Act of 2010, which authorized the program, stipulates that any Medicare savings deriving from ACOs must be divided between CMS and participating organizations. Organizations can choose between two financial models: One track allows participants to retain 60% of overall savings but also requires them to assume financial risk from the start; a second track delays any risk until the third year and offers 50% savings. In exchange, ACOs must achieve an average savings of 2% per patient, as well as meet or beat thresholds for 65 measures of quality.

Organizational Uproar

Critics contend that the recommended rules are so onerous and bureaucratic that the program is likely to attract few takers. In its comment letter, SHM expressed an opinion shared by many: "Although the ACO concept holds much promise, the proposed rule as written presents many barriers to successful ACO development and operations. Establishing an ACO will require an enormous upfront investment from participating providers, but the proposed rule does not allow for enough flexibility to ensure a reasonable return on investment." (Read SHM’s response letter at www.hospital medicine.org/advocacy.)

The American College of Physicians similarly warned that the proposed rules set the bar too high for many would-be participants. "The required administrative, infrastructure, service delivery, and financial resources and the need to accept risk will effectively limit participation to those few large entities already organized under an ACO-like structure; that already have ready access to capital, substantial infrastructure development, and experience operating under an integrative service/payment model (e.g. Medicare Advantage)," the ACP wrote in its response letter (www.acponline.org/run ning_practice/aco/acp_comments.pdf).

The tone was markedly different in letters from consumer and advocacy groups, including one by the Campaign for Better Care, signed by more than 40 organizations (www.national­partnership.org). "Overall we believe you are moving in the right direction with the proposed rule, and we applaud your commitment to ensuring ACOs deliver truly patient-centered care," the letter stated. Acknowledging the negative feedback, the letter continued, "While some are concerned about asking too much of ACOs, we cannot expect genuine transformation to be easy, and we know that these new models must be held to standards that ensure they deliver on the promise of better care, better health, and lower cost."

Accountability Gap

Michael W. Painter, JD, MD, senior program officer at the Robert Wood Johnson Foundation in Princeton, N.J., helped research and write the foundation’s own comment letter, which he says tried to bridge the divide between provider and patient groups.

"We did get behind the notion of ratcheting up the accountability for quality and cost, including the risk, as soon as it makes sense to do it," he says. "Not dragging our feet, recognizing that we have to do it rapidly, but it has to be balanced by being reasonable to help move from where we are."

Given the mandate for change, Dr. Painter says, the negative tone of many letters from provider organizations shouldn’t be surprising. "What we’re asking the hospital, the health professionals, to do is to change fairly radically and embrace this accountability. So as you just walk through the door of this conversation, it’s not surprising that they would balk," he says. "Nobody wants to take on all of this new responsibility. It’s no fault of theirs; they’ve just been following the rules of the road of the current system and the payment schemes to try to be successful in that environment."

Success, of course, depends on financial stability, and Dr. Painter says the worry that participating ACOs could open themselves up to financial risk too soon is "absolutely a legitimate concern." CMS, he says, should give providers clear guidance and assistance, as well as assurance that the regulations won’t change on them once they’ve enrolled.

So far, at least, CMS has not swayed some of the very institutions that government officials have lauded as examples of how ACOs should be run. In June, the Mayo Clinic in Rochester, Minn., announced that it would not participate. As reported by the Minneapolis Star Tribune, clinic officials said the proposed regulations clashed with Mayo’s existing Medicare operations. One of the clinic’s chief complaints is the proposed requirement that patients be added to oversight boards charged with assessing performance, something that Mayo argues is unnecessary to deliver patient-centered care. Antitrust rules represent another major concern for Mayo and others that argue their dominant position as healthcare providers in rural communities could run afoul of the regulations.

Cleveland Clinic likewise blasted the proposed ACO rules in a letter. "Rather than providing a broad framework that focuses on results as the key criteria of success, the Proposed Rule is replete with (1) prescriptive requirements that have little to do with outcomes, and (2) many detailed governance and reporting requirements that create significant administrative burdens," stated Delos Cosgrove, MD, the clinic’s CEO and president.

Furthermore, Cosgrove’s letter concluded that the shared-savings component "is structured in such a way that creates real uncertainty about whether applicants will be able to achieve success."

The American Medical Group Association went so far as to include in its letter the results of a member survey, which showed 93% would not enroll under the current ACO rules.

No Turning Back

Dr. Painter says the pushback is to be expected. Although the country has no choice but to move toward more accountability, he says, it’s impossible for the first attempt at a proposed rule to be the "magic bullet" that gets it exactly right. "One, this is a radical departure, and two, when you get into the nitty-gritty of the proposed rule and people crunch the numbers, if it’s not going to work for them or it’s simply not enticing enough for them, they [CMS] need to go back to the table and make it that way," he says.

Organizations like the American Medical Association have been particularly vocal about asking CMS to delay issuing its final rule, slated for January. So far, Dr. Painter says, CMS officials have indicated that the timeline will proceed according to schedule, though he notes that providers have raised plenty of valid concerns that should be addressed.

"Would I be surprised if there’s a delay? No. This is a big deal," he says.

Along with some expected rule changes, he says the newly formed Center for Medicare and Medicaid Innovation could play a key role in offering assistance and developing alternative ACO models and pilot programs.

Regardless of whether the voluntary CMS program ultimately pleases both providers and patients, though, one thing seems certain: The accountable-care concept is here to stay.

Bryn Nelson is a freelance medical writer based in Seattle

The reviews are in, and most healthcare provider groups are finding little to their liking in the proposed rules for the Centers for Medicare & Medicaid Services’ (CMS) voluntary Accountable Care Organization (ACO) program. Organizations like SHM have publically supported the concept of an ACO, but details in the 128 pages of proposed rules released March 31 apparently were not what they had in mind. The problem, as many provider groups detailed in a flurry of letters sent before the June 6 deadline for comments, is too much stick and not enough carrot.

The Patient Protection and Affordable Care Act of 2010, which authorized the program, stipulates that any Medicare savings deriving from ACOs must be divided between CMS and participating organizations. Organizations can choose between two financial models: One track allows participants to retain 60% of overall savings but also requires them to assume financial risk from the start; a second track delays any risk until the third year and offers 50% savings. In exchange, ACOs must achieve an average savings of 2% per patient, as well as meet or beat thresholds for 65 measures of quality.

Organizational Uproar

Critics contend that the recommended rules are so onerous and bureaucratic that the program is likely to attract few takers. In its comment letter, SHM expressed an opinion shared by many: "Although the ACO concept holds much promise, the proposed rule as written presents many barriers to successful ACO development and operations. Establishing an ACO will require an enormous upfront investment from participating providers, but the proposed rule does not allow for enough flexibility to ensure a reasonable return on investment." (Read SHM’s response letter at www.hospital medicine.org/advocacy.)

The American College of Physicians similarly warned that the proposed rules set the bar too high for many would-be participants. "The required administrative, infrastructure, service delivery, and financial resources and the need to accept risk will effectively limit participation to those few large entities already organized under an ACO-like structure; that already have ready access to capital, substantial infrastructure development, and experience operating under an integrative service/payment model (e.g. Medicare Advantage)," the ACP wrote in its response letter (www.acponline.org/run ning_practice/aco/acp_comments.pdf).

The tone was markedly different in letters from consumer and advocacy groups, including one by the Campaign for Better Care, signed by more than 40 organizations (www.national­partnership.org). "Overall we believe you are moving in the right direction with the proposed rule, and we applaud your commitment to ensuring ACOs deliver truly patient-centered care," the letter stated. Acknowledging the negative feedback, the letter continued, "While some are concerned about asking too much of ACOs, we cannot expect genuine transformation to be easy, and we know that these new models must be held to standards that ensure they deliver on the promise of better care, better health, and lower cost."

Accountability Gap

Michael W. Painter, JD, MD, senior program officer at the Robert Wood Johnson Foundation in Princeton, N.J., helped research and write the foundation’s own comment letter, which he says tried to bridge the divide between provider and patient groups.

"We did get behind the notion of ratcheting up the accountability for quality and cost, including the risk, as soon as it makes sense to do it," he says. "Not dragging our feet, recognizing that we have to do it rapidly, but it has to be balanced by being reasonable to help move from where we are."

Given the mandate for change, Dr. Painter says, the negative tone of many letters from provider organizations shouldn’t be surprising. "What we’re asking the hospital, the health professionals, to do is to change fairly radically and embrace this accountability. So as you just walk through the door of this conversation, it’s not surprising that they would balk," he says. "Nobody wants to take on all of this new responsibility. It’s no fault of theirs; they’ve just been following the rules of the road of the current system and the payment schemes to try to be successful in that environment."

Success, of course, depends on financial stability, and Dr. Painter says the worry that participating ACOs could open themselves up to financial risk too soon is "absolutely a legitimate concern." CMS, he says, should give providers clear guidance and assistance, as well as assurance that the regulations won’t change on them once they’ve enrolled.

So far, at least, CMS has not swayed some of the very institutions that government officials have lauded as examples of how ACOs should be run. In June, the Mayo Clinic in Rochester, Minn., announced that it would not participate. As reported by the Minneapolis Star Tribune, clinic officials said the proposed regulations clashed with Mayo’s existing Medicare operations. One of the clinic’s chief complaints is the proposed requirement that patients be added to oversight boards charged with assessing performance, something that Mayo argues is unnecessary to deliver patient-centered care. Antitrust rules represent another major concern for Mayo and others that argue their dominant position as healthcare providers in rural communities could run afoul of the regulations.

Cleveland Clinic likewise blasted the proposed ACO rules in a letter. "Rather than providing a broad framework that focuses on results as the key criteria of success, the Proposed Rule is replete with (1) prescriptive requirements that have little to do with outcomes, and (2) many detailed governance and reporting requirements that create significant administrative burdens," stated Delos Cosgrove, MD, the clinic’s CEO and president.

Furthermore, Cosgrove’s letter concluded that the shared-savings component "is structured in such a way that creates real uncertainty about whether applicants will be able to achieve success."

The American Medical Group Association went so far as to include in its letter the results of a member survey, which showed 93% would not enroll under the current ACO rules.

No Turning Back

Dr. Painter says the pushback is to be expected. Although the country has no choice but to move toward more accountability, he says, it’s impossible for the first attempt at a proposed rule to be the "magic bullet" that gets it exactly right. "One, this is a radical departure, and two, when you get into the nitty-gritty of the proposed rule and people crunch the numbers, if it’s not going to work for them or it’s simply not enticing enough for them, they [CMS] need to go back to the table and make it that way," he says.

Organizations like the American Medical Association have been particularly vocal about asking CMS to delay issuing its final rule, slated for January. So far, Dr. Painter says, CMS officials have indicated that the timeline will proceed according to schedule, though he notes that providers have raised plenty of valid concerns that should be addressed.

"Would I be surprised if there’s a delay? No. This is a big deal," he says.

Along with some expected rule changes, he says the newly formed Center for Medicare and Medicaid Innovation could play a key role in offering assistance and developing alternative ACO models and pilot programs.

Regardless of whether the voluntary CMS program ultimately pleases both providers and patients, though, one thing seems certain: The accountable-care concept is here to stay.

Bryn Nelson is a freelance medical writer based in Seattle

The federal government is taking a hard look at many of its regulations, and hospitalists might have the chance to help identify those that no longer make sense.

On Jan. 18, President Obama issued Executive Order 13563, which calls, in part, for a comprehensive retrospective review of existing government regulations. The stated goal of this review is to improve or remove those rules that are out of date, unnecessary, excessively burdensome, or in conflict with other rules.

The Office of Information and Regulatory Affairs (OIRA), the executive-level department charged with overseeing the execution of this order, asked federal agencies to submit preliminary plans for how they will conduct their internal reviews. The agencies responded, and on May 26, the White House released 30 agency preliminary plans to the public, including those prepared by the Department of Commerce, the Department of Energy, and the Department of Health and Human Services (HHS).

When reviewing some of these publicly available preliminary plans, the easy answer for some observers is to say that most rules should be eliminated. Rules requiring the use of such technologies as film X-rays instead of digital images are obvious culprits in the out-of date category; rules defining milk as "oil" (subjecting it to the same costly environmental safeguards as real oil) are just as absurd. Both of these regulations are being lifted as a result of the review.

In contrast, many rules actually do protect public health and safety and will not be subject to review. For example, as a result of federal rulemaking, highway deaths are at the lowest level in 60 years and the risk of contracting salmonella from eggs is relatively low.

As part of HHS, the Center for Medicare & Medicaid Services (CMS) specifically stated that "the goal of the retrospective review will be to identify opportunities to improve patient care and outcomes and reduce system costs by removing obsolete or burdensome requirements." A major CMS concern will be to prevent the elimination or revision of a regulation only to find that the problem it sought to solve resurfaces, or that its removal or revision results in unanticipated and more serious outcomes.

This review could significantly impact HM in areas of quality measurement and reporting requirements:

• What quality measurements might not accomplish their intent?
• What measures might result in more harm than good?
• What reporting or process requirements could be changed to make for less duplication?
• If requirements cannot be eliminated, how can they be improved?

Due to hospitalist expertise in quality-improvement (QI) efforts and cost containment, these stated goals and the concerns that come with them are areas where hospitalists are likely to have some good answers. Hospitalists should not hesitate to provide their input to SHM Government Relations staff so that your ideas can be shared with CMS.

A complete list of agency proposals is available at www.whitehouse.gov/21stcentury gov/actions/21st-century-regulatory-system.

The federal government is taking a hard look at many of its regulations, and hospitalists might have the chance to help identify those that no longer make sense.

On Jan. 18, President Obama issued Executive Order 13563, which calls, in part, for a comprehensive retrospective review of existing government regulations. The stated goal of this review is to improve or remove those rules that are out of date, unnecessary, excessively burdensome, or in conflict with other rules.

The Office of Information and Regulatory Affairs (OIRA), the executive-level department charged with overseeing the execution of this order, asked federal agencies to submit preliminary plans for how they will conduct their internal reviews. The agencies responded, and on May 26, the White House released 30 agency preliminary plans to the public, including those prepared by the Department of Commerce, the Department of Energy, and the Department of Health and Human Services (HHS).

When reviewing some of these publicly available preliminary plans, the easy answer for some observers is to say that most rules should be eliminated. Rules requiring the use of such technologies as film X-rays instead of digital images are obvious culprits in the out-of date category; rules defining milk as "oil" (subjecting it to the same costly environmental safeguards as real oil) are just as absurd. Both of these regulations are being lifted as a result of the review.

In contrast, many rules actually do protect public health and safety and will not be subject to review. For example, as a result of federal rulemaking, highway deaths are at the lowest level in 60 years and the risk of contracting salmonella from eggs is relatively low.

As part of HHS, the Center for Medicare & Medicaid Services (CMS) specifically stated that "the goal of the retrospective review will be to identify opportunities to improve patient care and outcomes and reduce system costs by removing obsolete or burdensome requirements." A major CMS concern will be to prevent the elimination or revision of a regulation only to find that the problem it sought to solve resurfaces, or that its removal or revision results in unanticipated and more serious outcomes.

This review could significantly impact HM in areas of quality measurement and reporting requirements:

• What quality measurements might not accomplish their intent?
• What measures might result in more harm than good?
• What reporting or process requirements could be changed to make for less duplication?
• If requirements cannot be eliminated, how can they be improved?

Due to hospitalist expertise in quality-improvement (QI) efforts and cost containment, these stated goals and the concerns that come with them are areas where hospitalists are likely to have some good answers. Hospitalists should not hesitate to provide their input to SHM Government Relations staff so that your ideas can be shared with CMS.

A complete list of agency proposals is available at www.whitehouse.gov/21stcentury gov/actions/21st-century-regulatory-system.

The federal government is taking a hard look at many of its regulations, and hospitalists might have the chance to help identify those that no longer make sense.

On Jan. 18, President Obama issued Executive Order 13563, which calls, in part, for a comprehensive retrospective review of existing government regulations. The stated goal of this review is to improve or remove those rules that are out of date, unnecessary, excessively burdensome, or in conflict with other rules.

The Office of Information and Regulatory Affairs (OIRA), the executive-level department charged with overseeing the execution of this order, asked federal agencies to submit preliminary plans for how they will conduct their internal reviews. The agencies responded, and on May 26, the White House released 30 agency preliminary plans to the public, including those prepared by the Department of Commerce, the Department of Energy, and the Department of Health and Human Services (HHS).

When reviewing some of these publicly available preliminary plans, the easy answer for some observers is to say that most rules should be eliminated. Rules requiring the use of such technologies as film X-rays instead of digital images are obvious culprits in the out-of date category; rules defining milk as "oil" (subjecting it to the same costly environmental safeguards as real oil) are just as absurd. Both of these regulations are being lifted as a result of the review.

In contrast, many rules actually do protect public health and safety and will not be subject to review. For example, as a result of federal rulemaking, highway deaths are at the lowest level in 60 years and the risk of contracting salmonella from eggs is relatively low.

As part of HHS, the Center for Medicare & Medicaid Services (CMS) specifically stated that "the goal of the retrospective review will be to identify opportunities to improve patient care and outcomes and reduce system costs by removing obsolete or burdensome requirements." A major CMS concern will be to prevent the elimination or revision of a regulation only to find that the problem it sought to solve resurfaces, or that its removal or revision results in unanticipated and more serious outcomes.

This review could significantly impact HM in areas of quality measurement and reporting requirements:

• What quality measurements might not accomplish their intent?
• What measures might result in more harm than good?
• What reporting or process requirements could be changed to make for less duplication?
• If requirements cannot be eliminated, how can they be improved?

Due to hospitalist expertise in quality-improvement (QI) efforts and cost containment, these stated goals and the concerns that come with them are areas where hospitalists are likely to have some good answers. Hospitalists should not hesitate to provide their input to SHM Government Relations staff so that your ideas can be shared with CMS.

A complete list of agency proposals is available at www.whitehouse.gov/21stcentury gov/actions/21st-century-regulatory-system.

“ACO” is probably the most common acronym to come out of the Affordable Care Act of 2010 (ACA). Over the last several months, much of the public dialogue has focused on the confusion surrounding the “ACO Proposed Rule.” And now there are three new ACO initiatives, which were announced in May by the Centers for Medicare & Medicaid Services (CMS).

So, what’s the difference? And what does it mean for hospitalists?

The ACA provides multiple pathways to develop and support ACOs, or accountable-care organizations. The proposed rule released in March 2011 was for the Medicare Shared Savings Program (MSSP). Through this program, healthcare providers can join together in ACOs to integrate and coordinate services in return for a share of any savings to the Medicare program. These ACOs will be rewarded for lowering growth in Medicare costs while meeting performance standards on quality of care and putting patients first.

Three other initiatives from the newly created Center for Medicare and Medicaid Innovation give providers a broad range of options and support, and reflect the varying needs of providers in embarking on delivery system reforms. They are:

• Pioneer ACO Model: Provides a faster path for mature ACOs that already have begun coordinating care for patients. This model is estimated to save Medicare as much as $430 million over three years through better managing care for beneficiaries and eliminating duplication. It is designed to move away from the fee-for-service (FFS) payment model more quickly than its MSSP counterpart. In year three of the program, Pioneer ACOs that have shown savings over the first two years will be eligible to move to a population-based payment model. The MSSP version is based completely on FFS.
• Advance Payment ACO Initiative: Would allow certain ACOs participating in the MSSP access to a portion of their shared savings up front, helping providers make the infrastructure and staff investments crucial to successful ACOs.
• Accelerated Development Learning Sessions: These sessions will provide the executive leadership teams from existing or emerging ACO entities the opportunity to learn about essential ACO functions and ways to build capacity needed to achieve better care, better health, and lower costs through integrated care models. Three sessions will be offered in the fall: San Francisco in September, Philadelphia in October, and Atlanta in November. For more info, visit https://acoregister.rti.org.

For more information about ACOs, visit www.healthcare.gov.

How hospitalists will be impacted under the ACO model is largely up to the individual hospitalists. Hospitalists are uniquely positioned to lead the system-level changes and quality-improvement (QI) efforts that will be critical to ACO success, and will bring significant value to the ACO model due to the central role that many hospitalists play in promoting team-based care, care coordination, and improving transitions of care. All of these roles are critical to delivering higher-quality care more efficiently.

CMS has provided detailed information on the above programs via Healthcare.gov. SHM submitted comments on the Medicare Shared Savings Program and the Advance Payment ACO Initiative, which can be found in the Advocacy section of www.hospitalmedicine.org under “SHM Letters.” TH

“ACO” is probably the most common acronym to come out of the Affordable Care Act of 2010 (ACA). Over the last several months, much of the public dialogue has focused on the confusion surrounding the “ACO Proposed Rule.” And now there are three new ACO initiatives, which were announced in May by the Centers for Medicare & Medicaid Services (CMS).

So, what’s the difference? And what does it mean for hospitalists?

The ACA provides multiple pathways to develop and support ACOs, or accountable-care organizations. The proposed rule released in March 2011 was for the Medicare Shared Savings Program (MSSP). Through this program, healthcare providers can join together in ACOs to integrate and coordinate services in return for a share of any savings to the Medicare program. These ACOs will be rewarded for lowering growth in Medicare costs while meeting performance standards on quality of care and putting patients first.

Three other initiatives from the newly created Center for Medicare and Medicaid Innovation give providers a broad range of options and support, and reflect the varying needs of providers in embarking on delivery system reforms. They are:

• Pioneer ACO Model: Provides a faster path for mature ACOs that already have begun coordinating care for patients. This model is estimated to save Medicare as much as $430 million over three years through better managing care for beneficiaries and eliminating duplication. It is designed to move away from the fee-for-service (FFS) payment model more quickly than its MSSP counterpart. In year three of the program, Pioneer ACOs that have shown savings over the first two years will be eligible to move to a population-based payment model. The MSSP version is based completely on FFS.
• Advance Payment ACO Initiative: Would allow certain ACOs participating in the MSSP access to a portion of their shared savings up front, helping providers make the infrastructure and staff investments crucial to successful ACOs.
• Accelerated Development Learning Sessions: These sessions will provide the executive leadership teams from existing or emerging ACO entities the opportunity to learn about essential ACO functions and ways to build capacity needed to achieve better care, better health, and lower costs through integrated care models. Three sessions will be offered in the fall: San Francisco in September, Philadelphia in October, and Atlanta in November. For more info, visit https://acoregister.rti.org.

For more information about ACOs, visit www.healthcare.gov.

How hospitalists will be impacted under the ACO model is largely up to the individual hospitalists. Hospitalists are uniquely positioned to lead the system-level changes and quality-improvement (QI) efforts that will be critical to ACO success, and will bring significant value to the ACO model due to the central role that many hospitalists play in promoting team-based care, care coordination, and improving transitions of care. All of these roles are critical to delivering higher-quality care more efficiently.

CMS has provided detailed information on the above programs via Healthcare.gov. SHM submitted comments on the Medicare Shared Savings Program and the Advance Payment ACO Initiative, which can be found in the Advocacy section of www.hospitalmedicine.org under “SHM Letters.” TH

“ACO” is probably the most common acronym to come out of the Affordable Care Act of 2010 (ACA). Over the last several months, much of the public dialogue has focused on the confusion surrounding the “ACO Proposed Rule.” And now there are three new ACO initiatives, which were announced in May by the Centers for Medicare & Medicaid Services (CMS).

So, what’s the difference? And what does it mean for hospitalists?

The ACA provides multiple pathways to develop and support ACOs, or accountable-care organizations. The proposed rule released in March 2011 was for the Medicare Shared Savings Program (MSSP). Through this program, healthcare providers can join together in ACOs to integrate and coordinate services in return for a share of any savings to the Medicare program. These ACOs will be rewarded for lowering growth in Medicare costs while meeting performance standards on quality of care and putting patients first.

Three other initiatives from the newly created Center for Medicare and Medicaid Innovation give providers a broad range of options and support, and reflect the varying needs of providers in embarking on delivery system reforms. They are:

• Pioneer ACO Model: Provides a faster path for mature ACOs that already have begun coordinating care for patients. This model is estimated to save Medicare as much as $430 million over three years through better managing care for beneficiaries and eliminating duplication. It is designed to move away from the fee-for-service (FFS) payment model more quickly than its MSSP counterpart. In year three of the program, Pioneer ACOs that have shown savings over the first two years will be eligible to move to a population-based payment model. The MSSP version is based completely on FFS.
• Advance Payment ACO Initiative: Would allow certain ACOs participating in the MSSP access to a portion of their shared savings up front, helping providers make the infrastructure and staff investments crucial to successful ACOs.
• Accelerated Development Learning Sessions: These sessions will provide the executive leadership teams from existing or emerging ACO entities the opportunity to learn about essential ACO functions and ways to build capacity needed to achieve better care, better health, and lower costs through integrated care models. Three sessions will be offered in the fall: San Francisco in September, Philadelphia in October, and Atlanta in November. For more info, visit https://acoregister.rti.org.

For more information about ACOs, visit www.healthcare.gov.

How hospitalists will be impacted under the ACO model is largely up to the individual hospitalists. Hospitalists are uniquely positioned to lead the system-level changes and quality-improvement (QI) efforts that will be critical to ACO success, and will bring significant value to the ACO model due to the central role that many hospitalists play in promoting team-based care, care coordination, and improving transitions of care. All of these roles are critical to delivering higher-quality care more efficiently.

CMS has provided detailed information on the above programs via Healthcare.gov. SHM submitted comments on the Medicare Shared Savings Program and the Advance Payment ACO Initiative, which can be found in the Advocacy section of www.hospitalmedicine.org under “SHM Letters.” TH

Dr. Conway

Patrick Conway, MD, MSc, SFHM, a pediatric hospitalist and director of hospital medicine at Cincinnati Children’s Hospital Medical Center, has been appointed chief medical officer of the Centers for Medicare & Medicaid Services (CMS). Dr. Conway’s key responsibilities will be administering federal healthcare quality initiatives and setting the government’s quality agenda in an era of massive changes resulting from the Patient Protection and Accountable Care Act of 2010 (ACA).

Dr. Conway, who previously served as CMO of the Policy Division of the Office of Secretary of Health and Human Services and was a 2007-2008 White House fellow assigned to the Agency for Healthcare Research and Quality (AHRQ), is a leader in safety, quality, and outcomes initiatives at Cincinnati Children’s, and is the immediate past chair of SHM’s Public Policy Committee. He also served on the Federal Coordinating Council for Comparative Effectiveness Research. In his new job, which he started May 9, he is directing CMS’ Office of Clinical Standards and Quality, which coordinates development and implementation of a CMS-wide approach to promoting health quality.

“Patrick Conway’s appointment represents a major milestone for hospitalists and patients alike,” says Larry Wellikson, MD, SFHM, CEO of SHM. “As hospitalists approach the 15th anniversary of the specialty, it is fitting that one of our own takes on the considerable responsibility of caring for millions of Americans through Medicare and Medicaid. Dr. Conway and thousands of other hospitalists have been on the front lines of systematically improving patient care for more than a decade; his sound judgment and compassion as a clinician are now a major national asset.”

Dr. Conway maintains his associate professorship at the University of Cincinnati and will work some weekends seeing patients at Children’s National Medical Center in Washington, D.C. “I love patient care, so I don’t want to stop doing that. Plus, it helps me connect to the front lines of providing medical care,” he says.

“Dr. Conway’s passion for improving healthcare delivery systems, his day-to-day experience as a hospitalist physician, and his accomplishments in quality-improvement research, such as implementing evidence-based healthcare for all children, provide a strong background for his critical role at CMS as chief medical officer,” says Arnold W. Strauss, MD, chair of pediatrics at the University of Cincinnati, where many of the pediatric physicians at Children’s Hospital hold academic appointments. “Dr. Conway and our colleagues at Cincinnati Children’s have demonstrated that improving patient outcomes at lower cost—the goal of healthcare reform—is feasible.”

Dr. Conway’s role at CMS will include major components of surveys, certification, and accreditation issues for hospitals and other Medicare providers; healthcare information technology; and hospital value-based purchasing initiatives (see “Value-Based Purchasing Raises the Stakes,” The Hospitalist, May 2011, p. 1).

But his initial priorities will focus on quality-measures development, illustrated by CMS’ Hospital Compare website (www.hospitalcompare.hhs.gov), and quality improvement. Another major issue involves care transitions and readmissions, “which I try to frame positively—how can we have the most effective care transitions possible?” he says. “SHM and its publications have done a good job of stressing how hospitals and hospitalists can add value.”

Emphasizing his own experience directing an HM department for a health system that admits 7,000 pediatric patients per year, Dr. Conway says other hospitalists can take a similar lead in embracing quality measurement in their hospitals. “I may be working on quality measures for fiscal years 2013 and 2014, but you already know what will be measured in 2012. Don’t wait until September 2012 to get started,” he explains. “Hospitalists can help their institution pose the question: ‘What do we want to get better at in the next year?’ Then you test. Understand your current performance, set a goal, compare benchmarks with other hospitals, and keep working on improvement.”

Over the course of a year, he adds, quality will improve, and then your HM group will have “something to talk about with hospital administrators.”

Married with two children, says his experience at both the macro and micro levels of healthcare will benefit the overall system. “I actually think if we realign incentives, the system can perform better,” he says. “So I see it as an opportunity to perform a public service. But we also need front-line clinicians, including hospitalists, working to improve our healthcare system. … We need frontline providers that are measuring the quality of their care and improving it.” TH

Larry Beresford is a freelance writer based in California.

Dr. Conway

Patrick Conway, MD, MSc, SFHM, a pediatric hospitalist and director of hospital medicine at Cincinnati Children’s Hospital Medical Center, has been appointed chief medical officer of the Centers for Medicare & Medicaid Services (CMS). Dr. Conway’s key responsibilities will be administering federal healthcare quality initiatives and setting the government’s quality agenda in an era of massive changes resulting from the Patient Protection and Accountable Care Act of 2010 (ACA).

Dr. Conway, who previously served as CMO of the Policy Division of the Office of Secretary of Health and Human Services and was a 2007-2008 White House fellow assigned to the Agency for Healthcare Research and Quality (AHRQ), is a leader in safety, quality, and outcomes initiatives at Cincinnati Children’s, and is the immediate past chair of SHM’s Public Policy Committee. He also served on the Federal Coordinating Council for Comparative Effectiveness Research. In his new job, which he started May 9, he is directing CMS’ Office of Clinical Standards and Quality, which coordinates development and implementation of a CMS-wide approach to promoting health quality.

“Patrick Conway’s appointment represents a major milestone for hospitalists and patients alike,” says Larry Wellikson, MD, SFHM, CEO of SHM. “As hospitalists approach the 15th anniversary of the specialty, it is fitting that one of our own takes on the considerable responsibility of caring for millions of Americans through Medicare and Medicaid. Dr. Conway and thousands of other hospitalists have been on the front lines of systematically improving patient care for more than a decade; his sound judgment and compassion as a clinician are now a major national asset.”

Dr. Conway maintains his associate professorship at the University of Cincinnati and will work some weekends seeing patients at Children’s National Medical Center in Washington, D.C. “I love patient care, so I don’t want to stop doing that. Plus, it helps me connect to the front lines of providing medical care,” he says.

“Dr. Conway’s passion for improving healthcare delivery systems, his day-to-day experience as a hospitalist physician, and his accomplishments in quality-improvement research, such as implementing evidence-based healthcare for all children, provide a strong background for his critical role at CMS as chief medical officer,” says Arnold W. Strauss, MD, chair of pediatrics at the University of Cincinnati, where many of the pediatric physicians at Children’s Hospital hold academic appointments. “Dr. Conway and our colleagues at Cincinnati Children’s have demonstrated that improving patient outcomes at lower cost—the goal of healthcare reform—is feasible.”

Dr. Conway’s role at CMS will include major components of surveys, certification, and accreditation issues for hospitals and other Medicare providers; healthcare information technology; and hospital value-based purchasing initiatives (see “Value-Based Purchasing Raises the Stakes,” The Hospitalist, May 2011, p. 1).

But his initial priorities will focus on quality-measures development, illustrated by CMS’ Hospital Compare website (www.hospitalcompare.hhs.gov), and quality improvement. Another major issue involves care transitions and readmissions, “which I try to frame positively—how can we have the most effective care transitions possible?” he says. “SHM and its publications have done a good job of stressing how hospitals and hospitalists can add value.”

Emphasizing his own experience directing an HM department for a health system that admits 7,000 pediatric patients per year, Dr. Conway says other hospitalists can take a similar lead in embracing quality measurement in their hospitals. “I may be working on quality measures for fiscal years 2013 and 2014, but you already know what will be measured in 2012. Don’t wait until September 2012 to get started,” he explains. “Hospitalists can help their institution pose the question: ‘What do we want to get better at in the next year?’ Then you test. Understand your current performance, set a goal, compare benchmarks with other hospitals, and keep working on improvement.”

Over the course of a year, he adds, quality will improve, and then your HM group will have “something to talk about with hospital administrators.”

Married with two children, says his experience at both the macro and micro levels of healthcare will benefit the overall system. “I actually think if we realign incentives, the system can perform better,” he says. “So I see it as an opportunity to perform a public service. But we also need front-line clinicians, including hospitalists, working to improve our healthcare system. … We need frontline providers that are measuring the quality of their care and improving it.” TH

Larry Beresford is a freelance writer based in California.

Dr. Conway

Patrick Conway, MD, MSc, SFHM, a pediatric hospitalist and director of hospital medicine at Cincinnati Children’s Hospital Medical Center, has been appointed chief medical officer of the Centers for Medicare & Medicaid Services (CMS). Dr. Conway’s key responsibilities will be administering federal healthcare quality initiatives and setting the government’s quality agenda in an era of massive changes resulting from the Patient Protection and Accountable Care Act of 2010 (ACA).

Dr. Conway, who previously served as CMO of the Policy Division of the Office of Secretary of Health and Human Services and was a 2007-2008 White House fellow assigned to the Agency for Healthcare Research and Quality (AHRQ), is a leader in safety, quality, and outcomes initiatives at Cincinnati Children’s, and is the immediate past chair of SHM’s Public Policy Committee. He also served on the Federal Coordinating Council for Comparative Effectiveness Research. In his new job, which he started May 9, he is directing CMS’ Office of Clinical Standards and Quality, which coordinates development and implementation of a CMS-wide approach to promoting health quality.

“Patrick Conway’s appointment represents a major milestone for hospitalists and patients alike,” says Larry Wellikson, MD, SFHM, CEO of SHM. “As hospitalists approach the 15th anniversary of the specialty, it is fitting that one of our own takes on the considerable responsibility of caring for millions of Americans through Medicare and Medicaid. Dr. Conway and thousands of other hospitalists have been on the front lines of systematically improving patient care for more than a decade; his sound judgment and compassion as a clinician are now a major national asset.”

Dr. Conway maintains his associate professorship at the University of Cincinnati and will work some weekends seeing patients at Children’s National Medical Center in Washington, D.C. “I love patient care, so I don’t want to stop doing that. Plus, it helps me connect to the front lines of providing medical care,” he says.

“Dr. Conway’s passion for improving healthcare delivery systems, his day-to-day experience as a hospitalist physician, and his accomplishments in quality-improvement research, such as implementing evidence-based healthcare for all children, provide a strong background for his critical role at CMS as chief medical officer,” says Arnold W. Strauss, MD, chair of pediatrics at the University of Cincinnati, where many of the pediatric physicians at Children’s Hospital hold academic appointments. “Dr. Conway and our colleagues at Cincinnati Children’s have demonstrated that improving patient outcomes at lower cost—the goal of healthcare reform—is feasible.”

Dr. Conway’s role at CMS will include major components of surveys, certification, and accreditation issues for hospitals and other Medicare providers; healthcare information technology; and hospital value-based purchasing initiatives (see “Value-Based Purchasing Raises the Stakes,” The Hospitalist, May 2011, p. 1).

But his initial priorities will focus on quality-measures development, illustrated by CMS’ Hospital Compare website (www.hospitalcompare.hhs.gov), and quality improvement. Another major issue involves care transitions and readmissions, “which I try to frame positively—how can we have the most effective care transitions possible?” he says. “SHM and its publications have done a good job of stressing how hospitals and hospitalists can add value.”

Emphasizing his own experience directing an HM department for a health system that admits 7,000 pediatric patients per year, Dr. Conway says other hospitalists can take a similar lead in embracing quality measurement in their hospitals. “I may be working on quality measures for fiscal years 2013 and 2014, but you already know what will be measured in 2012. Don’t wait until September 2012 to get started,” he explains. “Hospitalists can help their institution pose the question: ‘What do we want to get better at in the next year?’ Then you test. Understand your current performance, set a goal, compare benchmarks with other hospitals, and keep working on improvement.”

Over the course of a year, he adds, quality will improve, and then your HM group will have “something to talk about with hospital administrators.”

Married with two children, says his experience at both the macro and micro levels of healthcare will benefit the overall system. “I actually think if we realign incentives, the system can perform better,” he says. “So I see it as an opportunity to perform a public service. But we also need front-line clinicians, including hospitalists, working to improve our healthcare system. … We need frontline providers that are measuring the quality of their care and improving it.” TH

Larry Beresford is a freelance writer based in California.

Doctors and hospitals need each other. Healthcare reform is requiring hospitals to rely more heavily on physicians to help them meet quality, safety, and efficiency goals. But in return, doctors are demanding more financial security and a larger role in hospital leadership.

Just how far are they willing to take their mutual relationship to meet their individual needs? A new report by professional services company PwC (formerly PricewaterhouseCoopers) examines the mindsets of potential partners, including an online survey of more than 1,000 doctors and in-depth interviews with 28 healthcare executives. The results suggest plenty of opportunities for alignment, though perhaps also the need for serious pre-marriage counseling.

“From Courtship to Marriage Part II” (www.PwC.com/us/PhysicianHospitalAlignment) follows an initial report that emphasizes the element of trust that’s necessary for any doctor-hospital alignment to succeed. This time around, the sequel is focusing on more concrete steps needed to take the budding relationship to the next level and sustain it. In particular, the new report focuses on sharing power (governance), sharing resources (compensation), and sharing outcomes (guidelines).

The PwC report preempts the naysayers by acknowledging at the outset that “hospitals and physicians have been to the altar before, but many of those marriages ended in divorce.” So what’s different from the 1990s, that decade of broken marriages doomed by the irreconcilable differences over capitation?

“Number one is that back in the ’90s, there wasn’t a clear consensus in defining and determining what is quality,” says Warren Skea, a director in the PwC Health Enterprise Growth Practice. In the intervening years, he says, membership societies—SHM among them—and nonprofit organizations, such as the National Quality Forum, have helped address the need to define and measure healthcare quality. The Centers for Medicare & Medicaid Services (CMS) followed up by adopting and implementing some of those measures in programs, including hospital value-based purchasing (see “Value-Based Purchasing Raises the Stakes,” May 2011, p. 1).

Another missing component in the ’90s, Skea says, was an adequate set of tools for gauging quality. “Even if we did agree what quality was, we couldn’t go back in there and measure it in a valid way,” he explains. “We just didn’t have that capacity.”

A third lesson learned the hard way is that decision-making should involve all physicians, from primary-care doctors to specialists. That power-sharing will be critical, Skea says, as reimbursement models move away from fee-for-service, transaction-based compensation methods and toward paying for outcomes and quality. Silos of care are out, and transitioning patients across a continuum of care is definitely in.

Sound familiar? It should, and the similarity to the hospitalist job description isn’t lost on Skea. “I think hospitalists have served as a very good illustrative example of how physicians can add value to that efficiency equation, improve quality, increase [good] outcomes—all of those things,” he says. In fact, Skea says, the question now is how the quarterback role assumed by hospitalists can be translated or projected to the larger industry and other settings (e.g. outpatient clinics, home care rehabilitation, and continuing care facilities).

Accountable-care organizations (ACOs) are a hot topic in any discussion of better patient transitions and closer doctor-hospital alignments, but they’re hardly the only wedding chapels in town. The new report sketches out the corresponding amenities of a comanagement model and provider-owned plan, and Skea notes that part of the new Center for Medicare & Medicaid Innovation’s mandate will be to investigate other promising methods for encouraging providers to work together.

Leaders, Partners

For most doctors, according to the survey, working together means making joint decisions. More than 90% said they should be involved in “hospital governance activities such as serving on boards, being in management, and taking part in performance.”

“That didn’t surprise me at all; there’s a huge appetite for physicians to be involved in strategic governance and oversight,” Skea says. “That’s where hospitalists have been really good: taking it to that next level of strategy and leadership.”

Next to compensation, he says, governance is the biggest issue for many hospital-affiliated physicians. One wrinkle, however, is what the report’s authors heard from hospital executives. “There’s a recognition by hospital executives that they need those physicians in those governance roles,” Skea says. But the executives felt that more physicians should be trained and educated in business and financial decision-making.

Some of the training strategies, he says, are homegrown. One hospital client, for example, is providing its physicians with courses in statistical analysis, financial modeling, and change management, and referring to the educational package as “MBA in a box.” Other hospitals are steering their physicians toward outside sources of instruction. SHM’s four-day Leadership Academy (www.hospitalmedicine.org/leadership) offers another resource for hospitalists seeking more prominent roles within their institutions.

Along with a desire for more power-sharing, doctors looking to a hospital setting have clearly indicated that they expect to hold their own financially. According to the survey, 83% of doctors considering hospital employment expect to be paid as much as or more than they are currently earning.

And therein lies another potential sticking point. Based on past experience, doctors might expect that hospitals’ financial resources will still allow them to maximize their compensation. But as health reform plays out, Skea cautions, “everybody is going to have to do more with less.”

Compromise Ahead

But other survey results hint at the potential for compromise. According to the report, physicians agreed that half of their compensation should be a fixed salary, while the remaining half could be based on meeting productivity, quality, patient satisfaction, and cost-of-care goals, with the potential for performance rewards. “This shows that physicians realize the health system is changing to track and reward performance and that they can influence the quality and cost of care delivery at the institutional level,” the report states.

And as for the guidelines doctors follow while delivering healthcare, 62% of those surveyed believe nationally accepted guidelines should guide the way they practice medicine; 30% prefer local guidelines.

Skea says he was a bit surprised that nearly 1 in 3 doctors are still resistant to national guidelines, though he believes that number is on the wane. After an initial pushback, he says, doctors seem to be gravitating toward the national standards, due in part to physician societies taking active roles in the discussions.

So what should hospitalists take away from all of this? Skea says they should continue to highlight and demonstrate the value they provide in standardizing care, measuring quality, and improving efficiencies in the four walls of the hospital. “They’ve had a track record, I think they have the mindset, and they’ve had the relationship with hospital executives,” he says.

Hospitalists likely will be called upon to help educate their physician colleagues in other specialties. Because of their background and history of success, Skea says, “they could be one of the real leaders and catalysts for change within an ACO or some of these other more integrated and aligned delivery models, and then move into governance.”

With a little assistance, perhaps this marriage might work after all. TH

Bryn Nelson is a freelance medical writer based in Seattle.

Doctors and hospitals need each other. Healthcare reform is requiring hospitals to rely more heavily on physicians to help them meet quality, safety, and efficiency goals. But in return, doctors are demanding more financial security and a larger role in hospital leadership.

Just how far are they willing to take their mutual relationship to meet their individual needs? A new report by professional services company PwC (formerly PricewaterhouseCoopers) examines the mindsets of potential partners, including an online survey of more than 1,000 doctors and in-depth interviews with 28 healthcare executives. The results suggest plenty of opportunities for alignment, though perhaps also the need for serious pre-marriage counseling.

“From Courtship to Marriage Part II” (www.PwC.com/us/PhysicianHospitalAlignment) follows an initial report that emphasizes the element of trust that’s necessary for any doctor-hospital alignment to succeed. This time around, the sequel is focusing on more concrete steps needed to take the budding relationship to the next level and sustain it. In particular, the new report focuses on sharing power (governance), sharing resources (compensation), and sharing outcomes (guidelines).

The PwC report preempts the naysayers by acknowledging at the outset that “hospitals and physicians have been to the altar before, but many of those marriages ended in divorce.” So what’s different from the 1990s, that decade of broken marriages doomed by the irreconcilable differences over capitation?

“Number one is that back in the ’90s, there wasn’t a clear consensus in defining and determining what is quality,” says Warren Skea, a director in the PwC Health Enterprise Growth Practice. In the intervening years, he says, membership societies—SHM among them—and nonprofit organizations, such as the National Quality Forum, have helped address the need to define and measure healthcare quality. The Centers for Medicare & Medicaid Services (CMS) followed up by adopting and implementing some of those measures in programs, including hospital value-based purchasing (see “Value-Based Purchasing Raises the Stakes,” May 2011, p. 1).

Another missing component in the ’90s, Skea says, was an adequate set of tools for gauging quality. “Even if we did agree what quality was, we couldn’t go back in there and measure it in a valid way,” he explains. “We just didn’t have that capacity.”

A third lesson learned the hard way is that decision-making should involve all physicians, from primary-care doctors to specialists. That power-sharing will be critical, Skea says, as reimbursement models move away from fee-for-service, transaction-based compensation methods and toward paying for outcomes and quality. Silos of care are out, and transitioning patients across a continuum of care is definitely in.

Sound familiar? It should, and the similarity to the hospitalist job description isn’t lost on Skea. “I think hospitalists have served as a very good illustrative example of how physicians can add value to that efficiency equation, improve quality, increase [good] outcomes—all of those things,” he says. In fact, Skea says, the question now is how the quarterback role assumed by hospitalists can be translated or projected to the larger industry and other settings (e.g. outpatient clinics, home care rehabilitation, and continuing care facilities).

Accountable-care organizations (ACOs) are a hot topic in any discussion of better patient transitions and closer doctor-hospital alignments, but they’re hardly the only wedding chapels in town. The new report sketches out the corresponding amenities of a comanagement model and provider-owned plan, and Skea notes that part of the new Center for Medicare & Medicaid Innovation’s mandate will be to investigate other promising methods for encouraging providers to work together.

Leaders, Partners

For most doctors, according to the survey, working together means making joint decisions. More than 90% said they should be involved in “hospital governance activities such as serving on boards, being in management, and taking part in performance.”

“That didn’t surprise me at all; there’s a huge appetite for physicians to be involved in strategic governance and oversight,” Skea says. “That’s where hospitalists have been really good: taking it to that next level of strategy and leadership.”

Next to compensation, he says, governance is the biggest issue for many hospital-affiliated physicians. One wrinkle, however, is what the report’s authors heard from hospital executives. “There’s a recognition by hospital executives that they need those physicians in those governance roles,” Skea says. But the executives felt that more physicians should be trained and educated in business and financial decision-making.

Some of the training strategies, he says, are homegrown. One hospital client, for example, is providing its physicians with courses in statistical analysis, financial modeling, and change management, and referring to the educational package as “MBA in a box.” Other hospitals are steering their physicians toward outside sources of instruction. SHM’s four-day Leadership Academy (www.hospitalmedicine.org/leadership) offers another resource for hospitalists seeking more prominent roles within their institutions.

Along with a desire for more power-sharing, doctors looking to a hospital setting have clearly indicated that they expect to hold their own financially. According to the survey, 83% of doctors considering hospital employment expect to be paid as much as or more than they are currently earning.

And therein lies another potential sticking point. Based on past experience, doctors might expect that hospitals’ financial resources will still allow them to maximize their compensation. But as health reform plays out, Skea cautions, “everybody is going to have to do more with less.”

Compromise Ahead

But other survey results hint at the potential for compromise. According to the report, physicians agreed that half of their compensation should be a fixed salary, while the remaining half could be based on meeting productivity, quality, patient satisfaction, and cost-of-care goals, with the potential for performance rewards. “This shows that physicians realize the health system is changing to track and reward performance and that they can influence the quality and cost of care delivery at the institutional level,” the report states.

And as for the guidelines doctors follow while delivering healthcare, 62% of those surveyed believe nationally accepted guidelines should guide the way they practice medicine; 30% prefer local guidelines.

Skea says he was a bit surprised that nearly 1 in 3 doctors are still resistant to national guidelines, though he believes that number is on the wane. After an initial pushback, he says, doctors seem to be gravitating toward the national standards, due in part to physician societies taking active roles in the discussions.

So what should hospitalists take away from all of this? Skea says they should continue to highlight and demonstrate the value they provide in standardizing care, measuring quality, and improving efficiencies in the four walls of the hospital. “They’ve had a track record, I think they have the mindset, and they’ve had the relationship with hospital executives,” he says.

Hospitalists likely will be called upon to help educate their physician colleagues in other specialties. Because of their background and history of success, Skea says, “they could be one of the real leaders and catalysts for change within an ACO or some of these other more integrated and aligned delivery models, and then move into governance.”

With a little assistance, perhaps this marriage might work after all. TH

Bryn Nelson is a freelance medical writer based in Seattle.

Doctors and hospitals need each other. Healthcare reform is requiring hospitals to rely more heavily on physicians to help them meet quality, safety, and efficiency goals. But in return, doctors are demanding more financial security and a larger role in hospital leadership.

Just how far are they willing to take their mutual relationship to meet their individual needs? A new report by professional services company PwC (formerly PricewaterhouseCoopers) examines the mindsets of potential partners, including an online survey of more than 1,000 doctors and in-depth interviews with 28 healthcare executives. The results suggest plenty of opportunities for alignment, though perhaps also the need for serious pre-marriage counseling.

“From Courtship to Marriage Part II” (www.PwC.com/us/PhysicianHospitalAlignment) follows an initial report that emphasizes the element of trust that’s necessary for any doctor-hospital alignment to succeed. This time around, the sequel is focusing on more concrete steps needed to take the budding relationship to the next level and sustain it. In particular, the new report focuses on sharing power (governance), sharing resources (compensation), and sharing outcomes (guidelines).

The PwC report preempts the naysayers by acknowledging at the outset that “hospitals and physicians have been to the altar before, but many of those marriages ended in divorce.” So what’s different from the 1990s, that decade of broken marriages doomed by the irreconcilable differences over capitation?

“Number one is that back in the ’90s, there wasn’t a clear consensus in defining and determining what is quality,” says Warren Skea, a director in the PwC Health Enterprise Growth Practice. In the intervening years, he says, membership societies—SHM among them—and nonprofit organizations, such as the National Quality Forum, have helped address the need to define and measure healthcare quality. The Centers for Medicare & Medicaid Services (CMS) followed up by adopting and implementing some of those measures in programs, including hospital value-based purchasing (see “Value-Based Purchasing Raises the Stakes,” May 2011, p. 1).

Another missing component in the ’90s, Skea says, was an adequate set of tools for gauging quality. “Even if we did agree what quality was, we couldn’t go back in there and measure it in a valid way,” he explains. “We just didn’t have that capacity.”

A third lesson learned the hard way is that decision-making should involve all physicians, from primary-care doctors to specialists. That power-sharing will be critical, Skea says, as reimbursement models move away from fee-for-service, transaction-based compensation methods and toward paying for outcomes and quality. Silos of care are out, and transitioning patients across a continuum of care is definitely in.

Sound familiar? It should, and the similarity to the hospitalist job description isn’t lost on Skea. “I think hospitalists have served as a very good illustrative example of how physicians can add value to that efficiency equation, improve quality, increase [good] outcomes—all of those things,” he says. In fact, Skea says, the question now is how the quarterback role assumed by hospitalists can be translated or projected to the larger industry and other settings (e.g. outpatient clinics, home care rehabilitation, and continuing care facilities).

Accountable-care organizations (ACOs) are a hot topic in any discussion of better patient transitions and closer doctor-hospital alignments, but they’re hardly the only wedding chapels in town. The new report sketches out the corresponding amenities of a comanagement model and provider-owned plan, and Skea notes that part of the new Center for Medicare & Medicaid Innovation’s mandate will be to investigate other promising methods for encouraging providers to work together.

Leaders, Partners

For most doctors, according to the survey, working together means making joint decisions. More than 90% said they should be involved in “hospital governance activities such as serving on boards, being in management, and taking part in performance.”

“That didn’t surprise me at all; there’s a huge appetite for physicians to be involved in strategic governance and oversight,” Skea says. “That’s where hospitalists have been really good: taking it to that next level of strategy and leadership.”

Next to compensation, he says, governance is the biggest issue for many hospital-affiliated physicians. One wrinkle, however, is what the report’s authors heard from hospital executives. “There’s a recognition by hospital executives that they need those physicians in those governance roles,” Skea says. But the executives felt that more physicians should be trained and educated in business and financial decision-making.

Some of the training strategies, he says, are homegrown. One hospital client, for example, is providing its physicians with courses in statistical analysis, financial modeling, and change management, and referring to the educational package as “MBA in a box.” Other hospitals are steering their physicians toward outside sources of instruction. SHM’s four-day Leadership Academy (www.hospitalmedicine.org/leadership) offers another resource for hospitalists seeking more prominent roles within their institutions.

Along with a desire for more power-sharing, doctors looking to a hospital setting have clearly indicated that they expect to hold their own financially. According to the survey, 83% of doctors considering hospital employment expect to be paid as much as or more than they are currently earning.

And therein lies another potential sticking point. Based on past experience, doctors might expect that hospitals’ financial resources will still allow them to maximize their compensation. But as health reform plays out, Skea cautions, “everybody is going to have to do more with less.”

Compromise Ahead

But other survey results hint at the potential for compromise. According to the report, physicians agreed that half of their compensation should be a fixed salary, while the remaining half could be based on meeting productivity, quality, patient satisfaction, and cost-of-care goals, with the potential for performance rewards. “This shows that physicians realize the health system is changing to track and reward performance and that they can influence the quality and cost of care delivery at the institutional level,” the report states.

And as for the guidelines doctors follow while delivering healthcare, 62% of those surveyed believe nationally accepted guidelines should guide the way they practice medicine; 30% prefer local guidelines.

Skea says he was a bit surprised that nearly 1 in 3 doctors are still resistant to national guidelines, though he believes that number is on the wane. After an initial pushback, he says, doctors seem to be gravitating toward the national standards, due in part to physician societies taking active roles in the discussions.

So what should hospitalists take away from all of this? Skea says they should continue to highlight and demonstrate the value they provide in standardizing care, measuring quality, and improving efficiencies in the four walls of the hospital. “They’ve had a track record, I think they have the mindset, and they’ve had the relationship with hospital executives,” he says.

Hospitalists likely will be called upon to help educate their physician colleagues in other specialties. Because of their background and history of success, Skea says, “they could be one of the real leaders and catalysts for change within an ACO or some of these other more integrated and aligned delivery models, and then move into governance.”

With a little assistance, perhaps this marriage might work after all. TH

Bryn Nelson is a freelance medical writer based in Seattle.

On April 12, U.S. Department of Health and Human Services (HHS) Secretary Kathleen Sebelius joined the Centers for Medicare & Medicaid Services (CMS) administrator Donald Berwick, MD, in announcing a major patient-safety initiative bringing together hospitals, clinicians, consumers, employers, federal and state governments, and many more groups around two common goals: reducing harm caused to patients in hospitals and reducing hospital readmissions.

SHM was one of the first physician groups to sign on to the Pledge of Support, which aims to reduce hospital-acquired conditions by 40% and decrease preventable readmissions within 30 days of discharge by 20%, both by the end of 2013.

The pledge includes specific expectations for each of the different healthcare entities signing on. By signing, SHM agrees on behalf of hospitalists that they will work together to redesign activities within the hospital to reduce harm, learn from experiences and share best practices, and engage with patients and families to implement practices that foster more patient-centered care that improves safety, communication, and care coordination.

HHS is committing a total of $1 billion from the Patient Protection and Affordable Care Act of 2010 (ACA) to support hospitals and other providers in their efforts to reach these goals. Of the funding, $500 million will come through the Community-Based Care Transitions Program (CCTP) created in the ACA to help community-based organizations partnering with eligible hospitals to improve transitions between settings of care. The other $500 million will come from the Centers for Medicare and Medicaid Innovation (CMMI) to test different models of improving patient care, patient engagement, and collaboration in order to reduce hospital-acquired conditions and improve care transitions nationwide.

The partnership takes the best ideas from the public and private sectors and accelerates their spread to achieve a safer, higher-quality healthcare system for all Americans. It aligns Dr. Berwick’s triple aim (improve care, improve people’s health, and reduce the overall cost of healthcare) with SHM’s efforts to improve quality and patient safety through innovation and collaboration.

SHM’s Project BOOST (www.hospitalmedicine.org/boost) is listed in the solicitation for applications for the CCTP, and SHM’s VTE resource room is among the resources posted on the partnership website.

For more information on the initiative, visit www.healthcare.gov. TH

On April 12, U.S. Department of Health and Human Services (HHS) Secretary Kathleen Sebelius joined the Centers for Medicare & Medicaid Services (CMS) administrator Donald Berwick, MD, in announcing a major patient-safety initiative bringing together hospitals, clinicians, consumers, employers, federal and state governments, and many more groups around two common goals: reducing harm caused to patients in hospitals and reducing hospital readmissions.

SHM was one of the first physician groups to sign on to the Pledge of Support, which aims to reduce hospital-acquired conditions by 40% and decrease preventable readmissions within 30 days of discharge by 20%, both by the end of 2013.

The pledge includes specific expectations for each of the different healthcare entities signing on. By signing, SHM agrees on behalf of hospitalists that they will work together to redesign activities within the hospital to reduce harm, learn from experiences and share best practices, and engage with patients and families to implement practices that foster more patient-centered care that improves safety, communication, and care coordination.

HHS is committing a total of $1 billion from the Patient Protection and Affordable Care Act of 2010 (ACA) to support hospitals and other providers in their efforts to reach these goals. Of the funding, $500 million will come through the Community-Based Care Transitions Program (CCTP) created in the ACA to help community-based organizations partnering with eligible hospitals to improve transitions between settings of care. The other $500 million will come from the Centers for Medicare and Medicaid Innovation (CMMI) to test different models of improving patient care, patient engagement, and collaboration in order to reduce hospital-acquired conditions and improve care transitions nationwide.

The partnership takes the best ideas from the public and private sectors and accelerates their spread to achieve a safer, higher-quality healthcare system for all Americans. It aligns Dr. Berwick’s triple aim (improve care, improve people’s health, and reduce the overall cost of healthcare) with SHM’s efforts to improve quality and patient safety through innovation and collaboration.

SHM’s Project BOOST (www.hospitalmedicine.org/boost) is listed in the solicitation for applications for the CCTP, and SHM’s VTE resource room is among the resources posted on the partnership website.

For more information on the initiative, visit www.healthcare.gov. TH

On April 12, U.S. Department of Health and Human Services (HHS) Secretary Kathleen Sebelius joined the Centers for Medicare & Medicaid Services (CMS) administrator Donald Berwick, MD, in announcing a major patient-safety initiative bringing together hospitals, clinicians, consumers, employers, federal and state governments, and many more groups around two common goals: reducing harm caused to patients in hospitals and reducing hospital readmissions.

SHM was one of the first physician groups to sign on to the Pledge of Support, which aims to reduce hospital-acquired conditions by 40% and decrease preventable readmissions within 30 days of discharge by 20%, both by the end of 2013.

The pledge includes specific expectations for each of the different healthcare entities signing on. By signing, SHM agrees on behalf of hospitalists that they will work together to redesign activities within the hospital to reduce harm, learn from experiences and share best practices, and engage with patients and families to implement practices that foster more patient-centered care that improves safety, communication, and care coordination.

HHS is committing a total of $1 billion from the Patient Protection and Affordable Care Act of 2010 (ACA) to support hospitals and other providers in their efforts to reach these goals. Of the funding, $500 million will come through the Community-Based Care Transitions Program (CCTP) created in the ACA to help community-based organizations partnering with eligible hospitals to improve transitions between settings of care. The other $500 million will come from the Centers for Medicare and Medicaid Innovation (CMMI) to test different models of improving patient care, patient engagement, and collaboration in order to reduce hospital-acquired conditions and improve care transitions nationwide.

The partnership takes the best ideas from the public and private sectors and accelerates their spread to achieve a safer, higher-quality healthcare system for all Americans. It aligns Dr. Berwick’s triple aim (improve care, improve people’s health, and reduce the overall cost of healthcare) with SHM’s efforts to improve quality and patient safety through innovation and collaboration.

SHM’s Project BOOST (www.hospitalmedicine.org/boost) is listed in the solicitation for applications for the CCTP, and SHM’s VTE resource room is among the resources posted on the partnership website.

For more information on the initiative, visit www.healthcare.gov. TH

As of April 1, physicians who order home care services for their Medicare patients are required to document that they had a face-to-face encounter with the patient prior to certifying the patient’s eligibility for home care services. The face-to-face encounter is a mandated provision of the Affordable Care Act (ACA) of 2010, which is intended to reduce fraud and abuse among home health providers.

Despite this goal, the new documentation requirement poses the threat of a significant paperwork burden on practitioners, including hospitalists.

Many providers have remained unaware of this new requirement, but those who are aware have been experiencing confusion as to what, if any, additional paperwork is required of physicians. SHM, along with the American Medical Association (AMA) and other physician groups, have requested clarification from the Centers for Medicare & Medicaid Services (CMS) regarding the documentation requirement. SHM also is advocating that CMS keep the additional paperwork burden to a minimum.

CMS denied a request to extend the implementation deadline to allow for more provider education. Despite denying the extension, CMS has committed to continue monitoring for problems and unintended consequences caused by the new requirement.

CMS also has clarified the face-to-face documentation requirements: “Physicians may attach existing documentation as long as it includes necessary information and evidences the need for home health services.”

An example would be for a physician to attach the patient’s discharge summary or relevant portion of the patient’s medical record that evidences the need for home health services. Instead of creating an entirely new document or filling out an additional form to evidence the face-to-face encounter, physicians will have some flexibility in determining the existing documentation they will use. This is an option that hopefully will reduce some of the burden.

CMS could produce further guidelines in the future. SHM intends to continue following the issue and advocating on behalf of hospitalists. For the most up-to-date information, visit http://questions.cms.hhs.gov and enter the search term “home health face-to-face.” TH

As of April 1, physicians who order home care services for their Medicare patients are required to document that they had a face-to-face encounter with the patient prior to certifying the patient’s eligibility for home care services. The face-to-face encounter is a mandated provision of the Affordable Care Act (ACA) of 2010, which is intended to reduce fraud and abuse among home health providers.

Despite this goal, the new documentation requirement poses the threat of a significant paperwork burden on practitioners, including hospitalists.

Many providers have remained unaware of this new requirement, but those who are aware have been experiencing confusion as to what, if any, additional paperwork is required of physicians. SHM, along with the American Medical Association (AMA) and other physician groups, have requested clarification from the Centers for Medicare & Medicaid Services (CMS) regarding the documentation requirement. SHM also is advocating that CMS keep the additional paperwork burden to a minimum.

CMS denied a request to extend the implementation deadline to allow for more provider education. Despite denying the extension, CMS has committed to continue monitoring for problems and unintended consequences caused by the new requirement.

CMS also has clarified the face-to-face documentation requirements: “Physicians may attach existing documentation as long as it includes necessary information and evidences the need for home health services.”

An example would be for a physician to attach the patient’s discharge summary or relevant portion of the patient’s medical record that evidences the need for home health services. Instead of creating an entirely new document or filling out an additional form to evidence the face-to-face encounter, physicians will have some flexibility in determining the existing documentation they will use. This is an option that hopefully will reduce some of the burden.

CMS could produce further guidelines in the future. SHM intends to continue following the issue and advocating on behalf of hospitalists. For the most up-to-date information, visit http://questions.cms.hhs.gov and enter the search term “home health face-to-face.” TH

As of April 1, physicians who order home care services for their Medicare patients are required to document that they had a face-to-face encounter with the patient prior to certifying the patient’s eligibility for home care services. The face-to-face encounter is a mandated provision of the Affordable Care Act (ACA) of 2010, which is intended to reduce fraud and abuse among home health providers.

Despite this goal, the new documentation requirement poses the threat of a significant paperwork burden on practitioners, including hospitalists.

Many providers have remained unaware of this new requirement, but those who are aware have been experiencing confusion as to what, if any, additional paperwork is required of physicians. SHM, along with the American Medical Association (AMA) and other physician groups, have requested clarification from the Centers for Medicare & Medicaid Services (CMS) regarding the documentation requirement. SHM also is advocating that CMS keep the additional paperwork burden to a minimum.

CMS denied a request to extend the implementation deadline to allow for more provider education. Despite denying the extension, CMS has committed to continue monitoring for problems and unintended consequences caused by the new requirement.

CMS also has clarified the face-to-face documentation requirements: “Physicians may attach existing documentation as long as it includes necessary information and evidences the need for home health services.”

An example would be for a physician to attach the patient’s discharge summary or relevant portion of the patient’s medical record that evidences the need for home health services. Instead of creating an entirely new document or filling out an additional form to evidence the face-to-face encounter, physicians will have some flexibility in determining the existing documentation they will use. This is an option that hopefully will reduce some of the burden.

CMS could produce further guidelines in the future. SHM intends to continue following the issue and advocating on behalf of hospitalists. For the most up-to-date information, visit http://questions.cms.hhs.gov and enter the search term “home health face-to-face.” TH

If the road to hell is paved with good intentions, then hell is full of unintended consequences.

The debate about whether hospitals’ reimbursements should be based on quality performance is not a unique concept. Similar systems have been implemented in other fields (e.g. education), and we in the medical field can learn from their experiences. In education, testing students is the driving force in measuring a “quality outcome.”

A growing number of educators now believe that the focus on testing to measure quality has actually reduced the quality of education; they cite the bureaucratic, inflexible, and cumbersome requirements placed on the educators, and the diversion of precious resources to focus on standardized test scores. The actual education of the students becomes secondary, and there are allegations of school systems manipulating their data to ensure maximum funding.

With the drive to pay-for-performance in the medical field, will the actual medical care of the patient become secondary to hitting the “quality” metrics set by the government? Add in a volatile mix of money, and this becomes a recipe for disaster.

Questions are many:

• What standards of quality are we going to use?
• Do these metrics truly translate into “quality”?
• Will the goal of reaching these metrics become the main focus of the hospitals instead of actual patient care?
• Is the goal to really improve the quality of healthcare, or is it just another vehicle for government and private third parties to come up with another excuse to reduce reimbursement in the name of quality?

Even now, ED physicians are giving antibiotics liberally for fear that they will be admonished for “missing” the pneumonia core measures. Whether this is appropriate care for the patient is irrelevant to hitting the statistical goal. Where is the incentive to deliver appropriate care? Are we even asking the right questions? Do bureaucrats know that even if appropriate, timely, quality care is given that a positive outcome is not guaranteed?

The field of medicine has made incredible advances in patient care, but the fact remains that a certain percentage of the sick and elderly become sicker and eventually die, especially in hospitals.

Potential Problems are Many

Unintended consequences pose a real danger to a system that rewards and penalizes. One potential issue is the “rich getting richer and the poor getting poorer,” as more provider focus is placed on buffering statistics by keeping healthy people healthier to achieve better outcomes, meanwhile shunning or diverting the seriously sick patients in order to keep quality metrics within goal.

How will the government and insurance providers guarantee the accuracy of each hospital’s statistics?

Think of the money and resources that will be diverted away from the clinical arena and into the bureaucratic nightmare of record-keeping needed to implement this pay-for-performance system. How many billions of dollars will be needed to fund this new bureaucracy? Do we need another bureaucratic, punitive layer in our already cumbersome medical system?

My answer is clear: No! TH

Dr. Yu is medical director of adult hospitalist services at Presbyterian Medical Group in Albuquerque, N.M., and a Team Hospitalist member.

If the road to hell is paved with good intentions, then hell is full of unintended consequences.

The debate about whether hospitals’ reimbursements should be based on quality performance is not a unique concept. Similar systems have been implemented in other fields (e.g. education), and we in the medical field can learn from their experiences. In education, testing students is the driving force in measuring a “quality outcome.”

A growing number of educators now believe that the focus on testing to measure quality has actually reduced the quality of education; they cite the bureaucratic, inflexible, and cumbersome requirements placed on the educators, and the diversion of precious resources to focus on standardized test scores. The actual education of the students becomes secondary, and there are allegations of school systems manipulating their data to ensure maximum funding.

With the drive to pay-for-performance in the medical field, will the actual medical care of the patient become secondary to hitting the “quality” metrics set by the government? Add in a volatile mix of money, and this becomes a recipe for disaster.

Questions are many:

• What standards of quality are we going to use?
• Do these metrics truly translate into “quality”?
• Will the goal of reaching these metrics become the main focus of the hospitals instead of actual patient care?
• Is the goal to really improve the quality of healthcare, or is it just another vehicle for government and private third parties to come up with another excuse to reduce reimbursement in the name of quality?

Even now, ED physicians are giving antibiotics liberally for fear that they will be admonished for “missing” the pneumonia core measures. Whether this is appropriate care for the patient is irrelevant to hitting the statistical goal. Where is the incentive to deliver appropriate care? Are we even asking the right questions? Do bureaucrats know that even if appropriate, timely, quality care is given that a positive outcome is not guaranteed?

The field of medicine has made incredible advances in patient care, but the fact remains that a certain percentage of the sick and elderly become sicker and eventually die, especially in hospitals.

Potential Problems are Many

Unintended consequences pose a real danger to a system that rewards and penalizes. One potential issue is the “rich getting richer and the poor getting poorer,” as more provider focus is placed on buffering statistics by keeping healthy people healthier to achieve better outcomes, meanwhile shunning or diverting the seriously sick patients in order to keep quality metrics within goal.

How will the government and insurance providers guarantee the accuracy of each hospital’s statistics?

Think of the money and resources that will be diverted away from the clinical arena and into the bureaucratic nightmare of record-keeping needed to implement this pay-for-performance system. How many billions of dollars will be needed to fund this new bureaucracy? Do we need another bureaucratic, punitive layer in our already cumbersome medical system?

My answer is clear: No! TH

Dr. Yu is medical director of adult hospitalist services at Presbyterian Medical Group in Albuquerque, N.M., and a Team Hospitalist member.

If the road to hell is paved with good intentions, then hell is full of unintended consequences.

The debate about whether hospitals’ reimbursements should be based on quality performance is not a unique concept. Similar systems have been implemented in other fields (e.g. education), and we in the medical field can learn from their experiences. In education, testing students is the driving force in measuring a “quality outcome.”

A growing number of educators now believe that the focus on testing to measure quality has actually reduced the quality of education; they cite the bureaucratic, inflexible, and cumbersome requirements placed on the educators, and the diversion of precious resources to focus on standardized test scores. The actual education of the students becomes secondary, and there are allegations of school systems manipulating their data to ensure maximum funding.

With the drive to pay-for-performance in the medical field, will the actual medical care of the patient become secondary to hitting the “quality” metrics set by the government? Add in a volatile mix of money, and this becomes a recipe for disaster.

Questions are many:

• What standards of quality are we going to use?
• Do these metrics truly translate into “quality”?
• Will the goal of reaching these metrics become the main focus of the hospitals instead of actual patient care?
• Is the goal to really improve the quality of healthcare, or is it just another vehicle for government and private third parties to come up with another excuse to reduce reimbursement in the name of quality?

Even now, ED physicians are giving antibiotics liberally for fear that they will be admonished for “missing” the pneumonia core measures. Whether this is appropriate care for the patient is irrelevant to hitting the statistical goal. Where is the incentive to deliver appropriate care? Are we even asking the right questions? Do bureaucrats know that even if appropriate, timely, quality care is given that a positive outcome is not guaranteed?

The field of medicine has made incredible advances in patient care, but the fact remains that a certain percentage of the sick and elderly become sicker and eventually die, especially in hospitals.

Potential Problems are Many

Unintended consequences pose a real danger to a system that rewards and penalizes. One potential issue is the “rich getting richer and the poor getting poorer,” as more provider focus is placed on buffering statistics by keeping healthy people healthier to achieve better outcomes, meanwhile shunning or diverting the seriously sick patients in order to keep quality metrics within goal.

How will the government and insurance providers guarantee the accuracy of each hospital’s statistics?

Think of the money and resources that will be diverted away from the clinical arena and into the bureaucratic nightmare of record-keeping needed to implement this pay-for-performance system. How many billions of dollars will be needed to fund this new bureaucracy? Do we need another bureaucratic, punitive layer in our already cumbersome medical system?

My answer is clear: No! TH

Dr. Yu is medical director of adult hospitalist services at Presbyterian Medical Group in Albuquerque, N.M., and a Team Hospitalist member.

Ask a hospitalist “Is quality important?” and most will answer “Yes.” Now ask the hospital’s CEO/CFO that same question, and you’ll get a resounding “Yes.”

Quality, as the primary determinant of value, has become priority No. 1 for hospitals.¹ And with the Centers for Medicare & Medicaid Services’ (CMS) proposed rules for value-based purchasing (VBP), starting with a 1% withholding of Medicare reimbursement for demonstration of quality-measure performance, big dollars are at risk for hospitals.²

As the key providers of inpatient care, hospitalists will share in this financial accountability. The next-generation HM program must show value not only through efficiency and cost reduction, but also expanded services and quality.

Quality is a means of defining good care. Historically, the medical profession has escaped external accountability for quality as part of practitioner autonomy. Today, more than ever, consumer groups, payors, and regulatory bodies are demanding demonstration of quality outcomes, which impacts reimbursement and market share.

Is this demand for quality performance negative? Misused, it can be a mechanism for cost control through seemingly arbitrary indicators. Considered more broadly, it can be positive: We will be able to evaluate our practices to improve care.

Either way, the quality ship has sailed. Accepting this change, we see that the direction and execution are largely left open-ended, which brings another positive: HM has an opportunity to charter the course.

Hospitalists are inpatient care experts; we understand and improve health systems to provide excellent care. Above all else, quality is what we stand for. As a field, we are at the leading edge of change. Getting ahead of quality at each of our institutions is a great opportunity, and helping hospitals implement and deliver on quality initiatives is job security. Being held to what we value, hospitalists should be incentivized by quality performance.

Quality and Compensation

Why tie compensation to quality outcomes? First, hospitals are financially accountable for performance, and HM is financially accountable to hospitals. Second, we incent important objectives, in addition to other mechanisms (e.g. transparent reporting), to drive performance.

The majority of HM programs have an incentive component to their compensation structure, and quality is the leading performance incentive (hospitalists in these programs also have higher incomes).³ We can expect to see HM compensation structures evolve toward pay-for-performance or gainsharing models. HM groups should turn their focus to using incentives or bonuses. Here are some tips:

1. Lead quality initiatives. Participate in hospital-based patient safety and satisfaction projects. Communicate the importance to your group to achieve buy-in.
2. Define mutual goals. Choose two or three measurable areas that are the top priority items for the hospital and your group, and put them on your scorecard. Consider measuring team performance.
3. Make it count. Make the amount of financial incentive a portion of compensation that is meaningful. Share data—and the effect on compensation—regularly to drive performance.

Quality is ours to lead. Define and deliver it, and you’ll find your group to be indispensable to the hospital, with dollars to gain—for all the right reasons. TH

Dr. Wright is senior medical officer at Hospitalists Management Company in Wisconsin and a Team Hospitalist member.

References

1. Wachter RM, Goldman L. The hospitalist movement 5 years later. JAMA. 2002;287:487-494.
2. Centers for Medicare & Medicaid Services. Medicare program: hospital patient value-based purchasing program. Federal Register. 2011;76(9).
3. State of Hospital Medicine: 2010 Report Based on 2009 Data. SHM website. Available at: www.hospitalmedicine.org/survey. Accessed April 2, 2011.

Ask a hospitalist “Is quality important?” and most will answer “Yes.” Now ask the hospital’s CEO/CFO that same question, and you’ll get a resounding “Yes.”

Quality, as the primary determinant of value, has become priority No. 1 for hospitals.¹ And with the Centers for Medicare & Medicaid Services’ (CMS) proposed rules for value-based purchasing (VBP), starting with a 1% withholding of Medicare reimbursement for demonstration of quality-measure performance, big dollars are at risk for hospitals.²

As the key providers of inpatient care, hospitalists will share in this financial accountability. The next-generation HM program must show value not only through efficiency and cost reduction, but also expanded services and quality.

Quality is a means of defining good care. Historically, the medical profession has escaped external accountability for quality as part of practitioner autonomy. Today, more than ever, consumer groups, payors, and regulatory bodies are demanding demonstration of quality outcomes, which impacts reimbursement and market share.

Is this demand for quality performance negative? Misused, it can be a mechanism for cost control through seemingly arbitrary indicators. Considered more broadly, it can be positive: We will be able to evaluate our practices to improve care.

Either way, the quality ship has sailed. Accepting this change, we see that the direction and execution are largely left open-ended, which brings another positive: HM has an opportunity to charter the course.

Hospitalists are inpatient care experts; we understand and improve health systems to provide excellent care. Above all else, quality is what we stand for. As a field, we are at the leading edge of change. Getting ahead of quality at each of our institutions is a great opportunity, and helping hospitals implement and deliver on quality initiatives is job security. Being held to what we value, hospitalists should be incentivized by quality performance.

Quality and Compensation

Why tie compensation to quality outcomes? First, hospitals are financially accountable for performance, and HM is financially accountable to hospitals. Second, we incent important objectives, in addition to other mechanisms (e.g. transparent reporting), to drive performance.

The majority of HM programs have an incentive component to their compensation structure, and quality is the leading performance incentive (hospitalists in these programs also have higher incomes).³ We can expect to see HM compensation structures evolve toward pay-for-performance or gainsharing models. HM groups should turn their focus to using incentives or bonuses. Here are some tips:

1. Lead quality initiatives. Participate in hospital-based patient safety and satisfaction projects. Communicate the importance to your group to achieve buy-in.
2. Define mutual goals. Choose two or three measurable areas that are the top priority items for the hospital and your group, and put them on your scorecard. Consider measuring team performance.
3. Make it count. Make the amount of financial incentive a portion of compensation that is meaningful. Share data—and the effect on compensation—regularly to drive performance.

Quality is ours to lead. Define and deliver it, and you’ll find your group to be indispensable to the hospital, with dollars to gain—for all the right reasons. TH

Dr. Wright is senior medical officer at Hospitalists Management Company in Wisconsin and a Team Hospitalist member.

References

1. Wachter RM, Goldman L. The hospitalist movement 5 years later. JAMA. 2002;287:487-494.
2. Centers for Medicare & Medicaid Services. Medicare program: hospital patient value-based purchasing program. Federal Register. 2011;76(9).
3. State of Hospital Medicine: 2010 Report Based on 2009 Data. SHM website. Available at: www.hospitalmedicine.org/survey. Accessed April 2, 2011.

Ask a hospitalist “Is quality important?” and most will answer “Yes.” Now ask the hospital’s CEO/CFO that same question, and you’ll get a resounding “Yes.”

Quality, as the primary determinant of value, has become priority No. 1 for hospitals.¹ And with the Centers for Medicare & Medicaid Services’ (CMS) proposed rules for value-based purchasing (VBP), starting with a 1% withholding of Medicare reimbursement for demonstration of quality-measure performance, big dollars are at risk for hospitals.²

As the key providers of inpatient care, hospitalists will share in this financial accountability. The next-generation HM program must show value not only through efficiency and cost reduction, but also expanded services and quality.

Quality is a means of defining good care. Historically, the medical profession has escaped external accountability for quality as part of practitioner autonomy. Today, more than ever, consumer groups, payors, and regulatory bodies are demanding demonstration of quality outcomes, which impacts reimbursement and market share.

Is this demand for quality performance negative? Misused, it can be a mechanism for cost control through seemingly arbitrary indicators. Considered more broadly, it can be positive: We will be able to evaluate our practices to improve care.

Either way, the quality ship has sailed. Accepting this change, we see that the direction and execution are largely left open-ended, which brings another positive: HM has an opportunity to charter the course.

Hospitalists are inpatient care experts; we understand and improve health systems to provide excellent care. Above all else, quality is what we stand for. As a field, we are at the leading edge of change. Getting ahead of quality at each of our institutions is a great opportunity, and helping hospitals implement and deliver on quality initiatives is job security. Being held to what we value, hospitalists should be incentivized by quality performance.

Quality and Compensation

Why tie compensation to quality outcomes? First, hospitals are financially accountable for performance, and HM is financially accountable to hospitals. Second, we incent important objectives, in addition to other mechanisms (e.g. transparent reporting), to drive performance.

The majority of HM programs have an incentive component to their compensation structure, and quality is the leading performance incentive (hospitalists in these programs also have higher incomes).³ We can expect to see HM compensation structures evolve toward pay-for-performance or gainsharing models. HM groups should turn their focus to using incentives or bonuses. Here are some tips:

1. Lead quality initiatives. Participate in hospital-based patient safety and satisfaction projects. Communicate the importance to your group to achieve buy-in.
2. Define mutual goals. Choose two or three measurable areas that are the top priority items for the hospital and your group, and put them on your scorecard. Consider measuring team performance.
3. Make it count. Make the amount of financial incentive a portion of compensation that is meaningful. Share data—and the effect on compensation—regularly to drive performance.

Quality is ours to lead. Define and deliver it, and you’ll find your group to be indispensable to the hospital, with dollars to gain—for all the right reasons. TH

Dr. Wright is senior medical officer at Hospitalists Management Company in Wisconsin and a Team Hospitalist member.

References

1. Wachter RM, Goldman L. The hospitalist movement 5 years later. JAMA. 2002;287:487-494.
2. Centers for Medicare & Medicaid Services. Medicare program: hospital patient value-based purchasing program. Federal Register. 2011;76(9).
3. State of Hospital Medicine: 2010 Report Based on 2009 Data. SHM website. Available at: www.hospitalmedicine.org/survey. Accessed April 2, 2011.