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Access Problems Persist Despite Health Insurance: Lessons from Massachusetts
A surprising lesson from Massachusetts is that expanding health insurance coverage does not automatically improve access to healthcare services. Here’s proof:
- More than half of primary-care physicians (PCPs) in Massachusetts are not accepting new patients.
- Wait times to see PCPs remain high: 48 days for internal medicine, 36 days for family medicine.
- The percentage of internal medicine physicians accepting Medicaid has decreased by double digits.
- Many physicians who accept Medicaid report that a lack of qualified specialists in their area is a major problem that limits their ability to provide high-quality care.
- Many physicians who accept a high proportion of Medicaid patients are in solo or two-physician practices, and have limited ability to expand hours of availability.
- ED use increased 10% from 2004 to 2008, and high levels of ED use have persisted since the reform law was enacted—a strong indicator of PCP shortages. Massachusetts has 491 ED visits per 1,000 residents, compared with a national average of 401 visits per 1,000 residents.
- Preventable hospitalization rates have not decreased, and are comparable to that of Medicaid patients and uninsured patients—remaining at about 10% from 2004 to 2008.
A surprising lesson from Massachusetts is that expanding health insurance coverage does not automatically improve access to healthcare services. Here’s proof:
- More than half of primary-care physicians (PCPs) in Massachusetts are not accepting new patients.
- Wait times to see PCPs remain high: 48 days for internal medicine, 36 days for family medicine.
- The percentage of internal medicine physicians accepting Medicaid has decreased by double digits.
- Many physicians who accept Medicaid report that a lack of qualified specialists in their area is a major problem that limits their ability to provide high-quality care.
- Many physicians who accept a high proportion of Medicaid patients are in solo or two-physician practices, and have limited ability to expand hours of availability.
- ED use increased 10% from 2004 to 2008, and high levels of ED use have persisted since the reform law was enacted—a strong indicator of PCP shortages. Massachusetts has 491 ED visits per 1,000 residents, compared with a national average of 401 visits per 1,000 residents.
- Preventable hospitalization rates have not decreased, and are comparable to that of Medicaid patients and uninsured patients—remaining at about 10% from 2004 to 2008.
A surprising lesson from Massachusetts is that expanding health insurance coverage does not automatically improve access to healthcare services. Here’s proof:
- More than half of primary-care physicians (PCPs) in Massachusetts are not accepting new patients.
- Wait times to see PCPs remain high: 48 days for internal medicine, 36 days for family medicine.
- The percentage of internal medicine physicians accepting Medicaid has decreased by double digits.
- Many physicians who accept Medicaid report that a lack of qualified specialists in their area is a major problem that limits their ability to provide high-quality care.
- Many physicians who accept a high proportion of Medicaid patients are in solo or two-physician practices, and have limited ability to expand hours of availability.
- ED use increased 10% from 2004 to 2008, and high levels of ED use have persisted since the reform law was enacted—a strong indicator of PCP shortages. Massachusetts has 491 ED visits per 1,000 residents, compared with a national average of 401 visits per 1,000 residents.
- Preventable hospitalization rates have not decreased, and are comparable to that of Medicaid patients and uninsured patients—remaining at about 10% from 2004 to 2008.
IPAB is Medicare's New Hammer for Spending Accountability
Now that the latest annual “doc fix” is in, physicians have been granted another reprieve from potentially crippling cuts to their Medicare reimbursement under the flawed sustainable growth rate (SGR) payment formula.
Beginning this year, there’s a new player in town that will have the authority to achieve what Congress has consistently failed to do—cut Medicare provider spending to keep it below a cap—and it can do so with unprecedented autonomy.
Say hello to the Independent Payment Advisory Board (IPAB), a creature of the Affordable Care Act (ACA) that will propose ways to reduce “overpayment” to Medicare providers if target-spending levels are exceeded.
What distinguishes the IPAB from the Medicare Payment Advisory Commission (MedPAC) is that its proposals will automatically become law, unless Congress enacts its own proposals that reduce Medicare provider spending by at least as much as IPAB’s, or the Senate musters a three-fifths majority vote to override IPAB’s proposals entirely. Further, the IPAB’s changes to Medicare cannot be overruled by the executive branch or a court of law.
MedPAC never wielded such authority; in fact, many of its cost-control recommendations were ignored.
—Judith Feder, PhD, professor of public policy, Georgetown University, Washington, D.C., former dean, Georgetown Public Policy Institute, fellow, the Urban Institute
The IPAB comes to life this year, with a $15 million appropriation from the ACA, and begins ramping up its operations (see “The IPAB Timetable,” p. 26). The board will be comprised of a 15-member, multi-stakeholder group—expected to include physicians, nurses, medical experts, economists, consumer advocates, and others—appointed by the President and subject to Senate confirmation.
Incendiary Reactions
Dubbed by its most vociferous and largely Republican critics as “dangerously powerful,” “the real death panel,” and “bureaucrats deciding whether you get care,” the IPAB even has some Democrats decrying its power grab. Rep. Pete Stark (D-Calif.) called the IPAB “an unprecedented abrogation of Congressional authority to an unelected, unaccountable body of so-called experts.”1
Even Allyson Schwartz (D-Pa.), who helped draft the ACA, has come out against the IPAB, joining a handful of Democrats and more than 200 Republicans in signing on to a bill (H.R. 452) to repeal the ACA’s IPAB provision. The Senate has a similar bill (S. 668).
Although the IPAB legally is barred from formally making recommendations to ration care, increase beneficiary premiums or cost sharing, and from restricting benefits or eligibility criteria, critics worry that its authority to control prices could hurt patients by driving Medicare payments so low that physicians cease to offer certain services to them.
Enforcement Power
IPAB will have unprecedented power to enforce Medicare’s provider spending benchmarks. Beginning in 2014, if Medicare’s projected spending growth rate per beneficiary rises above an inflation threshold of Gross Domestic Product per capita plus 1%, the IPAB would be triggered and would propose ways to trim provider payments. President Obama has since proposed a lower threshold of GDP per capita plus 0.5%, meaning that the IPAB would be triggered earlier and likely would have deeper cuts to make.
It is unclear how the spending growth benchmark will be affected by the $123 billion in Medicare payment cuts to hospitals and other providers over nine years, which were triggered when the so-called “super committee” failed to reach a budget-cutting consensus last fall.
U.S. Department of Health and Human Services (HHS) Secretary Kathleen Sebelius describes the IPAB as a “backstop to ensure that rising costs don’t accelerate out of control, threatening Medicare’s stability,” and she maintains that the board is a necessary fallback mechanism to enforce Medicare spending within budget while healthcare providers continue to prove the effectiveness of various value-based delivery and reimbursement reform projects the ACA is funding.2
Impact on Physicians
“The IPAB is a structural intervention to put pressure on Congress, the Executive, and CMS [Centers for Medicare & Medicaid Services] to guarantee the ACA’s investment in cost-containment, and it gives physicians the incentive to act on its principles,” says Judith Feder, PhD, professor of public policy at Georgetown University, former dean of the Georgetown Public Policy Institute, and a fellow at the Urban Institute.
Dr. Feder was a co-signer of a letter sent by 100 health policy experts and economists—including Congressional Budget Office founding director Alice Rivlin, now with the Brookings Institute—to congressional leaders last May urging them to abandon attempts to repeal the IPAB provision. Dr. Feder maintains that the IPAB will marshal “the expertise of professionals who can weigh evidence on how payment incentives affect care delivery and suggest sensible improvements, while forcing debate on difficult choices that Congress has thus far failed to address.”
Because of the changes the ACA has already made to provider reimbursement and Medicare Advantage plan funding, Feder says that Medicare’s average annual growth rate for the next decade is projected to be a full percentage point below per capita growth in GDP. On top of that, she says, “the ACA’s other payment reform experiments have the potential to improve quality and cut spending growth even further by reducing payment for overpriced or undesirable care–like unnecessary hospital readmissions–and rewarding efficiently provided, coordinated care.” By Feder’s analysis, the IPAB would not likely be triggered for a decade, but stands ready as a backup, if needed. Indeed, she favors extending IPAB’s authority beyond Medicare, to allow a system-wide spending target that creates an all-payer incentive to assure that providers really change their behavior to boost quality and efficiency.
Impact on Hospitalists
If the IPAB does come into play, Feder believes that hospitalists have less to worry about than other physician specialists, because the Board’s cost-reduction proposals would likely focus on services where overpayment is the most acute – like imaging and high-cost specialty procedures. “If hospitalists are promoting efficient, coordinated care, their position can only be enhanced by IPAB’s recommendations, to the extent that they can demonstrate value for the healthcare dollar spent,” she says.
Necessary quality and cost reforms that patients deserve, and physicians want to deliver, have been stymied for too long by a crippled Congress, and by powerful special interest agendas, says SHM Public Policy Committee member Bradley Flansbaum DO, MPH, FACP, SFHM, director of the HM program at Lenox Hill Hospital in New York City, and clinical assistant professor of medicine at NYU School of Medicine. Reform requires some real enforcement authority to put value-based quality above the fray, he adds.
“CMS just does not have the teeth to do that right now; they are in the cross-hairs, and an IPAB-like body is needed to insulate Congress from the politically-risky choices, bring evidence and expertise to the decisions, bust through the politics, and get the job done,” Dr. Flansbaum says.
Dr. Flansbaum illustrates the problem by pointing to recent clinical studies that show percutaneous vertebroplasty, which injects bone cement into the spine to treat fractures, to be no better than a placebo in relieving pain. Medicare and private health insurers have been covering vertebroplasty for many years, despite the absence of rigorous study of its effectiveness. The same likely holds true for scores of other expensive treatments and surgical procedures. “Who, exactly, is going to put the kibosh on this?” Dr. Flansbaum asks. “The free market, which includes surgeons, hospitals, and device companies, each with their agendas, or regulators?”
Dr. Flansbaum believes that, in order to effectively bring down costs, the IPAB should not be restricted to supply-side proposals (i.e. provider reimbursement), but also should be allowed to propose demand-side changes to Medicare’s benefit plans, such as tiered network pricing with higher premiums to cover the latest and most expensive technologies.
SHM supports the need for an independent entity to check the growth in Medicare spending, but it does not support the IPAB as it is currently established under the ACA because certain groups (including hospitals) are protected from its scrutiny during its first several years—a limitation that SHM says puts the board’s legitimacy into question and seriously weakens its potential cost-saving effectiveness. SHM supports replacing the IPAB with an independent board that (1) subjects all Medicare providers and suppliers to the same scrutiny without special interest carve-outs, (2) balances cost-saving with QI considerations, (3) protects delivery of quality services, and (4) ensures board membership that represents all potentially affected groups, including physicians. (Read the entire statement in the “Where We Stand” section of SHM’s Advocacy microsite at www.hospitalmedicine.org/advocacy.)
By removing the IPAB’s present handcuffs—opening its scope to all providers, as well as to demand-side changes in Medicare’s benefit structure—an IPAB-like entity with the proper staff and expertise can rationally think-out the choices that Congress will never make, according to Dr. Flansbaum.
“For the sake of our economy and our future generations, healthcare costs have to come down, even if that means some short-term pain,” he says. “Hospitals may take a hit. Some physician income might take a hit. Otherwise, there won’t be any hospitals or salaries to be hit.”
Christopher Guadagnino is a freelance writer in Philadelphia.
Reference
- Statement of Congressman Pete Stark Supporting Health Care Reform, March 21, 2010. Available at: http://www.stark.house.gov/index.php?option=com_content&view=article&id=1534:statement-of-congressman-pete-stark-supporting-health-care-reform&catid=67:floor-statements-2010-. Accessed Jan. 5, 2012.
- Kathleen Sebelius, “IPAB Will Protect Medicare.” Politico, June 23, 2011. Available at: http://dyn.politico.com/printstory.cfm?uuid=FDE594BA-87EE-4DA5-9841-33804926EF36. Accessed Jan. 5, 2012.
Now that the latest annual “doc fix” is in, physicians have been granted another reprieve from potentially crippling cuts to their Medicare reimbursement under the flawed sustainable growth rate (SGR) payment formula.
Beginning this year, there’s a new player in town that will have the authority to achieve what Congress has consistently failed to do—cut Medicare provider spending to keep it below a cap—and it can do so with unprecedented autonomy.
Say hello to the Independent Payment Advisory Board (IPAB), a creature of the Affordable Care Act (ACA) that will propose ways to reduce “overpayment” to Medicare providers if target-spending levels are exceeded.
What distinguishes the IPAB from the Medicare Payment Advisory Commission (MedPAC) is that its proposals will automatically become law, unless Congress enacts its own proposals that reduce Medicare provider spending by at least as much as IPAB’s, or the Senate musters a three-fifths majority vote to override IPAB’s proposals entirely. Further, the IPAB’s changes to Medicare cannot be overruled by the executive branch or a court of law.
MedPAC never wielded such authority; in fact, many of its cost-control recommendations were ignored.
—Judith Feder, PhD, professor of public policy, Georgetown University, Washington, D.C., former dean, Georgetown Public Policy Institute, fellow, the Urban Institute
The IPAB comes to life this year, with a $15 million appropriation from the ACA, and begins ramping up its operations (see “The IPAB Timetable,” p. 26). The board will be comprised of a 15-member, multi-stakeholder group—expected to include physicians, nurses, medical experts, economists, consumer advocates, and others—appointed by the President and subject to Senate confirmation.
Incendiary Reactions
Dubbed by its most vociferous and largely Republican critics as “dangerously powerful,” “the real death panel,” and “bureaucrats deciding whether you get care,” the IPAB even has some Democrats decrying its power grab. Rep. Pete Stark (D-Calif.) called the IPAB “an unprecedented abrogation of Congressional authority to an unelected, unaccountable body of so-called experts.”1
Even Allyson Schwartz (D-Pa.), who helped draft the ACA, has come out against the IPAB, joining a handful of Democrats and more than 200 Republicans in signing on to a bill (H.R. 452) to repeal the ACA’s IPAB provision. The Senate has a similar bill (S. 668).
Although the IPAB legally is barred from formally making recommendations to ration care, increase beneficiary premiums or cost sharing, and from restricting benefits or eligibility criteria, critics worry that its authority to control prices could hurt patients by driving Medicare payments so low that physicians cease to offer certain services to them.
Enforcement Power
IPAB will have unprecedented power to enforce Medicare’s provider spending benchmarks. Beginning in 2014, if Medicare’s projected spending growth rate per beneficiary rises above an inflation threshold of Gross Domestic Product per capita plus 1%, the IPAB would be triggered and would propose ways to trim provider payments. President Obama has since proposed a lower threshold of GDP per capita plus 0.5%, meaning that the IPAB would be triggered earlier and likely would have deeper cuts to make.
It is unclear how the spending growth benchmark will be affected by the $123 billion in Medicare payment cuts to hospitals and other providers over nine years, which were triggered when the so-called “super committee” failed to reach a budget-cutting consensus last fall.
U.S. Department of Health and Human Services (HHS) Secretary Kathleen Sebelius describes the IPAB as a “backstop to ensure that rising costs don’t accelerate out of control, threatening Medicare’s stability,” and she maintains that the board is a necessary fallback mechanism to enforce Medicare spending within budget while healthcare providers continue to prove the effectiveness of various value-based delivery and reimbursement reform projects the ACA is funding.2
Impact on Physicians
“The IPAB is a structural intervention to put pressure on Congress, the Executive, and CMS [Centers for Medicare & Medicaid Services] to guarantee the ACA’s investment in cost-containment, and it gives physicians the incentive to act on its principles,” says Judith Feder, PhD, professor of public policy at Georgetown University, former dean of the Georgetown Public Policy Institute, and a fellow at the Urban Institute.
Dr. Feder was a co-signer of a letter sent by 100 health policy experts and economists—including Congressional Budget Office founding director Alice Rivlin, now with the Brookings Institute—to congressional leaders last May urging them to abandon attempts to repeal the IPAB provision. Dr. Feder maintains that the IPAB will marshal “the expertise of professionals who can weigh evidence on how payment incentives affect care delivery and suggest sensible improvements, while forcing debate on difficult choices that Congress has thus far failed to address.”
Because of the changes the ACA has already made to provider reimbursement and Medicare Advantage plan funding, Feder says that Medicare’s average annual growth rate for the next decade is projected to be a full percentage point below per capita growth in GDP. On top of that, she says, “the ACA’s other payment reform experiments have the potential to improve quality and cut spending growth even further by reducing payment for overpriced or undesirable care–like unnecessary hospital readmissions–and rewarding efficiently provided, coordinated care.” By Feder’s analysis, the IPAB would not likely be triggered for a decade, but stands ready as a backup, if needed. Indeed, she favors extending IPAB’s authority beyond Medicare, to allow a system-wide spending target that creates an all-payer incentive to assure that providers really change their behavior to boost quality and efficiency.
Impact on Hospitalists
If the IPAB does come into play, Feder believes that hospitalists have less to worry about than other physician specialists, because the Board’s cost-reduction proposals would likely focus on services where overpayment is the most acute – like imaging and high-cost specialty procedures. “If hospitalists are promoting efficient, coordinated care, their position can only be enhanced by IPAB’s recommendations, to the extent that they can demonstrate value for the healthcare dollar spent,” she says.
Necessary quality and cost reforms that patients deserve, and physicians want to deliver, have been stymied for too long by a crippled Congress, and by powerful special interest agendas, says SHM Public Policy Committee member Bradley Flansbaum DO, MPH, FACP, SFHM, director of the HM program at Lenox Hill Hospital in New York City, and clinical assistant professor of medicine at NYU School of Medicine. Reform requires some real enforcement authority to put value-based quality above the fray, he adds.
“CMS just does not have the teeth to do that right now; they are in the cross-hairs, and an IPAB-like body is needed to insulate Congress from the politically-risky choices, bring evidence and expertise to the decisions, bust through the politics, and get the job done,” Dr. Flansbaum says.
Dr. Flansbaum illustrates the problem by pointing to recent clinical studies that show percutaneous vertebroplasty, which injects bone cement into the spine to treat fractures, to be no better than a placebo in relieving pain. Medicare and private health insurers have been covering vertebroplasty for many years, despite the absence of rigorous study of its effectiveness. The same likely holds true for scores of other expensive treatments and surgical procedures. “Who, exactly, is going to put the kibosh on this?” Dr. Flansbaum asks. “The free market, which includes surgeons, hospitals, and device companies, each with their agendas, or regulators?”
Dr. Flansbaum believes that, in order to effectively bring down costs, the IPAB should not be restricted to supply-side proposals (i.e. provider reimbursement), but also should be allowed to propose demand-side changes to Medicare’s benefit plans, such as tiered network pricing with higher premiums to cover the latest and most expensive technologies.
SHM supports the need for an independent entity to check the growth in Medicare spending, but it does not support the IPAB as it is currently established under the ACA because certain groups (including hospitals) are protected from its scrutiny during its first several years—a limitation that SHM says puts the board’s legitimacy into question and seriously weakens its potential cost-saving effectiveness. SHM supports replacing the IPAB with an independent board that (1) subjects all Medicare providers and suppliers to the same scrutiny without special interest carve-outs, (2) balances cost-saving with QI considerations, (3) protects delivery of quality services, and (4) ensures board membership that represents all potentially affected groups, including physicians. (Read the entire statement in the “Where We Stand” section of SHM’s Advocacy microsite at www.hospitalmedicine.org/advocacy.)
By removing the IPAB’s present handcuffs—opening its scope to all providers, as well as to demand-side changes in Medicare’s benefit structure—an IPAB-like entity with the proper staff and expertise can rationally think-out the choices that Congress will never make, according to Dr. Flansbaum.
“For the sake of our economy and our future generations, healthcare costs have to come down, even if that means some short-term pain,” he says. “Hospitals may take a hit. Some physician income might take a hit. Otherwise, there won’t be any hospitals or salaries to be hit.”
Christopher Guadagnino is a freelance writer in Philadelphia.
Reference
- Statement of Congressman Pete Stark Supporting Health Care Reform, March 21, 2010. Available at: http://www.stark.house.gov/index.php?option=com_content&view=article&id=1534:statement-of-congressman-pete-stark-supporting-health-care-reform&catid=67:floor-statements-2010-. Accessed Jan. 5, 2012.
- Kathleen Sebelius, “IPAB Will Protect Medicare.” Politico, June 23, 2011. Available at: http://dyn.politico.com/printstory.cfm?uuid=FDE594BA-87EE-4DA5-9841-33804926EF36. Accessed Jan. 5, 2012.
Now that the latest annual “doc fix” is in, physicians have been granted another reprieve from potentially crippling cuts to their Medicare reimbursement under the flawed sustainable growth rate (SGR) payment formula.
Beginning this year, there’s a new player in town that will have the authority to achieve what Congress has consistently failed to do—cut Medicare provider spending to keep it below a cap—and it can do so with unprecedented autonomy.
Say hello to the Independent Payment Advisory Board (IPAB), a creature of the Affordable Care Act (ACA) that will propose ways to reduce “overpayment” to Medicare providers if target-spending levels are exceeded.
What distinguishes the IPAB from the Medicare Payment Advisory Commission (MedPAC) is that its proposals will automatically become law, unless Congress enacts its own proposals that reduce Medicare provider spending by at least as much as IPAB’s, or the Senate musters a three-fifths majority vote to override IPAB’s proposals entirely. Further, the IPAB’s changes to Medicare cannot be overruled by the executive branch or a court of law.
MedPAC never wielded such authority; in fact, many of its cost-control recommendations were ignored.
—Judith Feder, PhD, professor of public policy, Georgetown University, Washington, D.C., former dean, Georgetown Public Policy Institute, fellow, the Urban Institute
The IPAB comes to life this year, with a $15 million appropriation from the ACA, and begins ramping up its operations (see “The IPAB Timetable,” p. 26). The board will be comprised of a 15-member, multi-stakeholder group—expected to include physicians, nurses, medical experts, economists, consumer advocates, and others—appointed by the President and subject to Senate confirmation.
Incendiary Reactions
Dubbed by its most vociferous and largely Republican critics as “dangerously powerful,” “the real death panel,” and “bureaucrats deciding whether you get care,” the IPAB even has some Democrats decrying its power grab. Rep. Pete Stark (D-Calif.) called the IPAB “an unprecedented abrogation of Congressional authority to an unelected, unaccountable body of so-called experts.”1
Even Allyson Schwartz (D-Pa.), who helped draft the ACA, has come out against the IPAB, joining a handful of Democrats and more than 200 Republicans in signing on to a bill (H.R. 452) to repeal the ACA’s IPAB provision. The Senate has a similar bill (S. 668).
Although the IPAB legally is barred from formally making recommendations to ration care, increase beneficiary premiums or cost sharing, and from restricting benefits or eligibility criteria, critics worry that its authority to control prices could hurt patients by driving Medicare payments so low that physicians cease to offer certain services to them.
Enforcement Power
IPAB will have unprecedented power to enforce Medicare’s provider spending benchmarks. Beginning in 2014, if Medicare’s projected spending growth rate per beneficiary rises above an inflation threshold of Gross Domestic Product per capita plus 1%, the IPAB would be triggered and would propose ways to trim provider payments. President Obama has since proposed a lower threshold of GDP per capita plus 0.5%, meaning that the IPAB would be triggered earlier and likely would have deeper cuts to make.
It is unclear how the spending growth benchmark will be affected by the $123 billion in Medicare payment cuts to hospitals and other providers over nine years, which were triggered when the so-called “super committee” failed to reach a budget-cutting consensus last fall.
U.S. Department of Health and Human Services (HHS) Secretary Kathleen Sebelius describes the IPAB as a “backstop to ensure that rising costs don’t accelerate out of control, threatening Medicare’s stability,” and she maintains that the board is a necessary fallback mechanism to enforce Medicare spending within budget while healthcare providers continue to prove the effectiveness of various value-based delivery and reimbursement reform projects the ACA is funding.2
Impact on Physicians
“The IPAB is a structural intervention to put pressure on Congress, the Executive, and CMS [Centers for Medicare & Medicaid Services] to guarantee the ACA’s investment in cost-containment, and it gives physicians the incentive to act on its principles,” says Judith Feder, PhD, professor of public policy at Georgetown University, former dean of the Georgetown Public Policy Institute, and a fellow at the Urban Institute.
Dr. Feder was a co-signer of a letter sent by 100 health policy experts and economists—including Congressional Budget Office founding director Alice Rivlin, now with the Brookings Institute—to congressional leaders last May urging them to abandon attempts to repeal the IPAB provision. Dr. Feder maintains that the IPAB will marshal “the expertise of professionals who can weigh evidence on how payment incentives affect care delivery and suggest sensible improvements, while forcing debate on difficult choices that Congress has thus far failed to address.”
Because of the changes the ACA has already made to provider reimbursement and Medicare Advantage plan funding, Feder says that Medicare’s average annual growth rate for the next decade is projected to be a full percentage point below per capita growth in GDP. On top of that, she says, “the ACA’s other payment reform experiments have the potential to improve quality and cut spending growth even further by reducing payment for overpriced or undesirable care–like unnecessary hospital readmissions–and rewarding efficiently provided, coordinated care.” By Feder’s analysis, the IPAB would not likely be triggered for a decade, but stands ready as a backup, if needed. Indeed, she favors extending IPAB’s authority beyond Medicare, to allow a system-wide spending target that creates an all-payer incentive to assure that providers really change their behavior to boost quality and efficiency.
Impact on Hospitalists
If the IPAB does come into play, Feder believes that hospitalists have less to worry about than other physician specialists, because the Board’s cost-reduction proposals would likely focus on services where overpayment is the most acute – like imaging and high-cost specialty procedures. “If hospitalists are promoting efficient, coordinated care, their position can only be enhanced by IPAB’s recommendations, to the extent that they can demonstrate value for the healthcare dollar spent,” she says.
Necessary quality and cost reforms that patients deserve, and physicians want to deliver, have been stymied for too long by a crippled Congress, and by powerful special interest agendas, says SHM Public Policy Committee member Bradley Flansbaum DO, MPH, FACP, SFHM, director of the HM program at Lenox Hill Hospital in New York City, and clinical assistant professor of medicine at NYU School of Medicine. Reform requires some real enforcement authority to put value-based quality above the fray, he adds.
“CMS just does not have the teeth to do that right now; they are in the cross-hairs, and an IPAB-like body is needed to insulate Congress from the politically-risky choices, bring evidence and expertise to the decisions, bust through the politics, and get the job done,” Dr. Flansbaum says.
Dr. Flansbaum illustrates the problem by pointing to recent clinical studies that show percutaneous vertebroplasty, which injects bone cement into the spine to treat fractures, to be no better than a placebo in relieving pain. Medicare and private health insurers have been covering vertebroplasty for many years, despite the absence of rigorous study of its effectiveness. The same likely holds true for scores of other expensive treatments and surgical procedures. “Who, exactly, is going to put the kibosh on this?” Dr. Flansbaum asks. “The free market, which includes surgeons, hospitals, and device companies, each with their agendas, or regulators?”
Dr. Flansbaum believes that, in order to effectively bring down costs, the IPAB should not be restricted to supply-side proposals (i.e. provider reimbursement), but also should be allowed to propose demand-side changes to Medicare’s benefit plans, such as tiered network pricing with higher premiums to cover the latest and most expensive technologies.
SHM supports the need for an independent entity to check the growth in Medicare spending, but it does not support the IPAB as it is currently established under the ACA because certain groups (including hospitals) are protected from its scrutiny during its first several years—a limitation that SHM says puts the board’s legitimacy into question and seriously weakens its potential cost-saving effectiveness. SHM supports replacing the IPAB with an independent board that (1) subjects all Medicare providers and suppliers to the same scrutiny without special interest carve-outs, (2) balances cost-saving with QI considerations, (3) protects delivery of quality services, and (4) ensures board membership that represents all potentially affected groups, including physicians. (Read the entire statement in the “Where We Stand” section of SHM’s Advocacy microsite at www.hospitalmedicine.org/advocacy.)
By removing the IPAB’s present handcuffs—opening its scope to all providers, as well as to demand-side changes in Medicare’s benefit structure—an IPAB-like entity with the proper staff and expertise can rationally think-out the choices that Congress will never make, according to Dr. Flansbaum.
“For the sake of our economy and our future generations, healthcare costs have to come down, even if that means some short-term pain,” he says. “Hospitals may take a hit. Some physician income might take a hit. Otherwise, there won’t be any hospitals or salaries to be hit.”
Christopher Guadagnino is a freelance writer in Philadelphia.
Reference
- Statement of Congressman Pete Stark Supporting Health Care Reform, March 21, 2010. Available at: http://www.stark.house.gov/index.php?option=com_content&view=article&id=1534:statement-of-congressman-pete-stark-supporting-health-care-reform&catid=67:floor-statements-2010-. Accessed Jan. 5, 2012.
- Kathleen Sebelius, “IPAB Will Protect Medicare.” Politico, June 23, 2011. Available at: http://dyn.politico.com/printstory.cfm?uuid=FDE594BA-87EE-4DA5-9841-33804926EF36. Accessed Jan. 5, 2012.
Life in the Gap
This year will be a pivotal one in the brave new world of healthcare reform. While fee-for-service and volume-based reimbursement will not disappear, most would concede that those programs’ days are numbered, as public and private payors inexorably migrate to value-based payment mechanisms that hold physicians and hospitals increasingly accountable for more coordinated, safer, higher-quality, and more efficient care.
The Centers for Medicare & Medicaid Services (CMS) is busy putting more provider skin in the game as its shifts from volume to value. It has ramped up its Hospital Value-Based Purchasing Plan (VBP) by adding a third performance domain—quality outcome metrics—to the existing domains of core measure care processes and patient satisfaction scores. VBP will penalize hospitals for preventable readmissions. Armed with a new innovation center established by the Affordable Care Act, CMS is accelerating its experiments with such care and reimbursement models as bundled payments, accountable-care organizations (ACOs), and medical homes. Can it be very long before invitations for provider participation become subpoenas?
While the brunt of value-based reimbursement incentives have so far been directed at hospitals, “At what point will this shift begin putting the practicing physician at risk?” asks Sean Muldoon, MD, MPH, FCCP, FACPM, senior vice president and chief medical officer of Louisville, Ky.-based Kindred Healthcare’s hospital division.
“We’re living in a time of great uncertainty—from the economic, regulatory, and legislative standpoints—and we have to make the best decisions based on what we currently believe is coming,” says Ron Greeno, MD, FCCP, MHM, chief medical officer of Cogent HMG and chair of SHM’s Public Policy Committee.
As change un-folds, some see great opportunity. “Hospitalists are in an enviable position as drivers of change,” says David B. Nash, MD, MBA, professor of health policy and dean of Thomas Jefferson University’s School of Population Health in Philadelphia. “As frontline troops of hospital-based care, they are going to play a critical role in ensuring the most efficient patient stay possible to help hospitals survive under new reimbursement models.”
Evolving Environment
Confidence that HM is well-positioned to drive value is especially welcome as the field looks back on 15 years of its existence in a soul-searching appraisal of just how much value it has driven thus far. The evidence is mixed. The profession’s clearest documented success has been preventing delays in patient discharge. That achievement has yet to be buttressed by clear evidence of concomitant gains in quality attributable to hospitalist care.
In fact, a widely publicized study in the Annals of Internal Medicine this year has caused a good deal of hand-wringing, as it suggests that HM-driven efficiency improvements may simply be attributable to shifting costs elsewhere because their patients tend to have higher readmission rates.1
That finding highlights a defining challenge of healthcare reform: how to achieve better value (quality per unit cost) within a care delivery and payment infrastructure that still pays for fragmented care. That infrastructure is trying to achieve the integration that is needed—both in the hospital and post-discharge, with preventive and acute care, at the individual patient and population levels.
“We’re being asked to prepare for an entirely different system, one which cares for populations of patients and tries to keep them out of the hospital,” Dr. Greeno says, “but our payment encourages just the opposite.”
Transitioning to value-based models while still functioning largely in a volume-based, fee-for-service environment is much like having one foot on the dock and one foot on a boat that is leaving the dock. That’s how the American Hospital Association put it in a report it released in September, “Hospitals and Care Systems of the Future.” Providers are struggling to navigate “life in the gap” between a volume-based “first curve” environment that inadequately rewards innovation and a “second curve” environment in which reimbursement is integrally tied to delivering coordinated care that demonstrates value, the AHA notes, using terminology coined by healthcare futurist Ian Morrison.
Navigation
Hospitalists will need to seize collaborative opportunities with hospitals to develop strategies to navigate this “life in the gap” during the transition to value-based reimbursement models of the second curve. As Jeff Glasheen, MD, SFHM, physician editor of The Hospitalist, provocatively wrote in his September 2011 column: “We must improve the quality of care to levels that, if necessary, Medicare would happily pay more for. This must be our singular goal” (see “Fiddling As HM Burns,” The Hospitalist). Assuming that money will follow quality, hospitals should be willing to invest in hospitalist-led processes and safety improvement activities, which likely will be the standard of care tomorrow, even if they do not turn a profit today.
Hospitalists will be the “effector arm” of crucial care-management practices under new payment models, Dr. Nash predicts. He says HM should focus on helping to make the model work—for example, championing evidence-based protocols and approved drug formularies, eliminating wasteful tests, and promoting better medication reconciliation and care transitions (see “Reconciliation Act,”).“Because they are on-site full-time, hospitalists are in the cat-bird seat to teach other attending physicians about the importance of reading from the same hymnal on these best practices,” he adds.
Dr. Greeno agrees reform needs to be cost-effective as well as patient-focused.
“The pressure on hospitalists to demonstrate our value has never been higher,” he says, urging hospitalists to pay particular attention to key features of reform to which they are already accountable, such as improving patient satisfaction and promoting evidence-based interventions that prevent readmissions and hospital-acquired conditions (see “Priorities in an Age of Reform,” left).
Dr. Greeno notes that SHM’s advocacy activities have been ramped up significantly to stay on top of reform developments—and ensure that policymakers hear hospitalists’ voices. “If we want to have a positive impact, we must track these changes, understand them, influence them, implement them, and make them successful,” he says. “That’s the challenge our field faces. There’s no physician organization that knows more about what goes on in a hospital than we do, and we will help policymakers and hospitals to make intelligent decisions.”
Chris Guadagnino is a freelance medical writer based in Philadelphia.
Reference
This year will be a pivotal one in the brave new world of healthcare reform. While fee-for-service and volume-based reimbursement will not disappear, most would concede that those programs’ days are numbered, as public and private payors inexorably migrate to value-based payment mechanisms that hold physicians and hospitals increasingly accountable for more coordinated, safer, higher-quality, and more efficient care.
The Centers for Medicare & Medicaid Services (CMS) is busy putting more provider skin in the game as its shifts from volume to value. It has ramped up its Hospital Value-Based Purchasing Plan (VBP) by adding a third performance domain—quality outcome metrics—to the existing domains of core measure care processes and patient satisfaction scores. VBP will penalize hospitals for preventable readmissions. Armed with a new innovation center established by the Affordable Care Act, CMS is accelerating its experiments with such care and reimbursement models as bundled payments, accountable-care organizations (ACOs), and medical homes. Can it be very long before invitations for provider participation become subpoenas?
While the brunt of value-based reimbursement incentives have so far been directed at hospitals, “At what point will this shift begin putting the practicing physician at risk?” asks Sean Muldoon, MD, MPH, FCCP, FACPM, senior vice president and chief medical officer of Louisville, Ky.-based Kindred Healthcare’s hospital division.
“We’re living in a time of great uncertainty—from the economic, regulatory, and legislative standpoints—and we have to make the best decisions based on what we currently believe is coming,” says Ron Greeno, MD, FCCP, MHM, chief medical officer of Cogent HMG and chair of SHM’s Public Policy Committee.
As change un-folds, some see great opportunity. “Hospitalists are in an enviable position as drivers of change,” says David B. Nash, MD, MBA, professor of health policy and dean of Thomas Jefferson University’s School of Population Health in Philadelphia. “As frontline troops of hospital-based care, they are going to play a critical role in ensuring the most efficient patient stay possible to help hospitals survive under new reimbursement models.”
Evolving Environment
Confidence that HM is well-positioned to drive value is especially welcome as the field looks back on 15 years of its existence in a soul-searching appraisal of just how much value it has driven thus far. The evidence is mixed. The profession’s clearest documented success has been preventing delays in patient discharge. That achievement has yet to be buttressed by clear evidence of concomitant gains in quality attributable to hospitalist care.
In fact, a widely publicized study in the Annals of Internal Medicine this year has caused a good deal of hand-wringing, as it suggests that HM-driven efficiency improvements may simply be attributable to shifting costs elsewhere because their patients tend to have higher readmission rates.1
That finding highlights a defining challenge of healthcare reform: how to achieve better value (quality per unit cost) within a care delivery and payment infrastructure that still pays for fragmented care. That infrastructure is trying to achieve the integration that is needed—both in the hospital and post-discharge, with preventive and acute care, at the individual patient and population levels.
“We’re being asked to prepare for an entirely different system, one which cares for populations of patients and tries to keep them out of the hospital,” Dr. Greeno says, “but our payment encourages just the opposite.”
Transitioning to value-based models while still functioning largely in a volume-based, fee-for-service environment is much like having one foot on the dock and one foot on a boat that is leaving the dock. That’s how the American Hospital Association put it in a report it released in September, “Hospitals and Care Systems of the Future.” Providers are struggling to navigate “life in the gap” between a volume-based “first curve” environment that inadequately rewards innovation and a “second curve” environment in which reimbursement is integrally tied to delivering coordinated care that demonstrates value, the AHA notes, using terminology coined by healthcare futurist Ian Morrison.
Navigation
Hospitalists will need to seize collaborative opportunities with hospitals to develop strategies to navigate this “life in the gap” during the transition to value-based reimbursement models of the second curve. As Jeff Glasheen, MD, SFHM, physician editor of The Hospitalist, provocatively wrote in his September 2011 column: “We must improve the quality of care to levels that, if necessary, Medicare would happily pay more for. This must be our singular goal” (see “Fiddling As HM Burns,” The Hospitalist). Assuming that money will follow quality, hospitals should be willing to invest in hospitalist-led processes and safety improvement activities, which likely will be the standard of care tomorrow, even if they do not turn a profit today.
Hospitalists will be the “effector arm” of crucial care-management practices under new payment models, Dr. Nash predicts. He says HM should focus on helping to make the model work—for example, championing evidence-based protocols and approved drug formularies, eliminating wasteful tests, and promoting better medication reconciliation and care transitions (see “Reconciliation Act,”).“Because they are on-site full-time, hospitalists are in the cat-bird seat to teach other attending physicians about the importance of reading from the same hymnal on these best practices,” he adds.
Dr. Greeno agrees reform needs to be cost-effective as well as patient-focused.
“The pressure on hospitalists to demonstrate our value has never been higher,” he says, urging hospitalists to pay particular attention to key features of reform to which they are already accountable, such as improving patient satisfaction and promoting evidence-based interventions that prevent readmissions and hospital-acquired conditions (see “Priorities in an Age of Reform,” left).
Dr. Greeno notes that SHM’s advocacy activities have been ramped up significantly to stay on top of reform developments—and ensure that policymakers hear hospitalists’ voices. “If we want to have a positive impact, we must track these changes, understand them, influence them, implement them, and make them successful,” he says. “That’s the challenge our field faces. There’s no physician organization that knows more about what goes on in a hospital than we do, and we will help policymakers and hospitals to make intelligent decisions.”
Chris Guadagnino is a freelance medical writer based in Philadelphia.
Reference
This year will be a pivotal one in the brave new world of healthcare reform. While fee-for-service and volume-based reimbursement will not disappear, most would concede that those programs’ days are numbered, as public and private payors inexorably migrate to value-based payment mechanisms that hold physicians and hospitals increasingly accountable for more coordinated, safer, higher-quality, and more efficient care.
The Centers for Medicare & Medicaid Services (CMS) is busy putting more provider skin in the game as its shifts from volume to value. It has ramped up its Hospital Value-Based Purchasing Plan (VBP) by adding a third performance domain—quality outcome metrics—to the existing domains of core measure care processes and patient satisfaction scores. VBP will penalize hospitals for preventable readmissions. Armed with a new innovation center established by the Affordable Care Act, CMS is accelerating its experiments with such care and reimbursement models as bundled payments, accountable-care organizations (ACOs), and medical homes. Can it be very long before invitations for provider participation become subpoenas?
While the brunt of value-based reimbursement incentives have so far been directed at hospitals, “At what point will this shift begin putting the practicing physician at risk?” asks Sean Muldoon, MD, MPH, FCCP, FACPM, senior vice president and chief medical officer of Louisville, Ky.-based Kindred Healthcare’s hospital division.
“We’re living in a time of great uncertainty—from the economic, regulatory, and legislative standpoints—and we have to make the best decisions based on what we currently believe is coming,” says Ron Greeno, MD, FCCP, MHM, chief medical officer of Cogent HMG and chair of SHM’s Public Policy Committee.
As change un-folds, some see great opportunity. “Hospitalists are in an enviable position as drivers of change,” says David B. Nash, MD, MBA, professor of health policy and dean of Thomas Jefferson University’s School of Population Health in Philadelphia. “As frontline troops of hospital-based care, they are going to play a critical role in ensuring the most efficient patient stay possible to help hospitals survive under new reimbursement models.”
Evolving Environment
Confidence that HM is well-positioned to drive value is especially welcome as the field looks back on 15 years of its existence in a soul-searching appraisal of just how much value it has driven thus far. The evidence is mixed. The profession’s clearest documented success has been preventing delays in patient discharge. That achievement has yet to be buttressed by clear evidence of concomitant gains in quality attributable to hospitalist care.
In fact, a widely publicized study in the Annals of Internal Medicine this year has caused a good deal of hand-wringing, as it suggests that HM-driven efficiency improvements may simply be attributable to shifting costs elsewhere because their patients tend to have higher readmission rates.1
That finding highlights a defining challenge of healthcare reform: how to achieve better value (quality per unit cost) within a care delivery and payment infrastructure that still pays for fragmented care. That infrastructure is trying to achieve the integration that is needed—both in the hospital and post-discharge, with preventive and acute care, at the individual patient and population levels.
“We’re being asked to prepare for an entirely different system, one which cares for populations of patients and tries to keep them out of the hospital,” Dr. Greeno says, “but our payment encourages just the opposite.”
Transitioning to value-based models while still functioning largely in a volume-based, fee-for-service environment is much like having one foot on the dock and one foot on a boat that is leaving the dock. That’s how the American Hospital Association put it in a report it released in September, “Hospitals and Care Systems of the Future.” Providers are struggling to navigate “life in the gap” between a volume-based “first curve” environment that inadequately rewards innovation and a “second curve” environment in which reimbursement is integrally tied to delivering coordinated care that demonstrates value, the AHA notes, using terminology coined by healthcare futurist Ian Morrison.
Navigation
Hospitalists will need to seize collaborative opportunities with hospitals to develop strategies to navigate this “life in the gap” during the transition to value-based reimbursement models of the second curve. As Jeff Glasheen, MD, SFHM, physician editor of The Hospitalist, provocatively wrote in his September 2011 column: “We must improve the quality of care to levels that, if necessary, Medicare would happily pay more for. This must be our singular goal” (see “Fiddling As HM Burns,” The Hospitalist). Assuming that money will follow quality, hospitals should be willing to invest in hospitalist-led processes and safety improvement activities, which likely will be the standard of care tomorrow, even if they do not turn a profit today.
Hospitalists will be the “effector arm” of crucial care-management practices under new payment models, Dr. Nash predicts. He says HM should focus on helping to make the model work—for example, championing evidence-based protocols and approved drug formularies, eliminating wasteful tests, and promoting better medication reconciliation and care transitions (see “Reconciliation Act,”).“Because they are on-site full-time, hospitalists are in the cat-bird seat to teach other attending physicians about the importance of reading from the same hymnal on these best practices,” he adds.
Dr. Greeno agrees reform needs to be cost-effective as well as patient-focused.
“The pressure on hospitalists to demonstrate our value has never been higher,” he says, urging hospitalists to pay particular attention to key features of reform to which they are already accountable, such as improving patient satisfaction and promoting evidence-based interventions that prevent readmissions and hospital-acquired conditions (see “Priorities in an Age of Reform,” left).
Dr. Greeno notes that SHM’s advocacy activities have been ramped up significantly to stay on top of reform developments—and ensure that policymakers hear hospitalists’ voices. “If we want to have a positive impact, we must track these changes, understand them, influence them, implement them, and make them successful,” he says. “That’s the challenge our field faces. There’s no physician organization that knows more about what goes on in a hospital than we do, and we will help policymakers and hospitals to make intelligent decisions.”
Chris Guadagnino is a freelance medical writer based in Philadelphia.
Reference
Business Blueprint
When your group needed a director, everybody stepped back except you. Or maybe you’re thinking about transitioning into a hospital administrative leadership role like department chair, patient safety officer, vice president of medical affairs, chief medical officer, or even CEO.
“Over the next 10 years, the single largest source of new CMOs might be hospitalists,” says John Nelson, MD, MHM, medical director at Overlake Hospital in Bellevue, Wash., and principal of the consulting firm Nelson Flores Hospital Medicine Consultants.
You might already have discovered that these responsibilities require skills that weren't taught in medical school, and you could be struggling. The trick is figuring out which skills you need to strengthen, as well as selecting the right training venues.
You'll need financial and business literacy, technical savvy for process and system improvements, planning ability, and emotional intelligence to engineer cooperative relationships between multiple stakeholders. Successful career advancement ultimately requires leadership acumen: proof that you can run a business, manage upstream and downstream communication, and handle administrative and liaison duties within the hospital.
“As healthcare reform begins to financially incentivize things like safe patient handoffs and more evidence-based medicine, the business part of running a practice is going to quickly align with quality and safety outcomes. That’s what hospital medicine leaders should be focusing on,” says Lakshmi K. Halasyamani, MD, SFHM, vice president of quality and systems improvement at Saint Joseph Mercy Hospital in Ann Arbor, Mich., and an SHM board member.
There is no shortage of training options, including books, mentorships, hospital committee membership, workshops, courses, and master’s-level programs in business leadership. And as the healthcare landscape continues to evolve, there will be a growing demand for physicians, particularly hospitalists, with greater procedural and conceptual understanding of healthcare systems.
For more about hospitalists becoming the business leaders in healthcare, check out this month’s cover story, "Business Blueprint."
When your group needed a director, everybody stepped back except you. Or maybe you’re thinking about transitioning into a hospital administrative leadership role like department chair, patient safety officer, vice president of medical affairs, chief medical officer, or even CEO.
“Over the next 10 years, the single largest source of new CMOs might be hospitalists,” says John Nelson, MD, MHM, medical director at Overlake Hospital in Bellevue, Wash., and principal of the consulting firm Nelson Flores Hospital Medicine Consultants.
You might already have discovered that these responsibilities require skills that weren't taught in medical school, and you could be struggling. The trick is figuring out which skills you need to strengthen, as well as selecting the right training venues.
You'll need financial and business literacy, technical savvy for process and system improvements, planning ability, and emotional intelligence to engineer cooperative relationships between multiple stakeholders. Successful career advancement ultimately requires leadership acumen: proof that you can run a business, manage upstream and downstream communication, and handle administrative and liaison duties within the hospital.
“As healthcare reform begins to financially incentivize things like safe patient handoffs and more evidence-based medicine, the business part of running a practice is going to quickly align with quality and safety outcomes. That’s what hospital medicine leaders should be focusing on,” says Lakshmi K. Halasyamani, MD, SFHM, vice president of quality and systems improvement at Saint Joseph Mercy Hospital in Ann Arbor, Mich., and an SHM board member.
There is no shortage of training options, including books, mentorships, hospital committee membership, workshops, courses, and master’s-level programs in business leadership. And as the healthcare landscape continues to evolve, there will be a growing demand for physicians, particularly hospitalists, with greater procedural and conceptual understanding of healthcare systems.
For more about hospitalists becoming the business leaders in healthcare, check out this month’s cover story, "Business Blueprint."
When your group needed a director, everybody stepped back except you. Or maybe you’re thinking about transitioning into a hospital administrative leadership role like department chair, patient safety officer, vice president of medical affairs, chief medical officer, or even CEO.
“Over the next 10 years, the single largest source of new CMOs might be hospitalists,” says John Nelson, MD, MHM, medical director at Overlake Hospital in Bellevue, Wash., and principal of the consulting firm Nelson Flores Hospital Medicine Consultants.
You might already have discovered that these responsibilities require skills that weren't taught in medical school, and you could be struggling. The trick is figuring out which skills you need to strengthen, as well as selecting the right training venues.
You'll need financial and business literacy, technical savvy for process and system improvements, planning ability, and emotional intelligence to engineer cooperative relationships between multiple stakeholders. Successful career advancement ultimately requires leadership acumen: proof that you can run a business, manage upstream and downstream communication, and handle administrative and liaison duties within the hospital.
“As healthcare reform begins to financially incentivize things like safe patient handoffs and more evidence-based medicine, the business part of running a practice is going to quickly align with quality and safety outcomes. That’s what hospital medicine leaders should be focusing on,” says Lakshmi K. Halasyamani, MD, SFHM, vice president of quality and systems improvement at Saint Joseph Mercy Hospital in Ann Arbor, Mich., and an SHM board member.
There is no shortage of training options, including books, mentorships, hospital committee membership, workshops, courses, and master’s-level programs in business leadership. And as the healthcare landscape continues to evolve, there will be a growing demand for physicians, particularly hospitalists, with greater procedural and conceptual understanding of healthcare systems.
For more about hospitalists becoming the business leaders in healthcare, check out this month’s cover story, "Business Blueprint."
Attention to Detail
Hospitalists will be essential players in helping their institutions prepare for the Recovery Audit Contractor (RAC) program, now being rolled out nationwide by the Centers for Medicare & Medicaid Services (CMS). The program is part of CMS’ arsenal to ferret out improper payments and prevent fraud, waste, and abuse in the Medicare system.
All providers who bill Medicare fee-for-service are fair game for an RAC audit, which scrutinizes medical records to validate diagnosis-related groups (DRGs), coding, and the necessity of care provided by hospitals. Hospitalists are being asked to document their diagnosis and treatment decisions more precisely and thoroughly than ever, ensuring that DRG coding is appropriate, medical necessity is watertight, and hospitals are defended from costly overpayment recovery.
Specificity of documentation is the hospitalist’s most potent weapon against this new layer of federal audits.
In a three-year demonstration of the RAC program that ended in March 2008, one-third of all medical records audited resulted in an overpayment finding and collection. RACs collected more than $900 million in overpayments and returned nearly $38 million in underpayments. One-third of provider appeals (physician, hospital, and other providers) were successful during the demo program, according to a June 2008 CMS evaluation report. (Download a copy of the report at www.cms.hhs.gov/RAC/Downloads/RAC_Demonstration_Evaluation_Report.pdf.)
How the Audits Work
Listen to an interview with Dr. Pinson
Out of concern that the Medicare Trust Fund might not be adequately protected against improper payments by existing error detection and prevention efforts, Congress directed CMS to use RACs to identify and recoup Medicare overpayments under Section 306 of the Medicare Modernization Act of 2003, and directed CMS to make the program permanent by 2010 under Section 302 of the Tax Relief and Health Care Act of 2006. According to CMS, RACs were implemented so that physicians and other providers could avoid submitting claims that do not comply with Medicare rules, CMS could lower its error rate, and taxpayers and future Medicare beneficiaries would be protected.1
CMS has contracted with four regional RACs for the national program, and each will use proprietary auditing software to review paid claims from Medicare Part A and Part B providers to ensure that they meet Medicare’s statutory, regulatory, and policy requirements and regulations.
The RACs use automated review for claims that clearly contain errors that resulted in improper payments (e.g., claims for duplicate or uncovered services, claims that violate a written Medicare policy or sanctioned coding guideline), in which case the RAC notifies the provider of the overpayment. For cases in which there is a high probability—but not certainty—that the claim contains an overpayment, the RAC requests medical records from the provider (including imaged medical records on CD or DVD) to conduct a complex review and make a determination as to whether payment of the claim was correct, or whether there was an over- or underpayment.
CMS uses a Web-based data warehouse to ensure that RACs do not review claims that have previously been reviewed by another entity, such as a Medicare carrier, fiscal intermediary, the Office of Inspector General, or a quality-improvement organization (QIO).
The four regional RACs are ramping up their claim review activities in all states, says Connie Leonard, director of CMS’ Division of Recovery Audit Operations. When overpayments are confirmed, the RACs issue letters demanding providers to repay their Medicare carrier or intermediary within 30 days. For confirmed underpayments, RACs inform the provider’s Medicare contractor or fiscal intermediary, which then forwards the additional payment, Leonard says.
Providers can repay an overpayment by check or installment plan on or before 30 days after receiving the RAC demand letter. The Medicare contractors use recoupment—reducing present or future Medicare payments—on day 41. Providers who wish to dispute overpayment charges can take their case through the usual Medicare claims appeal process. RACs also offer a “discussion period”—from the date the provider gets a “Detailed Review Results” letter until the date of recoupment—to discuss with the RAC an improper payment determination outside the normal appeal process, Leonard says.
—Kathy DeVault, RHIA, CCS, CCS-P, manager, Professional Practice Resources, American Health Information Management Association, Chicago
If providers disagree with the RAC’s determination, Leonard says, they should either 1) pay by check by day 30 and file for appeal by day 120 of the demand letter; 2) allow recoupment on day 41 and file for appeal by day 120; 3) stop the recoupment by filing an appeal by day 30; or 4) request an extended payment plan and appeal by day 120.
Some physicians in the demonstration project regarded the third-party RAC companies as “bounty hunters” operating without sufficient CMS oversight, imposing undue administrative burdens on physician practices, and lacking the clinical expertise to adjudicate claims appropriately, according to Michael Schweitz, MD, a rheumatologist from West Palm Beach, Fla., who testified before a Congressional committee in 2008 about RAC activities.
In response, CMS has modified the program (see “Refinements in Permanent RAC Program,” p. 8) in several ways to address those flaws and ensure a fair and smooth auditing process, Leonard says. (Listen to an audio interview with Ms. Leonard)
All About the Details
Because RACs focus on coding and documentation that fails to support DRG designations, hospitalists who focus on accurate and precise documentation that can be coded properly will greatly help their hospitals defend against RAC audits, as well as yield better payment and improved quality scores, says Richard D. Pinson, MD, FACP, CCS, principal of HCQ Consulting in Nashville, Tenn. Pinson will present “Documentation Tips Your Hospital Will Love You For” at HM10 in Washington, D.C., this month. A video/audio download of the presentation will be available on SHM’s Web site in May.
“Coding rules and terminology often don’t match what we’re used to writing in the record, so hospitalists need to learn what these connections are and use them in their medical record documentation,” Pinson says. “This is a core skill for hospitalists: being able to translate clinical terminology into the correct coding terminology for hospitals and coders.”
For example, if a hospitalist sees that a pre-operative patient has severe congestive heart failure, that condition cannot be coded as a complication of the patient’s care or considered as such in the DRG assignment, Pinson explains. If the hospitalist says the patient has an acute exacerbation of systolic heart failure, then that is a major comorbidity and ought to be documented as such. The average value of a major comorbidity in a surgical case could be as much as $20,000 per case, Pinson notes. If the DRG assignment included acute exacerbation but the medical chart only said severe congestive heart failure, the hospital would face recoupment of payment from an RAC audit.
“If we’re inconsistent or ambiguous in how we apply our terms, we can end up inadvertently upcoding. The key is: Learn to use the right terms that correspond to the right codes, based on what your patient actually has, and then be consistent throughout the record in your use of those terms,” Pinson says. For example, “we may admit a patient and say at the very beginning that the patient probably has aspiration pneumonia. We then treat the patient for aspiration pneumonia but leave it out of the discharge summary. The coder may code aspiration pneumonia, but the RAC auditor may point out that it was only mentioned in the patient’s record once, as possible, and may recoup any payment for treatment beyond simple pneumonia.”
Level of care and symptom-based DRG designations are red flags for RAC recovery, Pinson says. When the auditor sees a DRG based on symptoms rather than diagnoses (e.g., chest pain, syncope, transient ischemic attack, dehydration) and it is billed as inpatient status instead of observation status, that’s a target. Those symptoms, he says, often don’t meet the medical necessity criteria for inpatient status.
Pinson advises hospitalists to ask their institution’s case-management department, or hire an external consultant, to abstract key criteria for patient status designation, and to consider starting a patient as observation status until a precise diagnosis can be made that warrants hospital admission. Hospitalists should then describe the patient’s situation more precisely in the medical record as a diagnosis, not just as symptoms—e.g., syncope suspected due to cardiac arrhythmia, or chest pain suspected to be angina.
“For inpatient billing, those uncertain diagnoses, described that way, count as if they were established conditions. They don’t go into symptom DRGs,” Pinson says. “If you’re doing these things to protect the validity of you hospital’s billing, you’ll be protecting yourself at the same time, and it’s unlikely that RACs will single you out at all for auditing.”
Hospitalists can be valuable participants on their institutions’ RAC response team, providing clinical clarification on cases and helping to draft appeal letters.
There are several other red flags that RACs zero in on and hospitalists should watch out for, says Kathy DeVault, RHIA, CCS, CCS-P, manager of Professional Practice Resources for the American Health Information Management Association (AHIMA). Specificity in the medical record makes all the difference. For example, by identifying incorrect coding for excisional debridement (removal of infected tissue), RACs collected nearly $18 million in overpayments in fiscal-year 2006 because medical record documentation omitted such details as the word “excisional” (e.g., sharp debridement coded as excisional debridement), whether it was performed in the operating room or not, instruments used, the extent and depth of the procedure, and if the cutting of tissue was outside or beyond the wound margin.
DeVault warns that “RACs are targeting confusion between septicemia and urosepsis.” According to CMS, if the hospital reports a patient’s principal diagnosis as septicemia (03.89) but the medical record indicates the diagnosis of urosepsis, the RAC will bump the diagnosis code down to urinary tract infection (599.0), a lower-payment DRG, and demand recoupment.1
Urosepsis does not have a specific ICD-9-CM diagnosis code, and defaults to a simple UTI code, as referenced in ICD-9-CM. Unless the physician states in his or her documentation that the patient’s condition was systemic sepsis or septicemia, urosepsis would be coded as a UTI. RACS also denied some respiratory-failure claims for incorrect sequencing of principal diagnosis (e.g., respiratory failure vs. sepsis). The American Hospital Association has issued a regulatory advisory about these issues (web.mhanet.com/userdocs/articles/RAC/AHA_RAC_Coding Advisory_071608.pdf).
DeVault highlights three additional RAC targets that might impact HM:
- Documentation for transbronchial biopsy (a surgical DRG) in which the medical record only shows pathology of bronchus tissue (which RACs regard as nonsurgical);
- Failure to document the severity of a patient’s anemia as such to meet the medical necessity requirement of a blood transfusion (e.g., a chronic blood loss anemia or a pernicious anemia); and
- Documentation of treatments performed by intensivists in an ICU. By the time a patient’s attending physician sees their patient out of the ICU, DeVault says, their acute renal failure could be turned around but the attending might not document what happened in the ICU. The intensivist must see to it that the documentation allows the appropriate DRG assignment for the level of care the patient received.
AHIMA has published a 65-page RAC Audit Toolkit that describes the audit process, outlines preparations and procedures, and offers concrete guidance for appeals. Download a copy at www.ahima.org/infocenter/documents/RACToolkitFINAL.pdf. TH
Chris Guadagnino is a freelance medical writer based in Philadelphia.
Reference
- The Medicare Recovery Audit Contractor (RAC) program: an evaluation of the 3-year demonstration. CMS Web site. Available at: www.cms.hhs.gov/RAC/Downloads/RACEvaluationReport.pdf. Accessed March 3, 2010.
Refinements in CMS’ Permanent RAC Program
Based on lessons learned from demonstration programs, CMS has made a number of changes to the permanent Recovery Audit Contractor (RAC) program.
Among the changes are:
- RACs cannot audit claims earlier than three years from the start of the program, with a maximum look-back date of October 1, 2007;
- For physicians, RACs are limited to requesting 10 medical records per 45 days from a single physician, 20 medical records from a small practice of two to five physicians, 30 from a group of six to 15, and 50 from a large group of more than 16 physicians;
- For hospitals, RACs are limited to requesting 1% of all claims submitted for the previous calendar year, divided into eight periods (45 days). Although the RACs may go more than 45 days between record requests, in no case shall they make requests more frequently than every 45 days;
- RACs must send a “Detailed Review Results” letter within 60 calendar days of receipt of the medical records they request for review;
- Each RAC must hire a physician medical director and certified coders, and providers may request the credentials of their auditor and request to speak to their RAC’s medical director regarding a claim denial;
- All new issues that an RAC wishes to pursue for overpayments must be validated by CMS or an independent RAC validation contractor, and posted to the RAC’s Web site before widespread review;
- RACS must have a Web-based “Claim Status” platform that will allow providers to track the status of medical record submissions to RACs;
- RACs must pay back contingency fees when an improper payment determination is overturned at any level in the appeals process (demo RACs were allowed to retain them on determinations overturned on second- and third-level appeal); and
- RAC validation contractors will conduct a third-party review of RAC claims determinations and provide annual accuracy scores for each RAC.—CG
Hospitalists will be essential players in helping their institutions prepare for the Recovery Audit Contractor (RAC) program, now being rolled out nationwide by the Centers for Medicare & Medicaid Services (CMS). The program is part of CMS’ arsenal to ferret out improper payments and prevent fraud, waste, and abuse in the Medicare system.
All providers who bill Medicare fee-for-service are fair game for an RAC audit, which scrutinizes medical records to validate diagnosis-related groups (DRGs), coding, and the necessity of care provided by hospitals. Hospitalists are being asked to document their diagnosis and treatment decisions more precisely and thoroughly than ever, ensuring that DRG coding is appropriate, medical necessity is watertight, and hospitals are defended from costly overpayment recovery.
Specificity of documentation is the hospitalist’s most potent weapon against this new layer of federal audits.
In a three-year demonstration of the RAC program that ended in March 2008, one-third of all medical records audited resulted in an overpayment finding and collection. RACs collected more than $900 million in overpayments and returned nearly $38 million in underpayments. One-third of provider appeals (physician, hospital, and other providers) were successful during the demo program, according to a June 2008 CMS evaluation report. (Download a copy of the report at www.cms.hhs.gov/RAC/Downloads/RAC_Demonstration_Evaluation_Report.pdf.)
How the Audits Work
Listen to an interview with Dr. Pinson
Out of concern that the Medicare Trust Fund might not be adequately protected against improper payments by existing error detection and prevention efforts, Congress directed CMS to use RACs to identify and recoup Medicare overpayments under Section 306 of the Medicare Modernization Act of 2003, and directed CMS to make the program permanent by 2010 under Section 302 of the Tax Relief and Health Care Act of 2006. According to CMS, RACs were implemented so that physicians and other providers could avoid submitting claims that do not comply with Medicare rules, CMS could lower its error rate, and taxpayers and future Medicare beneficiaries would be protected.1
CMS has contracted with four regional RACs for the national program, and each will use proprietary auditing software to review paid claims from Medicare Part A and Part B providers to ensure that they meet Medicare’s statutory, regulatory, and policy requirements and regulations.
The RACs use automated review for claims that clearly contain errors that resulted in improper payments (e.g., claims for duplicate or uncovered services, claims that violate a written Medicare policy or sanctioned coding guideline), in which case the RAC notifies the provider of the overpayment. For cases in which there is a high probability—but not certainty—that the claim contains an overpayment, the RAC requests medical records from the provider (including imaged medical records on CD or DVD) to conduct a complex review and make a determination as to whether payment of the claim was correct, or whether there was an over- or underpayment.
CMS uses a Web-based data warehouse to ensure that RACs do not review claims that have previously been reviewed by another entity, such as a Medicare carrier, fiscal intermediary, the Office of Inspector General, or a quality-improvement organization (QIO).
The four regional RACs are ramping up their claim review activities in all states, says Connie Leonard, director of CMS’ Division of Recovery Audit Operations. When overpayments are confirmed, the RACs issue letters demanding providers to repay their Medicare carrier or intermediary within 30 days. For confirmed underpayments, RACs inform the provider’s Medicare contractor or fiscal intermediary, which then forwards the additional payment, Leonard says.
Providers can repay an overpayment by check or installment plan on or before 30 days after receiving the RAC demand letter. The Medicare contractors use recoupment—reducing present or future Medicare payments—on day 41. Providers who wish to dispute overpayment charges can take their case through the usual Medicare claims appeal process. RACs also offer a “discussion period”—from the date the provider gets a “Detailed Review Results” letter until the date of recoupment—to discuss with the RAC an improper payment determination outside the normal appeal process, Leonard says.
—Kathy DeVault, RHIA, CCS, CCS-P, manager, Professional Practice Resources, American Health Information Management Association, Chicago
If providers disagree with the RAC’s determination, Leonard says, they should either 1) pay by check by day 30 and file for appeal by day 120 of the demand letter; 2) allow recoupment on day 41 and file for appeal by day 120; 3) stop the recoupment by filing an appeal by day 30; or 4) request an extended payment plan and appeal by day 120.
Some physicians in the demonstration project regarded the third-party RAC companies as “bounty hunters” operating without sufficient CMS oversight, imposing undue administrative burdens on physician practices, and lacking the clinical expertise to adjudicate claims appropriately, according to Michael Schweitz, MD, a rheumatologist from West Palm Beach, Fla., who testified before a Congressional committee in 2008 about RAC activities.
In response, CMS has modified the program (see “Refinements in Permanent RAC Program,” p. 8) in several ways to address those flaws and ensure a fair and smooth auditing process, Leonard says. (Listen to an audio interview with Ms. Leonard)
All About the Details
Because RACs focus on coding and documentation that fails to support DRG designations, hospitalists who focus on accurate and precise documentation that can be coded properly will greatly help their hospitals defend against RAC audits, as well as yield better payment and improved quality scores, says Richard D. Pinson, MD, FACP, CCS, principal of HCQ Consulting in Nashville, Tenn. Pinson will present “Documentation Tips Your Hospital Will Love You For” at HM10 in Washington, D.C., this month. A video/audio download of the presentation will be available on SHM’s Web site in May.
“Coding rules and terminology often don’t match what we’re used to writing in the record, so hospitalists need to learn what these connections are and use them in their medical record documentation,” Pinson says. “This is a core skill for hospitalists: being able to translate clinical terminology into the correct coding terminology for hospitals and coders.”
For example, if a hospitalist sees that a pre-operative patient has severe congestive heart failure, that condition cannot be coded as a complication of the patient’s care or considered as such in the DRG assignment, Pinson explains. If the hospitalist says the patient has an acute exacerbation of systolic heart failure, then that is a major comorbidity and ought to be documented as such. The average value of a major comorbidity in a surgical case could be as much as $20,000 per case, Pinson notes. If the DRG assignment included acute exacerbation but the medical chart only said severe congestive heart failure, the hospital would face recoupment of payment from an RAC audit.
“If we’re inconsistent or ambiguous in how we apply our terms, we can end up inadvertently upcoding. The key is: Learn to use the right terms that correspond to the right codes, based on what your patient actually has, and then be consistent throughout the record in your use of those terms,” Pinson says. For example, “we may admit a patient and say at the very beginning that the patient probably has aspiration pneumonia. We then treat the patient for aspiration pneumonia but leave it out of the discharge summary. The coder may code aspiration pneumonia, but the RAC auditor may point out that it was only mentioned in the patient’s record once, as possible, and may recoup any payment for treatment beyond simple pneumonia.”
Level of care and symptom-based DRG designations are red flags for RAC recovery, Pinson says. When the auditor sees a DRG based on symptoms rather than diagnoses (e.g., chest pain, syncope, transient ischemic attack, dehydration) and it is billed as inpatient status instead of observation status, that’s a target. Those symptoms, he says, often don’t meet the medical necessity criteria for inpatient status.
Pinson advises hospitalists to ask their institution’s case-management department, or hire an external consultant, to abstract key criteria for patient status designation, and to consider starting a patient as observation status until a precise diagnosis can be made that warrants hospital admission. Hospitalists should then describe the patient’s situation more precisely in the medical record as a diagnosis, not just as symptoms—e.g., syncope suspected due to cardiac arrhythmia, or chest pain suspected to be angina.
“For inpatient billing, those uncertain diagnoses, described that way, count as if they were established conditions. They don’t go into symptom DRGs,” Pinson says. “If you’re doing these things to protect the validity of you hospital’s billing, you’ll be protecting yourself at the same time, and it’s unlikely that RACs will single you out at all for auditing.”
Hospitalists can be valuable participants on their institutions’ RAC response team, providing clinical clarification on cases and helping to draft appeal letters.
There are several other red flags that RACs zero in on and hospitalists should watch out for, says Kathy DeVault, RHIA, CCS, CCS-P, manager of Professional Practice Resources for the American Health Information Management Association (AHIMA). Specificity in the medical record makes all the difference. For example, by identifying incorrect coding for excisional debridement (removal of infected tissue), RACs collected nearly $18 million in overpayments in fiscal-year 2006 because medical record documentation omitted such details as the word “excisional” (e.g., sharp debridement coded as excisional debridement), whether it was performed in the operating room or not, instruments used, the extent and depth of the procedure, and if the cutting of tissue was outside or beyond the wound margin.
DeVault warns that “RACs are targeting confusion between septicemia and urosepsis.” According to CMS, if the hospital reports a patient’s principal diagnosis as septicemia (03.89) but the medical record indicates the diagnosis of urosepsis, the RAC will bump the diagnosis code down to urinary tract infection (599.0), a lower-payment DRG, and demand recoupment.1
Urosepsis does not have a specific ICD-9-CM diagnosis code, and defaults to a simple UTI code, as referenced in ICD-9-CM. Unless the physician states in his or her documentation that the patient’s condition was systemic sepsis or septicemia, urosepsis would be coded as a UTI. RACS also denied some respiratory-failure claims for incorrect sequencing of principal diagnosis (e.g., respiratory failure vs. sepsis). The American Hospital Association has issued a regulatory advisory about these issues (web.mhanet.com/userdocs/articles/RAC/AHA_RAC_Coding Advisory_071608.pdf).
DeVault highlights three additional RAC targets that might impact HM:
- Documentation for transbronchial biopsy (a surgical DRG) in which the medical record only shows pathology of bronchus tissue (which RACs regard as nonsurgical);
- Failure to document the severity of a patient’s anemia as such to meet the medical necessity requirement of a blood transfusion (e.g., a chronic blood loss anemia or a pernicious anemia); and
- Documentation of treatments performed by intensivists in an ICU. By the time a patient’s attending physician sees their patient out of the ICU, DeVault says, their acute renal failure could be turned around but the attending might not document what happened in the ICU. The intensivist must see to it that the documentation allows the appropriate DRG assignment for the level of care the patient received.
AHIMA has published a 65-page RAC Audit Toolkit that describes the audit process, outlines preparations and procedures, and offers concrete guidance for appeals. Download a copy at www.ahima.org/infocenter/documents/RACToolkitFINAL.pdf. TH
Chris Guadagnino is a freelance medical writer based in Philadelphia.
Reference
- The Medicare Recovery Audit Contractor (RAC) program: an evaluation of the 3-year demonstration. CMS Web site. Available at: www.cms.hhs.gov/RAC/Downloads/RACEvaluationReport.pdf. Accessed March 3, 2010.
Refinements in CMS’ Permanent RAC Program
Based on lessons learned from demonstration programs, CMS has made a number of changes to the permanent Recovery Audit Contractor (RAC) program.
Among the changes are:
- RACs cannot audit claims earlier than three years from the start of the program, with a maximum look-back date of October 1, 2007;
- For physicians, RACs are limited to requesting 10 medical records per 45 days from a single physician, 20 medical records from a small practice of two to five physicians, 30 from a group of six to 15, and 50 from a large group of more than 16 physicians;
- For hospitals, RACs are limited to requesting 1% of all claims submitted for the previous calendar year, divided into eight periods (45 days). Although the RACs may go more than 45 days between record requests, in no case shall they make requests more frequently than every 45 days;
- RACs must send a “Detailed Review Results” letter within 60 calendar days of receipt of the medical records they request for review;
- Each RAC must hire a physician medical director and certified coders, and providers may request the credentials of their auditor and request to speak to their RAC’s medical director regarding a claim denial;
- All new issues that an RAC wishes to pursue for overpayments must be validated by CMS or an independent RAC validation contractor, and posted to the RAC’s Web site before widespread review;
- RACS must have a Web-based “Claim Status” platform that will allow providers to track the status of medical record submissions to RACs;
- RACs must pay back contingency fees when an improper payment determination is overturned at any level in the appeals process (demo RACs were allowed to retain them on determinations overturned on second- and third-level appeal); and
- RAC validation contractors will conduct a third-party review of RAC claims determinations and provide annual accuracy scores for each RAC.—CG
Hospitalists will be essential players in helping their institutions prepare for the Recovery Audit Contractor (RAC) program, now being rolled out nationwide by the Centers for Medicare & Medicaid Services (CMS). The program is part of CMS’ arsenal to ferret out improper payments and prevent fraud, waste, and abuse in the Medicare system.
All providers who bill Medicare fee-for-service are fair game for an RAC audit, which scrutinizes medical records to validate diagnosis-related groups (DRGs), coding, and the necessity of care provided by hospitals. Hospitalists are being asked to document their diagnosis and treatment decisions more precisely and thoroughly than ever, ensuring that DRG coding is appropriate, medical necessity is watertight, and hospitals are defended from costly overpayment recovery.
Specificity of documentation is the hospitalist’s most potent weapon against this new layer of federal audits.
In a three-year demonstration of the RAC program that ended in March 2008, one-third of all medical records audited resulted in an overpayment finding and collection. RACs collected more than $900 million in overpayments and returned nearly $38 million in underpayments. One-third of provider appeals (physician, hospital, and other providers) were successful during the demo program, according to a June 2008 CMS evaluation report. (Download a copy of the report at www.cms.hhs.gov/RAC/Downloads/RAC_Demonstration_Evaluation_Report.pdf.)
How the Audits Work
Listen to an interview with Dr. Pinson
Out of concern that the Medicare Trust Fund might not be adequately protected against improper payments by existing error detection and prevention efforts, Congress directed CMS to use RACs to identify and recoup Medicare overpayments under Section 306 of the Medicare Modernization Act of 2003, and directed CMS to make the program permanent by 2010 under Section 302 of the Tax Relief and Health Care Act of 2006. According to CMS, RACs were implemented so that physicians and other providers could avoid submitting claims that do not comply with Medicare rules, CMS could lower its error rate, and taxpayers and future Medicare beneficiaries would be protected.1
CMS has contracted with four regional RACs for the national program, and each will use proprietary auditing software to review paid claims from Medicare Part A and Part B providers to ensure that they meet Medicare’s statutory, regulatory, and policy requirements and regulations.
The RACs use automated review for claims that clearly contain errors that resulted in improper payments (e.g., claims for duplicate or uncovered services, claims that violate a written Medicare policy or sanctioned coding guideline), in which case the RAC notifies the provider of the overpayment. For cases in which there is a high probability—but not certainty—that the claim contains an overpayment, the RAC requests medical records from the provider (including imaged medical records on CD or DVD) to conduct a complex review and make a determination as to whether payment of the claim was correct, or whether there was an over- or underpayment.
CMS uses a Web-based data warehouse to ensure that RACs do not review claims that have previously been reviewed by another entity, such as a Medicare carrier, fiscal intermediary, the Office of Inspector General, or a quality-improvement organization (QIO).
The four regional RACs are ramping up their claim review activities in all states, says Connie Leonard, director of CMS’ Division of Recovery Audit Operations. When overpayments are confirmed, the RACs issue letters demanding providers to repay their Medicare carrier or intermediary within 30 days. For confirmed underpayments, RACs inform the provider’s Medicare contractor or fiscal intermediary, which then forwards the additional payment, Leonard says.
Providers can repay an overpayment by check or installment plan on or before 30 days after receiving the RAC demand letter. The Medicare contractors use recoupment—reducing present or future Medicare payments—on day 41. Providers who wish to dispute overpayment charges can take their case through the usual Medicare claims appeal process. RACs also offer a “discussion period”—from the date the provider gets a “Detailed Review Results” letter until the date of recoupment—to discuss with the RAC an improper payment determination outside the normal appeal process, Leonard says.
—Kathy DeVault, RHIA, CCS, CCS-P, manager, Professional Practice Resources, American Health Information Management Association, Chicago
If providers disagree with the RAC’s determination, Leonard says, they should either 1) pay by check by day 30 and file for appeal by day 120 of the demand letter; 2) allow recoupment on day 41 and file for appeal by day 120; 3) stop the recoupment by filing an appeal by day 30; or 4) request an extended payment plan and appeal by day 120.
Some physicians in the demonstration project regarded the third-party RAC companies as “bounty hunters” operating without sufficient CMS oversight, imposing undue administrative burdens on physician practices, and lacking the clinical expertise to adjudicate claims appropriately, according to Michael Schweitz, MD, a rheumatologist from West Palm Beach, Fla., who testified before a Congressional committee in 2008 about RAC activities.
In response, CMS has modified the program (see “Refinements in Permanent RAC Program,” p. 8) in several ways to address those flaws and ensure a fair and smooth auditing process, Leonard says. (Listen to an audio interview with Ms. Leonard)
All About the Details
Because RACs focus on coding and documentation that fails to support DRG designations, hospitalists who focus on accurate and precise documentation that can be coded properly will greatly help their hospitals defend against RAC audits, as well as yield better payment and improved quality scores, says Richard D. Pinson, MD, FACP, CCS, principal of HCQ Consulting in Nashville, Tenn. Pinson will present “Documentation Tips Your Hospital Will Love You For” at HM10 in Washington, D.C., this month. A video/audio download of the presentation will be available on SHM’s Web site in May.
“Coding rules and terminology often don’t match what we’re used to writing in the record, so hospitalists need to learn what these connections are and use them in their medical record documentation,” Pinson says. “This is a core skill for hospitalists: being able to translate clinical terminology into the correct coding terminology for hospitals and coders.”
For example, if a hospitalist sees that a pre-operative patient has severe congestive heart failure, that condition cannot be coded as a complication of the patient’s care or considered as such in the DRG assignment, Pinson explains. If the hospitalist says the patient has an acute exacerbation of systolic heart failure, then that is a major comorbidity and ought to be documented as such. The average value of a major comorbidity in a surgical case could be as much as $20,000 per case, Pinson notes. If the DRG assignment included acute exacerbation but the medical chart only said severe congestive heart failure, the hospital would face recoupment of payment from an RAC audit.
“If we’re inconsistent or ambiguous in how we apply our terms, we can end up inadvertently upcoding. The key is: Learn to use the right terms that correspond to the right codes, based on what your patient actually has, and then be consistent throughout the record in your use of those terms,” Pinson says. For example, “we may admit a patient and say at the very beginning that the patient probably has aspiration pneumonia. We then treat the patient for aspiration pneumonia but leave it out of the discharge summary. The coder may code aspiration pneumonia, but the RAC auditor may point out that it was only mentioned in the patient’s record once, as possible, and may recoup any payment for treatment beyond simple pneumonia.”
Level of care and symptom-based DRG designations are red flags for RAC recovery, Pinson says. When the auditor sees a DRG based on symptoms rather than diagnoses (e.g., chest pain, syncope, transient ischemic attack, dehydration) and it is billed as inpatient status instead of observation status, that’s a target. Those symptoms, he says, often don’t meet the medical necessity criteria for inpatient status.
Pinson advises hospitalists to ask their institution’s case-management department, or hire an external consultant, to abstract key criteria for patient status designation, and to consider starting a patient as observation status until a precise diagnosis can be made that warrants hospital admission. Hospitalists should then describe the patient’s situation more precisely in the medical record as a diagnosis, not just as symptoms—e.g., syncope suspected due to cardiac arrhythmia, or chest pain suspected to be angina.
“For inpatient billing, those uncertain diagnoses, described that way, count as if they were established conditions. They don’t go into symptom DRGs,” Pinson says. “If you’re doing these things to protect the validity of you hospital’s billing, you’ll be protecting yourself at the same time, and it’s unlikely that RACs will single you out at all for auditing.”
Hospitalists can be valuable participants on their institutions’ RAC response team, providing clinical clarification on cases and helping to draft appeal letters.
There are several other red flags that RACs zero in on and hospitalists should watch out for, says Kathy DeVault, RHIA, CCS, CCS-P, manager of Professional Practice Resources for the American Health Information Management Association (AHIMA). Specificity in the medical record makes all the difference. For example, by identifying incorrect coding for excisional debridement (removal of infected tissue), RACs collected nearly $18 million in overpayments in fiscal-year 2006 because medical record documentation omitted such details as the word “excisional” (e.g., sharp debridement coded as excisional debridement), whether it was performed in the operating room or not, instruments used, the extent and depth of the procedure, and if the cutting of tissue was outside or beyond the wound margin.
DeVault warns that “RACs are targeting confusion between septicemia and urosepsis.” According to CMS, if the hospital reports a patient’s principal diagnosis as septicemia (03.89) but the medical record indicates the diagnosis of urosepsis, the RAC will bump the diagnosis code down to urinary tract infection (599.0), a lower-payment DRG, and demand recoupment.1
Urosepsis does not have a specific ICD-9-CM diagnosis code, and defaults to a simple UTI code, as referenced in ICD-9-CM. Unless the physician states in his or her documentation that the patient’s condition was systemic sepsis or septicemia, urosepsis would be coded as a UTI. RACS also denied some respiratory-failure claims for incorrect sequencing of principal diagnosis (e.g., respiratory failure vs. sepsis). The American Hospital Association has issued a regulatory advisory about these issues (web.mhanet.com/userdocs/articles/RAC/AHA_RAC_Coding Advisory_071608.pdf).
DeVault highlights three additional RAC targets that might impact HM:
- Documentation for transbronchial biopsy (a surgical DRG) in which the medical record only shows pathology of bronchus tissue (which RACs regard as nonsurgical);
- Failure to document the severity of a patient’s anemia as such to meet the medical necessity requirement of a blood transfusion (e.g., a chronic blood loss anemia or a pernicious anemia); and
- Documentation of treatments performed by intensivists in an ICU. By the time a patient’s attending physician sees their patient out of the ICU, DeVault says, their acute renal failure could be turned around but the attending might not document what happened in the ICU. The intensivist must see to it that the documentation allows the appropriate DRG assignment for the level of care the patient received.
AHIMA has published a 65-page RAC Audit Toolkit that describes the audit process, outlines preparations and procedures, and offers concrete guidance for appeals. Download a copy at www.ahima.org/infocenter/documents/RACToolkitFINAL.pdf. TH
Chris Guadagnino is a freelance medical writer based in Philadelphia.
Reference
- The Medicare Recovery Audit Contractor (RAC) program: an evaluation of the 3-year demonstration. CMS Web site. Available at: www.cms.hhs.gov/RAC/Downloads/RACEvaluationReport.pdf. Accessed March 3, 2010.
Refinements in CMS’ Permanent RAC Program
Based on lessons learned from demonstration programs, CMS has made a number of changes to the permanent Recovery Audit Contractor (RAC) program.
Among the changes are:
- RACs cannot audit claims earlier than three years from the start of the program, with a maximum look-back date of October 1, 2007;
- For physicians, RACs are limited to requesting 10 medical records per 45 days from a single physician, 20 medical records from a small practice of two to five physicians, 30 from a group of six to 15, and 50 from a large group of more than 16 physicians;
- For hospitals, RACs are limited to requesting 1% of all claims submitted for the previous calendar year, divided into eight periods (45 days). Although the RACs may go more than 45 days between record requests, in no case shall they make requests more frequently than every 45 days;
- RACs must send a “Detailed Review Results” letter within 60 calendar days of receipt of the medical records they request for review;
- Each RAC must hire a physician medical director and certified coders, and providers may request the credentials of their auditor and request to speak to their RAC’s medical director regarding a claim denial;
- All new issues that an RAC wishes to pursue for overpayments must be validated by CMS or an independent RAC validation contractor, and posted to the RAC’s Web site before widespread review;
- RACS must have a Web-based “Claim Status” platform that will allow providers to track the status of medical record submissions to RACs;
- RACs must pay back contingency fees when an improper payment determination is overturned at any level in the appeals process (demo RACs were allowed to retain them on determinations overturned on second- and third-level appeal); and
- RAC validation contractors will conduct a third-party review of RAC claims determinations and provide annual accuracy scores for each RAC.—CG
ONLINE EXCLUSIVE: Audio interviews with Medicare audit program experts
ONLINE EXCLUSIVE: Audio interview with HM director Greg Maynard
Prevent Defense
Three U.S. medical centers have been recognized for innovative approaches to preventing DVT and its potentially fatal complications, which include pulmonary embolism (PE). Central to each of the DVT prevention strategies is a risk assessment tool that is easy to use, built directly into routine care, and linked directly to guideline-recommended choices for prophylaxis.
The University of California at San Diego (UCSD) Medical Center, Johns Hopkins Hospital in Baltimore, and the Veterans Affairs (VA) Medical Center in Washington, D.C., each received the first DVTeamCare Hospital Award. The North American Thrombosis Forum (NATF), in conjunction with pharmaceutical company Eisai Inc., recognized each center’s accomplishment based upon an evaluation by an independent panel of expert judges.
—Gregory A. Maynard, MD, FHM, hospital medicine division chief, University of California at San Diego
The award reflects NATF’s goal of enhancing thrombosis education, prevention, diagnosis, and treatment to improve patient outcomes, says NATF Executive Director Ilene Sussman, PhD. Dr. Sussman notes that DVT affects more than 600,000 Americans annually, kills more than 100,000, and is one of the leading causes of preventable deaths in hospitals. Preventable DVT-related complication is on Medicare’s list of “never events,” for which hospitals will no longer be reimbursed.
UCSD, representing medical centers with more than 200 beds, imbedded its VTE prevention protocol into admission, transfer, and perioperative order sets across all medical and surgical services, says Gregory A. Maynard, MD, FHM, hospital medicine division chief. The protocol flags three levels of DVT risk, notes possible contraindications for a particular kind of patient, and presents a set of options for guideline-recommended prophylaxis. The protocol can be paper- or computer-based. Prompting concurrent intervention is a central component of UCSD’s implementation strategy, “identifying in real-time patients who are not receiving the right DVT prophylaxis and having a front-line nurse or pharmacist intervene appropriately,” Dr. Maynard explains.
The percent of UCSD’s patients on adequate prophylaxis rose to more than 98% in the past two years, up from about 50% before the intervention, while preventable VTE dropped by 85%—about 50 fewer cases per year in a hospital with fewer than 300 beds. “Having DVT prevention protocols such as these in place allows hospitalists to provide better care with less effort by leaving hospitalists free to focus on more complicated patient-care issues,” Dr. Maynard says.
UCSD has partnered with SHM to develop DVT prevention toolkits and mentored collaboratives, with which hospitalists can take the lead on QI projects at their local institutions. SHM’s online VTE Implementation Guide is available at www.hospitalmedicine.org/ResourceRoomRedesign/RR_VTE/VTE_Home.cfm.
Johns Hopkins Hospital, representing medical centers with more than 200 beds, developed a mandatory computer-based decision-support system to facilitate specialty-specific risk-factor assessment and the application of risk-appropriate VTE prophylaxis, says Michael Streiff, MD, FACP, director of Johns Hopkins’ Anticoagulation Management Service and Outpatient Clinic, and a member of its Evidence-Based Practice Center. Before a physician can issue any orders—medications, lab tests, nursing instructions, etc.—using a physician transfer order set, the computerized order-entry system automatically guides them through a concise set of questions about a patient’s DVT risk factors, contraindications for blood thinners, and guideline-recommended prophylaxis choices, Dr. Streiff says.
Since implementing the system, the percent of patients being DVT-risk-stratified within 24 hours of hospital admission rose to more than 90%, and nearly 9 in 10 of the appropriate patients are now receiving risk-appropriate, American College of Chest Physicians-approved DVT prophylaxis, up from about 26% before the intervention, Dr. Streiff notes.
The VA Medical Center in Washington, D.C., representing medical centers with fewer than 200 beds, participated in a mentorship collaborative with UCSD’s Dr. Maynard and designed a seven-step process that walks providers through an evidence-based risk-factor assessment to determine appropriate thromboprophylactic therapy, says Divya Shroff, MD, associate chief of staff, Informatics. The guideline-driven steps are integrated into the VA’s computerized patient medical record system and take no more than 60 seconds to follow, says pharmacy practice resident Jovonne H. Jones, PharmD. The steps include:
- Assess patient DVT risk level;
- Educate patient about the order;
- Identify contraindications, if any;
- Choose prophylaxis drug or device;
- Accept order for drug or device;
- Check if additional prophylactic method is needed; and
- Accept the final order.
After the intervention, the rate at which patients receive appropriate prophylaxis upon admission more than doubled. Twenty VA medical centers around the country are in the process of implementing the system, Jones says.
The award-winning protocols will be presented at an NATF-hosted program April 9 at Harvard Medical School. The protocols and implementation plans will be made available at www.DVTeamCareAward.com to help other hospitals enhance their efforts to prevent DVT. TH
Chris Guadagnino is a freelance medical writer based in Philadelphia.
Three U.S. medical centers have been recognized for innovative approaches to preventing DVT and its potentially fatal complications, which include pulmonary embolism (PE). Central to each of the DVT prevention strategies is a risk assessment tool that is easy to use, built directly into routine care, and linked directly to guideline-recommended choices for prophylaxis.
The University of California at San Diego (UCSD) Medical Center, Johns Hopkins Hospital in Baltimore, and the Veterans Affairs (VA) Medical Center in Washington, D.C., each received the first DVTeamCare Hospital Award. The North American Thrombosis Forum (NATF), in conjunction with pharmaceutical company Eisai Inc., recognized each center’s accomplishment based upon an evaluation by an independent panel of expert judges.
—Gregory A. Maynard, MD, FHM, hospital medicine division chief, University of California at San Diego
The award reflects NATF’s goal of enhancing thrombosis education, prevention, diagnosis, and treatment to improve patient outcomes, says NATF Executive Director Ilene Sussman, PhD. Dr. Sussman notes that DVT affects more than 600,000 Americans annually, kills more than 100,000, and is one of the leading causes of preventable deaths in hospitals. Preventable DVT-related complication is on Medicare’s list of “never events,” for which hospitals will no longer be reimbursed.
UCSD, representing medical centers with more than 200 beds, imbedded its VTE prevention protocol into admission, transfer, and perioperative order sets across all medical and surgical services, says Gregory A. Maynard, MD, FHM, hospital medicine division chief. The protocol flags three levels of DVT risk, notes possible contraindications for a particular kind of patient, and presents a set of options for guideline-recommended prophylaxis. The protocol can be paper- or computer-based. Prompting concurrent intervention is a central component of UCSD’s implementation strategy, “identifying in real-time patients who are not receiving the right DVT prophylaxis and having a front-line nurse or pharmacist intervene appropriately,” Dr. Maynard explains.
The percent of UCSD’s patients on adequate prophylaxis rose to more than 98% in the past two years, up from about 50% before the intervention, while preventable VTE dropped by 85%—about 50 fewer cases per year in a hospital with fewer than 300 beds. “Having DVT prevention protocols such as these in place allows hospitalists to provide better care with less effort by leaving hospitalists free to focus on more complicated patient-care issues,” Dr. Maynard says.
UCSD has partnered with SHM to develop DVT prevention toolkits and mentored collaboratives, with which hospitalists can take the lead on QI projects at their local institutions. SHM’s online VTE Implementation Guide is available at www.hospitalmedicine.org/ResourceRoomRedesign/RR_VTE/VTE_Home.cfm.
Johns Hopkins Hospital, representing medical centers with more than 200 beds, developed a mandatory computer-based decision-support system to facilitate specialty-specific risk-factor assessment and the application of risk-appropriate VTE prophylaxis, says Michael Streiff, MD, FACP, director of Johns Hopkins’ Anticoagulation Management Service and Outpatient Clinic, and a member of its Evidence-Based Practice Center. Before a physician can issue any orders—medications, lab tests, nursing instructions, etc.—using a physician transfer order set, the computerized order-entry system automatically guides them through a concise set of questions about a patient’s DVT risk factors, contraindications for blood thinners, and guideline-recommended prophylaxis choices, Dr. Streiff says.
Since implementing the system, the percent of patients being DVT-risk-stratified within 24 hours of hospital admission rose to more than 90%, and nearly 9 in 10 of the appropriate patients are now receiving risk-appropriate, American College of Chest Physicians-approved DVT prophylaxis, up from about 26% before the intervention, Dr. Streiff notes.
The VA Medical Center in Washington, D.C., representing medical centers with fewer than 200 beds, participated in a mentorship collaborative with UCSD’s Dr. Maynard and designed a seven-step process that walks providers through an evidence-based risk-factor assessment to determine appropriate thromboprophylactic therapy, says Divya Shroff, MD, associate chief of staff, Informatics. The guideline-driven steps are integrated into the VA’s computerized patient medical record system and take no more than 60 seconds to follow, says pharmacy practice resident Jovonne H. Jones, PharmD. The steps include:
- Assess patient DVT risk level;
- Educate patient about the order;
- Identify contraindications, if any;
- Choose prophylaxis drug or device;
- Accept order for drug or device;
- Check if additional prophylactic method is needed; and
- Accept the final order.
After the intervention, the rate at which patients receive appropriate prophylaxis upon admission more than doubled. Twenty VA medical centers around the country are in the process of implementing the system, Jones says.
The award-winning protocols will be presented at an NATF-hosted program April 9 at Harvard Medical School. The protocols and implementation plans will be made available at www.DVTeamCareAward.com to help other hospitals enhance their efforts to prevent DVT. TH
Chris Guadagnino is a freelance medical writer based in Philadelphia.
Three U.S. medical centers have been recognized for innovative approaches to preventing DVT and its potentially fatal complications, which include pulmonary embolism (PE). Central to each of the DVT prevention strategies is a risk assessment tool that is easy to use, built directly into routine care, and linked directly to guideline-recommended choices for prophylaxis.
The University of California at San Diego (UCSD) Medical Center, Johns Hopkins Hospital in Baltimore, and the Veterans Affairs (VA) Medical Center in Washington, D.C., each received the first DVTeamCare Hospital Award. The North American Thrombosis Forum (NATF), in conjunction with pharmaceutical company Eisai Inc., recognized each center’s accomplishment based upon an evaluation by an independent panel of expert judges.
—Gregory A. Maynard, MD, FHM, hospital medicine division chief, University of California at San Diego
The award reflects NATF’s goal of enhancing thrombosis education, prevention, diagnosis, and treatment to improve patient outcomes, says NATF Executive Director Ilene Sussman, PhD. Dr. Sussman notes that DVT affects more than 600,000 Americans annually, kills more than 100,000, and is one of the leading causes of preventable deaths in hospitals. Preventable DVT-related complication is on Medicare’s list of “never events,” for which hospitals will no longer be reimbursed.
UCSD, representing medical centers with more than 200 beds, imbedded its VTE prevention protocol into admission, transfer, and perioperative order sets across all medical and surgical services, says Gregory A. Maynard, MD, FHM, hospital medicine division chief. The protocol flags three levels of DVT risk, notes possible contraindications for a particular kind of patient, and presents a set of options for guideline-recommended prophylaxis. The protocol can be paper- or computer-based. Prompting concurrent intervention is a central component of UCSD’s implementation strategy, “identifying in real-time patients who are not receiving the right DVT prophylaxis and having a front-line nurse or pharmacist intervene appropriately,” Dr. Maynard explains.
The percent of UCSD’s patients on adequate prophylaxis rose to more than 98% in the past two years, up from about 50% before the intervention, while preventable VTE dropped by 85%—about 50 fewer cases per year in a hospital with fewer than 300 beds. “Having DVT prevention protocols such as these in place allows hospitalists to provide better care with less effort by leaving hospitalists free to focus on more complicated patient-care issues,” Dr. Maynard says.
UCSD has partnered with SHM to develop DVT prevention toolkits and mentored collaboratives, with which hospitalists can take the lead on QI projects at their local institutions. SHM’s online VTE Implementation Guide is available at www.hospitalmedicine.org/ResourceRoomRedesign/RR_VTE/VTE_Home.cfm.
Johns Hopkins Hospital, representing medical centers with more than 200 beds, developed a mandatory computer-based decision-support system to facilitate specialty-specific risk-factor assessment and the application of risk-appropriate VTE prophylaxis, says Michael Streiff, MD, FACP, director of Johns Hopkins’ Anticoagulation Management Service and Outpatient Clinic, and a member of its Evidence-Based Practice Center. Before a physician can issue any orders—medications, lab tests, nursing instructions, etc.—using a physician transfer order set, the computerized order-entry system automatically guides them through a concise set of questions about a patient’s DVT risk factors, contraindications for blood thinners, and guideline-recommended prophylaxis choices, Dr. Streiff says.
Since implementing the system, the percent of patients being DVT-risk-stratified within 24 hours of hospital admission rose to more than 90%, and nearly 9 in 10 of the appropriate patients are now receiving risk-appropriate, American College of Chest Physicians-approved DVT prophylaxis, up from about 26% before the intervention, Dr. Streiff notes.
The VA Medical Center in Washington, D.C., representing medical centers with fewer than 200 beds, participated in a mentorship collaborative with UCSD’s Dr. Maynard and designed a seven-step process that walks providers through an evidence-based risk-factor assessment to determine appropriate thromboprophylactic therapy, says Divya Shroff, MD, associate chief of staff, Informatics. The guideline-driven steps are integrated into the VA’s computerized patient medical record system and take no more than 60 seconds to follow, says pharmacy practice resident Jovonne H. Jones, PharmD. The steps include:
- Assess patient DVT risk level;
- Educate patient about the order;
- Identify contraindications, if any;
- Choose prophylaxis drug or device;
- Accept order for drug or device;
- Check if additional prophylactic method is needed; and
- Accept the final order.
After the intervention, the rate at which patients receive appropriate prophylaxis upon admission more than doubled. Twenty VA medical centers around the country are in the process of implementing the system, Jones says.
The award-winning protocols will be presented at an NATF-hosted program April 9 at Harvard Medical School. The protocols and implementation plans will be made available at www.DVTeamCareAward.com to help other hospitals enhance their efforts to prevent DVT. TH
Chris Guadagnino is a freelance medical writer based in Philadelphia.
Prevention Prowess
Three medical centers have been nationally recognized for innovative approaches to preventing DVT and its potentially fatal complications. Central to each of the prevention strategies is a risk assessment tool that is easy to use, built directly into routine care, and linked directly to guideline-recommended choices for prophylaxis.
The North American Thrombosis Forum (NATF), in coordination with the pharmaceutical company Eisai Inc., recognized the following centers with the first DVTeamCare Hospital Award:
- The University of California at San Diego Medical Center was awarded as a representative of medical centers with more than 200 beds. The hospital embedded its VTE prevention protocol into admission, transfer, and perioperative order sets across all medical and surgical services, says Gregory A. Maynard, MD, chief of the division of hospital medicine. The protocol flags three levels of DVT risk, notes possible contraindications for a particular kind of patient, and presents a set of options for guideline-recommended prophylaxis. The protocol can be paper- or computer-based.
- The Johns Hopkins Hospital in Baltimore, also awarded as a representative for medical centers with more than 200 beds, developed a mandatory computer-based decision support system to facilitate specialty-specific risk factor assessment and the application of risk-appropriate VTE prophylaxis.
- The Washington, D.C., Veterans Affairs Medical Center won in the category representing medical centers with fewer than 200 beds. The hospital designed a seven-step process that walks providers through an evidence-based risk-factor assessment to determine appropriate thromboprophylactic therapy.
The DVTeamCare Hospital Award reflects NATF's goal of enhancing thrombosis education, prevention, diagnosis, and treatment to improve patient outcomes, says NATF Executive Director Ilene Sussman, PhD.
Dr. Maynard and his UCSD colleagues have made their DVT prophylaxis toolkit available to other hospitalists wanting to lead similar efforts in their own hospital. The toolkit is posted both on the AHRQ and SHM Web sites.
"SHM and AHRQ should feel proud about this because we were one of the first places to do this successfully at such a high level," Dr. Maynard says. "We partnered with others and with SHM to build similar toolkits. SHM built VTE prevention collaboratives that enroll hospitalist leaders and mentor them through the process of VTE prevention performance improvement, tracking results longitudinally. Divya Shroff and her group in Washington, D.C., were enrolled in that VTE prevention collaborative. Their team won an award in VTE prevention by following the road map and by coming up with a good order set for DVT prevention that could be used in their VA hospital and in many other VAs across the country. I think that speaks to the strength of the concepts that we're using."
Each of the award-winning protocols will be presented at an NATF-sponsored program April 9 at Harvard Medical School in Boston. After the presentation, the winning protocols and implementation plans will be available at www.DVTeamCareAward.com to help other hospitals enhance their efforts to prevent DVT.
Three medical centers have been nationally recognized for innovative approaches to preventing DVT and its potentially fatal complications. Central to each of the prevention strategies is a risk assessment tool that is easy to use, built directly into routine care, and linked directly to guideline-recommended choices for prophylaxis.
The North American Thrombosis Forum (NATF), in coordination with the pharmaceutical company Eisai Inc., recognized the following centers with the first DVTeamCare Hospital Award:
- The University of California at San Diego Medical Center was awarded as a representative of medical centers with more than 200 beds. The hospital embedded its VTE prevention protocol into admission, transfer, and perioperative order sets across all medical and surgical services, says Gregory A. Maynard, MD, chief of the division of hospital medicine. The protocol flags three levels of DVT risk, notes possible contraindications for a particular kind of patient, and presents a set of options for guideline-recommended prophylaxis. The protocol can be paper- or computer-based.
- The Johns Hopkins Hospital in Baltimore, also awarded as a representative for medical centers with more than 200 beds, developed a mandatory computer-based decision support system to facilitate specialty-specific risk factor assessment and the application of risk-appropriate VTE prophylaxis.
- The Washington, D.C., Veterans Affairs Medical Center won in the category representing medical centers with fewer than 200 beds. The hospital designed a seven-step process that walks providers through an evidence-based risk-factor assessment to determine appropriate thromboprophylactic therapy.
The DVTeamCare Hospital Award reflects NATF's goal of enhancing thrombosis education, prevention, diagnosis, and treatment to improve patient outcomes, says NATF Executive Director Ilene Sussman, PhD.
Dr. Maynard and his UCSD colleagues have made their DVT prophylaxis toolkit available to other hospitalists wanting to lead similar efforts in their own hospital. The toolkit is posted both on the AHRQ and SHM Web sites.
"SHM and AHRQ should feel proud about this because we were one of the first places to do this successfully at such a high level," Dr. Maynard says. "We partnered with others and with SHM to build similar toolkits. SHM built VTE prevention collaboratives that enroll hospitalist leaders and mentor them through the process of VTE prevention performance improvement, tracking results longitudinally. Divya Shroff and her group in Washington, D.C., were enrolled in that VTE prevention collaborative. Their team won an award in VTE prevention by following the road map and by coming up with a good order set for DVT prevention that could be used in their VA hospital and in many other VAs across the country. I think that speaks to the strength of the concepts that we're using."
Each of the award-winning protocols will be presented at an NATF-sponsored program April 9 at Harvard Medical School in Boston. After the presentation, the winning protocols and implementation plans will be available at www.DVTeamCareAward.com to help other hospitals enhance their efforts to prevent DVT.
Three medical centers have been nationally recognized for innovative approaches to preventing DVT and its potentially fatal complications. Central to each of the prevention strategies is a risk assessment tool that is easy to use, built directly into routine care, and linked directly to guideline-recommended choices for prophylaxis.
The North American Thrombosis Forum (NATF), in coordination with the pharmaceutical company Eisai Inc., recognized the following centers with the first DVTeamCare Hospital Award:
- The University of California at San Diego Medical Center was awarded as a representative of medical centers with more than 200 beds. The hospital embedded its VTE prevention protocol into admission, transfer, and perioperative order sets across all medical and surgical services, says Gregory A. Maynard, MD, chief of the division of hospital medicine. The protocol flags three levels of DVT risk, notes possible contraindications for a particular kind of patient, and presents a set of options for guideline-recommended prophylaxis. The protocol can be paper- or computer-based.
- The Johns Hopkins Hospital in Baltimore, also awarded as a representative for medical centers with more than 200 beds, developed a mandatory computer-based decision support system to facilitate specialty-specific risk factor assessment and the application of risk-appropriate VTE prophylaxis.
- The Washington, D.C., Veterans Affairs Medical Center won in the category representing medical centers with fewer than 200 beds. The hospital designed a seven-step process that walks providers through an evidence-based risk-factor assessment to determine appropriate thromboprophylactic therapy.
The DVTeamCare Hospital Award reflects NATF's goal of enhancing thrombosis education, prevention, diagnosis, and treatment to improve patient outcomes, says NATF Executive Director Ilene Sussman, PhD.
Dr. Maynard and his UCSD colleagues have made their DVT prophylaxis toolkit available to other hospitalists wanting to lead similar efforts in their own hospital. The toolkit is posted both on the AHRQ and SHM Web sites.
"SHM and AHRQ should feel proud about this because we were one of the first places to do this successfully at such a high level," Dr. Maynard says. "We partnered with others and with SHM to build similar toolkits. SHM built VTE prevention collaboratives that enroll hospitalist leaders and mentor them through the process of VTE prevention performance improvement, tracking results longitudinally. Divya Shroff and her group in Washington, D.C., were enrolled in that VTE prevention collaborative. Their team won an award in VTE prevention by following the road map and by coming up with a good order set for DVT prevention that could be used in their VA hospital and in many other VAs across the country. I think that speaks to the strength of the concepts that we're using."
Each of the award-winning protocols will be presented at an NATF-sponsored program April 9 at Harvard Medical School in Boston. After the presentation, the winning protocols and implementation plans will be available at www.DVTeamCareAward.com to help other hospitals enhance their efforts to prevent DVT.
ONLINE EXCLUSIVE: Audio interview with Janet Corrigan, PhD, MBA
Dr. Corrigan notes there are abundant examples of guideline adherence boosting quality outcomes, length of stay, and time to clinical stability.
Click here to listen to the audio file
Dr. Corrigan notes there are abundant examples of guideline adherence boosting quality outcomes, length of stay, and time to clinical stability.
Click here to listen to the audio file
Dr. Corrigan notes there are abundant examples of guideline adherence boosting quality outcomes, length of stay, and time to clinical stability.
Click here to listen to the audio file