Joshua Lapps

A cornerstone of hospital medicine is the delivery of high-quality inpatient care by improving the performance of the systems and facilities in which hospitalists work. By extension, hospitalists are often held accountable, in varying ways, for improving the performance of facility metrics, such as those in the Hospital Value-Based Purchasing (HVBP), Inpatient Quality Reporting, and Hospital Readmissions Reduction programs.

Despite the work hospitalists were already doing to improve both efficiency and quality within their institutions, the 2010 Affordable Care Act introduced penalties for clinicians who did not submit qualifying provider-level data via the Physician Quality Reporting System program. Initially only an incentive program, PQRS was ultimately incorporated into the Physician Value-Based Payment (VBP) Modifier to make performance-based payment adjustments to Medicare physician payment. At this point, many hospitalists were not only accountable for helping to improve the metrics of their facilities, but also required to report individually or within their groups on provider-level measures, many of which were irrelevant to hospital medicine practice.

With this dual burden becoming evident, the Society of Hospital Medicine approached the Centers for Medicare & Medicaid Services with a possible solution. Could hospitalists elect to use their facilities’ metrics as a stand-in for the provider level metrics? Not only would this reduce the burden of reporting irrelevant metrics, but it would also help alleviate some of the disadvantages hospitalists face within Physician VBP.

The CMS was initially very supportive of the concept, but informed the SHM such alignment was not possible under existing law. In brief, the law required Physician VBP to remain completely within the Physician Fee Schedule and its related metrics; facility level metrics from a different payment system could not be used.

Undeterred, the SHM sought opportunities to change the law. As Congress was developing the Medicare Access and Chip Reauthorization Act (MACRA), the SHM worked closely with lawmakers to include language that would permit measures in “other payment systems” to be used for physician performance assessment. This language was retained in the final version of MACRA that was signed into law on April 16, 2015.

The SHM continued its advocacy, working closely with the CMS and its new authority to shape an option to align Medicare’s facility metrics and scores with provider reporting. Today that idea is a reality. Beginning this year, the CMS will have a new Merit-based Incentive Payment System (MIPS) reporting option available for hospitalists: facility-based measurement.

Facility-based measurement enables clinicians to receive a score for the Quality and Cost categories of the MIPS, without the need to collect and report on measures separately. Eligible providers would receive the MIPS score in those categories associated with the same percentile as their hospital’s score in HVBP. No more administrative work necessary to collect, clean and report on data for quality measures in the MIPS. If you are eligible, the CMS will automatically calculate a Quality and Cost score and combine this with your score from Improvement Activities and Promoting Interoperability (if you are not exempt) to give you a final MIPS score. If you decide to report on quality measures through the traditional MIPS pathway as well, the CMS will give you the higher of the scores.

There are certainly trade-offs associated with the facility-based measurement option. You do not have the burden of reporting measures on your own, but you do not get to pick what measures and what facility’s score you receive. Facility-level measures may be more difficult to improve performance, particularly as an individual, but the automatic application of facility-based measurement to eligible clinicians and groups serves as a backstop for MIPS reporting.

Aligning facility and clinician performance should encourage collaboration and innovation to meet these shared goals. As such, facility-based measurement represents a massive philosophical and practical shift in CMS measure reporting. As we enter these uncharted waters together, we hope to continue learning from your experiences and perspectives and working to refine facility-based measurement in the future.

For more information about facility-based reporting and the MIPS in general, visit www.macraforhm.org.

Mr. Lapps is government relations senior manager and Mr. Boswell is government relations director at the Society of Hospital Medicine.

Who is eligible for facility-based measurement?

• Individual providers who bill more than 75% of their Medicare Part B professional services in Place of Service 21 (Emergency Department), 22 (Hospital Outpatient), and 23 (Inpatient Hospital), billing at least one service in POS 21 or 23, and work in a hospital with an HVBP score.
• Groups who have at least 75% of their individual clinicians who meet the eligibility criteria.
• Nearly all hospitalists should qualify for facility-based measurement as individuals, while group eligibility depends on the demographics of their staff.

A cornerstone of hospital medicine is the delivery of high-quality inpatient care by improving the performance of the systems and facilities in which hospitalists work. By extension, hospitalists are often held accountable, in varying ways, for improving the performance of facility metrics, such as those in the Hospital Value-Based Purchasing (HVBP), Inpatient Quality Reporting, and Hospital Readmissions Reduction programs.

Despite the work hospitalists were already doing to improve both efficiency and quality within their institutions, the 2010 Affordable Care Act introduced penalties for clinicians who did not submit qualifying provider-level data via the Physician Quality Reporting System program. Initially only an incentive program, PQRS was ultimately incorporated into the Physician Value-Based Payment (VBP) Modifier to make performance-based payment adjustments to Medicare physician payment. At this point, many hospitalists were not only accountable for helping to improve the metrics of their facilities, but also required to report individually or within their groups on provider-level measures, many of which were irrelevant to hospital medicine practice.

With this dual burden becoming evident, the Society of Hospital Medicine approached the Centers for Medicare & Medicaid Services with a possible solution. Could hospitalists elect to use their facilities’ metrics as a stand-in for the provider level metrics? Not only would this reduce the burden of reporting irrelevant metrics, but it would also help alleviate some of the disadvantages hospitalists face within Physician VBP.

The CMS was initially very supportive of the concept, but informed the SHM such alignment was not possible under existing law. In brief, the law required Physician VBP to remain completely within the Physician Fee Schedule and its related metrics; facility level metrics from a different payment system could not be used.

Undeterred, the SHM sought opportunities to change the law. As Congress was developing the Medicare Access and Chip Reauthorization Act (MACRA), the SHM worked closely with lawmakers to include language that would permit measures in “other payment systems” to be used for physician performance assessment. This language was retained in the final version of MACRA that was signed into law on April 16, 2015.

The SHM continued its advocacy, working closely with the CMS and its new authority to shape an option to align Medicare’s facility metrics and scores with provider reporting. Today that idea is a reality. Beginning this year, the CMS will have a new Merit-based Incentive Payment System (MIPS) reporting option available for hospitalists: facility-based measurement.

Facility-based measurement enables clinicians to receive a score for the Quality and Cost categories of the MIPS, without the need to collect and report on measures separately. Eligible providers would receive the MIPS score in those categories associated with the same percentile as their hospital’s score in HVBP. No more administrative work necessary to collect, clean and report on data for quality measures in the MIPS. If you are eligible, the CMS will automatically calculate a Quality and Cost score and combine this with your score from Improvement Activities and Promoting Interoperability (if you are not exempt) to give you a final MIPS score. If you decide to report on quality measures through the traditional MIPS pathway as well, the CMS will give you the higher of the scores.

There are certainly trade-offs associated with the facility-based measurement option. You do not have the burden of reporting measures on your own, but you do not get to pick what measures and what facility’s score you receive. Facility-level measures may be more difficult to improve performance, particularly as an individual, but the automatic application of facility-based measurement to eligible clinicians and groups serves as a backstop for MIPS reporting.

Aligning facility and clinician performance should encourage collaboration and innovation to meet these shared goals. As such, facility-based measurement represents a massive philosophical and practical shift in CMS measure reporting. As we enter these uncharted waters together, we hope to continue learning from your experiences and perspectives and working to refine facility-based measurement in the future.

For more information about facility-based reporting and the MIPS in general, visit www.macraforhm.org.

Mr. Lapps is government relations senior manager and Mr. Boswell is government relations director at the Society of Hospital Medicine.

Who is eligible for facility-based measurement?

• Individual providers who bill more than 75% of their Medicare Part B professional services in Place of Service 21 (Emergency Department), 22 (Hospital Outpatient), and 23 (Inpatient Hospital), billing at least one service in POS 21 or 23, and work in a hospital with an HVBP score.
• Groups who have at least 75% of their individual clinicians who meet the eligibility criteria.
• Nearly all hospitalists should qualify for facility-based measurement as individuals, while group eligibility depends on the demographics of their staff.

A cornerstone of hospital medicine is the delivery of high-quality inpatient care by improving the performance of the systems and facilities in which hospitalists work. By extension, hospitalists are often held accountable, in varying ways, for improving the performance of facility metrics, such as those in the Hospital Value-Based Purchasing (HVBP), Inpatient Quality Reporting, and Hospital Readmissions Reduction programs.

Despite the work hospitalists were already doing to improve both efficiency and quality within their institutions, the 2010 Affordable Care Act introduced penalties for clinicians who did not submit qualifying provider-level data via the Physician Quality Reporting System program. Initially only an incentive program, PQRS was ultimately incorporated into the Physician Value-Based Payment (VBP) Modifier to make performance-based payment adjustments to Medicare physician payment. At this point, many hospitalists were not only accountable for helping to improve the metrics of their facilities, but also required to report individually or within their groups on provider-level measures, many of which were irrelevant to hospital medicine practice.

With this dual burden becoming evident, the Society of Hospital Medicine approached the Centers for Medicare & Medicaid Services with a possible solution. Could hospitalists elect to use their facilities’ metrics as a stand-in for the provider level metrics? Not only would this reduce the burden of reporting irrelevant metrics, but it would also help alleviate some of the disadvantages hospitalists face within Physician VBP.

The CMS was initially very supportive of the concept, but informed the SHM such alignment was not possible under existing law. In brief, the law required Physician VBP to remain completely within the Physician Fee Schedule and its related metrics; facility level metrics from a different payment system could not be used.

Undeterred, the SHM sought opportunities to change the law. As Congress was developing the Medicare Access and Chip Reauthorization Act (MACRA), the SHM worked closely with lawmakers to include language that would permit measures in “other payment systems” to be used for physician performance assessment. This language was retained in the final version of MACRA that was signed into law on April 16, 2015.

The SHM continued its advocacy, working closely with the CMS and its new authority to shape an option to align Medicare’s facility metrics and scores with provider reporting. Today that idea is a reality. Beginning this year, the CMS will have a new Merit-based Incentive Payment System (MIPS) reporting option available for hospitalists: facility-based measurement.

Facility-based measurement enables clinicians to receive a score for the Quality and Cost categories of the MIPS, without the need to collect and report on measures separately. Eligible providers would receive the MIPS score in those categories associated with the same percentile as their hospital’s score in HVBP. No more administrative work necessary to collect, clean and report on data for quality measures in the MIPS. If you are eligible, the CMS will automatically calculate a Quality and Cost score and combine this with your score from Improvement Activities and Promoting Interoperability (if you are not exempt) to give you a final MIPS score. If you decide to report on quality measures through the traditional MIPS pathway as well, the CMS will give you the higher of the scores.

There are certainly trade-offs associated with the facility-based measurement option. You do not have the burden of reporting measures on your own, but you do not get to pick what measures and what facility’s score you receive. Facility-level measures may be more difficult to improve performance, particularly as an individual, but the automatic application of facility-based measurement to eligible clinicians and groups serves as a backstop for MIPS reporting.

Aligning facility and clinician performance should encourage collaboration and innovation to meet these shared goals. As such, facility-based measurement represents a massive philosophical and practical shift in CMS measure reporting. As we enter these uncharted waters together, we hope to continue learning from your experiences and perspectives and working to refine facility-based measurement in the future.

For more information about facility-based reporting and the MIPS in general, visit www.macraforhm.org.

Mr. Lapps is government relations senior manager and Mr. Boswell is government relations director at the Society of Hospital Medicine.

Who is eligible for facility-based measurement?

• Individual providers who bill more than 75% of their Medicare Part B professional services in Place of Service 21 (Emergency Department), 22 (Hospital Outpatient), and 23 (Inpatient Hospital), billing at least one service in POS 21 or 23, and work in a hospital with an HVBP score.
• Groups who have at least 75% of their individual clinicians who meet the eligibility criteria.
• Nearly all hospitalists should qualify for facility-based measurement as individuals, while group eligibility depends on the demographics of their staff.

Federal programs can be enormously complicated, and the Medicare value-based payment programs, such as the Physician Quality Reporting System, the physician value-based payment modifier, and the new Merit-Based Incentive Payment System, are no exception.

It can be a challenge to navigate the rules, to identify how and which measures to report, and to determine how to integrate those requirements into your practice. Furthermore, the feedback from these programs to providers can be difficult to read and interpret.

Part of the value of being a member of the Society of Hospital Medicine (SHM) is having another set of eyes – particularly those that spend a significant amount of time immersed in federal regulations – to parse the policy-practice nexus. SHM hears from members all over the country, many in different practice types and with different policy needs. This knowledge can be shared, both with other members and with policymakers. A recent example highlights the power of this relationship.

Your membership contributes directly to the advocacy efforts of SHM, and the engagement of members with SHM staff on policy issues is a force multiplier for the effect SHM can have on policy decisions. There is a lot of value for belonging to SHM, and sometimes, we can put an exact number on it.

A solo-practicing hospitalist called seeking perspective on why he received a letter indicating he would be receiving a penalty in 2018 for failing the requirements of Physician Quality Reporting System reporting. This hospitalist had successfully reported on as many measures as he possibly could, so he could not understand why he would be receiving a penalty.

All told, a different read of the feedback reports, and some strategic questions from SHM staff, helped this hospitalist understand why he was being penalized and how, in this case, he could ask Centers for Medicare & Medicaid Services for reconsideration. Upon second review by CMS, the penalties were overturned, and this provider should save nearly $30,000 in Medicare payments in 2018.

SHM helped the provider by being a sounding board and by sharing information learned from experiences other members had had with these programs. In turn, the knowledge gained from this interaction will be used to fine-tune SHM’s educational materials and outreach efforts about these programs. It has also already contributed to advocacy efforts with CMS policymakers regarding how they can improve the programs to be more transparent and equitable. The learning is shared in both directions.

Mr. Lapps is the government relations manager at the Society of Hospital Medicine.

Federal programs can be enormously complicated, and the Medicare value-based payment programs, such as the Physician Quality Reporting System, the physician value-based payment modifier, and the new Merit-Based Incentive Payment System, are no exception.

It can be a challenge to navigate the rules, to identify how and which measures to report, and to determine how to integrate those requirements into your practice. Furthermore, the feedback from these programs to providers can be difficult to read and interpret.

Part of the value of being a member of the Society of Hospital Medicine (SHM) is having another set of eyes – particularly those that spend a significant amount of time immersed in federal regulations – to parse the policy-practice nexus. SHM hears from members all over the country, many in different practice types and with different policy needs. This knowledge can be shared, both with other members and with policymakers. A recent example highlights the power of this relationship.

Your membership contributes directly to the advocacy efforts of SHM, and the engagement of members with SHM staff on policy issues is a force multiplier for the effect SHM can have on policy decisions. There is a lot of value for belonging to SHM, and sometimes, we can put an exact number on it.

A solo-practicing hospitalist called seeking perspective on why he received a letter indicating he would be receiving a penalty in 2018 for failing the requirements of Physician Quality Reporting System reporting. This hospitalist had successfully reported on as many measures as he possibly could, so he could not understand why he would be receiving a penalty.

All told, a different read of the feedback reports, and some strategic questions from SHM staff, helped this hospitalist understand why he was being penalized and how, in this case, he could ask Centers for Medicare & Medicaid Services for reconsideration. Upon second review by CMS, the penalties were overturned, and this provider should save nearly $30,000 in Medicare payments in 2018.

SHM helped the provider by being a sounding board and by sharing information learned from experiences other members had had with these programs. In turn, the knowledge gained from this interaction will be used to fine-tune SHM’s educational materials and outreach efforts about these programs. It has also already contributed to advocacy efforts with CMS policymakers regarding how they can improve the programs to be more transparent and equitable. The learning is shared in both directions.

Mr. Lapps is the government relations manager at the Society of Hospital Medicine.

Federal programs can be enormously complicated, and the Medicare value-based payment programs, such as the Physician Quality Reporting System, the physician value-based payment modifier, and the new Merit-Based Incentive Payment System, are no exception.

It can be a challenge to navigate the rules, to identify how and which measures to report, and to determine how to integrate those requirements into your practice. Furthermore, the feedback from these programs to providers can be difficult to read and interpret.

Part of the value of being a member of the Society of Hospital Medicine (SHM) is having another set of eyes – particularly those that spend a significant amount of time immersed in federal regulations – to parse the policy-practice nexus. SHM hears from members all over the country, many in different practice types and with different policy needs. This knowledge can be shared, both with other members and with policymakers. A recent example highlights the power of this relationship.

Your membership contributes directly to the advocacy efforts of SHM, and the engagement of members with SHM staff on policy issues is a force multiplier for the effect SHM can have on policy decisions. There is a lot of value for belonging to SHM, and sometimes, we can put an exact number on it.

A solo-practicing hospitalist called seeking perspective on why he received a letter indicating he would be receiving a penalty in 2018 for failing the requirements of Physician Quality Reporting System reporting. This hospitalist had successfully reported on as many measures as he possibly could, so he could not understand why he would be receiving a penalty.

All told, a different read of the feedback reports, and some strategic questions from SHM staff, helped this hospitalist understand why he was being penalized and how, in this case, he could ask Centers for Medicare & Medicaid Services for reconsideration. Upon second review by CMS, the penalties were overturned, and this provider should save nearly $30,000 in Medicare payments in 2018.

SHM helped the provider by being a sounding board and by sharing information learned from experiences other members had had with these programs. In turn, the knowledge gained from this interaction will be used to fine-tune SHM’s educational materials and outreach efforts about these programs. It has also already contributed to advocacy efforts with CMS policymakers regarding how they can improve the programs to be more transparent and equitable. The learning is shared in both directions.

Mr. Lapps is the government relations manager at the Society of Hospital Medicine.

The diversity of hospitalist practice—from the variety of settings (such as inpatient acute, observation, post-discharge clinics, and post-acute-care facilities) to the differences in relationships with their facilities—is a strength of the specialty. It reflects the ability of the specialty to adapt to the unique needs of its local patients and institutions.

At the same time, it presents some unique challenges to developing strategies for identifying and assessing hospitalists. As the Medicare physician payment system moves toward value-based payment, hospitalists must report quality measures in the Physician Quality Reporting System (PQRS) or face ever-increasing penalties.

Many hospitalists are part of multispecialty groups aligned with a range of physicians employed by the same facility, including many academic hospitalists and those in integrated healthcare systems. Frequently for hospitalists in these groups, the group reports via a group-practice reporting option that uses measures for outpatient providers, capitalizing on the performances of those outpatient primary care providers in the group and making it generally unnecessary for these hospitalists to independently worry about PQRS reporting. Due to their employment model, they might also be somewhat insulated from seeing firsthand any value-based reimbursement adjustments from Medicare.

Hospitalists commonly are employed by single-specialty groups, medium or large in number of HM-focused providers, or increasingly a mix of hospitalists, emergency physicians, and hospitalists focused on skilled nursing facility (SNF) care. Still others are in small hospitalist groups or independent practitioners of hospital medicine. For these hospitalists, successful reporting of PQRS is important; they cannot rely on broad-based primary care group reporting options, and penalties can have an immediate impact on revenue streams.

PQRS, just like its hospital counterpart, the Inpatient Quality Reporting (IQR) system, was designed for use in an isolated healthcare delivery silo: PQRS was meant for physicians; IQR, for hospitals. This explicit design makes the measuring of hospitalists difficult within the current value-based payment programs because while the patient-care goals of hospitalists and their hospitals overlap, hospitalists are forced to report on physician-level metrics. Following this silo logic, the Centers for Medicare & Medicaid Services (CMS) has been removing physician-level PQRS measures that it views as redundant with facility-level IQR metrics, which has contributed to the detrimental reduction of relevant PQRS metrics for hospitalists over the years.

However, in large part due to the significant advocacy efforts of SHM around last year’s Medicare Access and CHIP Reauthorization Act (MACRA), CMS now has the ability to reverse this trend and include metrics from other programs, such as IQR metrics, as part of the quality or cost component of physician value-based payment. This would help to eliminate the artificial misalignment of quality goals and metrics for hospitalists and their facilities. Including hospital IQR metrics in the mandatory Medicare physician reporting programs would help to ensure hospitalists receive credit for the care they are providing for hospitalized patients and for the measures they are commonly held accountable for as part of their jobs.

As SHM advocates for hospitalists as the new Merit-Based Incentive Payment System (MIPS) reporting program unrolls as part of MACRA, we will keep these principles in mind: reduce administrative and reporting burdens, make metrics and their resulting data as actionable and useful as possible, and account for the important work hospitalists are doing in their facilities. As we are looking ahead at the future, we encourage you to make sure you are reporting in PQRS for 2016.

For more information about 2016 PQRS reporting, visit www.hospitalmedicine.org/pqrs. TH

Joshua Lapps is SHM’s government relations manager.

The diversity of hospitalist practice—from the variety of settings (such as inpatient acute, observation, post-discharge clinics, and post-acute-care facilities) to the differences in relationships with their facilities—is a strength of the specialty. It reflects the ability of the specialty to adapt to the unique needs of its local patients and institutions.

At the same time, it presents some unique challenges to developing strategies for identifying and assessing hospitalists. As the Medicare physician payment system moves toward value-based payment, hospitalists must report quality measures in the Physician Quality Reporting System (PQRS) or face ever-increasing penalties.

Many hospitalists are part of multispecialty groups aligned with a range of physicians employed by the same facility, including many academic hospitalists and those in integrated healthcare systems. Frequently for hospitalists in these groups, the group reports via a group-practice reporting option that uses measures for outpatient providers, capitalizing on the performances of those outpatient primary care providers in the group and making it generally unnecessary for these hospitalists to independently worry about PQRS reporting. Due to their employment model, they might also be somewhat insulated from seeing firsthand any value-based reimbursement adjustments from Medicare.

Hospitalists commonly are employed by single-specialty groups, medium or large in number of HM-focused providers, or increasingly a mix of hospitalists, emergency physicians, and hospitalists focused on skilled nursing facility (SNF) care. Still others are in small hospitalist groups or independent practitioners of hospital medicine. For these hospitalists, successful reporting of PQRS is important; they cannot rely on broad-based primary care group reporting options, and penalties can have an immediate impact on revenue streams.

PQRS, just like its hospital counterpart, the Inpatient Quality Reporting (IQR) system, was designed for use in an isolated healthcare delivery silo: PQRS was meant for physicians; IQR, for hospitals. This explicit design makes the measuring of hospitalists difficult within the current value-based payment programs because while the patient-care goals of hospitalists and their hospitals overlap, hospitalists are forced to report on physician-level metrics. Following this silo logic, the Centers for Medicare & Medicaid Services (CMS) has been removing physician-level PQRS measures that it views as redundant with facility-level IQR metrics, which has contributed to the detrimental reduction of relevant PQRS metrics for hospitalists over the years.

However, in large part due to the significant advocacy efforts of SHM around last year’s Medicare Access and CHIP Reauthorization Act (MACRA), CMS now has the ability to reverse this trend and include metrics from other programs, such as IQR metrics, as part of the quality or cost component of physician value-based payment. This would help to eliminate the artificial misalignment of quality goals and metrics for hospitalists and their facilities. Including hospital IQR metrics in the mandatory Medicare physician reporting programs would help to ensure hospitalists receive credit for the care they are providing for hospitalized patients and for the measures they are commonly held accountable for as part of their jobs.

As SHM advocates for hospitalists as the new Merit-Based Incentive Payment System (MIPS) reporting program unrolls as part of MACRA, we will keep these principles in mind: reduce administrative and reporting burdens, make metrics and their resulting data as actionable and useful as possible, and account for the important work hospitalists are doing in their facilities. As we are looking ahead at the future, we encourage you to make sure you are reporting in PQRS for 2016.

For more information about 2016 PQRS reporting, visit www.hospitalmedicine.org/pqrs. TH

Joshua Lapps is SHM’s government relations manager.

The diversity of hospitalist practice—from the variety of settings (such as inpatient acute, observation, post-discharge clinics, and post-acute-care facilities) to the differences in relationships with their facilities—is a strength of the specialty. It reflects the ability of the specialty to adapt to the unique needs of its local patients and institutions.

At the same time, it presents some unique challenges to developing strategies for identifying and assessing hospitalists. As the Medicare physician payment system moves toward value-based payment, hospitalists must report quality measures in the Physician Quality Reporting System (PQRS) or face ever-increasing penalties.

Many hospitalists are part of multispecialty groups aligned with a range of physicians employed by the same facility, including many academic hospitalists and those in integrated healthcare systems. Frequently for hospitalists in these groups, the group reports via a group-practice reporting option that uses measures for outpatient providers, capitalizing on the performances of those outpatient primary care providers in the group and making it generally unnecessary for these hospitalists to independently worry about PQRS reporting. Due to their employment model, they might also be somewhat insulated from seeing firsthand any value-based reimbursement adjustments from Medicare.

Hospitalists commonly are employed by single-specialty groups, medium or large in number of HM-focused providers, or increasingly a mix of hospitalists, emergency physicians, and hospitalists focused on skilled nursing facility (SNF) care. Still others are in small hospitalist groups or independent practitioners of hospital medicine. For these hospitalists, successful reporting of PQRS is important; they cannot rely on broad-based primary care group reporting options, and penalties can have an immediate impact on revenue streams.

PQRS, just like its hospital counterpart, the Inpatient Quality Reporting (IQR) system, was designed for use in an isolated healthcare delivery silo: PQRS was meant for physicians; IQR, for hospitals. This explicit design makes the measuring of hospitalists difficult within the current value-based payment programs because while the patient-care goals of hospitalists and their hospitals overlap, hospitalists are forced to report on physician-level metrics. Following this silo logic, the Centers for Medicare & Medicaid Services (CMS) has been removing physician-level PQRS measures that it views as redundant with facility-level IQR metrics, which has contributed to the detrimental reduction of relevant PQRS metrics for hospitalists over the years.

However, in large part due to the significant advocacy efforts of SHM around last year’s Medicare Access and CHIP Reauthorization Act (MACRA), CMS now has the ability to reverse this trend and include metrics from other programs, such as IQR metrics, as part of the quality or cost component of physician value-based payment. This would help to eliminate the artificial misalignment of quality goals and metrics for hospitalists and their facilities. Including hospital IQR metrics in the mandatory Medicare physician reporting programs would help to ensure hospitalists receive credit for the care they are providing for hospitalized patients and for the measures they are commonly held accountable for as part of their jobs.

As SHM advocates for hospitalists as the new Merit-Based Incentive Payment System (MIPS) reporting program unrolls as part of MACRA, we will keep these principles in mind: reduce administrative and reporting burdens, make metrics and their resulting data as actionable and useful as possible, and account for the important work hospitalists are doing in their facilities. As we are looking ahead at the future, we encourage you to make sure you are reporting in PQRS for 2016.

For more information about 2016 PQRS reporting, visit www.hospitalmedicine.org/pqrs. TH

Joshua Lapps is SHM’s government relations manager.

On the heels of last year’s repeal of the sustainable growth rate (SGR) formula, 2016 promises to be a year of significant changes for the healthcare system. These changes will require providers to focus not just on the immediate pressures and requirements coming from Medicare, of which there are many, but also to look down the road to how things will change in the coming years.

The final year of reporting on quality measures for the Physician Quality Reporting System (PQRS) is 2016, with performance impacting Medicare payments in 2018. Reporting on quality measures doesn’t end there, however. The Medicare Access and CHIP Reauthorization Act (MACRA) repealed the SGR and created two new pathways for pay-for-performance for physicians and most other providers: the Merit-based Incentive Payment System (MIPS) and alternative payment models. After this year, reporting quality measures becomes one component of the MIPS, a program similar to hospital value-based purchasing, but designed for providers.

Quality measures are here to stay. They form the backbone for evaluating whether healthcare is of value. Under the MIPS, quality measures are combined with cost measures, meaningful use, and clinical performance improvement activities to create an aggregate score for providers. That score will be used to determine payment adjustments for providers starting in 2019.

Also in 2016, the Centers for Medicare and Medicaid Services (CMS) will lay the foundation for the MIPS. It is a completely new program, and although it will build on elements of existing programs like PQRS, meaningful use, and the physician value-based payment modifier, its structure and ramifications are ultimately unknown. CMS has indicated its intention to issue the regulatory backbone of MIPS in just a few months. These regulations will be the new reality of Medicare’s fee-for-service for the foreseeable future.

The ramifications of MIPS cannot be understated. It will apply an adjustment based on performance on all Medicare Part B payments. That adjustment starts at +/- 4.0% in 2019 and rises to +/- 9.0% by 2022, a number that is not as far off as it seems based on how these programs operate.

SHM expects many of the current PQRS policies to be continued under MIPS, which means, unfortunately, that many of the challenges facing hospitalists will continue. Hospitalists do not have many measures to report on; most measures are developed for outpatient practices, are simply not reflective of the variability of hospitalist practice, and, even if specified for inpatient reporting, are not clinically relevant.

To meet the needs of hospitalists, SHM will advocate strongly for CMS to develop more flexible and relevant reporting options. We will work to ensure that hospitalists are not structurally disadvantaged by the policies set in place.

Given these upcoming changes, it is as important as ever for you to stay engaged and informed about the policy changes coming down the road. It might be just the start of the year, but already there’s a lot of critical work to do. To get involved and remain apprised of the changes, join SHM’s grassroots network at www.hospitalmedicine.org/grassroots. TH

Joshua Lapps is SHM’s government relations manager.

On the heels of last year’s repeal of the sustainable growth rate (SGR) formula, 2016 promises to be a year of significant changes for the healthcare system. These changes will require providers to focus not just on the immediate pressures and requirements coming from Medicare, of which there are many, but also to look down the road to how things will change in the coming years.

The final year of reporting on quality measures for the Physician Quality Reporting System (PQRS) is 2016, with performance impacting Medicare payments in 2018. Reporting on quality measures doesn’t end there, however. The Medicare Access and CHIP Reauthorization Act (MACRA) repealed the SGR and created two new pathways for pay-for-performance for physicians and most other providers: the Merit-based Incentive Payment System (MIPS) and alternative payment models. After this year, reporting quality measures becomes one component of the MIPS, a program similar to hospital value-based purchasing, but designed for providers.

Quality measures are here to stay. They form the backbone for evaluating whether healthcare is of value. Under the MIPS, quality measures are combined with cost measures, meaningful use, and clinical performance improvement activities to create an aggregate score for providers. That score will be used to determine payment adjustments for providers starting in 2019.

Also in 2016, the Centers for Medicare and Medicaid Services (CMS) will lay the foundation for the MIPS. It is a completely new program, and although it will build on elements of existing programs like PQRS, meaningful use, and the physician value-based payment modifier, its structure and ramifications are ultimately unknown. CMS has indicated its intention to issue the regulatory backbone of MIPS in just a few months. These regulations will be the new reality of Medicare’s fee-for-service for the foreseeable future.

The ramifications of MIPS cannot be understated. It will apply an adjustment based on performance on all Medicare Part B payments. That adjustment starts at +/- 4.0% in 2019 and rises to +/- 9.0% by 2022, a number that is not as far off as it seems based on how these programs operate.

SHM expects many of the current PQRS policies to be continued under MIPS, which means, unfortunately, that many of the challenges facing hospitalists will continue. Hospitalists do not have many measures to report on; most measures are developed for outpatient practices, are simply not reflective of the variability of hospitalist practice, and, even if specified for inpatient reporting, are not clinically relevant.

To meet the needs of hospitalists, SHM will advocate strongly for CMS to develop more flexible and relevant reporting options. We will work to ensure that hospitalists are not structurally disadvantaged by the policies set in place.

Given these upcoming changes, it is as important as ever for you to stay engaged and informed about the policy changes coming down the road. It might be just the start of the year, but already there’s a lot of critical work to do. To get involved and remain apprised of the changes, join SHM’s grassroots network at www.hospitalmedicine.org/grassroots. TH

Joshua Lapps is SHM’s government relations manager.

On the heels of last year’s repeal of the sustainable growth rate (SGR) formula, 2016 promises to be a year of significant changes for the healthcare system. These changes will require providers to focus not just on the immediate pressures and requirements coming from Medicare, of which there are many, but also to look down the road to how things will change in the coming years.

The final year of reporting on quality measures for the Physician Quality Reporting System (PQRS) is 2016, with performance impacting Medicare payments in 2018. Reporting on quality measures doesn’t end there, however. The Medicare Access and CHIP Reauthorization Act (MACRA) repealed the SGR and created two new pathways for pay-for-performance for physicians and most other providers: the Merit-based Incentive Payment System (MIPS) and alternative payment models. After this year, reporting quality measures becomes one component of the MIPS, a program similar to hospital value-based purchasing, but designed for providers.

Quality measures are here to stay. They form the backbone for evaluating whether healthcare is of value. Under the MIPS, quality measures are combined with cost measures, meaningful use, and clinical performance improvement activities to create an aggregate score for providers. That score will be used to determine payment adjustments for providers starting in 2019.

Also in 2016, the Centers for Medicare and Medicaid Services (CMS) will lay the foundation for the MIPS. It is a completely new program, and although it will build on elements of existing programs like PQRS, meaningful use, and the physician value-based payment modifier, its structure and ramifications are ultimately unknown. CMS has indicated its intention to issue the regulatory backbone of MIPS in just a few months. These regulations will be the new reality of Medicare’s fee-for-service for the foreseeable future.

The ramifications of MIPS cannot be understated. It will apply an adjustment based on performance on all Medicare Part B payments. That adjustment starts at +/- 4.0% in 2019 and rises to +/- 9.0% by 2022, a number that is not as far off as it seems based on how these programs operate.

SHM expects many of the current PQRS policies to be continued under MIPS, which means, unfortunately, that many of the challenges facing hospitalists will continue. Hospitalists do not have many measures to report on; most measures are developed for outpatient practices, are simply not reflective of the variability of hospitalist practice, and, even if specified for inpatient reporting, are not clinically relevant.

To meet the needs of hospitalists, SHM will advocate strongly for CMS to develop more flexible and relevant reporting options. We will work to ensure that hospitalists are not structurally disadvantaged by the policies set in place.

Given these upcoming changes, it is as important as ever for you to stay engaged and informed about the policy changes coming down the road. It might be just the start of the year, but already there’s a lot of critical work to do. To get involved and remain apprised of the changes, join SHM’s grassroots network at www.hospitalmedicine.org/grassroots. TH

Joshua Lapps is SHM’s government relations manager.

Nearly three-quarters of hospitals will be receiving penalties from the Centers for Medicare and Medicaid Services (CMS) in 2016 for excess readmissions, having failed to prevent enough patients from returning to the hospital 30 days post-discharge. With so many hospitals impacted by penalties, it is understandable that the underlying methodology of the Hospital Readmissions Reduction Program (HRRP) is coming under intense scrutiny.

Research published in JAMA Internal Medicine in September hit upon many of the myriad factors—often outside of the hospital or providers’ control—that influence whether a patient is readmitted to the hospital. This information adds weight to criticism of the measures included in the HRRP and asserts the need to refine or reform the measures to better account for readmissions preventable through the interventions of the healthcare system. The behavior these measures are meant to curb, including poor quality care, inadequate access to follow-up or medications, and gaps in transitions of care, are not identifiable within broad-based, all-cause readmission measures. Instead, hospitals are being penalized for all readmissions, a majority of which may be attributable to community or patient-related factors, such as sociodemographic or housing status, among other variables.

A growing consensus on two fronts asserts that these measures, as currently structured, might not be appropriate for use in pay-for-performance programs. Measure developers, bolstered by a recent decision by the National Quality Forum to institute a trial run of risk adjusting measures for sociodemographic status, are exploring the impact of using different available variables to enhance risk adjusting their measures. Measures for readmissions are at the front of the line of these efforts. Although it is only in the beginning stages, this work could change the foundation of all quality measures used in pay-for-performance programs.

In Congress, legislation has been introduced in both the House of Representatives and the Senate aiming to refine the HRRP through additional risk adjustments. The Establishing Beneficiary Equity in the Hospital Readmission Program Act of 2015 (H.R. 1343 and S. 688), introduced by Rep. Jim Renacci (R-Ohio) and Sen. Joe Manchin (D-W.V.), would create immediate relief for hospitals by implementing risk adjustment for dual-eligible patients and the socioeconomic status of the hospital’s patients. At the same time, when reports that are currently in progress about risk adjustment in readmission measures and the use of a 30-day window for categorizing readmissions are completed, CMS would be required to incorporate their findings into the risk adjustment in the HRRP in the future.

SHM is supporting both of these pathways toward improving risk adjustment in readmissions measures. By engaging in the measure process and advocating for the passage of legislation to refine risk adjustment, SHM has taken a stand. The goal of reducing preventable readmissions is too important to use imprecise metrics that seem to penalize the hospitals serving the nation’s neediest patients.

As hospitalists on the front line, you can join SHM in advocating for these common sense, and necessary, changes to the HRRP.

Visit SHM’s Legislative Action Center to send a message to Congress in support of the Establishing Beneficiary Equity in the Hospital Readmission Program Act of 2015.

Joshua Lapps is SHM’s government relations manager.

Nearly three-quarters of hospitals will be receiving penalties from the Centers for Medicare and Medicaid Services (CMS) in 2016 for excess readmissions, having failed to prevent enough patients from returning to the hospital 30 days post-discharge. With so many hospitals impacted by penalties, it is understandable that the underlying methodology of the Hospital Readmissions Reduction Program (HRRP) is coming under intense scrutiny.

Research published in JAMA Internal Medicine in September hit upon many of the myriad factors—often outside of the hospital or providers’ control—that influence whether a patient is readmitted to the hospital. This information adds weight to criticism of the measures included in the HRRP and asserts the need to refine or reform the measures to better account for readmissions preventable through the interventions of the healthcare system. The behavior these measures are meant to curb, including poor quality care, inadequate access to follow-up or medications, and gaps in transitions of care, are not identifiable within broad-based, all-cause readmission measures. Instead, hospitals are being penalized for all readmissions, a majority of which may be attributable to community or patient-related factors, such as sociodemographic or housing status, among other variables.

A growing consensus on two fronts asserts that these measures, as currently structured, might not be appropriate for use in pay-for-performance programs. Measure developers, bolstered by a recent decision by the National Quality Forum to institute a trial run of risk adjusting measures for sociodemographic status, are exploring the impact of using different available variables to enhance risk adjusting their measures. Measures for readmissions are at the front of the line of these efforts. Although it is only in the beginning stages, this work could change the foundation of all quality measures used in pay-for-performance programs.

In Congress, legislation has been introduced in both the House of Representatives and the Senate aiming to refine the HRRP through additional risk adjustments. The Establishing Beneficiary Equity in the Hospital Readmission Program Act of 2015 (H.R. 1343 and S. 688), introduced by Rep. Jim Renacci (R-Ohio) and Sen. Joe Manchin (D-W.V.), would create immediate relief for hospitals by implementing risk adjustment for dual-eligible patients and the socioeconomic status of the hospital’s patients. At the same time, when reports that are currently in progress about risk adjustment in readmission measures and the use of a 30-day window for categorizing readmissions are completed, CMS would be required to incorporate their findings into the risk adjustment in the HRRP in the future.

SHM is supporting both of these pathways toward improving risk adjustment in readmissions measures. By engaging in the measure process and advocating for the passage of legislation to refine risk adjustment, SHM has taken a stand. The goal of reducing preventable readmissions is too important to use imprecise metrics that seem to penalize the hospitals serving the nation’s neediest patients.

As hospitalists on the front line, you can join SHM in advocating for these common sense, and necessary, changes to the HRRP.

Visit SHM’s Legislative Action Center to send a message to Congress in support of the Establishing Beneficiary Equity in the Hospital Readmission Program Act of 2015.

Joshua Lapps is SHM’s government relations manager.

Nearly three-quarters of hospitals will be receiving penalties from the Centers for Medicare and Medicaid Services (CMS) in 2016 for excess readmissions, having failed to prevent enough patients from returning to the hospital 30 days post-discharge. With so many hospitals impacted by penalties, it is understandable that the underlying methodology of the Hospital Readmissions Reduction Program (HRRP) is coming under intense scrutiny.

Research published in JAMA Internal Medicine in September hit upon many of the myriad factors—often outside of the hospital or providers’ control—that influence whether a patient is readmitted to the hospital. This information adds weight to criticism of the measures included in the HRRP and asserts the need to refine or reform the measures to better account for readmissions preventable through the interventions of the healthcare system. The behavior these measures are meant to curb, including poor quality care, inadequate access to follow-up or medications, and gaps in transitions of care, are not identifiable within broad-based, all-cause readmission measures. Instead, hospitals are being penalized for all readmissions, a majority of which may be attributable to community or patient-related factors, such as sociodemographic or housing status, among other variables.

A growing consensus on two fronts asserts that these measures, as currently structured, might not be appropriate for use in pay-for-performance programs. Measure developers, bolstered by a recent decision by the National Quality Forum to institute a trial run of risk adjusting measures for sociodemographic status, are exploring the impact of using different available variables to enhance risk adjusting their measures. Measures for readmissions are at the front of the line of these efforts. Although it is only in the beginning stages, this work could change the foundation of all quality measures used in pay-for-performance programs.

In Congress, legislation has been introduced in both the House of Representatives and the Senate aiming to refine the HRRP through additional risk adjustments. The Establishing Beneficiary Equity in the Hospital Readmission Program Act of 2015 (H.R. 1343 and S. 688), introduced by Rep. Jim Renacci (R-Ohio) and Sen. Joe Manchin (D-W.V.), would create immediate relief for hospitals by implementing risk adjustment for dual-eligible patients and the socioeconomic status of the hospital’s patients. At the same time, when reports that are currently in progress about risk adjustment in readmission measures and the use of a 30-day window for categorizing readmissions are completed, CMS would be required to incorporate their findings into the risk adjustment in the HRRP in the future.

SHM is supporting both of these pathways toward improving risk adjustment in readmissions measures. By engaging in the measure process and advocating for the passage of legislation to refine risk adjustment, SHM has taken a stand. The goal of reducing preventable readmissions is too important to use imprecise metrics that seem to penalize the hospitals serving the nation’s neediest patients.

As hospitalists on the front line, you can join SHM in advocating for these common sense, and necessary, changes to the HRRP.

Visit SHM’s Legislative Action Center to send a message to Congress in support of the Establishing Beneficiary Equity in the Hospital Readmission Program Act of 2015.

Joshua Lapps is SHM’s government relations manager.

The Centers for Medicare and Medicaid Services (CMS) Innovation Center recently announced the development of a new accountable care organization (ACO) model—the Next Generation ACO—that hopes to move closer to the goal of efficient, coordinated care for Medicare beneficiaries.

“This ACO model provides for greater engagement of beneficiaries, a more predictable, prospective financial model, and more tools to coordinate care for beneficiaries,” writes Patrick Conway, MD, MSc, chief medical officer and deputy administrator for innovation and quality at CMS, in a blog post announcing the Next Generation ACO.

ACOs align hospitals, physicians, nursing facilities, and other critical healthcare providers as a sort of one-stop shop for seamless patient care across settings and among providers. By bringing together the full range of services, ACOs aim to provide higher quality coordinated care while reducing costs for patients and Medicare.

Since the passage of the Affordable Care Act, CMS has overseen two distinct tracks for ACOs: the Medicare Shared Savings Program and the Pioneer ACO. The Shared Savings Program was a first step in moving toward streamlined healthcare delivery systems while incentivizing care coordination across settings. Pioneer ACOs, on the other hand, were designed as a test for more aggressive reforms that promised higher potential rewards in exchange for higher risk, while moving participants toward population-based payments.

The Next Generation ACO builds off of the Pioneer and Shared Savings Program ACO models to test whether the fundamental concepts behind an ACO—improving care and reducing costs—can be achieved using stronger financial incentives. Notably, the Next Generation ACO establishes stable, prospective targets for benchmarking expenditures and offers an array of payment mechanisms, including capitation.

ACO goals read like a laundry list of hospitalist goals and practice, such as reducing readmissions, maximizing efficiency, improving care transitions, and reducing length of stay.

Participants of the Next Generation ACO model will have new tools to help coordinate patient care, including expanded coverage for telehealth and home health services and increased access for skilled nursing facility coverage without prior hospitalizations. Because the Next Generation ACO model comes from the CMS Innovation Center, it’s specifically designed to help policymakers evaluate the impact of reimbursement and system changes with an eye toward scalability. The knowledge gained from this model could help structure the Medicare payment system of tomorrow.

Hospitalists have long been interested in the impact of ACOs on their practices, with good reason. Hospitals form an integral part of an ACO, and hospitalists serve critical roles within their hospitals. ACO goals read like a laundry list of hospitalist goals and practice, such as reducing readmissions, maximizing efficiency, improving care transitions, and reducing length of stay. The Next Generation ACO model offers the potential to further capitalize on the expertise of hospitalists as the healthcare system explores ways to move away from traditional fee-for-service payments.

The way in which Medicare pays providers is evolving rapidly as CMS seeks to reimburse for the quality rather than the quantity of services provided to beneficiaries. Over the next five years, CMS has set aggressive targets for transitioning fee-for-service payments into value-based payment systems; the Next Generation ACO is one tool for helping to push that goal onward.

Joshua Lapps is SHM’s manager of government relations.

The Centers for Medicare and Medicaid Services (CMS) Innovation Center recently announced the development of a new accountable care organization (ACO) model—the Next Generation ACO—that hopes to move closer to the goal of efficient, coordinated care for Medicare beneficiaries.

“This ACO model provides for greater engagement of beneficiaries, a more predictable, prospective financial model, and more tools to coordinate care for beneficiaries,” writes Patrick Conway, MD, MSc, chief medical officer and deputy administrator for innovation and quality at CMS, in a blog post announcing the Next Generation ACO.

ACOs align hospitals, physicians, nursing facilities, and other critical healthcare providers as a sort of one-stop shop for seamless patient care across settings and among providers. By bringing together the full range of services, ACOs aim to provide higher quality coordinated care while reducing costs for patients and Medicare.

Since the passage of the Affordable Care Act, CMS has overseen two distinct tracks for ACOs: the Medicare Shared Savings Program and the Pioneer ACO. The Shared Savings Program was a first step in moving toward streamlined healthcare delivery systems while incentivizing care coordination across settings. Pioneer ACOs, on the other hand, were designed as a test for more aggressive reforms that promised higher potential rewards in exchange for higher risk, while moving participants toward population-based payments.

The Next Generation ACO builds off of the Pioneer and Shared Savings Program ACO models to test whether the fundamental concepts behind an ACO—improving care and reducing costs—can be achieved using stronger financial incentives. Notably, the Next Generation ACO establishes stable, prospective targets for benchmarking expenditures and offers an array of payment mechanisms, including capitation.

ACO goals read like a laundry list of hospitalist goals and practice, such as reducing readmissions, maximizing efficiency, improving care transitions, and reducing length of stay.

Participants of the Next Generation ACO model will have new tools to help coordinate patient care, including expanded coverage for telehealth and home health services and increased access for skilled nursing facility coverage without prior hospitalizations. Because the Next Generation ACO model comes from the CMS Innovation Center, it’s specifically designed to help policymakers evaluate the impact of reimbursement and system changes with an eye toward scalability. The knowledge gained from this model could help structure the Medicare payment system of tomorrow.

Hospitalists have long been interested in the impact of ACOs on their practices, with good reason. Hospitals form an integral part of an ACO, and hospitalists serve critical roles within their hospitals. ACO goals read like a laundry list of hospitalist goals and practice, such as reducing readmissions, maximizing efficiency, improving care transitions, and reducing length of stay. The Next Generation ACO model offers the potential to further capitalize on the expertise of hospitalists as the healthcare system explores ways to move away from traditional fee-for-service payments.

The way in which Medicare pays providers is evolving rapidly as CMS seeks to reimburse for the quality rather than the quantity of services provided to beneficiaries. Over the next five years, CMS has set aggressive targets for transitioning fee-for-service payments into value-based payment systems; the Next Generation ACO is one tool for helping to push that goal onward.

Joshua Lapps is SHM’s manager of government relations.

The Centers for Medicare and Medicaid Services (CMS) Innovation Center recently announced the development of a new accountable care organization (ACO) model—the Next Generation ACO—that hopes to move closer to the goal of efficient, coordinated care for Medicare beneficiaries.

“This ACO model provides for greater engagement of beneficiaries, a more predictable, prospective financial model, and more tools to coordinate care for beneficiaries,” writes Patrick Conway, MD, MSc, chief medical officer and deputy administrator for innovation and quality at CMS, in a blog post announcing the Next Generation ACO.

ACOs align hospitals, physicians, nursing facilities, and other critical healthcare providers as a sort of one-stop shop for seamless patient care across settings and among providers. By bringing together the full range of services, ACOs aim to provide higher quality coordinated care while reducing costs for patients and Medicare.

Since the passage of the Affordable Care Act, CMS has overseen two distinct tracks for ACOs: the Medicare Shared Savings Program and the Pioneer ACO. The Shared Savings Program was a first step in moving toward streamlined healthcare delivery systems while incentivizing care coordination across settings. Pioneer ACOs, on the other hand, were designed as a test for more aggressive reforms that promised higher potential rewards in exchange for higher risk, while moving participants toward population-based payments.

The Next Generation ACO builds off of the Pioneer and Shared Savings Program ACO models to test whether the fundamental concepts behind an ACO—improving care and reducing costs—can be achieved using stronger financial incentives. Notably, the Next Generation ACO establishes stable, prospective targets for benchmarking expenditures and offers an array of payment mechanisms, including capitation.

ACO goals read like a laundry list of hospitalist goals and practice, such as reducing readmissions, maximizing efficiency, improving care transitions, and reducing length of stay.

Participants of the Next Generation ACO model will have new tools to help coordinate patient care, including expanded coverage for telehealth and home health services and increased access for skilled nursing facility coverage without prior hospitalizations. Because the Next Generation ACO model comes from the CMS Innovation Center, it’s specifically designed to help policymakers evaluate the impact of reimbursement and system changes with an eye toward scalability. The knowledge gained from this model could help structure the Medicare payment system of tomorrow.

Hospitalists have long been interested in the impact of ACOs on their practices, with good reason. Hospitals form an integral part of an ACO, and hospitalists serve critical roles within their hospitals. ACO goals read like a laundry list of hospitalist goals and practice, such as reducing readmissions, maximizing efficiency, improving care transitions, and reducing length of stay. The Next Generation ACO model offers the potential to further capitalize on the expertise of hospitalists as the healthcare system explores ways to move away from traditional fee-for-service payments.

The way in which Medicare pays providers is evolving rapidly as CMS seeks to reimburse for the quality rather than the quantity of services provided to beneficiaries. Over the next five years, CMS has set aggressive targets for transitioning fee-for-service payments into value-based payment systems; the Next Generation ACO is one tool for helping to push that goal onward.

Joshua Lapps is SHM’s manager of government relations.

In recent months, numerous articles have come out targeting high-billing physicians—looking for smoking guns in recently released 2012 Medicare fee-for-service physician claims data. These data include both the amount each individual physician billed and the amount Medicare paid on average for services performed by all physicians treating Medicare beneficiaries.

Many physician groups, including the AMA, criticized the data release as having significant limitations, including clinical and billing practice realities that confound the layperson’s understanding of the data’s implications. Still, there is much physicians can learn by exploring this information, particularly those in a still-growing field like hospital medicine (HM).

There is no clear method to identify hospitalists within these data. Hospitalists are dispersed throughout their respective board certifications—internal medicine, family practice, pediatrics. The designations come directly from the Medicare specialty billing code; the code associated with the largest number of services becomes that provider’s de facto specialty. For the majority of providers, this will correspond with their board certification and their professional identity. A hospitalist’s unique practice is lost within these general identifiers.

However, the contours of that unique practice may provide some tools to identify hospitalists, albeit roughly, within the data and in the absence of a specialty billing code. Things like practice location and commonly billed Healthcare Common Procedure Coding System (HCPCS) codes can help sketch the boundaries of the field. Certainly, any classification methodology will have its share of imperfections and may exclude individuals who would otherwise identify as hospitalists. Regardless, such an exercise could identify trends in hospital medicine while providing a better understanding of the field as a whole.

HM does not have the traditional hallmark signifiers—board certification and Medicare specialty billing code—used by many specialties and subspecialties to frame their fields and to classify and compare physicians. The Medicare specialty billing code is a unique code applied to Medicare billing claims that tells Medicare exactly how the provider would like to be identified.

Because of its relative specificity and ready accessibility, the Centers for Medicare and Medicaid Services (CMS) uses the specialty billing code to create specialty comparison groups in pay-for-performance programs. Under the value-based payment modifier, hospitalists are compared against outpatient internal medicine or family medicine physicians, which makes them seem all the more expensive and less efficient.

SHM has been attuned to this particular issue since the early days of the physician value-based payment modifier. For nearly two years, SHM has repeatedly admonished CMS to compare hospitalists against other hospitalists in order for a pay-for-performance scheme to fairly and reasonably evaluate quality and efficiency. CMS acknowledged that many specialties and subspecialties may be masked within the current listing of Medicare specialty billing codes but yielded only so far as to say that aggrieved specialties can apply for their own code. SHM, for its part, applied for a specialty billing code for hospitalists in May 2014.

SHM has been actively exploring the data and looking at ways to identify hospitalists within this Medicare data. There’s an inherent value to this sort of self-reflection—it explains who we are and where we have been.

More importantly, it helps inform where we are going.

Joshua Lapps is SHM’s government relations manager.

In recent months, numerous articles have come out targeting high-billing physicians—looking for smoking guns in recently released 2012 Medicare fee-for-service physician claims data. These data include both the amount each individual physician billed and the amount Medicare paid on average for services performed by all physicians treating Medicare beneficiaries.

Many physician groups, including the AMA, criticized the data release as having significant limitations, including clinical and billing practice realities that confound the layperson’s understanding of the data’s implications. Still, there is much physicians can learn by exploring this information, particularly those in a still-growing field like hospital medicine (HM).

There is no clear method to identify hospitalists within these data. Hospitalists are dispersed throughout their respective board certifications—internal medicine, family practice, pediatrics. The designations come directly from the Medicare specialty billing code; the code associated with the largest number of services becomes that provider’s de facto specialty. For the majority of providers, this will correspond with their board certification and their professional identity. A hospitalist’s unique practice is lost within these general identifiers.

However, the contours of that unique practice may provide some tools to identify hospitalists, albeit roughly, within the data and in the absence of a specialty billing code. Things like practice location and commonly billed Healthcare Common Procedure Coding System (HCPCS) codes can help sketch the boundaries of the field. Certainly, any classification methodology will have its share of imperfections and may exclude individuals who would otherwise identify as hospitalists. Regardless, such an exercise could identify trends in hospital medicine while providing a better understanding of the field as a whole.

HM does not have the traditional hallmark signifiers—board certification and Medicare specialty billing code—used by many specialties and subspecialties to frame their fields and to classify and compare physicians. The Medicare specialty billing code is a unique code applied to Medicare billing claims that tells Medicare exactly how the provider would like to be identified.

Because of its relative specificity and ready accessibility, the Centers for Medicare and Medicaid Services (CMS) uses the specialty billing code to create specialty comparison groups in pay-for-performance programs. Under the value-based payment modifier, hospitalists are compared against outpatient internal medicine or family medicine physicians, which makes them seem all the more expensive and less efficient.

SHM has been attuned to this particular issue since the early days of the physician value-based payment modifier. For nearly two years, SHM has repeatedly admonished CMS to compare hospitalists against other hospitalists in order for a pay-for-performance scheme to fairly and reasonably evaluate quality and efficiency. CMS acknowledged that many specialties and subspecialties may be masked within the current listing of Medicare specialty billing codes but yielded only so far as to say that aggrieved specialties can apply for their own code. SHM, for its part, applied for a specialty billing code for hospitalists in May 2014.

SHM has been actively exploring the data and looking at ways to identify hospitalists within this Medicare data. There’s an inherent value to this sort of self-reflection—it explains who we are and where we have been.

More importantly, it helps inform where we are going.

Joshua Lapps is SHM’s government relations manager.

In recent months, numerous articles have come out targeting high-billing physicians—looking for smoking guns in recently released 2012 Medicare fee-for-service physician claims data. These data include both the amount each individual physician billed and the amount Medicare paid on average for services performed by all physicians treating Medicare beneficiaries.

Many physician groups, including the AMA, criticized the data release as having significant limitations, including clinical and billing practice realities that confound the layperson’s understanding of the data’s implications. Still, there is much physicians can learn by exploring this information, particularly those in a still-growing field like hospital medicine (HM).

There is no clear method to identify hospitalists within these data. Hospitalists are dispersed throughout their respective board certifications—internal medicine, family practice, pediatrics. The designations come directly from the Medicare specialty billing code; the code associated with the largest number of services becomes that provider’s de facto specialty. For the majority of providers, this will correspond with their board certification and their professional identity. A hospitalist’s unique practice is lost within these general identifiers.

However, the contours of that unique practice may provide some tools to identify hospitalists, albeit roughly, within the data and in the absence of a specialty billing code. Things like practice location and commonly billed Healthcare Common Procedure Coding System (HCPCS) codes can help sketch the boundaries of the field. Certainly, any classification methodology will have its share of imperfections and may exclude individuals who would otherwise identify as hospitalists. Regardless, such an exercise could identify trends in hospital medicine while providing a better understanding of the field as a whole.

HM does not have the traditional hallmark signifiers—board certification and Medicare specialty billing code—used by many specialties and subspecialties to frame their fields and to classify and compare physicians. The Medicare specialty billing code is a unique code applied to Medicare billing claims that tells Medicare exactly how the provider would like to be identified.

Because of its relative specificity and ready accessibility, the Centers for Medicare and Medicaid Services (CMS) uses the specialty billing code to create specialty comparison groups in pay-for-performance programs. Under the value-based payment modifier, hospitalists are compared against outpatient internal medicine or family medicine physicians, which makes them seem all the more expensive and less efficient.

SHM has been attuned to this particular issue since the early days of the physician value-based payment modifier. For nearly two years, SHM has repeatedly admonished CMS to compare hospitalists against other hospitalists in order for a pay-for-performance scheme to fairly and reasonably evaluate quality and efficiency. CMS acknowledged that many specialties and subspecialties may be masked within the current listing of Medicare specialty billing codes but yielded only so far as to say that aggrieved specialties can apply for their own code. SHM, for its part, applied for a specialty billing code for hospitalists in May 2014.

SHM has been actively exploring the data and looking at ways to identify hospitalists within this Medicare data. There’s an inherent value to this sort of self-reflection—it explains who we are and where we have been.

More importantly, it helps inform where we are going.

Joshua Lapps is SHM’s government relations manager.

“No man is an island.” Many of the reforms included in the Affordable Care Act (ACA) and other major healthcare legislation in the past decade put that sentiment into practice. This is a seismic shift in medicine and one that will reshape the way consumers and providers understand and relate to the healthcare system.

For consumers, the mandate to maintain health insurance coverage suggests the existence of a shared responsibility around health and wellness. This idea of community is central to many of the reforms for providers, as well. Value-based payment programs for both physicians and hospitals suggest that, given a scarce set of healthcare resources, we should be making sure that what Medicare is purchasing is of value. Even more telling, value is increasingly considered within a context of team-based and coordinated care. The future of healthcare, it seems, is pinned squarely on working together toward a common good.

The Physician Value-Based Payment Modifier (VBPM) is complementary to hospital value-based purchasing, moving the basis of physician payment toward the quality of care delivered, not simply the quantity of services rendered. The cost measures in the VBPM are unambiguously aligned with this ethos of community. Resource use per beneficiary is evaluated as an expression of the total costs borne by the healthcare system annually or within the context of an episode of care. So, in the value modifier, hospitalist groups can expect to see not just the costs that they charge, but also the costs of other physicians and other groups caring for the same Medicare patients. This is an explicit recognition of the myriad of providers engaged with each patient and their collective impact on the healthcare system.

At the same time, the VBPM strives to compare physicians by specialty, acknowledging that these separate communities within the healthcare system have different costs, patterns, and norms. For hospitalists, this comparison highlights some of the complexities of professional identity in what is still a relatively new field. For the measures to be meaningful and actionable, it is critical that comparisons be made amongst like providers.

SHM, through its Public Policy Committee and Performance Measurement and Reporting Committee, is diligently working to ensure that hospitalists are able to report on quality measures that make sense for their practices and that assessments are based on applicable and useful data for quality improvement. At the same time, these committees are working to ensure that hospitalists are evaluated using fair comparisons. In other words, hospitalists should be compared with other hospitalists.

At SHM’s annual meeting next month in Las Vegas (www.hospitalmedicine2014.org), healthcare reform will be discussed in greater detail during two sessions. One will focus on the current state of the ACA and reform efforts in general, and the other will be a workshop focusing specifically on participation in the VBPM. It is imperative that hospitalists are prepared to be successful as many of these changes unfold.

Joshua Lapps is SHM’s government relations specialist.

“No man is an island.” Many of the reforms included in the Affordable Care Act (ACA) and other major healthcare legislation in the past decade put that sentiment into practice. This is a seismic shift in medicine and one that will reshape the way consumers and providers understand and relate to the healthcare system.

For consumers, the mandate to maintain health insurance coverage suggests the existence of a shared responsibility around health and wellness. This idea of community is central to many of the reforms for providers, as well. Value-based payment programs for both physicians and hospitals suggest that, given a scarce set of healthcare resources, we should be making sure that what Medicare is purchasing is of value. Even more telling, value is increasingly considered within a context of team-based and coordinated care. The future of healthcare, it seems, is pinned squarely on working together toward a common good.

The Physician Value-Based Payment Modifier (VBPM) is complementary to hospital value-based purchasing, moving the basis of physician payment toward the quality of care delivered, not simply the quantity of services rendered. The cost measures in the VBPM are unambiguously aligned with this ethos of community. Resource use per beneficiary is evaluated as an expression of the total costs borne by the healthcare system annually or within the context of an episode of care. So, in the value modifier, hospitalist groups can expect to see not just the costs that they charge, but also the costs of other physicians and other groups caring for the same Medicare patients. This is an explicit recognition of the myriad of providers engaged with each patient and their collective impact on the healthcare system.

At the same time, the VBPM strives to compare physicians by specialty, acknowledging that these separate communities within the healthcare system have different costs, patterns, and norms. For hospitalists, this comparison highlights some of the complexities of professional identity in what is still a relatively new field. For the measures to be meaningful and actionable, it is critical that comparisons be made amongst like providers.

SHM, through its Public Policy Committee and Performance Measurement and Reporting Committee, is diligently working to ensure that hospitalists are able to report on quality measures that make sense for their practices and that assessments are based on applicable and useful data for quality improvement. At the same time, these committees are working to ensure that hospitalists are evaluated using fair comparisons. In other words, hospitalists should be compared with other hospitalists.

At SHM’s annual meeting next month in Las Vegas (www.hospitalmedicine2014.org), healthcare reform will be discussed in greater detail during two sessions. One will focus on the current state of the ACA and reform efforts in general, and the other will be a workshop focusing specifically on participation in the VBPM. It is imperative that hospitalists are prepared to be successful as many of these changes unfold.

Joshua Lapps is SHM’s government relations specialist.

“No man is an island.” Many of the reforms included in the Affordable Care Act (ACA) and other major healthcare legislation in the past decade put that sentiment into practice. This is a seismic shift in medicine and one that will reshape the way consumers and providers understand and relate to the healthcare system.

For consumers, the mandate to maintain health insurance coverage suggests the existence of a shared responsibility around health and wellness. This idea of community is central to many of the reforms for providers, as well. Value-based payment programs for both physicians and hospitals suggest that, given a scarce set of healthcare resources, we should be making sure that what Medicare is purchasing is of value. Even more telling, value is increasingly considered within a context of team-based and coordinated care. The future of healthcare, it seems, is pinned squarely on working together toward a common good.

The Physician Value-Based Payment Modifier (VBPM) is complementary to hospital value-based purchasing, moving the basis of physician payment toward the quality of care delivered, not simply the quantity of services rendered. The cost measures in the VBPM are unambiguously aligned with this ethos of community. Resource use per beneficiary is evaluated as an expression of the total costs borne by the healthcare system annually or within the context of an episode of care. So, in the value modifier, hospitalist groups can expect to see not just the costs that they charge, but also the costs of other physicians and other groups caring for the same Medicare patients. This is an explicit recognition of the myriad of providers engaged with each patient and their collective impact on the healthcare system.

At the same time, the VBPM strives to compare physicians by specialty, acknowledging that these separate communities within the healthcare system have different costs, patterns, and norms. For hospitalists, this comparison highlights some of the complexities of professional identity in what is still a relatively new field. For the measures to be meaningful and actionable, it is critical that comparisons be made amongst like providers.

SHM, through its Public Policy Committee and Performance Measurement and Reporting Committee, is diligently working to ensure that hospitalists are able to report on quality measures that make sense for their practices and that assessments are based on applicable and useful data for quality improvement. At the same time, these committees are working to ensure that hospitalists are evaluated using fair comparisons. In other words, hospitalists should be compared with other hospitalists.

At SHM’s annual meeting next month in Las Vegas (www.hospitalmedicine2014.org), healthcare reform will be discussed in greater detail during two sessions. One will focus on the current state of the ACA and reform efforts in general, and the other will be a workshop focusing specifically on participation in the VBPM. It is imperative that hospitalists are prepared to be successful as many of these changes unfold.

Joshua Lapps is SHM’s government relations specialist.

This legislation would authorize Medicare to provide coverage for voluntary advance care consultations every five years or at changes in the patient’s health, health-related condition, or care setting.

Although inevitable, death is often difficult to conceptualize and even more sensitive to discuss. For hospitalists and other care providers, conversations about the end of life with families and caregivers can be fraught with emotion. The fact that something is uncomfortable does not mean it is not useful or valuable, however. Patients must be able to vocalize their end-of-life wishes and should feel confident that the healthcare system is able to respond.

To help with this effort, the Society of Hospital Medicine is supporting legislation that would encourage voluntary end-of-life conversations between patients and their healthcare providers. Sponsored by U.S. Rep. Earl Blumenauer (D-Ore.), the Personalize Your Care Act of 2013 (H.R. 1173) would make Medicare reimbursement available for advance-care planning consultations, establish grants for state-level physician orders for life-sustaining treatment (POLST) programs, and require that advance directives be honored across state lines.

Hospitalists are integral team leaders for coordinating care and, as such, are often highly involved in end-of-life care for patients. They are at the front lines of these conversations, often tasked to plan end-of-life care and then carry out those plans. Many of their patients are acutely ill and need to face these critical decisions, often in real time.

End-of-life planning, like many other cognitive medical services, is not adequately reimbursed under current Medicare payment policy. This legislation would authorize Medicare to provide coverage for voluntary advance care consultations every five years or following changes in health, health-related condition, or care setting of the patient.

SHM is strongly supportive of adequate reimbursement for the counseling these patients require in planning their end-of-life care. The bill would make these conversations a practicable addition to the care and counseling workflow for healthcare providers and would ensure that they could occur at reasonable intervals and at significant changes in health or life events. These conversations would help ensure that patient wishes are respected at the end of life and prevent the use of unwanted treatments or interventions.

As the healthcare system works toward being more coordinated and more patient-centered, voluntary advance care planning is essential. Patients often see multiple providers at the end of their lives and—particularly as questions arise—it is imperative that providers have access to the most up-to-date advance care plans. H.R. 1173 works to address this gap by moving toward electronic health record display of advance directives and POLST.

Hospitalists may be eligible for reimbursement for these consultations, particularly in cases where these discussions did not occur in the outpatient setting. SHM is actively working with Rep. Blumenauer to ensure that all providers in a position to have these important conversations would be appropriately reimbursed. Patients need to have an active mechanism to ensure that their wishes are appropriately followed; this legislation would give them better access to these important and difficult conversations.

Joshua Lapps is SHM’s government relations specialist.

This legislation would authorize Medicare to provide coverage for voluntary advance care consultations every five years or at changes in the patient’s health, health-related condition, or care setting.

Although inevitable, death is often difficult to conceptualize and even more sensitive to discuss. For hospitalists and other care providers, conversations about the end of life with families and caregivers can be fraught with emotion. The fact that something is uncomfortable does not mean it is not useful or valuable, however. Patients must be able to vocalize their end-of-life wishes and should feel confident that the healthcare system is able to respond.

To help with this effort, the Society of Hospital Medicine is supporting legislation that would encourage voluntary end-of-life conversations between patients and their healthcare providers. Sponsored by U.S. Rep. Earl Blumenauer (D-Ore.), the Personalize Your Care Act of 2013 (H.R. 1173) would make Medicare reimbursement available for advance-care planning consultations, establish grants for state-level physician orders for life-sustaining treatment (POLST) programs, and require that advance directives be honored across state lines.

Hospitalists are integral team leaders for coordinating care and, as such, are often highly involved in end-of-life care for patients. They are at the front lines of these conversations, often tasked to plan end-of-life care and then carry out those plans. Many of their patients are acutely ill and need to face these critical decisions, often in real time.

End-of-life planning, like many other cognitive medical services, is not adequately reimbursed under current Medicare payment policy. This legislation would authorize Medicare to provide coverage for voluntary advance care consultations every five years or following changes in health, health-related condition, or care setting of the patient.

SHM is strongly supportive of adequate reimbursement for the counseling these patients require in planning their end-of-life care. The bill would make these conversations a practicable addition to the care and counseling workflow for healthcare providers and would ensure that they could occur at reasonable intervals and at significant changes in health or life events. These conversations would help ensure that patient wishes are respected at the end of life and prevent the use of unwanted treatments or interventions.

As the healthcare system works toward being more coordinated and more patient-centered, voluntary advance care planning is essential. Patients often see multiple providers at the end of their lives and—particularly as questions arise—it is imperative that providers have access to the most up-to-date advance care plans. H.R. 1173 works to address this gap by moving toward electronic health record display of advance directives and POLST.

Hospitalists may be eligible for reimbursement for these consultations, particularly in cases where these discussions did not occur in the outpatient setting. SHM is actively working with Rep. Blumenauer to ensure that all providers in a position to have these important conversations would be appropriately reimbursed. Patients need to have an active mechanism to ensure that their wishes are appropriately followed; this legislation would give them better access to these important and difficult conversations.

Joshua Lapps is SHM’s government relations specialist.

This legislation would authorize Medicare to provide coverage for voluntary advance care consultations every five years or at changes in the patient’s health, health-related condition, or care setting.

Although inevitable, death is often difficult to conceptualize and even more sensitive to discuss. For hospitalists and other care providers, conversations about the end of life with families and caregivers can be fraught with emotion. The fact that something is uncomfortable does not mean it is not useful or valuable, however. Patients must be able to vocalize their end-of-life wishes and should feel confident that the healthcare system is able to respond.

To help with this effort, the Society of Hospital Medicine is supporting legislation that would encourage voluntary end-of-life conversations between patients and their healthcare providers. Sponsored by U.S. Rep. Earl Blumenauer (D-Ore.), the Personalize Your Care Act of 2013 (H.R. 1173) would make Medicare reimbursement available for advance-care planning consultations, establish grants for state-level physician orders for life-sustaining treatment (POLST) programs, and require that advance directives be honored across state lines.

Hospitalists are integral team leaders for coordinating care and, as such, are often highly involved in end-of-life care for patients. They are at the front lines of these conversations, often tasked to plan end-of-life care and then carry out those plans. Many of their patients are acutely ill and need to face these critical decisions, often in real time.

End-of-life planning, like many other cognitive medical services, is not adequately reimbursed under current Medicare payment policy. This legislation would authorize Medicare to provide coverage for voluntary advance care consultations every five years or following changes in health, health-related condition, or care setting of the patient.

SHM is strongly supportive of adequate reimbursement for the counseling these patients require in planning their end-of-life care. The bill would make these conversations a practicable addition to the care and counseling workflow for healthcare providers and would ensure that they could occur at reasonable intervals and at significant changes in health or life events. These conversations would help ensure that patient wishes are respected at the end of life and prevent the use of unwanted treatments or interventions.

As the healthcare system works toward being more coordinated and more patient-centered, voluntary advance care planning is essential. Patients often see multiple providers at the end of their lives and—particularly as questions arise—it is imperative that providers have access to the most up-to-date advance care plans. H.R. 1173 works to address this gap by moving toward electronic health record display of advance directives and POLST.

Hospitalists may be eligible for reimbursement for these consultations, particularly in cases where these discussions did not occur in the outpatient setting. SHM is actively working with Rep. Blumenauer to ensure that all providers in a position to have these important conversations would be appropriately reimbursed. Patients need to have an active mechanism to ensure that their wishes are appropriately followed; this legislation would give them better access to these important and difficult conversations.

Joshua Lapps is SHM’s government relations specialist.

The Centers for Medicare & Medicaid Services (CMS) recently issued a Final Rule for the Inpatient Prospective Payment System, which guides payment and programs associated with inpatient hospitalizations. In this year’s rule, CMS adjusted the criteria for inpatient admissions in an attempt to simplify and clarify the decision-making process.

The policy would allow physicians to admit a patient if they reasonably expect and document in the medical record that a beneficiary will need to stay in the hospital for more than two midnights. Admissions based on this time-limited expectation will be presumed to be appropriate for Medicare Part A payment. CMS cited concerns about the growing trend of longer observation stays to support this change.

With observation stays, there are two major financial concerns for patients: whether the hospital stay is paid under Medicare Part A or Part B, and whether Medicare will pay for post-acute care in a skilled-nursing facility (SNF). Medicare Part A reimburses for inpatient admissions, with a one-time deductible for the benefit period. Outpatient services, such as observation care and physician services, are covered under Medicare Part B, which has copays and co-insurance that greatly increase the costs for beneficiaries. In addition, SNF coverage through Medicare Part A is determined by the three-day rule; a patient must be an inpatient for three days to qualify for coverage.

While the long-term impacts of this regulatory change to the admission criteria remain to be seen, SHM is concerned that the rule does not adequately address the broader problems associated with inpatient and observation status. As we note in our comments to CMS on the new rule:¹

Even with these changes, the central tension created by the bifurcation in admission status still remains.…Other policies and programs, such as the attempts to reduce admissions, may inadvertently add pressure to the admission decision.

Indeed, for beneficiaries, the barrier to SNF coverage remains. CMS takes care to note that, while time under emergency care and observation care count toward the two-midnight presumption for inpatient admission, it does not count toward the three-day rule for SNF coverage. This is particularly problematic; as advances in medicine allow for the treatment of higher-acuity and -severity conditions with observation stays or shorter inpatient stays, patients might not be getting the follow-up care they need. This puts them at risk for additional complications and, ultimately, readmissions to the hospital.

In an era of seeking value in the healthcare system, it seems like an opportunity lost to streamline and coordinate care across settings and to ensure that patients are getting the follow-up care they require. It is for this reason that hospitalists continue to push for passage of the Improving Access to Medicare Coverage Act, a bill sponsored by Rep. Joe Courtney (D-Conn.), Rep. Tom Latham (R-Iowa), and Sen. Sherrod Brown (D-Ohio) that would count observation status as time toward the three-day requirement for SNF coverage.

A recent Office of Inspector General (OIG) report for the U.S. Department of Health and Human Services on observation status sums up the problem succinctly.2 The OIG states that “CMS should consider how to ensure that beneficiaries with similar post-hospital care needs have the same access and cost-sharing for SNF services.”²

SHM concurs.

Joshua Lapps is SHM’s government relations specialist.

References

1. Society of Hospital Medicine. SHM submits comments in response to FY2014 inpatient prospective payment system proposed rule. Society of Hospital Medicine website. Available at: http://www.hospitalmedicine.org/AM/Template.cfm?Section=Letters_to_Congress_and_Regulatory_Agencies&Template=/CM/ContentDisplay.cfm&ContentID=34044. Accessed Sept. 9, 2013.
2. Office of Inspector General. Memorandum report: Hospitals’ use of observations stays and short inpatient stays for Medicare beneficiaries, OEI-02-12-00040. U.S. Department of Health and Human Services website. Available at: http://oig.hhs.gov/oei/reports/oei-02-12-00040.pdf. Accessed Sept. 9, 2013.

The Centers for Medicare & Medicaid Services (CMS) recently issued a Final Rule for the Inpatient Prospective Payment System, which guides payment and programs associated with inpatient hospitalizations. In this year’s rule, CMS adjusted the criteria for inpatient admissions in an attempt to simplify and clarify the decision-making process.

The policy would allow physicians to admit a patient if they reasonably expect and document in the medical record that a beneficiary will need to stay in the hospital for more than two midnights. Admissions based on this time-limited expectation will be presumed to be appropriate for Medicare Part A payment. CMS cited concerns about the growing trend of longer observation stays to support this change.

With observation stays, there are two major financial concerns for patients: whether the hospital stay is paid under Medicare Part A or Part B, and whether Medicare will pay for post-acute care in a skilled-nursing facility (SNF). Medicare Part A reimburses for inpatient admissions, with a one-time deductible for the benefit period. Outpatient services, such as observation care and physician services, are covered under Medicare Part B, which has copays and co-insurance that greatly increase the costs for beneficiaries. In addition, SNF coverage through Medicare Part A is determined by the three-day rule; a patient must be an inpatient for three days to qualify for coverage.

While the long-term impacts of this regulatory change to the admission criteria remain to be seen, SHM is concerned that the rule does not adequately address the broader problems associated with inpatient and observation status. As we note in our comments to CMS on the new rule:¹

Even with these changes, the central tension created by the bifurcation in admission status still remains.…Other policies and programs, such as the attempts to reduce admissions, may inadvertently add pressure to the admission decision.

Indeed, for beneficiaries, the barrier to SNF coverage remains. CMS takes care to note that, while time under emergency care and observation care count toward the two-midnight presumption for inpatient admission, it does not count toward the three-day rule for SNF coverage. This is particularly problematic; as advances in medicine allow for the treatment of higher-acuity and -severity conditions with observation stays or shorter inpatient stays, patients might not be getting the follow-up care they need. This puts them at risk for additional complications and, ultimately, readmissions to the hospital.

In an era of seeking value in the healthcare system, it seems like an opportunity lost to streamline and coordinate care across settings and to ensure that patients are getting the follow-up care they require. It is for this reason that hospitalists continue to push for passage of the Improving Access to Medicare Coverage Act, a bill sponsored by Rep. Joe Courtney (D-Conn.), Rep. Tom Latham (R-Iowa), and Sen. Sherrod Brown (D-Ohio) that would count observation status as time toward the three-day requirement for SNF coverage.

A recent Office of Inspector General (OIG) report for the U.S. Department of Health and Human Services on observation status sums up the problem succinctly.2 The OIG states that “CMS should consider how to ensure that beneficiaries with similar post-hospital care needs have the same access and cost-sharing for SNF services.”²

SHM concurs.

Joshua Lapps is SHM’s government relations specialist.

References

1. Society of Hospital Medicine. SHM submits comments in response to FY2014 inpatient prospective payment system proposed rule. Society of Hospital Medicine website. Available at: http://www.hospitalmedicine.org/AM/Template.cfm?Section=Letters_to_Congress_and_Regulatory_Agencies&Template=/CM/ContentDisplay.cfm&ContentID=34044. Accessed Sept. 9, 2013.
2. Office of Inspector General. Memorandum report: Hospitals’ use of observations stays and short inpatient stays for Medicare beneficiaries, OEI-02-12-00040. U.S. Department of Health and Human Services website. Available at: http://oig.hhs.gov/oei/reports/oei-02-12-00040.pdf. Accessed Sept. 9, 2013.

The Centers for Medicare & Medicaid Services (CMS) recently issued a Final Rule for the Inpatient Prospective Payment System, which guides payment and programs associated with inpatient hospitalizations. In this year’s rule, CMS adjusted the criteria for inpatient admissions in an attempt to simplify and clarify the decision-making process.

The policy would allow physicians to admit a patient if they reasonably expect and document in the medical record that a beneficiary will need to stay in the hospital for more than two midnights. Admissions based on this time-limited expectation will be presumed to be appropriate for Medicare Part A payment. CMS cited concerns about the growing trend of longer observation stays to support this change.

With observation stays, there are two major financial concerns for patients: whether the hospital stay is paid under Medicare Part A or Part B, and whether Medicare will pay for post-acute care in a skilled-nursing facility (SNF). Medicare Part A reimburses for inpatient admissions, with a one-time deductible for the benefit period. Outpatient services, such as observation care and physician services, are covered under Medicare Part B, which has copays and co-insurance that greatly increase the costs for beneficiaries. In addition, SNF coverage through Medicare Part A is determined by the three-day rule; a patient must be an inpatient for three days to qualify for coverage.

While the long-term impacts of this regulatory change to the admission criteria remain to be seen, SHM is concerned that the rule does not adequately address the broader problems associated with inpatient and observation status. As we note in our comments to CMS on the new rule:¹

Even with these changes, the central tension created by the bifurcation in admission status still remains.…Other policies and programs, such as the attempts to reduce admissions, may inadvertently add pressure to the admission decision.

Indeed, for beneficiaries, the barrier to SNF coverage remains. CMS takes care to note that, while time under emergency care and observation care count toward the two-midnight presumption for inpatient admission, it does not count toward the three-day rule for SNF coverage. This is particularly problematic; as advances in medicine allow for the treatment of higher-acuity and -severity conditions with observation stays or shorter inpatient stays, patients might not be getting the follow-up care they need. This puts them at risk for additional complications and, ultimately, readmissions to the hospital.

In an era of seeking value in the healthcare system, it seems like an opportunity lost to streamline and coordinate care across settings and to ensure that patients are getting the follow-up care they require. It is for this reason that hospitalists continue to push for passage of the Improving Access to Medicare Coverage Act, a bill sponsored by Rep. Joe Courtney (D-Conn.), Rep. Tom Latham (R-Iowa), and Sen. Sherrod Brown (D-Ohio) that would count observation status as time toward the three-day requirement for SNF coverage.

A recent Office of Inspector General (OIG) report for the U.S. Department of Health and Human Services on observation status sums up the problem succinctly.2 The OIG states that “CMS should consider how to ensure that beneficiaries with similar post-hospital care needs have the same access and cost-sharing for SNF services.”²

SHM concurs.

Joshua Lapps is SHM’s government relations specialist.

References

1. Society of Hospital Medicine. SHM submits comments in response to FY2014 inpatient prospective payment system proposed rule. Society of Hospital Medicine website. Available at: http://www.hospitalmedicine.org/AM/Template.cfm?Section=Letters_to_Congress_and_Regulatory_Agencies&Template=/CM/ContentDisplay.cfm&ContentID=34044. Accessed Sept. 9, 2013.
2. Office of Inspector General. Memorandum report: Hospitals’ use of observations stays and short inpatient stays for Medicare beneficiaries, OEI-02-12-00040. U.S. Department of Health and Human Services website. Available at: http://oig.hhs.gov/oei/reports/oei-02-12-00040.pdf. Accessed Sept. 9, 2013.