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Bipartisan Proposal to Repeal SGR Plan Likely to be Reintroduced
As the Obama administration begins its second term, a great deal of attention is being paid to the advance of its healthcare reform agenda. Long overdue for reform is the sustainable growth rate (SGR) formula—an ill-fated attempt to provide predictable control for federal spending on Medicare by providing yearly updates (i.e. reductions) to Medicare’s physician reimbursement rates.
By adjusting the payment rates, the SGR was supposed to help control the cost of healthcare by linking it more closely with national growth and changes in the Medicare-eligible population. With each passing year, however, bipartisan consensus has grown stronger, the message being that a straight, fee-for-service system that is updated annually based on an expenditure target cannot substitute for fundamental delivery system reforms.
Congress has acted to override the SGR’s implementation every year since 2003, with the latest round being a potential 27% gutting of Medicare reimbursement rates. This cycle is not only tiresome, but threatens a massive disruption to physician practices and to seniors’ access to the Medicare program.
“The SGR, while well-intentioned, is flawed, and Congress can provide its temporary override for only so long, while Medicare spending continues to grow,” says Ryan Genzink, PA-C, an SHM Public Policy Committee member and a physician assistant with IPC: The Hospitalist Co. in Grand Rapids, Mich.
Repeal and Reform
Although various SGR repeal bills have been introduced over the years, only one—the Medicare Physician Payment Innovation Act of 2012 (H.R. 5707)—supplements repeal with a realistic plan to move away from the current fee-for-service payment system (and its inherent inefficiencies) toward more cost-effective reimbursement models that are designed to promote quality and value through coordinated patient care.
This bipartisan bill, introduced by U.S. Reps. Allyson Schwartz (D-Pa.) and Joe Heck, DO (R-Nev.), would repeal the SGR, stabilize payments at current rates for 2013, replace scheduled reductions with positive and predictable updates from 2014 to 2017, and set an aggressive timetable for testing and evaluating new payment systems focused on improving quality and reducing costs (see “Specific Components of the Schwartz-Heck Proposal,” left). The bill is expected to be reintroduced in 2013.
“SHM agrees that it is time finally to eliminate the SGR and move away from the prevailing fee-for-service payment system, which rewards physicians for simply providing more services, to one that provides incentives to deliver higher-quality, cost-effective care to our nation’s seniors,” wrote SHM President Shaun Frost, MD, SFHM, in a letter of support last year to Schwartz and Heck, commending them for introducing their bill.
“By providing a menu of options for physician participation, including an alternative, value-driven fee-for-service system for physicians who are not able to participate in one of the new payment and delivery models, the legislation does not force all providers into a ‘one size fits all’ solution, allowing for broader support, innovation, and flexibility,” Dr. Frost said.
Advancing New Reimbursement Models
The Schwartz-Heck bill “gives a timeline for CMS to test and adopt different reimbursement models, which presents advantageous options for hospitalists,” says Lauren Doctoroff, MD, an SHM Public Policy Committee member, hospitalist, and medical director of the post-discharge clinic at Beth Israel Deaconess Medical Center in Boston. “Hospitalists already focus on providing higher-quality, lower-cost care to hospitalized patients in their daily practice. We build effective care transitions to the outpatient and extended care settings. Our strengths are perfectly aligned to help these new, value-based payment models succeed.”
In fact, Dr. Doctoroff notes, Beth Israel is a participant in CMS’ Medicare Pioneer Accountable Care Organization project as well as Massachusetts Blue Cross Blue Shield’s Alternative Quality Contract, both of which use a risk-sharing global payment model in which the hospital and its physician network agree to provide for the healthcare needs of a defined population for a pre-arranged reimbursement amount.
“The global payment model is an attractive one for hospitalists because we play a key role in managing hospitalized patients efficiently and well, while also encouraging collaboration between inpatient and outpatient providers to avoid duplication of services,” Dr. Doctoroff says. “Some bundled payment models, which tie reimbursement to a defined episode of care, also could be advantageous for hospitalists, who coordinate the patient’s care throughout their entire healthcare episode, from inpatient diagnosis through post-discharge.”
Alternative Fee-for-Service System
For physicians who choose not to adopt one of the new reimbursement models, the bill directs CMS to offer an alternative fee-for-service system with incentives for improved quality and lower cost. This alternative would be available to physicians (including hospitalists) who participate in approved quality-reporting options, including the Physician Quality Reporting System (PQRS) or an approved Maintenance of Certification (MOC) program with quality registries. It also would apply to physicians who fall into the top 25% of CMS’ Value-Based Payment Modifier program (VBPM).
Boosting Primary Care
In addition to expediting the rollout of CMS-endorsed alternate payment models, the Schwartz bill recognizes the importance of primary care as the foundation of an effective healthcare delivery system and redresses its undervaluation with a 2.5% reimbursement update for physicians and other healthcare professionals for whom 60% of their Medicare physician fee schedule allowable charges are from a designated set of primary-care, preventive, and care-coordination codes.
“SHM specifically advocated for the inclusion of primary-care billing codes that hospitalists use,” Dr. Doctoroff says, “including hospital inpatient visits and observational services.”
“Of all the attempts to deal with the SGR over the past several years, Rep. Schwartz’s bill makes the most sense,” Genzink says. “While it doesn’t answer all of the healthcare system’s problems, it encapsulates many of the goals of reform—especially the shift from fee-for-service toward a payment system based on quality and outcomes. It recognizes that no one model will work for all physicians and offers the flexibility of multiple pathways. And it has bipartisan support, which seems to be a rarity these days.”
Chris Guadagnino is a freelance medical writer in Philadelphia.
As the Obama administration begins its second term, a great deal of attention is being paid to the advance of its healthcare reform agenda. Long overdue for reform is the sustainable growth rate (SGR) formula—an ill-fated attempt to provide predictable control for federal spending on Medicare by providing yearly updates (i.e. reductions) to Medicare’s physician reimbursement rates.
By adjusting the payment rates, the SGR was supposed to help control the cost of healthcare by linking it more closely with national growth and changes in the Medicare-eligible population. With each passing year, however, bipartisan consensus has grown stronger, the message being that a straight, fee-for-service system that is updated annually based on an expenditure target cannot substitute for fundamental delivery system reforms.
Congress has acted to override the SGR’s implementation every year since 2003, with the latest round being a potential 27% gutting of Medicare reimbursement rates. This cycle is not only tiresome, but threatens a massive disruption to physician practices and to seniors’ access to the Medicare program.
“The SGR, while well-intentioned, is flawed, and Congress can provide its temporary override for only so long, while Medicare spending continues to grow,” says Ryan Genzink, PA-C, an SHM Public Policy Committee member and a physician assistant with IPC: The Hospitalist Co. in Grand Rapids, Mich.
Repeal and Reform
Although various SGR repeal bills have been introduced over the years, only one—the Medicare Physician Payment Innovation Act of 2012 (H.R. 5707)—supplements repeal with a realistic plan to move away from the current fee-for-service payment system (and its inherent inefficiencies) toward more cost-effective reimbursement models that are designed to promote quality and value through coordinated patient care.
This bipartisan bill, introduced by U.S. Reps. Allyson Schwartz (D-Pa.) and Joe Heck, DO (R-Nev.), would repeal the SGR, stabilize payments at current rates for 2013, replace scheduled reductions with positive and predictable updates from 2014 to 2017, and set an aggressive timetable for testing and evaluating new payment systems focused on improving quality and reducing costs (see “Specific Components of the Schwartz-Heck Proposal,” left). The bill is expected to be reintroduced in 2013.
“SHM agrees that it is time finally to eliminate the SGR and move away from the prevailing fee-for-service payment system, which rewards physicians for simply providing more services, to one that provides incentives to deliver higher-quality, cost-effective care to our nation’s seniors,” wrote SHM President Shaun Frost, MD, SFHM, in a letter of support last year to Schwartz and Heck, commending them for introducing their bill.
“By providing a menu of options for physician participation, including an alternative, value-driven fee-for-service system for physicians who are not able to participate in one of the new payment and delivery models, the legislation does not force all providers into a ‘one size fits all’ solution, allowing for broader support, innovation, and flexibility,” Dr. Frost said.
Advancing New Reimbursement Models
The Schwartz-Heck bill “gives a timeline for CMS to test and adopt different reimbursement models, which presents advantageous options for hospitalists,” says Lauren Doctoroff, MD, an SHM Public Policy Committee member, hospitalist, and medical director of the post-discharge clinic at Beth Israel Deaconess Medical Center in Boston. “Hospitalists already focus on providing higher-quality, lower-cost care to hospitalized patients in their daily practice. We build effective care transitions to the outpatient and extended care settings. Our strengths are perfectly aligned to help these new, value-based payment models succeed.”
In fact, Dr. Doctoroff notes, Beth Israel is a participant in CMS’ Medicare Pioneer Accountable Care Organization project as well as Massachusetts Blue Cross Blue Shield’s Alternative Quality Contract, both of which use a risk-sharing global payment model in which the hospital and its physician network agree to provide for the healthcare needs of a defined population for a pre-arranged reimbursement amount.
“The global payment model is an attractive one for hospitalists because we play a key role in managing hospitalized patients efficiently and well, while also encouraging collaboration between inpatient and outpatient providers to avoid duplication of services,” Dr. Doctoroff says. “Some bundled payment models, which tie reimbursement to a defined episode of care, also could be advantageous for hospitalists, who coordinate the patient’s care throughout their entire healthcare episode, from inpatient diagnosis through post-discharge.”
Alternative Fee-for-Service System
For physicians who choose not to adopt one of the new reimbursement models, the bill directs CMS to offer an alternative fee-for-service system with incentives for improved quality and lower cost. This alternative would be available to physicians (including hospitalists) who participate in approved quality-reporting options, including the Physician Quality Reporting System (PQRS) or an approved Maintenance of Certification (MOC) program with quality registries. It also would apply to physicians who fall into the top 25% of CMS’ Value-Based Payment Modifier program (VBPM).
Boosting Primary Care
In addition to expediting the rollout of CMS-endorsed alternate payment models, the Schwartz bill recognizes the importance of primary care as the foundation of an effective healthcare delivery system and redresses its undervaluation with a 2.5% reimbursement update for physicians and other healthcare professionals for whom 60% of their Medicare physician fee schedule allowable charges are from a designated set of primary-care, preventive, and care-coordination codes.
“SHM specifically advocated for the inclusion of primary-care billing codes that hospitalists use,” Dr. Doctoroff says, “including hospital inpatient visits and observational services.”
“Of all the attempts to deal with the SGR over the past several years, Rep. Schwartz’s bill makes the most sense,” Genzink says. “While it doesn’t answer all of the healthcare system’s problems, it encapsulates many of the goals of reform—especially the shift from fee-for-service toward a payment system based on quality and outcomes. It recognizes that no one model will work for all physicians and offers the flexibility of multiple pathways. And it has bipartisan support, which seems to be a rarity these days.”
Chris Guadagnino is a freelance medical writer in Philadelphia.
As the Obama administration begins its second term, a great deal of attention is being paid to the advance of its healthcare reform agenda. Long overdue for reform is the sustainable growth rate (SGR) formula—an ill-fated attempt to provide predictable control for federal spending on Medicare by providing yearly updates (i.e. reductions) to Medicare’s physician reimbursement rates.
By adjusting the payment rates, the SGR was supposed to help control the cost of healthcare by linking it more closely with national growth and changes in the Medicare-eligible population. With each passing year, however, bipartisan consensus has grown stronger, the message being that a straight, fee-for-service system that is updated annually based on an expenditure target cannot substitute for fundamental delivery system reforms.
Congress has acted to override the SGR’s implementation every year since 2003, with the latest round being a potential 27% gutting of Medicare reimbursement rates. This cycle is not only tiresome, but threatens a massive disruption to physician practices and to seniors’ access to the Medicare program.
“The SGR, while well-intentioned, is flawed, and Congress can provide its temporary override for only so long, while Medicare spending continues to grow,” says Ryan Genzink, PA-C, an SHM Public Policy Committee member and a physician assistant with IPC: The Hospitalist Co. in Grand Rapids, Mich.
Repeal and Reform
Although various SGR repeal bills have been introduced over the years, only one—the Medicare Physician Payment Innovation Act of 2012 (H.R. 5707)—supplements repeal with a realistic plan to move away from the current fee-for-service payment system (and its inherent inefficiencies) toward more cost-effective reimbursement models that are designed to promote quality and value through coordinated patient care.
This bipartisan bill, introduced by U.S. Reps. Allyson Schwartz (D-Pa.) and Joe Heck, DO (R-Nev.), would repeal the SGR, stabilize payments at current rates for 2013, replace scheduled reductions with positive and predictable updates from 2014 to 2017, and set an aggressive timetable for testing and evaluating new payment systems focused on improving quality and reducing costs (see “Specific Components of the Schwartz-Heck Proposal,” left). The bill is expected to be reintroduced in 2013.
“SHM agrees that it is time finally to eliminate the SGR and move away from the prevailing fee-for-service payment system, which rewards physicians for simply providing more services, to one that provides incentives to deliver higher-quality, cost-effective care to our nation’s seniors,” wrote SHM President Shaun Frost, MD, SFHM, in a letter of support last year to Schwartz and Heck, commending them for introducing their bill.
“By providing a menu of options for physician participation, including an alternative, value-driven fee-for-service system for physicians who are not able to participate in one of the new payment and delivery models, the legislation does not force all providers into a ‘one size fits all’ solution, allowing for broader support, innovation, and flexibility,” Dr. Frost said.
Advancing New Reimbursement Models
The Schwartz-Heck bill “gives a timeline for CMS to test and adopt different reimbursement models, which presents advantageous options for hospitalists,” says Lauren Doctoroff, MD, an SHM Public Policy Committee member, hospitalist, and medical director of the post-discharge clinic at Beth Israel Deaconess Medical Center in Boston. “Hospitalists already focus on providing higher-quality, lower-cost care to hospitalized patients in their daily practice. We build effective care transitions to the outpatient and extended care settings. Our strengths are perfectly aligned to help these new, value-based payment models succeed.”
In fact, Dr. Doctoroff notes, Beth Israel is a participant in CMS’ Medicare Pioneer Accountable Care Organization project as well as Massachusetts Blue Cross Blue Shield’s Alternative Quality Contract, both of which use a risk-sharing global payment model in which the hospital and its physician network agree to provide for the healthcare needs of a defined population for a pre-arranged reimbursement amount.
“The global payment model is an attractive one for hospitalists because we play a key role in managing hospitalized patients efficiently and well, while also encouraging collaboration between inpatient and outpatient providers to avoid duplication of services,” Dr. Doctoroff says. “Some bundled payment models, which tie reimbursement to a defined episode of care, also could be advantageous for hospitalists, who coordinate the patient’s care throughout their entire healthcare episode, from inpatient diagnosis through post-discharge.”
Alternative Fee-for-Service System
For physicians who choose not to adopt one of the new reimbursement models, the bill directs CMS to offer an alternative fee-for-service system with incentives for improved quality and lower cost. This alternative would be available to physicians (including hospitalists) who participate in approved quality-reporting options, including the Physician Quality Reporting System (PQRS) or an approved Maintenance of Certification (MOC) program with quality registries. It also would apply to physicians who fall into the top 25% of CMS’ Value-Based Payment Modifier program (VBPM).
Boosting Primary Care
In addition to expediting the rollout of CMS-endorsed alternate payment models, the Schwartz bill recognizes the importance of primary care as the foundation of an effective healthcare delivery system and redresses its undervaluation with a 2.5% reimbursement update for physicians and other healthcare professionals for whom 60% of their Medicare physician fee schedule allowable charges are from a designated set of primary-care, preventive, and care-coordination codes.
“SHM specifically advocated for the inclusion of primary-care billing codes that hospitalists use,” Dr. Doctoroff says, “including hospital inpatient visits and observational services.”
“Of all the attempts to deal with the SGR over the past several years, Rep. Schwartz’s bill makes the most sense,” Genzink says. “While it doesn’t answer all of the healthcare system’s problems, it encapsulates many of the goals of reform—especially the shift from fee-for-service toward a payment system based on quality and outcomes. It recognizes that no one model will work for all physicians and offers the flexibility of multiple pathways. And it has bipartisan support, which seems to be a rarity these days.”
Chris Guadagnino is a freelance medical writer in Philadelphia.
Soaring Healthcare Expenses Draw Attention to Price Transparency As Cost Control
As efforts intensify to rein in the soaring cost of healthcare, greater attention is being paid to the cost-control potential of price transparency. Initially envisioned as a consumer-driven dynamic, price transparency beckons physicians to consider much more seriously the cost impacts of their diagnostic and treatment decisions.
Consumer-Driven Approach
The U.S. Department of Health and Human Services (HHS) regards price transparency as an important weapon in its armamentarium of “value-driven” approaches to drive down the cost of healthcare. By unleashing the energy of the savvy shopper and empowering consumers with the ability to compare the price and quality of healthcare services, they can make informed choices of their doctors and hospitals. In turn, HHS hopes to motivate the entire system to provide better care for less money.
That “empowered consumerism” principle is the guiding impetus for the Affordable Care Act’s state-regulated health insurance exchange apparatus, which, beginning in 2014, will present a side-by-side comparison of health plan choices, premium costs, and out-of-pocket copays in a way that is designed to help consumers shop for better-value health plans.
Some health plans are using price transparency to nudge consumers to choose lower-cost healthcare service options. Anthem BlueCross BlueShield, for example, has launched the Compass SmartShopper program (www.compasssmartshopper.com), which gives members in New Hampshire, Connecticut, and Indiana $50 to $200 if they get a diagnostic test or surgical procedure at a less expensive facility. Anthem notes that the cost for the same service can vary greatly. For example, hernia repairs range in price from $4,026 to $7,498, and colonoscopies range from $1,450 to $2,973.
New price transparency tools also are available (HealthCareBlueBook.com and FairHealthConsumer.org, for example) to help consumers who face high deductibles or out-of-pocket costs to find “fair prices” for surgeries, hospital stays, doctor visits, and medical tests—and shop accordingly.
Despite these developments, however, there is limited evidence that the “empowered consumerism” approach to price transparency will spur consumers to choose lower-cost providers. Some experts note that many consumers equate higher-cost providers with higher quality, and caution that healthcare cost-profiling initiatives might even have the perverse effect of deterring them from seeking these providers.1 Cost measures, they argue, must be tied to quality information in order to neutralize the typical association of high costs with higher quality.1
Provider-Driven Approach
There are healthcare price transparency initiatives that address the supply side of the healthcare cost equation. These initiatives seek to educate physicians about the ways in which their clinical decisions drive cost and affect what patients pay for care. Some believe that this approach has the potential to make a much bigger dent in cost containment than the empowered-consumerism approach.
“Ninety percent of healthcare cost comes from a physician’s pen, but a lot of that spending doesn’t help patients get better,” says Neel Shah, MD, a Harvard-affiliated OBGYN and executive director of Costs of Care (www.costsofcare.org), a nonprofit aimed at empowering both patients and their caregivers to deflate medical bills. The challenge, he adds, is making physicians aware of how their decisions can inflate costs unnecessarily, and giving them the training and tools they need to take appropriate action.
“Just as the patient-safety movement helped caregivers think about how to prevent unintended harm, a new movement is needed to educate doctors, nurses, and other caregivers about the cost and value of their decisions, so they can avoid waste and protect patients from unintended financial harms as well,” Dr. Shah says.
Costs of Care recently launched its Teaching Value Project, which employs Web-based video education modules to help medical students and residents learn to optimize both quality and cost in clinical decision-making.
“We’re also developing an iPhone app to put cost and quality information at physicians’ fingertips at the critical moment when medical decisions are made,” Dr. Shah adds. “Just being able to see the price variation—an ultrasound versus a CT scan, a generic versus a brand-name medication, or the cost of a marginally valuable test—can help drive physician ordering behavior.”
Hospitalist Impacts
Robert A. Bessler, MD, CEO of Tacoma, Wash.-based hospitalist management firm Sound Physicians, says his hospitalists spend about $2 million a year “with their pen or computerized physician order entry.” A quarter of the cost is pharmacy-related, and the “majority of the rest is from bed-days.”
“The most expensive thing we do is make the decision to admit,” Dr. Bessler notes. “With hospitals switching from revenue centers to cost centers in a population health/ACO [accountable-care organization] environment, an increasingly important part of the hospitalist’s job will be asking
questions, such as, ‘Could this patient go to a nursing home tonight from the ER?’ and ‘Can my colleague in the post-acute environment take care of this patient, with the same effective outcome, if we provide more intense services in the nursing home, going forward?’”
Because most diagnostic testing is done on the front end of an inpatient’s stay, the hospitalist’s main contribution to cost control is to get that diagnosis right and use consults to answer specific questions, Dr. Bessler explains. “There is a direct correlation between the number of consults and the volume of procedures which lead to higher inpatient costs,” he adds.
As hospitals convert to value-based care models, and pressure increases on hospitalists to ramp up their analysis and sharing of cost data and resource utilization, not all physicians will find that conversion easy.
—Neel Shah, MD, executive director, Costs of Care
“We are trained to take good care of our patients, not to be financial stewards of the healthcare system,” says SHM Public Policy Committee member Bradley Flansbaum, DO, MPH, SFHM. “Now, physicians are being asked to do both—to watch our resource use without looking like we’re selling out to payors. You’re putting physicians in a difficult position. Will they say to patients, ‘You can’t have this service’? When does being pragmatic stewards of resources become rationing?” he cautions.
Dr. Shah concedes that there is a perceived tension between “what’s best” for my patient and “what’s best” for society. “We, as a profession, haven’t given serious attention to how to navigate those tensions,” he says.
Dr. Flansbaum, a hospitalist at Lenox Hill Hospital in New York City, says it’s time to start down the transparency road.
“Otherwise, we will have a centralized body making these decisions for us,” he says.
Christopher Guadagnino is a freelance medical writer in Philadelphia.
Reference
As efforts intensify to rein in the soaring cost of healthcare, greater attention is being paid to the cost-control potential of price transparency. Initially envisioned as a consumer-driven dynamic, price transparency beckons physicians to consider much more seriously the cost impacts of their diagnostic and treatment decisions.
Consumer-Driven Approach
The U.S. Department of Health and Human Services (HHS) regards price transparency as an important weapon in its armamentarium of “value-driven” approaches to drive down the cost of healthcare. By unleashing the energy of the savvy shopper and empowering consumers with the ability to compare the price and quality of healthcare services, they can make informed choices of their doctors and hospitals. In turn, HHS hopes to motivate the entire system to provide better care for less money.
That “empowered consumerism” principle is the guiding impetus for the Affordable Care Act’s state-regulated health insurance exchange apparatus, which, beginning in 2014, will present a side-by-side comparison of health plan choices, premium costs, and out-of-pocket copays in a way that is designed to help consumers shop for better-value health plans.
Some health plans are using price transparency to nudge consumers to choose lower-cost healthcare service options. Anthem BlueCross BlueShield, for example, has launched the Compass SmartShopper program (www.compasssmartshopper.com), which gives members in New Hampshire, Connecticut, and Indiana $50 to $200 if they get a diagnostic test or surgical procedure at a less expensive facility. Anthem notes that the cost for the same service can vary greatly. For example, hernia repairs range in price from $4,026 to $7,498, and colonoscopies range from $1,450 to $2,973.
New price transparency tools also are available (HealthCareBlueBook.com and FairHealthConsumer.org, for example) to help consumers who face high deductibles or out-of-pocket costs to find “fair prices” for surgeries, hospital stays, doctor visits, and medical tests—and shop accordingly.
Despite these developments, however, there is limited evidence that the “empowered consumerism” approach to price transparency will spur consumers to choose lower-cost providers. Some experts note that many consumers equate higher-cost providers with higher quality, and caution that healthcare cost-profiling initiatives might even have the perverse effect of deterring them from seeking these providers.1 Cost measures, they argue, must be tied to quality information in order to neutralize the typical association of high costs with higher quality.1
Provider-Driven Approach
There are healthcare price transparency initiatives that address the supply side of the healthcare cost equation. These initiatives seek to educate physicians about the ways in which their clinical decisions drive cost and affect what patients pay for care. Some believe that this approach has the potential to make a much bigger dent in cost containment than the empowered-consumerism approach.
“Ninety percent of healthcare cost comes from a physician’s pen, but a lot of that spending doesn’t help patients get better,” says Neel Shah, MD, a Harvard-affiliated OBGYN and executive director of Costs of Care (www.costsofcare.org), a nonprofit aimed at empowering both patients and their caregivers to deflate medical bills. The challenge, he adds, is making physicians aware of how their decisions can inflate costs unnecessarily, and giving them the training and tools they need to take appropriate action.
“Just as the patient-safety movement helped caregivers think about how to prevent unintended harm, a new movement is needed to educate doctors, nurses, and other caregivers about the cost and value of their decisions, so they can avoid waste and protect patients from unintended financial harms as well,” Dr. Shah says.
Costs of Care recently launched its Teaching Value Project, which employs Web-based video education modules to help medical students and residents learn to optimize both quality and cost in clinical decision-making.
“We’re also developing an iPhone app to put cost and quality information at physicians’ fingertips at the critical moment when medical decisions are made,” Dr. Shah adds. “Just being able to see the price variation—an ultrasound versus a CT scan, a generic versus a brand-name medication, or the cost of a marginally valuable test—can help drive physician ordering behavior.”
Hospitalist Impacts
Robert A. Bessler, MD, CEO of Tacoma, Wash.-based hospitalist management firm Sound Physicians, says his hospitalists spend about $2 million a year “with their pen or computerized physician order entry.” A quarter of the cost is pharmacy-related, and the “majority of the rest is from bed-days.”
“The most expensive thing we do is make the decision to admit,” Dr. Bessler notes. “With hospitals switching from revenue centers to cost centers in a population health/ACO [accountable-care organization] environment, an increasingly important part of the hospitalist’s job will be asking
questions, such as, ‘Could this patient go to a nursing home tonight from the ER?’ and ‘Can my colleague in the post-acute environment take care of this patient, with the same effective outcome, if we provide more intense services in the nursing home, going forward?’”
Because most diagnostic testing is done on the front end of an inpatient’s stay, the hospitalist’s main contribution to cost control is to get that diagnosis right and use consults to answer specific questions, Dr. Bessler explains. “There is a direct correlation between the number of consults and the volume of procedures which lead to higher inpatient costs,” he adds.
As hospitals convert to value-based care models, and pressure increases on hospitalists to ramp up their analysis and sharing of cost data and resource utilization, not all physicians will find that conversion easy.
—Neel Shah, MD, executive director, Costs of Care
“We are trained to take good care of our patients, not to be financial stewards of the healthcare system,” says SHM Public Policy Committee member Bradley Flansbaum, DO, MPH, SFHM. “Now, physicians are being asked to do both—to watch our resource use without looking like we’re selling out to payors. You’re putting physicians in a difficult position. Will they say to patients, ‘You can’t have this service’? When does being pragmatic stewards of resources become rationing?” he cautions.
Dr. Shah concedes that there is a perceived tension between “what’s best” for my patient and “what’s best” for society. “We, as a profession, haven’t given serious attention to how to navigate those tensions,” he says.
Dr. Flansbaum, a hospitalist at Lenox Hill Hospital in New York City, says it’s time to start down the transparency road.
“Otherwise, we will have a centralized body making these decisions for us,” he says.
Christopher Guadagnino is a freelance medical writer in Philadelphia.
Reference
As efforts intensify to rein in the soaring cost of healthcare, greater attention is being paid to the cost-control potential of price transparency. Initially envisioned as a consumer-driven dynamic, price transparency beckons physicians to consider much more seriously the cost impacts of their diagnostic and treatment decisions.
Consumer-Driven Approach
The U.S. Department of Health and Human Services (HHS) regards price transparency as an important weapon in its armamentarium of “value-driven” approaches to drive down the cost of healthcare. By unleashing the energy of the savvy shopper and empowering consumers with the ability to compare the price and quality of healthcare services, they can make informed choices of their doctors and hospitals. In turn, HHS hopes to motivate the entire system to provide better care for less money.
That “empowered consumerism” principle is the guiding impetus for the Affordable Care Act’s state-regulated health insurance exchange apparatus, which, beginning in 2014, will present a side-by-side comparison of health plan choices, premium costs, and out-of-pocket copays in a way that is designed to help consumers shop for better-value health plans.
Some health plans are using price transparency to nudge consumers to choose lower-cost healthcare service options. Anthem BlueCross BlueShield, for example, has launched the Compass SmartShopper program (www.compasssmartshopper.com), which gives members in New Hampshire, Connecticut, and Indiana $50 to $200 if they get a diagnostic test or surgical procedure at a less expensive facility. Anthem notes that the cost for the same service can vary greatly. For example, hernia repairs range in price from $4,026 to $7,498, and colonoscopies range from $1,450 to $2,973.
New price transparency tools also are available (HealthCareBlueBook.com and FairHealthConsumer.org, for example) to help consumers who face high deductibles or out-of-pocket costs to find “fair prices” for surgeries, hospital stays, doctor visits, and medical tests—and shop accordingly.
Despite these developments, however, there is limited evidence that the “empowered consumerism” approach to price transparency will spur consumers to choose lower-cost providers. Some experts note that many consumers equate higher-cost providers with higher quality, and caution that healthcare cost-profiling initiatives might even have the perverse effect of deterring them from seeking these providers.1 Cost measures, they argue, must be tied to quality information in order to neutralize the typical association of high costs with higher quality.1
Provider-Driven Approach
There are healthcare price transparency initiatives that address the supply side of the healthcare cost equation. These initiatives seek to educate physicians about the ways in which their clinical decisions drive cost and affect what patients pay for care. Some believe that this approach has the potential to make a much bigger dent in cost containment than the empowered-consumerism approach.
“Ninety percent of healthcare cost comes from a physician’s pen, but a lot of that spending doesn’t help patients get better,” says Neel Shah, MD, a Harvard-affiliated OBGYN and executive director of Costs of Care (www.costsofcare.org), a nonprofit aimed at empowering both patients and their caregivers to deflate medical bills. The challenge, he adds, is making physicians aware of how their decisions can inflate costs unnecessarily, and giving them the training and tools they need to take appropriate action.
“Just as the patient-safety movement helped caregivers think about how to prevent unintended harm, a new movement is needed to educate doctors, nurses, and other caregivers about the cost and value of their decisions, so they can avoid waste and protect patients from unintended financial harms as well,” Dr. Shah says.
Costs of Care recently launched its Teaching Value Project, which employs Web-based video education modules to help medical students and residents learn to optimize both quality and cost in clinical decision-making.
“We’re also developing an iPhone app to put cost and quality information at physicians’ fingertips at the critical moment when medical decisions are made,” Dr. Shah adds. “Just being able to see the price variation—an ultrasound versus a CT scan, a generic versus a brand-name medication, or the cost of a marginally valuable test—can help drive physician ordering behavior.”
Hospitalist Impacts
Robert A. Bessler, MD, CEO of Tacoma, Wash.-based hospitalist management firm Sound Physicians, says his hospitalists spend about $2 million a year “with their pen or computerized physician order entry.” A quarter of the cost is pharmacy-related, and the “majority of the rest is from bed-days.”
“The most expensive thing we do is make the decision to admit,” Dr. Bessler notes. “With hospitals switching from revenue centers to cost centers in a population health/ACO [accountable-care organization] environment, an increasingly important part of the hospitalist’s job will be asking
questions, such as, ‘Could this patient go to a nursing home tonight from the ER?’ and ‘Can my colleague in the post-acute environment take care of this patient, with the same effective outcome, if we provide more intense services in the nursing home, going forward?’”
Because most diagnostic testing is done on the front end of an inpatient’s stay, the hospitalist’s main contribution to cost control is to get that diagnosis right and use consults to answer specific questions, Dr. Bessler explains. “There is a direct correlation between the number of consults and the volume of procedures which lead to higher inpatient costs,” he adds.
As hospitals convert to value-based care models, and pressure increases on hospitalists to ramp up their analysis and sharing of cost data and resource utilization, not all physicians will find that conversion easy.
—Neel Shah, MD, executive director, Costs of Care
“We are trained to take good care of our patients, not to be financial stewards of the healthcare system,” says SHM Public Policy Committee member Bradley Flansbaum, DO, MPH, SFHM. “Now, physicians are being asked to do both—to watch our resource use without looking like we’re selling out to payors. You’re putting physicians in a difficult position. Will they say to patients, ‘You can’t have this service’? When does being pragmatic stewards of resources become rationing?” he cautions.
Dr. Shah concedes that there is a perceived tension between “what’s best” for my patient and “what’s best” for society. “We, as a profession, haven’t given serious attention to how to navigate those tensions,” he says.
Dr. Flansbaum, a hospitalist at Lenox Hill Hospital in New York City, says it’s time to start down the transparency road.
“Otherwise, we will have a centralized body making these decisions for us,” he says.
Christopher Guadagnino is a freelance medical writer in Philadelphia.
Reference
Healthcare Quality Accounting Metrics Need Improvement
—Gregg Meyer, MD, MSc, chief clinical officer and executive vice president for population health for the Dartmouth-Hitchcock Health System in Lebanon, N.H.
As healthcare quality reporting continues to evolve in this era of value-based purchasing (VBP), players on both the giving and receiving ends of performance incentives agree on the need to improve the accountability metrics with which providers are measured, ranked, rewarded, and penalized. Many of the measures currently in use—e.g., Centers for Medicare & Medicaid Services’ (CMS) core process measures and patient satisfaction ratings, the gross outcome metrics of mortality, infection, and readmission rates—are blunt instruments in need of refinement.
Entities such as the National Quality Forum (NQF), the American Medical Association’s Physician Consortium for Performance Improvement (PCPI), and the National Quality Measures Clearinghouse (NQMC) recognize the need to develop and endorse more timely, credible, and patient-centered outcome metrics. Largely missing from the current crop of outcome measure sets is a meaningful account of the patient’s perspective.
Enter patient-reported outcomes (PROs), defined as “any report of the status of a patient’s health condition that comes directly from the patient, without interpretation of the patient’s response by a clinician or anyone else.”1 PRO tools “measure what patients are able to do and how they feel by asking questions” (see “Types of Patient-Reported Outcomes [PROs],” p. 19).
If successfully adapted for public reporting on a wide scale, PROs could become the next evolutionary step in healthcare quality reporting, integrating health status and patient experience data into outcome metrics that truly matter to patients. They could enable a richer understanding of their clinical experiences and responses to therapy, and help providers target necessary improvements with greater precision.
“As a provider, I care about my patients not developing infections, getting the right medications, and not being readmitted. Patients, however, have a different set of priorities around issues like ‘How quickly will I be able to return to work? When will I be able to chase my grandkids around the yard? How much is this care going to cost me out of pocket?’” says healthcare quality expert Gregg Meyer, MD, MSc, chief clinical officer and executive vice president for population health for the Dartmouth-Hitchcock Health System in Lebanon, N.H. “This next generation of accountability will allow us to move from being provider- and payor-centered to becoming truly patient-centered, and will serve as a key reminder that patients are no longer passive participants. They are key partners, in both the delivery of care and the measurement of that care.”
The idea of PROs is one whose “time has finally arrived,” according to medical outcomes researcher David Cella, PhD, professor and chair of the Department of Medical Social Sciences at Northwestern University Feinberg School of Medicine in Chicago.
“The case for inclusion of outcomes that matter most to patients, like the effect of treatment upon their symptoms, function, and overall well-being, has always been compelling as an ideal to strive toward,” Cella adds. “PROs can and should be considered as true treatment outcome measures, and their ability to capture quality information efficiently make them well-suited for this role.”
The FDA even permits PROs (i.e. pain, anxiety, depression, sleep, and physical and social functioning) to be used as experimental endpoints for clinical trials to support claims in medical product labeling.2
The Patient Voice
The Department Health and Human Services (HHS) is searching for ways to fill current gaps in outcome measures, and has funded a patient outcomes project by the NQF to help ramp up patient-focused measure development activities within the federal government. In a recent report stemming from that project, the NQF states: “The patient’s voice is not readily captured in traditional health records and data systems, yet the beneficiary of healthcare services is often in the best position to evaluate the effectiveness of those services.”3
The NQF also is conducting foundational work to evaluate the most promising and viable PROs for quality measurement use and methodological issues involved in collecting and aggregating PRO data for provider performance assessment, says Helen Burstin, MD, MPH, NQF’s senior vice president for performance measures.
“PROs provide the opportunity to hear about the outcome of a clinician’s intervention directly from the patient—for example, visual improvement after cataract surgery, relief from nausea after chemotherapy, and mobility enhancement and pain relief after a hip or knee replacement,” she says. “The goal is to develop reliable and valid PRO performance measures that are applicable across multiple settings of care and/or multiple conditions, which the NQF can endorse for accountability and quality-improvement purposes.”
Specific NQF recommendations regarding PROs and performance measurement are expected to be available for review and comment this month, with a 30-day public and member comment period.
A wide variety of patient-level instruments to measure PROs have been used for clinical research purposes, many of which have been evaluated and catalogued within a system of assessment tools known as the National Institutes of Health’s (NIH) Patient-Reported Outcome Measurement Information System (PROMIS), Dr. Burstin says. PROMIS questionnaires prompt patients to measure such outcomes as how much difficulty they experience when walking a block on flat ground, getting in and out of bed, or doing strenuous activities, such as bicycling or jogging. NIH-funded studies using PROMIS tools are taking place at 12 sites across the country (http://nihpromis.org/default).
“PROMIS provides two distinct advantages to the PRO performance metric landscape,” argues Cella, who is principal investigator of the Statistical Center for PROMIS. “It has a computerized adaptive testing option, so efficient and accurate assessment is now possible at the individual patient level, with just a few questions per area. It also standardizes its scoring and reporting, such that many other similar measures can be used and their scores reported on a common, PROMIS metric.”
HM Applications
“The voice of the clinician is also needed during this PRO development process,” Dr. Burstin says. “We welcome hospitalists to engage in our projects and weigh in about the most meaningful and actionable patient outcomes that are relevant to their practice.”
“Taking PROs and applying them to hospital medicine is really doable if you take into account the lessons learned from providers who have already used PROs successfully in clinical settings,” says Pat Courneya, MD, medical director for HealthPartners Health Plan in Minnesota.
HealthPartners recently began using PROs in a quality measurement and reward program, offering financial bonuses to physical therapists who achieve a high PRO score relative to resource use (number of PT sessions required). “Having objective PRO measurements allows clinicians to create benchmarks for their patients regarding how much functional improvement they expect to achieve, and how many PT sessions are required to achieve that degree of improvement,” Dr. Courneya says. Using an interactive, Web-based PRO assessment tool, the program has helped tailor care to the expectations of patients while also significantly reducing the overall number of PT visits, especially by medically complex, post-operative patients.
HealthPartners has successfully used PROs as part of an innovative care model for managing patients with depression. At the outset of treatment, patients are administered the PHQ-9, a nine-item patient health questionnaire designed to assess depression symptoms and functional impairment, and derive a severity score. Patients receive care by a team composed of a primary-care physician, a care manager, and a consulting psychiatrist, after which their degree of symptom improvement is again measured. With this program, HealthPartners has achieved significantly more patients with depression into remission by six months compared with typical primary-care treatment, Dr. Courneya says. This model of care has since garnered a CMS Innovation Grant, managed by the HealthPartners Institute for Education and Research and directed by Minnesota’s Institute for Clinical Systems Improvement, aimed at spreading the model to five other states.
“PROs are potentially as useful for hospital medicine as for any other type of medical practice,” says Shaun Frost, MD, SFHM, SHM president and associate medical director of care delivery systems for HealthPartners Health Plan. “There is a big opportunity for hospitalists to incorporate shared decision-making to learn patients’ preferences, such as expectations of when they will be discharged, and understanding of therapeutic options.”
Peri-surgical care is a particularly important opportunity for hospitalists to demonstrate their value by leveraging PROs, according to Dr. Frost. “Patients sometimes come to the table with unrealistic prior expectations that physicians can make pain go away completely. We need to clarify their expectations preoperatively, when we meet them for the very first time, so that they establish a realistic baseline,” he says. “We then need to have a diligent conversation with them immediately after their operation to discuss their pain-management goals, a realistic physical therapy schedule, and post-discharge expectations.”
By clearly understanding patient objectives, hospitalists can “adjust the therapy they’re getting to their expectations, maximizing its effectiveness while minimizing delays in care and transitions to other care settings,” Dr. Frost says.
Chris Guadagnino is a freelance medical writer in Philadelphia.
References
- National Quality Forum. Patient-reported outcomes. National Quality Forum website. Available at: http://www.qualityforum.org/Projects/n-r/Patient-Reported_Outcomes/Patient-Reported_Outcomes.aspx. Accessed Oct. 2, 2012.
- U.S. Food and Drug Administration. The Patient-Reported Outcomes Consortium. U.S. Food and Drug Administration website. Available at: http://www.fda.gov/AboutFDA/PartnershipsCollaborations/PublicPrivatePartnershipProgram/ucm231129.htm. Accessed Oct. 2, 2012.
- National Quality Forum. National voluntary consensus standards for patient outcomes 2009.National Quality Forum website. Available at: http://www.qualityforum.org/Publications/2011/07/National_Voluntary_Consensus_Standards_for_Patient_Outcomes_2009.aspx. Accessed Oct. 2, 2012.
—Gregg Meyer, MD, MSc, chief clinical officer and executive vice president for population health for the Dartmouth-Hitchcock Health System in Lebanon, N.H.
As healthcare quality reporting continues to evolve in this era of value-based purchasing (VBP), players on both the giving and receiving ends of performance incentives agree on the need to improve the accountability metrics with which providers are measured, ranked, rewarded, and penalized. Many of the measures currently in use—e.g., Centers for Medicare & Medicaid Services’ (CMS) core process measures and patient satisfaction ratings, the gross outcome metrics of mortality, infection, and readmission rates—are blunt instruments in need of refinement.
Entities such as the National Quality Forum (NQF), the American Medical Association’s Physician Consortium for Performance Improvement (PCPI), and the National Quality Measures Clearinghouse (NQMC) recognize the need to develop and endorse more timely, credible, and patient-centered outcome metrics. Largely missing from the current crop of outcome measure sets is a meaningful account of the patient’s perspective.
Enter patient-reported outcomes (PROs), defined as “any report of the status of a patient’s health condition that comes directly from the patient, without interpretation of the patient’s response by a clinician or anyone else.”1 PRO tools “measure what patients are able to do and how they feel by asking questions” (see “Types of Patient-Reported Outcomes [PROs],” p. 19).
If successfully adapted for public reporting on a wide scale, PROs could become the next evolutionary step in healthcare quality reporting, integrating health status and patient experience data into outcome metrics that truly matter to patients. They could enable a richer understanding of their clinical experiences and responses to therapy, and help providers target necessary improvements with greater precision.
“As a provider, I care about my patients not developing infections, getting the right medications, and not being readmitted. Patients, however, have a different set of priorities around issues like ‘How quickly will I be able to return to work? When will I be able to chase my grandkids around the yard? How much is this care going to cost me out of pocket?’” says healthcare quality expert Gregg Meyer, MD, MSc, chief clinical officer and executive vice president for population health for the Dartmouth-Hitchcock Health System in Lebanon, N.H. “This next generation of accountability will allow us to move from being provider- and payor-centered to becoming truly patient-centered, and will serve as a key reminder that patients are no longer passive participants. They are key partners, in both the delivery of care and the measurement of that care.”
The idea of PROs is one whose “time has finally arrived,” according to medical outcomes researcher David Cella, PhD, professor and chair of the Department of Medical Social Sciences at Northwestern University Feinberg School of Medicine in Chicago.
“The case for inclusion of outcomes that matter most to patients, like the effect of treatment upon their symptoms, function, and overall well-being, has always been compelling as an ideal to strive toward,” Cella adds. “PROs can and should be considered as true treatment outcome measures, and their ability to capture quality information efficiently make them well-suited for this role.”
The FDA even permits PROs (i.e. pain, anxiety, depression, sleep, and physical and social functioning) to be used as experimental endpoints for clinical trials to support claims in medical product labeling.2
The Patient Voice
The Department Health and Human Services (HHS) is searching for ways to fill current gaps in outcome measures, and has funded a patient outcomes project by the NQF to help ramp up patient-focused measure development activities within the federal government. In a recent report stemming from that project, the NQF states: “The patient’s voice is not readily captured in traditional health records and data systems, yet the beneficiary of healthcare services is often in the best position to evaluate the effectiveness of those services.”3
The NQF also is conducting foundational work to evaluate the most promising and viable PROs for quality measurement use and methodological issues involved in collecting and aggregating PRO data for provider performance assessment, says Helen Burstin, MD, MPH, NQF’s senior vice president for performance measures.
“PROs provide the opportunity to hear about the outcome of a clinician’s intervention directly from the patient—for example, visual improvement after cataract surgery, relief from nausea after chemotherapy, and mobility enhancement and pain relief after a hip or knee replacement,” she says. “The goal is to develop reliable and valid PRO performance measures that are applicable across multiple settings of care and/or multiple conditions, which the NQF can endorse for accountability and quality-improvement purposes.”
Specific NQF recommendations regarding PROs and performance measurement are expected to be available for review and comment this month, with a 30-day public and member comment period.
A wide variety of patient-level instruments to measure PROs have been used for clinical research purposes, many of which have been evaluated and catalogued within a system of assessment tools known as the National Institutes of Health’s (NIH) Patient-Reported Outcome Measurement Information System (PROMIS), Dr. Burstin says. PROMIS questionnaires prompt patients to measure such outcomes as how much difficulty they experience when walking a block on flat ground, getting in and out of bed, or doing strenuous activities, such as bicycling or jogging. NIH-funded studies using PROMIS tools are taking place at 12 sites across the country (http://nihpromis.org/default).
“PROMIS provides two distinct advantages to the PRO performance metric landscape,” argues Cella, who is principal investigator of the Statistical Center for PROMIS. “It has a computerized adaptive testing option, so efficient and accurate assessment is now possible at the individual patient level, with just a few questions per area. It also standardizes its scoring and reporting, such that many other similar measures can be used and their scores reported on a common, PROMIS metric.”
HM Applications
“The voice of the clinician is also needed during this PRO development process,” Dr. Burstin says. “We welcome hospitalists to engage in our projects and weigh in about the most meaningful and actionable patient outcomes that are relevant to their practice.”
“Taking PROs and applying them to hospital medicine is really doable if you take into account the lessons learned from providers who have already used PROs successfully in clinical settings,” says Pat Courneya, MD, medical director for HealthPartners Health Plan in Minnesota.
HealthPartners recently began using PROs in a quality measurement and reward program, offering financial bonuses to physical therapists who achieve a high PRO score relative to resource use (number of PT sessions required). “Having objective PRO measurements allows clinicians to create benchmarks for their patients regarding how much functional improvement they expect to achieve, and how many PT sessions are required to achieve that degree of improvement,” Dr. Courneya says. Using an interactive, Web-based PRO assessment tool, the program has helped tailor care to the expectations of patients while also significantly reducing the overall number of PT visits, especially by medically complex, post-operative patients.
HealthPartners has successfully used PROs as part of an innovative care model for managing patients with depression. At the outset of treatment, patients are administered the PHQ-9, a nine-item patient health questionnaire designed to assess depression symptoms and functional impairment, and derive a severity score. Patients receive care by a team composed of a primary-care physician, a care manager, and a consulting psychiatrist, after which their degree of symptom improvement is again measured. With this program, HealthPartners has achieved significantly more patients with depression into remission by six months compared with typical primary-care treatment, Dr. Courneya says. This model of care has since garnered a CMS Innovation Grant, managed by the HealthPartners Institute for Education and Research and directed by Minnesota’s Institute for Clinical Systems Improvement, aimed at spreading the model to five other states.
“PROs are potentially as useful for hospital medicine as for any other type of medical practice,” says Shaun Frost, MD, SFHM, SHM president and associate medical director of care delivery systems for HealthPartners Health Plan. “There is a big opportunity for hospitalists to incorporate shared decision-making to learn patients’ preferences, such as expectations of when they will be discharged, and understanding of therapeutic options.”
Peri-surgical care is a particularly important opportunity for hospitalists to demonstrate their value by leveraging PROs, according to Dr. Frost. “Patients sometimes come to the table with unrealistic prior expectations that physicians can make pain go away completely. We need to clarify their expectations preoperatively, when we meet them for the very first time, so that they establish a realistic baseline,” he says. “We then need to have a diligent conversation with them immediately after their operation to discuss their pain-management goals, a realistic physical therapy schedule, and post-discharge expectations.”
By clearly understanding patient objectives, hospitalists can “adjust the therapy they’re getting to their expectations, maximizing its effectiveness while minimizing delays in care and transitions to other care settings,” Dr. Frost says.
Chris Guadagnino is a freelance medical writer in Philadelphia.
References
- National Quality Forum. Patient-reported outcomes. National Quality Forum website. Available at: http://www.qualityforum.org/Projects/n-r/Patient-Reported_Outcomes/Patient-Reported_Outcomes.aspx. Accessed Oct. 2, 2012.
- U.S. Food and Drug Administration. The Patient-Reported Outcomes Consortium. U.S. Food and Drug Administration website. Available at: http://www.fda.gov/AboutFDA/PartnershipsCollaborations/PublicPrivatePartnershipProgram/ucm231129.htm. Accessed Oct. 2, 2012.
- National Quality Forum. National voluntary consensus standards for patient outcomes 2009.National Quality Forum website. Available at: http://www.qualityforum.org/Publications/2011/07/National_Voluntary_Consensus_Standards_for_Patient_Outcomes_2009.aspx. Accessed Oct. 2, 2012.
—Gregg Meyer, MD, MSc, chief clinical officer and executive vice president for population health for the Dartmouth-Hitchcock Health System in Lebanon, N.H.
As healthcare quality reporting continues to evolve in this era of value-based purchasing (VBP), players on both the giving and receiving ends of performance incentives agree on the need to improve the accountability metrics with which providers are measured, ranked, rewarded, and penalized. Many of the measures currently in use—e.g., Centers for Medicare & Medicaid Services’ (CMS) core process measures and patient satisfaction ratings, the gross outcome metrics of mortality, infection, and readmission rates—are blunt instruments in need of refinement.
Entities such as the National Quality Forum (NQF), the American Medical Association’s Physician Consortium for Performance Improvement (PCPI), and the National Quality Measures Clearinghouse (NQMC) recognize the need to develop and endorse more timely, credible, and patient-centered outcome metrics. Largely missing from the current crop of outcome measure sets is a meaningful account of the patient’s perspective.
Enter patient-reported outcomes (PROs), defined as “any report of the status of a patient’s health condition that comes directly from the patient, without interpretation of the patient’s response by a clinician or anyone else.”1 PRO tools “measure what patients are able to do and how they feel by asking questions” (see “Types of Patient-Reported Outcomes [PROs],” p. 19).
If successfully adapted for public reporting on a wide scale, PROs could become the next evolutionary step in healthcare quality reporting, integrating health status and patient experience data into outcome metrics that truly matter to patients. They could enable a richer understanding of their clinical experiences and responses to therapy, and help providers target necessary improvements with greater precision.
“As a provider, I care about my patients not developing infections, getting the right medications, and not being readmitted. Patients, however, have a different set of priorities around issues like ‘How quickly will I be able to return to work? When will I be able to chase my grandkids around the yard? How much is this care going to cost me out of pocket?’” says healthcare quality expert Gregg Meyer, MD, MSc, chief clinical officer and executive vice president for population health for the Dartmouth-Hitchcock Health System in Lebanon, N.H. “This next generation of accountability will allow us to move from being provider- and payor-centered to becoming truly patient-centered, and will serve as a key reminder that patients are no longer passive participants. They are key partners, in both the delivery of care and the measurement of that care.”
The idea of PROs is one whose “time has finally arrived,” according to medical outcomes researcher David Cella, PhD, professor and chair of the Department of Medical Social Sciences at Northwestern University Feinberg School of Medicine in Chicago.
“The case for inclusion of outcomes that matter most to patients, like the effect of treatment upon their symptoms, function, and overall well-being, has always been compelling as an ideal to strive toward,” Cella adds. “PROs can and should be considered as true treatment outcome measures, and their ability to capture quality information efficiently make them well-suited for this role.”
The FDA even permits PROs (i.e. pain, anxiety, depression, sleep, and physical and social functioning) to be used as experimental endpoints for clinical trials to support claims in medical product labeling.2
The Patient Voice
The Department Health and Human Services (HHS) is searching for ways to fill current gaps in outcome measures, and has funded a patient outcomes project by the NQF to help ramp up patient-focused measure development activities within the federal government. In a recent report stemming from that project, the NQF states: “The patient’s voice is not readily captured in traditional health records and data systems, yet the beneficiary of healthcare services is often in the best position to evaluate the effectiveness of those services.”3
The NQF also is conducting foundational work to evaluate the most promising and viable PROs for quality measurement use and methodological issues involved in collecting and aggregating PRO data for provider performance assessment, says Helen Burstin, MD, MPH, NQF’s senior vice president for performance measures.
“PROs provide the opportunity to hear about the outcome of a clinician’s intervention directly from the patient—for example, visual improvement after cataract surgery, relief from nausea after chemotherapy, and mobility enhancement and pain relief after a hip or knee replacement,” she says. “The goal is to develop reliable and valid PRO performance measures that are applicable across multiple settings of care and/or multiple conditions, which the NQF can endorse for accountability and quality-improvement purposes.”
Specific NQF recommendations regarding PROs and performance measurement are expected to be available for review and comment this month, with a 30-day public and member comment period.
A wide variety of patient-level instruments to measure PROs have been used for clinical research purposes, many of which have been evaluated and catalogued within a system of assessment tools known as the National Institutes of Health’s (NIH) Patient-Reported Outcome Measurement Information System (PROMIS), Dr. Burstin says. PROMIS questionnaires prompt patients to measure such outcomes as how much difficulty they experience when walking a block on flat ground, getting in and out of bed, or doing strenuous activities, such as bicycling or jogging. NIH-funded studies using PROMIS tools are taking place at 12 sites across the country (http://nihpromis.org/default).
“PROMIS provides two distinct advantages to the PRO performance metric landscape,” argues Cella, who is principal investigator of the Statistical Center for PROMIS. “It has a computerized adaptive testing option, so efficient and accurate assessment is now possible at the individual patient level, with just a few questions per area. It also standardizes its scoring and reporting, such that many other similar measures can be used and their scores reported on a common, PROMIS metric.”
HM Applications
“The voice of the clinician is also needed during this PRO development process,” Dr. Burstin says. “We welcome hospitalists to engage in our projects and weigh in about the most meaningful and actionable patient outcomes that are relevant to their practice.”
“Taking PROs and applying them to hospital medicine is really doable if you take into account the lessons learned from providers who have already used PROs successfully in clinical settings,” says Pat Courneya, MD, medical director for HealthPartners Health Plan in Minnesota.
HealthPartners recently began using PROs in a quality measurement and reward program, offering financial bonuses to physical therapists who achieve a high PRO score relative to resource use (number of PT sessions required). “Having objective PRO measurements allows clinicians to create benchmarks for their patients regarding how much functional improvement they expect to achieve, and how many PT sessions are required to achieve that degree of improvement,” Dr. Courneya says. Using an interactive, Web-based PRO assessment tool, the program has helped tailor care to the expectations of patients while also significantly reducing the overall number of PT visits, especially by medically complex, post-operative patients.
HealthPartners has successfully used PROs as part of an innovative care model for managing patients with depression. At the outset of treatment, patients are administered the PHQ-9, a nine-item patient health questionnaire designed to assess depression symptoms and functional impairment, and derive a severity score. Patients receive care by a team composed of a primary-care physician, a care manager, and a consulting psychiatrist, after which their degree of symptom improvement is again measured. With this program, HealthPartners has achieved significantly more patients with depression into remission by six months compared with typical primary-care treatment, Dr. Courneya says. This model of care has since garnered a CMS Innovation Grant, managed by the HealthPartners Institute for Education and Research and directed by Minnesota’s Institute for Clinical Systems Improvement, aimed at spreading the model to five other states.
“PROs are potentially as useful for hospital medicine as for any other type of medical practice,” says Shaun Frost, MD, SFHM, SHM president and associate medical director of care delivery systems for HealthPartners Health Plan. “There is a big opportunity for hospitalists to incorporate shared decision-making to learn patients’ preferences, such as expectations of when they will be discharged, and understanding of therapeutic options.”
Peri-surgical care is a particularly important opportunity for hospitalists to demonstrate their value by leveraging PROs, according to Dr. Frost. “Patients sometimes come to the table with unrealistic prior expectations that physicians can make pain go away completely. We need to clarify their expectations preoperatively, when we meet them for the very first time, so that they establish a realistic baseline,” he says. “We then need to have a diligent conversation with them immediately after their operation to discuss their pain-management goals, a realistic physical therapy schedule, and post-discharge expectations.”
By clearly understanding patient objectives, hospitalists can “adjust the therapy they’re getting to their expectations, maximizing its effectiveness while minimizing delays in care and transitions to other care settings,” Dr. Frost says.
Chris Guadagnino is a freelance medical writer in Philadelphia.
References
- National Quality Forum. Patient-reported outcomes. National Quality Forum website. Available at: http://www.qualityforum.org/Projects/n-r/Patient-Reported_Outcomes/Patient-Reported_Outcomes.aspx. Accessed Oct. 2, 2012.
- U.S. Food and Drug Administration. The Patient-Reported Outcomes Consortium. U.S. Food and Drug Administration website. Available at: http://www.fda.gov/AboutFDA/PartnershipsCollaborations/PublicPrivatePartnershipProgram/ucm231129.htm. Accessed Oct. 2, 2012.
- National Quality Forum. National voluntary consensus standards for patient outcomes 2009.National Quality Forum website. Available at: http://www.qualityforum.org/Publications/2011/07/National_Voluntary_Consensus_Standards_for_Patient_Outcomes_2009.aspx. Accessed Oct. 2, 2012.
Patient Satisfaction Critical to Hospital Value-Based Purchasing Program
Should patient satisfaction factor prominently into healthcare pay-for-performance incentives? That question recently became moot as the Centers for Medicare & Medicaid Services (CMS) began withholding 1% of hospitals’ Medicare reimbursement as part of its Hospital Value-Based Purchasing Program, restoring it to institutions based upon their quality performance. Thirty percent of the program’s financial incentive is based upon how well hospitals score on patient satisfaction, as measured by the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey.
Despite those data having been collected and reported for years, their use as a healthcare performance indicator continues to be controversial. To win back reimbursement withholds, hospitals must earn perfect scores: The only winners are the ones for whom patients respond “always satisfied” to such questions as “How often did doctors treat you with courtesy and respect?” or “How often did doctors explain things in a way you could understand?” or “How often did hospital staff tell you what the medicine was for?”
A perfectly happy patient, skeptics say, isn’t necessarily one who has received the best medical care, and several analyses suggest that HCAHPS has unintended biases, making it a flawed accountability tool. Some of the nation’s most prestigious hospitals, for example, receive bad patient reviews despite getting high scores on clinical quality metrics.1
Conversely, many hospitals that receive high patient ratings have low clinical quality marks (e.g. significantly worse mortality rates than the national average for heart attacks, heart failure, or pneumonia).2
Safety-net hospitals perform more poorly than other hospitals on nearly every HCAHPS measure of patient experience, with gaps that are sizable and persistent. These institutions have the most fragile operating margins and are the least able to absorb the additional reimbursement cuts that will result from their low scores.3
Teaching hospitals and other large hospitals also score more poorly, on average, than do small community hospitals.4
Unexplained geographic disparities persist, with hospitals in cities and certain regions, such as the Northeast and California, scoring lower than other regions.1
Quality Requires Clarity
“These are valid criticisms. Just because someone receives the best medical care doesn’t mean they are the happiest—and vice versa,” says Peter Short, MD, senior vice president of medical affairs for Northeast Hospital Corp. in Massachusetts. “Are there biases [in the way patient satisfaction is measured]?
Absolutely. But we’re all being held accountable and we can’t wait for a perfect system.
“Any definition of high-quality medical care must take into consideration how it is perceived by patients,” he adds, particularly when “value” in healthcare means delivering high-quality, patient-friendly care at the lowest cost.
James Merlino, MD, FACS, FASCRS, chief experience officer for Cleveland Clinic, says little peer-reviewed research exists to show that HCAHPS is a robust process of measuring patient satisfaction, but he says CMS is “focusing on the right areas.”
“It’s hard to say that paying attention to the patient experience is not something we should do. And yet, many physicians and hospitals have not done a good job focusing on patient satisfaction,” Dr. Merlino says. “How well we communicate with patients goes to the heart of the patient-provider interaction: It’s crucial that patients are clearly informed what to do while they are in a hospital and after they are discharged. Poor communication can drive confusion, noncompliance, and complications.”
—John Wasson, MD, emeritus professor of community and family medicine at Dartmouth Medical School
Proven Improvements
Hospitalists will be leaders in driving patient satisfaction, Dr. Merlino says, given their central role in managing patients across the continuum of care. That role gives them great responsibility—and opportunity—to champion practices at their institutions that improve the hospital experience of their patients, many of whom have complicated illnesses requiring a potentially bewildering array of tests and procedures.
Several “best practices” have proven successful in boosting patient-satisfaction scores and can be readily adapted to a variety of local hospital settings, says Dr. Short, who is a speaker in SHM’s Hospital Value-Based Program Toolkit webinar series (see “Best Practices,”).
Cleveland Clinic has greatly boosted its physician communication scores by sharing HCAHPS performance data with physicians and by gleaning best practices from its high-scoring physicians, which include, for example, ensuring that residents and fellows speak with attendings before rounding with patients to ensure staff alignment and care coordination, Dr. Merlino explains.
Cleveland Clinic also is rolling out to its entire medical staff a communication training program taught by a carefully selected team of peer physicians, which Dr. Merlino says is proving to be very effective in boosting patient satisfaction and improving care by enhancing patient-physician conversations. The program features Kaiser Permanente’s “Four Habits” model to help organize medical interviews with patients:
- Invest in the beginning by creating rapport quickly, and let the patient know what to expect.
- Get the patient’s perspective by asking for their ideas concerning the meaning of symptoms and the request for care.
- Demonstrate empathy by being open to the patient’s emotions and conveying empathy verbally and nonverbally.
- Invest in the end by delivering diagnostic information, explaining the rationale for tests and treatments, involving the patient in decision-making, and reviewing the next steps.5
“Organizations have to evolve in an increasingly value-based healthcare environment by developing a culture that can adapt to any set of questions or regulations that CMS mandates,” Dr. Merlino adds.
Next-Generation Patient Satisfaction Measures
Tools to guide patients and healthcare/hospitalist teams toward more satisfying dialogues with patients—as well as tools to improve their outcomes—are becoming increasingly available, says John Wasson, MD, emeritus professor of community and family medicine at Dartmouth Medical School and a member of The Dartmouth Institute Patient-Reported Measure Trust, which is developing and testing next-generation, patient-reported healthcare measures.
One example is Howsyourhealth.org, a family of communication-enhancement tools designed to build patient confidence in managing and controlling their health problems by helping them “get what they want and need exactly when and how they want and need it,” Dr. Wasson says.
“Hospitalists and their teams might begin to think about processes that enhance a patient’s health confidence, which is very strongly associated with many outcomes,” he notes. The hospital version of the tool—at Howsyourcare.org—immediately provides information tailored to patients’ needs, as well as a summary hospitalists can review with their teams in order to improve patient/caregiver confidence for successful management of conditions when discharged, Dr. Wasson says.
“Overall patient satisfaction is not particularly useful for predicting health confidence,” he says. “Information quality tailored to patient need is what boosts patients’ health confidence—and has real power to improve patients’ clinical outcomes.”
Christopher Guadagnino is a freelance medical journalist in Philadelphia.
References
- Rau J. When TLC doesn't satisfy patients, elite hospitals may pay a price. Kaiser Health News website. Available at: http://www.kaiserhealthnews.org/stories/2011/november/08/patient-ratings-hospital-medicare-reimbursements.aspx. Accessed Aug. 15, 2012.
- Sternberg S, Schnaars C. Medicare data can help patients fill perception gap. USA Today website. Available at: http://www.usatoday.com/yourlife/health/healthcare/hospitals/2011-08-04-hospitals-patients-death-rates-Medicare_n.htm. Accessed Aug. 15, 2012.
- Chatterjee P, Joynt KE, Orav EJ, Jha AK. Patient experience in safety-net hospitals: implications for improving care and value-based purchasing. Arch Intern Med. 2012 Jul 16:1-7. doi: 10.1001/archinternmed.2012.3158 [Epub ahead of print].
- Rau J, Medicare to begin basing hospital payments on patient-satisfaction scores. Kaiser Health News website.. Available at: http://www.kaiserhealthnews.org/stories/2011/april/28/medicare-hospital-patient-satisfaction.aspx. Accessed Aug. 15, 2011.
- Frankel RM, Stein T. Getting the most out of the clinical encounter: the four habits model. The Permanente Journal website. Available at: http://xnet.kp.org/permanentejournal/fall99pj/habits.html. Accessed Aug. 15, 2012.
Should patient satisfaction factor prominently into healthcare pay-for-performance incentives? That question recently became moot as the Centers for Medicare & Medicaid Services (CMS) began withholding 1% of hospitals’ Medicare reimbursement as part of its Hospital Value-Based Purchasing Program, restoring it to institutions based upon their quality performance. Thirty percent of the program’s financial incentive is based upon how well hospitals score on patient satisfaction, as measured by the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey.
Despite those data having been collected and reported for years, their use as a healthcare performance indicator continues to be controversial. To win back reimbursement withholds, hospitals must earn perfect scores: The only winners are the ones for whom patients respond “always satisfied” to such questions as “How often did doctors treat you with courtesy and respect?” or “How often did doctors explain things in a way you could understand?” or “How often did hospital staff tell you what the medicine was for?”
A perfectly happy patient, skeptics say, isn’t necessarily one who has received the best medical care, and several analyses suggest that HCAHPS has unintended biases, making it a flawed accountability tool. Some of the nation’s most prestigious hospitals, for example, receive bad patient reviews despite getting high scores on clinical quality metrics.1
Conversely, many hospitals that receive high patient ratings have low clinical quality marks (e.g. significantly worse mortality rates than the national average for heart attacks, heart failure, or pneumonia).2
Safety-net hospitals perform more poorly than other hospitals on nearly every HCAHPS measure of patient experience, with gaps that are sizable and persistent. These institutions have the most fragile operating margins and are the least able to absorb the additional reimbursement cuts that will result from their low scores.3
Teaching hospitals and other large hospitals also score more poorly, on average, than do small community hospitals.4
Unexplained geographic disparities persist, with hospitals in cities and certain regions, such as the Northeast and California, scoring lower than other regions.1
Quality Requires Clarity
“These are valid criticisms. Just because someone receives the best medical care doesn’t mean they are the happiest—and vice versa,” says Peter Short, MD, senior vice president of medical affairs for Northeast Hospital Corp. in Massachusetts. “Are there biases [in the way patient satisfaction is measured]?
Absolutely. But we’re all being held accountable and we can’t wait for a perfect system.
“Any definition of high-quality medical care must take into consideration how it is perceived by patients,” he adds, particularly when “value” in healthcare means delivering high-quality, patient-friendly care at the lowest cost.
James Merlino, MD, FACS, FASCRS, chief experience officer for Cleveland Clinic, says little peer-reviewed research exists to show that HCAHPS is a robust process of measuring patient satisfaction, but he says CMS is “focusing on the right areas.”
“It’s hard to say that paying attention to the patient experience is not something we should do. And yet, many physicians and hospitals have not done a good job focusing on patient satisfaction,” Dr. Merlino says. “How well we communicate with patients goes to the heart of the patient-provider interaction: It’s crucial that patients are clearly informed what to do while they are in a hospital and after they are discharged. Poor communication can drive confusion, noncompliance, and complications.”
—John Wasson, MD, emeritus professor of community and family medicine at Dartmouth Medical School
Proven Improvements
Hospitalists will be leaders in driving patient satisfaction, Dr. Merlino says, given their central role in managing patients across the continuum of care. That role gives them great responsibility—and opportunity—to champion practices at their institutions that improve the hospital experience of their patients, many of whom have complicated illnesses requiring a potentially bewildering array of tests and procedures.
Several “best practices” have proven successful in boosting patient-satisfaction scores and can be readily adapted to a variety of local hospital settings, says Dr. Short, who is a speaker in SHM’s Hospital Value-Based Program Toolkit webinar series (see “Best Practices,”).
Cleveland Clinic has greatly boosted its physician communication scores by sharing HCAHPS performance data with physicians and by gleaning best practices from its high-scoring physicians, which include, for example, ensuring that residents and fellows speak with attendings before rounding with patients to ensure staff alignment and care coordination, Dr. Merlino explains.
Cleveland Clinic also is rolling out to its entire medical staff a communication training program taught by a carefully selected team of peer physicians, which Dr. Merlino says is proving to be very effective in boosting patient satisfaction and improving care by enhancing patient-physician conversations. The program features Kaiser Permanente’s “Four Habits” model to help organize medical interviews with patients:
- Invest in the beginning by creating rapport quickly, and let the patient know what to expect.
- Get the patient’s perspective by asking for their ideas concerning the meaning of symptoms and the request for care.
- Demonstrate empathy by being open to the patient’s emotions and conveying empathy verbally and nonverbally.
- Invest in the end by delivering diagnostic information, explaining the rationale for tests and treatments, involving the patient in decision-making, and reviewing the next steps.5
“Organizations have to evolve in an increasingly value-based healthcare environment by developing a culture that can adapt to any set of questions or regulations that CMS mandates,” Dr. Merlino adds.
Next-Generation Patient Satisfaction Measures
Tools to guide patients and healthcare/hospitalist teams toward more satisfying dialogues with patients—as well as tools to improve their outcomes—are becoming increasingly available, says John Wasson, MD, emeritus professor of community and family medicine at Dartmouth Medical School and a member of The Dartmouth Institute Patient-Reported Measure Trust, which is developing and testing next-generation, patient-reported healthcare measures.
One example is Howsyourhealth.org, a family of communication-enhancement tools designed to build patient confidence in managing and controlling their health problems by helping them “get what they want and need exactly when and how they want and need it,” Dr. Wasson says.
“Hospitalists and their teams might begin to think about processes that enhance a patient’s health confidence, which is very strongly associated with many outcomes,” he notes. The hospital version of the tool—at Howsyourcare.org—immediately provides information tailored to patients’ needs, as well as a summary hospitalists can review with their teams in order to improve patient/caregiver confidence for successful management of conditions when discharged, Dr. Wasson says.
“Overall patient satisfaction is not particularly useful for predicting health confidence,” he says. “Information quality tailored to patient need is what boosts patients’ health confidence—and has real power to improve patients’ clinical outcomes.”
Christopher Guadagnino is a freelance medical journalist in Philadelphia.
References
- Rau J. When TLC doesn't satisfy patients, elite hospitals may pay a price. Kaiser Health News website. Available at: http://www.kaiserhealthnews.org/stories/2011/november/08/patient-ratings-hospital-medicare-reimbursements.aspx. Accessed Aug. 15, 2012.
- Sternberg S, Schnaars C. Medicare data can help patients fill perception gap. USA Today website. Available at: http://www.usatoday.com/yourlife/health/healthcare/hospitals/2011-08-04-hospitals-patients-death-rates-Medicare_n.htm. Accessed Aug. 15, 2012.
- Chatterjee P, Joynt KE, Orav EJ, Jha AK. Patient experience in safety-net hospitals: implications for improving care and value-based purchasing. Arch Intern Med. 2012 Jul 16:1-7. doi: 10.1001/archinternmed.2012.3158 [Epub ahead of print].
- Rau J, Medicare to begin basing hospital payments on patient-satisfaction scores. Kaiser Health News website.. Available at: http://www.kaiserhealthnews.org/stories/2011/april/28/medicare-hospital-patient-satisfaction.aspx. Accessed Aug. 15, 2011.
- Frankel RM, Stein T. Getting the most out of the clinical encounter: the four habits model. The Permanente Journal website. Available at: http://xnet.kp.org/permanentejournal/fall99pj/habits.html. Accessed Aug. 15, 2012.
Should patient satisfaction factor prominently into healthcare pay-for-performance incentives? That question recently became moot as the Centers for Medicare & Medicaid Services (CMS) began withholding 1% of hospitals’ Medicare reimbursement as part of its Hospital Value-Based Purchasing Program, restoring it to institutions based upon their quality performance. Thirty percent of the program’s financial incentive is based upon how well hospitals score on patient satisfaction, as measured by the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey.
Despite those data having been collected and reported for years, their use as a healthcare performance indicator continues to be controversial. To win back reimbursement withholds, hospitals must earn perfect scores: The only winners are the ones for whom patients respond “always satisfied” to such questions as “How often did doctors treat you with courtesy and respect?” or “How often did doctors explain things in a way you could understand?” or “How often did hospital staff tell you what the medicine was for?”
A perfectly happy patient, skeptics say, isn’t necessarily one who has received the best medical care, and several analyses suggest that HCAHPS has unintended biases, making it a flawed accountability tool. Some of the nation’s most prestigious hospitals, for example, receive bad patient reviews despite getting high scores on clinical quality metrics.1
Conversely, many hospitals that receive high patient ratings have low clinical quality marks (e.g. significantly worse mortality rates than the national average for heart attacks, heart failure, or pneumonia).2
Safety-net hospitals perform more poorly than other hospitals on nearly every HCAHPS measure of patient experience, with gaps that are sizable and persistent. These institutions have the most fragile operating margins and are the least able to absorb the additional reimbursement cuts that will result from their low scores.3
Teaching hospitals and other large hospitals also score more poorly, on average, than do small community hospitals.4
Unexplained geographic disparities persist, with hospitals in cities and certain regions, such as the Northeast and California, scoring lower than other regions.1
Quality Requires Clarity
“These are valid criticisms. Just because someone receives the best medical care doesn’t mean they are the happiest—and vice versa,” says Peter Short, MD, senior vice president of medical affairs for Northeast Hospital Corp. in Massachusetts. “Are there biases [in the way patient satisfaction is measured]?
Absolutely. But we’re all being held accountable and we can’t wait for a perfect system.
“Any definition of high-quality medical care must take into consideration how it is perceived by patients,” he adds, particularly when “value” in healthcare means delivering high-quality, patient-friendly care at the lowest cost.
James Merlino, MD, FACS, FASCRS, chief experience officer for Cleveland Clinic, says little peer-reviewed research exists to show that HCAHPS is a robust process of measuring patient satisfaction, but he says CMS is “focusing on the right areas.”
“It’s hard to say that paying attention to the patient experience is not something we should do. And yet, many physicians and hospitals have not done a good job focusing on patient satisfaction,” Dr. Merlino says. “How well we communicate with patients goes to the heart of the patient-provider interaction: It’s crucial that patients are clearly informed what to do while they are in a hospital and after they are discharged. Poor communication can drive confusion, noncompliance, and complications.”
—John Wasson, MD, emeritus professor of community and family medicine at Dartmouth Medical School
Proven Improvements
Hospitalists will be leaders in driving patient satisfaction, Dr. Merlino says, given their central role in managing patients across the continuum of care. That role gives them great responsibility—and opportunity—to champion practices at their institutions that improve the hospital experience of their patients, many of whom have complicated illnesses requiring a potentially bewildering array of tests and procedures.
Several “best practices” have proven successful in boosting patient-satisfaction scores and can be readily adapted to a variety of local hospital settings, says Dr. Short, who is a speaker in SHM’s Hospital Value-Based Program Toolkit webinar series (see “Best Practices,”).
Cleveland Clinic has greatly boosted its physician communication scores by sharing HCAHPS performance data with physicians and by gleaning best practices from its high-scoring physicians, which include, for example, ensuring that residents and fellows speak with attendings before rounding with patients to ensure staff alignment and care coordination, Dr. Merlino explains.
Cleveland Clinic also is rolling out to its entire medical staff a communication training program taught by a carefully selected team of peer physicians, which Dr. Merlino says is proving to be very effective in boosting patient satisfaction and improving care by enhancing patient-physician conversations. The program features Kaiser Permanente’s “Four Habits” model to help organize medical interviews with patients:
- Invest in the beginning by creating rapport quickly, and let the patient know what to expect.
- Get the patient’s perspective by asking for their ideas concerning the meaning of symptoms and the request for care.
- Demonstrate empathy by being open to the patient’s emotions and conveying empathy verbally and nonverbally.
- Invest in the end by delivering diagnostic information, explaining the rationale for tests and treatments, involving the patient in decision-making, and reviewing the next steps.5
“Organizations have to evolve in an increasingly value-based healthcare environment by developing a culture that can adapt to any set of questions or regulations that CMS mandates,” Dr. Merlino adds.
Next-Generation Patient Satisfaction Measures
Tools to guide patients and healthcare/hospitalist teams toward more satisfying dialogues with patients—as well as tools to improve their outcomes—are becoming increasingly available, says John Wasson, MD, emeritus professor of community and family medicine at Dartmouth Medical School and a member of The Dartmouth Institute Patient-Reported Measure Trust, which is developing and testing next-generation, patient-reported healthcare measures.
One example is Howsyourhealth.org, a family of communication-enhancement tools designed to build patient confidence in managing and controlling their health problems by helping them “get what they want and need exactly when and how they want and need it,” Dr. Wasson says.
“Hospitalists and their teams might begin to think about processes that enhance a patient’s health confidence, which is very strongly associated with many outcomes,” he notes. The hospital version of the tool—at Howsyourcare.org—immediately provides information tailored to patients’ needs, as well as a summary hospitalists can review with their teams in order to improve patient/caregiver confidence for successful management of conditions when discharged, Dr. Wasson says.
“Overall patient satisfaction is not particularly useful for predicting health confidence,” he says. “Information quality tailored to patient need is what boosts patients’ health confidence—and has real power to improve patients’ clinical outcomes.”
Christopher Guadagnino is a freelance medical journalist in Philadelphia.
References
- Rau J. When TLC doesn't satisfy patients, elite hospitals may pay a price. Kaiser Health News website. Available at: http://www.kaiserhealthnews.org/stories/2011/november/08/patient-ratings-hospital-medicare-reimbursements.aspx. Accessed Aug. 15, 2012.
- Sternberg S, Schnaars C. Medicare data can help patients fill perception gap. USA Today website. Available at: http://www.usatoday.com/yourlife/health/healthcare/hospitals/2011-08-04-hospitals-patients-death-rates-Medicare_n.htm. Accessed Aug. 15, 2012.
- Chatterjee P, Joynt KE, Orav EJ, Jha AK. Patient experience in safety-net hospitals: implications for improving care and value-based purchasing. Arch Intern Med. 2012 Jul 16:1-7. doi: 10.1001/archinternmed.2012.3158 [Epub ahead of print].
- Rau J, Medicare to begin basing hospital payments on patient-satisfaction scores. Kaiser Health News website.. Available at: http://www.kaiserhealthnews.org/stories/2011/april/28/medicare-hospital-patient-satisfaction.aspx. Accessed Aug. 15, 2011.
- Frankel RM, Stein T. Getting the most out of the clinical encounter: the four habits model. The Permanente Journal website. Available at: http://xnet.kp.org/permanentejournal/fall99pj/habits.html. Accessed Aug. 15, 2012.
Is ‘Meaningful Use’ Safe?
Earlier this summer, the Centers for Medicare & Medicaid Services (CMS) announced that more than 100,000 healthcare providers and 48% of all eligible hospitals are using electronic health records (EHRs) that meet federal standards, and they have benefited from federal incentive programs to do so.1
According to CMS acting administrator Marilyn Tavenner, meeting that provider goal makes 2012 the “Year of Meaningful Use.” She also says healthcare providers have recognized the potential of EHRs to cut down on paperwork, eliminate duplicate screenings and tests, and facilitate better, safer, patient-centered care.2
Belying CMS’ celebratory declarations, however, are concerns among experts that health information technology’s (HIT) actual use falls short of its promise—and might even endanger patients—due to shortcomings in system interoperability, safety, accountability, and other issues.
“Federal funding of IT was a step in the right direction, but it has also created a guaranteed customer base for electronic medical records, so vendors have less incentive to improve their products to meet clinicians needs,” says Kendall M. Rogers, MD, CPE, FACP, SFHM, chair of SHsM’s IT Executive Committee and chief of hospital medicine at the University of New Mexico Health Sciences Center School of Medicine in Albuquerque. “We want systems that help us make better clinical decisions and allow us to work more efficiently. Unfortunately, many hospitalists are frustrated with existing HIT systems, knowing how much better they need to be. It can be a dangerous gamble to push rapid adoption of potentially unsafe systems in hospitals.”
Questioning HIT Safety
Health IT experts affirm that potential danger. Jerry Osheroff, MD, FACP, FACMI, principal and founder of TMIT Consulting LLC and former chief clinical informatics officer for Thomson Reuters Healthcare, says HIT “is most effective when it gets the right information to the right people, through the right channels, in the right format, at the right point in the workflow. The danger comes when it gets one of those five ‘rights’ wrong; that can lead to distraction, confusion, wasted time, missed improvement opportunities, and safety concerns.”
Last November, the Institute of Medicine (IOM) released a scathing critique of HIT’s current ability to ensure patient safety.3 As the federal government invests billions of dollars to encourage hospitals and healthcare providers to adopt HIT, the IOM report said, improvements in care and safety are not yet established, and little evidence exists that quantifies the magnitude of the risk associated with HIT problems—partly because many HIT vendors discourage providers from sharing patient-safety concerns with nondisclosure and “hold harmless” provisions in contracts that shift the liability of unsafe HIT features to care providers.3
The report also cautioned that serious errors involving these technologies—including medication dosing errors, failure to detect fatal illnesses, and treatment delays due to complex data interfaces and poor human-computer interactions or loss of data—have led to several reported patient deaths and injuries. Furthermore, there is no way to publicly track adverse outcomes because there is no systematic regulation or authority to collect, analyze, and disseminate such information.
The report concluded that the current state of safety and health IT is not acceptable and that regulation of the industry might be necessary because the private sector to date has not taken sufficient action on its own to improve HIT safety.
SHM applauds the IOM report as an overdue and direly needed call to action, Dr. Rogers says. SHM sent a letter to the U.S. Department of Health and Human Services underscoring the importance of the IOM report.
“In our practices, we have experienced the threats to patient safety outlined in the report: poor user-interface design, poor workflow, complex data interfaces, lack of system interoperability, and lack of sufficient vendor action to build safer products,” Dr. Rogers says.
“Lack of interoperability—preventing access to patient data from previous physician or other hospital visits—makes a mockery of a coordinated, patient-centered healthcare system,” says HIT researcher Ross Koppel, PhD, faculty member of University of Pennsylvania’s Sociology Department and School of Medicine.
Although Dr. Rogers acknowledges that HIT has the potential to revolutionize healthcare systems, boost quality and safety, and lower cost, he maintains that current HIT products fall short of those ambitious goals. “Vendors typically regard usability of their products as a convenience request by clinicians; any errors are regarded as training issues for physicians,” Dr. Rogers says. “But the way that data is presented on a screen matters—if it is difficult to input or retrieve data and leads to cognitive or process errors, that’s a product redesign issue for which vendors should be held accountable.”
Dr. Koppel says many HIT systems originated from billing system applications “and were not initially designed with the clinical perspective in mind. Hospitalists have to be particularly focused on usability of HIT systems when it comes to patient-safety impacts. They’re not the canary in the coal mine, they’re the miners—often the teachers guiding other clinicians on HIT use.”
Improvement Agenda
SHM fully supports many of the IOM’s recommendations to improve the safety and functionality of HIT systems, including these as stated in an email to its members:
- Remove contractual restrictions, promote public reporting of safety issues, and put a system in place for independent investigations that drive patient-safety improvement.
- Establish standards and a common infrastructure for “interoperable” data exchange across systems.
- Create dual accountability between vendors and providers to address safety concerns that might require
- changes in an IT product’s functionality or design.
- Promote research on usability and human-factors design, safer implementation, and sociotechnical systems associated with HIT.
- Promote education of safety, quality, and reliability principles in design and implementation of HIT among all levels of the workforce, including frontline clinicians and staff, hospital IT, and quality teams—as well as IT vendors themselves.
There also are ongoing efforts in the private sector to improve HIT system functionality. For example, the HIMSS CDS Guidebook Series, of which Dr. Osheroff is lead editor and author and Dr. Rogers is a contributing author, is a respected repository of information synthesizing and vetting critical guidance for the effective implementation of clinical decision support (CDS).
“We’re also working with Greg Maynard [senior vice president of SHM’s Center for Hospital Innovation & Improvement] to use the collaborative’s tools to disseminate clinical-decision-support best practices for improving VTE prophylaxis rates,” Dr. Osheroff notes.
Hospitalists, as central players in quality improvement (QI), standardization, and care coordination, are natural choices as HIT champions, with valuable insight into how HIT systems should be customized to accommodate workflows and order sets in an optimal fashion, Dr. Rogers says.
“As critical as we are about the status of current HIT systems, we believe that systems can be designed more effectively to meet our needs,” he says. “By adopting many of the improvements enumerated in the IOM report, hospitalists are uniquely positioned to advance HIT to help achieve the goals of safer, higher-quality, and more efficient care.”
Christopher Guadagnino is a freelance writer based in Philadelphia.
References
- Centers for Medicare & Medicaid Services. More than 100,000 health care providers paid for using electronic health records. Centers for Medicare & Medicaid Services website. Available at: http://www.cms.gov/apps/media/press/release.asp?Counter=4383&intNumPerPage=10&checkDate=&checkKey=&srchType=1&numDays=3500&sr. Accessed July 31, 2012.
- Centers for Medicare & Medicaid Services. 2012: the year of meaningful use. The CMS Blog website. Available at: http://blog.cms.gov/2012/03/23/2012-the-year-of-meaningful-use. Accessed July 18, 2012.
- Institute of Medicine of the National Academies. Health IT and patient safety: building safer systems for better care. Institute of Medicine of the National Academies website. Available at: http://www.iom.edu/Reports/2011/Health-IT-and-Patient-Safety-Building-Safer-Systems-for-Better-Care.aspx. Accessed July 14, 2012.
Earlier this summer, the Centers for Medicare & Medicaid Services (CMS) announced that more than 100,000 healthcare providers and 48% of all eligible hospitals are using electronic health records (EHRs) that meet federal standards, and they have benefited from federal incentive programs to do so.1
According to CMS acting administrator Marilyn Tavenner, meeting that provider goal makes 2012 the “Year of Meaningful Use.” She also says healthcare providers have recognized the potential of EHRs to cut down on paperwork, eliminate duplicate screenings and tests, and facilitate better, safer, patient-centered care.2
Belying CMS’ celebratory declarations, however, are concerns among experts that health information technology’s (HIT) actual use falls short of its promise—and might even endanger patients—due to shortcomings in system interoperability, safety, accountability, and other issues.
“Federal funding of IT was a step in the right direction, but it has also created a guaranteed customer base for electronic medical records, so vendors have less incentive to improve their products to meet clinicians needs,” says Kendall M. Rogers, MD, CPE, FACP, SFHM, chair of SHsM’s IT Executive Committee and chief of hospital medicine at the University of New Mexico Health Sciences Center School of Medicine in Albuquerque. “We want systems that help us make better clinical decisions and allow us to work more efficiently. Unfortunately, many hospitalists are frustrated with existing HIT systems, knowing how much better they need to be. It can be a dangerous gamble to push rapid adoption of potentially unsafe systems in hospitals.”
Questioning HIT Safety
Health IT experts affirm that potential danger. Jerry Osheroff, MD, FACP, FACMI, principal and founder of TMIT Consulting LLC and former chief clinical informatics officer for Thomson Reuters Healthcare, says HIT “is most effective when it gets the right information to the right people, through the right channels, in the right format, at the right point in the workflow. The danger comes when it gets one of those five ‘rights’ wrong; that can lead to distraction, confusion, wasted time, missed improvement opportunities, and safety concerns.”
Last November, the Institute of Medicine (IOM) released a scathing critique of HIT’s current ability to ensure patient safety.3 As the federal government invests billions of dollars to encourage hospitals and healthcare providers to adopt HIT, the IOM report said, improvements in care and safety are not yet established, and little evidence exists that quantifies the magnitude of the risk associated with HIT problems—partly because many HIT vendors discourage providers from sharing patient-safety concerns with nondisclosure and “hold harmless” provisions in contracts that shift the liability of unsafe HIT features to care providers.3
The report also cautioned that serious errors involving these technologies—including medication dosing errors, failure to detect fatal illnesses, and treatment delays due to complex data interfaces and poor human-computer interactions or loss of data—have led to several reported patient deaths and injuries. Furthermore, there is no way to publicly track adverse outcomes because there is no systematic regulation or authority to collect, analyze, and disseminate such information.
The report concluded that the current state of safety and health IT is not acceptable and that regulation of the industry might be necessary because the private sector to date has not taken sufficient action on its own to improve HIT safety.
SHM applauds the IOM report as an overdue and direly needed call to action, Dr. Rogers says. SHM sent a letter to the U.S. Department of Health and Human Services underscoring the importance of the IOM report.
“In our practices, we have experienced the threats to patient safety outlined in the report: poor user-interface design, poor workflow, complex data interfaces, lack of system interoperability, and lack of sufficient vendor action to build safer products,” Dr. Rogers says.
“Lack of interoperability—preventing access to patient data from previous physician or other hospital visits—makes a mockery of a coordinated, patient-centered healthcare system,” says HIT researcher Ross Koppel, PhD, faculty member of University of Pennsylvania’s Sociology Department and School of Medicine.
Although Dr. Rogers acknowledges that HIT has the potential to revolutionize healthcare systems, boost quality and safety, and lower cost, he maintains that current HIT products fall short of those ambitious goals. “Vendors typically regard usability of their products as a convenience request by clinicians; any errors are regarded as training issues for physicians,” Dr. Rogers says. “But the way that data is presented on a screen matters—if it is difficult to input or retrieve data and leads to cognitive or process errors, that’s a product redesign issue for which vendors should be held accountable.”
Dr. Koppel says many HIT systems originated from billing system applications “and were not initially designed with the clinical perspective in mind. Hospitalists have to be particularly focused on usability of HIT systems when it comes to patient-safety impacts. They’re not the canary in the coal mine, they’re the miners—often the teachers guiding other clinicians on HIT use.”
Improvement Agenda
SHM fully supports many of the IOM’s recommendations to improve the safety and functionality of HIT systems, including these as stated in an email to its members:
- Remove contractual restrictions, promote public reporting of safety issues, and put a system in place for independent investigations that drive patient-safety improvement.
- Establish standards and a common infrastructure for “interoperable” data exchange across systems.
- Create dual accountability between vendors and providers to address safety concerns that might require
- changes in an IT product’s functionality or design.
- Promote research on usability and human-factors design, safer implementation, and sociotechnical systems associated with HIT.
- Promote education of safety, quality, and reliability principles in design and implementation of HIT among all levels of the workforce, including frontline clinicians and staff, hospital IT, and quality teams—as well as IT vendors themselves.
There also are ongoing efforts in the private sector to improve HIT system functionality. For example, the HIMSS CDS Guidebook Series, of which Dr. Osheroff is lead editor and author and Dr. Rogers is a contributing author, is a respected repository of information synthesizing and vetting critical guidance for the effective implementation of clinical decision support (CDS).
“We’re also working with Greg Maynard [senior vice president of SHM’s Center for Hospital Innovation & Improvement] to use the collaborative’s tools to disseminate clinical-decision-support best practices for improving VTE prophylaxis rates,” Dr. Osheroff notes.
Hospitalists, as central players in quality improvement (QI), standardization, and care coordination, are natural choices as HIT champions, with valuable insight into how HIT systems should be customized to accommodate workflows and order sets in an optimal fashion, Dr. Rogers says.
“As critical as we are about the status of current HIT systems, we believe that systems can be designed more effectively to meet our needs,” he says. “By adopting many of the improvements enumerated in the IOM report, hospitalists are uniquely positioned to advance HIT to help achieve the goals of safer, higher-quality, and more efficient care.”
Christopher Guadagnino is a freelance writer based in Philadelphia.
References
- Centers for Medicare & Medicaid Services. More than 100,000 health care providers paid for using electronic health records. Centers for Medicare & Medicaid Services website. Available at: http://www.cms.gov/apps/media/press/release.asp?Counter=4383&intNumPerPage=10&checkDate=&checkKey=&srchType=1&numDays=3500&sr. Accessed July 31, 2012.
- Centers for Medicare & Medicaid Services. 2012: the year of meaningful use. The CMS Blog website. Available at: http://blog.cms.gov/2012/03/23/2012-the-year-of-meaningful-use. Accessed July 18, 2012.
- Institute of Medicine of the National Academies. Health IT and patient safety: building safer systems for better care. Institute of Medicine of the National Academies website. Available at: http://www.iom.edu/Reports/2011/Health-IT-and-Patient-Safety-Building-Safer-Systems-for-Better-Care.aspx. Accessed July 14, 2012.
Earlier this summer, the Centers for Medicare & Medicaid Services (CMS) announced that more than 100,000 healthcare providers and 48% of all eligible hospitals are using electronic health records (EHRs) that meet federal standards, and they have benefited from federal incentive programs to do so.1
According to CMS acting administrator Marilyn Tavenner, meeting that provider goal makes 2012 the “Year of Meaningful Use.” She also says healthcare providers have recognized the potential of EHRs to cut down on paperwork, eliminate duplicate screenings and tests, and facilitate better, safer, patient-centered care.2
Belying CMS’ celebratory declarations, however, are concerns among experts that health information technology’s (HIT) actual use falls short of its promise—and might even endanger patients—due to shortcomings in system interoperability, safety, accountability, and other issues.
“Federal funding of IT was a step in the right direction, but it has also created a guaranteed customer base for electronic medical records, so vendors have less incentive to improve their products to meet clinicians needs,” says Kendall M. Rogers, MD, CPE, FACP, SFHM, chair of SHsM’s IT Executive Committee and chief of hospital medicine at the University of New Mexico Health Sciences Center School of Medicine in Albuquerque. “We want systems that help us make better clinical decisions and allow us to work more efficiently. Unfortunately, many hospitalists are frustrated with existing HIT systems, knowing how much better they need to be. It can be a dangerous gamble to push rapid adoption of potentially unsafe systems in hospitals.”
Questioning HIT Safety
Health IT experts affirm that potential danger. Jerry Osheroff, MD, FACP, FACMI, principal and founder of TMIT Consulting LLC and former chief clinical informatics officer for Thomson Reuters Healthcare, says HIT “is most effective when it gets the right information to the right people, through the right channels, in the right format, at the right point in the workflow. The danger comes when it gets one of those five ‘rights’ wrong; that can lead to distraction, confusion, wasted time, missed improvement opportunities, and safety concerns.”
Last November, the Institute of Medicine (IOM) released a scathing critique of HIT’s current ability to ensure patient safety.3 As the federal government invests billions of dollars to encourage hospitals and healthcare providers to adopt HIT, the IOM report said, improvements in care and safety are not yet established, and little evidence exists that quantifies the magnitude of the risk associated with HIT problems—partly because many HIT vendors discourage providers from sharing patient-safety concerns with nondisclosure and “hold harmless” provisions in contracts that shift the liability of unsafe HIT features to care providers.3
The report also cautioned that serious errors involving these technologies—including medication dosing errors, failure to detect fatal illnesses, and treatment delays due to complex data interfaces and poor human-computer interactions or loss of data—have led to several reported patient deaths and injuries. Furthermore, there is no way to publicly track adverse outcomes because there is no systematic regulation or authority to collect, analyze, and disseminate such information.
The report concluded that the current state of safety and health IT is not acceptable and that regulation of the industry might be necessary because the private sector to date has not taken sufficient action on its own to improve HIT safety.
SHM applauds the IOM report as an overdue and direly needed call to action, Dr. Rogers says. SHM sent a letter to the U.S. Department of Health and Human Services underscoring the importance of the IOM report.
“In our practices, we have experienced the threats to patient safety outlined in the report: poor user-interface design, poor workflow, complex data interfaces, lack of system interoperability, and lack of sufficient vendor action to build safer products,” Dr. Rogers says.
“Lack of interoperability—preventing access to patient data from previous physician or other hospital visits—makes a mockery of a coordinated, patient-centered healthcare system,” says HIT researcher Ross Koppel, PhD, faculty member of University of Pennsylvania’s Sociology Department and School of Medicine.
Although Dr. Rogers acknowledges that HIT has the potential to revolutionize healthcare systems, boost quality and safety, and lower cost, he maintains that current HIT products fall short of those ambitious goals. “Vendors typically regard usability of their products as a convenience request by clinicians; any errors are regarded as training issues for physicians,” Dr. Rogers says. “But the way that data is presented on a screen matters—if it is difficult to input or retrieve data and leads to cognitive or process errors, that’s a product redesign issue for which vendors should be held accountable.”
Dr. Koppel says many HIT systems originated from billing system applications “and were not initially designed with the clinical perspective in mind. Hospitalists have to be particularly focused on usability of HIT systems when it comes to patient-safety impacts. They’re not the canary in the coal mine, they’re the miners—often the teachers guiding other clinicians on HIT use.”
Improvement Agenda
SHM fully supports many of the IOM’s recommendations to improve the safety and functionality of HIT systems, including these as stated in an email to its members:
- Remove contractual restrictions, promote public reporting of safety issues, and put a system in place for independent investigations that drive patient-safety improvement.
- Establish standards and a common infrastructure for “interoperable” data exchange across systems.
- Create dual accountability between vendors and providers to address safety concerns that might require
- changes in an IT product’s functionality or design.
- Promote research on usability and human-factors design, safer implementation, and sociotechnical systems associated with HIT.
- Promote education of safety, quality, and reliability principles in design and implementation of HIT among all levels of the workforce, including frontline clinicians and staff, hospital IT, and quality teams—as well as IT vendors themselves.
There also are ongoing efforts in the private sector to improve HIT system functionality. For example, the HIMSS CDS Guidebook Series, of which Dr. Osheroff is lead editor and author and Dr. Rogers is a contributing author, is a respected repository of information synthesizing and vetting critical guidance for the effective implementation of clinical decision support (CDS).
“We’re also working with Greg Maynard [senior vice president of SHM’s Center for Hospital Innovation & Improvement] to use the collaborative’s tools to disseminate clinical-decision-support best practices for improving VTE prophylaxis rates,” Dr. Osheroff notes.
Hospitalists, as central players in quality improvement (QI), standardization, and care coordination, are natural choices as HIT champions, with valuable insight into how HIT systems should be customized to accommodate workflows and order sets in an optimal fashion, Dr. Rogers says.
“As critical as we are about the status of current HIT systems, we believe that systems can be designed more effectively to meet our needs,” he says. “By adopting many of the improvements enumerated in the IOM report, hospitalists are uniquely positioned to advance HIT to help achieve the goals of safer, higher-quality, and more efficient care.”
Christopher Guadagnino is a freelance writer based in Philadelphia.
References
- Centers for Medicare & Medicaid Services. More than 100,000 health care providers paid for using electronic health records. Centers for Medicare & Medicaid Services website. Available at: http://www.cms.gov/apps/media/press/release.asp?Counter=4383&intNumPerPage=10&checkDate=&checkKey=&srchType=1&numDays=3500&sr. Accessed July 31, 2012.
- Centers for Medicare & Medicaid Services. 2012: the year of meaningful use. The CMS Blog website. Available at: http://blog.cms.gov/2012/03/23/2012-the-year-of-meaningful-use. Accessed July 18, 2012.
- Institute of Medicine of the National Academies. Health IT and patient safety: building safer systems for better care. Institute of Medicine of the National Academies website. Available at: http://www.iom.edu/Reports/2011/Health-IT-and-Patient-Safety-Building-Safer-Systems-for-Better-Care.aspx. Accessed July 14, 2012.
Established Performance Metrics Help CMS Expand Its Value-Based Purchasing Program
—Thomas B. Valuck, MD, JD, senior vice president of strategic partnerships, National Quality Forum, former CMS adviser
No longer content to be a passive purchaser of healthcare services, the Centers for Medicare & Medicaid Services (CMS) is becoming a savvier shopper, holding providers increasingly accountable for the quality and efficiency of the care they deliver. With its value-based purchasing (VPB) program for hospitals already in place, now it’s the physicians’ turn.
CMS is marching toward a value-based payment modifier program that will adjust physician reimbursement based on the relative quality and efficiency of care that physicians provide to Medicare fee-for-service patients. The program will begin January 2015 and will extend to all physicians in 2017. Like the hospital VBP program, it will be budget-neutral—meaning that payment will increase for some physicians but decrease for others.
The coming months mark a pivotal period for physicians as CMS tweaks its accountability apparatus in ways that will determine how reimbursement will rise and fall, for whom, and for what.
Menu of Metrics
In crafting the payment modifier program, CMS can tap performance metrics from several of its existing programs, including the Physician Quality Reporting System (PQRS), the soon-to-be-expanded Physician Compare website (www.medicare.gov/find-a-doctor/provider-search.aspx), and the Physician Feedback Program.
“These agendas are part of a continuum, and of equal importance, in the evolution toward physician value-based purchasing,” says Patrick J. Torcson, MD, MMM, FACP, SFHM, chair of SHM’s Performance Measurement and Reporting Committee, and director of hospital medicine at St. Tammany Parish Hospital in Covington, La.
PQRS began as a voluntary “pay for reporting” system that gave physicians a modest financial bonus (currently 0.5% of allowable Medicare charges) for submitting quality data (left). The Affordable Care Act (ACA) has since authorized CMS to penalize physicians who do not participate—1.5% of allowable Medicare charges beginning in 2015, and 2% in 2016.
The Physician Compare website, launched at the end of 2010, currently contains such rudimentary information as education, gender, and whether a physician is enrolled in Medicare and satisfactorily reports data to the PQRS. But as of January, the site will begin reporting some PQRS data, as well as other metrics.
CMS’ Physician Feedback Program provides quality and cost information to physicians in an effort to encourage them to improve the care they provide and its efficiency. CMS recently combined the program with its value-based payment modifier program as it moves toward physician reimbursement that it says will reward “value rather than volume.” The program, currently being piloted in Iowa, Nebraska, Kansas, and Missouri, issues to physicians confidential quality and resource use reports (QRURs) that compare their performance to peer groups in similar specialties by tracking PQRS results, Healthcare Effectiveness Data and Information Set (HEDIS) measures, and per-capita cost data and preventable hospital admission rates for various medical conditions. CMS will roll out the program nationwide next year.
Metrics Lack Relevance
Developing performance measures that capture the most relevant activities of physicians across many different specialties with equal validity is notoriously difficult—something that CMS acknowledges.1
Assigning the right patient to the right physician (i.e. figuring out who contributed what care, in what proportion, to which patient) also is fraught with complications, especially in the inpatient care setting, where a patient is likely to see many different physicians during a hospitalization.
SHM president Shaun Frost, MD, SFHM, highlighted these challenges in a letter sent in May to acting CMS administrator Marilyn B. Tavenner in which he pointed to dramatic data deficiencies in the initial round of QRURs sent to Physician Feedback Program participants that included hospitalists in Iowa, Nebraska, Kansas and Missouri. Because hospitalists were categorized as general internal-medicine physicians in the reports, their per-capita cost of care was dramatically higher (73% higher, in one case study) than the average cost of all internal-medicine physicians. No allowance was made for distinguishing the outpatient-oriented practice of a general internist from the inherently more expensive inpatient-focused hospitalist practice.
In the case study reviewed by SHM, the hospitalist’s patients saw, on average, 28 different physicians over the course of a year, during which the hospitalist contributed to the care of many patients but did not direct the care of any one of them—facts that clearly highlight the difficulty of assigning responsibility and accountability for a patient’s care when comparing physician performance.
“Based on the measurement used in the QRUR, it seems likely that a hospitalist would be severely disadvantaged with the introduction of a value-based modifier based on the present QRUR methodology,” Dr. Frost wrote.
SHM is similarly critical of the PQRS measures, which Dr. Torcson says lack relevance to hospitalist practices. “We want to be defined as HM physicians with our own unique measures of quality and cost,” he says. “Our results will look very different from those of an internist with a primarily outpatient practice.”
Dr. Torcson notes that SHM is an active participant in providing feedback during CMS rule proposals and has offered to work with the CMS on further refining the measures. For example, SHM proposed adding additional measures related to care transitions, given their particular relevance to hospitalist practices.
Rule-Changing Reform
The disruptive innovation of CMS’ healthcare reform agenda might wind up being a game-changer that dramatically affects the contours of all provider performance reporting and incentive systems, redefining the issues of physician accountability and patient assignment.
“We’re going to need to figure out how to restructure our measurement systems to match our evolving healthcare delivery and payment systems,” says Thomas B. Valuck, MD, JD, senior vice president of strategic partnerships for the National Quality Forum and former CMS adviser to the VBP program. Healthcare quality reporting should focus more on measures that cut across care contexts and assess whether the care provided truly made a difference for patients—metrics such as health improvement, return to functional status, level of patient involvement in the management of their care, provider team coordination, and other patient needs and preferences, Dr. Valuck believes.
“We need to be focused more on measures that encourage joint responsibility and cooperation among providers, and are important to patients across hospital, post-acute, and ambulatory settings, rather than those that are compartmentalized to one setting or relevant only to specific diseases or subspecialties,” Dr. Valuck says.
Such measure sets, while still retaining some disease- and physician-specific metrics, ideally would be complementary with families of related measures at the community, state, and national levels, Dr. Valuck says. “Such a multidimensional framework can begin to tell a meaningful story about what’s happening to the patient, and how well our system is delivering the right care,” he adds.
Dr. Torcson says HM has a pioneering role to play in this evolution, and he notes that SHM has proposed that CMS harmonize measures that align hospital-based physician activities (e.g. hospital medicine, emergency medicine, anesthesia, radiology) with hospital-level performance agendas so that physicians practicing together in the hospital setting can report on measures that are relevant to both.
Christopher Guadagnino is a freelance medical writer in Philadelphia.
Reference
- Centers for Medicare & Medicaid Services. Physician Quality Reporting System Town Hall Meeting. Available at: http://www.usqualitymeasures.org/shared/content/C4M_PQRS_transcript.pdf. Accessed July 3, 2012.
—Thomas B. Valuck, MD, JD, senior vice president of strategic partnerships, National Quality Forum, former CMS adviser
No longer content to be a passive purchaser of healthcare services, the Centers for Medicare & Medicaid Services (CMS) is becoming a savvier shopper, holding providers increasingly accountable for the quality and efficiency of the care they deliver. With its value-based purchasing (VPB) program for hospitals already in place, now it’s the physicians’ turn.
CMS is marching toward a value-based payment modifier program that will adjust physician reimbursement based on the relative quality and efficiency of care that physicians provide to Medicare fee-for-service patients. The program will begin January 2015 and will extend to all physicians in 2017. Like the hospital VBP program, it will be budget-neutral—meaning that payment will increase for some physicians but decrease for others.
The coming months mark a pivotal period for physicians as CMS tweaks its accountability apparatus in ways that will determine how reimbursement will rise and fall, for whom, and for what.
Menu of Metrics
In crafting the payment modifier program, CMS can tap performance metrics from several of its existing programs, including the Physician Quality Reporting System (PQRS), the soon-to-be-expanded Physician Compare website (www.medicare.gov/find-a-doctor/provider-search.aspx), and the Physician Feedback Program.
“These agendas are part of a continuum, and of equal importance, in the evolution toward physician value-based purchasing,” says Patrick J. Torcson, MD, MMM, FACP, SFHM, chair of SHM’s Performance Measurement and Reporting Committee, and director of hospital medicine at St. Tammany Parish Hospital in Covington, La.
PQRS began as a voluntary “pay for reporting” system that gave physicians a modest financial bonus (currently 0.5% of allowable Medicare charges) for submitting quality data (left). The Affordable Care Act (ACA) has since authorized CMS to penalize physicians who do not participate—1.5% of allowable Medicare charges beginning in 2015, and 2% in 2016.
The Physician Compare website, launched at the end of 2010, currently contains such rudimentary information as education, gender, and whether a physician is enrolled in Medicare and satisfactorily reports data to the PQRS. But as of January, the site will begin reporting some PQRS data, as well as other metrics.
CMS’ Physician Feedback Program provides quality and cost information to physicians in an effort to encourage them to improve the care they provide and its efficiency. CMS recently combined the program with its value-based payment modifier program as it moves toward physician reimbursement that it says will reward “value rather than volume.” The program, currently being piloted in Iowa, Nebraska, Kansas, and Missouri, issues to physicians confidential quality and resource use reports (QRURs) that compare their performance to peer groups in similar specialties by tracking PQRS results, Healthcare Effectiveness Data and Information Set (HEDIS) measures, and per-capita cost data and preventable hospital admission rates for various medical conditions. CMS will roll out the program nationwide next year.
Metrics Lack Relevance
Developing performance measures that capture the most relevant activities of physicians across many different specialties with equal validity is notoriously difficult—something that CMS acknowledges.1
Assigning the right patient to the right physician (i.e. figuring out who contributed what care, in what proportion, to which patient) also is fraught with complications, especially in the inpatient care setting, where a patient is likely to see many different physicians during a hospitalization.
SHM president Shaun Frost, MD, SFHM, highlighted these challenges in a letter sent in May to acting CMS administrator Marilyn B. Tavenner in which he pointed to dramatic data deficiencies in the initial round of QRURs sent to Physician Feedback Program participants that included hospitalists in Iowa, Nebraska, Kansas and Missouri. Because hospitalists were categorized as general internal-medicine physicians in the reports, their per-capita cost of care was dramatically higher (73% higher, in one case study) than the average cost of all internal-medicine physicians. No allowance was made for distinguishing the outpatient-oriented practice of a general internist from the inherently more expensive inpatient-focused hospitalist practice.
In the case study reviewed by SHM, the hospitalist’s patients saw, on average, 28 different physicians over the course of a year, during which the hospitalist contributed to the care of many patients but did not direct the care of any one of them—facts that clearly highlight the difficulty of assigning responsibility and accountability for a patient’s care when comparing physician performance.
“Based on the measurement used in the QRUR, it seems likely that a hospitalist would be severely disadvantaged with the introduction of a value-based modifier based on the present QRUR methodology,” Dr. Frost wrote.
SHM is similarly critical of the PQRS measures, which Dr. Torcson says lack relevance to hospitalist practices. “We want to be defined as HM physicians with our own unique measures of quality and cost,” he says. “Our results will look very different from those of an internist with a primarily outpatient practice.”
Dr. Torcson notes that SHM is an active participant in providing feedback during CMS rule proposals and has offered to work with the CMS on further refining the measures. For example, SHM proposed adding additional measures related to care transitions, given their particular relevance to hospitalist practices.
Rule-Changing Reform
The disruptive innovation of CMS’ healthcare reform agenda might wind up being a game-changer that dramatically affects the contours of all provider performance reporting and incentive systems, redefining the issues of physician accountability and patient assignment.
“We’re going to need to figure out how to restructure our measurement systems to match our evolving healthcare delivery and payment systems,” says Thomas B. Valuck, MD, JD, senior vice president of strategic partnerships for the National Quality Forum and former CMS adviser to the VBP program. Healthcare quality reporting should focus more on measures that cut across care contexts and assess whether the care provided truly made a difference for patients—metrics such as health improvement, return to functional status, level of patient involvement in the management of their care, provider team coordination, and other patient needs and preferences, Dr. Valuck believes.
“We need to be focused more on measures that encourage joint responsibility and cooperation among providers, and are important to patients across hospital, post-acute, and ambulatory settings, rather than those that are compartmentalized to one setting or relevant only to specific diseases or subspecialties,” Dr. Valuck says.
Such measure sets, while still retaining some disease- and physician-specific metrics, ideally would be complementary with families of related measures at the community, state, and national levels, Dr. Valuck says. “Such a multidimensional framework can begin to tell a meaningful story about what’s happening to the patient, and how well our system is delivering the right care,” he adds.
Dr. Torcson says HM has a pioneering role to play in this evolution, and he notes that SHM has proposed that CMS harmonize measures that align hospital-based physician activities (e.g. hospital medicine, emergency medicine, anesthesia, radiology) with hospital-level performance agendas so that physicians practicing together in the hospital setting can report on measures that are relevant to both.
Christopher Guadagnino is a freelance medical writer in Philadelphia.
Reference
- Centers for Medicare & Medicaid Services. Physician Quality Reporting System Town Hall Meeting. Available at: http://www.usqualitymeasures.org/shared/content/C4M_PQRS_transcript.pdf. Accessed July 3, 2012.
—Thomas B. Valuck, MD, JD, senior vice president of strategic partnerships, National Quality Forum, former CMS adviser
No longer content to be a passive purchaser of healthcare services, the Centers for Medicare & Medicaid Services (CMS) is becoming a savvier shopper, holding providers increasingly accountable for the quality and efficiency of the care they deliver. With its value-based purchasing (VPB) program for hospitals already in place, now it’s the physicians’ turn.
CMS is marching toward a value-based payment modifier program that will adjust physician reimbursement based on the relative quality and efficiency of care that physicians provide to Medicare fee-for-service patients. The program will begin January 2015 and will extend to all physicians in 2017. Like the hospital VBP program, it will be budget-neutral—meaning that payment will increase for some physicians but decrease for others.
The coming months mark a pivotal period for physicians as CMS tweaks its accountability apparatus in ways that will determine how reimbursement will rise and fall, for whom, and for what.
Menu of Metrics
In crafting the payment modifier program, CMS can tap performance metrics from several of its existing programs, including the Physician Quality Reporting System (PQRS), the soon-to-be-expanded Physician Compare website (www.medicare.gov/find-a-doctor/provider-search.aspx), and the Physician Feedback Program.
“These agendas are part of a continuum, and of equal importance, in the evolution toward physician value-based purchasing,” says Patrick J. Torcson, MD, MMM, FACP, SFHM, chair of SHM’s Performance Measurement and Reporting Committee, and director of hospital medicine at St. Tammany Parish Hospital in Covington, La.
PQRS began as a voluntary “pay for reporting” system that gave physicians a modest financial bonus (currently 0.5% of allowable Medicare charges) for submitting quality data (left). The Affordable Care Act (ACA) has since authorized CMS to penalize physicians who do not participate—1.5% of allowable Medicare charges beginning in 2015, and 2% in 2016.
The Physician Compare website, launched at the end of 2010, currently contains such rudimentary information as education, gender, and whether a physician is enrolled in Medicare and satisfactorily reports data to the PQRS. But as of January, the site will begin reporting some PQRS data, as well as other metrics.
CMS’ Physician Feedback Program provides quality and cost information to physicians in an effort to encourage them to improve the care they provide and its efficiency. CMS recently combined the program with its value-based payment modifier program as it moves toward physician reimbursement that it says will reward “value rather than volume.” The program, currently being piloted in Iowa, Nebraska, Kansas, and Missouri, issues to physicians confidential quality and resource use reports (QRURs) that compare their performance to peer groups in similar specialties by tracking PQRS results, Healthcare Effectiveness Data and Information Set (HEDIS) measures, and per-capita cost data and preventable hospital admission rates for various medical conditions. CMS will roll out the program nationwide next year.
Metrics Lack Relevance
Developing performance measures that capture the most relevant activities of physicians across many different specialties with equal validity is notoriously difficult—something that CMS acknowledges.1
Assigning the right patient to the right physician (i.e. figuring out who contributed what care, in what proportion, to which patient) also is fraught with complications, especially in the inpatient care setting, where a patient is likely to see many different physicians during a hospitalization.
SHM president Shaun Frost, MD, SFHM, highlighted these challenges in a letter sent in May to acting CMS administrator Marilyn B. Tavenner in which he pointed to dramatic data deficiencies in the initial round of QRURs sent to Physician Feedback Program participants that included hospitalists in Iowa, Nebraska, Kansas and Missouri. Because hospitalists were categorized as general internal-medicine physicians in the reports, their per-capita cost of care was dramatically higher (73% higher, in one case study) than the average cost of all internal-medicine physicians. No allowance was made for distinguishing the outpatient-oriented practice of a general internist from the inherently more expensive inpatient-focused hospitalist practice.
In the case study reviewed by SHM, the hospitalist’s patients saw, on average, 28 different physicians over the course of a year, during which the hospitalist contributed to the care of many patients but did not direct the care of any one of them—facts that clearly highlight the difficulty of assigning responsibility and accountability for a patient’s care when comparing physician performance.
“Based on the measurement used in the QRUR, it seems likely that a hospitalist would be severely disadvantaged with the introduction of a value-based modifier based on the present QRUR methodology,” Dr. Frost wrote.
SHM is similarly critical of the PQRS measures, which Dr. Torcson says lack relevance to hospitalist practices. “We want to be defined as HM physicians with our own unique measures of quality and cost,” he says. “Our results will look very different from those of an internist with a primarily outpatient practice.”
Dr. Torcson notes that SHM is an active participant in providing feedback during CMS rule proposals and has offered to work with the CMS on further refining the measures. For example, SHM proposed adding additional measures related to care transitions, given their particular relevance to hospitalist practices.
Rule-Changing Reform
The disruptive innovation of CMS’ healthcare reform agenda might wind up being a game-changer that dramatically affects the contours of all provider performance reporting and incentive systems, redefining the issues of physician accountability and patient assignment.
“We’re going to need to figure out how to restructure our measurement systems to match our evolving healthcare delivery and payment systems,” says Thomas B. Valuck, MD, JD, senior vice president of strategic partnerships for the National Quality Forum and former CMS adviser to the VBP program. Healthcare quality reporting should focus more on measures that cut across care contexts and assess whether the care provided truly made a difference for patients—metrics such as health improvement, return to functional status, level of patient involvement in the management of their care, provider team coordination, and other patient needs and preferences, Dr. Valuck believes.
“We need to be focused more on measures that encourage joint responsibility and cooperation among providers, and are important to patients across hospital, post-acute, and ambulatory settings, rather than those that are compartmentalized to one setting or relevant only to specific diseases or subspecialties,” Dr. Valuck says.
Such measure sets, while still retaining some disease- and physician-specific metrics, ideally would be complementary with families of related measures at the community, state, and national levels, Dr. Valuck says. “Such a multidimensional framework can begin to tell a meaningful story about what’s happening to the patient, and how well our system is delivering the right care,” he adds.
Dr. Torcson says HM has a pioneering role to play in this evolution, and he notes that SHM has proposed that CMS harmonize measures that align hospital-based physician activities (e.g. hospital medicine, emergency medicine, anesthesia, radiology) with hospital-level performance agendas so that physicians practicing together in the hospital setting can report on measures that are relevant to both.
Christopher Guadagnino is a freelance medical writer in Philadelphia.
Reference
- Centers for Medicare & Medicaid Services. Physician Quality Reporting System Town Hall Meeting. Available at: http://www.usqualitymeasures.org/shared/content/C4M_PQRS_transcript.pdf. Accessed July 3, 2012.
Hospitalists Can Help Solve Residency Duty-Hour Issues
It’s been one year since the Accreditation Council for Graduate Medical Education’s (ACGME) most recent residency program regulations took effect, updating standards put into place in 2003. The regulations are the latest manifestation of an ongoing challenge in medical training: how to strike the right balance of optimal clinical training with patient safety, resident well-being, and other concerns.
Clearly the most controversial change in the latest regulations is the restriction of first-year residents to a work shift of no more than 16 hours and older residents to 24 hours, with an additional four hours to manage transitions in care (previously, 30-hour shifts were permitted for all residents). ACGME applied the 16-hour restriction after extensive discussions with members of an Institute of Medicine committee that drafted a report at the request of Congress that explored the dangers to patient care of sleep-deprived caregivers. The IOM report argued that revisions to medical residents’ workloads and duty-hours were necessary to better protect patients against fatigue-related errors and to ensure that residents get the best educational experience.1
This month, the ACGME begins its annual reviews of institutions to gauge the impact of the new regulations. While few expect the ACGME to find decisive answers regarding optimal work-hour regulations for residents, the 16-hour rule has both its opponents and supporters. On balance, HM appears to be well-positioned to benefit from the changes, having been given yet another opportunity to demonstrate value by helping their institutions weather the changes, enhance the residency training experience, and support the patient safety imperative.
Is 16 the Magic Number?
In defending the new rules last year, ACGME CEO Thomas J. Nasca, MD, acknowledged that the evidence linking long duty-hours and patient safety is mixed, while also explaining that another part of the rationale for limiting shifts for the youngest residents was to ease them into the profession. Older residents, he said, must be taught to recognize and manage the fatigue they will encounter regularly in their actual clinical practice, where hours are not regulated.
“It makes sense how ACGME has structured this—giving trainees the chance to learn in a more measured way, while recognizing that more experienced residents have more mature judgment,” says Daniel D. Dressler, MD, MSc, SFHM, FACP, hospital medicine associate division director for education, and associate program director for the J. Willis Hurst Internal Medicine Residency Program at Emory University School of Medicine in Atlanta. “I believe it’s an overall positive move, in terms of morale and work/life balance.”
Others disagree. Patient safety expert Lucian Leape, MD, adjunct professor at Harvard School of Public Health, decried that the ACGME rules did not apply to all residents, just those in their first year, and he rejected the assumption that one can learn to tolerate sleep deprivation.2 HM pioneer Bob Wachter, MD, MHM, professor, chief of the division of hospital medicine, and chief of the medical service at University of California San Francisco Medical Center, agrees the work-hour restrictions are here to stay—and are a good thing. At his blog Wachter’s World, he recently posted that research shows “prolonged wakefulness” degrades cognitive skills, and equates to a blood-alcohol level of 0.1, or “legally drunk in every state.”
“Even without strong evidence one way or the other, if it has improved safety, I think 16 hours is probably right for interns, and 24-plus-four hours for second-year residents and above. It’s the ACGME’s best guess, to date, of the right balance,” says Jeffrey G. Wiese, MD, SFHM, FACP, associate dean for graduate medical education, director of the internal medicine program at Tulane University School of Medicine in New Orleans, and former SHM president. “It’s no huge intellectual stretch to say that someone who’s been up for 32 hours is not in the best condition to make optimal patient-care decisions.”
While preserving optimal cognitive abilities is important for all physicians, ACGME’s new work-hour limits matter even more to specialties like surgery, which rely heavily on manual dexterity skills, Dr. Wiese suggests. Ironically, surgical specialty societies have been among the most critical of the new limits.
“My surgical colleagues have been particularly vocal critics of the new work-hour limit,” says Dr. Dressler, noting that Emory’s residency programs are smaller and have greater challenges in adjusting for fewer work hours as they rely more heavily on residents for certain clinical tasks than do other specialties.
Ideally, Dr. Wiese maintains, resident duty-hours should be increased gradually based on progressively demonstrated levels of ability and competence by individual residents, regardless of program year. Such milestone-based accountability is supported by SHM as well as several other medical societies.
Continuity of Care
A downside to the work-hour limit is its potential to disrupt both the continuity of care and the learning process, as fewer patients are likely to be followed by a single resident from admission to resolution of a case. Dr. Wachter, who is chair of the American Board of Internal Medicine (ABIM) and a former SHM president, acknowledges this sacrifice, noting that care teams at his hospital inherit nearly half their patients as handoffs from night admitters, and some never know handed-off patients as well as those they admitted themselves.
“In a system in which half the patients are cared for by two sets of doctors during these crucial stages [early assessment, data gathering, and initial patient response], neither group fully sees this arc play out, and their education suffers,” he wrote on his blog.
New limits means “less flexibility,” says Dr. Dressler, “and it can become a hindrance to completing the work-up of a patient—like not being able to put a central line in at 8:30 p.m. ... Some trainees feel they have less continuity with their patients because of the shorter hours.”
—Jeffrey G. Wiese, MD, SFHM, FACP, associate dean, graduate medical education, director, internal medicine program, Tulane University School of Medicine, New Orleans, former SHM president
Thoughtful management is required to minimize schedule disruption and maximize learning opportunities, he adds. “We’ve decided that our interns will have five overnight shifts over 10 days as part of one of their 30-day rotations. It’s important that interns get overnight experience before their second year,” Dr. Dressler says. “We had to incorporate three interns per team instead of two. Any way you slice it, you’re going to need additional manpower from other sources.”
Such workforce issues are hot topics in teaching hospitals across the country, Dr. Wiese says. He also warns that using hospitalists solely as “resident extenders” is not sustainable. “If an academic program is using hospitalists as stopgap labor, they do so at the risk of accelerating burnout,” he says.
Hospitalist Opportunity
Hospitalists can and should, however, take full advantage of a much-needed niche that the new ACGME regulations have called attention to: the need for expertise in minimizing patient-care disruptions resulting from more frequent patient handoffs.
“Hospitalists have an opportunity to get more involved in residency training programs by sharing their knowledge of effective patient handoff protocols,” Dr. Dressler says. “Hospitalists have treaded those waters for over a decade. We’ve learned a lot about structuring handoff information effectively, and we can inform training programs about those issues.”
The increased urgency of effective handoff management might even lead to an increased investment in HM programs, Dr. Dressler believes. “The expectation, of course, is that we are able to demonstrate effective patient handoffs—and show that we’re ‘walking the walk,’ and not just talking about it,” he says.
Christopher Guadagnino is a freelance medical writer in Philadelphia.
References
- Institute of Medicine. Resident duty hours: enhancing sleep, supervision, and safety. Institute of Medicine website. Available at: http://www.nap.edu/catalog.php?record_id=12508#toc. Accessed May 1, 2012.
- Krups C. Residency programs scramble to adopt changes. American Medical News website. Available at: http://www.ama-assn.org/amednews/2011/07/11/prsa0711.htm#s1. Accessed May 1, 2012.
It’s been one year since the Accreditation Council for Graduate Medical Education’s (ACGME) most recent residency program regulations took effect, updating standards put into place in 2003. The regulations are the latest manifestation of an ongoing challenge in medical training: how to strike the right balance of optimal clinical training with patient safety, resident well-being, and other concerns.
Clearly the most controversial change in the latest regulations is the restriction of first-year residents to a work shift of no more than 16 hours and older residents to 24 hours, with an additional four hours to manage transitions in care (previously, 30-hour shifts were permitted for all residents). ACGME applied the 16-hour restriction after extensive discussions with members of an Institute of Medicine committee that drafted a report at the request of Congress that explored the dangers to patient care of sleep-deprived caregivers. The IOM report argued that revisions to medical residents’ workloads and duty-hours were necessary to better protect patients against fatigue-related errors and to ensure that residents get the best educational experience.1
This month, the ACGME begins its annual reviews of institutions to gauge the impact of the new regulations. While few expect the ACGME to find decisive answers regarding optimal work-hour regulations for residents, the 16-hour rule has both its opponents and supporters. On balance, HM appears to be well-positioned to benefit from the changes, having been given yet another opportunity to demonstrate value by helping their institutions weather the changes, enhance the residency training experience, and support the patient safety imperative.
Is 16 the Magic Number?
In defending the new rules last year, ACGME CEO Thomas J. Nasca, MD, acknowledged that the evidence linking long duty-hours and patient safety is mixed, while also explaining that another part of the rationale for limiting shifts for the youngest residents was to ease them into the profession. Older residents, he said, must be taught to recognize and manage the fatigue they will encounter regularly in their actual clinical practice, where hours are not regulated.
“It makes sense how ACGME has structured this—giving trainees the chance to learn in a more measured way, while recognizing that more experienced residents have more mature judgment,” says Daniel D. Dressler, MD, MSc, SFHM, FACP, hospital medicine associate division director for education, and associate program director for the J. Willis Hurst Internal Medicine Residency Program at Emory University School of Medicine in Atlanta. “I believe it’s an overall positive move, in terms of morale and work/life balance.”
Others disagree. Patient safety expert Lucian Leape, MD, adjunct professor at Harvard School of Public Health, decried that the ACGME rules did not apply to all residents, just those in their first year, and he rejected the assumption that one can learn to tolerate sleep deprivation.2 HM pioneer Bob Wachter, MD, MHM, professor, chief of the division of hospital medicine, and chief of the medical service at University of California San Francisco Medical Center, agrees the work-hour restrictions are here to stay—and are a good thing. At his blog Wachter’s World, he recently posted that research shows “prolonged wakefulness” degrades cognitive skills, and equates to a blood-alcohol level of 0.1, or “legally drunk in every state.”
“Even without strong evidence one way or the other, if it has improved safety, I think 16 hours is probably right for interns, and 24-plus-four hours for second-year residents and above. It’s the ACGME’s best guess, to date, of the right balance,” says Jeffrey G. Wiese, MD, SFHM, FACP, associate dean for graduate medical education, director of the internal medicine program at Tulane University School of Medicine in New Orleans, and former SHM president. “It’s no huge intellectual stretch to say that someone who’s been up for 32 hours is not in the best condition to make optimal patient-care decisions.”
While preserving optimal cognitive abilities is important for all physicians, ACGME’s new work-hour limits matter even more to specialties like surgery, which rely heavily on manual dexterity skills, Dr. Wiese suggests. Ironically, surgical specialty societies have been among the most critical of the new limits.
“My surgical colleagues have been particularly vocal critics of the new work-hour limit,” says Dr. Dressler, noting that Emory’s residency programs are smaller and have greater challenges in adjusting for fewer work hours as they rely more heavily on residents for certain clinical tasks than do other specialties.
Ideally, Dr. Wiese maintains, resident duty-hours should be increased gradually based on progressively demonstrated levels of ability and competence by individual residents, regardless of program year. Such milestone-based accountability is supported by SHM as well as several other medical societies.
Continuity of Care
A downside to the work-hour limit is its potential to disrupt both the continuity of care and the learning process, as fewer patients are likely to be followed by a single resident from admission to resolution of a case. Dr. Wachter, who is chair of the American Board of Internal Medicine (ABIM) and a former SHM president, acknowledges this sacrifice, noting that care teams at his hospital inherit nearly half their patients as handoffs from night admitters, and some never know handed-off patients as well as those they admitted themselves.
“In a system in which half the patients are cared for by two sets of doctors during these crucial stages [early assessment, data gathering, and initial patient response], neither group fully sees this arc play out, and their education suffers,” he wrote on his blog.
New limits means “less flexibility,” says Dr. Dressler, “and it can become a hindrance to completing the work-up of a patient—like not being able to put a central line in at 8:30 p.m. ... Some trainees feel they have less continuity with their patients because of the shorter hours.”
—Jeffrey G. Wiese, MD, SFHM, FACP, associate dean, graduate medical education, director, internal medicine program, Tulane University School of Medicine, New Orleans, former SHM president
Thoughtful management is required to minimize schedule disruption and maximize learning opportunities, he adds. “We’ve decided that our interns will have five overnight shifts over 10 days as part of one of their 30-day rotations. It’s important that interns get overnight experience before their second year,” Dr. Dressler says. “We had to incorporate three interns per team instead of two. Any way you slice it, you’re going to need additional manpower from other sources.”
Such workforce issues are hot topics in teaching hospitals across the country, Dr. Wiese says. He also warns that using hospitalists solely as “resident extenders” is not sustainable. “If an academic program is using hospitalists as stopgap labor, they do so at the risk of accelerating burnout,” he says.
Hospitalist Opportunity
Hospitalists can and should, however, take full advantage of a much-needed niche that the new ACGME regulations have called attention to: the need for expertise in minimizing patient-care disruptions resulting from more frequent patient handoffs.
“Hospitalists have an opportunity to get more involved in residency training programs by sharing their knowledge of effective patient handoff protocols,” Dr. Dressler says. “Hospitalists have treaded those waters for over a decade. We’ve learned a lot about structuring handoff information effectively, and we can inform training programs about those issues.”
The increased urgency of effective handoff management might even lead to an increased investment in HM programs, Dr. Dressler believes. “The expectation, of course, is that we are able to demonstrate effective patient handoffs—and show that we’re ‘walking the walk,’ and not just talking about it,” he says.
Christopher Guadagnino is a freelance medical writer in Philadelphia.
References
- Institute of Medicine. Resident duty hours: enhancing sleep, supervision, and safety. Institute of Medicine website. Available at: http://www.nap.edu/catalog.php?record_id=12508#toc. Accessed May 1, 2012.
- Krups C. Residency programs scramble to adopt changes. American Medical News website. Available at: http://www.ama-assn.org/amednews/2011/07/11/prsa0711.htm#s1. Accessed May 1, 2012.
It’s been one year since the Accreditation Council for Graduate Medical Education’s (ACGME) most recent residency program regulations took effect, updating standards put into place in 2003. The regulations are the latest manifestation of an ongoing challenge in medical training: how to strike the right balance of optimal clinical training with patient safety, resident well-being, and other concerns.
Clearly the most controversial change in the latest regulations is the restriction of first-year residents to a work shift of no more than 16 hours and older residents to 24 hours, with an additional four hours to manage transitions in care (previously, 30-hour shifts were permitted for all residents). ACGME applied the 16-hour restriction after extensive discussions with members of an Institute of Medicine committee that drafted a report at the request of Congress that explored the dangers to patient care of sleep-deprived caregivers. The IOM report argued that revisions to medical residents’ workloads and duty-hours were necessary to better protect patients against fatigue-related errors and to ensure that residents get the best educational experience.1
This month, the ACGME begins its annual reviews of institutions to gauge the impact of the new regulations. While few expect the ACGME to find decisive answers regarding optimal work-hour regulations for residents, the 16-hour rule has both its opponents and supporters. On balance, HM appears to be well-positioned to benefit from the changes, having been given yet another opportunity to demonstrate value by helping their institutions weather the changes, enhance the residency training experience, and support the patient safety imperative.
Is 16 the Magic Number?
In defending the new rules last year, ACGME CEO Thomas J. Nasca, MD, acknowledged that the evidence linking long duty-hours and patient safety is mixed, while also explaining that another part of the rationale for limiting shifts for the youngest residents was to ease them into the profession. Older residents, he said, must be taught to recognize and manage the fatigue they will encounter regularly in their actual clinical practice, where hours are not regulated.
“It makes sense how ACGME has structured this—giving trainees the chance to learn in a more measured way, while recognizing that more experienced residents have more mature judgment,” says Daniel D. Dressler, MD, MSc, SFHM, FACP, hospital medicine associate division director for education, and associate program director for the J. Willis Hurst Internal Medicine Residency Program at Emory University School of Medicine in Atlanta. “I believe it’s an overall positive move, in terms of morale and work/life balance.”
Others disagree. Patient safety expert Lucian Leape, MD, adjunct professor at Harvard School of Public Health, decried that the ACGME rules did not apply to all residents, just those in their first year, and he rejected the assumption that one can learn to tolerate sleep deprivation.2 HM pioneer Bob Wachter, MD, MHM, professor, chief of the division of hospital medicine, and chief of the medical service at University of California San Francisco Medical Center, agrees the work-hour restrictions are here to stay—and are a good thing. At his blog Wachter’s World, he recently posted that research shows “prolonged wakefulness” degrades cognitive skills, and equates to a blood-alcohol level of 0.1, or “legally drunk in every state.”
“Even without strong evidence one way or the other, if it has improved safety, I think 16 hours is probably right for interns, and 24-plus-four hours for second-year residents and above. It’s the ACGME’s best guess, to date, of the right balance,” says Jeffrey G. Wiese, MD, SFHM, FACP, associate dean for graduate medical education, director of the internal medicine program at Tulane University School of Medicine in New Orleans, and former SHM president. “It’s no huge intellectual stretch to say that someone who’s been up for 32 hours is not in the best condition to make optimal patient-care decisions.”
While preserving optimal cognitive abilities is important for all physicians, ACGME’s new work-hour limits matter even more to specialties like surgery, which rely heavily on manual dexterity skills, Dr. Wiese suggests. Ironically, surgical specialty societies have been among the most critical of the new limits.
“My surgical colleagues have been particularly vocal critics of the new work-hour limit,” says Dr. Dressler, noting that Emory’s residency programs are smaller and have greater challenges in adjusting for fewer work hours as they rely more heavily on residents for certain clinical tasks than do other specialties.
Ideally, Dr. Wiese maintains, resident duty-hours should be increased gradually based on progressively demonstrated levels of ability and competence by individual residents, regardless of program year. Such milestone-based accountability is supported by SHM as well as several other medical societies.
Continuity of Care
A downside to the work-hour limit is its potential to disrupt both the continuity of care and the learning process, as fewer patients are likely to be followed by a single resident from admission to resolution of a case. Dr. Wachter, who is chair of the American Board of Internal Medicine (ABIM) and a former SHM president, acknowledges this sacrifice, noting that care teams at his hospital inherit nearly half their patients as handoffs from night admitters, and some never know handed-off patients as well as those they admitted themselves.
“In a system in which half the patients are cared for by two sets of doctors during these crucial stages [early assessment, data gathering, and initial patient response], neither group fully sees this arc play out, and their education suffers,” he wrote on his blog.
New limits means “less flexibility,” says Dr. Dressler, “and it can become a hindrance to completing the work-up of a patient—like not being able to put a central line in at 8:30 p.m. ... Some trainees feel they have less continuity with their patients because of the shorter hours.”
—Jeffrey G. Wiese, MD, SFHM, FACP, associate dean, graduate medical education, director, internal medicine program, Tulane University School of Medicine, New Orleans, former SHM president
Thoughtful management is required to minimize schedule disruption and maximize learning opportunities, he adds. “We’ve decided that our interns will have five overnight shifts over 10 days as part of one of their 30-day rotations. It’s important that interns get overnight experience before their second year,” Dr. Dressler says. “We had to incorporate three interns per team instead of two. Any way you slice it, you’re going to need additional manpower from other sources.”
Such workforce issues are hot topics in teaching hospitals across the country, Dr. Wiese says. He also warns that using hospitalists solely as “resident extenders” is not sustainable. “If an academic program is using hospitalists as stopgap labor, they do so at the risk of accelerating burnout,” he says.
Hospitalist Opportunity
Hospitalists can and should, however, take full advantage of a much-needed niche that the new ACGME regulations have called attention to: the need for expertise in minimizing patient-care disruptions resulting from more frequent patient handoffs.
“Hospitalists have an opportunity to get more involved in residency training programs by sharing their knowledge of effective patient handoff protocols,” Dr. Dressler says. “Hospitalists have treaded those waters for over a decade. We’ve learned a lot about structuring handoff information effectively, and we can inform training programs about those issues.”
The increased urgency of effective handoff management might even lead to an increased investment in HM programs, Dr. Dressler believes. “The expectation, of course, is that we are able to demonstrate effective patient handoffs—and show that we’re ‘walking the walk,’ and not just talking about it,” he says.
Christopher Guadagnino is a freelance medical writer in Philadelphia.
References
- Institute of Medicine. Resident duty hours: enhancing sleep, supervision, and safety. Institute of Medicine website. Available at: http://www.nap.edu/catalog.php?record_id=12508#toc. Accessed May 1, 2012.
- Krups C. Residency programs scramble to adopt changes. American Medical News website. Available at: http://www.ama-assn.org/amednews/2011/07/11/prsa0711.htm#s1. Accessed May 1, 2012.
CER: Friend or Foe?
A key engine of healthcare reform is poised to accelerate, with the potential to improve clinical decision-making and care quality, curtail inappropriate utilization of ineffective treatments, and lower costs. Comparative-effectiveness research (CER), until now, has received relatively meager funding and has occupied a relatively low profile among policymakers, clinicians, and the public.
With a $1.1 billion injection from the American Recovery and Reinvestment Act of 2009 (better known as the “stimulus”) and dedicated funding mandated by the Affordable Care Act, a new national center dedicated to CER—the Patient-Centered Outcomes Research Institute (PCORI)—has recently released a draft of its national priorities and is mobilizing a national research agenda for CER.1
Demonized by critics as a prelude to coverage denials, healthcare rationing, and intrusion upon physicians’ clinical autonomy, CER is reconstituting its reputation as a non-coercive yet powerful tool to reduce uncertainty about which healthcare options work best for which patients, and to encourage adoption of care practices that are truly effective.
“I practice on weekends as a pediatric hospitalist, and it is still far too common to encounter a case for which we don’t have good, evidence-based guidance—such as whether surgery or medical management is best for a neurologically impaired child presenting with aspiration and gastroesophageal reflux disease,” says Patrick Conway, MD, MSc, SFHM, chief medical officer of the Center for Medicare & Medicaid Services (CMS) and director of its Office of Clinical Standards and Quality.
SHM strongly supported the creation of PCORI during the health reform debate, and hospitalists have important opportunities to be part of the nation’s CER agenda, as well as key beneficiaries of its results, according to Dr. Conway.
Efficacy vs. Effectiveness
While the traditional “gold standard” of clinical research is the randomized controlled trial, its focus on efficacy typically involves comparing some treatment to no treatment at all (a placebo), and requires highly controlled, ideal conditions, often with narrow patient-inclusion criteria. All of those requirements sacrifice generalizability to patients whom physicians encounter daily in clinical settings who often have multiple chronic conditions and comorbidities and might require multiple therapies, Dr. Conway says.
CER studies larger, more representative patient populations treated in real-world clinical circumstances, explains SHM Research Committee chairman David Meltzer, MD, PhD, FHM, who is a member of the PCORI’s Methodology Committee. “One of the big initial tasks of the PCORI is to produce a translation table of what research study designs—randomized controlled trials, head-to-head, observational studies, and others—can best answer which kinds of questions,” he says.
The PCORI’s ultimate goal, says Dr. Conway, is to enable better-informed decision-making between physicians and their patients by allowing for the “right treatments to the right patients at the right time.”
The Case for CER
The unrelenting reality of an unsustainable healthcare cost spiral that threatens to bankrupt the national economy might be changing the conversation about CER (see “PCORI: Built to Reject the Myth of Coercive Rationing,” at left). Add to that increasing gravitation by government and private insurers toward reimbursement models that reward providers for better outcomes, more efficient care, and evidence-based practices (and penalizes the opposite), and CER makes a lot of sense.
An estimated $158 billion to $226 billion in wasteful healthcare spending last year came from “subjecting patients to care that, according to sound science and the patients’ own preferences, cannot possibly help them—care rooted in outmoded habits, supply-driven behaviors, and ignoring science,” wrote former CMS administrator Donald Berwick, MD, MPP, and RAND researcher Andrew Hackbarth, MPhil.2
It appears as though physicians are becoming more receptive to their role as responsible stewards of finite healthcare resources, and are willing to abandon some common clinical practices that add little value to patient care when given credible evidence. In the recent Choosing Wisely campaign (www.ChoosingWisely.org), for example, nine medical specialty societies worked with the ABIM Foundation and Consumer Reports to publicize 45 tests and procedures—five from each society—that are commonly used in their field, but which evidence suggests might be unnecessary and inappropriate for many patients.
Physicians who in the past might have resisted traditional evidence-based guidelines as “cookie cutter” algorithms that “don’t apply to my particular patient” will find it harder to dismiss CER findings on that basis, Dr. Meltzer notes, because CER is designed at the outset to be relevant to specific subsets of patients in actual clinical settings.
Nevertheless, incentives will be required to drive rapid and widespread adoption of CER findings, Dr. Conway believes.
“Just creating evidence doesn’t create change,” he says. “Cycle time from research finding to implementation matters, and the typical 17 years [time lag from bench to bedside] is not going to cut it. We need to work with clinicians and patients to take new findings and implement them sooner.”
CMS already has selected some evidence-based process and outcome metrics for its value-based purchasing program. “As CER identifies new evidence-based process and outcome metrics, we could incorporate them,” Dr. Conway adds.
Private insurers could use CER findings when making coverage decisions for their health plans. By law, CMS is obligated to provide coverage to Medicare beneficiaries for healthcare services that are “reasonable and necessary,” and cannot exclude coverage based on the cost of services.
“CMS could use CER findings to make coverage determinations based on ineffectiveness, when there is compelling evidence that a service is ‘not reasonable and necessary,’” Dr. Conway states.
HM Opportunity
Dr. Conway says hospitalists are uniquely poised to seek funding for CER that builds upon several critically important topics, such as examining the best discharge planning processes and transition-of-care protocols for certain types of patients. Dr. Meltzer, who is chief of the section of hospital medicine at University of Chicago, says he is seeking funding for a study of alternative transfusion thresholds for older patients with anemia across different levels of patients’ functional status.
“That’s the type of patient-centered study that CER is especially equipped to handle,” Dr. Meltzer says.
CER promises to produce important evidence for clinical questions that hospitalists struggle with day to day, Dr. Conway says. “Hospitalists should take the lead in developing effective ways to disseminate those findings, to teach medical trainees about them, and to spearhead CER-based QI [quality improvement] implementation and tracking efforts at their institutions,” he adds.
Christopher Guadagnino is a freelance medical writer in Philadelphia.
References
- Patient-Centered Outcome Research Institute. Draft National Priorities for Research and Research Agenda, Version 1. Patient-Centered Outcome Research Institute website. Available at: http://interactive.snm.org/docs/PCORI-Draft-National-Priorities-and-Research-Agenda2.pdf. Accessed April 15, 2012.
- Berwick DM, Hackbarth AD. Eliminating waste in U.S. health care. Journal of the American Medical Association website. Available at: http://jama.ama-assn.org/content/307/14/1513.full. Accessed April 15, 2012.
- Selby JV. The researcher-in-chief at the Patient-Centered Outcomes Research Institute. Inverview by Susan Dentzer. Health Aff (Millwood). 2011;30(12):2252-2258.
A key engine of healthcare reform is poised to accelerate, with the potential to improve clinical decision-making and care quality, curtail inappropriate utilization of ineffective treatments, and lower costs. Comparative-effectiveness research (CER), until now, has received relatively meager funding and has occupied a relatively low profile among policymakers, clinicians, and the public.
With a $1.1 billion injection from the American Recovery and Reinvestment Act of 2009 (better known as the “stimulus”) and dedicated funding mandated by the Affordable Care Act, a new national center dedicated to CER—the Patient-Centered Outcomes Research Institute (PCORI)—has recently released a draft of its national priorities and is mobilizing a national research agenda for CER.1
Demonized by critics as a prelude to coverage denials, healthcare rationing, and intrusion upon physicians’ clinical autonomy, CER is reconstituting its reputation as a non-coercive yet powerful tool to reduce uncertainty about which healthcare options work best for which patients, and to encourage adoption of care practices that are truly effective.
“I practice on weekends as a pediatric hospitalist, and it is still far too common to encounter a case for which we don’t have good, evidence-based guidance—such as whether surgery or medical management is best for a neurologically impaired child presenting with aspiration and gastroesophageal reflux disease,” says Patrick Conway, MD, MSc, SFHM, chief medical officer of the Center for Medicare & Medicaid Services (CMS) and director of its Office of Clinical Standards and Quality.
SHM strongly supported the creation of PCORI during the health reform debate, and hospitalists have important opportunities to be part of the nation’s CER agenda, as well as key beneficiaries of its results, according to Dr. Conway.
Efficacy vs. Effectiveness
While the traditional “gold standard” of clinical research is the randomized controlled trial, its focus on efficacy typically involves comparing some treatment to no treatment at all (a placebo), and requires highly controlled, ideal conditions, often with narrow patient-inclusion criteria. All of those requirements sacrifice generalizability to patients whom physicians encounter daily in clinical settings who often have multiple chronic conditions and comorbidities and might require multiple therapies, Dr. Conway says.
CER studies larger, more representative patient populations treated in real-world clinical circumstances, explains SHM Research Committee chairman David Meltzer, MD, PhD, FHM, who is a member of the PCORI’s Methodology Committee. “One of the big initial tasks of the PCORI is to produce a translation table of what research study designs—randomized controlled trials, head-to-head, observational studies, and others—can best answer which kinds of questions,” he says.
The PCORI’s ultimate goal, says Dr. Conway, is to enable better-informed decision-making between physicians and their patients by allowing for the “right treatments to the right patients at the right time.”
The Case for CER
The unrelenting reality of an unsustainable healthcare cost spiral that threatens to bankrupt the national economy might be changing the conversation about CER (see “PCORI: Built to Reject the Myth of Coercive Rationing,” at left). Add to that increasing gravitation by government and private insurers toward reimbursement models that reward providers for better outcomes, more efficient care, and evidence-based practices (and penalizes the opposite), and CER makes a lot of sense.
An estimated $158 billion to $226 billion in wasteful healthcare spending last year came from “subjecting patients to care that, according to sound science and the patients’ own preferences, cannot possibly help them—care rooted in outmoded habits, supply-driven behaviors, and ignoring science,” wrote former CMS administrator Donald Berwick, MD, MPP, and RAND researcher Andrew Hackbarth, MPhil.2
It appears as though physicians are becoming more receptive to their role as responsible stewards of finite healthcare resources, and are willing to abandon some common clinical practices that add little value to patient care when given credible evidence. In the recent Choosing Wisely campaign (www.ChoosingWisely.org), for example, nine medical specialty societies worked with the ABIM Foundation and Consumer Reports to publicize 45 tests and procedures—five from each society—that are commonly used in their field, but which evidence suggests might be unnecessary and inappropriate for many patients.
Physicians who in the past might have resisted traditional evidence-based guidelines as “cookie cutter” algorithms that “don’t apply to my particular patient” will find it harder to dismiss CER findings on that basis, Dr. Meltzer notes, because CER is designed at the outset to be relevant to specific subsets of patients in actual clinical settings.
Nevertheless, incentives will be required to drive rapid and widespread adoption of CER findings, Dr. Conway believes.
“Just creating evidence doesn’t create change,” he says. “Cycle time from research finding to implementation matters, and the typical 17 years [time lag from bench to bedside] is not going to cut it. We need to work with clinicians and patients to take new findings and implement them sooner.”
CMS already has selected some evidence-based process and outcome metrics for its value-based purchasing program. “As CER identifies new evidence-based process and outcome metrics, we could incorporate them,” Dr. Conway adds.
Private insurers could use CER findings when making coverage decisions for their health plans. By law, CMS is obligated to provide coverage to Medicare beneficiaries for healthcare services that are “reasonable and necessary,” and cannot exclude coverage based on the cost of services.
“CMS could use CER findings to make coverage determinations based on ineffectiveness, when there is compelling evidence that a service is ‘not reasonable and necessary,’” Dr. Conway states.
HM Opportunity
Dr. Conway says hospitalists are uniquely poised to seek funding for CER that builds upon several critically important topics, such as examining the best discharge planning processes and transition-of-care protocols for certain types of patients. Dr. Meltzer, who is chief of the section of hospital medicine at University of Chicago, says he is seeking funding for a study of alternative transfusion thresholds for older patients with anemia across different levels of patients’ functional status.
“That’s the type of patient-centered study that CER is especially equipped to handle,” Dr. Meltzer says.
CER promises to produce important evidence for clinical questions that hospitalists struggle with day to day, Dr. Conway says. “Hospitalists should take the lead in developing effective ways to disseminate those findings, to teach medical trainees about them, and to spearhead CER-based QI [quality improvement] implementation and tracking efforts at their institutions,” he adds.
Christopher Guadagnino is a freelance medical writer in Philadelphia.
References
- Patient-Centered Outcome Research Institute. Draft National Priorities for Research and Research Agenda, Version 1. Patient-Centered Outcome Research Institute website. Available at: http://interactive.snm.org/docs/PCORI-Draft-National-Priorities-and-Research-Agenda2.pdf. Accessed April 15, 2012.
- Berwick DM, Hackbarth AD. Eliminating waste in U.S. health care. Journal of the American Medical Association website. Available at: http://jama.ama-assn.org/content/307/14/1513.full. Accessed April 15, 2012.
- Selby JV. The researcher-in-chief at the Patient-Centered Outcomes Research Institute. Inverview by Susan Dentzer. Health Aff (Millwood). 2011;30(12):2252-2258.
A key engine of healthcare reform is poised to accelerate, with the potential to improve clinical decision-making and care quality, curtail inappropriate utilization of ineffective treatments, and lower costs. Comparative-effectiveness research (CER), until now, has received relatively meager funding and has occupied a relatively low profile among policymakers, clinicians, and the public.
With a $1.1 billion injection from the American Recovery and Reinvestment Act of 2009 (better known as the “stimulus”) and dedicated funding mandated by the Affordable Care Act, a new national center dedicated to CER—the Patient-Centered Outcomes Research Institute (PCORI)—has recently released a draft of its national priorities and is mobilizing a national research agenda for CER.1
Demonized by critics as a prelude to coverage denials, healthcare rationing, and intrusion upon physicians’ clinical autonomy, CER is reconstituting its reputation as a non-coercive yet powerful tool to reduce uncertainty about which healthcare options work best for which patients, and to encourage adoption of care practices that are truly effective.
“I practice on weekends as a pediatric hospitalist, and it is still far too common to encounter a case for which we don’t have good, evidence-based guidance—such as whether surgery or medical management is best for a neurologically impaired child presenting with aspiration and gastroesophageal reflux disease,” says Patrick Conway, MD, MSc, SFHM, chief medical officer of the Center for Medicare & Medicaid Services (CMS) and director of its Office of Clinical Standards and Quality.
SHM strongly supported the creation of PCORI during the health reform debate, and hospitalists have important opportunities to be part of the nation’s CER agenda, as well as key beneficiaries of its results, according to Dr. Conway.
Efficacy vs. Effectiveness
While the traditional “gold standard” of clinical research is the randomized controlled trial, its focus on efficacy typically involves comparing some treatment to no treatment at all (a placebo), and requires highly controlled, ideal conditions, often with narrow patient-inclusion criteria. All of those requirements sacrifice generalizability to patients whom physicians encounter daily in clinical settings who often have multiple chronic conditions and comorbidities and might require multiple therapies, Dr. Conway says.
CER studies larger, more representative patient populations treated in real-world clinical circumstances, explains SHM Research Committee chairman David Meltzer, MD, PhD, FHM, who is a member of the PCORI’s Methodology Committee. “One of the big initial tasks of the PCORI is to produce a translation table of what research study designs—randomized controlled trials, head-to-head, observational studies, and others—can best answer which kinds of questions,” he says.
The PCORI’s ultimate goal, says Dr. Conway, is to enable better-informed decision-making between physicians and their patients by allowing for the “right treatments to the right patients at the right time.”
The Case for CER
The unrelenting reality of an unsustainable healthcare cost spiral that threatens to bankrupt the national economy might be changing the conversation about CER (see “PCORI: Built to Reject the Myth of Coercive Rationing,” at left). Add to that increasing gravitation by government and private insurers toward reimbursement models that reward providers for better outcomes, more efficient care, and evidence-based practices (and penalizes the opposite), and CER makes a lot of sense.
An estimated $158 billion to $226 billion in wasteful healthcare spending last year came from “subjecting patients to care that, according to sound science and the patients’ own preferences, cannot possibly help them—care rooted in outmoded habits, supply-driven behaviors, and ignoring science,” wrote former CMS administrator Donald Berwick, MD, MPP, and RAND researcher Andrew Hackbarth, MPhil.2
It appears as though physicians are becoming more receptive to their role as responsible stewards of finite healthcare resources, and are willing to abandon some common clinical practices that add little value to patient care when given credible evidence. In the recent Choosing Wisely campaign (www.ChoosingWisely.org), for example, nine medical specialty societies worked with the ABIM Foundation and Consumer Reports to publicize 45 tests and procedures—five from each society—that are commonly used in their field, but which evidence suggests might be unnecessary and inappropriate for many patients.
Physicians who in the past might have resisted traditional evidence-based guidelines as “cookie cutter” algorithms that “don’t apply to my particular patient” will find it harder to dismiss CER findings on that basis, Dr. Meltzer notes, because CER is designed at the outset to be relevant to specific subsets of patients in actual clinical settings.
Nevertheless, incentives will be required to drive rapid and widespread adoption of CER findings, Dr. Conway believes.
“Just creating evidence doesn’t create change,” he says. “Cycle time from research finding to implementation matters, and the typical 17 years [time lag from bench to bedside] is not going to cut it. We need to work with clinicians and patients to take new findings and implement them sooner.”
CMS already has selected some evidence-based process and outcome metrics for its value-based purchasing program. “As CER identifies new evidence-based process and outcome metrics, we could incorporate them,” Dr. Conway adds.
Private insurers could use CER findings when making coverage decisions for their health plans. By law, CMS is obligated to provide coverage to Medicare beneficiaries for healthcare services that are “reasonable and necessary,” and cannot exclude coverage based on the cost of services.
“CMS could use CER findings to make coverage determinations based on ineffectiveness, when there is compelling evidence that a service is ‘not reasonable and necessary,’” Dr. Conway states.
HM Opportunity
Dr. Conway says hospitalists are uniquely poised to seek funding for CER that builds upon several critically important topics, such as examining the best discharge planning processes and transition-of-care protocols for certain types of patients. Dr. Meltzer, who is chief of the section of hospital medicine at University of Chicago, says he is seeking funding for a study of alternative transfusion thresholds for older patients with anemia across different levels of patients’ functional status.
“That’s the type of patient-centered study that CER is especially equipped to handle,” Dr. Meltzer says.
CER promises to produce important evidence for clinical questions that hospitalists struggle with day to day, Dr. Conway says. “Hospitalists should take the lead in developing effective ways to disseminate those findings, to teach medical trainees about them, and to spearhead CER-based QI [quality improvement] implementation and tracking efforts at their institutions,” he adds.
Christopher Guadagnino is a freelance medical writer in Philadelphia.
References
- Patient-Centered Outcome Research Institute. Draft National Priorities for Research and Research Agenda, Version 1. Patient-Centered Outcome Research Institute website. Available at: http://interactive.snm.org/docs/PCORI-Draft-National-Priorities-and-Research-Agenda2.pdf. Accessed April 15, 2012.
- Berwick DM, Hackbarth AD. Eliminating waste in U.S. health care. Journal of the American Medical Association website. Available at: http://jama.ama-assn.org/content/307/14/1513.full. Accessed April 15, 2012.
- Selby JV. The researcher-in-chief at the Patient-Centered Outcomes Research Institute. Inverview by Susan Dentzer. Health Aff (Millwood). 2011;30(12):2252-2258.
Partnership for Patients: CMS’ Ambitious Program for Patient Safety Improvement
—Katharine Luther, RN, MPM, vice president of hospital portfolio planning and administration, Institute for Healthcare Improvement
Last April, the Centers for Medicare & Medicaid Services (CMS) unveiled “Partnership for Patients,” a landmark event in the patient safety movement that put a national spotlight on the continuing need to improve healthcare safety and quality. A year later, the initiative is getting off the ground, attempting to tackle ambitious goals and overcome methodological hurdles in a very tight timeframe.
Partnership for Patients is a $1 billion, nationwide educational collaborative in which participants pledge that they will try to achieve two things by the end of 2013: Reduce the incidence of preventable hospital-acquired conditions by 40% compared to 2010, and decrease preventable complications during transitions of care to reduce hospital readmissions by 20% compared with 2010.
More than 3,000 hospitals and 2,000 physician and nursing organizations have signed the pledge, and CMS recently awarded contracts to 26 Hospital Engagement Networks (HENs)—state, regional, and national hospitals and health systems that will serve as mobile classrooms that mentor as they implement new intervention strategies, track progress on quality improvement (QI), and develop learning collaboratives to spread effective interventions. CMS also has contracted with outside firms to create patient safety training materials, engage with patients and families to foster more patient-centered care, and evaluate the impact and effectiveness of the initiative.
SHM was one of the first physician groups to sign on to the initiative’s pledge of support, and both its Project BOOST (to reduce preventable readmissions) and its VTE Resource Room (to prevent hospital-acquired venous thromboembolism) are among the resources it is making available to the initiative’s HENs, says Wendy Nickel, MPH, associate vice president of SHM’s Center for Hospital Innovation and Improvement.
Worthy Goals
Despite success stories at some institutions in recent years, patient safety improvement still has far to go at U.S. hospitals. Currently, about 1 in every 20 patients acquires an infection in the hospital, 1 in 7 Medicare patients is harmed in the course of their hospital care, and nearly 1 in 5 is readmitted within 30 days of discharge. CMS estimates that meeting the goals of Partnership for Patients would mean more than 60,000 lives saved over the next three years and over 1.6 million patients spared a preventable complication requiring re-hospitalization within 30 days of discharge—all of which could save Medicare $50 billion over the next 10 years.1
Formidable Obstacles
While the initiative’s goals are certainly worthy, it remains to be seen how prepared hospitals are to achieve them, and whether available metrics are up to the task.
“The initiative is a positive step to improve collaboration among government, communities, and hospital sites in service of better patient care and safety—and so it deserves our endorsement,” says Greg Maynard, MD, MSc, SFHM, health sciences professor of medicine at the University of California at San Diego, director of the UC San Diego Center for Innovation and Improvement Science, and senior vice president of SHM’s Center for Hospital Innovation and Improvement. “But it’s an open question how successful it will be, since it offers no monetary piece of the pie to participating hospitals, and no financial penalties for failing to achieve its goals. The whole project feels rushed, for a major initiative like this, with such ambitious goals.”
The primary “carrot” the initiative offers hospitals, Dr. Maynard notes, is access to patient safety improvement expertise and resources that they would otherwise have to purchase on their own, including training materials, implementation guides, webinars, and site visits by HEN representatives.
As an indirect inducement to participate, CMS’ Hospital Readmissions Reduction Program begins this October and will penalize hospitals by as much as 1% of their total Medicare billings (increasing to 3% in 2015) for high rates of readmissions related to heart attack, heart failure, and pneumonia. CMS’ Value-Based Purchasing program also continues to reward and punish hospitals for their performance on core measures and patient satisfaction, with more metrics forthcoming.
Metric Morass
A major challenge to the success of Partnership for Patients will be the ability to formulate and share reliable, uniform patient safety metrics across institutions. The initiative gives each of the 26 HENs the flexibility to tailor their activities to the sites they are mentoring, and there is no clear way of making standardized comparisons of hospital performance across the HENs, Dr. Maynard says.
Metric validity is a crucial component of any QI initiative. And yet, the ability to reliably measure patient harm/adverse event rates at hospitals—and therefore achieving a solid “denominator” baseline with which to track progress—remains elusive. In a recent report, the U.S. Department of Health and Human Services’ Office of the Inspector General noted that hospital incident reporting systems capture only an estimated 14% of the patient harm events experienced by Medicare patients, reporting requirements remain unclear, and hospital staff continue to harbor misperceptions about what constitutes patient harm.2
In what almost sounds like “back to the drawing board,” the report recommended that CMS and the Agency for Healthcare Research and Quality (AHRQ) collaborate to create and promote a list of potentially reportable events for hospitals to use, and that CMS provide guidance to accreditors regarding their assessments of hospital efforts to track and analyze events.
The problem is that voluntary incident reporting systems are only one tool for identifying patient harm. Typically, however, they miss many things that can harm patients and are grossly under-reported. As a result, they need to be used in conjunction with other data sources, such as hospital infection rates, daily safety rounding on hospital units, and patient chart sampling, says Katharine Luther, RN, MPM, the Institute for Healthcare Improvement’s vice president of hospital portfolio planning and administration.
Another excellent surveillance instrument for capturing a count of possible harm events is a Global Trigger Tool, which samples patient charts to identify aberrant lab values, drug dosages, and other untoward events that might indicate harm, even though they might not easily be recognized as harmful by hospital staff, Luther says.
Warranted Optimism
Despite its aggressive timeline and inherent methodological challenges, Luther says the Partnership for Patients will galvanize and focus hospitals’ patient safety improvement efforts and provide a much-needed framework for implementation.
“We know of organizations that have greatly reduced the incidence of pressure ulcers, and have gone for a year or more with no cases of ventilator-associated pneumonia or central-line-associated bloodstream infection (CLABSI),” Luther says. “Exemplars like these are out there, so it can be done. Partnership for Patients brings a spotlight and an energy to the issue that will last long beyond the 24 months of this program.”
Chris Guadagnino is a freelance medical writer in Philadelphia.
References
- CMS Fact Sheet. Hospital Engagement Networks: Connecting Hospitals to Improve Care. Centers for Medicare & Medicaid website. Available at: http://www.cms.gov/apps/media/press/factsheet.asp?Counter=4219&intNumPerPage=10&checkDate=&checkKey=&srchType=1&numDays=3500&srchOpt=0&srchData=&keywordType=All&chkNewsType=6&intPage=&showAll=&pYear=&year=&desc=&cboOrder=date. Accessed Feb. 12, 2012.
- HHS Office of Inspector General. Hospital Incident Reporting Systems Do Not Capture Most Patient Harm. Office of Inspector General website. Available at: http://oig.hhs.gov/oei/reports/oei-06-09-00091.pdf. Accessed Feb. 12, 2012.
—Katharine Luther, RN, MPM, vice president of hospital portfolio planning and administration, Institute for Healthcare Improvement
Last April, the Centers for Medicare & Medicaid Services (CMS) unveiled “Partnership for Patients,” a landmark event in the patient safety movement that put a national spotlight on the continuing need to improve healthcare safety and quality. A year later, the initiative is getting off the ground, attempting to tackle ambitious goals and overcome methodological hurdles in a very tight timeframe.
Partnership for Patients is a $1 billion, nationwide educational collaborative in which participants pledge that they will try to achieve two things by the end of 2013: Reduce the incidence of preventable hospital-acquired conditions by 40% compared to 2010, and decrease preventable complications during transitions of care to reduce hospital readmissions by 20% compared with 2010.
More than 3,000 hospitals and 2,000 physician and nursing organizations have signed the pledge, and CMS recently awarded contracts to 26 Hospital Engagement Networks (HENs)—state, regional, and national hospitals and health systems that will serve as mobile classrooms that mentor as they implement new intervention strategies, track progress on quality improvement (QI), and develop learning collaboratives to spread effective interventions. CMS also has contracted with outside firms to create patient safety training materials, engage with patients and families to foster more patient-centered care, and evaluate the impact and effectiveness of the initiative.
SHM was one of the first physician groups to sign on to the initiative’s pledge of support, and both its Project BOOST (to reduce preventable readmissions) and its VTE Resource Room (to prevent hospital-acquired venous thromboembolism) are among the resources it is making available to the initiative’s HENs, says Wendy Nickel, MPH, associate vice president of SHM’s Center for Hospital Innovation and Improvement.
Worthy Goals
Despite success stories at some institutions in recent years, patient safety improvement still has far to go at U.S. hospitals. Currently, about 1 in every 20 patients acquires an infection in the hospital, 1 in 7 Medicare patients is harmed in the course of their hospital care, and nearly 1 in 5 is readmitted within 30 days of discharge. CMS estimates that meeting the goals of Partnership for Patients would mean more than 60,000 lives saved over the next three years and over 1.6 million patients spared a preventable complication requiring re-hospitalization within 30 days of discharge—all of which could save Medicare $50 billion over the next 10 years.1
Formidable Obstacles
While the initiative’s goals are certainly worthy, it remains to be seen how prepared hospitals are to achieve them, and whether available metrics are up to the task.
“The initiative is a positive step to improve collaboration among government, communities, and hospital sites in service of better patient care and safety—and so it deserves our endorsement,” says Greg Maynard, MD, MSc, SFHM, health sciences professor of medicine at the University of California at San Diego, director of the UC San Diego Center for Innovation and Improvement Science, and senior vice president of SHM’s Center for Hospital Innovation and Improvement. “But it’s an open question how successful it will be, since it offers no monetary piece of the pie to participating hospitals, and no financial penalties for failing to achieve its goals. The whole project feels rushed, for a major initiative like this, with such ambitious goals.”
The primary “carrot” the initiative offers hospitals, Dr. Maynard notes, is access to patient safety improvement expertise and resources that they would otherwise have to purchase on their own, including training materials, implementation guides, webinars, and site visits by HEN representatives.
As an indirect inducement to participate, CMS’ Hospital Readmissions Reduction Program begins this October and will penalize hospitals by as much as 1% of their total Medicare billings (increasing to 3% in 2015) for high rates of readmissions related to heart attack, heart failure, and pneumonia. CMS’ Value-Based Purchasing program also continues to reward and punish hospitals for their performance on core measures and patient satisfaction, with more metrics forthcoming.
Metric Morass
A major challenge to the success of Partnership for Patients will be the ability to formulate and share reliable, uniform patient safety metrics across institutions. The initiative gives each of the 26 HENs the flexibility to tailor their activities to the sites they are mentoring, and there is no clear way of making standardized comparisons of hospital performance across the HENs, Dr. Maynard says.
Metric validity is a crucial component of any QI initiative. And yet, the ability to reliably measure patient harm/adverse event rates at hospitals—and therefore achieving a solid “denominator” baseline with which to track progress—remains elusive. In a recent report, the U.S. Department of Health and Human Services’ Office of the Inspector General noted that hospital incident reporting systems capture only an estimated 14% of the patient harm events experienced by Medicare patients, reporting requirements remain unclear, and hospital staff continue to harbor misperceptions about what constitutes patient harm.2
In what almost sounds like “back to the drawing board,” the report recommended that CMS and the Agency for Healthcare Research and Quality (AHRQ) collaborate to create and promote a list of potentially reportable events for hospitals to use, and that CMS provide guidance to accreditors regarding their assessments of hospital efforts to track and analyze events.
The problem is that voluntary incident reporting systems are only one tool for identifying patient harm. Typically, however, they miss many things that can harm patients and are grossly under-reported. As a result, they need to be used in conjunction with other data sources, such as hospital infection rates, daily safety rounding on hospital units, and patient chart sampling, says Katharine Luther, RN, MPM, the Institute for Healthcare Improvement’s vice president of hospital portfolio planning and administration.
Another excellent surveillance instrument for capturing a count of possible harm events is a Global Trigger Tool, which samples patient charts to identify aberrant lab values, drug dosages, and other untoward events that might indicate harm, even though they might not easily be recognized as harmful by hospital staff, Luther says.
Warranted Optimism
Despite its aggressive timeline and inherent methodological challenges, Luther says the Partnership for Patients will galvanize and focus hospitals’ patient safety improvement efforts and provide a much-needed framework for implementation.
“We know of organizations that have greatly reduced the incidence of pressure ulcers, and have gone for a year or more with no cases of ventilator-associated pneumonia or central-line-associated bloodstream infection (CLABSI),” Luther says. “Exemplars like these are out there, so it can be done. Partnership for Patients brings a spotlight and an energy to the issue that will last long beyond the 24 months of this program.”
Chris Guadagnino is a freelance medical writer in Philadelphia.
References
- CMS Fact Sheet. Hospital Engagement Networks: Connecting Hospitals to Improve Care. Centers for Medicare & Medicaid website. Available at: http://www.cms.gov/apps/media/press/factsheet.asp?Counter=4219&intNumPerPage=10&checkDate=&checkKey=&srchType=1&numDays=3500&srchOpt=0&srchData=&keywordType=All&chkNewsType=6&intPage=&showAll=&pYear=&year=&desc=&cboOrder=date. Accessed Feb. 12, 2012.
- HHS Office of Inspector General. Hospital Incident Reporting Systems Do Not Capture Most Patient Harm. Office of Inspector General website. Available at: http://oig.hhs.gov/oei/reports/oei-06-09-00091.pdf. Accessed Feb. 12, 2012.
—Katharine Luther, RN, MPM, vice president of hospital portfolio planning and administration, Institute for Healthcare Improvement
Last April, the Centers for Medicare & Medicaid Services (CMS) unveiled “Partnership for Patients,” a landmark event in the patient safety movement that put a national spotlight on the continuing need to improve healthcare safety and quality. A year later, the initiative is getting off the ground, attempting to tackle ambitious goals and overcome methodological hurdles in a very tight timeframe.
Partnership for Patients is a $1 billion, nationwide educational collaborative in which participants pledge that they will try to achieve two things by the end of 2013: Reduce the incidence of preventable hospital-acquired conditions by 40% compared to 2010, and decrease preventable complications during transitions of care to reduce hospital readmissions by 20% compared with 2010.
More than 3,000 hospitals and 2,000 physician and nursing organizations have signed the pledge, and CMS recently awarded contracts to 26 Hospital Engagement Networks (HENs)—state, regional, and national hospitals and health systems that will serve as mobile classrooms that mentor as they implement new intervention strategies, track progress on quality improvement (QI), and develop learning collaboratives to spread effective interventions. CMS also has contracted with outside firms to create patient safety training materials, engage with patients and families to foster more patient-centered care, and evaluate the impact and effectiveness of the initiative.
SHM was one of the first physician groups to sign on to the initiative’s pledge of support, and both its Project BOOST (to reduce preventable readmissions) and its VTE Resource Room (to prevent hospital-acquired venous thromboembolism) are among the resources it is making available to the initiative’s HENs, says Wendy Nickel, MPH, associate vice president of SHM’s Center for Hospital Innovation and Improvement.
Worthy Goals
Despite success stories at some institutions in recent years, patient safety improvement still has far to go at U.S. hospitals. Currently, about 1 in every 20 patients acquires an infection in the hospital, 1 in 7 Medicare patients is harmed in the course of their hospital care, and nearly 1 in 5 is readmitted within 30 days of discharge. CMS estimates that meeting the goals of Partnership for Patients would mean more than 60,000 lives saved over the next three years and over 1.6 million patients spared a preventable complication requiring re-hospitalization within 30 days of discharge—all of which could save Medicare $50 billion over the next 10 years.1
Formidable Obstacles
While the initiative’s goals are certainly worthy, it remains to be seen how prepared hospitals are to achieve them, and whether available metrics are up to the task.
“The initiative is a positive step to improve collaboration among government, communities, and hospital sites in service of better patient care and safety—and so it deserves our endorsement,” says Greg Maynard, MD, MSc, SFHM, health sciences professor of medicine at the University of California at San Diego, director of the UC San Diego Center for Innovation and Improvement Science, and senior vice president of SHM’s Center for Hospital Innovation and Improvement. “But it’s an open question how successful it will be, since it offers no monetary piece of the pie to participating hospitals, and no financial penalties for failing to achieve its goals. The whole project feels rushed, for a major initiative like this, with such ambitious goals.”
The primary “carrot” the initiative offers hospitals, Dr. Maynard notes, is access to patient safety improvement expertise and resources that they would otherwise have to purchase on their own, including training materials, implementation guides, webinars, and site visits by HEN representatives.
As an indirect inducement to participate, CMS’ Hospital Readmissions Reduction Program begins this October and will penalize hospitals by as much as 1% of their total Medicare billings (increasing to 3% in 2015) for high rates of readmissions related to heart attack, heart failure, and pneumonia. CMS’ Value-Based Purchasing program also continues to reward and punish hospitals for their performance on core measures and patient satisfaction, with more metrics forthcoming.
Metric Morass
A major challenge to the success of Partnership for Patients will be the ability to formulate and share reliable, uniform patient safety metrics across institutions. The initiative gives each of the 26 HENs the flexibility to tailor their activities to the sites they are mentoring, and there is no clear way of making standardized comparisons of hospital performance across the HENs, Dr. Maynard says.
Metric validity is a crucial component of any QI initiative. And yet, the ability to reliably measure patient harm/adverse event rates at hospitals—and therefore achieving a solid “denominator” baseline with which to track progress—remains elusive. In a recent report, the U.S. Department of Health and Human Services’ Office of the Inspector General noted that hospital incident reporting systems capture only an estimated 14% of the patient harm events experienced by Medicare patients, reporting requirements remain unclear, and hospital staff continue to harbor misperceptions about what constitutes patient harm.2
In what almost sounds like “back to the drawing board,” the report recommended that CMS and the Agency for Healthcare Research and Quality (AHRQ) collaborate to create and promote a list of potentially reportable events for hospitals to use, and that CMS provide guidance to accreditors regarding their assessments of hospital efforts to track and analyze events.
The problem is that voluntary incident reporting systems are only one tool for identifying patient harm. Typically, however, they miss many things that can harm patients and are grossly under-reported. As a result, they need to be used in conjunction with other data sources, such as hospital infection rates, daily safety rounding on hospital units, and patient chart sampling, says Katharine Luther, RN, MPM, the Institute for Healthcare Improvement’s vice president of hospital portfolio planning and administration.
Another excellent surveillance instrument for capturing a count of possible harm events is a Global Trigger Tool, which samples patient charts to identify aberrant lab values, drug dosages, and other untoward events that might indicate harm, even though they might not easily be recognized as harmful by hospital staff, Luther says.
Warranted Optimism
Despite its aggressive timeline and inherent methodological challenges, Luther says the Partnership for Patients will galvanize and focus hospitals’ patient safety improvement efforts and provide a much-needed framework for implementation.
“We know of organizations that have greatly reduced the incidence of pressure ulcers, and have gone for a year or more with no cases of ventilator-associated pneumonia or central-line-associated bloodstream infection (CLABSI),” Luther says. “Exemplars like these are out there, so it can be done. Partnership for Patients brings a spotlight and an energy to the issue that will last long beyond the 24 months of this program.”
Chris Guadagnino is a freelance medical writer in Philadelphia.
References
- CMS Fact Sheet. Hospital Engagement Networks: Connecting Hospitals to Improve Care. Centers for Medicare & Medicaid website. Available at: http://www.cms.gov/apps/media/press/factsheet.asp?Counter=4219&intNumPerPage=10&checkDate=&checkKey=&srchType=1&numDays=3500&srchOpt=0&srchData=&keywordType=All&chkNewsType=6&intPage=&showAll=&pYear=&year=&desc=&cboOrder=date. Accessed Feb. 12, 2012.
- HHS Office of Inspector General. Hospital Incident Reporting Systems Do Not Capture Most Patient Harm. Office of Inspector General website. Available at: http://oig.hhs.gov/oei/reports/oei-06-09-00091.pdf. Accessed Feb. 12, 2012.
Massachusetts Healthcare Law Highlights Implications for National Healthcare Reform
Next month marks the sixth anniversary of former Massachusetts governor Mitt Romney’s signing into law a health insurance reform bill that brought near-universal coverage to the state’s residents. The Massachusetts experience represents a microcosm of what might be expected on a national scale with the Affordable Care Act (ACA): success in covering the uninsured, but persistent access and cost challenges that can only be overcome with fundamental payment reform.
“There is more going on in Massachusetts than anywhere else in the country, by far—in terms of coverage, delivery, and finance reform of healthcare,” says Stuart H. Altman, PhD, professor of national health policy at Brandeis University in Waltham, Mass. “The state’s example sends the positive message that the healthcare delivery system can be improved, but it takes time. Massachusetts is ahead of most states.”
Positives & Negatives
The Massachusetts law expands Medicaid enrollment to those earning up to 300% of the federal poverty level; offers state-subsidized commercial health insurance coverage to all other uninsured citizens; and allows young adults to remain on a parent’s plan until age 25. The law also mandates that employers with more than 10 employees offer subsidized health insurance coverage, and that every state resident over 18 purchase coverage or face tax penalties.
—Stuart H. Altman, PhD, professor of national health policy, Brandeis University, Waltham, Mass.
The law has brought coverage to nearly 412,000 previously uninsured residents (as of December 2010, the latest figures available), and less than 2% of residents remain uninsured—down from about 10% before the law was enacted.1
The law has not constrained the cost of healthcare in Massachusetts, which remains among the most expensive in the nation, and which current Massachusetts Gov. Deval Patrick acknowledges is continuing to rise at an unsustainable rate. A bill before the state legislature would give the governor the authority to review reimbursement contracts, to determine whether the fees paid by insurers to providers are appropriate, before approving insurance premium rates.
More surprising are the serious healthcare access challenges that persist in the state despite nearly universal health insurance coverage. The Massachusetts Medical Society outlined these challenges in a December 2011 white paper (see “Access Problems Persist Despite Insurance,” left).1
One of the biggest challenges the state faces is a dearth of primary-care physicians (PCPs). “One of the biggest lessons learned is that insurance expansion did not lead to better access,” observes Winthrop F. Whitcomb, MD, MHM, medical director of Healthcare Quality at Baystate Medical Center in Springfield, Mass., and co-founder of SHM. “Medicaid is a loss-leader and does not pay enough to cover the cost of running a medical practice. Expanding Medicaid may actually make access worse if primary-care physicians opt out of it.”
Insurance reform has not made it any easier for a hospitalist to find a PCP for a patient who comes to the hospital without one, Dr. Whitcomb says, or to discharge a patient to a long-term or post-acute-care setting that their insurance covers inadequately, if at all.
“We do continue to see ED visits and hospital admissions that would have been preventable had the patient seen a PCP first,” says SHM President Joseph Ming Wah Li, MD, SFHM, director of hospital medicine at Beth Israel Deaconess Medical Center in Boston.
Dr. Li says his group has experienced difficulties getting patients hooked up with timely and appropriate post-discharge follow-up care because of packed PCP schedules. In response, they developed a hospitalist-run, post-discharge clinic for outpatients to fill in the gap and provide their patients with the follow-up care they need.
“My hospitalists will manage the patient through their episode of care, regardless of whether they are an inpatient or outpatient, until their PCP is available,” Dr. Li says. “I would love to see our hospitalist-run, post-discharge clinic made obsolete by PCPs with available appointments.”
Fundamental Payment Reform
Access and cost problems like these have serious national implications, as Medicaid eligibility under the ACA is expected to grow by 16 million people by 2019, or roughly 25%. The Massachusetts experience suggests that decreasing financial barriers to care can raise other barriers, such as inadequate physician availability, and does nothing to address the 800-pound gorilla of spiraling costs.
Critics who dismiss the Massachusetts experiment as “doing nothing to control costs” miss the larger picture of innovation occurring in the state, however. Insurance reform was never intended to be the end of the story.
In response to a mandate to investigate reforming and restructuring the payment system as the next step in statewide healthcare reform, a Special Commission on the Health Care Payment System released recommendations in July 2009 (www.mass.gov/eohhs/docs/dhcfp/pc/final-report/final-report.pdf) that proposed that Massachusetts phase out fee-for-service reimbursement and replace it with an accountable-care approach that incorporated a global payment model combining elements of risk-adjusted capitation, pay-for-performance, evidence-based guidelines, and medical-home-style care coordination. Although a bill to accelerate statewide implementation of the model awaits a vote in the state legislature, the private health insurance market is well into the game.
Blue Cross Blue Shield of Massachusetts has been using a version of the model (known as the “alternative quality contract”) since 2009, with the goal of reducing healthcare cost growth by half over five years by holding providers accountable for cost and quality, and encouraging the most appropriate treatments by the right kind of providers in the most appropriate settings. Participating hospital and physician groups receive a monthly global fee for each patient (adjusted annually for patient health status and inflation) in return for providing them with all the preventive, primary, specialty, hospital, and follow-up care they need. Providers have the incentive to reduce inefficiencies, and they can earn additional incentive payments for meeting or exceeding clinical performance measures tied to process, outcomes, and patient care experience.
More than a third of the insurer’s provider network is participating in this alternative quality contract program, and early results are promising. A recent Harvard Medical School study found that medical spending at the end of the first year was nearly 2% lower among physicians and hospitals participating in the program compared with those working under traditional fee-for-service contracts, largely the result of physicians changing referral patterns and shifting care to lower-cost facilities.2 Quality of care among participants was significantly higher than that of non-participants in the insurer’s network, especially for adults with chronic illness and for children.
Several major healthcare delivery systems in Massachusetts are taking the accountable-care model to the next level this year by participating in the Pioneer Accountable Care Organizations (ACO) initiative, which also replaces fee-for-service with global revenue sharing plus quality and care-coordination incentives.
Part of the reason that providers in Massachusetts and around the country have a genuine interest in testing global payments and other value-based models is that they fear the day when the government and private sectors say “We just don’t have the money” and exert draconian fee-for-service rate control, Altman maintains.
Hospitalist Impacts
Hospitalists could find their referral patterns shifted slightly under global payment arrangements—potentially seeing fewer consults for low-risk patients and seeing greater demand for their services for more medically complex patients, Dr. Whitcomb says. HM likely will be the most heavily involved in ACOs that cover the Medicare population, whose patients are of higher acuity and more frequently hospitalized.
When fee-for-service reimbursement ultimately does give way to alternative reimbursement models, such as global payments, effective team-based care will become paramount to ensure effective hospital discharges and that preventable readmissions are minimized, Dr. Li says. He urges hospitalists to prepare their programs to manage a sicker patient population, and to cultivate the strongest possible coordination and alignment with PCPs, discharge planning professionals, and outpatient providers of all sorts. That way, hospitalists will be positioned to leverage their value in a healthcare system that requires value.
Christopher Guadagnino is a freelance medical writer based in Philadelphia.
For SHM’s official position on issues like healthcare reform, value-based purchasing, and medical errors, visit www.hospitalmedicine.org/advocacy
Next month marks the sixth anniversary of former Massachusetts governor Mitt Romney’s signing into law a health insurance reform bill that brought near-universal coverage to the state’s residents. The Massachusetts experience represents a microcosm of what might be expected on a national scale with the Affordable Care Act (ACA): success in covering the uninsured, but persistent access and cost challenges that can only be overcome with fundamental payment reform.
“There is more going on in Massachusetts than anywhere else in the country, by far—in terms of coverage, delivery, and finance reform of healthcare,” says Stuart H. Altman, PhD, professor of national health policy at Brandeis University in Waltham, Mass. “The state’s example sends the positive message that the healthcare delivery system can be improved, but it takes time. Massachusetts is ahead of most states.”
Positives & Negatives
The Massachusetts law expands Medicaid enrollment to those earning up to 300% of the federal poverty level; offers state-subsidized commercial health insurance coverage to all other uninsured citizens; and allows young adults to remain on a parent’s plan until age 25. The law also mandates that employers with more than 10 employees offer subsidized health insurance coverage, and that every state resident over 18 purchase coverage or face tax penalties.
—Stuart H. Altman, PhD, professor of national health policy, Brandeis University, Waltham, Mass.
The law has brought coverage to nearly 412,000 previously uninsured residents (as of December 2010, the latest figures available), and less than 2% of residents remain uninsured—down from about 10% before the law was enacted.1
The law has not constrained the cost of healthcare in Massachusetts, which remains among the most expensive in the nation, and which current Massachusetts Gov. Deval Patrick acknowledges is continuing to rise at an unsustainable rate. A bill before the state legislature would give the governor the authority to review reimbursement contracts, to determine whether the fees paid by insurers to providers are appropriate, before approving insurance premium rates.
More surprising are the serious healthcare access challenges that persist in the state despite nearly universal health insurance coverage. The Massachusetts Medical Society outlined these challenges in a December 2011 white paper (see “Access Problems Persist Despite Insurance,” left).1
One of the biggest challenges the state faces is a dearth of primary-care physicians (PCPs). “One of the biggest lessons learned is that insurance expansion did not lead to better access,” observes Winthrop F. Whitcomb, MD, MHM, medical director of Healthcare Quality at Baystate Medical Center in Springfield, Mass., and co-founder of SHM. “Medicaid is a loss-leader and does not pay enough to cover the cost of running a medical practice. Expanding Medicaid may actually make access worse if primary-care physicians opt out of it.”
Insurance reform has not made it any easier for a hospitalist to find a PCP for a patient who comes to the hospital without one, Dr. Whitcomb says, or to discharge a patient to a long-term or post-acute-care setting that their insurance covers inadequately, if at all.
“We do continue to see ED visits and hospital admissions that would have been preventable had the patient seen a PCP first,” says SHM President Joseph Ming Wah Li, MD, SFHM, director of hospital medicine at Beth Israel Deaconess Medical Center in Boston.
Dr. Li says his group has experienced difficulties getting patients hooked up with timely and appropriate post-discharge follow-up care because of packed PCP schedules. In response, they developed a hospitalist-run, post-discharge clinic for outpatients to fill in the gap and provide their patients with the follow-up care they need.
“My hospitalists will manage the patient through their episode of care, regardless of whether they are an inpatient or outpatient, until their PCP is available,” Dr. Li says. “I would love to see our hospitalist-run, post-discharge clinic made obsolete by PCPs with available appointments.”
Fundamental Payment Reform
Access and cost problems like these have serious national implications, as Medicaid eligibility under the ACA is expected to grow by 16 million people by 2019, or roughly 25%. The Massachusetts experience suggests that decreasing financial barriers to care can raise other barriers, such as inadequate physician availability, and does nothing to address the 800-pound gorilla of spiraling costs.
Critics who dismiss the Massachusetts experiment as “doing nothing to control costs” miss the larger picture of innovation occurring in the state, however. Insurance reform was never intended to be the end of the story.
In response to a mandate to investigate reforming and restructuring the payment system as the next step in statewide healthcare reform, a Special Commission on the Health Care Payment System released recommendations in July 2009 (www.mass.gov/eohhs/docs/dhcfp/pc/final-report/final-report.pdf) that proposed that Massachusetts phase out fee-for-service reimbursement and replace it with an accountable-care approach that incorporated a global payment model combining elements of risk-adjusted capitation, pay-for-performance, evidence-based guidelines, and medical-home-style care coordination. Although a bill to accelerate statewide implementation of the model awaits a vote in the state legislature, the private health insurance market is well into the game.
Blue Cross Blue Shield of Massachusetts has been using a version of the model (known as the “alternative quality contract”) since 2009, with the goal of reducing healthcare cost growth by half over five years by holding providers accountable for cost and quality, and encouraging the most appropriate treatments by the right kind of providers in the most appropriate settings. Participating hospital and physician groups receive a monthly global fee for each patient (adjusted annually for patient health status and inflation) in return for providing them with all the preventive, primary, specialty, hospital, and follow-up care they need. Providers have the incentive to reduce inefficiencies, and they can earn additional incentive payments for meeting or exceeding clinical performance measures tied to process, outcomes, and patient care experience.
More than a third of the insurer’s provider network is participating in this alternative quality contract program, and early results are promising. A recent Harvard Medical School study found that medical spending at the end of the first year was nearly 2% lower among physicians and hospitals participating in the program compared with those working under traditional fee-for-service contracts, largely the result of physicians changing referral patterns and shifting care to lower-cost facilities.2 Quality of care among participants was significantly higher than that of non-participants in the insurer’s network, especially for adults with chronic illness and for children.
Several major healthcare delivery systems in Massachusetts are taking the accountable-care model to the next level this year by participating in the Pioneer Accountable Care Organizations (ACO) initiative, which also replaces fee-for-service with global revenue sharing plus quality and care-coordination incentives.
Part of the reason that providers in Massachusetts and around the country have a genuine interest in testing global payments and other value-based models is that they fear the day when the government and private sectors say “We just don’t have the money” and exert draconian fee-for-service rate control, Altman maintains.
Hospitalist Impacts
Hospitalists could find their referral patterns shifted slightly under global payment arrangements—potentially seeing fewer consults for low-risk patients and seeing greater demand for their services for more medically complex patients, Dr. Whitcomb says. HM likely will be the most heavily involved in ACOs that cover the Medicare population, whose patients are of higher acuity and more frequently hospitalized.
When fee-for-service reimbursement ultimately does give way to alternative reimbursement models, such as global payments, effective team-based care will become paramount to ensure effective hospital discharges and that preventable readmissions are minimized, Dr. Li says. He urges hospitalists to prepare their programs to manage a sicker patient population, and to cultivate the strongest possible coordination and alignment with PCPs, discharge planning professionals, and outpatient providers of all sorts. That way, hospitalists will be positioned to leverage their value in a healthcare system that requires value.
Christopher Guadagnino is a freelance medical writer based in Philadelphia.
For SHM’s official position on issues like healthcare reform, value-based purchasing, and medical errors, visit www.hospitalmedicine.org/advocacy
Next month marks the sixth anniversary of former Massachusetts governor Mitt Romney’s signing into law a health insurance reform bill that brought near-universal coverage to the state’s residents. The Massachusetts experience represents a microcosm of what might be expected on a national scale with the Affordable Care Act (ACA): success in covering the uninsured, but persistent access and cost challenges that can only be overcome with fundamental payment reform.
“There is more going on in Massachusetts than anywhere else in the country, by far—in terms of coverage, delivery, and finance reform of healthcare,” says Stuart H. Altman, PhD, professor of national health policy at Brandeis University in Waltham, Mass. “The state’s example sends the positive message that the healthcare delivery system can be improved, but it takes time. Massachusetts is ahead of most states.”
Positives & Negatives
The Massachusetts law expands Medicaid enrollment to those earning up to 300% of the federal poverty level; offers state-subsidized commercial health insurance coverage to all other uninsured citizens; and allows young adults to remain on a parent’s plan until age 25. The law also mandates that employers with more than 10 employees offer subsidized health insurance coverage, and that every state resident over 18 purchase coverage or face tax penalties.
—Stuart H. Altman, PhD, professor of national health policy, Brandeis University, Waltham, Mass.
The law has brought coverage to nearly 412,000 previously uninsured residents (as of December 2010, the latest figures available), and less than 2% of residents remain uninsured—down from about 10% before the law was enacted.1
The law has not constrained the cost of healthcare in Massachusetts, which remains among the most expensive in the nation, and which current Massachusetts Gov. Deval Patrick acknowledges is continuing to rise at an unsustainable rate. A bill before the state legislature would give the governor the authority to review reimbursement contracts, to determine whether the fees paid by insurers to providers are appropriate, before approving insurance premium rates.
More surprising are the serious healthcare access challenges that persist in the state despite nearly universal health insurance coverage. The Massachusetts Medical Society outlined these challenges in a December 2011 white paper (see “Access Problems Persist Despite Insurance,” left).1
One of the biggest challenges the state faces is a dearth of primary-care physicians (PCPs). “One of the biggest lessons learned is that insurance expansion did not lead to better access,” observes Winthrop F. Whitcomb, MD, MHM, medical director of Healthcare Quality at Baystate Medical Center in Springfield, Mass., and co-founder of SHM. “Medicaid is a loss-leader and does not pay enough to cover the cost of running a medical practice. Expanding Medicaid may actually make access worse if primary-care physicians opt out of it.”
Insurance reform has not made it any easier for a hospitalist to find a PCP for a patient who comes to the hospital without one, Dr. Whitcomb says, or to discharge a patient to a long-term or post-acute-care setting that their insurance covers inadequately, if at all.
“We do continue to see ED visits and hospital admissions that would have been preventable had the patient seen a PCP first,” says SHM President Joseph Ming Wah Li, MD, SFHM, director of hospital medicine at Beth Israel Deaconess Medical Center in Boston.
Dr. Li says his group has experienced difficulties getting patients hooked up with timely and appropriate post-discharge follow-up care because of packed PCP schedules. In response, they developed a hospitalist-run, post-discharge clinic for outpatients to fill in the gap and provide their patients with the follow-up care they need.
“My hospitalists will manage the patient through their episode of care, regardless of whether they are an inpatient or outpatient, until their PCP is available,” Dr. Li says. “I would love to see our hospitalist-run, post-discharge clinic made obsolete by PCPs with available appointments.”
Fundamental Payment Reform
Access and cost problems like these have serious national implications, as Medicaid eligibility under the ACA is expected to grow by 16 million people by 2019, or roughly 25%. The Massachusetts experience suggests that decreasing financial barriers to care can raise other barriers, such as inadequate physician availability, and does nothing to address the 800-pound gorilla of spiraling costs.
Critics who dismiss the Massachusetts experiment as “doing nothing to control costs” miss the larger picture of innovation occurring in the state, however. Insurance reform was never intended to be the end of the story.
In response to a mandate to investigate reforming and restructuring the payment system as the next step in statewide healthcare reform, a Special Commission on the Health Care Payment System released recommendations in July 2009 (www.mass.gov/eohhs/docs/dhcfp/pc/final-report/final-report.pdf) that proposed that Massachusetts phase out fee-for-service reimbursement and replace it with an accountable-care approach that incorporated a global payment model combining elements of risk-adjusted capitation, pay-for-performance, evidence-based guidelines, and medical-home-style care coordination. Although a bill to accelerate statewide implementation of the model awaits a vote in the state legislature, the private health insurance market is well into the game.
Blue Cross Blue Shield of Massachusetts has been using a version of the model (known as the “alternative quality contract”) since 2009, with the goal of reducing healthcare cost growth by half over five years by holding providers accountable for cost and quality, and encouraging the most appropriate treatments by the right kind of providers in the most appropriate settings. Participating hospital and physician groups receive a monthly global fee for each patient (adjusted annually for patient health status and inflation) in return for providing them with all the preventive, primary, specialty, hospital, and follow-up care they need. Providers have the incentive to reduce inefficiencies, and they can earn additional incentive payments for meeting or exceeding clinical performance measures tied to process, outcomes, and patient care experience.
More than a third of the insurer’s provider network is participating in this alternative quality contract program, and early results are promising. A recent Harvard Medical School study found that medical spending at the end of the first year was nearly 2% lower among physicians and hospitals participating in the program compared with those working under traditional fee-for-service contracts, largely the result of physicians changing referral patterns and shifting care to lower-cost facilities.2 Quality of care among participants was significantly higher than that of non-participants in the insurer’s network, especially for adults with chronic illness and for children.
Several major healthcare delivery systems in Massachusetts are taking the accountable-care model to the next level this year by participating in the Pioneer Accountable Care Organizations (ACO) initiative, which also replaces fee-for-service with global revenue sharing plus quality and care-coordination incentives.
Part of the reason that providers in Massachusetts and around the country have a genuine interest in testing global payments and other value-based models is that they fear the day when the government and private sectors say “We just don’t have the money” and exert draconian fee-for-service rate control, Altman maintains.
Hospitalist Impacts
Hospitalists could find their referral patterns shifted slightly under global payment arrangements—potentially seeing fewer consults for low-risk patients and seeing greater demand for their services for more medically complex patients, Dr. Whitcomb says. HM likely will be the most heavily involved in ACOs that cover the Medicare population, whose patients are of higher acuity and more frequently hospitalized.
When fee-for-service reimbursement ultimately does give way to alternative reimbursement models, such as global payments, effective team-based care will become paramount to ensure effective hospital discharges and that preventable readmissions are minimized, Dr. Li says. He urges hospitalists to prepare their programs to manage a sicker patient population, and to cultivate the strongest possible coordination and alignment with PCPs, discharge planning professionals, and outpatient providers of all sorts. That way, hospitalists will be positioned to leverage their value in a healthcare system that requires value.
Christopher Guadagnino is a freelance medical writer based in Philadelphia.
For SHM’s official position on issues like healthcare reform, value-based purchasing, and medical errors, visit www.hospitalmedicine.org/advocacy