Public Policy

With the growth of HM has come a major change in the way healthcare is delivered in hospitals across the country: Hospitalists have become one of the major providers of care for hospitalized medical patients. Recent reports suggest that hospitalists care for more than 50% of Medicare patients admitted with a medical diagnosis. In addition to that staggering figure, hospitalists increasingly have assumed care for many surgical patients, have staffed observation units, created procedure services, assumed care of many subspecialty services, and have taken the lead on hospital-based IT and quality-improvement (QI) endeavors, among other key services.

It is hard to argue against the assertion that HM’s emergence over the past decade and a half is one of the most significant game-changers in all of healthcare. Despite this important impact on the structure of care delivery, HM to date has fallen short of the contributions made by many other disciplines over the years in one key area: the generation of new knowledge through research.

New Specialties’ Research Focus

Think for a minute of the contributions of the next two youngest specialties—critical-care medicine and emergency medicine. Both fields have transformed care delivery, as did HM, but in contrast, both critical-care and emergency medicine have well-established investigators and an impressive research agenda. They have had a major impact on the care of patients everywhere.

For example, the critical-care community developed new treatment paradigms for sepsis that grew out of basic science work exploring the roles of cytokines and the inflammatory cascade in infection. Its clinical-research networks have developed and tested new ventilator- and fluid-management strategies for acute respiratory distress syndrome.

Similarly, the emergency medicine community has developed new algorithms for the treatment of cardiac arrest, trauma, and many other common emergency diagnoses that are now implemented in EDs all over the country.

We, the HM community, should aspire to do the same.

By saying we need to do more, I do not mean to undermine the many important contributions we are making. Just pick up any issue of the Journal of Hospital Medicine, and you will find a wealth of literature describing the important work of hospitalists everywhere. But to have a lasting impact, we need to continue to expand on this work to advance the national health research agenda by having hospitalists pursue clinical and comparative-effectiveness research, quality and safety research, health system innovations work, and even basic science research.

Research Assistance

SHM has always prided itself in being at the forefront of training and networking opportunities for hospitalists. It should come as no surprise that SHM continues to lead in the creation of opportunities designed to enhance HM research.

To advance the research agenda, we need to advance researchers. HM researchers struggle to find funding for their work in a federal infrastructure that emphasizes disease- and organ-based investigation. A hospitalist investigator often explores areas that cross disease boundaries, or pursues work that falls into the realm of “quality and safety,” which tends to have fewer funding opportunities. Hospitalist investigators need a hand getting started, and SHM is going to lend that hand.

At HM10 this month in Washington, D.C., we will announce the recipients of the newly created SHM Junior Faculty Development Award. The award will provide two recipients with $25,000 per year for two consecutive years. This award is a mentored research award, which means it is intended to support junior hospitalist faculty as they apply for a research career development award. The goal in creating this award is to fulfill SHM’s mission of promoting excellence in the practice of HM through research, and to build a generation of effective hospitalist researchers who can define and explore questions pertinent to the general medical care of hospitalized patients.

We hope these awards, through funding and mentoring, boost successful hospitalist investigators, grow the number of hospitalist-initiated research projects, and show academic institutions that hospitalist research ideas have merit. It also is likely that, over time, the awards will create a network of SHM-funded investigators whose collaboration and interaction will further accelerate HM research.

Our hope is that this effort benefits not just the investigators receiving the money, but also all practicing hospitalists and their patients by further clarifying the best methods to care for hospitalized patients, by creating new treatment paradigms, and advancing the science of HM for the benefit of all.

Please join me in congratulating the recipients of this important and prestigious award. TH

Dr. Flanders is president of SHM.

With the growth of HM has come a major change in the way healthcare is delivered in hospitals across the country: Hospitalists have become one of the major providers of care for hospitalized medical patients. Recent reports suggest that hospitalists care for more than 50% of Medicare patients admitted with a medical diagnosis. In addition to that staggering figure, hospitalists increasingly have assumed care for many surgical patients, have staffed observation units, created procedure services, assumed care of many subspecialty services, and have taken the lead on hospital-based IT and quality-improvement (QI) endeavors, among other key services.

It is hard to argue against the assertion that HM’s emergence over the past decade and a half is one of the most significant game-changers in all of healthcare. Despite this important impact on the structure of care delivery, HM to date has fallen short of the contributions made by many other disciplines over the years in one key area: the generation of new knowledge through research.

New Specialties’ Research Focus

Think for a minute of the contributions of the next two youngest specialties—critical-care medicine and emergency medicine. Both fields have transformed care delivery, as did HM, but in contrast, both critical-care and emergency medicine have well-established investigators and an impressive research agenda. They have had a major impact on the care of patients everywhere.

For example, the critical-care community developed new treatment paradigms for sepsis that grew out of basic science work exploring the roles of cytokines and the inflammatory cascade in infection. Its clinical-research networks have developed and tested new ventilator- and fluid-management strategies for acute respiratory distress syndrome.

Similarly, the emergency medicine community has developed new algorithms for the treatment of cardiac arrest, trauma, and many other common emergency diagnoses that are now implemented in EDs all over the country.

We, the HM community, should aspire to do the same.

By saying we need to do more, I do not mean to undermine the many important contributions we are making. Just pick up any issue of the Journal of Hospital Medicine, and you will find a wealth of literature describing the important work of hospitalists everywhere. But to have a lasting impact, we need to continue to expand on this work to advance the national health research agenda by having hospitalists pursue clinical and comparative-effectiveness research, quality and safety research, health system innovations work, and even basic science research.

Research Assistance

SHM has always prided itself in being at the forefront of training and networking opportunities for hospitalists. It should come as no surprise that SHM continues to lead in the creation of opportunities designed to enhance HM research.

To advance the research agenda, we need to advance researchers. HM researchers struggle to find funding for their work in a federal infrastructure that emphasizes disease- and organ-based investigation. A hospitalist investigator often explores areas that cross disease boundaries, or pursues work that falls into the realm of “quality and safety,” which tends to have fewer funding opportunities. Hospitalist investigators need a hand getting started, and SHM is going to lend that hand.

At HM10 this month in Washington, D.C., we will announce the recipients of the newly created SHM Junior Faculty Development Award. The award will provide two recipients with $25,000 per year for two consecutive years. This award is a mentored research award, which means it is intended to support junior hospitalist faculty as they apply for a research career development award. The goal in creating this award is to fulfill SHM’s mission of promoting excellence in the practice of HM through research, and to build a generation of effective hospitalist researchers who can define and explore questions pertinent to the general medical care of hospitalized patients.

We hope these awards, through funding and mentoring, boost successful hospitalist investigators, grow the number of hospitalist-initiated research projects, and show academic institutions that hospitalist research ideas have merit. It also is likely that, over time, the awards will create a network of SHM-funded investigators whose collaboration and interaction will further accelerate HM research.

Our hope is that this effort benefits not just the investigators receiving the money, but also all practicing hospitalists and their patients by further clarifying the best methods to care for hospitalized patients, by creating new treatment paradigms, and advancing the science of HM for the benefit of all.

Please join me in congratulating the recipients of this important and prestigious award. TH

Dr. Flanders is president of SHM.

With the growth of HM has come a major change in the way healthcare is delivered in hospitals across the country: Hospitalists have become one of the major providers of care for hospitalized medical patients. Recent reports suggest that hospitalists care for more than 50% of Medicare patients admitted with a medical diagnosis. In addition to that staggering figure, hospitalists increasingly have assumed care for many surgical patients, have staffed observation units, created procedure services, assumed care of many subspecialty services, and have taken the lead on hospital-based IT and quality-improvement (QI) endeavors, among other key services.

It is hard to argue against the assertion that HM’s emergence over the past decade and a half is one of the most significant game-changers in all of healthcare. Despite this important impact on the structure of care delivery, HM to date has fallen short of the contributions made by many other disciplines over the years in one key area: the generation of new knowledge through research.

New Specialties’ Research Focus

Think for a minute of the contributions of the next two youngest specialties—critical-care medicine and emergency medicine. Both fields have transformed care delivery, as did HM, but in contrast, both critical-care and emergency medicine have well-established investigators and an impressive research agenda. They have had a major impact on the care of patients everywhere.

For example, the critical-care community developed new treatment paradigms for sepsis that grew out of basic science work exploring the roles of cytokines and the inflammatory cascade in infection. Its clinical-research networks have developed and tested new ventilator- and fluid-management strategies for acute respiratory distress syndrome.

Similarly, the emergency medicine community has developed new algorithms for the treatment of cardiac arrest, trauma, and many other common emergency diagnoses that are now implemented in EDs all over the country.

We, the HM community, should aspire to do the same.

By saying we need to do more, I do not mean to undermine the many important contributions we are making. Just pick up any issue of the Journal of Hospital Medicine, and you will find a wealth of literature describing the important work of hospitalists everywhere. But to have a lasting impact, we need to continue to expand on this work to advance the national health research agenda by having hospitalists pursue clinical and comparative-effectiveness research, quality and safety research, health system innovations work, and even basic science research.

Research Assistance

SHM has always prided itself in being at the forefront of training and networking opportunities for hospitalists. It should come as no surprise that SHM continues to lead in the creation of opportunities designed to enhance HM research.

To advance the research agenda, we need to advance researchers. HM researchers struggle to find funding for their work in a federal infrastructure that emphasizes disease- and organ-based investigation. A hospitalist investigator often explores areas that cross disease boundaries, or pursues work that falls into the realm of “quality and safety,” which tends to have fewer funding opportunities. Hospitalist investigators need a hand getting started, and SHM is going to lend that hand.

At HM10 this month in Washington, D.C., we will announce the recipients of the newly created SHM Junior Faculty Development Award. The award will provide two recipients with $25,000 per year for two consecutive years. This award is a mentored research award, which means it is intended to support junior hospitalist faculty as they apply for a research career development award. The goal in creating this award is to fulfill SHM’s mission of promoting excellence in the practice of HM through research, and to build a generation of effective hospitalist researchers who can define and explore questions pertinent to the general medical care of hospitalized patients.

We hope these awards, through funding and mentoring, boost successful hospitalist investigators, grow the number of hospitalist-initiated research projects, and show academic institutions that hospitalist research ideas have merit. It also is likely that, over time, the awards will create a network of SHM-funded investigators whose collaboration and interaction will further accelerate HM research.

Our hope is that this effort benefits not just the investigators receiving the money, but also all practicing hospitalists and their patients by further clarifying the best methods to care for hospitalized patients, by creating new treatment paradigms, and advancing the science of HM for the benefit of all.

Please join me in congratulating the recipients of this important and prestigious award. TH

Dr. Flanders is president of SHM.

Whether pure political theater or a real attempt at bipartisanship, the Feb. 25 healthcare summit was a milestone on the way to March’s riveting Congressional vote in favor of healtcare reform.

Both parties arrived with some newly dusted off—or slightly tweaked—ideas to throw into the mix, in part to give voters the impression that they knew best how to move forward with healthcare reform. In the end, the legislation that narrowly prevailed March 20 incorporated some of those ideas while dumping or reshaping others (items in the reconciliation bill weren’t finalized at press time).

The fight isn’t over, however, and we are likely to hear the same dueling themes again: more federal government intervention versus more market-driven solutions for addressing access and cost. Most of the ideas influence hospital care, frequently cited as one of the most expensive sectors of healthcare. Here’s a look at key proposals that rose to the top of their parties’ wish lists in February, and how they fared in March.

Idea: Allow People to Buy Health Insurance across State Lines

Although not new, Republican legislators revived the idea bandied about during the Bush administration, and made it a key element of their alternative to the Democratic plan. Ultimately, it would hold insurance companies accountable through robust competition, but without a “federal bureaucracy,” Rep. Marsha Blackburn (R-Tenn.) said at the summit. With competition fueling reduced insurance premiums for consumers, the argument goes, the number of insured increases.

Michael Cousineau, an associate professor of research at the University of Southern California and a specialist in health policy and health services, isn’t having it. “I think that it’s a stupid proposal,” he says. First, he argues, it’s not practical for someone in California to buy a policy from Mississippi. If a consumer has a problem with an out-of-state health plan refusing to cover care, he asks, “who are you going to complain to?”

If insurance companies set up shop in the states with the lowest level of regulation, he says, younger and healthier adults would migrate to those cheaper plans, leaving the older and sicker adults who really need healthcare in plans with the strongest consumer protections. “So you’ll end up with this massive problem of sick people in some plans and well people in the other plans, and it’s just going to create havoc. I don’t think it’s a sustainable mechanism,” he says. Doctors, hospitals, and even insurers themselves would hate it, he says, because of the massive influx of out-of-state insurance companies.

Democrats, including Oregon Sen. Ron Wyden, introduced their own version of the proposal, but on a more regional level and with more rigorous oversight. Currently, insurance plans must meet the requirements of the states in which they’re sold. But states have incredibly varied mandates about what kind of healthcare must be covered. “If you permit the interstate sales of insurance under the current plans, then more or less all of those state rules go out the door,” says Leighton Ku, a health policy analyst at George Washington University. Although sidestepping state-specific regulations would permit people to buy insurance from the state with the cheapest plan, he says, “in many cases, that would be because the state has the fewest restrictions on it.”

And therein lies another big concern, he says: “That it essentially begins to create a race to the bottom.”

At the summit, President Obama supported selling insurance across state lines, but through a national exchange with at least “minimal standards” through which any insurer could participate.

Ultimately, the new legislation will allow states to form exchanges, but with an option for regional exchanges as well.

Idea: Create a Health Insurance Rate Authority

Championed by Obama, this proposal arrived on the heels of several high-profile rate increases that have generated considerable public angst. Not coincidentally, the House Energy and Commerce Committee held a hearing about soaring premiums the day before the summit.

At the hearing, legislators questioned Wellpoint president and CEO Angela Braly about the company’s Anthem Blue Cross unit and its plans to raise insurance premiums by as much as 39% for some Californians (overall, premium increases average 25%). Braly, in turn, blamed the surge on rising and “unsustainable” pharmacy and hospital care costs, the latter driven primarily by hospital reimbursement rates.

Although the general concept of federal oversight is useful, Ku says, the big question is one of authority. Regulating insurers has traditionally fallen to state governments, which likely will be reluctant to give up jurisdictional power but might accept federal assistance.

“I think in general it would help, but I don’t think it’s going to have as much of an impact unless we control the cost-of-care downlink,” Cousineau adds. Including a mandate for individuals to buy health insurance reduces the need for the authority, though he concedes that some cynics doubt whether health insurers will voluntarily lower rates even if more young, healthy people buy policies. Republicans oppose the idea of an individual mandate and a new federal regulatory entity.

In the March bill, the individual mandate prevailed while the idea of a new insurance watchdog fell by the wayside.

Idea: Provide State Grants to Expand High-Risk Pools for Uninsured

The idea, proposed by Republicans in several iterations, including Sen. John McCain (R-Ariz.) when he ran for president, was offered as a potential alternative to banning insurance companies from denying coverage to patients with pre-existing conditions. Many states already offer high-risk patient pools for patients who have been excluded from the private market, but some have long waiting lists. The Health Insurance Plan of California (HPIC), for example, has a two-year wait, according to Cousineau.

“It’s not a bad idea,” he says of a federal subsidy, but because the pools only include high-risk patients, he says they won’t solve the problem of expensive premiums. Cousineau prefers state-based exchanges that aren’t segregated by risk and spread the cost over a wider range of people, which is included in the March bill. “Otherwise, it’s too expensive, and you’re asking the states to pay for part of it,” he says.

Ku believes high-risk pools could deliver some relief to patients currently priced out of the market. “It’s not going to help the neediest of the needy, but could help some,” he says. As a temporary fix, the new legislation sets up high-risk pools in states that lack them, with $5 billion from the federal coffers. The mechanism will be phased out in 2014, however; by then, all insurers will be banned from denying coverage to anyone.

Idea: Gradually Close the “Doughnut Hole”

An idea popular with senior citizens, closing the gap in Medicare’s Part D prescription drug coverage gained further traction under Obama’s healthcare plan and was included in the healthcare reconciliation bill. The doughnut-hole closure is paid for with savings from cuts to the Medicare Advantage program.

Experts question whether it will affect as many patients as has been widely assumed. “I think it’s an important thing to do,” Cousineau says, “but I’m not as worried as much about the costs there as I am in other parts of the program.”

Uncertainties aside, closing Medicare’s doughnut hole could help ease at least one headache cited by hospitalists: struggling to sort through hospitalized patients’ formularies to insure they can afford the drugs they need upon discharge—so they won’t end up back in the hospital. TH

Bryn Nelson is a freelance medical writer based in Seattle.

Whether pure political theater or a real attempt at bipartisanship, the Feb. 25 healthcare summit was a milestone on the way to March’s riveting Congressional vote in favor of healtcare reform.

Both parties arrived with some newly dusted off—or slightly tweaked—ideas to throw into the mix, in part to give voters the impression that they knew best how to move forward with healthcare reform. In the end, the legislation that narrowly prevailed March 20 incorporated some of those ideas while dumping or reshaping others (items in the reconciliation bill weren’t finalized at press time).

The fight isn’t over, however, and we are likely to hear the same dueling themes again: more federal government intervention versus more market-driven solutions for addressing access and cost. Most of the ideas influence hospital care, frequently cited as one of the most expensive sectors of healthcare. Here’s a look at key proposals that rose to the top of their parties’ wish lists in February, and how they fared in March.

Idea: Allow People to Buy Health Insurance across State Lines

Although not new, Republican legislators revived the idea bandied about during the Bush administration, and made it a key element of their alternative to the Democratic plan. Ultimately, it would hold insurance companies accountable through robust competition, but without a “federal bureaucracy,” Rep. Marsha Blackburn (R-Tenn.) said at the summit. With competition fueling reduced insurance premiums for consumers, the argument goes, the number of insured increases.

Michael Cousineau, an associate professor of research at the University of Southern California and a specialist in health policy and health services, isn’t having it. “I think that it’s a stupid proposal,” he says. First, he argues, it’s not practical for someone in California to buy a policy from Mississippi. If a consumer has a problem with an out-of-state health plan refusing to cover care, he asks, “who are you going to complain to?”

If insurance companies set up shop in the states with the lowest level of regulation, he says, younger and healthier adults would migrate to those cheaper plans, leaving the older and sicker adults who really need healthcare in plans with the strongest consumer protections. “So you’ll end up with this massive problem of sick people in some plans and well people in the other plans, and it’s just going to create havoc. I don’t think it’s a sustainable mechanism,” he says. Doctors, hospitals, and even insurers themselves would hate it, he says, because of the massive influx of out-of-state insurance companies.

Democrats, including Oregon Sen. Ron Wyden, introduced their own version of the proposal, but on a more regional level and with more rigorous oversight. Currently, insurance plans must meet the requirements of the states in which they’re sold. But states have incredibly varied mandates about what kind of healthcare must be covered. “If you permit the interstate sales of insurance under the current plans, then more or less all of those state rules go out the door,” says Leighton Ku, a health policy analyst at George Washington University. Although sidestepping state-specific regulations would permit people to buy insurance from the state with the cheapest plan, he says, “in many cases, that would be because the state has the fewest restrictions on it.”

And therein lies another big concern, he says: “That it essentially begins to create a race to the bottom.”

At the summit, President Obama supported selling insurance across state lines, but through a national exchange with at least “minimal standards” through which any insurer could participate.

Ultimately, the new legislation will allow states to form exchanges, but with an option for regional exchanges as well.

Idea: Create a Health Insurance Rate Authority

Championed by Obama, this proposal arrived on the heels of several high-profile rate increases that have generated considerable public angst. Not coincidentally, the House Energy and Commerce Committee held a hearing about soaring premiums the day before the summit.

At the hearing, legislators questioned Wellpoint president and CEO Angela Braly about the company’s Anthem Blue Cross unit and its plans to raise insurance premiums by as much as 39% for some Californians (overall, premium increases average 25%). Braly, in turn, blamed the surge on rising and “unsustainable” pharmacy and hospital care costs, the latter driven primarily by hospital reimbursement rates.

Although the general concept of federal oversight is useful, Ku says, the big question is one of authority. Regulating insurers has traditionally fallen to state governments, which likely will be reluctant to give up jurisdictional power but might accept federal assistance.

“I think in general it would help, but I don’t think it’s going to have as much of an impact unless we control the cost-of-care downlink,” Cousineau adds. Including a mandate for individuals to buy health insurance reduces the need for the authority, though he concedes that some cynics doubt whether health insurers will voluntarily lower rates even if more young, healthy people buy policies. Republicans oppose the idea of an individual mandate and a new federal regulatory entity.

In the March bill, the individual mandate prevailed while the idea of a new insurance watchdog fell by the wayside.

Idea: Provide State Grants to Expand High-Risk Pools for Uninsured

The idea, proposed by Republicans in several iterations, including Sen. John McCain (R-Ariz.) when he ran for president, was offered as a potential alternative to banning insurance companies from denying coverage to patients with pre-existing conditions. Many states already offer high-risk patient pools for patients who have been excluded from the private market, but some have long waiting lists. The Health Insurance Plan of California (HPIC), for example, has a two-year wait, according to Cousineau.

“It’s not a bad idea,” he says of a federal subsidy, but because the pools only include high-risk patients, he says they won’t solve the problem of expensive premiums. Cousineau prefers state-based exchanges that aren’t segregated by risk and spread the cost over a wider range of people, which is included in the March bill. “Otherwise, it’s too expensive, and you’re asking the states to pay for part of it,” he says.

Ku believes high-risk pools could deliver some relief to patients currently priced out of the market. “It’s not going to help the neediest of the needy, but could help some,” he says. As a temporary fix, the new legislation sets up high-risk pools in states that lack them, with $5 billion from the federal coffers. The mechanism will be phased out in 2014, however; by then, all insurers will be banned from denying coverage to anyone.

Idea: Gradually Close the “Doughnut Hole”

An idea popular with senior citizens, closing the gap in Medicare’s Part D prescription drug coverage gained further traction under Obama’s healthcare plan and was included in the healthcare reconciliation bill. The doughnut-hole closure is paid for with savings from cuts to the Medicare Advantage program.

Experts question whether it will affect as many patients as has been widely assumed. “I think it’s an important thing to do,” Cousineau says, “but I’m not as worried as much about the costs there as I am in other parts of the program.”

Uncertainties aside, closing Medicare’s doughnut hole could help ease at least one headache cited by hospitalists: struggling to sort through hospitalized patients’ formularies to insure they can afford the drugs they need upon discharge—so they won’t end up back in the hospital. TH

Bryn Nelson is a freelance medical writer based in Seattle.

Whether pure political theater or a real attempt at bipartisanship, the Feb. 25 healthcare summit was a milestone on the way to March’s riveting Congressional vote in favor of healtcare reform.

Both parties arrived with some newly dusted off—or slightly tweaked—ideas to throw into the mix, in part to give voters the impression that they knew best how to move forward with healthcare reform. In the end, the legislation that narrowly prevailed March 20 incorporated some of those ideas while dumping or reshaping others (items in the reconciliation bill weren’t finalized at press time).

The fight isn’t over, however, and we are likely to hear the same dueling themes again: more federal government intervention versus more market-driven solutions for addressing access and cost. Most of the ideas influence hospital care, frequently cited as one of the most expensive sectors of healthcare. Here’s a look at key proposals that rose to the top of their parties’ wish lists in February, and how they fared in March.

Idea: Allow People to Buy Health Insurance across State Lines

Although not new, Republican legislators revived the idea bandied about during the Bush administration, and made it a key element of their alternative to the Democratic plan. Ultimately, it would hold insurance companies accountable through robust competition, but without a “federal bureaucracy,” Rep. Marsha Blackburn (R-Tenn.) said at the summit. With competition fueling reduced insurance premiums for consumers, the argument goes, the number of insured increases.

Michael Cousineau, an associate professor of research at the University of Southern California and a specialist in health policy and health services, isn’t having it. “I think that it’s a stupid proposal,” he says. First, he argues, it’s not practical for someone in California to buy a policy from Mississippi. If a consumer has a problem with an out-of-state health plan refusing to cover care, he asks, “who are you going to complain to?”

If insurance companies set up shop in the states with the lowest level of regulation, he says, younger and healthier adults would migrate to those cheaper plans, leaving the older and sicker adults who really need healthcare in plans with the strongest consumer protections. “So you’ll end up with this massive problem of sick people in some plans and well people in the other plans, and it’s just going to create havoc. I don’t think it’s a sustainable mechanism,” he says. Doctors, hospitals, and even insurers themselves would hate it, he says, because of the massive influx of out-of-state insurance companies.

Democrats, including Oregon Sen. Ron Wyden, introduced their own version of the proposal, but on a more regional level and with more rigorous oversight. Currently, insurance plans must meet the requirements of the states in which they’re sold. But states have incredibly varied mandates about what kind of healthcare must be covered. “If you permit the interstate sales of insurance under the current plans, then more or less all of those state rules go out the door,” says Leighton Ku, a health policy analyst at George Washington University. Although sidestepping state-specific regulations would permit people to buy insurance from the state with the cheapest plan, he says, “in many cases, that would be because the state has the fewest restrictions on it.”

And therein lies another big concern, he says: “That it essentially begins to create a race to the bottom.”

At the summit, President Obama supported selling insurance across state lines, but through a national exchange with at least “minimal standards” through which any insurer could participate.

Ultimately, the new legislation will allow states to form exchanges, but with an option for regional exchanges as well.

Idea: Create a Health Insurance Rate Authority

Championed by Obama, this proposal arrived on the heels of several high-profile rate increases that have generated considerable public angst. Not coincidentally, the House Energy and Commerce Committee held a hearing about soaring premiums the day before the summit.

At the hearing, legislators questioned Wellpoint president and CEO Angela Braly about the company’s Anthem Blue Cross unit and its plans to raise insurance premiums by as much as 39% for some Californians (overall, premium increases average 25%). Braly, in turn, blamed the surge on rising and “unsustainable” pharmacy and hospital care costs, the latter driven primarily by hospital reimbursement rates.

Although the general concept of federal oversight is useful, Ku says, the big question is one of authority. Regulating insurers has traditionally fallen to state governments, which likely will be reluctant to give up jurisdictional power but might accept federal assistance.

“I think in general it would help, but I don’t think it’s going to have as much of an impact unless we control the cost-of-care downlink,” Cousineau adds. Including a mandate for individuals to buy health insurance reduces the need for the authority, though he concedes that some cynics doubt whether health insurers will voluntarily lower rates even if more young, healthy people buy policies. Republicans oppose the idea of an individual mandate and a new federal regulatory entity.

In the March bill, the individual mandate prevailed while the idea of a new insurance watchdog fell by the wayside.

Idea: Provide State Grants to Expand High-Risk Pools for Uninsured

The idea, proposed by Republicans in several iterations, including Sen. John McCain (R-Ariz.) when he ran for president, was offered as a potential alternative to banning insurance companies from denying coverage to patients with pre-existing conditions. Many states already offer high-risk patient pools for patients who have been excluded from the private market, but some have long waiting lists. The Health Insurance Plan of California (HPIC), for example, has a two-year wait, according to Cousineau.

“It’s not a bad idea,” he says of a federal subsidy, but because the pools only include high-risk patients, he says they won’t solve the problem of expensive premiums. Cousineau prefers state-based exchanges that aren’t segregated by risk and spread the cost over a wider range of people, which is included in the March bill. “Otherwise, it’s too expensive, and you’re asking the states to pay for part of it,” he says.

Ku believes high-risk pools could deliver some relief to patients currently priced out of the market. “It’s not going to help the neediest of the needy, but could help some,” he says. As a temporary fix, the new legislation sets up high-risk pools in states that lack them, with $5 billion from the federal coffers. The mechanism will be phased out in 2014, however; by then, all insurers will be banned from denying coverage to anyone.

Idea: Gradually Close the “Doughnut Hole”

An idea popular with senior citizens, closing the gap in Medicare’s Part D prescription drug coverage gained further traction under Obama’s healthcare plan and was included in the healthcare reconciliation bill. The doughnut-hole closure is paid for with savings from cuts to the Medicare Advantage program.

Experts question whether it will affect as many patients as has been widely assumed. “I think it’s an important thing to do,” Cousineau says, “but I’m not as worried as much about the costs there as I am in other parts of the program.”

Uncertainties aside, closing Medicare’s doughnut hole could help ease at least one headache cited by hospitalists: struggling to sort through hospitalized patients’ formularies to insure they can afford the drugs they need upon discharge—so they won’t end up back in the hospital. TH

Bryn Nelson is a freelance medical writer based in Seattle.

Thousands of Michigan residents will have a better chance of avoiding readmission to the hospital thanks to a groundbreaking new collaboration between three of the state’s healthcare leaders.

Based on SHM’s Project BOOST (Better Outcomes for Older Adults through Safe Transitions) model, the collaborative program will be managed by the University of Michigan in collaboration with Blue Cross Blue Shield of Michigan. The Michigan Blues provide and administer health benefits to 4.7 million Michigan residents.

Project BOOST helps hospitals reduce readmission rates by providing them with proven resources and expert mentoring to optimize the discharge transition process, enhance patient and family education practices, and improve the flow of information between inpatient and outpatient providers. Project BOOST was developed through a grant from the John A. Hartford Foundation. Earlier in the year, the program recruited 15 Michigan sites to participate. Training begins in May.

Each improvement team will be assigned a mentor to coach them through the process of planning, implementing, and evaluating Project BOOST at their site. Program participants will receive face-to-face training, monthly coaching sessions with their mentors, and a comprehensive toolkit to implement Project BOOST. Sites also participate in an online peer learning and collaboration network.

“This kind of innovative, targeted program benefits both the patient and the healthcare provider by establishing better communication between all parties,” says Scott Flanders, MD, FHM, associate professor and director of hospital medicine at the University of Michigan in Ann Arbor, and SHM president.

To Flanders, it’s no coincidence that hospitalists are taking the lead in improving hospital discharges. “Readmissions are a pervasive but preventable problem,” he says. “Hospitalists are uniquely positioned to provide leadership within the hospital, to promote positive, system-based changes that improve patient satisfaction, and promote collaboration between hospitalists and primary-care physicians.”

In addition to being preventable, readmissions are costly, draining the resources, time, and energy of the patient, PCPs, and hospitals. Research in the April 2009 New England Journal of Medicine indicates that 20% of hospitalized patients are readmitted to the hospital within a month of their discharge.1 Nationally, readmissions cost Medicare $17.4 billion each year.1

Collaborative Partnerships

Prior to the program’s launch in Michigan, SHM recruited and mentored Project BOOST sites independently. However, like many productive relationships in a hospital, Project BOOST in Michigan depends on collaboration between experts.

“Blue Cross Blue Shield of Michigan is confident that this project, like our other Value Partnership programs that focus on robust, statewide, data-driven quality-improvement (QI) partnerships, will have a positive impact on thousands of Michigan lives,” says David Share, MD, MPH, BCBS Michigan’s senior associate medical director of Healthcare Quality. “We look forward to helping hospitals, physicians, and patients work together to assure smooth transitions between inpatient and outpatient care, and to reduce readmissions and improve the patient experience.”

For University of Michigan hospitalist Christopher Kim, MD, MBA, FHM, Project BOOST is a chance to work with a diverse set of groups. “We are grateful for the opportunity to work with not just Blue Cross Blue Shield of Michigan, but also with the other physician organizations across our state to implement and share best-practice ideas in transitions of care,” says Kim, director of the statewide collaborative program on transitions of care.

Results and Reports

Having launched six pilot sites just two years ago, adding 24 additional sites in 2009, Project BOOST is still a relatively young QI program, which makes reliable quantitative data about its effectiveness tough to come by. The expansion into Michigan gives SHM and others the prospect of programwide measurement of how Project BOOST affects discharge and reduces readmissions.

“This is a tremendous opportunity to improve patient safety, reduce readmissions, and study the impact of Project BOOST interventions through patient-level data,” says Mark Williams, MD, FHM, Journal of Hospital Medicine editor, principal investigator for Project BOOST, and former SHM president. “We’re thrilled to be working with the state’s healthcare leaders to implement this critical program.”

Nonetheless, in the absence of comprehensive data, the early reports from Project BOOST sites are promising. At Piedmont Hospital in the Atlanta area, the rate of readmission among patients under the age of 70 participating in BOOST is 8.5%, compared with 25.5% among nonparticipants. The readmission rate among BOOST participants at Piedmont over the age of 70 was 22%, compared with 26% of nonparticipants. When SSM St. Mary’s Medical Center in St. Louis implemented BOOST at its 33-bed hospitalist unit, 30-day readmissions dropped to 7% from 12% within three months.

Patient satisfaction rates also increased markedly, to 68% from 52%. And in 2009, the University of Pennsylvania Health System awarded its annual Operational Quality and Safety Award to the Project BOOST implementation team at the hospital.

BOOST’s Reach Expands

Project BOOST leaders are planning an aggressive expansion in the near future. In addition to the potential for new program sites, SHM has made materials available to hospitalists through the Project BOOST Resource Room at SHM’s newly redesigned Web site (see “The New Face of HospitalMedicine.org,” p. 12), www.hospitalmedicine.org/boost.

In addition to free resources, new BOOST materials are for sale through SHM’s online store. The Project BOOST Implementation Guide—available electronically for free through the resource room—is now available for sale as a hard copy. The online store also features a new Project BOOST instructional DVD for hospitalists, “Using Teach Back to Improve Communication with Patients.” TH

Brendon Shank is a freelance writer based in Philadelphia.

Reference

1. Rehospitalizations among patients in the Medicare fee-for-service program. N Engl J Med. 2009;360(14): 1418-1428.

Chapter Updates

The Historic Main Street Trolley in Memphis, Tenn.

Memphis

The Memphis chapter held its quarterly meeting Feb. 4 at Erling Jensen in Memphis, Tenn. Dr. William Edmonson of the North Mississippi Medical Center in Tupelo, Miss., discussed “Updates on COPD.” Boehringer Engelheim sponsored the dinner meeting, which was attended by hospitalists and physicians in the area as well as hospital nurses and administration.

Milwaukee/Southeast Wisconsin

The Milwaukee/Southeast Wisconsin chapter’s Feb. 27 meeting in the Columbia Hospital Auditorium brought together hospitalists, nurse practitioners, pharmacists, and others from the Milwaukee area. Attendees were able to obtain CME credit on topics including acute coronary syndrome, hyponatremia, and sepsis. The meeting highlight was a presentation from Dr. Alpesh Amin, interim chair of the Department of Medicine at the University of California at Irvine. Dr. Amin discussed how to start up a local SHM chapter. Sponsorship from CME University helped make the chapter’s first HM symposium a success.

Nebraska Area

Lincoln HM group Bryan LGH hosted the Nebraska Area chapter quarterly meeting Feb. 23. Dr. Tamer Mahrous gave an overview of coding issues for hospitalists. A copy of the presentation will be sent to all of the chapter members.

The chapter elected officers to serve terms through 2012. They include: Dr. Eric Rice, president; Russ Cowles, vice president; Alissa Clough, secretary; and Jay Snow, officer at large.

Several additional items were discussed, including topics for upcoming meetings, how the chapter can best take advantage of opportunities at HM10, the possibility of launching a chapter newsletter, and organizational issues.

Thousands of Michigan residents will have a better chance of avoiding readmission to the hospital thanks to a groundbreaking new collaboration between three of the state’s healthcare leaders.

Based on SHM’s Project BOOST (Better Outcomes for Older Adults through Safe Transitions) model, the collaborative program will be managed by the University of Michigan in collaboration with Blue Cross Blue Shield of Michigan. The Michigan Blues provide and administer health benefits to 4.7 million Michigan residents.

Project BOOST helps hospitals reduce readmission rates by providing them with proven resources and expert mentoring to optimize the discharge transition process, enhance patient and family education practices, and improve the flow of information between inpatient and outpatient providers. Project BOOST was developed through a grant from the John A. Hartford Foundation. Earlier in the year, the program recruited 15 Michigan sites to participate. Training begins in May.

Each improvement team will be assigned a mentor to coach them through the process of planning, implementing, and evaluating Project BOOST at their site. Program participants will receive face-to-face training, monthly coaching sessions with their mentors, and a comprehensive toolkit to implement Project BOOST. Sites also participate in an online peer learning and collaboration network.

“This kind of innovative, targeted program benefits both the patient and the healthcare provider by establishing better communication between all parties,” says Scott Flanders, MD, FHM, associate professor and director of hospital medicine at the University of Michigan in Ann Arbor, and SHM president.

To Flanders, it’s no coincidence that hospitalists are taking the lead in improving hospital discharges. “Readmissions are a pervasive but preventable problem,” he says. “Hospitalists are uniquely positioned to provide leadership within the hospital, to promote positive, system-based changes that improve patient satisfaction, and promote collaboration between hospitalists and primary-care physicians.”

In addition to being preventable, readmissions are costly, draining the resources, time, and energy of the patient, PCPs, and hospitals. Research in the April 2009 New England Journal of Medicine indicates that 20% of hospitalized patients are readmitted to the hospital within a month of their discharge.1 Nationally, readmissions cost Medicare $17.4 billion each year.1

Collaborative Partnerships

Prior to the program’s launch in Michigan, SHM recruited and mentored Project BOOST sites independently. However, like many productive relationships in a hospital, Project BOOST in Michigan depends on collaboration between experts.

“Blue Cross Blue Shield of Michigan is confident that this project, like our other Value Partnership programs that focus on robust, statewide, data-driven quality-improvement (QI) partnerships, will have a positive impact on thousands of Michigan lives,” says David Share, MD, MPH, BCBS Michigan’s senior associate medical director of Healthcare Quality. “We look forward to helping hospitals, physicians, and patients work together to assure smooth transitions between inpatient and outpatient care, and to reduce readmissions and improve the patient experience.”

For University of Michigan hospitalist Christopher Kim, MD, MBA, FHM, Project BOOST is a chance to work with a diverse set of groups. “We are grateful for the opportunity to work with not just Blue Cross Blue Shield of Michigan, but also with the other physician organizations across our state to implement and share best-practice ideas in transitions of care,” says Kim, director of the statewide collaborative program on transitions of care.

Results and Reports

Having launched six pilot sites just two years ago, adding 24 additional sites in 2009, Project BOOST is still a relatively young QI program, which makes reliable quantitative data about its effectiveness tough to come by. The expansion into Michigan gives SHM and others the prospect of programwide measurement of how Project BOOST affects discharge and reduces readmissions.

“This is a tremendous opportunity to improve patient safety, reduce readmissions, and study the impact of Project BOOST interventions through patient-level data,” says Mark Williams, MD, FHM, Journal of Hospital Medicine editor, principal investigator for Project BOOST, and former SHM president. “We’re thrilled to be working with the state’s healthcare leaders to implement this critical program.”

Nonetheless, in the absence of comprehensive data, the early reports from Project BOOST sites are promising. At Piedmont Hospital in the Atlanta area, the rate of readmission among patients under the age of 70 participating in BOOST is 8.5%, compared with 25.5% among nonparticipants. The readmission rate among BOOST participants at Piedmont over the age of 70 was 22%, compared with 26% of nonparticipants. When SSM St. Mary’s Medical Center in St. Louis implemented BOOST at its 33-bed hospitalist unit, 30-day readmissions dropped to 7% from 12% within three months.

Patient satisfaction rates also increased markedly, to 68% from 52%. And in 2009, the University of Pennsylvania Health System awarded its annual Operational Quality and Safety Award to the Project BOOST implementation team at the hospital.

BOOST’s Reach Expands

Project BOOST leaders are planning an aggressive expansion in the near future. In addition to the potential for new program sites, SHM has made materials available to hospitalists through the Project BOOST Resource Room at SHM’s newly redesigned Web site (see “The New Face of HospitalMedicine.org,” p. 12), www.hospitalmedicine.org/boost.

In addition to free resources, new BOOST materials are for sale through SHM’s online store. The Project BOOST Implementation Guide—available electronically for free through the resource room—is now available for sale as a hard copy. The online store also features a new Project BOOST instructional DVD for hospitalists, “Using Teach Back to Improve Communication with Patients.” TH

Brendon Shank is a freelance writer based in Philadelphia.

Reference

1. Rehospitalizations among patients in the Medicare fee-for-service program. N Engl J Med. 2009;360(14): 1418-1428.

Chapter Updates

The Historic Main Street Trolley in Memphis, Tenn.

Memphis

The Memphis chapter held its quarterly meeting Feb. 4 at Erling Jensen in Memphis, Tenn. Dr. William Edmonson of the North Mississippi Medical Center in Tupelo, Miss., discussed “Updates on COPD.” Boehringer Engelheim sponsored the dinner meeting, which was attended by hospitalists and physicians in the area as well as hospital nurses and administration.

Milwaukee/Southeast Wisconsin

The Milwaukee/Southeast Wisconsin chapter’s Feb. 27 meeting in the Columbia Hospital Auditorium brought together hospitalists, nurse practitioners, pharmacists, and others from the Milwaukee area. Attendees were able to obtain CME credit on topics including acute coronary syndrome, hyponatremia, and sepsis. The meeting highlight was a presentation from Dr. Alpesh Amin, interim chair of the Department of Medicine at the University of California at Irvine. Dr. Amin discussed how to start up a local SHM chapter. Sponsorship from CME University helped make the chapter’s first HM symposium a success.

Nebraska Area

Lincoln HM group Bryan LGH hosted the Nebraska Area chapter quarterly meeting Feb. 23. Dr. Tamer Mahrous gave an overview of coding issues for hospitalists. A copy of the presentation will be sent to all of the chapter members.

The chapter elected officers to serve terms through 2012. They include: Dr. Eric Rice, president; Russ Cowles, vice president; Alissa Clough, secretary; and Jay Snow, officer at large.

Several additional items were discussed, including topics for upcoming meetings, how the chapter can best take advantage of opportunities at HM10, the possibility of launching a chapter newsletter, and organizational issues.

Thousands of Michigan residents will have a better chance of avoiding readmission to the hospital thanks to a groundbreaking new collaboration between three of the state’s healthcare leaders.

Based on SHM’s Project BOOST (Better Outcomes for Older Adults through Safe Transitions) model, the collaborative program will be managed by the University of Michigan in collaboration with Blue Cross Blue Shield of Michigan. The Michigan Blues provide and administer health benefits to 4.7 million Michigan residents.

Project BOOST helps hospitals reduce readmission rates by providing them with proven resources and expert mentoring to optimize the discharge transition process, enhance patient and family education practices, and improve the flow of information between inpatient and outpatient providers. Project BOOST was developed through a grant from the John A. Hartford Foundation. Earlier in the year, the program recruited 15 Michigan sites to participate. Training begins in May.

Each improvement team will be assigned a mentor to coach them through the process of planning, implementing, and evaluating Project BOOST at their site. Program participants will receive face-to-face training, monthly coaching sessions with their mentors, and a comprehensive toolkit to implement Project BOOST. Sites also participate in an online peer learning and collaboration network.

“This kind of innovative, targeted program benefits both the patient and the healthcare provider by establishing better communication between all parties,” says Scott Flanders, MD, FHM, associate professor and director of hospital medicine at the University of Michigan in Ann Arbor, and SHM president.

To Flanders, it’s no coincidence that hospitalists are taking the lead in improving hospital discharges. “Readmissions are a pervasive but preventable problem,” he says. “Hospitalists are uniquely positioned to provide leadership within the hospital, to promote positive, system-based changes that improve patient satisfaction, and promote collaboration between hospitalists and primary-care physicians.”

In addition to being preventable, readmissions are costly, draining the resources, time, and energy of the patient, PCPs, and hospitals. Research in the April 2009 New England Journal of Medicine indicates that 20% of hospitalized patients are readmitted to the hospital within a month of their discharge.1 Nationally, readmissions cost Medicare $17.4 billion each year.1

Collaborative Partnerships

Prior to the program’s launch in Michigan, SHM recruited and mentored Project BOOST sites independently. However, like many productive relationships in a hospital, Project BOOST in Michigan depends on collaboration between experts.

“Blue Cross Blue Shield of Michigan is confident that this project, like our other Value Partnership programs that focus on robust, statewide, data-driven quality-improvement (QI) partnerships, will have a positive impact on thousands of Michigan lives,” says David Share, MD, MPH, BCBS Michigan’s senior associate medical director of Healthcare Quality. “We look forward to helping hospitals, physicians, and patients work together to assure smooth transitions between inpatient and outpatient care, and to reduce readmissions and improve the patient experience.”

For University of Michigan hospitalist Christopher Kim, MD, MBA, FHM, Project BOOST is a chance to work with a diverse set of groups. “We are grateful for the opportunity to work with not just Blue Cross Blue Shield of Michigan, but also with the other physician organizations across our state to implement and share best-practice ideas in transitions of care,” says Kim, director of the statewide collaborative program on transitions of care.

Results and Reports

Having launched six pilot sites just two years ago, adding 24 additional sites in 2009, Project BOOST is still a relatively young QI program, which makes reliable quantitative data about its effectiveness tough to come by. The expansion into Michigan gives SHM and others the prospect of programwide measurement of how Project BOOST affects discharge and reduces readmissions.

“This is a tremendous opportunity to improve patient safety, reduce readmissions, and study the impact of Project BOOST interventions through patient-level data,” says Mark Williams, MD, FHM, Journal of Hospital Medicine editor, principal investigator for Project BOOST, and former SHM president. “We’re thrilled to be working with the state’s healthcare leaders to implement this critical program.”

Nonetheless, in the absence of comprehensive data, the early reports from Project BOOST sites are promising. At Piedmont Hospital in the Atlanta area, the rate of readmission among patients under the age of 70 participating in BOOST is 8.5%, compared with 25.5% among nonparticipants. The readmission rate among BOOST participants at Piedmont over the age of 70 was 22%, compared with 26% of nonparticipants. When SSM St. Mary’s Medical Center in St. Louis implemented BOOST at its 33-bed hospitalist unit, 30-day readmissions dropped to 7% from 12% within three months.

Patient satisfaction rates also increased markedly, to 68% from 52%. And in 2009, the University of Pennsylvania Health System awarded its annual Operational Quality and Safety Award to the Project BOOST implementation team at the hospital.

BOOST’s Reach Expands

Project BOOST leaders are planning an aggressive expansion in the near future. In addition to the potential for new program sites, SHM has made materials available to hospitalists through the Project BOOST Resource Room at SHM’s newly redesigned Web site (see “The New Face of HospitalMedicine.org,” p. 12), www.hospitalmedicine.org/boost.

In addition to free resources, new BOOST materials are for sale through SHM’s online store. The Project BOOST Implementation Guide—available electronically for free through the resource room—is now available for sale as a hard copy. The online store also features a new Project BOOST instructional DVD for hospitalists, “Using Teach Back to Improve Communication with Patients.” TH

Brendon Shank is a freelance writer based in Philadelphia.

Reference

1. Rehospitalizations among patients in the Medicare fee-for-service program. N Engl J Med. 2009;360(14): 1418-1428.

Chapter Updates

The Historic Main Street Trolley in Memphis, Tenn.

Memphis

The Memphis chapter held its quarterly meeting Feb. 4 at Erling Jensen in Memphis, Tenn. Dr. William Edmonson of the North Mississippi Medical Center in Tupelo, Miss., discussed “Updates on COPD.” Boehringer Engelheim sponsored the dinner meeting, which was attended by hospitalists and physicians in the area as well as hospital nurses and administration.

Milwaukee/Southeast Wisconsin

The Milwaukee/Southeast Wisconsin chapter’s Feb. 27 meeting in the Columbia Hospital Auditorium brought together hospitalists, nurse practitioners, pharmacists, and others from the Milwaukee area. Attendees were able to obtain CME credit on topics including acute coronary syndrome, hyponatremia, and sepsis. The meeting highlight was a presentation from Dr. Alpesh Amin, interim chair of the Department of Medicine at the University of California at Irvine. Dr. Amin discussed how to start up a local SHM chapter. Sponsorship from CME University helped make the chapter’s first HM symposium a success.

Nebraska Area

Lincoln HM group Bryan LGH hosted the Nebraska Area chapter quarterly meeting Feb. 23. Dr. Tamer Mahrous gave an overview of coding issues for hospitalists. A copy of the presentation will be sent to all of the chapter members.

The chapter elected officers to serve terms through 2012. They include: Dr. Eric Rice, president; Russ Cowles, vice president; Alissa Clough, secretary; and Jay Snow, officer at large.

Several additional items were discussed, including topics for upcoming meetings, how the chapter can best take advantage of opportunities at HM10, the possibility of launching a chapter newsletter, and organizational issues.

Hospitalists will be essential players in helping their institutions prepare for the Recovery Audit Contractor (RAC) program, now being rolled out nationwide by the Centers for Medicare & Medicaid Services (CMS). The program is part of CMS’ arsenal to ferret out improper payments and prevent fraud, waste, and abuse in the Medicare system.

All providers who bill Medicare fee-for-service are fair game for an RAC audit, which scrutinizes medical records to validate diagnosis-related groups (DRGs), coding, and the necessity of care provided by hospitals. Hospitalists are being asked to document their diagnosis and treatment decisions more precisely and thoroughly than ever, ensuring that DRG coding is appropriate, medical necessity is watertight, and hospitals are defended from costly overpayment recovery.

Specificity of documentation is the hospitalist’s most potent weapon against this new layer of federal audits.

In a three-year demonstration of the RAC program that ended in March 2008, one-third of all medical records audited resulted in an overpayment finding and collection. RACs collected more than $900 million in overpayments and returned nearly $38 million in underpayments. One-third of provider appeals (physician, hospital, and other providers) were successful during the demo program, according to a June 2008 CMS evaluation report. (Download a copy of the report at www.cms.hhs.gov/RAC/Downloads/RAC_Demonstration_Evaluation_Report.pdf.)

How the Audits Work

Coding rules and terminology often don’t match what we’re used to writing in the record. So hospitalists need to learn what these connections are and use them in their medical record documentation. This is a core skill for hospitalists: being able to translate clinical terminology into the correct coding terminology for hospitals and coders.—Richard D. Pinson, MD, FACP, CCS, principal, HCQ Consulting, Nashville, Tenn.

Listen to an interview with Dr. Pinson

Out of concern that the Medicare Trust Fund might not be adequately protected against improper payments by existing error detection and prevention efforts, Congress directed CMS to use RACs to identify and recoup Medicare overpayments under Section 306 of the Medicare Modernization Act of 2003, and directed CMS to make the program permanent by 2010 under Section 302 of the Tax Relief and Health Care Act of 2006. According to CMS, RACs were implemented so that physicians and other providers could avoid submitting claims that do not comply with Medicare rules, CMS could lower its error rate, and taxpayers and future Medicare beneficiaries would be protected.1

CMS has contracted with four regional RACs for the national program, and each will use proprietary auditing software to review paid claims from Medicare Part A and Part B providers to ensure that they meet Medicare’s statutory, regulatory, and policy requirements and regulations.

The RACs use automated review for claims that clearly contain errors that resulted in improper payments (e.g., claims for duplicate or uncovered services, claims that violate a written Medicare policy or sanctioned coding guideline), in which case the RAC notifies the provider of the overpayment. For cases in which there is a high probability—but not certainty—that the claim contains an overpayment, the RAC requests medical records from the provider (including imaged medical records on CD or DVD) to conduct a complex review and make a determination as to whether payment of the claim was correct, or whether there was an over- or underpayment.

CMS uses a Web-based data warehouse to ensure that RACs do not review claims that have previously been reviewed by another entity, such as a Medicare carrier, fiscal intermediary, the Office of Inspector General, or a quality-improvement organization (QIO).

Connie Leonard

The four regional RACs are ramping up their claim review activities in all states, says Connie Leonard, director of CMS’ Division of Recovery Audit Operations. When overpayments are confirmed, the RACs issue letters demanding providers to repay their Medicare carrier or intermediary within 30 days. For confirmed underpayments, RACs inform the provider’s Medicare contractor or fiscal intermediary, which then forwards the additional payment, Leonard says.

Providers can repay an overpayment by check or installment plan on or before 30 days after receiving the RAC demand letter. The Medicare contractors use recoupment—reducing present or future Medicare payments—on day 41. Providers who wish to dispute overpayment charges can take their case through the usual Medicare claims appeal process. RACs also offer a “discussion period”—from the date the provider gets a “Detailed Review Results” letter until the date of recoupment—to discuss with the RAC an improper payment determination outside the normal appeal process, Leonard says.

RACs are targeting confusion between septicemia and urosepsis.

—Kathy DeVault, RHIA, CCS, CCS-P, manager, Professional Practice Resources, American Health Information Management Association, Chicago

If providers disagree with the RAC’s determination, Leonard says, they should either 1) pay by check by day 30 and file for appeal by day 120 of the demand letter; 2) allow recoupment on day 41 and file for appeal by day 120; 3) stop the recoupment by filing an appeal by day 30; or 4) request an extended payment plan and appeal by day 120.

Some physicians in the demonstration project regarded the third-party RAC companies as “bounty hunters” operating without sufficient CMS oversight, imposing undue administrative burdens on physician practices, and lacking the clinical expertise to adjudicate claims appropriately, according to Michael Schweitz, MD, a rheumatologist from West Palm Beach, Fla., who testified before a Congressional committee in 2008 about RAC activities.

In response, CMS has modified the program (see “Refinements in Permanent RAC Program,” p. 8) in several ways to address those flaws and ensure a fair and smooth auditing process, Leonard says. (Listen to an audio interview with Ms. Leonard)

Connie Leonard

All About the Details

Because RACs focus on coding and documentation that fails to support DRG designations, hospitalists who focus on accurate and precise documentation that can be coded properly will greatly help their hospitals defend against RAC audits, as well as yield better payment and improved quality scores, says Richard D. Pinson, MD, FACP, CCS, principal of HCQ Consulting in Nashville, Tenn. Pinson will present “Documentation Tips Your Hospital Will Love You For” at HM10 in Washington, D.C., this month. A video/audio download of the presentation will be available on SHM’s Web site in May.

“Coding rules and terminology often don’t match what we’re used to writing in the record, so hospitalists need to learn what these connections are and use them in their medical record documentation,” Pinson says. “This is a core skill for hospitalists: being able to translate clinical terminology into the correct coding terminology for hospitals and coders.”

For example, if a hospitalist sees that a pre-operative patient has severe congestive heart failure, that condition cannot be coded as a complication of the patient’s care or considered as such in the DRG assignment, Pinson explains. If the hospitalist says the patient has an acute exacerbation of systolic heart failure, then that is a major comorbidity and ought to be documented as such. The average value of a major comorbidity in a surgical case could be as much as $20,000 per case, Pinson notes. If the DRG assignment included acute exacerbation but the medical chart only said severe congestive heart failure, the hospital would face recoupment of payment from an RAC audit.

“If we’re inconsistent or ambiguous in how we apply our terms, we can end up inadvertently upcoding. The key is: Learn to use the right terms that correspond to the right codes, based on what your patient actually has, and then be consistent throughout the record in your use of those terms,” Pinson says. For example, “we may admit a patient and say at the very beginning that the patient probably has aspiration pneumonia. We then treat the patient for aspiration pneumonia but leave it out of the discharge summary. The coder may code aspiration pneumonia, but the RAC auditor may point out that it was only mentioned in the patient’s record once, as possible, and may recoup any payment for treatment beyond simple pneumonia.”

Level of care and symptom-based DRG designations are red flags for RAC recovery, Pinson says. When the auditor sees a DRG based on symptoms rather than diagnoses (e.g., chest pain, syncope, transient ischemic attack, dehydration) and it is billed as inpatient status instead of observation status, that’s a target. Those symptoms, he says, often don’t meet the medical necessity criteria for inpatient status.

Pinson advises hospitalists to ask their institution’s case-management department, or hire an external consultant, to abstract key criteria for patient status designation, and to consider starting a patient as observation status until a precise diagnosis can be made that warrants hospital admission. Hospitalists should then describe the patient’s situation more precisely in the medical record as a diagnosis, not just as symptoms—e.g., syncope suspected due to cardiac arrhythmia, or chest pain suspected to be angina.

“For inpatient billing, those uncertain diagnoses, described that way, count as if they were established conditions. They don’t go into symptom DRGs,” Pinson says. “If you’re doing these things to protect the validity of you hospital’s billing, you’ll be protecting yourself at the same time, and it’s unlikely that RACs will single you out at all for auditing.”

Hospitalists can be valuable participants on their institutions’ RAC response team, providing clinical clarification on cases and helping to draft appeal letters.

There are several other red flags that RACs zero in on and hospitalists should watch out for, says Kathy DeVault, RHIA, CCS, CCS-P, manager of Professional Practice Resources for the American Health Information Management Association (AHIMA). Specificity in the medical record makes all the difference. For example, by identifying incorrect coding for excisional debridement (removal of infected tissue), RACs collected nearly $18 million in overpayments in fiscal-year 2006 because medical record documentation omitted such details as the word “excisional” (e.g., sharp debridement coded as excisional debridement), whether it was performed in the operating room or not, instruments used, the extent and depth of the procedure, and if the cutting of tissue was outside or beyond the wound margin.

DeVault warns that “RACs are targeting confusion between septicemia and urosepsis.” According to CMS, if the hospital reports a patient’s principal diagnosis as septicemia (03.89) but the medical record indicates the diagnosis of urosepsis, the RAC will bump the diagnosis code down to urinary tract infection (599.0), a lower-payment DRG, and demand recoupment.1

Urosepsis does not have a specific ICD-9-CM diagnosis code, and defaults to a simple UTI code, as referenced in ICD-9-CM. Unless the physician states in his or her documentation that the patient’s condition was systemic sepsis or septicemia, urosepsis would be coded as a UTI. RACS also denied some respiratory-failure claims for incorrect sequencing of principal diagnosis (e.g., respiratory failure vs. sepsis). The American Hospital Association has issued a regulatory advisory about these issues (web.mhanet.com/userdocs/articles/RAC/AHA_RAC_Coding Advisory_071608.pdf).

DeVault highlights three additional RAC targets that might impact HM:

• Documentation for transbronchial biopsy (a surgical DRG) in which the medical record only shows pathology of bronchus tissue (which RACs regard as nonsurgical);
• Failure to document the severity of a patient’s anemia as such to meet the medical necessity requirement of a blood transfusion (e.g., a chronic blood loss anemia or a pernicious anemia); and
• Documentation of treatments performed by intensivists in an ICU. By the time a patient’s attending physician sees their patient out of the ICU, DeVault says, their acute renal failure could be turned around but the attending might not document what happened in the ICU. The intensivist must see to it that the documentation allows the appropriate DRG assignment for the level of care the patient received.

AHIMA has published a 65-page RAC Audit Toolkit that describes the audit process, outlines preparations and procedures, and offers concrete guidance for appeals. Download a copy at www.ahima.org/infocenter/documents/RACToolkitFINAL.pdf. TH

Chris Guadagnino is a freelance medical writer based in Philadelphia.

Reference

1. The Medicare Recovery Audit Contractor (RAC) program: an evaluation of the 3-year demonstration. CMS Web site. Available at: www.cms.hhs.gov/RAC/Downloads/RACEvaluationReport.pdf. Accessed March 3, 2010.

Refinements in CMS’ Permanent RAC Program

Connie Leonard

Based on lessons learned from demonstration programs, CMS has made a number of changes to the permanent Recovery Audit Contractor (RAC) program.

Among the changes are:

• RACs cannot audit claims earlier than three years from the start of the program, with a maximum look-back date of October 1, 2007;
• For physicians, RACs are limited to requesting 10 medical records per 45 days from a single physician, 20 medical records from a small practice of two to five physicians, 30 from a group of six to 15, and 50 from a large group of more than 16 physicians;
• For hospitals, RACs are limited to requesting 1% of all claims submitted for the previous calendar year, divided into eight periods (45 days). Although the RACs may go more than 45 days between record requests, in no case shall they make requests more frequently than every 45 days;
• RACs must send a “Detailed Review Results” letter within 60 calendar days of receipt of the medical records they request for review;
• Each RAC must hire a physician medical director and certified coders, and providers may request the credentials of their auditor and request to speak to their RAC’s medical director regarding a claim denial;
• All new issues that an RAC wishes to pursue for overpayments must be validated by CMS or an independent RAC validation contractor, and posted to the RAC’s Web site before widespread review;
• RACS must have a Web-based “Claim Status” platform that will allow providers to track the status of medical record submissions to RACs;
• RACs must pay back contingency fees when an improper payment determination is overturned at any level in the appeals process (demo RACs were allowed to retain them on determinations overturned on second- and third-level appeal); and
• RAC validation contractors will conduct a third-party review of RAC claims determinations and provide annual accuracy scores for each RAC.—CG

Hospitalists will be essential players in helping their institutions prepare for the Recovery Audit Contractor (RAC) program, now being rolled out nationwide by the Centers for Medicare & Medicaid Services (CMS). The program is part of CMS’ arsenal to ferret out improper payments and prevent fraud, waste, and abuse in the Medicare system.

All providers who bill Medicare fee-for-service are fair game for an RAC audit, which scrutinizes medical records to validate diagnosis-related groups (DRGs), coding, and the necessity of care provided by hospitals. Hospitalists are being asked to document their diagnosis and treatment decisions more precisely and thoroughly than ever, ensuring that DRG coding is appropriate, medical necessity is watertight, and hospitals are defended from costly overpayment recovery.

Specificity of documentation is the hospitalist’s most potent weapon against this new layer of federal audits.

In a three-year demonstration of the RAC program that ended in March 2008, one-third of all medical records audited resulted in an overpayment finding and collection. RACs collected more than $900 million in overpayments and returned nearly $38 million in underpayments. One-third of provider appeals (physician, hospital, and other providers) were successful during the demo program, according to a June 2008 CMS evaluation report. (Download a copy of the report at www.cms.hhs.gov/RAC/Downloads/RAC_Demonstration_Evaluation_Report.pdf.)

How the Audits Work

Coding rules and terminology often don’t match what we’re used to writing in the record. So hospitalists need to learn what these connections are and use them in their medical record documentation. This is a core skill for hospitalists: being able to translate clinical terminology into the correct coding terminology for hospitals and coders.—Richard D. Pinson, MD, FACP, CCS, principal, HCQ Consulting, Nashville, Tenn.

Listen to an interview with Dr. Pinson

Out of concern that the Medicare Trust Fund might not be adequately protected against improper payments by existing error detection and prevention efforts, Congress directed CMS to use RACs to identify and recoup Medicare overpayments under Section 306 of the Medicare Modernization Act of 2003, and directed CMS to make the program permanent by 2010 under Section 302 of the Tax Relief and Health Care Act of 2006. According to CMS, RACs were implemented so that physicians and other providers could avoid submitting claims that do not comply with Medicare rules, CMS could lower its error rate, and taxpayers and future Medicare beneficiaries would be protected.1

CMS has contracted with four regional RACs for the national program, and each will use proprietary auditing software to review paid claims from Medicare Part A and Part B providers to ensure that they meet Medicare’s statutory, regulatory, and policy requirements and regulations.

The RACs use automated review for claims that clearly contain errors that resulted in improper payments (e.g., claims for duplicate or uncovered services, claims that violate a written Medicare policy or sanctioned coding guideline), in which case the RAC notifies the provider of the overpayment. For cases in which there is a high probability—but not certainty—that the claim contains an overpayment, the RAC requests medical records from the provider (including imaged medical records on CD or DVD) to conduct a complex review and make a determination as to whether payment of the claim was correct, or whether there was an over- or underpayment.

CMS uses a Web-based data warehouse to ensure that RACs do not review claims that have previously been reviewed by another entity, such as a Medicare carrier, fiscal intermediary, the Office of Inspector General, or a quality-improvement organization (QIO).

Connie Leonard

The four regional RACs are ramping up their claim review activities in all states, says Connie Leonard, director of CMS’ Division of Recovery Audit Operations. When overpayments are confirmed, the RACs issue letters demanding providers to repay their Medicare carrier or intermediary within 30 days. For confirmed underpayments, RACs inform the provider’s Medicare contractor or fiscal intermediary, which then forwards the additional payment, Leonard says.

Providers can repay an overpayment by check or installment plan on or before 30 days after receiving the RAC demand letter. The Medicare contractors use recoupment—reducing present or future Medicare payments—on day 41. Providers who wish to dispute overpayment charges can take their case through the usual Medicare claims appeal process. RACs also offer a “discussion period”—from the date the provider gets a “Detailed Review Results” letter until the date of recoupment—to discuss with the RAC an improper payment determination outside the normal appeal process, Leonard says.

RACs are targeting confusion between septicemia and urosepsis.

—Kathy DeVault, RHIA, CCS, CCS-P, manager, Professional Practice Resources, American Health Information Management Association, Chicago

If providers disagree with the RAC’s determination, Leonard says, they should either 1) pay by check by day 30 and file for appeal by day 120 of the demand letter; 2) allow recoupment on day 41 and file for appeal by day 120; 3) stop the recoupment by filing an appeal by day 30; or 4) request an extended payment plan and appeal by day 120.

Some physicians in the demonstration project regarded the third-party RAC companies as “bounty hunters” operating without sufficient CMS oversight, imposing undue administrative burdens on physician practices, and lacking the clinical expertise to adjudicate claims appropriately, according to Michael Schweitz, MD, a rheumatologist from West Palm Beach, Fla., who testified before a Congressional committee in 2008 about RAC activities.

In response, CMS has modified the program (see “Refinements in Permanent RAC Program,” p. 8) in several ways to address those flaws and ensure a fair and smooth auditing process, Leonard says. (Listen to an audio interview with Ms. Leonard)

Connie Leonard

All About the Details

Because RACs focus on coding and documentation that fails to support DRG designations, hospitalists who focus on accurate and precise documentation that can be coded properly will greatly help their hospitals defend against RAC audits, as well as yield better payment and improved quality scores, says Richard D. Pinson, MD, FACP, CCS, principal of HCQ Consulting in Nashville, Tenn. Pinson will present “Documentation Tips Your Hospital Will Love You For” at HM10 in Washington, D.C., this month. A video/audio download of the presentation will be available on SHM’s Web site in May.

“Coding rules and terminology often don’t match what we’re used to writing in the record, so hospitalists need to learn what these connections are and use them in their medical record documentation,” Pinson says. “This is a core skill for hospitalists: being able to translate clinical terminology into the correct coding terminology for hospitals and coders.”

For example, if a hospitalist sees that a pre-operative patient has severe congestive heart failure, that condition cannot be coded as a complication of the patient’s care or considered as such in the DRG assignment, Pinson explains. If the hospitalist says the patient has an acute exacerbation of systolic heart failure, then that is a major comorbidity and ought to be documented as such. The average value of a major comorbidity in a surgical case could be as much as $20,000 per case, Pinson notes. If the DRG assignment included acute exacerbation but the medical chart only said severe congestive heart failure, the hospital would face recoupment of payment from an RAC audit.

“If we’re inconsistent or ambiguous in how we apply our terms, we can end up inadvertently upcoding. The key is: Learn to use the right terms that correspond to the right codes, based on what your patient actually has, and then be consistent throughout the record in your use of those terms,” Pinson says. For example, “we may admit a patient and say at the very beginning that the patient probably has aspiration pneumonia. We then treat the patient for aspiration pneumonia but leave it out of the discharge summary. The coder may code aspiration pneumonia, but the RAC auditor may point out that it was only mentioned in the patient’s record once, as possible, and may recoup any payment for treatment beyond simple pneumonia.”

Level of care and symptom-based DRG designations are red flags for RAC recovery, Pinson says. When the auditor sees a DRG based on symptoms rather than diagnoses (e.g., chest pain, syncope, transient ischemic attack, dehydration) and it is billed as inpatient status instead of observation status, that’s a target. Those symptoms, he says, often don’t meet the medical necessity criteria for inpatient status.

Pinson advises hospitalists to ask their institution’s case-management department, or hire an external consultant, to abstract key criteria for patient status designation, and to consider starting a patient as observation status until a precise diagnosis can be made that warrants hospital admission. Hospitalists should then describe the patient’s situation more precisely in the medical record as a diagnosis, not just as symptoms—e.g., syncope suspected due to cardiac arrhythmia, or chest pain suspected to be angina.

“For inpatient billing, those uncertain diagnoses, described that way, count as if they were established conditions. They don’t go into symptom DRGs,” Pinson says. “If you’re doing these things to protect the validity of you hospital’s billing, you’ll be protecting yourself at the same time, and it’s unlikely that RACs will single you out at all for auditing.”

Hospitalists can be valuable participants on their institutions’ RAC response team, providing clinical clarification on cases and helping to draft appeal letters.

There are several other red flags that RACs zero in on and hospitalists should watch out for, says Kathy DeVault, RHIA, CCS, CCS-P, manager of Professional Practice Resources for the American Health Information Management Association (AHIMA). Specificity in the medical record makes all the difference. For example, by identifying incorrect coding for excisional debridement (removal of infected tissue), RACs collected nearly $18 million in overpayments in fiscal-year 2006 because medical record documentation omitted such details as the word “excisional” (e.g., sharp debridement coded as excisional debridement), whether it was performed in the operating room or not, instruments used, the extent and depth of the procedure, and if the cutting of tissue was outside or beyond the wound margin.

DeVault warns that “RACs are targeting confusion between septicemia and urosepsis.” According to CMS, if the hospital reports a patient’s principal diagnosis as septicemia (03.89) but the medical record indicates the diagnosis of urosepsis, the RAC will bump the diagnosis code down to urinary tract infection (599.0), a lower-payment DRG, and demand recoupment.1

Urosepsis does not have a specific ICD-9-CM diagnosis code, and defaults to a simple UTI code, as referenced in ICD-9-CM. Unless the physician states in his or her documentation that the patient’s condition was systemic sepsis or septicemia, urosepsis would be coded as a UTI. RACS also denied some respiratory-failure claims for incorrect sequencing of principal diagnosis (e.g., respiratory failure vs. sepsis). The American Hospital Association has issued a regulatory advisory about these issues (web.mhanet.com/userdocs/articles/RAC/AHA_RAC_Coding Advisory_071608.pdf).

DeVault highlights three additional RAC targets that might impact HM:

• Documentation for transbronchial biopsy (a surgical DRG) in which the medical record only shows pathology of bronchus tissue (which RACs regard as nonsurgical);
• Failure to document the severity of a patient’s anemia as such to meet the medical necessity requirement of a blood transfusion (e.g., a chronic blood loss anemia or a pernicious anemia); and
• Documentation of treatments performed by intensivists in an ICU. By the time a patient’s attending physician sees their patient out of the ICU, DeVault says, their acute renal failure could be turned around but the attending might not document what happened in the ICU. The intensivist must see to it that the documentation allows the appropriate DRG assignment for the level of care the patient received.

AHIMA has published a 65-page RAC Audit Toolkit that describes the audit process, outlines preparations and procedures, and offers concrete guidance for appeals. Download a copy at www.ahima.org/infocenter/documents/RACToolkitFINAL.pdf. TH

Chris Guadagnino is a freelance medical writer based in Philadelphia.

Reference

1. The Medicare Recovery Audit Contractor (RAC) program: an evaluation of the 3-year demonstration. CMS Web site. Available at: www.cms.hhs.gov/RAC/Downloads/RACEvaluationReport.pdf. Accessed March 3, 2010.

Refinements in CMS’ Permanent RAC Program

Connie Leonard

Based on lessons learned from demonstration programs, CMS has made a number of changes to the permanent Recovery Audit Contractor (RAC) program.

Among the changes are:

• RACs cannot audit claims earlier than three years from the start of the program, with a maximum look-back date of October 1, 2007;
• For physicians, RACs are limited to requesting 10 medical records per 45 days from a single physician, 20 medical records from a small practice of two to five physicians, 30 from a group of six to 15, and 50 from a large group of more than 16 physicians;
• For hospitals, RACs are limited to requesting 1% of all claims submitted for the previous calendar year, divided into eight periods (45 days). Although the RACs may go more than 45 days between record requests, in no case shall they make requests more frequently than every 45 days;
• RACs must send a “Detailed Review Results” letter within 60 calendar days of receipt of the medical records they request for review;
• Each RAC must hire a physician medical director and certified coders, and providers may request the credentials of their auditor and request to speak to their RAC’s medical director regarding a claim denial;
• All new issues that an RAC wishes to pursue for overpayments must be validated by CMS or an independent RAC validation contractor, and posted to the RAC’s Web site before widespread review;
• RACS must have a Web-based “Claim Status” platform that will allow providers to track the status of medical record submissions to RACs;
• RACs must pay back contingency fees when an improper payment determination is overturned at any level in the appeals process (demo RACs were allowed to retain them on determinations overturned on second- and third-level appeal); and
• RAC validation contractors will conduct a third-party review of RAC claims determinations and provide annual accuracy scores for each RAC.—CG

Hospitalists will be essential players in helping their institutions prepare for the Recovery Audit Contractor (RAC) program, now being rolled out nationwide by the Centers for Medicare & Medicaid Services (CMS). The program is part of CMS’ arsenal to ferret out improper payments and prevent fraud, waste, and abuse in the Medicare system.

All providers who bill Medicare fee-for-service are fair game for an RAC audit, which scrutinizes medical records to validate diagnosis-related groups (DRGs), coding, and the necessity of care provided by hospitals. Hospitalists are being asked to document their diagnosis and treatment decisions more precisely and thoroughly than ever, ensuring that DRG coding is appropriate, medical necessity is watertight, and hospitals are defended from costly overpayment recovery.

Specificity of documentation is the hospitalist’s most potent weapon against this new layer of federal audits.

In a three-year demonstration of the RAC program that ended in March 2008, one-third of all medical records audited resulted in an overpayment finding and collection. RACs collected more than $900 million in overpayments and returned nearly $38 million in underpayments. One-third of provider appeals (physician, hospital, and other providers) were successful during the demo program, according to a June 2008 CMS evaluation report. (Download a copy of the report at www.cms.hhs.gov/RAC/Downloads/RAC_Demonstration_Evaluation_Report.pdf.)

How the Audits Work

Coding rules and terminology often don’t match what we’re used to writing in the record. So hospitalists need to learn what these connections are and use them in their medical record documentation. This is a core skill for hospitalists: being able to translate clinical terminology into the correct coding terminology for hospitals and coders.—Richard D. Pinson, MD, FACP, CCS, principal, HCQ Consulting, Nashville, Tenn.

Listen to an interview with Dr. Pinson

Out of concern that the Medicare Trust Fund might not be adequately protected against improper payments by existing error detection and prevention efforts, Congress directed CMS to use RACs to identify and recoup Medicare overpayments under Section 306 of the Medicare Modernization Act of 2003, and directed CMS to make the program permanent by 2010 under Section 302 of the Tax Relief and Health Care Act of 2006. According to CMS, RACs were implemented so that physicians and other providers could avoid submitting claims that do not comply with Medicare rules, CMS could lower its error rate, and taxpayers and future Medicare beneficiaries would be protected.1

CMS has contracted with four regional RACs for the national program, and each will use proprietary auditing software to review paid claims from Medicare Part A and Part B providers to ensure that they meet Medicare’s statutory, regulatory, and policy requirements and regulations.

The RACs use automated review for claims that clearly contain errors that resulted in improper payments (e.g., claims for duplicate or uncovered services, claims that violate a written Medicare policy or sanctioned coding guideline), in which case the RAC notifies the provider of the overpayment. For cases in which there is a high probability—but not certainty—that the claim contains an overpayment, the RAC requests medical records from the provider (including imaged medical records on CD or DVD) to conduct a complex review and make a determination as to whether payment of the claim was correct, or whether there was an over- or underpayment.

CMS uses a Web-based data warehouse to ensure that RACs do not review claims that have previously been reviewed by another entity, such as a Medicare carrier, fiscal intermediary, the Office of Inspector General, or a quality-improvement organization (QIO).

Connie Leonard

The four regional RACs are ramping up their claim review activities in all states, says Connie Leonard, director of CMS’ Division of Recovery Audit Operations. When overpayments are confirmed, the RACs issue letters demanding providers to repay their Medicare carrier or intermediary within 30 days. For confirmed underpayments, RACs inform the provider’s Medicare contractor or fiscal intermediary, which then forwards the additional payment, Leonard says.

Providers can repay an overpayment by check or installment plan on or before 30 days after receiving the RAC demand letter. The Medicare contractors use recoupment—reducing present or future Medicare payments—on day 41. Providers who wish to dispute overpayment charges can take their case through the usual Medicare claims appeal process. RACs also offer a “discussion period”—from the date the provider gets a “Detailed Review Results” letter until the date of recoupment—to discuss with the RAC an improper payment determination outside the normal appeal process, Leonard says.

RACs are targeting confusion between septicemia and urosepsis.

—Kathy DeVault, RHIA, CCS, CCS-P, manager, Professional Practice Resources, American Health Information Management Association, Chicago

If providers disagree with the RAC’s determination, Leonard says, they should either 1) pay by check by day 30 and file for appeal by day 120 of the demand letter; 2) allow recoupment on day 41 and file for appeal by day 120; 3) stop the recoupment by filing an appeal by day 30; or 4) request an extended payment plan and appeal by day 120.

Some physicians in the demonstration project regarded the third-party RAC companies as “bounty hunters” operating without sufficient CMS oversight, imposing undue administrative burdens on physician practices, and lacking the clinical expertise to adjudicate claims appropriately, according to Michael Schweitz, MD, a rheumatologist from West Palm Beach, Fla., who testified before a Congressional committee in 2008 about RAC activities.

In response, CMS has modified the program (see “Refinements in Permanent RAC Program,” p. 8) in several ways to address those flaws and ensure a fair and smooth auditing process, Leonard says. (Listen to an audio interview with Ms. Leonard)

Connie Leonard

All About the Details

Because RACs focus on coding and documentation that fails to support DRG designations, hospitalists who focus on accurate and precise documentation that can be coded properly will greatly help their hospitals defend against RAC audits, as well as yield better payment and improved quality scores, says Richard D. Pinson, MD, FACP, CCS, principal of HCQ Consulting in Nashville, Tenn. Pinson will present “Documentation Tips Your Hospital Will Love You For” at HM10 in Washington, D.C., this month. A video/audio download of the presentation will be available on SHM’s Web site in May.

“Coding rules and terminology often don’t match what we’re used to writing in the record, so hospitalists need to learn what these connections are and use them in their medical record documentation,” Pinson says. “This is a core skill for hospitalists: being able to translate clinical terminology into the correct coding terminology for hospitals and coders.”

For example, if a hospitalist sees that a pre-operative patient has severe congestive heart failure, that condition cannot be coded as a complication of the patient’s care or considered as such in the DRG assignment, Pinson explains. If the hospitalist says the patient has an acute exacerbation of systolic heart failure, then that is a major comorbidity and ought to be documented as such. The average value of a major comorbidity in a surgical case could be as much as $20,000 per case, Pinson notes. If the DRG assignment included acute exacerbation but the medical chart only said severe congestive heart failure, the hospital would face recoupment of payment from an RAC audit.

“If we’re inconsistent or ambiguous in how we apply our terms, we can end up inadvertently upcoding. The key is: Learn to use the right terms that correspond to the right codes, based on what your patient actually has, and then be consistent throughout the record in your use of those terms,” Pinson says. For example, “we may admit a patient and say at the very beginning that the patient probably has aspiration pneumonia. We then treat the patient for aspiration pneumonia but leave it out of the discharge summary. The coder may code aspiration pneumonia, but the RAC auditor may point out that it was only mentioned in the patient’s record once, as possible, and may recoup any payment for treatment beyond simple pneumonia.”

Level of care and symptom-based DRG designations are red flags for RAC recovery, Pinson says. When the auditor sees a DRG based on symptoms rather than diagnoses (e.g., chest pain, syncope, transient ischemic attack, dehydration) and it is billed as inpatient status instead of observation status, that’s a target. Those symptoms, he says, often don’t meet the medical necessity criteria for inpatient status.

Pinson advises hospitalists to ask their institution’s case-management department, or hire an external consultant, to abstract key criteria for patient status designation, and to consider starting a patient as observation status until a precise diagnosis can be made that warrants hospital admission. Hospitalists should then describe the patient’s situation more precisely in the medical record as a diagnosis, not just as symptoms—e.g., syncope suspected due to cardiac arrhythmia, or chest pain suspected to be angina.

“For inpatient billing, those uncertain diagnoses, described that way, count as if they were established conditions. They don’t go into symptom DRGs,” Pinson says. “If you’re doing these things to protect the validity of you hospital’s billing, you’ll be protecting yourself at the same time, and it’s unlikely that RACs will single you out at all for auditing.”

Hospitalists can be valuable participants on their institutions’ RAC response team, providing clinical clarification on cases and helping to draft appeal letters.

There are several other red flags that RACs zero in on and hospitalists should watch out for, says Kathy DeVault, RHIA, CCS, CCS-P, manager of Professional Practice Resources for the American Health Information Management Association (AHIMA). Specificity in the medical record makes all the difference. For example, by identifying incorrect coding for excisional debridement (removal of infected tissue), RACs collected nearly $18 million in overpayments in fiscal-year 2006 because medical record documentation omitted such details as the word “excisional” (e.g., sharp debridement coded as excisional debridement), whether it was performed in the operating room or not, instruments used, the extent and depth of the procedure, and if the cutting of tissue was outside or beyond the wound margin.

DeVault warns that “RACs are targeting confusion between septicemia and urosepsis.” According to CMS, if the hospital reports a patient’s principal diagnosis as septicemia (03.89) but the medical record indicates the diagnosis of urosepsis, the RAC will bump the diagnosis code down to urinary tract infection (599.0), a lower-payment DRG, and demand recoupment.1

Urosepsis does not have a specific ICD-9-CM diagnosis code, and defaults to a simple UTI code, as referenced in ICD-9-CM. Unless the physician states in his or her documentation that the patient’s condition was systemic sepsis or septicemia, urosepsis would be coded as a UTI. RACS also denied some respiratory-failure claims for incorrect sequencing of principal diagnosis (e.g., respiratory failure vs. sepsis). The American Hospital Association has issued a regulatory advisory about these issues (web.mhanet.com/userdocs/articles/RAC/AHA_RAC_Coding Advisory_071608.pdf).

DeVault highlights three additional RAC targets that might impact HM:

• Documentation for transbronchial biopsy (a surgical DRG) in which the medical record only shows pathology of bronchus tissue (which RACs regard as nonsurgical);
• Failure to document the severity of a patient’s anemia as such to meet the medical necessity requirement of a blood transfusion (e.g., a chronic blood loss anemia or a pernicious anemia); and
• Documentation of treatments performed by intensivists in an ICU. By the time a patient’s attending physician sees their patient out of the ICU, DeVault says, their acute renal failure could be turned around but the attending might not document what happened in the ICU. The intensivist must see to it that the documentation allows the appropriate DRG assignment for the level of care the patient received.

AHIMA has published a 65-page RAC Audit Toolkit that describes the audit process, outlines preparations and procedures, and offers concrete guidance for appeals. Download a copy at www.ahima.org/infocenter/documents/RACToolkitFINAL.pdf. TH

Chris Guadagnino is a freelance medical writer based in Philadelphia.

Reference

1. The Medicare Recovery Audit Contractor (RAC) program: an evaluation of the 3-year demonstration. CMS Web site. Available at: www.cms.hhs.gov/RAC/Downloads/RACEvaluationReport.pdf. Accessed March 3, 2010.

Refinements in CMS’ Permanent RAC Program

Connie Leonard

Based on lessons learned from demonstration programs, CMS has made a number of changes to the permanent Recovery Audit Contractor (RAC) program.

Among the changes are:

• RACs cannot audit claims earlier than three years from the start of the program, with a maximum look-back date of October 1, 2007;
• For physicians, RACs are limited to requesting 10 medical records per 45 days from a single physician, 20 medical records from a small practice of two to five physicians, 30 from a group of six to 15, and 50 from a large group of more than 16 physicians;
• For hospitals, RACs are limited to requesting 1% of all claims submitted for the previous calendar year, divided into eight periods (45 days). Although the RACs may go more than 45 days between record requests, in no case shall they make requests more frequently than every 45 days;
• RACs must send a “Detailed Review Results” letter within 60 calendar days of receipt of the medical records they request for review;
• Each RAC must hire a physician medical director and certified coders, and providers may request the credentials of their auditor and request to speak to their RAC’s medical director regarding a claim denial;
• All new issues that an RAC wishes to pursue for overpayments must be validated by CMS or an independent RAC validation contractor, and posted to the RAC’s Web site before widespread review;
• RACS must have a Web-based “Claim Status” platform that will allow providers to track the status of medical record submissions to RACs;
• RACs must pay back contingency fees when an improper payment determination is overturned at any level in the appeals process (demo RACs were allowed to retain them on determinations overturned on second- and third-level appeal); and
• RAC validation contractors will conduct a third-party review of RAC claims determinations and provide annual accuracy scores for each RAC.—CG

Massachusetts Update

With the ongoing debate about healthcare reform, I’m curious to know how it worked out in Massachusetts. Didn’t they give everyone health insurance several years ago?

R. McCoy, MD

Birmingham, Ala.

Dr. Hospitalist responds: In 2006, Massachusetts legislators took the same approach to healthcare insurance as they do to auto insurance: require everyone to purchase a plan. If you can’t afford to purchase health insurance, the state provides you insurance through a state-subsidized plan. The state covers individuals earning up to 100% of the federal poverty level (FPL) and partially subsidizes coverage for those earning up to 300% of the FPL.

So how did Massachusetts come up with the money to pay for healthcare insurance for all of its residents? The state traditionally utilized money from a “free-care pool” to partially reimburse hospitals and community health centers for the care provided to indigents. The money in the free-care pool was generated from state and federal taxes, and from assessments on hospitals and healthcare insurance providers. With expanded insurance coverage, Massachusetts estimated that the cost of healthcare delivered to the uninsured would decrease, and the free-care pool could offset the remaining costs of insuring those below the FPL.

Starting in 2007, residents of Massachusetts were required to demonstrate proof of health insurance on their state income tax returns. The state levied penalties on those who failed to obtain coverage. The legislation also required insurers’ family plans to cover young adults up to age 25 or at least two years after they were no longer dependent on their parents. Additionally, businesses with 10 or more employees had to contribute a reasonable amount to their employees’ health insurance premiums or risk a financial penalty.

The Massachusetts health plan has produced both intended and unintended consequences. The plan was successful in its primary goal of insuring its citizens. By the end of 2008, 97% of Massachusetts’ residents were covered. But the system has not increased access to providers because of a shortage of primary-care physicians (PCPs). (Critics also point out that the plan has done nothing to increase the numbers of PCPs in the state.)

Another unexpected outcome is that healthcare costs have increased. The initial expectation was that increasing the percentage of insured individuals would lower overall costs. However, this has not been realized. In fact, the reallocation of funds from the free-care pool has birthed other problems. The state’s “safety net” hospitals—which traditionally have served urban, low-income populations—have experienced financial hardships.

These unexpected findings have not deterred Massachusetts from further efforts to address healthcare reform. In 2008, a special commission was charged with recommendations for a “common payment methodology” that would apply to both public and private payors. The goal is to slow the growth of healthcare costs without adversely affecting the quality of care.

The commission issued its recommendations in July 2009 (www.mass.gov). It suggested “Massachusetts has among the highest healthcare costs in the U.S. … and based on recent history, are projected to grow faster than for the U.S. as a whole.” In its report, the commission was critical of the present fee-for-service reimbursement model and stated that the model was the primary reason for escalating healthcare costs.

The commission noted the fee-for-service model rewards providers for providing more, but not better, care and also encourages providers to provide more-costly services without regard to evidence-based guidelines or a patient’s need. The commission recommended that “global payments with adjustments to reward provision of accessible and high-quality care become the predominant form of payment to providers in Massachusetts.” For the record, the legislature has not acted on the commission recommendations. TH

IMAGE SOURCE: AMANE KANEKO

Massachusetts Update

With the ongoing debate about healthcare reform, I’m curious to know how it worked out in Massachusetts. Didn’t they give everyone health insurance several years ago?

R. McCoy, MD

Birmingham, Ala.

Dr. Hospitalist responds: In 2006, Massachusetts legislators took the same approach to healthcare insurance as they do to auto insurance: require everyone to purchase a plan. If you can’t afford to purchase health insurance, the state provides you insurance through a state-subsidized plan. The state covers individuals earning up to 100% of the federal poverty level (FPL) and partially subsidizes coverage for those earning up to 300% of the FPL.

So how did Massachusetts come up with the money to pay for healthcare insurance for all of its residents? The state traditionally utilized money from a “free-care pool” to partially reimburse hospitals and community health centers for the care provided to indigents. The money in the free-care pool was generated from state and federal taxes, and from assessments on hospitals and healthcare insurance providers. With expanded insurance coverage, Massachusetts estimated that the cost of healthcare delivered to the uninsured would decrease, and the free-care pool could offset the remaining costs of insuring those below the FPL.

Starting in 2007, residents of Massachusetts were required to demonstrate proof of health insurance on their state income tax returns. The state levied penalties on those who failed to obtain coverage. The legislation also required insurers’ family plans to cover young adults up to age 25 or at least two years after they were no longer dependent on their parents. Additionally, businesses with 10 or more employees had to contribute a reasonable amount to their employees’ health insurance premiums or risk a financial penalty.

The Massachusetts health plan has produced both intended and unintended consequences. The plan was successful in its primary goal of insuring its citizens. By the end of 2008, 97% of Massachusetts’ residents were covered. But the system has not increased access to providers because of a shortage of primary-care physicians (PCPs). (Critics also point out that the plan has done nothing to increase the numbers of PCPs in the state.)

Another unexpected outcome is that healthcare costs have increased. The initial expectation was that increasing the percentage of insured individuals would lower overall costs. However, this has not been realized. In fact, the reallocation of funds from the free-care pool has birthed other problems. The state’s “safety net” hospitals—which traditionally have served urban, low-income populations—have experienced financial hardships.

These unexpected findings have not deterred Massachusetts from further efforts to address healthcare reform. In 2008, a special commission was charged with recommendations for a “common payment methodology” that would apply to both public and private payors. The goal is to slow the growth of healthcare costs without adversely affecting the quality of care.

The commission issued its recommendations in July 2009 (www.mass.gov). It suggested “Massachusetts has among the highest healthcare costs in the U.S. … and based on recent history, are projected to grow faster than for the U.S. as a whole.” In its report, the commission was critical of the present fee-for-service reimbursement model and stated that the model was the primary reason for escalating healthcare costs.

The commission noted the fee-for-service model rewards providers for providing more, but not better, care and also encourages providers to provide more-costly services without regard to evidence-based guidelines or a patient’s need. The commission recommended that “global payments with adjustments to reward provision of accessible and high-quality care become the predominant form of payment to providers in Massachusetts.” For the record, the legislature has not acted on the commission recommendations. TH

IMAGE SOURCE: AMANE KANEKO

Massachusetts Update

With the ongoing debate about healthcare reform, I’m curious to know how it worked out in Massachusetts. Didn’t they give everyone health insurance several years ago?

R. McCoy, MD

Birmingham, Ala.

Dr. Hospitalist responds: In 2006, Massachusetts legislators took the same approach to healthcare insurance as they do to auto insurance: require everyone to purchase a plan. If you can’t afford to purchase health insurance, the state provides you insurance through a state-subsidized plan. The state covers individuals earning up to 100% of the federal poverty level (FPL) and partially subsidizes coverage for those earning up to 300% of the FPL.

So how did Massachusetts come up with the money to pay for healthcare insurance for all of its residents? The state traditionally utilized money from a “free-care pool” to partially reimburse hospitals and community health centers for the care provided to indigents. The money in the free-care pool was generated from state and federal taxes, and from assessments on hospitals and healthcare insurance providers. With expanded insurance coverage, Massachusetts estimated that the cost of healthcare delivered to the uninsured would decrease, and the free-care pool could offset the remaining costs of insuring those below the FPL.

Starting in 2007, residents of Massachusetts were required to demonstrate proof of health insurance on their state income tax returns. The state levied penalties on those who failed to obtain coverage. The legislation also required insurers’ family plans to cover young adults up to age 25 or at least two years after they were no longer dependent on their parents. Additionally, businesses with 10 or more employees had to contribute a reasonable amount to their employees’ health insurance premiums or risk a financial penalty.

The Massachusetts health plan has produced both intended and unintended consequences. The plan was successful in its primary goal of insuring its citizens. By the end of 2008, 97% of Massachusetts’ residents were covered. But the system has not increased access to providers because of a shortage of primary-care physicians (PCPs). (Critics also point out that the plan has done nothing to increase the numbers of PCPs in the state.)

Another unexpected outcome is that healthcare costs have increased. The initial expectation was that increasing the percentage of insured individuals would lower overall costs. However, this has not been realized. In fact, the reallocation of funds from the free-care pool has birthed other problems. The state’s “safety net” hospitals—which traditionally have served urban, low-income populations—have experienced financial hardships.

These unexpected findings have not deterred Massachusetts from further efforts to address healthcare reform. In 2008, a special commission was charged with recommendations for a “common payment methodology” that would apply to both public and private payors. The goal is to slow the growth of healthcare costs without adversely affecting the quality of care.

The commission issued its recommendations in July 2009 (www.mass.gov). It suggested “Massachusetts has among the highest healthcare costs in the U.S. … and based on recent history, are projected to grow faster than for the U.S. as a whole.” In its report, the commission was critical of the present fee-for-service reimbursement model and stated that the model was the primary reason for escalating healthcare costs.

The commission noted the fee-for-service model rewards providers for providing more, but not better, care and also encourages providers to provide more-costly services without regard to evidence-based guidelines or a patient’s need. The commission recommended that “global payments with adjustments to reward provision of accessible and high-quality care become the predominant form of payment to providers in Massachusetts.” For the record, the legislature has not acted on the commission recommendations. TH

IMAGE SOURCE: AMANE KANEKO

While most of the focus has been on D.C. and the trillions of dollars to be spent on healthcare reform, HM has grown substantially in the last decade without any significant payment reform or new regulation. This is all the more incredible because the rise of HM has involved two institutions not synonymous with accepting or adapting to change: physicians and hospitals.

In the coming years, hospitals face important challenges, including their fiscal survival, public trust, workforce shortages, difficulty deciding whether their physicians are partners or competitors, and figuring out what to do about all this patient safety and performance improvement hubbub.

Although 2010’s version of healthcare reform will be about increasing access (see “An Imperfect Solution,” January 2010, p. 44), there are still the seeds planted to address the next two pillars of reform: reducing cost and rewarding performance. Together, they create the value proposition in healthcare. All this will make the coming decade one in which the hospital as an institution will need to evolve and adapt if it is to survive.

What is Quality?

As we enter a transitional phase, in some ways, we aren’t even clear on just what quality healthcare is:

• Is quality defined as a payment issue? We see this in discussions of not paying for “never events” or denying payment for readmissions.
• Is quality about being more satisfied? This is found in emphasis on the surveys of patient and family satisfaction that drive hospital CEO compensation and bonuses, as well as in efforts to improve staff retention or in recognition by business, insurers, and government.
• Is quality just checking things off on a clipboard? We all see the endless list of quality measures and increasing documentation that providers have told their patients to stop smoking or get a flu shot, but is that really the quality we are seeking in healthcare?
• Is quality just avoiding embarrassment? Is the best driver of performance improvement outraged hospital trustees wielding printouts comparing hospitals?

We do know that in some ways, the discussion at most of our hospitals has shifted from “Is quality important?” to “How do we do it?” And in this discussion, HM and SHM have taken a leading role in the “solutions” to the problem. Our innovative programs help reduce unnecessary DVTs, improve glycemic control, and refine the discharge process (see Project BOOST) for better patient/family satisfaction, reduced ED visits, and reduced readmissions.

New Ways to Deliver Care

The hospital of the future—I’m talking 2020—will not be defined by bricks and walls. The hospital stay will not end with a patient in a wheelchair being helped into their car. We already know that most patients don’t leave the hospital cured, but are discharged when they are not sick enough to need to stay recumbent in the most expensive hotel in the city. Often these patients are in midcourse of an acute illness, frequently imposed on top of chronic dysfunctions.

While the patient as the true “medical home” for their health and illness have always borne the potholes of slipped handoffs and information transfer deficits, hospitalists now have a clear view of the precarious nature of post-discharge care. Bundling and payment reform, designed to reward coordination of care and the reduction of readmissions to the ED, might be a revenue-driven boost to our ill-designed healthcare system, but the hospital, with the help of their hospitalists, can take the lead in fixing these problems. And we don’t have to wait for payment reform.

The good news is we aren’t alone in our efforts to change the culture, even the mission, of our hospitals. In a time of healthcarewide workforce shortages, there are increasing demands for direct inpatient care, coupled with the added time needed to document current performance and train and implement needed improvements. The only way to meet all of the volume and performance demands is with process change. We need a different way to deliver care to hospitalized patients.

All-Star Teams

High-performing organizations are composed of high-performance teams and a set of operating principles that create a widespread culture of motivated individuals who are focused on metrics, are execution-driven, and are committed to continual improvement and rapid adaptation.

The characteristics of high-performance teams are that they:

• Self-correct and reallocate resources;
• Have clear roles and responsibilities;
• Have clear, valued, and shared visions;
• Have strong team leadership;
• Develop a strong sense of “collective” trust and confidence; and
• Manage and optimize performance outcomes.

SHM has taken the lead at a national level in helping to organize the Hospital Care Collaborative (HCC), which is made up of CEOs and leaders in nursing, pharmacy, case management, social workers, and respiratory therapy. The HCC has published a set of “Common Principles” (see “Common Principles for the Hospital Care Collaborative”) and is planning to develop practical strategies for building high-performance teams at our nation’s hospitals.

SHM recently received support from Ortho-McNeil and has created a partnership with the American Hospital Association, American Organization of Nurse Executives, and American College of Physician Executives to develop principles and strategies to implement high-performance teams and to use this as a springboard to look at hospital care in the broadest sense (including transfers with medical home and accountable-care organizations). To start, SHM has convened a blue-ribbon group of hospital CMOs, CQOs, nursing executives, and other leaders in the hospital C-suite. Former SHM president Pat Cawley, MD, MBA, FHM, assistant professor and executive medical officer at the Medical University of South Carolina in Charleston, will chair this effort.

In these two initiatives, SHM and national hospital leaders are providing direction and innovation at two entry points—the C-suite and executive team—as well as on the front lines with the other healthcare professionals who care for our nation’s hospitalized patients.

More to Come

HM has had an interesting decade, growing to more than 30,000 hospitalists now practicing in 75% of our nation’s hospitals. We’ve taken on comanagement and are providing real success as change agents. But the decade to come will see the reinvention of our nation’s hospitals and distinct changes in workflow and responsibilities. We are moving from care based on the unit of the visit or the procedure to episodes of care. We are moving from a system that rewards just doing something to one that rewards doing the correct thing and doing it well. We are moving our hospitals from a swap meet where each physician has a booth and everyone supports those individual efforts to an institution with a culture that is patient-centered, based on quality measurement and performance, and provides care delivered by teams of health professionals working in concert.

This is a world that hospitalists can thrive in and, with your help and direction, SHM will provide the tools along the way. TH

Dr. Wellikson is CEO of SHM.

While most of the focus has been on D.C. and the trillions of dollars to be spent on healthcare reform, HM has grown substantially in the last decade without any significant payment reform or new regulation. This is all the more incredible because the rise of HM has involved two institutions not synonymous with accepting or adapting to change: physicians and hospitals.

In the coming years, hospitals face important challenges, including their fiscal survival, public trust, workforce shortages, difficulty deciding whether their physicians are partners or competitors, and figuring out what to do about all this patient safety and performance improvement hubbub.

Although 2010’s version of healthcare reform will be about increasing access (see “An Imperfect Solution,” January 2010, p. 44), there are still the seeds planted to address the next two pillars of reform: reducing cost and rewarding performance. Together, they create the value proposition in healthcare. All this will make the coming decade one in which the hospital as an institution will need to evolve and adapt if it is to survive.

What is Quality?

As we enter a transitional phase, in some ways, we aren’t even clear on just what quality healthcare is:

• Is quality defined as a payment issue? We see this in discussions of not paying for “never events” or denying payment for readmissions.
• Is quality about being more satisfied? This is found in emphasis on the surveys of patient and family satisfaction that drive hospital CEO compensation and bonuses, as well as in efforts to improve staff retention or in recognition by business, insurers, and government.
• Is quality just checking things off on a clipboard? We all see the endless list of quality measures and increasing documentation that providers have told their patients to stop smoking or get a flu shot, but is that really the quality we are seeking in healthcare?
• Is quality just avoiding embarrassment? Is the best driver of performance improvement outraged hospital trustees wielding printouts comparing hospitals?

We do know that in some ways, the discussion at most of our hospitals has shifted from “Is quality important?” to “How do we do it?” And in this discussion, HM and SHM have taken a leading role in the “solutions” to the problem. Our innovative programs help reduce unnecessary DVTs, improve glycemic control, and refine the discharge process (see Project BOOST) for better patient/family satisfaction, reduced ED visits, and reduced readmissions.

New Ways to Deliver Care

The hospital of the future—I’m talking 2020—will not be defined by bricks and walls. The hospital stay will not end with a patient in a wheelchair being helped into their car. We already know that most patients don’t leave the hospital cured, but are discharged when they are not sick enough to need to stay recumbent in the most expensive hotel in the city. Often these patients are in midcourse of an acute illness, frequently imposed on top of chronic dysfunctions.

While the patient as the true “medical home” for their health and illness have always borne the potholes of slipped handoffs and information transfer deficits, hospitalists now have a clear view of the precarious nature of post-discharge care. Bundling and payment reform, designed to reward coordination of care and the reduction of readmissions to the ED, might be a revenue-driven boost to our ill-designed healthcare system, but the hospital, with the help of their hospitalists, can take the lead in fixing these problems. And we don’t have to wait for payment reform.

The good news is we aren’t alone in our efforts to change the culture, even the mission, of our hospitals. In a time of healthcarewide workforce shortages, there are increasing demands for direct inpatient care, coupled with the added time needed to document current performance and train and implement needed improvements. The only way to meet all of the volume and performance demands is with process change. We need a different way to deliver care to hospitalized patients.

All-Star Teams

High-performing organizations are composed of high-performance teams and a set of operating principles that create a widespread culture of motivated individuals who are focused on metrics, are execution-driven, and are committed to continual improvement and rapid adaptation.

The characteristics of high-performance teams are that they:

• Self-correct and reallocate resources;
• Have clear roles and responsibilities;
• Have clear, valued, and shared visions;
• Have strong team leadership;
• Develop a strong sense of “collective” trust and confidence; and
• Manage and optimize performance outcomes.

SHM has taken the lead at a national level in helping to organize the Hospital Care Collaborative (HCC), which is made up of CEOs and leaders in nursing, pharmacy, case management, social workers, and respiratory therapy. The HCC has published a set of “Common Principles” (see “Common Principles for the Hospital Care Collaborative”) and is planning to develop practical strategies for building high-performance teams at our nation’s hospitals.

SHM recently received support from Ortho-McNeil and has created a partnership with the American Hospital Association, American Organization of Nurse Executives, and American College of Physician Executives to develop principles and strategies to implement high-performance teams and to use this as a springboard to look at hospital care in the broadest sense (including transfers with medical home and accountable-care organizations). To start, SHM has convened a blue-ribbon group of hospital CMOs, CQOs, nursing executives, and other leaders in the hospital C-suite. Former SHM president Pat Cawley, MD, MBA, FHM, assistant professor and executive medical officer at the Medical University of South Carolina in Charleston, will chair this effort.

In these two initiatives, SHM and national hospital leaders are providing direction and innovation at two entry points—the C-suite and executive team—as well as on the front lines with the other healthcare professionals who care for our nation’s hospitalized patients.

More to Come

HM has had an interesting decade, growing to more than 30,000 hospitalists now practicing in 75% of our nation’s hospitals. We’ve taken on comanagement and are providing real success as change agents. But the decade to come will see the reinvention of our nation’s hospitals and distinct changes in workflow and responsibilities. We are moving from care based on the unit of the visit or the procedure to episodes of care. We are moving from a system that rewards just doing something to one that rewards doing the correct thing and doing it well. We are moving our hospitals from a swap meet where each physician has a booth and everyone supports those individual efforts to an institution with a culture that is patient-centered, based on quality measurement and performance, and provides care delivered by teams of health professionals working in concert.

This is a world that hospitalists can thrive in and, with your help and direction, SHM will provide the tools along the way. TH

Dr. Wellikson is CEO of SHM.

While most of the focus has been on D.C. and the trillions of dollars to be spent on healthcare reform, HM has grown substantially in the last decade without any significant payment reform or new regulation. This is all the more incredible because the rise of HM has involved two institutions not synonymous with accepting or adapting to change: physicians and hospitals.

In the coming years, hospitals face important challenges, including their fiscal survival, public trust, workforce shortages, difficulty deciding whether their physicians are partners or competitors, and figuring out what to do about all this patient safety and performance improvement hubbub.

Although 2010’s version of healthcare reform will be about increasing access (see “An Imperfect Solution,” January 2010, p. 44), there are still the seeds planted to address the next two pillars of reform: reducing cost and rewarding performance. Together, they create the value proposition in healthcare. All this will make the coming decade one in which the hospital as an institution will need to evolve and adapt if it is to survive.

What is Quality?

As we enter a transitional phase, in some ways, we aren’t even clear on just what quality healthcare is:

• Is quality defined as a payment issue? We see this in discussions of not paying for “never events” or denying payment for readmissions.
• Is quality about being more satisfied? This is found in emphasis on the surveys of patient and family satisfaction that drive hospital CEO compensation and bonuses, as well as in efforts to improve staff retention or in recognition by business, insurers, and government.
• Is quality just checking things off on a clipboard? We all see the endless list of quality measures and increasing documentation that providers have told their patients to stop smoking or get a flu shot, but is that really the quality we are seeking in healthcare?
• Is quality just avoiding embarrassment? Is the best driver of performance improvement outraged hospital trustees wielding printouts comparing hospitals?

We do know that in some ways, the discussion at most of our hospitals has shifted from “Is quality important?” to “How do we do it?” And in this discussion, HM and SHM have taken a leading role in the “solutions” to the problem. Our innovative programs help reduce unnecessary DVTs, improve glycemic control, and refine the discharge process (see Project BOOST) for better patient/family satisfaction, reduced ED visits, and reduced readmissions.

New Ways to Deliver Care

The hospital of the future—I’m talking 2020—will not be defined by bricks and walls. The hospital stay will not end with a patient in a wheelchair being helped into their car. We already know that most patients don’t leave the hospital cured, but are discharged when they are not sick enough to need to stay recumbent in the most expensive hotel in the city. Often these patients are in midcourse of an acute illness, frequently imposed on top of chronic dysfunctions.

While the patient as the true “medical home” for their health and illness have always borne the potholes of slipped handoffs and information transfer deficits, hospitalists now have a clear view of the precarious nature of post-discharge care. Bundling and payment reform, designed to reward coordination of care and the reduction of readmissions to the ED, might be a revenue-driven boost to our ill-designed healthcare system, but the hospital, with the help of their hospitalists, can take the lead in fixing these problems. And we don’t have to wait for payment reform.

The good news is we aren’t alone in our efforts to change the culture, even the mission, of our hospitals. In a time of healthcarewide workforce shortages, there are increasing demands for direct inpatient care, coupled with the added time needed to document current performance and train and implement needed improvements. The only way to meet all of the volume and performance demands is with process change. We need a different way to deliver care to hospitalized patients.

All-Star Teams

High-performing organizations are composed of high-performance teams and a set of operating principles that create a widespread culture of motivated individuals who are focused on metrics, are execution-driven, and are committed to continual improvement and rapid adaptation.

The characteristics of high-performance teams are that they:

• Self-correct and reallocate resources;
• Have clear roles and responsibilities;
• Have clear, valued, and shared visions;
• Have strong team leadership;
• Develop a strong sense of “collective” trust and confidence; and
• Manage and optimize performance outcomes.

SHM has taken the lead at a national level in helping to organize the Hospital Care Collaborative (HCC), which is made up of CEOs and leaders in nursing, pharmacy, case management, social workers, and respiratory therapy. The HCC has published a set of “Common Principles” (see “Common Principles for the Hospital Care Collaborative”) and is planning to develop practical strategies for building high-performance teams at our nation’s hospitals.

SHM recently received support from Ortho-McNeil and has created a partnership with the American Hospital Association, American Organization of Nurse Executives, and American College of Physician Executives to develop principles and strategies to implement high-performance teams and to use this as a springboard to look at hospital care in the broadest sense (including transfers with medical home and accountable-care organizations). To start, SHM has convened a blue-ribbon group of hospital CMOs, CQOs, nursing executives, and other leaders in the hospital C-suite. Former SHM president Pat Cawley, MD, MBA, FHM, assistant professor and executive medical officer at the Medical University of South Carolina in Charleston, will chair this effort.

In these two initiatives, SHM and national hospital leaders are providing direction and innovation at two entry points—the C-suite and executive team—as well as on the front lines with the other healthcare professionals who care for our nation’s hospitalized patients.

More to Come

HM has had an interesting decade, growing to more than 30,000 hospitalists now practicing in 75% of our nation’s hospitals. We’ve taken on comanagement and are providing real success as change agents. But the decade to come will see the reinvention of our nation’s hospitals and distinct changes in workflow and responsibilities. We are moving from care based on the unit of the visit or the procedure to episodes of care. We are moving from a system that rewards just doing something to one that rewards doing the correct thing and doing it well. We are moving our hospitals from a swap meet where each physician has a booth and everyone supports those individual efforts to an institution with a culture that is patient-centered, based on quality measurement and performance, and provides care delivered by teams of health professionals working in concert.

This is a world that hospitalists can thrive in and, with your help and direction, SHM will provide the tools along the way. TH

Dr. Wellikson is CEO of SHM.

Just when you thought you had heard the last about the Health Insurance Portability and Accountability Act (HIPAA), the Department of Health and Human Services (HHS) has promulgated new rules for notifying individuals when their protected health information has been breached. These “breach notification” regulations implement provisions of the Health Information Technology for Economic and Clinical Health (HITECH) Act, passed as part of the American Recovery and Reinvestment Act (ARRA) of 2009. The regulations became effective in September.

The regulations require covered entities (health plans, healthcare clearing houses, and healthcare providers) to promptly notify individuals affected by a breach, as well as the HHS secretary and the media in cases in which a breach affects more than 500 individuals.  Breaches affecting fewer than 500 individuals must be reported to HHS annually. Notably, breaches will be posted on the HHS Web site. The regulations also require business associates to notify covered entities with whom they work of breaches.

All Breaches Not Equal

Any impermissible acquisition, access, use, or disclosure of unsecured protected health information that compromises the security or privacy of the information triggers the new breach notification requirement. Health information is unsecured only if it is not encrypted or destroyed. Security or privacy is compromised when a breach poses a significant risk of financial, reputational, or other harm. To determine whether a significant risk of harm exists, a covered entity must document a fact-based assessment of the risk involved, including evaluation of:

• What happened to the information (e.g., Was a laptop stolen and never recovered or lost but subsequently found? Was an unauthorized access intentional or accidental?);
• The nature of the information (e.g., Did the information contain Social Security numbers and other data that could lead to identity theft? Did the information involve sensitive health information?);
• Steps that could mitigate the potential harm (e.g., call the recipient and request destruction of the information and confirmation); and
• The number of individual identifiers present in the information (e.g., Did the information have name, birth date, and Social Security number, or only a medical record number?).

Consequently, breaches that do not involve information that can be used to identify a specific individual are not reportable. Moreover, inadvertent breaches to other covered entities pose a low risk of harm. For example, if medical records are inadvertently faxed to the wrong pharmacy or other healthcare provider, there is low risk of harm because the recipient is independently required to comply with HIPAA.

Additionally, the regulations expressly exclude the following events from the definition of a breach:

• Unintentional, good-faith access by an employee or agent if the information has not been redisclosed. An example would be mail sent to or opened by the wrong staff member;
• Inadvertent disclosures among persons otherwise authorized to access protected health information within the same entity, provided the information is not redisclosed; and
• When an unauthorized recipient could not have retained the information (e.g., paperwork given to the wrong patient but returned immediately without being read).

In each of the examples above, a covered entity does not need to provide breach notification because a breach has not occurred under the regulations.

Notification Requirements

Unless law enforcement makes a written request for a covered entity to delay notification, covered entities must provide written notice to each individual affected by a breach as soon as possible but no later than 60 calendar days from discovery of the breach. Importantly, a covered entity is liable for appropriate notification if they know, or should know, of a breach. Moreover, the knowledge of an employee is imputed to an employer. Further, business associates must notify covered entities of any breaches. Thus, policies and procedures should include training of a covered entity’s workforce and ensuring business associates’ compliance.

While there is not a prescribed form for notice, the regulations do require some specific elements, including:

• Description of the breach and the dates, if known;
• Description of the protected health information involved;
• Steps the affected individual should take to protect themselves (e.g., cancel credit cards);
• Description of the steps being taken by the covered entity; and
• Contact information to obtain more information, which must include a toll-free telephone number, e-mail or postal address, or Web site.

If 10 or more individuals are involved for which the entity does not have adequate contact information, notice can be accomplished by a conspicuous posting on the entity’s Web site for at least 90 days, or a posting in print or broadcast media. In either case, an active toll-free telephone number where individuals can find out if they were affected must be available for 90 days.

If a breach involves more than 500 people from any one state, notification must include prominent media outlets. Moreover, the covered entity must notify the HHS secretary at the time notice is provided to affected individuals. Breaches involving fewer than 500 individuals must be reported annually through the Office of Civil Rights Web site.

Sanctions and Penalties

HHS is required to audit, investigate, and impose civil monetary penalties for offenses resulting from willful neglect. Fortunately, HHS has indicated that it will not be imposing sanctions for unintentional violations of the notification requirements until March. This gives providers some time to implement the necessary processes. Nonetheless, it is important to implement compliance processes now, as the penalties for noncompliance can be severe. Under the new law, penalties are tiered based on knowledge, and are capped at $1.5 million annually.

For more information about HIPAA, visit www.hhs.gov/ocr/privacy. TH

Patrick T. O’Rourke works in the Office of University Counsel at the University of Colorado Denver. Kari Hershey is a public relations consultant with Budman & Hershey, LLC, in Denver.

Just when you thought you had heard the last about the Health Insurance Portability and Accountability Act (HIPAA), the Department of Health and Human Services (HHS) has promulgated new rules for notifying individuals when their protected health information has been breached. These “breach notification” regulations implement provisions of the Health Information Technology for Economic and Clinical Health (HITECH) Act, passed as part of the American Recovery and Reinvestment Act (ARRA) of 2009. The regulations became effective in September.

The regulations require covered entities (health plans, healthcare clearing houses, and healthcare providers) to promptly notify individuals affected by a breach, as well as the HHS secretary and the media in cases in which a breach affects more than 500 individuals.  Breaches affecting fewer than 500 individuals must be reported to HHS annually. Notably, breaches will be posted on the HHS Web site. The regulations also require business associates to notify covered entities with whom they work of breaches.

All Breaches Not Equal

Any impermissible acquisition, access, use, or disclosure of unsecured protected health information that compromises the security or privacy of the information triggers the new breach notification requirement. Health information is unsecured only if it is not encrypted or destroyed. Security or privacy is compromised when a breach poses a significant risk of financial, reputational, or other harm. To determine whether a significant risk of harm exists, a covered entity must document a fact-based assessment of the risk involved, including evaluation of:

• What happened to the information (e.g., Was a laptop stolen and never recovered or lost but subsequently found? Was an unauthorized access intentional or accidental?);
• The nature of the information (e.g., Did the information contain Social Security numbers and other data that could lead to identity theft? Did the information involve sensitive health information?);
• Steps that could mitigate the potential harm (e.g., call the recipient and request destruction of the information and confirmation); and
• The number of individual identifiers present in the information (e.g., Did the information have name, birth date, and Social Security number, or only a medical record number?).

Consequently, breaches that do not involve information that can be used to identify a specific individual are not reportable. Moreover, inadvertent breaches to other covered entities pose a low risk of harm. For example, if medical records are inadvertently faxed to the wrong pharmacy or other healthcare provider, there is low risk of harm because the recipient is independently required to comply with HIPAA.

Additionally, the regulations expressly exclude the following events from the definition of a breach:

• Unintentional, good-faith access by an employee or agent if the information has not been redisclosed. An example would be mail sent to or opened by the wrong staff member;
• Inadvertent disclosures among persons otherwise authorized to access protected health information within the same entity, provided the information is not redisclosed; and
• When an unauthorized recipient could not have retained the information (e.g., paperwork given to the wrong patient but returned immediately without being read).

In each of the examples above, a covered entity does not need to provide breach notification because a breach has not occurred under the regulations.

Notification Requirements

Unless law enforcement makes a written request for a covered entity to delay notification, covered entities must provide written notice to each individual affected by a breach as soon as possible but no later than 60 calendar days from discovery of the breach. Importantly, a covered entity is liable for appropriate notification if they know, or should know, of a breach. Moreover, the knowledge of an employee is imputed to an employer. Further, business associates must notify covered entities of any breaches. Thus, policies and procedures should include training of a covered entity’s workforce and ensuring business associates’ compliance.

While there is not a prescribed form for notice, the regulations do require some specific elements, including:

• Description of the breach and the dates, if known;
• Description of the protected health information involved;
• Steps the affected individual should take to protect themselves (e.g., cancel credit cards);
• Description of the steps being taken by the covered entity; and
• Contact information to obtain more information, which must include a toll-free telephone number, e-mail or postal address, or Web site.

If 10 or more individuals are involved for which the entity does not have adequate contact information, notice can be accomplished by a conspicuous posting on the entity’s Web site for at least 90 days, or a posting in print or broadcast media. In either case, an active toll-free telephone number where individuals can find out if they were affected must be available for 90 days.

If a breach involves more than 500 people from any one state, notification must include prominent media outlets. Moreover, the covered entity must notify the HHS secretary at the time notice is provided to affected individuals. Breaches involving fewer than 500 individuals must be reported annually through the Office of Civil Rights Web site.

Sanctions and Penalties

HHS is required to audit, investigate, and impose civil monetary penalties for offenses resulting from willful neglect. Fortunately, HHS has indicated that it will not be imposing sanctions for unintentional violations of the notification requirements until March. This gives providers some time to implement the necessary processes. Nonetheless, it is important to implement compliance processes now, as the penalties for noncompliance can be severe. Under the new law, penalties are tiered based on knowledge, and are capped at $1.5 million annually.

For more information about HIPAA, visit www.hhs.gov/ocr/privacy. TH

Patrick T. O’Rourke works in the Office of University Counsel at the University of Colorado Denver. Kari Hershey is a public relations consultant with Budman & Hershey, LLC, in Denver.

Just when you thought you had heard the last about the Health Insurance Portability and Accountability Act (HIPAA), the Department of Health and Human Services (HHS) has promulgated new rules for notifying individuals when their protected health information has been breached. These “breach notification” regulations implement provisions of the Health Information Technology for Economic and Clinical Health (HITECH) Act, passed as part of the American Recovery and Reinvestment Act (ARRA) of 2009. The regulations became effective in September.

The regulations require covered entities (health plans, healthcare clearing houses, and healthcare providers) to promptly notify individuals affected by a breach, as well as the HHS secretary and the media in cases in which a breach affects more than 500 individuals.  Breaches affecting fewer than 500 individuals must be reported to HHS annually. Notably, breaches will be posted on the HHS Web site. The regulations also require business associates to notify covered entities with whom they work of breaches.

All Breaches Not Equal

Any impermissible acquisition, access, use, or disclosure of unsecured protected health information that compromises the security or privacy of the information triggers the new breach notification requirement. Health information is unsecured only if it is not encrypted or destroyed. Security or privacy is compromised when a breach poses a significant risk of financial, reputational, or other harm. To determine whether a significant risk of harm exists, a covered entity must document a fact-based assessment of the risk involved, including evaluation of:

• What happened to the information (e.g., Was a laptop stolen and never recovered or lost but subsequently found? Was an unauthorized access intentional or accidental?);
• The nature of the information (e.g., Did the information contain Social Security numbers and other data that could lead to identity theft? Did the information involve sensitive health information?);
• Steps that could mitigate the potential harm (e.g., call the recipient and request destruction of the information and confirmation); and
• The number of individual identifiers present in the information (e.g., Did the information have name, birth date, and Social Security number, or only a medical record number?).

Consequently, breaches that do not involve information that can be used to identify a specific individual are not reportable. Moreover, inadvertent breaches to other covered entities pose a low risk of harm. For example, if medical records are inadvertently faxed to the wrong pharmacy or other healthcare provider, there is low risk of harm because the recipient is independently required to comply with HIPAA.

Additionally, the regulations expressly exclude the following events from the definition of a breach:

• Unintentional, good-faith access by an employee or agent if the information has not been redisclosed. An example would be mail sent to or opened by the wrong staff member;
• Inadvertent disclosures among persons otherwise authorized to access protected health information within the same entity, provided the information is not redisclosed; and
• When an unauthorized recipient could not have retained the information (e.g., paperwork given to the wrong patient but returned immediately without being read).

In each of the examples above, a covered entity does not need to provide breach notification because a breach has not occurred under the regulations.

Notification Requirements

Unless law enforcement makes a written request for a covered entity to delay notification, covered entities must provide written notice to each individual affected by a breach as soon as possible but no later than 60 calendar days from discovery of the breach. Importantly, a covered entity is liable for appropriate notification if they know, or should know, of a breach. Moreover, the knowledge of an employee is imputed to an employer. Further, business associates must notify covered entities of any breaches. Thus, policies and procedures should include training of a covered entity’s workforce and ensuring business associates’ compliance.

While there is not a prescribed form for notice, the regulations do require some specific elements, including:

• Description of the breach and the dates, if known;
• Description of the protected health information involved;
• Steps the affected individual should take to protect themselves (e.g., cancel credit cards);
• Description of the steps being taken by the covered entity; and
• Contact information to obtain more information, which must include a toll-free telephone number, e-mail or postal address, or Web site.

If 10 or more individuals are involved for which the entity does not have adequate contact information, notice can be accomplished by a conspicuous posting on the entity’s Web site for at least 90 days, or a posting in print or broadcast media. In either case, an active toll-free telephone number where individuals can find out if they were affected must be available for 90 days.

If a breach involves more than 500 people from any one state, notification must include prominent media outlets. Moreover, the covered entity must notify the HHS secretary at the time notice is provided to affected individuals. Breaches involving fewer than 500 individuals must be reported annually through the Office of Civil Rights Web site.

Sanctions and Penalties

HHS is required to audit, investigate, and impose civil monetary penalties for offenses resulting from willful neglect. Fortunately, HHS has indicated that it will not be imposing sanctions for unintentional violations of the notification requirements until March. This gives providers some time to implement the necessary processes. Nonetheless, it is important to implement compliance processes now, as the penalties for noncompliance can be severe. Under the new law, penalties are tiered based on knowledge, and are capped at $1.5 million annually.

For more information about HIPAA, visit www.hhs.gov/ocr/privacy. TH

Patrick T. O’Rourke works in the Office of University Counsel at the University of Colorado Denver. Kari Hershey is a public relations consultant with Budman & Hershey, LLC, in Denver.

Advocates have written open letters to politicians describing it as “the least-expensive and best-known way to lower healthcare costs.” Detractors have blogged that it has saved almost no money and instead “gutted patient rights.” Among the recent templates for whether and how to proceed on the contentious issue of tort reform, Texas has become a prime example of either the wisdom or the folly of capping medical liability payouts, depending on your vantage point.

Tort reform is backed by most doctors and the insurance industry but opposed by lawyers and consumer advocates. The Congressional Budget Office has documented increases in both medical liability premiums and average malpractice claim payments that have significantly outpaced inflation. Congress itself has largely punted on the issue, however, leaving most of the wrangling over specifics to individual states.

Which brings us to Texas. In reaction to the perception that unsustainable medical liability costs were driving away doctors and driving up healthcare costs, state voters in 2003 approved Proposition 12. Among its provisions, the state constitutional amendment capped noneconomic medical liability payouts at $250,000 in nearly all cases.

Much of the ensuing debate over whether Texas did the right thing has focused on cost: For example, will the reduction in malpractice claims translate into significant savings within the healthcare system? Is tort reform relevant in recouping the perceived waste from “defensive medicine,” in which physicians are presumed to order unnecessary tests and procedures out of fear of lawsuits?

More centrally, however, the question boils down to this: Does tort reform improve the ability of doctors to do their jobs, and the opportunity for patients to benefit from that care? So far, statistics, reports, and anecdotal information suggest that Texas has achieved the first goal but not necessarily the latter, highlighting the extreme difficulty in striking the right balance.

Mission: Predictable

Kirk A. Calhoun, MD, who became president of the University of Texas Health Science Center at Tyler in 2002, points to two principal benefits of the state’s tort reform. First, the package of reforms led to a significant number of physicians migrating to Texas and helping to deal with the state’s chronic doctor shortage. For doctors, part of that attraction was the second big benefit, a significant decrease in liability insurance premiums.

“It has resulted in making Texas a more attractive state in which to practice medicine,” Dr. Calhoun says. “As a result of those expenses going down, we are able to better invest in our primary mission, and on patient care.”

Kenneth McDaniel, a program specialist in professional liability in the Texas Department of Insurance, says the dearth of affordable or available malpractice insurance in the state had spiraled into a crisis. “In Texas, we were staring at the brink of a chasm so deep that we virtually had to do something,” he says. “We were within probably some months or a year of having almost no malpractice insurance industry at all. It had become very dire.”

McDaniel stresses that the new liability cap is only for intangibles or pain and suffering, and it leaves intact the potential for higher economic damages. “But those can be predicted,” he says. “As soon as claims became more predictable, insurers started coming back into the field.” A summary of 17 companies’ rates supplied by McDaniel includes four new arrivals to the medical liability market and the return of a fifth.

At the very least, tort reform appears to have dramatically curbed the number and cost of claims in Texas. From 2003 to 2007, malpractice payments to patients dropped by two-thirds. Liability premiums paid by doctors also have fallen, by an average of 27.5%, and more insurers have rejoined the market. “We are now back to, I would say, a pretty healthy environment,” McDaniel says.

Physician-Friendly Environs

Hospitalist Gregory Johnson, MD, chair of the Texas Medical Association’s Young Physicians Section, moved to Texas in 2002, just before the reforms were approved. “The best part about Prop 12 passing is the fact that Texas is now seen as a very physician-friendly environment,” says Johnson, who now serves as a Houston-based regional chief medical officer for Tacoma, Wash.-based Sound Physicians. The significant drops in malpractice insurance rates and lawsuits have made it far easier for him to recruit out-of-state doctors. “That basically comes off any physician’s radar as a particular concern.”

Most Texas hospitals and healthcare systems do not employ physicians directly. Instead, they contract or affiliate with private or nonprofit physicians groups. Due to that arrangement, Dr. Johnson explains, the cost of insurance premiums “becomes a much more individually based and personal issue because it’s coming out of an individual’s pocket, or a group’s pocket.”

From his own experience, Dr. Johnson says, he believes hospitalists are more willing to go to underserved parts of the state because of tort reform. Three years ago, he helped start Amarillo Hospitalist Services, a program that began with three doctors and has since grown to eight, all affiliated with Northwest Texas Hospital.

Of course, hospitalists appear to be thriving in major metropolitan areas, too. Dr. Johnson’s new employer, Sound Physicians, now operates three HM programs within Houston’s Memorial Hermann Healthcare System and employs about two-dozen physicians in all. More are on the way. “We’re actively hiring,” he says.

Mixed Outcomes

Statistics from the Texas Medical Board and Department of State Health Services confirm the anecdotal evidence that a more doctor-friendly Texas is paying dividends. Even so, they paint a somewhat more complicated picture than some commentators have portrayed in recent editorials. Doctors have indeed flocked to the state—some 11,000 since 2002 alone, an increase of 31%. That rate has far outpaced the state’s overall population growth of 14.2%.

But not all areas of the state have benefited equally from the influx.

Starr County, the third-poorest county in the U.S. based on per capita income, is among those that have fared well since 2002. Overall, its number of doctors increased from 14 to 24, a net increase of 71%, as its population rose by a projected 17%. But the next five poorest counties in Texas, accounting for nearly 86,000 residents in 2002, lost six doctors during the same time period—a 12.5% decline, even as their collective population rose by a projected 10.2%. Contrary to some public pronouncements, tort reform alone has not solved the chronic shortage of doctors in poor rural areas.

A withering report released in December by Washington, D.C.-based Public Citizen, a nonprofit consumer advocacy group, offers a harsher assessment, concluding that Texas’ “experiment with medical liability caps has failed” (www.citizen.org/publications/release.cfm?ID=7721). The report suggests that Texas’ dead-last ranking in percentage of uninsured residents (25%) and the doctor shortage in rural areas have actually grown worse since tort reform. Meanwhile, the cost of health insurance has more than doubled, while the cost of healthcare also has increased at nearly double the national average, other metrics that led to the organization’s vote of no confidence.

The impact on quality of care has been harder to assess. But Dr. Johnson and other observers say they haven’t seen any dip within hospitals. “I think that we as physicians and we as hospitalists really want to focus on our patients, and we can help to drive down those costs if we’re given the freedom to do our job,” he says. Tort reform, he adds, has helped doctors do precisely that.

Dr. Calhoun agrees. “No one wants to be sued. Everyone wants to do a good job,” he says. The threat of a lawsuit alone is only one of many factors influencing quality, he adds. But creating a more inviting environment for doctors can make a big difference by encouraging the increased use of hospitalists. “Having a hospitalist in the hospital all the time,” he says, “is an obvious quality improvement.” TH

Bryn Nelson is a freelance medical writer based in Seattle.

IMAGE SOURCE: DRASCHWARTZ/ISTOCK.COM

Advocates have written open letters to politicians describing it as “the least-expensive and best-known way to lower healthcare costs.” Detractors have blogged that it has saved almost no money and instead “gutted patient rights.” Among the recent templates for whether and how to proceed on the contentious issue of tort reform, Texas has become a prime example of either the wisdom or the folly of capping medical liability payouts, depending on your vantage point.

Tort reform is backed by most doctors and the insurance industry but opposed by lawyers and consumer advocates. The Congressional Budget Office has documented increases in both medical liability premiums and average malpractice claim payments that have significantly outpaced inflation. Congress itself has largely punted on the issue, however, leaving most of the wrangling over specifics to individual states.

Which brings us to Texas. In reaction to the perception that unsustainable medical liability costs were driving away doctors and driving up healthcare costs, state voters in 2003 approved Proposition 12. Among its provisions, the state constitutional amendment capped noneconomic medical liability payouts at $250,000 in nearly all cases.

Much of the ensuing debate over whether Texas did the right thing has focused on cost: For example, will the reduction in malpractice claims translate into significant savings within the healthcare system? Is tort reform relevant in recouping the perceived waste from “defensive medicine,” in which physicians are presumed to order unnecessary tests and procedures out of fear of lawsuits?

More centrally, however, the question boils down to this: Does tort reform improve the ability of doctors to do their jobs, and the opportunity for patients to benefit from that care? So far, statistics, reports, and anecdotal information suggest that Texas has achieved the first goal but not necessarily the latter, highlighting the extreme difficulty in striking the right balance.

Mission: Predictable

Kirk A. Calhoun, MD, who became president of the University of Texas Health Science Center at Tyler in 2002, points to two principal benefits of the state’s tort reform. First, the package of reforms led to a significant number of physicians migrating to Texas and helping to deal with the state’s chronic doctor shortage. For doctors, part of that attraction was the second big benefit, a significant decrease in liability insurance premiums.

“It has resulted in making Texas a more attractive state in which to practice medicine,” Dr. Calhoun says. “As a result of those expenses going down, we are able to better invest in our primary mission, and on patient care.”

Kenneth McDaniel, a program specialist in professional liability in the Texas Department of Insurance, says the dearth of affordable or available malpractice insurance in the state had spiraled into a crisis. “In Texas, we were staring at the brink of a chasm so deep that we virtually had to do something,” he says. “We were within probably some months or a year of having almost no malpractice insurance industry at all. It had become very dire.”

McDaniel stresses that the new liability cap is only for intangibles or pain and suffering, and it leaves intact the potential for higher economic damages. “But those can be predicted,” he says. “As soon as claims became more predictable, insurers started coming back into the field.” A summary of 17 companies’ rates supplied by McDaniel includes four new arrivals to the medical liability market and the return of a fifth.

At the very least, tort reform appears to have dramatically curbed the number and cost of claims in Texas. From 2003 to 2007, malpractice payments to patients dropped by two-thirds. Liability premiums paid by doctors also have fallen, by an average of 27.5%, and more insurers have rejoined the market. “We are now back to, I would say, a pretty healthy environment,” McDaniel says.

Physician-Friendly Environs

Hospitalist Gregory Johnson, MD, chair of the Texas Medical Association’s Young Physicians Section, moved to Texas in 2002, just before the reforms were approved. “The best part about Prop 12 passing is the fact that Texas is now seen as a very physician-friendly environment,” says Johnson, who now serves as a Houston-based regional chief medical officer for Tacoma, Wash.-based Sound Physicians. The significant drops in malpractice insurance rates and lawsuits have made it far easier for him to recruit out-of-state doctors. “That basically comes off any physician’s radar as a particular concern.”

Most Texas hospitals and healthcare systems do not employ physicians directly. Instead, they contract or affiliate with private or nonprofit physicians groups. Due to that arrangement, Dr. Johnson explains, the cost of insurance premiums “becomes a much more individually based and personal issue because it’s coming out of an individual’s pocket, or a group’s pocket.”

From his own experience, Dr. Johnson says, he believes hospitalists are more willing to go to underserved parts of the state because of tort reform. Three years ago, he helped start Amarillo Hospitalist Services, a program that began with three doctors and has since grown to eight, all affiliated with Northwest Texas Hospital.

Of course, hospitalists appear to be thriving in major metropolitan areas, too. Dr. Johnson’s new employer, Sound Physicians, now operates three HM programs within Houston’s Memorial Hermann Healthcare System and employs about two-dozen physicians in all. More are on the way. “We’re actively hiring,” he says.

Mixed Outcomes

Statistics from the Texas Medical Board and Department of State Health Services confirm the anecdotal evidence that a more doctor-friendly Texas is paying dividends. Even so, they paint a somewhat more complicated picture than some commentators have portrayed in recent editorials. Doctors have indeed flocked to the state—some 11,000 since 2002 alone, an increase of 31%. That rate has far outpaced the state’s overall population growth of 14.2%.

But not all areas of the state have benefited equally from the influx.

Starr County, the third-poorest county in the U.S. based on per capita income, is among those that have fared well since 2002. Overall, its number of doctors increased from 14 to 24, a net increase of 71%, as its population rose by a projected 17%. But the next five poorest counties in Texas, accounting for nearly 86,000 residents in 2002, lost six doctors during the same time period—a 12.5% decline, even as their collective population rose by a projected 10.2%. Contrary to some public pronouncements, tort reform alone has not solved the chronic shortage of doctors in poor rural areas.

A withering report released in December by Washington, D.C.-based Public Citizen, a nonprofit consumer advocacy group, offers a harsher assessment, concluding that Texas’ “experiment with medical liability caps has failed” (www.citizen.org/publications/release.cfm?ID=7721). The report suggests that Texas’ dead-last ranking in percentage of uninsured residents (25%) and the doctor shortage in rural areas have actually grown worse since tort reform. Meanwhile, the cost of health insurance has more than doubled, while the cost of healthcare also has increased at nearly double the national average, other metrics that led to the organization’s vote of no confidence.

The impact on quality of care has been harder to assess. But Dr. Johnson and other observers say they haven’t seen any dip within hospitals. “I think that we as physicians and we as hospitalists really want to focus on our patients, and we can help to drive down those costs if we’re given the freedom to do our job,” he says. Tort reform, he adds, has helped doctors do precisely that.

Dr. Calhoun agrees. “No one wants to be sued. Everyone wants to do a good job,” he says. The threat of a lawsuit alone is only one of many factors influencing quality, he adds. But creating a more inviting environment for doctors can make a big difference by encouraging the increased use of hospitalists. “Having a hospitalist in the hospital all the time,” he says, “is an obvious quality improvement.” TH

Bryn Nelson is a freelance medical writer based in Seattle.

IMAGE SOURCE: DRASCHWARTZ/ISTOCK.COM

Advocates have written open letters to politicians describing it as “the least-expensive and best-known way to lower healthcare costs.” Detractors have blogged that it has saved almost no money and instead “gutted patient rights.” Among the recent templates for whether and how to proceed on the contentious issue of tort reform, Texas has become a prime example of either the wisdom or the folly of capping medical liability payouts, depending on your vantage point.

Tort reform is backed by most doctors and the insurance industry but opposed by lawyers and consumer advocates. The Congressional Budget Office has documented increases in both medical liability premiums and average malpractice claim payments that have significantly outpaced inflation. Congress itself has largely punted on the issue, however, leaving most of the wrangling over specifics to individual states.

Which brings us to Texas. In reaction to the perception that unsustainable medical liability costs were driving away doctors and driving up healthcare costs, state voters in 2003 approved Proposition 12. Among its provisions, the state constitutional amendment capped noneconomic medical liability payouts at $250,000 in nearly all cases.

Much of the ensuing debate over whether Texas did the right thing has focused on cost: For example, will the reduction in malpractice claims translate into significant savings within the healthcare system? Is tort reform relevant in recouping the perceived waste from “defensive medicine,” in which physicians are presumed to order unnecessary tests and procedures out of fear of lawsuits?

More centrally, however, the question boils down to this: Does tort reform improve the ability of doctors to do their jobs, and the opportunity for patients to benefit from that care? So far, statistics, reports, and anecdotal information suggest that Texas has achieved the first goal but not necessarily the latter, highlighting the extreme difficulty in striking the right balance.

Mission: Predictable

Kirk A. Calhoun, MD, who became president of the University of Texas Health Science Center at Tyler in 2002, points to two principal benefits of the state’s tort reform. First, the package of reforms led to a significant number of physicians migrating to Texas and helping to deal with the state’s chronic doctor shortage. For doctors, part of that attraction was the second big benefit, a significant decrease in liability insurance premiums.

“It has resulted in making Texas a more attractive state in which to practice medicine,” Dr. Calhoun says. “As a result of those expenses going down, we are able to better invest in our primary mission, and on patient care.”

Kenneth McDaniel, a program specialist in professional liability in the Texas Department of Insurance, says the dearth of affordable or available malpractice insurance in the state had spiraled into a crisis. “In Texas, we were staring at the brink of a chasm so deep that we virtually had to do something,” he says. “We were within probably some months or a year of having almost no malpractice insurance industry at all. It had become very dire.”

McDaniel stresses that the new liability cap is only for intangibles or pain and suffering, and it leaves intact the potential for higher economic damages. “But those can be predicted,” he says. “As soon as claims became more predictable, insurers started coming back into the field.” A summary of 17 companies’ rates supplied by McDaniel includes four new arrivals to the medical liability market and the return of a fifth.

At the very least, tort reform appears to have dramatically curbed the number and cost of claims in Texas. From 2003 to 2007, malpractice payments to patients dropped by two-thirds. Liability premiums paid by doctors also have fallen, by an average of 27.5%, and more insurers have rejoined the market. “We are now back to, I would say, a pretty healthy environment,” McDaniel says.

Physician-Friendly Environs

Hospitalist Gregory Johnson, MD, chair of the Texas Medical Association’s Young Physicians Section, moved to Texas in 2002, just before the reforms were approved. “The best part about Prop 12 passing is the fact that Texas is now seen as a very physician-friendly environment,” says Johnson, who now serves as a Houston-based regional chief medical officer for Tacoma, Wash.-based Sound Physicians. The significant drops in malpractice insurance rates and lawsuits have made it far easier for him to recruit out-of-state doctors. “That basically comes off any physician’s radar as a particular concern.”

Most Texas hospitals and healthcare systems do not employ physicians directly. Instead, they contract or affiliate with private or nonprofit physicians groups. Due to that arrangement, Dr. Johnson explains, the cost of insurance premiums “becomes a much more individually based and personal issue because it’s coming out of an individual’s pocket, or a group’s pocket.”

From his own experience, Dr. Johnson says, he believes hospitalists are more willing to go to underserved parts of the state because of tort reform. Three years ago, he helped start Amarillo Hospitalist Services, a program that began with three doctors and has since grown to eight, all affiliated with Northwest Texas Hospital.

Of course, hospitalists appear to be thriving in major metropolitan areas, too. Dr. Johnson’s new employer, Sound Physicians, now operates three HM programs within Houston’s Memorial Hermann Healthcare System and employs about two-dozen physicians in all. More are on the way. “We’re actively hiring,” he says.

Mixed Outcomes

Statistics from the Texas Medical Board and Department of State Health Services confirm the anecdotal evidence that a more doctor-friendly Texas is paying dividends. Even so, they paint a somewhat more complicated picture than some commentators have portrayed in recent editorials. Doctors have indeed flocked to the state—some 11,000 since 2002 alone, an increase of 31%. That rate has far outpaced the state’s overall population growth of 14.2%.

But not all areas of the state have benefited equally from the influx.

Starr County, the third-poorest county in the U.S. based on per capita income, is among those that have fared well since 2002. Overall, its number of doctors increased from 14 to 24, a net increase of 71%, as its population rose by a projected 17%. But the next five poorest counties in Texas, accounting for nearly 86,000 residents in 2002, lost six doctors during the same time period—a 12.5% decline, even as their collective population rose by a projected 10.2%. Contrary to some public pronouncements, tort reform alone has not solved the chronic shortage of doctors in poor rural areas.

A withering report released in December by Washington, D.C.-based Public Citizen, a nonprofit consumer advocacy group, offers a harsher assessment, concluding that Texas’ “experiment with medical liability caps has failed” (www.citizen.org/publications/release.cfm?ID=7721). The report suggests that Texas’ dead-last ranking in percentage of uninsured residents (25%) and the doctor shortage in rural areas have actually grown worse since tort reform. Meanwhile, the cost of health insurance has more than doubled, while the cost of healthcare also has increased at nearly double the national average, other metrics that led to the organization’s vote of no confidence.

The impact on quality of care has been harder to assess. But Dr. Johnson and other observers say they haven’t seen any dip within hospitals. “I think that we as physicians and we as hospitalists really want to focus on our patients, and we can help to drive down those costs if we’re given the freedom to do our job,” he says. Tort reform, he adds, has helped doctors do precisely that.

Dr. Calhoun agrees. “No one wants to be sued. Everyone wants to do a good job,” he says. The threat of a lawsuit alone is only one of many factors influencing quality, he adds. But creating a more inviting environment for doctors can make a big difference by encouraging the increased use of hospitalists. “Having a hospitalist in the hospital all the time,” he says, “is an obvious quality improvement.” TH

Bryn Nelson is a freelance medical writer based in Seattle.

IMAGE SOURCE: DRASCHWARTZ/ISTOCK.COM

In light of the recent elimination of consultation codes from the Medicare Physician Fee Schedule, physicians of all specialties are being asked to report initial hospital care services (99221-99223) for their first encounter with a patient.1 This leaves hospitalists with questions about the billing and financial implications of reporting admissions services.

Here’s a typical scenario: Dr. A admits a Medicare patient to the hospital from the ED for hyperglycemia and dehydration in the setting of uncontrolled diabetes. He performs and documents an initial hospital-care service on day one of the admission. On day two, another hospitalist, Dr. B, who works in the same HM group, sees the patient for the first time. What should each of the physicians report for their first encounter with the patient?

Each hospitalist should select the CPT code that best fits the service and their role in the case. Remember, only one physician is named “attending of record” or “admitting physician.”

When billing during the course of the hospitalization, consider all physicians of the same specialty in the same provider group as the “admitting physician/group.”

Admissions Service

On day one, Dr. A admits the patient. He performs and documents a comprehensive history, a comprehensive exam, and medical decision-making of high complexity. The documentation corresponds to the highest initial admission service, 99223. Given the recent Medicare billing changes, the attending of record is required to append modifier “AI” (principal physician of record) to the admission service (e.g., 99223-AI).

The purpose of this modifier is “to identify the physician who oversees the patient’s care from all other physicians who may be furnishing specialty care.”2 This modifier has no financial implications. It does not increase or decrease the payment associated with the reported visit level (i.e., 99223 is reimbursed at a national rate of approximately $190, with or without modifier AI).

Initial Encounter by Team Members

As previously stated, the elimination of consultation services requires physicians to report their initial hospital encounter with an initial hospital-care code (i.e., 99221-99223). However, Medicare states that “physicians in the same group practice who are in the same specialty must bill and be paid as though they were a single physician.”3 This means followup services performed on days subsequent to a group member’s initial admission service must be reported with subsequent hospital-care codes (99231-99233). Therefore, in the scenario above, Dr. B is obligated to report the appropriate subsequent hospital-care code for his patient encounter on day two.

Incomplete Documentation

Initial hospital-care services (99221-99223) require the physician to obtain, perform, and document the necessary elements of history, physical exam, and medical decision-making in support of the code reported on the claim. There are occasions when the physician’s documentation does not support the lowest code (i.e., 99221). A reasonable approach is to report the service with an unlisted E&M code (99499). “Unlisted” codes do not have a payor-recognized code description or fee. When reporting an unlisted code, the biller must manually enter a charge description (e.g., expanded problem-focused admissions service) and a fee. A payor-prompted request for documentation is likely before payment is made.

Some payors have more specific references to the situation and allow for options. Two options exist for coding services that do not meet the work and/or medical necessity requirements of 99221-99223: report an unlisted E&M service (99499); or report a subsequent hospital care code (99231-99233) that appropriately reflects physician work and medical necessity for the service, and avoids mandatory medical record submission and manual medical review.4

In fact, Medicare Administrator Contractor TrailBlazer Health’s Web site (www.trailblazerhealth.com) offers guidance to physicians who are unsure if subsequent hospital care is an appropriate choice for this dilemma: “TrailBlazer recognizes provider reluctance to miscode initial hospital care as subsequent hospital care. However, doing so is preferable in that it allows Medicare to process and pay the claims much more efficiently. For those concerned about miscoding these services, please understand that TrailBlazer will not find fault with providers who choose this option when records appropriately demonstrate the work and medical necessity of the subsequent code chosen.”4 TH

Carol Pohlig is a billing and coding expert with the University of Pennsylvania Medical Center, Philadelphia. She also is faculty for SHM’s inpatient coding course.

References

1. CMS announces payment, policy changes for physicians services to Medicare beneficiaries in 2010. Centers for Medicare and Medicaid Services Web site. Available at: www.cms.hhs.gov/apps/media/ press/release.asp?Counter=3539&intNumPerPage=10&checkDate=&checkKey=&srchType=1&numDays=3500&srchOpt=0&srchData=&keywordType=All&chkNewsType=1%2C+2%2C+3%2C+4%2C+5&intPage=&showAll=&pYear=&year=&desc=&cboOrder=date. Accessed Nov. 12, 2009.
2. Revisions to Consultation Services Payment Policy. Medicare Learning Network Web site. Available at: www.cms.hhs.gov/MLNMattersArticles/downloads/ MM6740.pdf. Accessed Jan. 16, 2010.
3. Medicare Claims Processing Manual: Chapter 12, Section 30.6.5. CMS Web site. Available at: www.cms.hhs.gov/manuals/downloads/clm104c12.pdf. Accessed Jan. 16, 2010.
4. Update-evaluation and management services formerly coded as consultations. Trailblazer Health Enterprises Web site. Available at: www.trailblazerhealth.com/Tools/Notices.aspx?DomainID=1. Accessed Jan. 17, 2010.
5. Beebe M, Dalton J, Espronceda M, Evans D, Glenn R. Current Procedural Terminology Professional Edition. Chicago: American Medical Association Press; 2009;14-15.

In light of the recent elimination of consultation codes from the Medicare Physician Fee Schedule, physicians of all specialties are being asked to report initial hospital care services (99221-99223) for their first encounter with a patient.1 This leaves hospitalists with questions about the billing and financial implications of reporting admissions services.

Here’s a typical scenario: Dr. A admits a Medicare patient to the hospital from the ED for hyperglycemia and dehydration in the setting of uncontrolled diabetes. He performs and documents an initial hospital-care service on day one of the admission. On day two, another hospitalist, Dr. B, who works in the same HM group, sees the patient for the first time. What should each of the physicians report for their first encounter with the patient?

Each hospitalist should select the CPT code that best fits the service and their role in the case. Remember, only one physician is named “attending of record” or “admitting physician.”

When billing during the course of the hospitalization, consider all physicians of the same specialty in the same provider group as the “admitting physician/group.”

Admissions Service

On day one, Dr. A admits the patient. He performs and documents a comprehensive history, a comprehensive exam, and medical decision-making of high complexity. The documentation corresponds to the highest initial admission service, 99223. Given the recent Medicare billing changes, the attending of record is required to append modifier “AI” (principal physician of record) to the admission service (e.g., 99223-AI).

The purpose of this modifier is “to identify the physician who oversees the patient’s care from all other physicians who may be furnishing specialty care.”2 This modifier has no financial implications. It does not increase or decrease the payment associated with the reported visit level (i.e., 99223 is reimbursed at a national rate of approximately $190, with or without modifier AI).

Initial Encounter by Team Members

As previously stated, the elimination of consultation services requires physicians to report their initial hospital encounter with an initial hospital-care code (i.e., 99221-99223). However, Medicare states that “physicians in the same group practice who are in the same specialty must bill and be paid as though they were a single physician.”3 This means followup services performed on days subsequent to a group member’s initial admission service must be reported with subsequent hospital-care codes (99231-99233). Therefore, in the scenario above, Dr. B is obligated to report the appropriate subsequent hospital-care code for his patient encounter on day two.

Incomplete Documentation

Initial hospital-care services (99221-99223) require the physician to obtain, perform, and document the necessary elements of history, physical exam, and medical decision-making in support of the code reported on the claim. There are occasions when the physician’s documentation does not support the lowest code (i.e., 99221). A reasonable approach is to report the service with an unlisted E&M code (99499). “Unlisted” codes do not have a payor-recognized code description or fee. When reporting an unlisted code, the biller must manually enter a charge description (e.g., expanded problem-focused admissions service) and a fee. A payor-prompted request for documentation is likely before payment is made.

Some payors have more specific references to the situation and allow for options. Two options exist for coding services that do not meet the work and/or medical necessity requirements of 99221-99223: report an unlisted E&M service (99499); or report a subsequent hospital care code (99231-99233) that appropriately reflects physician work and medical necessity for the service, and avoids mandatory medical record submission and manual medical review.4

In fact, Medicare Administrator Contractor TrailBlazer Health’s Web site (www.trailblazerhealth.com) offers guidance to physicians who are unsure if subsequent hospital care is an appropriate choice for this dilemma: “TrailBlazer recognizes provider reluctance to miscode initial hospital care as subsequent hospital care. However, doing so is preferable in that it allows Medicare to process and pay the claims much more efficiently. For those concerned about miscoding these services, please understand that TrailBlazer will not find fault with providers who choose this option when records appropriately demonstrate the work and medical necessity of the subsequent code chosen.”4 TH

Carol Pohlig is a billing and coding expert with the University of Pennsylvania Medical Center, Philadelphia. She also is faculty for SHM’s inpatient coding course.

References

1. CMS announces payment, policy changes for physicians services to Medicare beneficiaries in 2010. Centers for Medicare and Medicaid Services Web site. Available at: www.cms.hhs.gov/apps/media/ press/release.asp?Counter=3539&intNumPerPage=10&checkDate=&checkKey=&srchType=1&numDays=3500&srchOpt=0&srchData=&keywordType=All&chkNewsType=1%2C+2%2C+3%2C+4%2C+5&intPage=&showAll=&pYear=&year=&desc=&cboOrder=date. Accessed Nov. 12, 2009.
2. Revisions to Consultation Services Payment Policy. Medicare Learning Network Web site. Available at: www.cms.hhs.gov/MLNMattersArticles/downloads/ MM6740.pdf. Accessed Jan. 16, 2010.
3. Medicare Claims Processing Manual: Chapter 12, Section 30.6.5. CMS Web site. Available at: www.cms.hhs.gov/manuals/downloads/clm104c12.pdf. Accessed Jan. 16, 2010.
4. Update-evaluation and management services formerly coded as consultations. Trailblazer Health Enterprises Web site. Available at: www.trailblazerhealth.com/Tools/Notices.aspx?DomainID=1. Accessed Jan. 17, 2010.
5. Beebe M, Dalton J, Espronceda M, Evans D, Glenn R. Current Procedural Terminology Professional Edition. Chicago: American Medical Association Press; 2009;14-15.

In light of the recent elimination of consultation codes from the Medicare Physician Fee Schedule, physicians of all specialties are being asked to report initial hospital care services (99221-99223) for their first encounter with a patient.1 This leaves hospitalists with questions about the billing and financial implications of reporting admissions services.

Here’s a typical scenario: Dr. A admits a Medicare patient to the hospital from the ED for hyperglycemia and dehydration in the setting of uncontrolled diabetes. He performs and documents an initial hospital-care service on day one of the admission. On day two, another hospitalist, Dr. B, who works in the same HM group, sees the patient for the first time. What should each of the physicians report for their first encounter with the patient?

Each hospitalist should select the CPT code that best fits the service and their role in the case. Remember, only one physician is named “attending of record” or “admitting physician.”

When billing during the course of the hospitalization, consider all physicians of the same specialty in the same provider group as the “admitting physician/group.”

Admissions Service

On day one, Dr. A admits the patient. He performs and documents a comprehensive history, a comprehensive exam, and medical decision-making of high complexity. The documentation corresponds to the highest initial admission service, 99223. Given the recent Medicare billing changes, the attending of record is required to append modifier “AI” (principal physician of record) to the admission service (e.g., 99223-AI).

The purpose of this modifier is “to identify the physician who oversees the patient’s care from all other physicians who may be furnishing specialty care.”2 This modifier has no financial implications. It does not increase or decrease the payment associated with the reported visit level (i.e., 99223 is reimbursed at a national rate of approximately $190, with or without modifier AI).

Initial Encounter by Team Members

As previously stated, the elimination of consultation services requires physicians to report their initial hospital encounter with an initial hospital-care code (i.e., 99221-99223). However, Medicare states that “physicians in the same group practice who are in the same specialty must bill and be paid as though they were a single physician.”3 This means followup services performed on days subsequent to a group member’s initial admission service must be reported with subsequent hospital-care codes (99231-99233). Therefore, in the scenario above, Dr. B is obligated to report the appropriate subsequent hospital-care code for his patient encounter on day two.

Incomplete Documentation

Initial hospital-care services (99221-99223) require the physician to obtain, perform, and document the necessary elements of history, physical exam, and medical decision-making in support of the code reported on the claim. There are occasions when the physician’s documentation does not support the lowest code (i.e., 99221). A reasonable approach is to report the service with an unlisted E&M code (99499). “Unlisted” codes do not have a payor-recognized code description or fee. When reporting an unlisted code, the biller must manually enter a charge description (e.g., expanded problem-focused admissions service) and a fee. A payor-prompted request for documentation is likely before payment is made.

Some payors have more specific references to the situation and allow for options. Two options exist for coding services that do not meet the work and/or medical necessity requirements of 99221-99223: report an unlisted E&M service (99499); or report a subsequent hospital care code (99231-99233) that appropriately reflects physician work and medical necessity for the service, and avoids mandatory medical record submission and manual medical review.4

In fact, Medicare Administrator Contractor TrailBlazer Health’s Web site (www.trailblazerhealth.com) offers guidance to physicians who are unsure if subsequent hospital care is an appropriate choice for this dilemma: “TrailBlazer recognizes provider reluctance to miscode initial hospital care as subsequent hospital care. However, doing so is preferable in that it allows Medicare to process and pay the claims much more efficiently. For those concerned about miscoding these services, please understand that TrailBlazer will not find fault with providers who choose this option when records appropriately demonstrate the work and medical necessity of the subsequent code chosen.”4 TH

Carol Pohlig is a billing and coding expert with the University of Pennsylvania Medical Center, Philadelphia. She also is faculty for SHM’s inpatient coding course.

References

1. CMS announces payment, policy changes for physicians services to Medicare beneficiaries in 2010. Centers for Medicare and Medicaid Services Web site. Available at: www.cms.hhs.gov/apps/media/ press/release.asp?Counter=3539&intNumPerPage=10&checkDate=&checkKey=&srchType=1&numDays=3500&srchOpt=0&srchData=&keywordType=All&chkNewsType=1%2C+2%2C+3%2C+4%2C+5&intPage=&showAll=&pYear=&year=&desc=&cboOrder=date. Accessed Nov. 12, 2009.
2. Revisions to Consultation Services Payment Policy. Medicare Learning Network Web site. Available at: www.cms.hhs.gov/MLNMattersArticles/downloads/ MM6740.pdf. Accessed Jan. 16, 2010.
3. Medicare Claims Processing Manual: Chapter 12, Section 30.6.5. CMS Web site. Available at: www.cms.hhs.gov/manuals/downloads/clm104c12.pdf. Accessed Jan. 16, 2010.
4. Update-evaluation and management services formerly coded as consultations. Trailblazer Health Enterprises Web site. Available at: www.trailblazerhealth.com/Tools/Notices.aspx?DomainID=1. Accessed Jan. 17, 2010.
5. Beebe M, Dalton J, Espronceda M, Evans D, Glenn R. Current Procedural Terminology Professional Edition. Chicago: American Medical Association Press; 2009;14-15.

Like so many things in HM, the story of how hospitalists first learned about the focused practice program is a modern one.

It started with a text message, which led to a blog post, which reached thousands of readers, many of them hospitalists interested in how to bolster their bona fides in a specialty known for its explosive growth in recent years.

Now, hospitalists certified in internal medicine have the opportunity to reinforce their commitment to the specialty by maintaining their certification through the Focused Practice in Hospital Medicine pathway offered by the American Board of Internal Medicine (ABIM). The Focused Practice in Hospital Medicine (FPHM) Maintenance of Certification (MOC) program enables hospitalists to distinguish their practice within the larger specialty of internal medicine.

The Evolution of FPHM

The new pathway has been years in the making, and it reflects the growing influence of HM in healthcare, according to ABIM Chief Medical Officer Eric Holmboe, MD. He sees the FPHM as the result of a combination of factors, including the fact that the specialty now has more than 30,000 hospitalists practicing nationwide. “If you look at the past years, this has been a viable and vibrant practice,” he says. “If you look at the number of people doing hospital medicine, it’s a factor.”

For Holmboe, it also is a shift in how individuals are recognized based on their practice areas. “This is an acknowledgement by ABIM and the American Board of Medical Specialties to look at Maintenance of Certification in terms of what the individual actually does,” he explains. “Hospitalists play a very important role in the hospital.”

He also credits the leadership of the HM movement—especially pioneers like Robert Wachter, MD, FHM. One of HM’s most ardent champions, Dr. Wachter, chief of the hospital medicine division, professor, and associate chair of the Department of Medicine at the University of California at San Francisco, worked with ABIM to find a way to recognize hospitalists’ specialized skill sets and their commitment to inpatient medicine. After more than a decade of advocating for a board-certified process to recognize the field, Dr. Wachter, an ABIM board member, began receiving multiple text messages from colleagues announcing that ABIM had approved the focused-practice program. He wrote a post on his blog, Wachter’s World (www.wachtersworld.com), that outlined the need for the FPHM and the significance for aspiring hospitalists.

“In any case, this is an important milestone for the field,” Dr. Wachter wrote in his Sept. 23, 2009, blog entry, “Board Certification for Hospitalists: It’s Heeeere!” “In fact, when I first began speaking to groups of hospitalists nearly 15 years ago, I often showed a slide listing the elements of a true specialty, and one by one we’ve ticked them off,” wrote Dr. Wachter, a former SHM president. “The only unchecked box was recognition of the field as a legitimate ‘specialty,’ as codified by the ABMS board certification process.”

Unchecked, that is, until now.

In early 2011, the medical world will be introduced to the first internists recognized for their focus in HM. For Holmboe, the FPHM is the beginning of an even larger movement.

“The goal is continued interest: getting people involved in quality in their hospital and encouraging people to change behaviors and be recognized by patients and credentialists as valuable,” he says. “That’s the primary mission of ABIM: using certification to improve care.”

Fellow in Hospital Medicine Spotlight

O’Neil Pyke, MD, FHM

Dr. Pyke is a clinical instructor at Commonwealth Medical College and a medical director at the Wyoming Valley Health Care System in Wilkes-Barre, Pa. He also serves as a consultant for various hospitalist programs, most actively for his own private consulting company, AMP Hospitalist Consulting, which partners with Salem, N.H.-based physician staffing company Medicus Healthcare Solutions.

Undergraduate Education: Queens College, City University of New York, Flushing, N.Y.

Medical School: Ohio State University College of Medicine and Public Health, Columbus

Notable: Dr. Pyke was born in Jamaica and moved to New York during high school. He says he owes everything to his parents. His parents, who had no education beyond high school, pushed Dr. Pyke and his siblings to achieve more than they did. His sister is an OB-GYN and his brother is pursuing a medical degree.

FYI: Dr. Pyke enjoys playing golf, cheering for his beloved Ohio State Buckeyes, and spends every Friday night with his wife and two daughters—he even admits to watching “chick flicks” on family night.

For more information about the FHM designation, visit www.hospitalmedicine.org/fellows.

Requirements and Process

Shortly after the program’s approval, ABIM, which administers the FPHM program, went to work in defining the process for the FPHM application and building infrastructure to support the tests. Holmboe expects ABIM will be ready to process pre-applications by April or May. While some details may change, the FPHM application will dovetail with ABIM’s MOC process.

Although hospitalists’ MOC must be current in order to apply for FPHM, hospitalists can begin the FPHM application process at any time. Hospitalists do not need to wait until their next MOC renewal.

Before beginning the application process, hospitalists should ensure that they are eligible. ABIM requires FPHM candidates to have:

• A current or previous ABIM certification in internal medicine;
• A valid, unrestricted medical license and confirmation of good standing in the local practice community;
• ACLS certification; and
• At least three years of hospital medicine practice experience.

Candidates who meet the requirements can then begin the enrollment process by:

1. Submitting attestations. Both the hospitalist and a senior officer at the hospital must provide attestations that demonstrate the hospitalist’s experience in HM and his or her commitment to the principles of the specialty.
2. Performing a self-assessment. Hospitalists must quantify their experience in HM through an MOC self-assessment. Candidates must achieve at least 100 MOC points. Successful applicants must submit a new self-assessment every three years. The self-assessment can be conducted before or after the exam.
3. Taking the MOC examination in Hospital Medicine. Registration for the first HM examination will begin in May. The exam will be conducted in October, and diplomates can take the exam at any time in the process.

Passing the exam and completing the other requirements will earn ABIM diplomats recognition as “Board Certified in Internal Medicine with a Focused Practice in Hospital Medicine.” ABIM will notify successful applicants in late 2010 and ship personalized certificates in early 2011. TH

Brendon Shank is a freelance writer based in Philadelphia.

Like so many things in HM, the story of how hospitalists first learned about the focused practice program is a modern one.

It started with a text message, which led to a blog post, which reached thousands of readers, many of them hospitalists interested in how to bolster their bona fides in a specialty known for its explosive growth in recent years.

Now, hospitalists certified in internal medicine have the opportunity to reinforce their commitment to the specialty by maintaining their certification through the Focused Practice in Hospital Medicine pathway offered by the American Board of Internal Medicine (ABIM). The Focused Practice in Hospital Medicine (FPHM) Maintenance of Certification (MOC) program enables hospitalists to distinguish their practice within the larger specialty of internal medicine.

The Evolution of FPHM

The new pathway has been years in the making, and it reflects the growing influence of HM in healthcare, according to ABIM Chief Medical Officer Eric Holmboe, MD. He sees the FPHM as the result of a combination of factors, including the fact that the specialty now has more than 30,000 hospitalists practicing nationwide. “If you look at the past years, this has been a viable and vibrant practice,” he says. “If you look at the number of people doing hospital medicine, it’s a factor.”

For Holmboe, it also is a shift in how individuals are recognized based on their practice areas. “This is an acknowledgement by ABIM and the American Board of Medical Specialties to look at Maintenance of Certification in terms of what the individual actually does,” he explains. “Hospitalists play a very important role in the hospital.”

He also credits the leadership of the HM movement—especially pioneers like Robert Wachter, MD, FHM. One of HM’s most ardent champions, Dr. Wachter, chief of the hospital medicine division, professor, and associate chair of the Department of Medicine at the University of California at San Francisco, worked with ABIM to find a way to recognize hospitalists’ specialized skill sets and their commitment to inpatient medicine. After more than a decade of advocating for a board-certified process to recognize the field, Dr. Wachter, an ABIM board member, began receiving multiple text messages from colleagues announcing that ABIM had approved the focused-practice program. He wrote a post on his blog, Wachter’s World (www.wachtersworld.com), that outlined the need for the FPHM and the significance for aspiring hospitalists.

“In any case, this is an important milestone for the field,” Dr. Wachter wrote in his Sept. 23, 2009, blog entry, “Board Certification for Hospitalists: It’s Heeeere!” “In fact, when I first began speaking to groups of hospitalists nearly 15 years ago, I often showed a slide listing the elements of a true specialty, and one by one we’ve ticked them off,” wrote Dr. Wachter, a former SHM president. “The only unchecked box was recognition of the field as a legitimate ‘specialty,’ as codified by the ABMS board certification process.”

Unchecked, that is, until now.

In early 2011, the medical world will be introduced to the first internists recognized for their focus in HM. For Holmboe, the FPHM is the beginning of an even larger movement.

“The goal is continued interest: getting people involved in quality in their hospital and encouraging people to change behaviors and be recognized by patients and credentialists as valuable,” he says. “That’s the primary mission of ABIM: using certification to improve care.”

Fellow in Hospital Medicine Spotlight

O’Neil Pyke, MD, FHM

Dr. Pyke is a clinical instructor at Commonwealth Medical College and a medical director at the Wyoming Valley Health Care System in Wilkes-Barre, Pa. He also serves as a consultant for various hospitalist programs, most actively for his own private consulting company, AMP Hospitalist Consulting, which partners with Salem, N.H.-based physician staffing company Medicus Healthcare Solutions.

Undergraduate Education: Queens College, City University of New York, Flushing, N.Y.

Medical School: Ohio State University College of Medicine and Public Health, Columbus

Notable: Dr. Pyke was born in Jamaica and moved to New York during high school. He says he owes everything to his parents. His parents, who had no education beyond high school, pushed Dr. Pyke and his siblings to achieve more than they did. His sister is an OB-GYN and his brother is pursuing a medical degree.

FYI: Dr. Pyke enjoys playing golf, cheering for his beloved Ohio State Buckeyes, and spends every Friday night with his wife and two daughters—he even admits to watching “chick flicks” on family night.

For more information about the FHM designation, visit www.hospitalmedicine.org/fellows.

Requirements and Process

Shortly after the program’s approval, ABIM, which administers the FPHM program, went to work in defining the process for the FPHM application and building infrastructure to support the tests. Holmboe expects ABIM will be ready to process pre-applications by April or May. While some details may change, the FPHM application will dovetail with ABIM’s MOC process.

Although hospitalists’ MOC must be current in order to apply for FPHM, hospitalists can begin the FPHM application process at any time. Hospitalists do not need to wait until their next MOC renewal.

Before beginning the application process, hospitalists should ensure that they are eligible. ABIM requires FPHM candidates to have:

• A current or previous ABIM certification in internal medicine;
• A valid, unrestricted medical license and confirmation of good standing in the local practice community;
• ACLS certification; and
• At least three years of hospital medicine practice experience.

Candidates who meet the requirements can then begin the enrollment process by:

1. Submitting attestations. Both the hospitalist and a senior officer at the hospital must provide attestations that demonstrate the hospitalist’s experience in HM and his or her commitment to the principles of the specialty.
2. Performing a self-assessment. Hospitalists must quantify their experience in HM through an MOC self-assessment. Candidates must achieve at least 100 MOC points. Successful applicants must submit a new self-assessment every three years. The self-assessment can be conducted before or after the exam.
3. Taking the MOC examination in Hospital Medicine. Registration for the first HM examination will begin in May. The exam will be conducted in October, and diplomates can take the exam at any time in the process.

Passing the exam and completing the other requirements will earn ABIM diplomats recognition as “Board Certified in Internal Medicine with a Focused Practice in Hospital Medicine.” ABIM will notify successful applicants in late 2010 and ship personalized certificates in early 2011. TH

Brendon Shank is a freelance writer based in Philadelphia.

Like so many things in HM, the story of how hospitalists first learned about the focused practice program is a modern one.

It started with a text message, which led to a blog post, which reached thousands of readers, many of them hospitalists interested in how to bolster their bona fides in a specialty known for its explosive growth in recent years.

Now, hospitalists certified in internal medicine have the opportunity to reinforce their commitment to the specialty by maintaining their certification through the Focused Practice in Hospital Medicine pathway offered by the American Board of Internal Medicine (ABIM). The Focused Practice in Hospital Medicine (FPHM) Maintenance of Certification (MOC) program enables hospitalists to distinguish their practice within the larger specialty of internal medicine.

The Evolution of FPHM

The new pathway has been years in the making, and it reflects the growing influence of HM in healthcare, according to ABIM Chief Medical Officer Eric Holmboe, MD. He sees the FPHM as the result of a combination of factors, including the fact that the specialty now has more than 30,000 hospitalists practicing nationwide. “If you look at the past years, this has been a viable and vibrant practice,” he says. “If you look at the number of people doing hospital medicine, it’s a factor.”

For Holmboe, it also is a shift in how individuals are recognized based on their practice areas. “This is an acknowledgement by ABIM and the American Board of Medical Specialties to look at Maintenance of Certification in terms of what the individual actually does,” he explains. “Hospitalists play a very important role in the hospital.”

He also credits the leadership of the HM movement—especially pioneers like Robert Wachter, MD, FHM. One of HM’s most ardent champions, Dr. Wachter, chief of the hospital medicine division, professor, and associate chair of the Department of Medicine at the University of California at San Francisco, worked with ABIM to find a way to recognize hospitalists’ specialized skill sets and their commitment to inpatient medicine. After more than a decade of advocating for a board-certified process to recognize the field, Dr. Wachter, an ABIM board member, began receiving multiple text messages from colleagues announcing that ABIM had approved the focused-practice program. He wrote a post on his blog, Wachter’s World (www.wachtersworld.com), that outlined the need for the FPHM and the significance for aspiring hospitalists.

“In any case, this is an important milestone for the field,” Dr. Wachter wrote in his Sept. 23, 2009, blog entry, “Board Certification for Hospitalists: It’s Heeeere!” “In fact, when I first began speaking to groups of hospitalists nearly 15 years ago, I often showed a slide listing the elements of a true specialty, and one by one we’ve ticked them off,” wrote Dr. Wachter, a former SHM president. “The only unchecked box was recognition of the field as a legitimate ‘specialty,’ as codified by the ABMS board certification process.”

Unchecked, that is, until now.

In early 2011, the medical world will be introduced to the first internists recognized for their focus in HM. For Holmboe, the FPHM is the beginning of an even larger movement.

“The goal is continued interest: getting people involved in quality in their hospital and encouraging people to change behaviors and be recognized by patients and credentialists as valuable,” he says. “That’s the primary mission of ABIM: using certification to improve care.”

Fellow in Hospital Medicine Spotlight

O’Neil Pyke, MD, FHM

Dr. Pyke is a clinical instructor at Commonwealth Medical College and a medical director at the Wyoming Valley Health Care System in Wilkes-Barre, Pa. He also serves as a consultant for various hospitalist programs, most actively for his own private consulting company, AMP Hospitalist Consulting, which partners with Salem, N.H.-based physician staffing company Medicus Healthcare Solutions.

Undergraduate Education: Queens College, City University of New York, Flushing, N.Y.

Medical School: Ohio State University College of Medicine and Public Health, Columbus

Notable: Dr. Pyke was born in Jamaica and moved to New York during high school. He says he owes everything to his parents. His parents, who had no education beyond high school, pushed Dr. Pyke and his siblings to achieve more than they did. His sister is an OB-GYN and his brother is pursuing a medical degree.

FYI: Dr. Pyke enjoys playing golf, cheering for his beloved Ohio State Buckeyes, and spends every Friday night with his wife and two daughters—he even admits to watching “chick flicks” on family night.

For more information about the FHM designation, visit www.hospitalmedicine.org/fellows.

Requirements and Process

Shortly after the program’s approval, ABIM, which administers the FPHM program, went to work in defining the process for the FPHM application and building infrastructure to support the tests. Holmboe expects ABIM will be ready to process pre-applications by April or May. While some details may change, the FPHM application will dovetail with ABIM’s MOC process.

Although hospitalists’ MOC must be current in order to apply for FPHM, hospitalists can begin the FPHM application process at any time. Hospitalists do not need to wait until their next MOC renewal.

Before beginning the application process, hospitalists should ensure that they are eligible. ABIM requires FPHM candidates to have:

• A current or previous ABIM certification in internal medicine;
• A valid, unrestricted medical license and confirmation of good standing in the local practice community;
• ACLS certification; and
• At least three years of hospital medicine practice experience.

Candidates who meet the requirements can then begin the enrollment process by:

1. Submitting attestations. Both the hospitalist and a senior officer at the hospital must provide attestations that demonstrate the hospitalist’s experience in HM and his or her commitment to the principles of the specialty.
2. Performing a self-assessment. Hospitalists must quantify their experience in HM through an MOC self-assessment. Candidates must achieve at least 100 MOC points. Successful applicants must submit a new self-assessment every three years. The self-assessment can be conducted before or after the exam.
3. Taking the MOC examination in Hospital Medicine. Registration for the first HM examination will begin in May. The exam will be conducted in October, and diplomates can take the exam at any time in the process.

Passing the exam and completing the other requirements will earn ABIM diplomats recognition as “Board Certified in Internal Medicine with a Focused Practice in Hospital Medicine.” ABIM will notify successful applicants in late 2010 and ship personalized certificates in early 2011. TH

Brendon Shank is a freelance writer based in Philadelphia.