Quality

Background: Frailty, history of dementia (HoD), and acute confusional states (ACS) are common in older patients admitted to hospital.

Objective: To study the association of frailty (≥six points in the Clinical Frailty Scale [CFS]), HoD, and ACS with hospital outcomes, controlling for age, gender, acute illness severity (measured by a Modified Early Warning Score in the emergency department), comorbidity (Charlson Comorbidity Index), and discharging specialty (general medicine, geriatric medicine, surgery).

Design: Retrospective, observational study.

Setting: Large university hospital in England.

Patients: We analyzed 8,202 first nonelective inpatient episodes of people ages 75 years and older between October 2014 and October 2015.

Measurements: The outcomes studied were prolonged length of stay (LOS 10 days), inpatient mortality, delayed discharge, institutionalization, and 30-day readmission. Statistical analyses were based on multivariate regression models.

Results: Independently of controlling variables, prolonged LOS was predicted by CFS greater than or equal to 6: odds ratio (OR) = 1.55; 95% confidence interval (CI), 1.36-1.77; P less than .001; HOD: OR = 2.16; 95% CI, 1.79-2.61; P less than .001; and ACS: OR = 3.31; 95% CI, 2.64-4.15; P less than .001. Inpatient mortality was predicted by CFS greater than or equal to 6: OR = 2.29; 95% CI, 1.79-2.94, P less than .001. Delayed discharge was predicted by CFS greater than or equal to 6: OR = 1.46; 95% CI, 1.27-1.67; P less than .001; HOD: OR = 2.17; 95% CI, 1.80-2.62; P less than .001, and ACS: OR = 2.29; 95% CI: 1.83-2.85; P less than .001. Institutionalization was predicted by CFS greater than or equal to 6: OR=2.56; 95% CI, 2.09-3.14; P less than .001; HOD: OR = 2.51; 95% CI, 2.00-3.14; P less than .001; and ACS: OR = 1.93; 95% CI, 1.46-2.56; P less than .001. Readmission was predicted by ACS: OR = 1.36; 95% CI, 1.09-1.71; P = .006.

Conclusion: Routine screening for frailty, HoD, and ACS in hospitals may aid the development of acute care pathways for older adults.

Read the full article at journalofhospitalmedicine.com.

Also in JHM this month…

• Screening for Depression in Hospitalized Medical Patients

AUTHORS: Waguih William IsHak, MD, FAPA, Katherine Collison, Itai Danovitch, MD, MBA, Lili Shek, MD, Payam Kharazi, Tae Kim, DO Candidate, Karim Y. Jaffer, MD Candidate, Lancer Naghdechi, DO Candidate, Enrique Lopez, PsyD, Teryl Nuckols, MD, MSHS, FHM
 

• Patient-Level Exclusions from mHealth in a Safety-Net Health System

AUTHORS: Keiki Hinami, MD, MS, Bhrandon A. Harris, MD, Ricardo Uriostegui, MD, Wilnise Jasmin, MD, MBA, Mario Lopez, MD, William E. Trick, MD
 

• Medical and Economic Burden of Heparin-Induced Thrombocytopenia: A Retrospective Nationwide Inpatient Sample (NIS) Study

AUTHORS: Ranjan Pathak, MD, Vijaya Raj Bhatt, MD, Paras Karmacharya, MD, Madan Raj Aryal, MD, Anthony A. Donato, MD, MHPE
 

• Assessment of the Readability, Understandability and Completeness of Pediatric Hospital Medicine Discharge Instructions

AUTHORS: Ndidi I. Unaka, MD, Med, Angela Statile, MD, Med, Julianne Haney, Andrew F. Beck, MD, MPH, Patrick W. Brady, MD, MSc, Karen E. Jerardi, MD, MEd
 

• Impact of Patient-Centered Discharge Tools: A Systematic Review

AUTHORS: Karen Okrainec, MD, MSc, Davina Lau, BSc, Howard B Abrams, MD, Shoshanna Hahn-Goldberg, PhD, Ronak Brahmbhatt, MBBS, MPH, Tai Huynh, MBA, Kenneth Lam, MD, Chaim M Bell, MD, PhD

Background: Frailty, history of dementia (HoD), and acute confusional states (ACS) are common in older patients admitted to hospital.

Objective: To study the association of frailty (≥six points in the Clinical Frailty Scale [CFS]), HoD, and ACS with hospital outcomes, controlling for age, gender, acute illness severity (measured by a Modified Early Warning Score in the emergency department), comorbidity (Charlson Comorbidity Index), and discharging specialty (general medicine, geriatric medicine, surgery).

Design: Retrospective, observational study.

Setting: Large university hospital in England.

Patients: We analyzed 8,202 first nonelective inpatient episodes of people ages 75 years and older between October 2014 and October 2015.

Measurements: The outcomes studied were prolonged length of stay (LOS 10 days), inpatient mortality, delayed discharge, institutionalization, and 30-day readmission. Statistical analyses were based on multivariate regression models.

Results: Independently of controlling variables, prolonged LOS was predicted by CFS greater than or equal to 6: odds ratio (OR) = 1.55; 95% confidence interval (CI), 1.36-1.77; P less than .001; HOD: OR = 2.16; 95% CI, 1.79-2.61; P less than .001; and ACS: OR = 3.31; 95% CI, 2.64-4.15; P less than .001. Inpatient mortality was predicted by CFS greater than or equal to 6: OR = 2.29; 95% CI, 1.79-2.94, P less than .001. Delayed discharge was predicted by CFS greater than or equal to 6: OR = 1.46; 95% CI, 1.27-1.67; P less than .001; HOD: OR = 2.17; 95% CI, 1.80-2.62; P less than .001, and ACS: OR = 2.29; 95% CI: 1.83-2.85; P less than .001. Institutionalization was predicted by CFS greater than or equal to 6: OR=2.56; 95% CI, 2.09-3.14; P less than .001; HOD: OR = 2.51; 95% CI, 2.00-3.14; P less than .001; and ACS: OR = 1.93; 95% CI, 1.46-2.56; P less than .001. Readmission was predicted by ACS: OR = 1.36; 95% CI, 1.09-1.71; P = .006.

Conclusion: Routine screening for frailty, HoD, and ACS in hospitals may aid the development of acute care pathways for older adults.

Read the full article at journalofhospitalmedicine.com.

Also in JHM this month…

• Screening for Depression in Hospitalized Medical Patients

AUTHORS: Waguih William IsHak, MD, FAPA, Katherine Collison, Itai Danovitch, MD, MBA, Lili Shek, MD, Payam Kharazi, Tae Kim, DO Candidate, Karim Y. Jaffer, MD Candidate, Lancer Naghdechi, DO Candidate, Enrique Lopez, PsyD, Teryl Nuckols, MD, MSHS, FHM
 

• Patient-Level Exclusions from mHealth in a Safety-Net Health System

AUTHORS: Keiki Hinami, MD, MS, Bhrandon A. Harris, MD, Ricardo Uriostegui, MD, Wilnise Jasmin, MD, MBA, Mario Lopez, MD, William E. Trick, MD
 

• Medical and Economic Burden of Heparin-Induced Thrombocytopenia: A Retrospective Nationwide Inpatient Sample (NIS) Study

AUTHORS: Ranjan Pathak, MD, Vijaya Raj Bhatt, MD, Paras Karmacharya, MD, Madan Raj Aryal, MD, Anthony A. Donato, MD, MHPE
 

• Assessment of the Readability, Understandability and Completeness of Pediatric Hospital Medicine Discharge Instructions

AUTHORS: Ndidi I. Unaka, MD, Med, Angela Statile, MD, Med, Julianne Haney, Andrew F. Beck, MD, MPH, Patrick W. Brady, MD, MSc, Karen E. Jerardi, MD, MEd
 

• Impact of Patient-Centered Discharge Tools: A Systematic Review

AUTHORS: Karen Okrainec, MD, MSc, Davina Lau, BSc, Howard B Abrams, MD, Shoshanna Hahn-Goldberg, PhD, Ronak Brahmbhatt, MBBS, MPH, Tai Huynh, MBA, Kenneth Lam, MD, Chaim M Bell, MD, PhD

Background: Frailty, history of dementia (HoD), and acute confusional states (ACS) are common in older patients admitted to hospital.

Objective: To study the association of frailty (≥six points in the Clinical Frailty Scale [CFS]), HoD, and ACS with hospital outcomes, controlling for age, gender, acute illness severity (measured by a Modified Early Warning Score in the emergency department), comorbidity (Charlson Comorbidity Index), and discharging specialty (general medicine, geriatric medicine, surgery).

Design: Retrospective, observational study.

Setting: Large university hospital in England.

Patients: We analyzed 8,202 first nonelective inpatient episodes of people ages 75 years and older between October 2014 and October 2015.

Measurements: The outcomes studied were prolonged length of stay (LOS 10 days), inpatient mortality, delayed discharge, institutionalization, and 30-day readmission. Statistical analyses were based on multivariate regression models.

Results: Independently of controlling variables, prolonged LOS was predicted by CFS greater than or equal to 6: odds ratio (OR) = 1.55; 95% confidence interval (CI), 1.36-1.77; P less than .001; HOD: OR = 2.16; 95% CI, 1.79-2.61; P less than .001; and ACS: OR = 3.31; 95% CI, 2.64-4.15; P less than .001. Inpatient mortality was predicted by CFS greater than or equal to 6: OR = 2.29; 95% CI, 1.79-2.94, P less than .001. Delayed discharge was predicted by CFS greater than or equal to 6: OR = 1.46; 95% CI, 1.27-1.67; P less than .001; HOD: OR = 2.17; 95% CI, 1.80-2.62; P less than .001, and ACS: OR = 2.29; 95% CI: 1.83-2.85; P less than .001. Institutionalization was predicted by CFS greater than or equal to 6: OR=2.56; 95% CI, 2.09-3.14; P less than .001; HOD: OR = 2.51; 95% CI, 2.00-3.14; P less than .001; and ACS: OR = 1.93; 95% CI, 1.46-2.56; P less than .001. Readmission was predicted by ACS: OR = 1.36; 95% CI, 1.09-1.71; P = .006.

Conclusion: Routine screening for frailty, HoD, and ACS in hospitals may aid the development of acute care pathways for older adults.

Read the full article at journalofhospitalmedicine.com.

Also in JHM this month…

• Screening for Depression in Hospitalized Medical Patients

AUTHORS: Waguih William IsHak, MD, FAPA, Katherine Collison, Itai Danovitch, MD, MBA, Lili Shek, MD, Payam Kharazi, Tae Kim, DO Candidate, Karim Y. Jaffer, MD Candidate, Lancer Naghdechi, DO Candidate, Enrique Lopez, PsyD, Teryl Nuckols, MD, MSHS, FHM
 

• Patient-Level Exclusions from mHealth in a Safety-Net Health System

AUTHORS: Keiki Hinami, MD, MS, Bhrandon A. Harris, MD, Ricardo Uriostegui, MD, Wilnise Jasmin, MD, MBA, Mario Lopez, MD, William E. Trick, MD
 

• Medical and Economic Burden of Heparin-Induced Thrombocytopenia: A Retrospective Nationwide Inpatient Sample (NIS) Study

AUTHORS: Ranjan Pathak, MD, Vijaya Raj Bhatt, MD, Paras Karmacharya, MD, Madan Raj Aryal, MD, Anthony A. Donato, MD, MHPE
 

• Assessment of the Readability, Understandability and Completeness of Pediatric Hospital Medicine Discharge Instructions

AUTHORS: Ndidi I. Unaka, MD, Med, Angela Statile, MD, Med, Julianne Haney, Andrew F. Beck, MD, MPH, Patrick W. Brady, MD, MSc, Karen E. Jerardi, MD, MEd
 

• Impact of Patient-Centered Discharge Tools: A Systematic Review

AUTHORS: Karen Okrainec, MD, MSc, Davina Lau, BSc, Howard B Abrams, MD, Shoshanna Hahn-Goldberg, PhD, Ronak Brahmbhatt, MBBS, MPH, Tai Huynh, MBA, Kenneth Lam, MD, Chaim M Bell, MD, PhD

The online rating business is proliferating in the medical industry. This should really come as no surprise as health care is a service industry and online ratings have long been a staple in most other service industries. It has become routine practice for most of us to search such online reviews when seeking a pair of shoes, a toaster, or a restaurant; we almost can’t help but scour these sites to help us make the best decision possible.

• Anticipated cost (is the physician or practice in or out of network?).
• Availability or access to the service (location of the practice and how long it will take to be seen).
• How good the services and care will be when they get there.

• They felt it was “tacky” and that the profession of medicine should not be relegated to oversimplified service ratings. They worried that they would feel pressured to please the patient rather than “do the right thing” for the patient. For example, they would be less likely to give difficult advice (such as lose weight or stop smoking) or to resist prescribing medications that they deemed unnecessary or frankly dangerous (for example, antibiotics or narcotics).

Although these are valid concerns, it is hard to ignore the proliferation and traffic of these online websites. For you and your team, I would recommend taking a look at what is online about the members of your group and thinking about online strategies to take control of the conversation.

I don’t think the controversy over online physician ratings will wane anytime soon, but there is no doubt that they are profitable for companies and are therefore highly likely to continue to multiply.

References

1.Hanauer DA, Zheng K, Singer DC, Gebremariam A, Davis MM. Public awareness, perception, and use of online physician rating sites. JAMA. 2014;311(7):734-735. 2. A to Z provider listing: find a U of U Health Care physician by last name. University of Utah website. Available at http://healthcare.utah.edu/fad. Accessed Nov. 16, 2016.

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

The online rating business is proliferating in the medical industry. This should really come as no surprise as health care is a service industry and online ratings have long been a staple in most other service industries. It has become routine practice for most of us to search such online reviews when seeking a pair of shoes, a toaster, or a restaurant; we almost can’t help but scour these sites to help us make the best decision possible.

• Anticipated cost (is the physician or practice in or out of network?).
• Availability or access to the service (location of the practice and how long it will take to be seen).
• How good the services and care will be when they get there.

• They felt it was “tacky” and that the profession of medicine should not be relegated to oversimplified service ratings. They worried that they would feel pressured to please the patient rather than “do the right thing” for the patient. For example, they would be less likely to give difficult advice (such as lose weight or stop smoking) or to resist prescribing medications that they deemed unnecessary or frankly dangerous (for example, antibiotics or narcotics).

Although these are valid concerns, it is hard to ignore the proliferation and traffic of these online websites. For you and your team, I would recommend taking a look at what is online about the members of your group and thinking about online strategies to take control of the conversation.

I don’t think the controversy over online physician ratings will wane anytime soon, but there is no doubt that they are profitable for companies and are therefore highly likely to continue to multiply.

References

1.Hanauer DA, Zheng K, Singer DC, Gebremariam A, Davis MM. Public awareness, perception, and use of online physician rating sites. JAMA. 2014;311(7):734-735. 2. A to Z provider listing: find a U of U Health Care physician by last name. University of Utah website. Available at http://healthcare.utah.edu/fad. Accessed Nov. 16, 2016.

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

The online rating business is proliferating in the medical industry. This should really come as no surprise as health care is a service industry and online ratings have long been a staple in most other service industries. It has become routine practice for most of us to search such online reviews when seeking a pair of shoes, a toaster, or a restaurant; we almost can’t help but scour these sites to help us make the best decision possible.

• Anticipated cost (is the physician or practice in or out of network?).
• Availability or access to the service (location of the practice and how long it will take to be seen).
• How good the services and care will be when they get there.

• They felt it was “tacky” and that the profession of medicine should not be relegated to oversimplified service ratings. They worried that they would feel pressured to please the patient rather than “do the right thing” for the patient. For example, they would be less likely to give difficult advice (such as lose weight or stop smoking) or to resist prescribing medications that they deemed unnecessary or frankly dangerous (for example, antibiotics or narcotics).

Although these are valid concerns, it is hard to ignore the proliferation and traffic of these online websites. For you and your team, I would recommend taking a look at what is online about the members of your group and thinking about online strategies to take control of the conversation.

I don’t think the controversy over online physician ratings will wane anytime soon, but there is no doubt that they are profitable for companies and are therefore highly likely to continue to multiply.

References

1.Hanauer DA, Zheng K, Singer DC, Gebremariam A, Davis MM. Public awareness, perception, and use of online physician rating sites. JAMA. 2014;311(7):734-735. 2. A to Z provider listing: find a U of U Health Care physician by last name. University of Utah website. Available at http://healthcare.utah.edu/fad. Accessed Nov. 16, 2016.

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

The New Year brings new leadership in the United States, with President-elect Donald Trump taking office later this month. With a Republican-controlled Congress, party leaders have the opportunity to shape the nation’s policies around conservative ideals. This includes health care.

Since the Affordable Care Act (ACA) was passed in 2010, Republicans have vowed to repeal and replace it. This could be their opportunity.

However, “there is no clear coalescence around specific policy reforms that would replace the Affordable Care Act,” says Christine Eibner, PhD, a senior economist at Rand and a professor at the Pardee Rand Graduate School.

As a candidate, Trump did little to advance policy ideas around health care. Meanwhile, House Speaker Paul Ryan (R-Wis.) and others have, over the years, proposed reforms with which Trump may or may not agree.

Where we stand January 2017

Whether the Republicans can or will repeal the ACA in its entirety and improve it remains unknown. But, the experts say, the landmark law has left its mark on the American health care system.

“Everyone is complaining about the uncertainty created by the election, but we have been dealing with a highly uncertain environment for many years,” says Ron Greeno, MD, FCCP, MHM, senior advisor for medical affairs at TeamHealth, chair of the SHM Public Policy Committee, and SHM president-elect. “There will be changes, but things were going to change no matter the outcome of the election. It continues to require tolerance for change and tolerance for uncertainty.”

In an analysis for the Commonwealth Fund, Dr. Eibner investigated the economic implications of aspects of Trump’s plans as a candidate. Using a computer model that incorporates economic theory and data to simulate the effects of health policy changes, Dr. Eibner found that Trump’s plans (full repeal alone or repeal with tax deductions for health care premiums, Medicaid block grants, or selling health insurance across state lines) would increase the number of uninsured people by 16 million to 25 million, disproportionately impact low-income and sicker patients, expose individual market enrollees to higher out-of-pocket costs, and increase the federal deficit by $0.5 billion to $41 billion.¹ The Congressional Budget Office (CBO) estimates full repeal could increase the federal deficit by $137 billion to $353 billion by 2025.² Rep. Ryan’s plan, A Better Way, proposes providing people more control over their health care, giving tax credits instead of subsidies for premiums, capping the employer-sponsored health insurance tax exclusion, and expanding use of health savings accounts.³ However, Rep. Ryan’s plan “doesn’t reduce the cost of health care. It puts more onus on individuals, and their costs go up,” Ms. Hoffman says. “The weight of that will be more on people who have preexisting conditions.”

Key provisions: A delicate balance

Many people equate the ACA with the individual mandate, which requires nearly all Americans to purchase health insurance or pay a fine. The federal government provides subsidies to enrollees between 138% and 400% of the federal poverty level so their out-of-pocket costs never exceed a defined threshold even if premiums go up. These could be on the chopping block.

“The last bill Congress passed to repeal the Affordable Care Act, which Obama vetoed, repealed the individual mandate and subsidies for people to buy insurance,” Ms. Hoffman says. “If they do repeal it, private insurance through the exchanges will crumble.”

Mr. Trump’s tax deductions to offset premium costs are based on income, making them more generous for higher-income earners than low-income ones, Hoffman adds.

And … Medicare

The other entitlement program facing abrupt change is Medicare, typically considered the third rail of American politics.

“This is the hot political moment,” Ms. Hoffman says. “This is the point where the Republicans think they can tick off their wish list. For many Republicans, this kind of entitlement program is the opposite of what they believe in.”

Though Mr. Trump has said before he would not alter Medicare, he remained quiet on this point in the aftermath of the election. Repealing the ACA would affect Medicare by potentially reopening the Part D prescription drug doughnut hole and eliminating some of the savings provisions in the law. In fact, the CBO estimates Medicare’s direct spending would increase $802 billion between 2016 and 2025.¹ Rep. Ryan has talked about privatizing Medicare by offering seniors who rely on it vouchers to apply toward private insurance.

“At the highest level, it’s moving Medicare from a defined benefit to a defined contribution program,” Ms. Hoffman says. “It shifts financial risk from the federal government onto beneficiaries. If Medicare spending continues to grow faster than the rest of the economy, Medicare beneficiaries will pay more and more.”

Seniors may also find themselves rationing or skimping on care.

Despite Rep. Ryan’s statements to the contrary, Medicare is not broken because of the ACA, Ms. Hoffman says. Its solvency has been prolonged, and though the reasons are not clear, Medicare spending has slowed since the passage of the ACA.⁶

MACRA launch

Another key factor in the health care policy landscape is MACRA, the Medicare Access and CHIP Reauthorization Act, which fundamentally shifts the way the government administrates and reimburses physicians for health care. MACRA begins in 2017. Dr. Greeno is concerned that changes to the ACA will impact the testing of payment models CMS is testing.

“There are hundreds of hospitals and thousands of physicians already invested in different models, so I don’t expect anybody has any desire to pull the rug from under physicians who are testing alternative payment models [APMs],” he says. “MACRA was passed on a strong bipartisan vote, and it created an APM track. Obviously, Congress intended APM models to continue to expand.”

Dr. Greeno says hospitalists are helping “shape these models,” working with the CMS and the Physician-Focused Payment Model Technical Advisory Committee (PTAC) “to ensure physicians participate in APMs and feel engaged rather than being a worker in a model someone else controls.”

On the campaign trail, Mr. Trump spoke of importing pharmaceuticals from overseas in an effort to control high prices. This policy is no longer part of his online plan. He also proposes allowing the sale of health insurance across state lines.

“It would be giving enrollees in states with stricter regulations the opportunity to circumvent to a looser state, which undermines the state with the stricter regulations,” Dr. Eibner says. “That would really create winners and losers. People who are healthy can buy a policy in a state with looser regulations, and their costs would likely fall. But someone sicker and older, it would be harder.”

Ms. Hoffman defines such a plan as a “race to the bottom.” Without well-established networks of physicians and hospitals, startup costs in new states are prohibitive, and many insurers may not wish to compete across state lines, she adds.

Repeal of the ACA could also limit some of the health benefits it required of plans on the individual market. For example, policymakers might be allowed to strip the contraceptive coverage regulation, which provides for free birth control.

“The reality is a lot of things changing in health care now were changing before the Affordable Care Act passed – PQRS, value-based purchasing, hospital-acquired infections,” Dr. Greeno says. “MACRA will continue the journey away from fee-for-service toward outcome-based models.”

At such a pivotal time, he strongly encourages hospitalists to join SHM if they are not already members and to get involved in SHM’s Grassroots Network.

“For a society of our age – young – and size, we’ve been tremendously impactful in helping with delivery system reform,” Dr. Greeno says. “I think it’s because we’re supporting change, not trying to stop it. We just want it to be intelligent change.”

He also is “convinced” hospitalists will be “critical to the redesign of the health care system. Since we are going to be taking care of the majority of hospitalized adult patients in hospitals, hospitalists want to have our say.” 

Kelly April Tyrrell is a freelance writer in Madison, Wis.

References

1. Eibner C. Donald Trump’s health care reform proposals: Anticipated effects on insurance coverage, out-of-pocket costs, and the federal deficit. The Commonweath Fund website. Available at: http://www.commonwealthfund.org/publications/issue-briefs/2016/sep/trump-presidential-health-care-proposal. Accessed Nov. 17, 2016.

2. Budgetary and economic effects of repealing the Affordable Care Act. Congressional Budget Office website. Available at: https://www.cbo.gov/sites/default/files/114th-congress-2015-2016/reports/50252-Effects_of_ACA_Repeal.pdf. Accessed Nov. 15, 2016.

3. Our vision for a confident America. A Better Way website. Available at: http://abetterway.speaker.gov. Accessed Nov. 17, 2016.

4. Pollitz K. High-risk pools for uninsurable individuals. Kaiser Family Foundation website. Available at: http://kff.org/health-reform/issue-brief/high-risk-pools-for-uninsurable-individuals/. Accessed Nov. 17, 2016.

5. How accessible is individual health insurance for consumers in less-than-ideal health? Kaiser Family Foundation website. Available at: https://kaiserfamilyfoundation.files.wordpress.com/2013/01/how-accessible-is-individual-health-insurance-for-consumer-in-less-than-perfect-health-report.pdf. Accessed Nov. 17, 2016.

6. The Affordable Care Act and Medicare. The Commonwealth Fund website. Available at: http://www.commonwealthfund.org/publications/fund-reports/2015/jun/medicare-affordable-care-act Accessed Nov. 17, 2016.

The New Year brings new leadership in the United States, with President-elect Donald Trump taking office later this month. With a Republican-controlled Congress, party leaders have the opportunity to shape the nation’s policies around conservative ideals. This includes health care.

Since the Affordable Care Act (ACA) was passed in 2010, Republicans have vowed to repeal and replace it. This could be their opportunity.

However, “there is no clear coalescence around specific policy reforms that would replace the Affordable Care Act,” says Christine Eibner, PhD, a senior economist at Rand and a professor at the Pardee Rand Graduate School.

As a candidate, Trump did little to advance policy ideas around health care. Meanwhile, House Speaker Paul Ryan (R-Wis.) and others have, over the years, proposed reforms with which Trump may or may not agree.

Where we stand January 2017

Whether the Republicans can or will repeal the ACA in its entirety and improve it remains unknown. But, the experts say, the landmark law has left its mark on the American health care system.

“Everyone is complaining about the uncertainty created by the election, but we have been dealing with a highly uncertain environment for many years,” says Ron Greeno, MD, FCCP, MHM, senior advisor for medical affairs at TeamHealth, chair of the SHM Public Policy Committee, and SHM president-elect. “There will be changes, but things were going to change no matter the outcome of the election. It continues to require tolerance for change and tolerance for uncertainty.”

In an analysis for the Commonwealth Fund, Dr. Eibner investigated the economic implications of aspects of Trump’s plans as a candidate. Using a computer model that incorporates economic theory and data to simulate the effects of health policy changes, Dr. Eibner found that Trump’s plans (full repeal alone or repeal with tax deductions for health care premiums, Medicaid block grants, or selling health insurance across state lines) would increase the number of uninsured people by 16 million to 25 million, disproportionately impact low-income and sicker patients, expose individual market enrollees to higher out-of-pocket costs, and increase the federal deficit by $0.5 billion to $41 billion.¹ The Congressional Budget Office (CBO) estimates full repeal could increase the federal deficit by $137 billion to $353 billion by 2025.² Rep. Ryan’s plan, A Better Way, proposes providing people more control over their health care, giving tax credits instead of subsidies for premiums, capping the employer-sponsored health insurance tax exclusion, and expanding use of health savings accounts.³ However, Rep. Ryan’s plan “doesn’t reduce the cost of health care. It puts more onus on individuals, and their costs go up,” Ms. Hoffman says. “The weight of that will be more on people who have preexisting conditions.”

Key provisions: A delicate balance

Many people equate the ACA with the individual mandate, which requires nearly all Americans to purchase health insurance or pay a fine. The federal government provides subsidies to enrollees between 138% and 400% of the federal poverty level so their out-of-pocket costs never exceed a defined threshold even if premiums go up. These could be on the chopping block.

“The last bill Congress passed to repeal the Affordable Care Act, which Obama vetoed, repealed the individual mandate and subsidies for people to buy insurance,” Ms. Hoffman says. “If they do repeal it, private insurance through the exchanges will crumble.”

Mr. Trump’s tax deductions to offset premium costs are based on income, making them more generous for higher-income earners than low-income ones, Hoffman adds.

And … Medicare

The other entitlement program facing abrupt change is Medicare, typically considered the third rail of American politics.

“This is the hot political moment,” Ms. Hoffman says. “This is the point where the Republicans think they can tick off their wish list. For many Republicans, this kind of entitlement program is the opposite of what they believe in.”

Though Mr. Trump has said before he would not alter Medicare, he remained quiet on this point in the aftermath of the election. Repealing the ACA would affect Medicare by potentially reopening the Part D prescription drug doughnut hole and eliminating some of the savings provisions in the law. In fact, the CBO estimates Medicare’s direct spending would increase $802 billion between 2016 and 2025.¹ Rep. Ryan has talked about privatizing Medicare by offering seniors who rely on it vouchers to apply toward private insurance.

“At the highest level, it’s moving Medicare from a defined benefit to a defined contribution program,” Ms. Hoffman says. “It shifts financial risk from the federal government onto beneficiaries. If Medicare spending continues to grow faster than the rest of the economy, Medicare beneficiaries will pay more and more.”

Seniors may also find themselves rationing or skimping on care.

Despite Rep. Ryan’s statements to the contrary, Medicare is not broken because of the ACA, Ms. Hoffman says. Its solvency has been prolonged, and though the reasons are not clear, Medicare spending has slowed since the passage of the ACA.⁶

MACRA launch

Another key factor in the health care policy landscape is MACRA, the Medicare Access and CHIP Reauthorization Act, which fundamentally shifts the way the government administrates and reimburses physicians for health care. MACRA begins in 2017. Dr. Greeno is concerned that changes to the ACA will impact the testing of payment models CMS is testing.

“There are hundreds of hospitals and thousands of physicians already invested in different models, so I don’t expect anybody has any desire to pull the rug from under physicians who are testing alternative payment models [APMs],” he says. “MACRA was passed on a strong bipartisan vote, and it created an APM track. Obviously, Congress intended APM models to continue to expand.”

Dr. Greeno says hospitalists are helping “shape these models,” working with the CMS and the Physician-Focused Payment Model Technical Advisory Committee (PTAC) “to ensure physicians participate in APMs and feel engaged rather than being a worker in a model someone else controls.”

On the campaign trail, Mr. Trump spoke of importing pharmaceuticals from overseas in an effort to control high prices. This policy is no longer part of his online plan. He also proposes allowing the sale of health insurance across state lines.

“It would be giving enrollees in states with stricter regulations the opportunity to circumvent to a looser state, which undermines the state with the stricter regulations,” Dr. Eibner says. “That would really create winners and losers. People who are healthy can buy a policy in a state with looser regulations, and their costs would likely fall. But someone sicker and older, it would be harder.”

Ms. Hoffman defines such a plan as a “race to the bottom.” Without well-established networks of physicians and hospitals, startup costs in new states are prohibitive, and many insurers may not wish to compete across state lines, she adds.

Repeal of the ACA could also limit some of the health benefits it required of plans on the individual market. For example, policymakers might be allowed to strip the contraceptive coverage regulation, which provides for free birth control.

“The reality is a lot of things changing in health care now were changing before the Affordable Care Act passed – PQRS, value-based purchasing, hospital-acquired infections,” Dr. Greeno says. “MACRA will continue the journey away from fee-for-service toward outcome-based models.”

At such a pivotal time, he strongly encourages hospitalists to join SHM if they are not already members and to get involved in SHM’s Grassroots Network.

“For a society of our age – young – and size, we’ve been tremendously impactful in helping with delivery system reform,” Dr. Greeno says. “I think it’s because we’re supporting change, not trying to stop it. We just want it to be intelligent change.”

He also is “convinced” hospitalists will be “critical to the redesign of the health care system. Since we are going to be taking care of the majority of hospitalized adult patients in hospitals, hospitalists want to have our say.” 

Kelly April Tyrrell is a freelance writer in Madison, Wis.

References

1. Eibner C. Donald Trump’s health care reform proposals: Anticipated effects on insurance coverage, out-of-pocket costs, and the federal deficit. The Commonweath Fund website. Available at: http://www.commonwealthfund.org/publications/issue-briefs/2016/sep/trump-presidential-health-care-proposal. Accessed Nov. 17, 2016.

2. Budgetary and economic effects of repealing the Affordable Care Act. Congressional Budget Office website. Available at: https://www.cbo.gov/sites/default/files/114th-congress-2015-2016/reports/50252-Effects_of_ACA_Repeal.pdf. Accessed Nov. 15, 2016.

3. Our vision for a confident America. A Better Way website. Available at: http://abetterway.speaker.gov. Accessed Nov. 17, 2016.

4. Pollitz K. High-risk pools for uninsurable individuals. Kaiser Family Foundation website. Available at: http://kff.org/health-reform/issue-brief/high-risk-pools-for-uninsurable-individuals/. Accessed Nov. 17, 2016.

5. How accessible is individual health insurance for consumers in less-than-ideal health? Kaiser Family Foundation website. Available at: https://kaiserfamilyfoundation.files.wordpress.com/2013/01/how-accessible-is-individual-health-insurance-for-consumer-in-less-than-perfect-health-report.pdf. Accessed Nov. 17, 2016.

6. The Affordable Care Act and Medicare. The Commonwealth Fund website. Available at: http://www.commonwealthfund.org/publications/fund-reports/2015/jun/medicare-affordable-care-act Accessed Nov. 17, 2016.

The New Year brings new leadership in the United States, with President-elect Donald Trump taking office later this month. With a Republican-controlled Congress, party leaders have the opportunity to shape the nation’s policies around conservative ideals. This includes health care.

Since the Affordable Care Act (ACA) was passed in 2010, Republicans have vowed to repeal and replace it. This could be their opportunity.

However, “there is no clear coalescence around specific policy reforms that would replace the Affordable Care Act,” says Christine Eibner, PhD, a senior economist at Rand and a professor at the Pardee Rand Graduate School.

As a candidate, Trump did little to advance policy ideas around health care. Meanwhile, House Speaker Paul Ryan (R-Wis.) and others have, over the years, proposed reforms with which Trump may or may not agree.

Where we stand January 2017

Whether the Republicans can or will repeal the ACA in its entirety and improve it remains unknown. But, the experts say, the landmark law has left its mark on the American health care system.

“Everyone is complaining about the uncertainty created by the election, but we have been dealing with a highly uncertain environment for many years,” says Ron Greeno, MD, FCCP, MHM, senior advisor for medical affairs at TeamHealth, chair of the SHM Public Policy Committee, and SHM president-elect. “There will be changes, but things were going to change no matter the outcome of the election. It continues to require tolerance for change and tolerance for uncertainty.”

In an analysis for the Commonwealth Fund, Dr. Eibner investigated the economic implications of aspects of Trump’s plans as a candidate. Using a computer model that incorporates economic theory and data to simulate the effects of health policy changes, Dr. Eibner found that Trump’s plans (full repeal alone or repeal with tax deductions for health care premiums, Medicaid block grants, or selling health insurance across state lines) would increase the number of uninsured people by 16 million to 25 million, disproportionately impact low-income and sicker patients, expose individual market enrollees to higher out-of-pocket costs, and increase the federal deficit by $0.5 billion to $41 billion.¹ The Congressional Budget Office (CBO) estimates full repeal could increase the federal deficit by $137 billion to $353 billion by 2025.² Rep. Ryan’s plan, A Better Way, proposes providing people more control over their health care, giving tax credits instead of subsidies for premiums, capping the employer-sponsored health insurance tax exclusion, and expanding use of health savings accounts.³ However, Rep. Ryan’s plan “doesn’t reduce the cost of health care. It puts more onus on individuals, and their costs go up,” Ms. Hoffman says. “The weight of that will be more on people who have preexisting conditions.”

Key provisions: A delicate balance

Many people equate the ACA with the individual mandate, which requires nearly all Americans to purchase health insurance or pay a fine. The federal government provides subsidies to enrollees between 138% and 400% of the federal poverty level so their out-of-pocket costs never exceed a defined threshold even if premiums go up. These could be on the chopping block.

“The last bill Congress passed to repeal the Affordable Care Act, which Obama vetoed, repealed the individual mandate and subsidies for people to buy insurance,” Ms. Hoffman says. “If they do repeal it, private insurance through the exchanges will crumble.”

Mr. Trump’s tax deductions to offset premium costs are based on income, making them more generous for higher-income earners than low-income ones, Hoffman adds.

And … Medicare

The other entitlement program facing abrupt change is Medicare, typically considered the third rail of American politics.

“This is the hot political moment,” Ms. Hoffman says. “This is the point where the Republicans think they can tick off their wish list. For many Republicans, this kind of entitlement program is the opposite of what they believe in.”

Though Mr. Trump has said before he would not alter Medicare, he remained quiet on this point in the aftermath of the election. Repealing the ACA would affect Medicare by potentially reopening the Part D prescription drug doughnut hole and eliminating some of the savings provisions in the law. In fact, the CBO estimates Medicare’s direct spending would increase $802 billion between 2016 and 2025.¹ Rep. Ryan has talked about privatizing Medicare by offering seniors who rely on it vouchers to apply toward private insurance.

“At the highest level, it’s moving Medicare from a defined benefit to a defined contribution program,” Ms. Hoffman says. “It shifts financial risk from the federal government onto beneficiaries. If Medicare spending continues to grow faster than the rest of the economy, Medicare beneficiaries will pay more and more.”

Seniors may also find themselves rationing or skimping on care.

Despite Rep. Ryan’s statements to the contrary, Medicare is not broken because of the ACA, Ms. Hoffman says. Its solvency has been prolonged, and though the reasons are not clear, Medicare spending has slowed since the passage of the ACA.⁶

MACRA launch

Another key factor in the health care policy landscape is MACRA, the Medicare Access and CHIP Reauthorization Act, which fundamentally shifts the way the government administrates and reimburses physicians for health care. MACRA begins in 2017. Dr. Greeno is concerned that changes to the ACA will impact the testing of payment models CMS is testing.

“There are hundreds of hospitals and thousands of physicians already invested in different models, so I don’t expect anybody has any desire to pull the rug from under physicians who are testing alternative payment models [APMs],” he says. “MACRA was passed on a strong bipartisan vote, and it created an APM track. Obviously, Congress intended APM models to continue to expand.”

Dr. Greeno says hospitalists are helping “shape these models,” working with the CMS and the Physician-Focused Payment Model Technical Advisory Committee (PTAC) “to ensure physicians participate in APMs and feel engaged rather than being a worker in a model someone else controls.”

On the campaign trail, Mr. Trump spoke of importing pharmaceuticals from overseas in an effort to control high prices. This policy is no longer part of his online plan. He also proposes allowing the sale of health insurance across state lines.

“It would be giving enrollees in states with stricter regulations the opportunity to circumvent to a looser state, which undermines the state with the stricter regulations,” Dr. Eibner says. “That would really create winners and losers. People who are healthy can buy a policy in a state with looser regulations, and their costs would likely fall. But someone sicker and older, it would be harder.”

Ms. Hoffman defines such a plan as a “race to the bottom.” Without well-established networks of physicians and hospitals, startup costs in new states are prohibitive, and many insurers may not wish to compete across state lines, she adds.

Repeal of the ACA could also limit some of the health benefits it required of plans on the individual market. For example, policymakers might be allowed to strip the contraceptive coverage regulation, which provides for free birth control.

“The reality is a lot of things changing in health care now were changing before the Affordable Care Act passed – PQRS, value-based purchasing, hospital-acquired infections,” Dr. Greeno says. “MACRA will continue the journey away from fee-for-service toward outcome-based models.”

At such a pivotal time, he strongly encourages hospitalists to join SHM if they are not already members and to get involved in SHM’s Grassroots Network.

“For a society of our age – young – and size, we’ve been tremendously impactful in helping with delivery system reform,” Dr. Greeno says. “I think it’s because we’re supporting change, not trying to stop it. We just want it to be intelligent change.”

He also is “convinced” hospitalists will be “critical to the redesign of the health care system. Since we are going to be taking care of the majority of hospitalized adult patients in hospitals, hospitalists want to have our say.” 

Kelly April Tyrrell is a freelance writer in Madison, Wis.

References

1. Eibner C. Donald Trump’s health care reform proposals: Anticipated effects on insurance coverage, out-of-pocket costs, and the federal deficit. The Commonweath Fund website. Available at: http://www.commonwealthfund.org/publications/issue-briefs/2016/sep/trump-presidential-health-care-proposal. Accessed Nov. 17, 2016.

2. Budgetary and economic effects of repealing the Affordable Care Act. Congressional Budget Office website. Available at: https://www.cbo.gov/sites/default/files/114th-congress-2015-2016/reports/50252-Effects_of_ACA_Repeal.pdf. Accessed Nov. 15, 2016.

3. Our vision for a confident America. A Better Way website. Available at: http://abetterway.speaker.gov. Accessed Nov. 17, 2016.

4. Pollitz K. High-risk pools for uninsurable individuals. Kaiser Family Foundation website. Available at: http://kff.org/health-reform/issue-brief/high-risk-pools-for-uninsurable-individuals/. Accessed Nov. 17, 2016.

5. How accessible is individual health insurance for consumers in less-than-ideal health? Kaiser Family Foundation website. Available at: https://kaiserfamilyfoundation.files.wordpress.com/2013/01/how-accessible-is-individual-health-insurance-for-consumer-in-less-than-perfect-health-report.pdf. Accessed Nov. 17, 2016.

6. The Affordable Care Act and Medicare. The Commonwealth Fund website. Available at: http://www.commonwealthfund.org/publications/fund-reports/2015/jun/medicare-affordable-care-act Accessed Nov. 17, 2016.

Editor’s note: “Everything We Say and Do” is an informational series developed by SHM’s Patient Experience Committee to provide readers with thoughtful and actionable communication tactics that have great potential to positively impact patients’ experience of care. Each article will focus on how the contributor applies one or more of the “key communication” tactics in practice to maintain provider accountability for “everything we say and do that affects our patients’ thoughts, feelings, and well-being.”

Thomas Northcut/Thinkstock

What I say and do

I inform my patients that I have reviewed their chart and that I am familiar with their diagnosis.

Why I do it

In the hospital setting, in particular, patients are concerned about communication between their various healthcare professionals. Many times, the patient’s primary-care provider works strictly in the outpatient setting, so the hospitalist is the person who assumes total care of the patient throughout hospitalization. This understandably creates anxiety for patients and families because they wonder if the hospitalist really knows their medical history. One way to alleviate this anxiety is to review your patients’ charts prior to speaking with them and to verbally let your patients know you are familiar with their diagnoses.

How I do it

Step 1: Before entering the room, I review my patient’s chart. If I am taking over the service from my colleague, I review all notes from the current hospitalization to ensure I understand everything that has happened. I also review tests, procedures, and radiographic studies. To gain a better understanding of my patient, I read the most recent discharge summary and outpatient clinic note. Likewise, if I am admitting a new patient to the hospital, before entering the room to do the history and physical examination, I review recent hospitalizations, clinic notes, and emergency department visits.

I also like to review the chart to see if I have taken care of the patient before. Patients often remember me even though I may not remember them, so reviewing my prior notes may be helpful. Thankfully, my electronic health record (EHR) has a search function where I can enter my name or any other keyword and it searches for patient records based on this keyword.

Step 2: Even though reading the chart and being informed about my patient is important, it is only the first step. The next step is to let my patient and family know that I have read the chart and that I am up-to-date on my patient’s diagnosis. I feel it is very important for me to verbalize that I have read the chart because without doing this, my patients never really know that I took the time prior to entering the room to learn about them.

I might say:

• “I was reviewing your chart before I came in, and I saw that your daughter brought you to the hospital for chest pain.”
• “I read your chart and saw that you have been to the emergency room twice in the last week.”
• “I read your primary-care doctor’s note, and I saw that she recently treated you for pneumonia.”
• “I read your chart, and I wanted to confirm a few things I read to ensure we are on the same page.”

There are many different ways you can phrase this, but the important point is to make sure your patients know you read the chart by specifically referencing something you learned. This helps your patients feel more confident that you know their medical history.

I know some of the doctors reading this column see patients in the outpatient setting. One way to help yourself remember pertinent facts about a patient’s medical history is to include these facts in a specific place in your clinic note. That way, prior to seeing the patient, you can always review your last note and know the important information about your patient’s medical history will always be in the same place in each note. Another tip is to use your EHR’s note function. My EHR has “sticky notes,” and they provide a place for the PCP to store information about the patient without it becoming part of the permanent medical record.
 

These notes allow the PCP to record important events that happen between one clinic visit and the next. Thus, when the patient returns to the clinic, the PCP opens the chart, reviews the sticky note, and enters the exam room prepared to discuss significant events in the patient’s recent medical history.

In the end, it does not matter which technique you use. It simply matters that you take time to review your patient’s chart prior to entering the room and that you verbalize what you have learned. In patients, this inspires confidence and trust and helps alleviate concerns that the physician does not know important information in their medical history. 

Dr. Dorrah is regional medical director for quality and the patient experience at Baylor Scott & White Health in Round Rock, Tex. She is a member of SHM’s Patient Experience Committee.

Editor’s note: “Everything We Say and Do” is an informational series developed by SHM’s Patient Experience Committee to provide readers with thoughtful and actionable communication tactics that have great potential to positively impact patients’ experience of care. Each article will focus on how the contributor applies one or more of the “key communication” tactics in practice to maintain provider accountability for “everything we say and do that affects our patients’ thoughts, feelings, and well-being.”

Thomas Northcut/Thinkstock

What I say and do

I inform my patients that I have reviewed their chart and that I am familiar with their diagnosis.

Why I do it

In the hospital setting, in particular, patients are concerned about communication between their various healthcare professionals. Many times, the patient’s primary-care provider works strictly in the outpatient setting, so the hospitalist is the person who assumes total care of the patient throughout hospitalization. This understandably creates anxiety for patients and families because they wonder if the hospitalist really knows their medical history. One way to alleviate this anxiety is to review your patients’ charts prior to speaking with them and to verbally let your patients know you are familiar with their diagnoses.

How I do it

Step 1: Before entering the room, I review my patient’s chart. If I am taking over the service from my colleague, I review all notes from the current hospitalization to ensure I understand everything that has happened. I also review tests, procedures, and radiographic studies. To gain a better understanding of my patient, I read the most recent discharge summary and outpatient clinic note. Likewise, if I am admitting a new patient to the hospital, before entering the room to do the history and physical examination, I review recent hospitalizations, clinic notes, and emergency department visits.

I also like to review the chart to see if I have taken care of the patient before. Patients often remember me even though I may not remember them, so reviewing my prior notes may be helpful. Thankfully, my electronic health record (EHR) has a search function where I can enter my name or any other keyword and it searches for patient records based on this keyword.

Step 2: Even though reading the chart and being informed about my patient is important, it is only the first step. The next step is to let my patient and family know that I have read the chart and that I am up-to-date on my patient’s diagnosis. I feel it is very important for me to verbalize that I have read the chart because without doing this, my patients never really know that I took the time prior to entering the room to learn about them.

I might say:

• “I was reviewing your chart before I came in, and I saw that your daughter brought you to the hospital for chest pain.”
• “I read your chart and saw that you have been to the emergency room twice in the last week.”
• “I read your primary-care doctor’s note, and I saw that she recently treated you for pneumonia.”
• “I read your chart, and I wanted to confirm a few things I read to ensure we are on the same page.”

There are many different ways you can phrase this, but the important point is to make sure your patients know you read the chart by specifically referencing something you learned. This helps your patients feel more confident that you know their medical history.

I know some of the doctors reading this column see patients in the outpatient setting. One way to help yourself remember pertinent facts about a patient’s medical history is to include these facts in a specific place in your clinic note. That way, prior to seeing the patient, you can always review your last note and know the important information about your patient’s medical history will always be in the same place in each note. Another tip is to use your EHR’s note function. My EHR has “sticky notes,” and they provide a place for the PCP to store information about the patient without it becoming part of the permanent medical record.
 

These notes allow the PCP to record important events that happen between one clinic visit and the next. Thus, when the patient returns to the clinic, the PCP opens the chart, reviews the sticky note, and enters the exam room prepared to discuss significant events in the patient’s recent medical history.

In the end, it does not matter which technique you use. It simply matters that you take time to review your patient’s chart prior to entering the room and that you verbalize what you have learned. In patients, this inspires confidence and trust and helps alleviate concerns that the physician does not know important information in their medical history. 

Dr. Dorrah is regional medical director for quality and the patient experience at Baylor Scott & White Health in Round Rock, Tex. She is a member of SHM’s Patient Experience Committee.

Editor’s note: “Everything We Say and Do” is an informational series developed by SHM’s Patient Experience Committee to provide readers with thoughtful and actionable communication tactics that have great potential to positively impact patients’ experience of care. Each article will focus on how the contributor applies one or more of the “key communication” tactics in practice to maintain provider accountability for “everything we say and do that affects our patients’ thoughts, feelings, and well-being.”

Thomas Northcut/Thinkstock

What I say and do

I inform my patients that I have reviewed their chart and that I am familiar with their diagnosis.

Why I do it

In the hospital setting, in particular, patients are concerned about communication between their various healthcare professionals. Many times, the patient’s primary-care provider works strictly in the outpatient setting, so the hospitalist is the person who assumes total care of the patient throughout hospitalization. This understandably creates anxiety for patients and families because they wonder if the hospitalist really knows their medical history. One way to alleviate this anxiety is to review your patients’ charts prior to speaking with them and to verbally let your patients know you are familiar with their diagnoses.

How I do it

Step 1: Before entering the room, I review my patient’s chart. If I am taking over the service from my colleague, I review all notes from the current hospitalization to ensure I understand everything that has happened. I also review tests, procedures, and radiographic studies. To gain a better understanding of my patient, I read the most recent discharge summary and outpatient clinic note. Likewise, if I am admitting a new patient to the hospital, before entering the room to do the history and physical examination, I review recent hospitalizations, clinic notes, and emergency department visits.

I also like to review the chart to see if I have taken care of the patient before. Patients often remember me even though I may not remember them, so reviewing my prior notes may be helpful. Thankfully, my electronic health record (EHR) has a search function where I can enter my name or any other keyword and it searches for patient records based on this keyword.

Step 2: Even though reading the chart and being informed about my patient is important, it is only the first step. The next step is to let my patient and family know that I have read the chart and that I am up-to-date on my patient’s diagnosis. I feel it is very important for me to verbalize that I have read the chart because without doing this, my patients never really know that I took the time prior to entering the room to learn about them.

I might say:

• “I was reviewing your chart before I came in, and I saw that your daughter brought you to the hospital for chest pain.”
• “I read your chart and saw that you have been to the emergency room twice in the last week.”
• “I read your primary-care doctor’s note, and I saw that she recently treated you for pneumonia.”
• “I read your chart, and I wanted to confirm a few things I read to ensure we are on the same page.”

There are many different ways you can phrase this, but the important point is to make sure your patients know you read the chart by specifically referencing something you learned. This helps your patients feel more confident that you know their medical history.

I know some of the doctors reading this column see patients in the outpatient setting. One way to help yourself remember pertinent facts about a patient’s medical history is to include these facts in a specific place in your clinic note. That way, prior to seeing the patient, you can always review your last note and know the important information about your patient’s medical history will always be in the same place in each note. Another tip is to use your EHR’s note function. My EHR has “sticky notes,” and they provide a place for the PCP to store information about the patient without it becoming part of the permanent medical record.
 

These notes allow the PCP to record important events that happen between one clinic visit and the next. Thus, when the patient returns to the clinic, the PCP opens the chart, reviews the sticky note, and enters the exam room prepared to discuss significant events in the patient’s recent medical history.

In the end, it does not matter which technique you use. It simply matters that you take time to review your patient’s chart prior to entering the room and that you verbalize what you have learned. In patients, this inspires confidence and trust and helps alleviate concerns that the physician does not know important information in their medical history. 

Dr. Dorrah is regional medical director for quality and the patient experience at Baylor Scott & White Health in Round Rock, Tex. She is a member of SHM’s Patient Experience Committee.

When choosing quality improvement activities, hospitalists have no shortage of choices. In this column, I offer a strategic guide for hospitalists as they assess where best to spend their energy as the shift to value-based care progresses. This includes the introduction of MACRA, the landmark new payment program for doctors and other clinicians (aka the Medicare Access and CHIP Reauthorization Act of 2015), with its incentives for participation in alternative payment models.

Since 1983, Medicare has reimbursed hospitals using a lump-sum payment known as a diagnosis-related group, or DRG. Since then, hospitals have focused a good deal of their energy on removing needless expenses from the hospitalization to improve their bottom line, recognizing the DRG payment they receive is relatively fixed. To this end, a major strategy has been to use hospitalists to decrease length of stay and “right size” the utilization of in-hospital tests and treatments.

However, things are changing as we enter the era of alternative payment models such as accountable care organizations (ACOs) and bundled payments. The lens Medicare (and, to a great extent, commercial payors) peers through to assess inpatient hospital costs is the DRG payment amount. Beyond that, Medicare has little visibility into the actual costs hospitals incur. Since hospital spending equates to the payment amount for a DRG, it becomes apparent that the incremental opportunity for hospitalists to improve value (quality divided by cost) in alternative payment models stems from payments outside the DRG. Such payments include those related to the post-acute period such as nursing and rehabilitation facilities, readmissions, and part B activity (e.g., consultants and outpatient tests).

What does this mean for hospitalists? MACRA begins in 2019, but initial payments will be based on 2017 performance. The associated advantage of participating in an “advanced alternative payment model” where there is accountability for care beyond the hospitalization is that hospitalists will be rewarded for taking costs out of the post-acute time period.

To be clear, hospitalists should remain agents of in-hospital efficiency and quality. After all, that is how we add value to the hospitals in which we practice. All things being equal, however, hospitalists should focus on practices that will improve value beyond the four walls of the hospital.

Here is my shortlist of these practices. While there is crossover between the categories, I divide the practices into those that improve value during the DRG period and also post-DRG and those that improve value primarily post-DRG (thanks to Choosing Wisely for contributing to the recommendations with an asterisk1):

Thinking outside the DRG box will require an adjustment to the approach taken by hospitalists because the current demands are often more than enough for a day’s work. Hospitalists will be called upon to innovate and fashion better approaches to care. This will require support by other members of the healthcare team so hospitalists can work smarter, not harder, to meet the requirements of a changing healthcare system. A prerequisite is better payment models that align financial incentives so that providing higher-value care is sustainable and appropriately rewarded.

Reference

Clinician lists. Choosing Wisely website. Accessed October 25, 2016.

When choosing quality improvement activities, hospitalists have no shortage of choices. In this column, I offer a strategic guide for hospitalists as they assess where best to spend their energy as the shift to value-based care progresses. This includes the introduction of MACRA, the landmark new payment program for doctors and other clinicians (aka the Medicare Access and CHIP Reauthorization Act of 2015), with its incentives for participation in alternative payment models.

Since 1983, Medicare has reimbursed hospitals using a lump-sum payment known as a diagnosis-related group, or DRG. Since then, hospitals have focused a good deal of their energy on removing needless expenses from the hospitalization to improve their bottom line, recognizing the DRG payment they receive is relatively fixed. To this end, a major strategy has been to use hospitalists to decrease length of stay and “right size” the utilization of in-hospital tests and treatments.

However, things are changing as we enter the era of alternative payment models such as accountable care organizations (ACOs) and bundled payments. The lens Medicare (and, to a great extent, commercial payors) peers through to assess inpatient hospital costs is the DRG payment amount. Beyond that, Medicare has little visibility into the actual costs hospitals incur. Since hospital spending equates to the payment amount for a DRG, it becomes apparent that the incremental opportunity for hospitalists to improve value (quality divided by cost) in alternative payment models stems from payments outside the DRG. Such payments include those related to the post-acute period such as nursing and rehabilitation facilities, readmissions, and part B activity (e.g., consultants and outpatient tests).

What does this mean for hospitalists? MACRA begins in 2019, but initial payments will be based on 2017 performance. The associated advantage of participating in an “advanced alternative payment model” where there is accountability for care beyond the hospitalization is that hospitalists will be rewarded for taking costs out of the post-acute time period.

To be clear, hospitalists should remain agents of in-hospital efficiency and quality. After all, that is how we add value to the hospitals in which we practice. All things being equal, however, hospitalists should focus on practices that will improve value beyond the four walls of the hospital.

Here is my shortlist of these practices. While there is crossover between the categories, I divide the practices into those that improve value during the DRG period and also post-DRG and those that improve value primarily post-DRG (thanks to Choosing Wisely for contributing to the recommendations with an asterisk1):

Thinking outside the DRG box will require an adjustment to the approach taken by hospitalists because the current demands are often more than enough for a day’s work. Hospitalists will be called upon to innovate and fashion better approaches to care. This will require support by other members of the healthcare team so hospitalists can work smarter, not harder, to meet the requirements of a changing healthcare system. A prerequisite is better payment models that align financial incentives so that providing higher-value care is sustainable and appropriately rewarded.

Reference

Clinician lists. Choosing Wisely website. Accessed October 25, 2016.

When choosing quality improvement activities, hospitalists have no shortage of choices. In this column, I offer a strategic guide for hospitalists as they assess where best to spend their energy as the shift to value-based care progresses. This includes the introduction of MACRA, the landmark new payment program for doctors and other clinicians (aka the Medicare Access and CHIP Reauthorization Act of 2015), with its incentives for participation in alternative payment models.

Since 1983, Medicare has reimbursed hospitals using a lump-sum payment known as a diagnosis-related group, or DRG. Since then, hospitals have focused a good deal of their energy on removing needless expenses from the hospitalization to improve their bottom line, recognizing the DRG payment they receive is relatively fixed. To this end, a major strategy has been to use hospitalists to decrease length of stay and “right size” the utilization of in-hospital tests and treatments.

However, things are changing as we enter the era of alternative payment models such as accountable care organizations (ACOs) and bundled payments. The lens Medicare (and, to a great extent, commercial payors) peers through to assess inpatient hospital costs is the DRG payment amount. Beyond that, Medicare has little visibility into the actual costs hospitals incur. Since hospital spending equates to the payment amount for a DRG, it becomes apparent that the incremental opportunity for hospitalists to improve value (quality divided by cost) in alternative payment models stems from payments outside the DRG. Such payments include those related to the post-acute period such as nursing and rehabilitation facilities, readmissions, and part B activity (e.g., consultants and outpatient tests).

What does this mean for hospitalists? MACRA begins in 2019, but initial payments will be based on 2017 performance. The associated advantage of participating in an “advanced alternative payment model” where there is accountability for care beyond the hospitalization is that hospitalists will be rewarded for taking costs out of the post-acute time period.

To be clear, hospitalists should remain agents of in-hospital efficiency and quality. After all, that is how we add value to the hospitals in which we practice. All things being equal, however, hospitalists should focus on practices that will improve value beyond the four walls of the hospital.

Here is my shortlist of these practices. While there is crossover between the categories, I divide the practices into those that improve value during the DRG period and also post-DRG and those that improve value primarily post-DRG (thanks to Choosing Wisely for contributing to the recommendations with an asterisk1):

Thinking outside the DRG box will require an adjustment to the approach taken by hospitalists because the current demands are often more than enough for a day’s work. Hospitalists will be called upon to innovate and fashion better approaches to care. This will require support by other members of the healthcare team so hospitalists can work smarter, not harder, to meet the requirements of a changing healthcare system. A prerequisite is better payment models that align financial incentives so that providing higher-value care is sustainable and appropriately rewarded.

Reference

Clinician lists. Choosing Wisely website. Accessed October 25, 2016.

Between 700,000 and 1 million people fall each year in U.S. hospitals, and about a third of those result in injuries that add an additional 6.3 days to hospital stays, according to a report from the Joint Commission Center for Transforming Healthcare. Some 11,000 falls are fatal. The Joint Commission Center for Transforming Healthcare has now issued a report on the subject called “Preventing Patient Falls: A Systematic Approach from the Joint Commission Center for Transforming Healthcare Project.”1

“We try to pick those topics that healthcare organizations just haven’t been able to fully tackle even though they’ve put a lot of time and resources into trying to fix them,” says Kelly Barnes, MS, a center project lead in the Center for Transforming Healthcare at The Joint Commission.

The Joint Commission project involved seven hospitals that used Robust Process Improvement, which incorporates tools from Lean Six Sigma and change management methodologies, to reduce falls with injury on inpatient pilot units within their organizations.

During the project, each organization identified the specific factors that led to falls with injury in their environment and developed solutions targeted to those factors. The organizations identified 30 root causes and developed 21 targeted solutions. Because the contributing factors were different at each organization, solution sets were unique to each. Afterward, the organizations saw an aggregate 35% reduction in falls and a 62% reduction in falls with injury.

“One of the takeaways is that you really need support across an organization to have success,” Barnes says. “The more engaged the entire organization is from top down all the way to the bottom, the more successful people are in solving the problems.”

The study resulted in a Targeted Solutions Tool (TST), free to all Joint Commission–accredited customers, to help hospitals.

“You can put your data right into the tool,” Barnes says. “It tells you what your top contributing factors are, and it gives you the solutions that have worked for those contributing factors at other organizations.”

Reference

Health Research & Educational Trust. Preventing patient falls: a systematic approach from the Joint Commission Center for Transforming Healthcare project. Hospitals in Pursuit of Excellence website.

Between 700,000 and 1 million people fall each year in U.S. hospitals, and about a third of those result in injuries that add an additional 6.3 days to hospital stays, according to a report from the Joint Commission Center for Transforming Healthcare. Some 11,000 falls are fatal. The Joint Commission Center for Transforming Healthcare has now issued a report on the subject called “Preventing Patient Falls: A Systematic Approach from the Joint Commission Center for Transforming Healthcare Project.”1

“We try to pick those topics that healthcare organizations just haven’t been able to fully tackle even though they’ve put a lot of time and resources into trying to fix them,” says Kelly Barnes, MS, a center project lead in the Center for Transforming Healthcare at The Joint Commission.

The Joint Commission project involved seven hospitals that used Robust Process Improvement, which incorporates tools from Lean Six Sigma and change management methodologies, to reduce falls with injury on inpatient pilot units within their organizations.

During the project, each organization identified the specific factors that led to falls with injury in their environment and developed solutions targeted to those factors. The organizations identified 30 root causes and developed 21 targeted solutions. Because the contributing factors were different at each organization, solution sets were unique to each. Afterward, the organizations saw an aggregate 35% reduction in falls and a 62% reduction in falls with injury.

“One of the takeaways is that you really need support across an organization to have success,” Barnes says. “The more engaged the entire organization is from top down all the way to the bottom, the more successful people are in solving the problems.”

The study resulted in a Targeted Solutions Tool (TST), free to all Joint Commission–accredited customers, to help hospitals.

“You can put your data right into the tool,” Barnes says. “It tells you what your top contributing factors are, and it gives you the solutions that have worked for those contributing factors at other organizations.”

Reference

Health Research & Educational Trust. Preventing patient falls: a systematic approach from the Joint Commission Center for Transforming Healthcare project. Hospitals in Pursuit of Excellence website.

Between 700,000 and 1 million people fall each year in U.S. hospitals, and about a third of those result in injuries that add an additional 6.3 days to hospital stays, according to a report from the Joint Commission Center for Transforming Healthcare. Some 11,000 falls are fatal. The Joint Commission Center for Transforming Healthcare has now issued a report on the subject called “Preventing Patient Falls: A Systematic Approach from the Joint Commission Center for Transforming Healthcare Project.”1

“We try to pick those topics that healthcare organizations just haven’t been able to fully tackle even though they’ve put a lot of time and resources into trying to fix them,” says Kelly Barnes, MS, a center project lead in the Center for Transforming Healthcare at The Joint Commission.

The Joint Commission project involved seven hospitals that used Robust Process Improvement, which incorporates tools from Lean Six Sigma and change management methodologies, to reduce falls with injury on inpatient pilot units within their organizations.

During the project, each organization identified the specific factors that led to falls with injury in their environment and developed solutions targeted to those factors. The organizations identified 30 root causes and developed 21 targeted solutions. Because the contributing factors were different at each organization, solution sets were unique to each. Afterward, the organizations saw an aggregate 35% reduction in falls and a 62% reduction in falls with injury.

“One of the takeaways is that you really need support across an organization to have success,” Barnes says. “The more engaged the entire organization is from top down all the way to the bottom, the more successful people are in solving the problems.”

The study resulted in a Targeted Solutions Tool (TST), free to all Joint Commission–accredited customers, to help hospitals.

“You can put your data right into the tool,” Barnes says. “It tells you what your top contributing factors are, and it gives you the solutions that have worked for those contributing factors at other organizations.”

Reference

Health Research & Educational Trust. Preventing patient falls: a systematic approach from the Joint Commission Center for Transforming Healthcare project. Hospitals in Pursuit of Excellence website.

Inpatient hospitalization can be a key time for patients to quit smoking, according to an abstract called “No More Butts: An Automated System for Inpatient Smoking Cessation Team Consults.”1

“Tobacco smoking continues to be one of the most important public health threats that we face,” says lead author Sujatha Sankaran, MD, assistant clinical professor in the division of hospital medicine and medical director of smoking cessation at the University of California, San Francisco. “Hospitalization is an extremely important moment and provides an excellent opportunity to counsel and provide cessation resources for people who are concerned about their health.”

Inpatients who receive smoking cessation counseling, nicotine replacement, and referral to outpatient resources have increased quit rates six weeks after hospital discharge, their research showed.

However, according to the abstract, in 2014:

• 34.5% of tobacco users admitted to one 600-bed academic hospital were documented as having received and accepted tobacco cessation counseling
• 45.7% of tobacco users received nicotine replacement therapy
• 1.35% of tobacco users received after-discharge consultations to outpatient smoking cessation resources

Researchers piloted a system in which a dedicated respiratory therapist–staffed smoking cessation consult service was trained to provide targeted tobacco cessation services to all inpatients who use tobacco. Of 1944 patients identified as using tobacco, 1545 received and accepted cessation counseling from a trained member of the Smoking Cessation Team, 1526 received nicotine replacement therapy, and 464 received an electronic referral to either a telephone or in-person quit line

“Hospitalists know firsthand the serious harm that tobacco use causes to patients but often are overwhelmed by the acute issues of patients and are unable to fully address tobacco use with hospitalized patients,” Dr. Sankaran says. “An automated cessation service can help lessen this burden by providing automatic cessation resources to all tobacco users.”

Reference

1. Sankaran S, Burke R, O’Keefe S. No more butts: an automated system for inpatient smoking cessation team consults [abstract]. J Hosp Med. 2016;11(suppl 1). Accessed November 9, 2016.

Inpatient hospitalization can be a key time for patients to quit smoking, according to an abstract called “No More Butts: An Automated System for Inpatient Smoking Cessation Team Consults.”1

“Tobacco smoking continues to be one of the most important public health threats that we face,” says lead author Sujatha Sankaran, MD, assistant clinical professor in the division of hospital medicine and medical director of smoking cessation at the University of California, San Francisco. “Hospitalization is an extremely important moment and provides an excellent opportunity to counsel and provide cessation resources for people who are concerned about their health.”

Inpatients who receive smoking cessation counseling, nicotine replacement, and referral to outpatient resources have increased quit rates six weeks after hospital discharge, their research showed.

However, according to the abstract, in 2014:

• 34.5% of tobacco users admitted to one 600-bed academic hospital were documented as having received and accepted tobacco cessation counseling
• 45.7% of tobacco users received nicotine replacement therapy
• 1.35% of tobacco users received after-discharge consultations to outpatient smoking cessation resources

Researchers piloted a system in which a dedicated respiratory therapist–staffed smoking cessation consult service was trained to provide targeted tobacco cessation services to all inpatients who use tobacco. Of 1944 patients identified as using tobacco, 1545 received and accepted cessation counseling from a trained member of the Smoking Cessation Team, 1526 received nicotine replacement therapy, and 464 received an electronic referral to either a telephone or in-person quit line

“Hospitalists know firsthand the serious harm that tobacco use causes to patients but often are overwhelmed by the acute issues of patients and are unable to fully address tobacco use with hospitalized patients,” Dr. Sankaran says. “An automated cessation service can help lessen this burden by providing automatic cessation resources to all tobacco users.”

Reference

1. Sankaran S, Burke R, O’Keefe S. No more butts: an automated system for inpatient smoking cessation team consults [abstract]. J Hosp Med. 2016;11(suppl 1). Accessed November 9, 2016.

Inpatient hospitalization can be a key time for patients to quit smoking, according to an abstract called “No More Butts: An Automated System for Inpatient Smoking Cessation Team Consults.”1

“Tobacco smoking continues to be one of the most important public health threats that we face,” says lead author Sujatha Sankaran, MD, assistant clinical professor in the division of hospital medicine and medical director of smoking cessation at the University of California, San Francisco. “Hospitalization is an extremely important moment and provides an excellent opportunity to counsel and provide cessation resources for people who are concerned about their health.”

Inpatients who receive smoking cessation counseling, nicotine replacement, and referral to outpatient resources have increased quit rates six weeks after hospital discharge, their research showed.

However, according to the abstract, in 2014:

• 34.5% of tobacco users admitted to one 600-bed academic hospital were documented as having received and accepted tobacco cessation counseling
• 45.7% of tobacco users received nicotine replacement therapy
• 1.35% of tobacco users received after-discharge consultations to outpatient smoking cessation resources

Researchers piloted a system in which a dedicated respiratory therapist–staffed smoking cessation consult service was trained to provide targeted tobacco cessation services to all inpatients who use tobacco. Of 1944 patients identified as using tobacco, 1545 received and accepted cessation counseling from a trained member of the Smoking Cessation Team, 1526 received nicotine replacement therapy, and 464 received an electronic referral to either a telephone or in-person quit line

“Hospitalists know firsthand the serious harm that tobacco use causes to patients but often are overwhelmed by the acute issues of patients and are unable to fully address tobacco use with hospitalized patients,” Dr. Sankaran says. “An automated cessation service can help lessen this burden by providing automatic cessation resources to all tobacco users.”

Reference

1. Sankaran S, Burke R, O’Keefe S. No more butts: an automated system for inpatient smoking cessation team consults [abstract]. J Hosp Med. 2016;11(suppl 1). Accessed November 9, 2016.