Kelly April Tyrrell

 

A bipartisan bill introduced in the U.S. Senate in late March 2017 would authorize the Center for Medicare & Medicaid Innovation (CMMI) to test expanded telehealth services provided to Medicare beneficiaries.

The Telehealth Innovation and Improvement Act (S.787), currently in the Senate Finance Committee, was introduced by Sen. Gary Peters (D-Mich.) and Sen. Cory Gardner (R-Colo.). A similar bill they introduced in 2015 was never enacted.

However, there are physicians hoping to see this bill or others like it granted consideration. Currently, the Centers for Medicare & Medicaid Services reimburses only for certain telemedicine services provided in rural or underserved geographic areas, but the new bill would apply in suburban and urban areas as well, based on pilot testing of models and evaluating them for cost, quality, and effectiveness. Successful models would be covered by Medicare.

“Medicare has made some provisions for specific rural sites and niche areas, but writ large, there’s no prescribed way for people to just open a telemedicine shop and begin to bill,” said Bradley Flansbaum, DO, MPH, MHM, a member of the SHM Public Policy Committee.

With the exception of telestroke and critical care, “evidence is needed for the type of setting and type of clinical problems addressed by telemedicine. It’s not been tested enough,” added Dr. Flansbaum, who holds a dual appointment in hospital medicine and population health at Geisinger Medical Center in Danville, Penn. “How does it work for routine inpatient problems and how do hospitalists use it? We haven’t seen data there and that’s where a pilot comes in.”

Talbot McCormick, MD, or “Dr. Mac,” is a hospitalist and CEO of Eagle Telemedicine in Atlanta, a physician group whose employees provide a variety of telehealth services to hospitals around the country, from 5-bed critical access facilities to larger, urban hospitals with 300-400 beds. At present, the company contracts with hospitals and compensates its physicians based on their level of experience, availability, hours worked, and the services they provide each hospital. Eagle’s business model relies on the additional value it provides hospitals that may not be able to staff certain specialties or keep hospitalists on at night.

Dr. Mac believes it inconsistent that, in many circumstances, physicians providing services via telemedicine technology are not reimbursed by Medicare and other payers.

“The expansion and ability to provide care in more unique ways – more specialties and in more environments – has expanded more quickly than the systems of reimbursement for professional fees have and it really is a bit of a hodgepodge now,” he said. “We certainly are pleased that this is getting attention and that we have leaders pushing for this in Congress. We don’t know for sure how the final legislation (on this bill) may look but hopefully there will be some form of this that will come to fruition.”

Whether telemedicine can reduce costs while improving outcomes, or improve outcomes without increasing costs, remains unsettled. A study published in Health Affairs in March 2017 indicates that while telehealth can improve access to care, it results in greater utilization, thereby increasing costs.¹

The study relied on claims data for more than 300,000 patients in the California Public Employees’ Retirement System during 2011-2013. It looked at utilization of direct-to-consumer telehealth and spending for acute respiratory illness, one of the most common reasons patients seek telehealth services. While, per episode, telehealth visits cost 50% less than did an outpatient visit and less than 5% of an emergency department visit, annual spending per individual for acute respiratory illness went up $45 because, as the authors estimated, 88% of direct-to-consumer telehealth visits represented new utilization.

Whether this would be the case for hospitalist patients remains to be tested.

“It gets back to whether or not you’re adding a necessary service or substituting a less expensive one for a more expensive one,” said Dr. Flansbaum. “Are physicians providing a needed service or adding unnecessary visits to the system?”

Jayne Lee, MD, has been a hospitalist with Eagle for nearly a decade. Before making the transition from an in-hospital physician to one treating patients from behind a robot – with assistance at the point of service from a nurse – she was working 10 shifts in a row at her home in the United States before traveling to her home in Paris. Dr. Mac offered her the opportunity to practice full time as a telehospitalist from overseas. Today, she is also the company’s chief medical officer and estimates she’s had more than 7,000 patient encounters using telemedicine technology.

“I was skeptical at first,” she said, “but the more I worked in telemedicine, the more I liked it, and I found that working remotely was pretty similar to working on the ground. The physical exam is different, but given technology, we have easily been able to listen to the heart and lungs as easily as at the bedside.”

Dr. Lee is licensed in multiple states – a barrier that plagues many would-be telehealth providers, but which Eagle has solved with its licensing and credentialing staff – and because she is often providing services at night to urban and rural areas, she sees a broad range of patients.

“We see things from coronary artery disease, COPD [chronic obstructive pulmonary disease] exacerbations, and diabetes-related conditions to drug overdoses and alcohol abuse,” she said. “I enjoy seeing the variety of patients I encounter every night.”

Dr. Lee has to navigate each health system’s electronic medical records and triage systems but, she says, patient care has remained the same. And she’s providing services for hospitals that may not have another hospitalist to assign.

“Our practices keep growing, a sign that hospitals are needing our services now more than ever, given that there is a physician shortage and given the financial constraints we’re seeing in the healthcare system.” she said.

 

References

1. Ashwood JS, Mehrota A, Cowling D, et al. Direct-to-consumer telehealth may increase access to care but does not decrease spending. Health Affairs. 2017; 36(3):485-491. doi: 10.1377/hlthaff.2016.1130.

 

A bipartisan bill introduced in the U.S. Senate in late March 2017 would authorize the Center for Medicare & Medicaid Innovation (CMMI) to test expanded telehealth services provided to Medicare beneficiaries.

The Telehealth Innovation and Improvement Act (S.787), currently in the Senate Finance Committee, was introduced by Sen. Gary Peters (D-Mich.) and Sen. Cory Gardner (R-Colo.). A similar bill they introduced in 2015 was never enacted.

However, there are physicians hoping to see this bill or others like it granted consideration. Currently, the Centers for Medicare & Medicaid Services reimburses only for certain telemedicine services provided in rural or underserved geographic areas, but the new bill would apply in suburban and urban areas as well, based on pilot testing of models and evaluating them for cost, quality, and effectiveness. Successful models would be covered by Medicare.

“Medicare has made some provisions for specific rural sites and niche areas, but writ large, there’s no prescribed way for people to just open a telemedicine shop and begin to bill,” said Bradley Flansbaum, DO, MPH, MHM, a member of the SHM Public Policy Committee.

With the exception of telestroke and critical care, “evidence is needed for the type of setting and type of clinical problems addressed by telemedicine. It’s not been tested enough,” added Dr. Flansbaum, who holds a dual appointment in hospital medicine and population health at Geisinger Medical Center in Danville, Penn. “How does it work for routine inpatient problems and how do hospitalists use it? We haven’t seen data there and that’s where a pilot comes in.”

Talbot McCormick, MD, or “Dr. Mac,” is a hospitalist and CEO of Eagle Telemedicine in Atlanta, a physician group whose employees provide a variety of telehealth services to hospitals around the country, from 5-bed critical access facilities to larger, urban hospitals with 300-400 beds. At present, the company contracts with hospitals and compensates its physicians based on their level of experience, availability, hours worked, and the services they provide each hospital. Eagle’s business model relies on the additional value it provides hospitals that may not be able to staff certain specialties or keep hospitalists on at night.

Dr. Mac believes it inconsistent that, in many circumstances, physicians providing services via telemedicine technology are not reimbursed by Medicare and other payers.

“The expansion and ability to provide care in more unique ways – more specialties and in more environments – has expanded more quickly than the systems of reimbursement for professional fees have and it really is a bit of a hodgepodge now,” he said. “We certainly are pleased that this is getting attention and that we have leaders pushing for this in Congress. We don’t know for sure how the final legislation (on this bill) may look but hopefully there will be some form of this that will come to fruition.”

Whether telemedicine can reduce costs while improving outcomes, or improve outcomes without increasing costs, remains unsettled. A study published in Health Affairs in March 2017 indicates that while telehealth can improve access to care, it results in greater utilization, thereby increasing costs.¹

The study relied on claims data for more than 300,000 patients in the California Public Employees’ Retirement System during 2011-2013. It looked at utilization of direct-to-consumer telehealth and spending for acute respiratory illness, one of the most common reasons patients seek telehealth services. While, per episode, telehealth visits cost 50% less than did an outpatient visit and less than 5% of an emergency department visit, annual spending per individual for acute respiratory illness went up $45 because, as the authors estimated, 88% of direct-to-consumer telehealth visits represented new utilization.

Whether this would be the case for hospitalist patients remains to be tested.

“It gets back to whether or not you’re adding a necessary service or substituting a less expensive one for a more expensive one,” said Dr. Flansbaum. “Are physicians providing a needed service or adding unnecessary visits to the system?”

Jayne Lee, MD, has been a hospitalist with Eagle for nearly a decade. Before making the transition from an in-hospital physician to one treating patients from behind a robot – with assistance at the point of service from a nurse – she was working 10 shifts in a row at her home in the United States before traveling to her home in Paris. Dr. Mac offered her the opportunity to practice full time as a telehospitalist from overseas. Today, she is also the company’s chief medical officer and estimates she’s had more than 7,000 patient encounters using telemedicine technology.

“I was skeptical at first,” she said, “but the more I worked in telemedicine, the more I liked it, and I found that working remotely was pretty similar to working on the ground. The physical exam is different, but given technology, we have easily been able to listen to the heart and lungs as easily as at the bedside.”

Dr. Lee is licensed in multiple states – a barrier that plagues many would-be telehealth providers, but which Eagle has solved with its licensing and credentialing staff – and because she is often providing services at night to urban and rural areas, she sees a broad range of patients.

“We see things from coronary artery disease, COPD [chronic obstructive pulmonary disease] exacerbations, and diabetes-related conditions to drug overdoses and alcohol abuse,” she said. “I enjoy seeing the variety of patients I encounter every night.”

Dr. Lee has to navigate each health system’s electronic medical records and triage systems but, she says, patient care has remained the same. And she’s providing services for hospitals that may not have another hospitalist to assign.

“Our practices keep growing, a sign that hospitals are needing our services now more than ever, given that there is a physician shortage and given the financial constraints we’re seeing in the healthcare system.” she said.

 

References

1. Ashwood JS, Mehrota A, Cowling D, et al. Direct-to-consumer telehealth may increase access to care but does not decrease spending. Health Affairs. 2017; 36(3):485-491. doi: 10.1377/hlthaff.2016.1130.

 

A bipartisan bill introduced in the U.S. Senate in late March 2017 would authorize the Center for Medicare & Medicaid Innovation (CMMI) to test expanded telehealth services provided to Medicare beneficiaries.

The Telehealth Innovation and Improvement Act (S.787), currently in the Senate Finance Committee, was introduced by Sen. Gary Peters (D-Mich.) and Sen. Cory Gardner (R-Colo.). A similar bill they introduced in 2015 was never enacted.

However, there are physicians hoping to see this bill or others like it granted consideration. Currently, the Centers for Medicare & Medicaid Services reimburses only for certain telemedicine services provided in rural or underserved geographic areas, but the new bill would apply in suburban and urban areas as well, based on pilot testing of models and evaluating them for cost, quality, and effectiveness. Successful models would be covered by Medicare.

“Medicare has made some provisions for specific rural sites and niche areas, but writ large, there’s no prescribed way for people to just open a telemedicine shop and begin to bill,” said Bradley Flansbaum, DO, MPH, MHM, a member of the SHM Public Policy Committee.

With the exception of telestroke and critical care, “evidence is needed for the type of setting and type of clinical problems addressed by telemedicine. It’s not been tested enough,” added Dr. Flansbaum, who holds a dual appointment in hospital medicine and population health at Geisinger Medical Center in Danville, Penn. “How does it work for routine inpatient problems and how do hospitalists use it? We haven’t seen data there and that’s where a pilot comes in.”

Talbot McCormick, MD, or “Dr. Mac,” is a hospitalist and CEO of Eagle Telemedicine in Atlanta, a physician group whose employees provide a variety of telehealth services to hospitals around the country, from 5-bed critical access facilities to larger, urban hospitals with 300-400 beds. At present, the company contracts with hospitals and compensates its physicians based on their level of experience, availability, hours worked, and the services they provide each hospital. Eagle’s business model relies on the additional value it provides hospitals that may not be able to staff certain specialties or keep hospitalists on at night.

Dr. Mac believes it inconsistent that, in many circumstances, physicians providing services via telemedicine technology are not reimbursed by Medicare and other payers.

“The expansion and ability to provide care in more unique ways – more specialties and in more environments – has expanded more quickly than the systems of reimbursement for professional fees have and it really is a bit of a hodgepodge now,” he said. “We certainly are pleased that this is getting attention and that we have leaders pushing for this in Congress. We don’t know for sure how the final legislation (on this bill) may look but hopefully there will be some form of this that will come to fruition.”

Whether telemedicine can reduce costs while improving outcomes, or improve outcomes without increasing costs, remains unsettled. A study published in Health Affairs in March 2017 indicates that while telehealth can improve access to care, it results in greater utilization, thereby increasing costs.¹

The study relied on claims data for more than 300,000 patients in the California Public Employees’ Retirement System during 2011-2013. It looked at utilization of direct-to-consumer telehealth and spending for acute respiratory illness, one of the most common reasons patients seek telehealth services. While, per episode, telehealth visits cost 50% less than did an outpatient visit and less than 5% of an emergency department visit, annual spending per individual for acute respiratory illness went up $45 because, as the authors estimated, 88% of direct-to-consumer telehealth visits represented new utilization.

Whether this would be the case for hospitalist patients remains to be tested.

“It gets back to whether or not you’re adding a necessary service or substituting a less expensive one for a more expensive one,” said Dr. Flansbaum. “Are physicians providing a needed service or adding unnecessary visits to the system?”

Jayne Lee, MD, has been a hospitalist with Eagle for nearly a decade. Before making the transition from an in-hospital physician to one treating patients from behind a robot – with assistance at the point of service from a nurse – she was working 10 shifts in a row at her home in the United States before traveling to her home in Paris. Dr. Mac offered her the opportunity to practice full time as a telehospitalist from overseas. Today, she is also the company’s chief medical officer and estimates she’s had more than 7,000 patient encounters using telemedicine technology.

“I was skeptical at first,” she said, “but the more I worked in telemedicine, the more I liked it, and I found that working remotely was pretty similar to working on the ground. The physical exam is different, but given technology, we have easily been able to listen to the heart and lungs as easily as at the bedside.”

Dr. Lee is licensed in multiple states – a barrier that plagues many would-be telehealth providers, but which Eagle has solved with its licensing and credentialing staff – and because she is often providing services at night to urban and rural areas, she sees a broad range of patients.

“We see things from coronary artery disease, COPD [chronic obstructive pulmonary disease] exacerbations, and diabetes-related conditions to drug overdoses and alcohol abuse,” she said. “I enjoy seeing the variety of patients I encounter every night.”

Dr. Lee has to navigate each health system’s electronic medical records and triage systems but, she says, patient care has remained the same. And she’s providing services for hospitals that may not have another hospitalist to assign.

“Our practices keep growing, a sign that hospitals are needing our services now more than ever, given that there is a physician shortage and given the financial constraints we’re seeing in the healthcare system.” she said.

 

References

1. Ashwood JS, Mehrota A, Cowling D, et al. Direct-to-consumer telehealth may increase access to care but does not decrease spending. Health Affairs. 2017; 36(3):485-491. doi: 10.1377/hlthaff.2016.1130.

 

Several months into 2017, physicians around the country are preparing for the first benchmark year of MACRA, the Medicare Access and CHIP Reauthorization Act. Passed in 2015, MACRA is the bipartisan health care law responsible for eliminating the Sustainable Growth Rate and it promises to continue to fundamentally alter the way providers are paid. This year determines reimbursement in 2019.

Under the law, physicians must report performance under one of two pathways: MIPS, the Merit-based Incentive Payment System, or participation in a qualified Advanced Alternative Payment Model, or Advanced APM. The first, MIPS, replaces the Physician Quality Reporting System, Meaningful Use and the Physician Value-Based Payment Modifier and is the track most providers can expect to follow, at least initially, because most will not meet the requirements for Advanced APMs.^1,2

This is especially true for hospitalists, most of whom are not yet participating in qualifying alternative payment models.²

The MIPS track is budget neutral, which means for every physician or physician group that receives a boost in reimbursement, another will receive a cut. Others will receive a neutral adjustment. All physicians see an annual 0.5% increase in payment between 2016 and 2019 and MIPS clinicians receive a 0.25% annual boost starting in 2026. Providers participating in Advanced APMs will also receive an annual 5% payment bonus between 2019 and 2024, and a 0.75% annual increase in payments beginning in 2026.¹

Both pathways are complex and will affect different clinicians in unique ways, particularly hospitalists.

“A large percentage of hospitalists are actually employed... and the question is whether there is a change in their compensation structure as a result of a negative score,” said Kavita Patel, MD, a practicing internist and nonresident fellow of the Brookings Institution. “That’s why MACRA is complicated: It’s not just that hospitalists are different, it’s that they’re compensated differently as well.”

Some health policy experts, like Robert Berenson, MD, FACP, Institute Fellow of the Health Policy Center at the Urban Institute, say MACRA could actually drive more hospitalists into employment to avoid the costs associated with complying with the law.

Regardless, there is much about MACRA that hospitalists should familiarize themselves with this year. The CMS has announced 2018 will also be a transition year and, as such, additional rules are forthcoming.

“It’s not an easy piece of legislation to understand and there are still areas that need to be clarified in the coming months,” said Nasim Afsarmanesh, MD, SFHM, a hospitalist and member of the Society for Hospital Medicine’s Public Policy Committee.

Here is what to know for now:
 

MIPS

All providers who receive Medicare Physician Fee Schedule payments and do not participate in an Advanced APM will fall into MIPS, and reporting applies to all patients, not just Medicare beneficiaries.³ There are, however, exemptions: providers in their first year of Medicare, those billing Medicare Part B less than $30,000 annually, and those who see 100 or fewer Medicare patients.⁴

Under MIPS, physicians are scored on a scale of 1 to 100 based on performance across four weighted categories: Quality (60%), Advancing Care Information (25%), Improvement Activities (15%), and Cost (not included for 2017). Hospitalists who provide 75% or more of their services in hospital inpatient or outpatient settings, or in the emergency department, are exempt from Advancing Care Information, which replaced meaningful use. As a result, the Quality category will make up 85% of the overall score in 2017.

The CMS also announced added flexibility for 2017 with regard to reporting under MIPS, intended to give providers who need it extra time to prepare.⁵ Physicians and physician groups can report for a full year, starting January 1, 2017, or report for just 90 days, to be eligible for a positive payment adjustment. To avoid a negative adjustment, they can simply submit more than one quality measure, improvement activity, or advancing care information measure (for those not exempt). Or, providers can choose to report nothing and incur a negative 4% payment.

The approach to MIPS in 2017 will vary widely among SHM members, said Joshua Boswell, SHM’s director of government relations.

“Some are looking to do just the bare minimum, not because of their lack of readiness, but for at least this year, to avoid the time, resources, and cost associated with reporting.” he said. “Other groups are considering jumping in with both feet and fully reporting, their thinking being that they can’t lose, and if there is money on the table for high performers, they might as well go for it.”

For 2017, providers who score 70 or more points are eligible for a performance bonus, drawn from a $500 million pool set aside by CMS. The minimum point threshold defined by CMS is three, which a clinician can earn by submitting just one of the six required quality measures.⁴

The CMS has defined 271 total quality measures under MIPS, 13 of which are designated as hospitalist specialty measures. However, SHM believes just seven are applicable to hospitalists. Public Policy Committee chair and SHM president Ron Greeno, MD, MHM, says most clinicians will only be able to reliably report on four.

“We’re working to ensure the program is structured so that providers can confidently report on just the measures applicable to them, even if it’s fewer than six,” he said. To ensure physicians are not penalized or disadvantaged for being unable to report the required number of measures, Dr. Greeno said CMS is working to develop a validation test, though it has not yet released details.

The measures most applicable to hospitalists include two related to heart failure (ACE inhibitor/angiotensin receptor blocker for left ventricular systolic dysfunction [LVSD] and beta-blocker for LVSD), one stroke measure (DC on antithrombotic therapy), advance care planning, prevention of catheter-related bloodstream infection (central venous catheter insertion protocol), documentation of current medications and appropriate treatment of methicillin-resistant Staphylococcus aureus bacteremia.

“This isn’t one of those things that will impact everybody equally,” said Dr. Afsarmanesh. For example, most hospitalists should be able to easily report on advanced care planning and medication documentation, she said, but in some hospitals the stroke measures may be captured in the emergency department; many hospitalists may not achieve enough reportable stroke management cases.

However, Dr. Afsarmanesh expects hospitalists will shine in the improvement activities category. “It’s part of our DNA,” she said. “Improvement activities... have become part of the core responsibilities for many of us within hospitalist groups, hospitals, and health systems.”

In 2017, CMS requires providers to report four improvement activities, which include: implementation of antibiotic stewardship programs, connecting patients to community chronic-disease management programs, and integrating pharmacists into a patient care team. Dr. Afsarmanesh suggests hospitalists visit SHM’s Quality and Innovation guide for ideas, implementation toolkits, and more.

In the cost category, “for the most part, hospitalists aren’t acquainted with cost and there is not a lot of cost transparency around what we do... In general, medical care needs to be discussed between physicians and patients so they can weigh the cost-benefit,” she said, which includes not just dollars and cents, but the impact associated with procedures, like radiation exposure from a CT scan.

However, Dr. Afsarmanesh acknowledges this is challenging, given the overall lack of cost transparency in the American health care system. “It is disjointed and we don’t have any other system where the professionals who do the work are so far-removed from the actual cost,” she said. “The good thing is, I think we are heading toward an era of more cost-conscious practice.”

In addition, hospitalists are poised to help with overall cost-reduction in the hospital. “I could imagine something relevant around readmissions and total cost,” said Dr. Patel. “But risk-adjustment is key.”

This category will increase to 30% of a provider’s or group’s overall score by payment year 2021, CMS says. It will be determined using claims data to calculate per capita costs for all attributed beneficiaries and a Medicare Spending per Beneficiary measure. The CMS also says it is finalizing 10 episode-based measures determined to be reliable and that will be made available to providers in feedback reports starting in 2018.⁴

Clinicians may report MIPS data as individual providers (a single National Provider Identifier tied to a single Tax Identification Number) by sending data for each category through electronic health records, registries, or qualified clinical data registries. Quality data may be reported through Medicare claims.

Hospitalists who report through a group will receive a single payment adjustment based on the group’s performance, using group-level data for each category. Groups can submit using the same mechanisms as individual providers, or through a CMS web interface (though groups must register by June 30, 2017).⁵

The SHM has also asked CMS to consider allowing employed hospitalists to align with and report with their facilities, though Dr. Greeno says this should be voluntary since not every hospitalist may be interested in reporting through their hospital. Dr. Greeno says CMS is “very interested and receptive” to how it could be done.

“We are trying to create the incentive for everybody to provide care at lower costs,” Dr. Greeno said. “There are two goals: Create alignment, and decrease the reporting burden on hospitalist groups.”

Additionally, CMS recognizes the potential burden MIPS imposes on small practices and is working to allow individuals and groups of 10 or fewer clinicians to combine to create virtual groups. This option is not available in 2017.⁴

The CMS has also authorized $100 million, dispersed over 5 years, for certain organizations to provide technical assistance to MIPS providers with fewer than 15 clinicians, in rural areas and those in health professional shortage areas.⁴

According to Modern Healthcare, projections by CMS, released last May, show that 87% of solo practitioners and 70% of physician groups with two to nine providers will see their reimbursement rates fall in 2019. Meanwhile, 55% of groups with 25 to 99 providers and 81% of those with 100 or more clinicians will see an increase in reimbursement.⁷

“I think it’s going to be pretty tough unless you’re big enough to commit the resources you need to do it right,” Dr. Greeno said. “If I was just a really small group with very little overhead, no infrastructure to support, I’d consider taking the penalty and just living with it because I don’t have many costs and just pay my own salary. But it’s still a hard road.”

Dr. Afsarmanesh says SHM continues to look across the board and advocate for all its members.

In 2019, physicians reporting under MIPS will see up to a 4% increase and as low as a 4% decrease in reimbursement. This rises to plus-or-minus 5% in 2020, 7% in 2021 and 9% thereafter.²

Dr. Patel and many others say it appears to be the intention of CMS to move providers toward alternative payment models. A January 2015 news release from the U.S. Department of Health and Human Services announced a goal of tying 50% of Medicare payments to Accountable Care Organizations (ACO) by the end of 2018 (it’s worth noting this was pre-MACRA, and not all ACOs qualify as Advanced APMs).⁸

“The awkwardness and clunkiness of MIPS needs to be addressed in order to make it successful because many people will be in MIPS,” Dr. Patel said. “I think it’s the intention to move people into Advanced APMs, but how long it takes to get to that point – 3-5 years, it could be 10 – physicians have to thrive in MIPS in order to live.”

One of the most important things, she and Dr. Berenson said, is adequately capturing the quality and scope of the care physicians provide.

“I know hospitalists complain how little their care is reflected in HCAHPS (the Hospital Consumer Assessment of Healthcare Providers and Systems) and the quality measures they have now, and readmission rates don’t reflect what doctors do inside the hospital. My colleagues are telling me they want something better,” Dr. Patel said.
 

 

Advanced APMs

Physicians who participate in Advanced APMs are exempt from MIPS. Advanced APMs must use Certified Electronic Health Record Technology (CEHRT) and take on a minimum amount of risk. For 2017 and 2018, providers must risk losing the lesser of 3% of their total Medicare expenditures or 8% of their revenue.⁹ They are paid based on the parameters of their particular model.

Additionally, for the 2019 payment year, 25% of a provider’s or group’s Medicare payments or 20% of their patients must be through the Advanced APM. This increases to 50% of payments and 35% of patients for 2021 and 2022, and in 2023, to 75% of payments and 50% of patients.

In 2017, APMs that meet the criteria for Advanced include: Comprehensive End-Stage Renal Disease Care, Comprehensive Primary Care Plus, Next Generation ACO Model, Shared Savings Program Tracks 2 and 3, Comprehensive Joint Replacement Payment Model Track 1, the Vermont Medicare ACO Initiative, and the Oncology Care Model. (APMs that do not qualify must report under MIPS.)⁵

The CMS also says that services provided at critical access hospitals, rural health clinics, and federally qualified health centers may qualify using patient counts, and medical home models and the Medicaid Medical Home Model may also be considered Advanced APMs using financial criteria.⁴

At this time, SHM is unable to quantify the number of hospitalists participating in Advanced APMs, and some, Dr. Greeno said, may not know whether they are part of an Advanced APM.

Currently, BPCI (Bundled Payments for Care Improvement) is the only alternative payment model in which hospitalists can directly take risk, Dr. Greeno says, but it does not yet qualify as an Advanced APM. However, that could change.

Prior to the passage of MACRA, Brandeis University worked with CMS to create the Episode Grouper for Medicare (EGM), software that converts claims data into episodes of care based on a patient’s condition or conditions or procedures. The American College of Surgeons (ACS) has since proposed an alternative payment model, called ACS-Brandeis, that would use the diagnostic grouper to take into account all of the work done by every provider on any episode admitted to the hospital and use algorithms to decide who affected a particular patient’s care.

“Anyone who takes care of the patient can take risk or gain share if the episode initiator allows them,” said Dr. Greeno.

For example, if a patient is admitted for surgery, but has an internist on their case because they have diabetes and heart failure, and they also have an anesthesiologist and an infectious disease specialist, everybody has an impact on their care and makes decisions about the resources used on the case. The risk associated with the case is effectively divided.

The ACS submitted the proposal to PTAC (the Physician-Focused Payment Model Technical Advisory Committee) in 2016 and SHM submitted a letter of support.

“In this model, everybody’s taking risk and everybody has the opportunity to gain share if the patient is managed well,” said Dr. Greeno. “It’s a very complicated, very complex model... Theoretically, everybody on that case should be optimally engaged – that’s the beauty of it – but we don’t know if it will work.”

The SHM got involved at the request of ACS, because it would not apply solely to surgical patients. Dr. Greeno says ACS asked SHM to look at common surgical diagnoses and review every medical scenario that could come to pass, from heart failure and pneumonia to infection.

“There’s bundles within bundles, medical bundles within surgical bundles,” he said. “It’s fascinating and it’s daunting but it is truly a big data approach to episodes of care. We’re thrilled to be invited and ACS was very enthusiastic about our involvement.”

Dr. Patel, who sits on PTAC, is heartened by the amount of physician-led innovation taking place. “Proposals are coming directly from doctors; they are telling us what they want,” she said.

For Dr. Greeno, this captures the intent of MACRA: “There is going to be a continual increase in the sophistication of models, and hopefully toward ones that are better and better and create the right incentives for everyone involved in the health care system.”


References

1. S. Findlay. Medicare’s new physician payment system. http://www.healthaffairs.org/healthpolicybriefs/brief.php?brief_id=156. Published April 21, 2016. Accessed March 6, 2017.

2. The Society of Hospital Medicine. Medicare physician payments are changing. http://www.macraforhm.org/. Accessed March 6, 2017.

3. A. Maciejowski. MACRA: What’s really in the final rule. http://blog.ncqa.org/macra-whats-really-in-the-final-rule/. Blog post published November 15, 2016. Accessed March 6, 2017.

4. Department of Health and Human Services, Centers for Medicare and Medicaid Services. Quality Payment Program executive summary. https://qpp.cms.gov/docs/QPP_Executive_Summary_of_Final_Rule.pdf. Published Oct. 14, 2016. Accessed March 6, 2017.

5. Department of Health and Human Services, Centers for Medicare and Medicaid Services. Quality Payment Program: Modernizing Medicare to provide better care and smarter spending for a healthier America. https://qpp.cms.gov/. Accessed March 6, 2017.

6. D. Barkholz. Potential MACRA byproduct: physician consolidation. http://www.modernhealthcare.com/article/20160630/NEWS/160639995. Published June 30, 2016. Accessed March 6, 2017.

7. United States Department of Health and Human Services. Better, smarter, healthier: In historic announcement, HHS sets clear goals and timeline for shifting Medicare reimbursement from volume to value. http://wayback.archive-it.org/3926/20170127185400/https://www.hhs.gov/about/news/2015/01/26/better-smarter-healthier-in-historic-announcement-hhs-sets-clear-goals-and-timeline-for-shifting-medicare-reimbursements-from-volume-to-value.html. Published January 26, 2015. Accessed March 6, 2017.

8. B. Wynne. MACRA Final Rule: CMS strikes a balance; will docs hang on? http://healthaffairs.org/blog/2016/10/17/macra-final-rule-cms-strikes-a-balance-will-docs-hang-on/. Published October 17, 2016. Accessed March 6, 2017.

9. United States Department of Health and Human Services, Office of the Assistant Secretary for Planning and Evaluation. Documents for Public Comment: Physician-Focused Payment Model Technical Advisory Committee. Proposal for a Physician-Focused Payment Model: CAS-Brandeis Advanced Alternative Payment Model, American College of Surgeons. https://aspe.hhs.gov/system/files/pdf/253406/TheACSBrandeisAdvancedAPM-ACS.pdf. Published December 13, 2016. Accessed March 6, 2017.

 

Several months into 2017, physicians around the country are preparing for the first benchmark year of MACRA, the Medicare Access and CHIP Reauthorization Act. Passed in 2015, MACRA is the bipartisan health care law responsible for eliminating the Sustainable Growth Rate and it promises to continue to fundamentally alter the way providers are paid. This year determines reimbursement in 2019.

Under the law, physicians must report performance under one of two pathways: MIPS, the Merit-based Incentive Payment System, or participation in a qualified Advanced Alternative Payment Model, or Advanced APM. The first, MIPS, replaces the Physician Quality Reporting System, Meaningful Use and the Physician Value-Based Payment Modifier and is the track most providers can expect to follow, at least initially, because most will not meet the requirements for Advanced APMs.^1,2

This is especially true for hospitalists, most of whom are not yet participating in qualifying alternative payment models.²

The MIPS track is budget neutral, which means for every physician or physician group that receives a boost in reimbursement, another will receive a cut. Others will receive a neutral adjustment. All physicians see an annual 0.5% increase in payment between 2016 and 2019 and MIPS clinicians receive a 0.25% annual boost starting in 2026. Providers participating in Advanced APMs will also receive an annual 5% payment bonus between 2019 and 2024, and a 0.75% annual increase in payments beginning in 2026.¹

Both pathways are complex and will affect different clinicians in unique ways, particularly hospitalists.

“A large percentage of hospitalists are actually employed... and the question is whether there is a change in their compensation structure as a result of a negative score,” said Kavita Patel, MD, a practicing internist and nonresident fellow of the Brookings Institution. “That’s why MACRA is complicated: It’s not just that hospitalists are different, it’s that they’re compensated differently as well.”

Some health policy experts, like Robert Berenson, MD, FACP, Institute Fellow of the Health Policy Center at the Urban Institute, say MACRA could actually drive more hospitalists into employment to avoid the costs associated with complying with the law.

Regardless, there is much about MACRA that hospitalists should familiarize themselves with this year. The CMS has announced 2018 will also be a transition year and, as such, additional rules are forthcoming.

“It’s not an easy piece of legislation to understand and there are still areas that need to be clarified in the coming months,” said Nasim Afsarmanesh, MD, SFHM, a hospitalist and member of the Society for Hospital Medicine’s Public Policy Committee.

Here is what to know for now:
 

MIPS

All providers who receive Medicare Physician Fee Schedule payments and do not participate in an Advanced APM will fall into MIPS, and reporting applies to all patients, not just Medicare beneficiaries.³ There are, however, exemptions: providers in their first year of Medicare, those billing Medicare Part B less than $30,000 annually, and those who see 100 or fewer Medicare patients.⁴

Under MIPS, physicians are scored on a scale of 1 to 100 based on performance across four weighted categories: Quality (60%), Advancing Care Information (25%), Improvement Activities (15%), and Cost (not included for 2017). Hospitalists who provide 75% or more of their services in hospital inpatient or outpatient settings, or in the emergency department, are exempt from Advancing Care Information, which replaced meaningful use. As a result, the Quality category will make up 85% of the overall score in 2017.

The CMS also announced added flexibility for 2017 with regard to reporting under MIPS, intended to give providers who need it extra time to prepare.⁵ Physicians and physician groups can report for a full year, starting January 1, 2017, or report for just 90 days, to be eligible for a positive payment adjustment. To avoid a negative adjustment, they can simply submit more than one quality measure, improvement activity, or advancing care information measure (for those not exempt). Or, providers can choose to report nothing and incur a negative 4% payment.

The approach to MIPS in 2017 will vary widely among SHM members, said Joshua Boswell, SHM’s director of government relations.

“Some are looking to do just the bare minimum, not because of their lack of readiness, but for at least this year, to avoid the time, resources, and cost associated with reporting.” he said. “Other groups are considering jumping in with both feet and fully reporting, their thinking being that they can’t lose, and if there is money on the table for high performers, they might as well go for it.”

For 2017, providers who score 70 or more points are eligible for a performance bonus, drawn from a $500 million pool set aside by CMS. The minimum point threshold defined by CMS is three, which a clinician can earn by submitting just one of the six required quality measures.⁴

The CMS has defined 271 total quality measures under MIPS, 13 of which are designated as hospitalist specialty measures. However, SHM believes just seven are applicable to hospitalists. Public Policy Committee chair and SHM president Ron Greeno, MD, MHM, says most clinicians will only be able to reliably report on four.

“We’re working to ensure the program is structured so that providers can confidently report on just the measures applicable to them, even if it’s fewer than six,” he said. To ensure physicians are not penalized or disadvantaged for being unable to report the required number of measures, Dr. Greeno said CMS is working to develop a validation test, though it has not yet released details.

The measures most applicable to hospitalists include two related to heart failure (ACE inhibitor/angiotensin receptor blocker for left ventricular systolic dysfunction [LVSD] and beta-blocker for LVSD), one stroke measure (DC on antithrombotic therapy), advance care planning, prevention of catheter-related bloodstream infection (central venous catheter insertion protocol), documentation of current medications and appropriate treatment of methicillin-resistant Staphylococcus aureus bacteremia.

“This isn’t one of those things that will impact everybody equally,” said Dr. Afsarmanesh. For example, most hospitalists should be able to easily report on advanced care planning and medication documentation, she said, but in some hospitals the stroke measures may be captured in the emergency department; many hospitalists may not achieve enough reportable stroke management cases.

However, Dr. Afsarmanesh expects hospitalists will shine in the improvement activities category. “It’s part of our DNA,” she said. “Improvement activities... have become part of the core responsibilities for many of us within hospitalist groups, hospitals, and health systems.”

In 2017, CMS requires providers to report four improvement activities, which include: implementation of antibiotic stewardship programs, connecting patients to community chronic-disease management programs, and integrating pharmacists into a patient care team. Dr. Afsarmanesh suggests hospitalists visit SHM’s Quality and Innovation guide for ideas, implementation toolkits, and more.

In the cost category, “for the most part, hospitalists aren’t acquainted with cost and there is not a lot of cost transparency around what we do... In general, medical care needs to be discussed between physicians and patients so they can weigh the cost-benefit,” she said, which includes not just dollars and cents, but the impact associated with procedures, like radiation exposure from a CT scan.

However, Dr. Afsarmanesh acknowledges this is challenging, given the overall lack of cost transparency in the American health care system. “It is disjointed and we don’t have any other system where the professionals who do the work are so far-removed from the actual cost,” she said. “The good thing is, I think we are heading toward an era of more cost-conscious practice.”

In addition, hospitalists are poised to help with overall cost-reduction in the hospital. “I could imagine something relevant around readmissions and total cost,” said Dr. Patel. “But risk-adjustment is key.”

This category will increase to 30% of a provider’s or group’s overall score by payment year 2021, CMS says. It will be determined using claims data to calculate per capita costs for all attributed beneficiaries and a Medicare Spending per Beneficiary measure. The CMS also says it is finalizing 10 episode-based measures determined to be reliable and that will be made available to providers in feedback reports starting in 2018.⁴

Clinicians may report MIPS data as individual providers (a single National Provider Identifier tied to a single Tax Identification Number) by sending data for each category through electronic health records, registries, or qualified clinical data registries. Quality data may be reported through Medicare claims.

Hospitalists who report through a group will receive a single payment adjustment based on the group’s performance, using group-level data for each category. Groups can submit using the same mechanisms as individual providers, or through a CMS web interface (though groups must register by June 30, 2017).⁵

The SHM has also asked CMS to consider allowing employed hospitalists to align with and report with their facilities, though Dr. Greeno says this should be voluntary since not every hospitalist may be interested in reporting through their hospital. Dr. Greeno says CMS is “very interested and receptive” to how it could be done.

“We are trying to create the incentive for everybody to provide care at lower costs,” Dr. Greeno said. “There are two goals: Create alignment, and decrease the reporting burden on hospitalist groups.”

Additionally, CMS recognizes the potential burden MIPS imposes on small practices and is working to allow individuals and groups of 10 or fewer clinicians to combine to create virtual groups. This option is not available in 2017.⁴

The CMS has also authorized $100 million, dispersed over 5 years, for certain organizations to provide technical assistance to MIPS providers with fewer than 15 clinicians, in rural areas and those in health professional shortage areas.⁴

According to Modern Healthcare, projections by CMS, released last May, show that 87% of solo practitioners and 70% of physician groups with two to nine providers will see their reimbursement rates fall in 2019. Meanwhile, 55% of groups with 25 to 99 providers and 81% of those with 100 or more clinicians will see an increase in reimbursement.⁷

“I think it’s going to be pretty tough unless you’re big enough to commit the resources you need to do it right,” Dr. Greeno said. “If I was just a really small group with very little overhead, no infrastructure to support, I’d consider taking the penalty and just living with it because I don’t have many costs and just pay my own salary. But it’s still a hard road.”

Dr. Afsarmanesh says SHM continues to look across the board and advocate for all its members.

In 2019, physicians reporting under MIPS will see up to a 4% increase and as low as a 4% decrease in reimbursement. This rises to plus-or-minus 5% in 2020, 7% in 2021 and 9% thereafter.²

Dr. Patel and many others say it appears to be the intention of CMS to move providers toward alternative payment models. A January 2015 news release from the U.S. Department of Health and Human Services announced a goal of tying 50% of Medicare payments to Accountable Care Organizations (ACO) by the end of 2018 (it’s worth noting this was pre-MACRA, and not all ACOs qualify as Advanced APMs).⁸

“The awkwardness and clunkiness of MIPS needs to be addressed in order to make it successful because many people will be in MIPS,” Dr. Patel said. “I think it’s the intention to move people into Advanced APMs, but how long it takes to get to that point – 3-5 years, it could be 10 – physicians have to thrive in MIPS in order to live.”

One of the most important things, she and Dr. Berenson said, is adequately capturing the quality and scope of the care physicians provide.

“I know hospitalists complain how little their care is reflected in HCAHPS (the Hospital Consumer Assessment of Healthcare Providers and Systems) and the quality measures they have now, and readmission rates don’t reflect what doctors do inside the hospital. My colleagues are telling me they want something better,” Dr. Patel said.
 

 

Advanced APMs

Physicians who participate in Advanced APMs are exempt from MIPS. Advanced APMs must use Certified Electronic Health Record Technology (CEHRT) and take on a minimum amount of risk. For 2017 and 2018, providers must risk losing the lesser of 3% of their total Medicare expenditures or 8% of their revenue.⁹ They are paid based on the parameters of their particular model.

Additionally, for the 2019 payment year, 25% of a provider’s or group’s Medicare payments or 20% of their patients must be through the Advanced APM. This increases to 50% of payments and 35% of patients for 2021 and 2022, and in 2023, to 75% of payments and 50% of patients.

In 2017, APMs that meet the criteria for Advanced include: Comprehensive End-Stage Renal Disease Care, Comprehensive Primary Care Plus, Next Generation ACO Model, Shared Savings Program Tracks 2 and 3, Comprehensive Joint Replacement Payment Model Track 1, the Vermont Medicare ACO Initiative, and the Oncology Care Model. (APMs that do not qualify must report under MIPS.)⁵

The CMS also says that services provided at critical access hospitals, rural health clinics, and federally qualified health centers may qualify using patient counts, and medical home models and the Medicaid Medical Home Model may also be considered Advanced APMs using financial criteria.⁴

At this time, SHM is unable to quantify the number of hospitalists participating in Advanced APMs, and some, Dr. Greeno said, may not know whether they are part of an Advanced APM.

Currently, BPCI (Bundled Payments for Care Improvement) is the only alternative payment model in which hospitalists can directly take risk, Dr. Greeno says, but it does not yet qualify as an Advanced APM. However, that could change.

Prior to the passage of MACRA, Brandeis University worked with CMS to create the Episode Grouper for Medicare (EGM), software that converts claims data into episodes of care based on a patient’s condition or conditions or procedures. The American College of Surgeons (ACS) has since proposed an alternative payment model, called ACS-Brandeis, that would use the diagnostic grouper to take into account all of the work done by every provider on any episode admitted to the hospital and use algorithms to decide who affected a particular patient’s care.

“Anyone who takes care of the patient can take risk or gain share if the episode initiator allows them,” said Dr. Greeno.

For example, if a patient is admitted for surgery, but has an internist on their case because they have diabetes and heart failure, and they also have an anesthesiologist and an infectious disease specialist, everybody has an impact on their care and makes decisions about the resources used on the case. The risk associated with the case is effectively divided.

The ACS submitted the proposal to PTAC (the Physician-Focused Payment Model Technical Advisory Committee) in 2016 and SHM submitted a letter of support.

“In this model, everybody’s taking risk and everybody has the opportunity to gain share if the patient is managed well,” said Dr. Greeno. “It’s a very complicated, very complex model... Theoretically, everybody on that case should be optimally engaged – that’s the beauty of it – but we don’t know if it will work.”

The SHM got involved at the request of ACS, because it would not apply solely to surgical patients. Dr. Greeno says ACS asked SHM to look at common surgical diagnoses and review every medical scenario that could come to pass, from heart failure and pneumonia to infection.

“There’s bundles within bundles, medical bundles within surgical bundles,” he said. “It’s fascinating and it’s daunting but it is truly a big data approach to episodes of care. We’re thrilled to be invited and ACS was very enthusiastic about our involvement.”

Dr. Patel, who sits on PTAC, is heartened by the amount of physician-led innovation taking place. “Proposals are coming directly from doctors; they are telling us what they want,” she said.

For Dr. Greeno, this captures the intent of MACRA: “There is going to be a continual increase in the sophistication of models, and hopefully toward ones that are better and better and create the right incentives for everyone involved in the health care system.”


References

1. S. Findlay. Medicare’s new physician payment system. http://www.healthaffairs.org/healthpolicybriefs/brief.php?brief_id=156. Published April 21, 2016. Accessed March 6, 2017.

2. The Society of Hospital Medicine. Medicare physician payments are changing. http://www.macraforhm.org/. Accessed March 6, 2017.

3. A. Maciejowski. MACRA: What’s really in the final rule. http://blog.ncqa.org/macra-whats-really-in-the-final-rule/. Blog post published November 15, 2016. Accessed March 6, 2017.

4. Department of Health and Human Services, Centers for Medicare and Medicaid Services. Quality Payment Program executive summary. https://qpp.cms.gov/docs/QPP_Executive_Summary_of_Final_Rule.pdf. Published Oct. 14, 2016. Accessed March 6, 2017.

5. Department of Health and Human Services, Centers for Medicare and Medicaid Services. Quality Payment Program: Modernizing Medicare to provide better care and smarter spending for a healthier America. https://qpp.cms.gov/. Accessed March 6, 2017.

6. D. Barkholz. Potential MACRA byproduct: physician consolidation. http://www.modernhealthcare.com/article/20160630/NEWS/160639995. Published June 30, 2016. Accessed March 6, 2017.

7. United States Department of Health and Human Services. Better, smarter, healthier: In historic announcement, HHS sets clear goals and timeline for shifting Medicare reimbursement from volume to value. http://wayback.archive-it.org/3926/20170127185400/https://www.hhs.gov/about/news/2015/01/26/better-smarter-healthier-in-historic-announcement-hhs-sets-clear-goals-and-timeline-for-shifting-medicare-reimbursements-from-volume-to-value.html. Published January 26, 2015. Accessed March 6, 2017.

8. B. Wynne. MACRA Final Rule: CMS strikes a balance; will docs hang on? http://healthaffairs.org/blog/2016/10/17/macra-final-rule-cms-strikes-a-balance-will-docs-hang-on/. Published October 17, 2016. Accessed March 6, 2017.

9. United States Department of Health and Human Services, Office of the Assistant Secretary for Planning and Evaluation. Documents for Public Comment: Physician-Focused Payment Model Technical Advisory Committee. Proposal for a Physician-Focused Payment Model: CAS-Brandeis Advanced Alternative Payment Model, American College of Surgeons. https://aspe.hhs.gov/system/files/pdf/253406/TheACSBrandeisAdvancedAPM-ACS.pdf. Published December 13, 2016. Accessed March 6, 2017.

 

Several months into 2017, physicians around the country are preparing for the first benchmark year of MACRA, the Medicare Access and CHIP Reauthorization Act. Passed in 2015, MACRA is the bipartisan health care law responsible for eliminating the Sustainable Growth Rate and it promises to continue to fundamentally alter the way providers are paid. This year determines reimbursement in 2019.

Under the law, physicians must report performance under one of two pathways: MIPS, the Merit-based Incentive Payment System, or participation in a qualified Advanced Alternative Payment Model, or Advanced APM. The first, MIPS, replaces the Physician Quality Reporting System, Meaningful Use and the Physician Value-Based Payment Modifier and is the track most providers can expect to follow, at least initially, because most will not meet the requirements for Advanced APMs.^1,2

This is especially true for hospitalists, most of whom are not yet participating in qualifying alternative payment models.²

The MIPS track is budget neutral, which means for every physician or physician group that receives a boost in reimbursement, another will receive a cut. Others will receive a neutral adjustment. All physicians see an annual 0.5% increase in payment between 2016 and 2019 and MIPS clinicians receive a 0.25% annual boost starting in 2026. Providers participating in Advanced APMs will also receive an annual 5% payment bonus between 2019 and 2024, and a 0.75% annual increase in payments beginning in 2026.¹

Both pathways are complex and will affect different clinicians in unique ways, particularly hospitalists.

“A large percentage of hospitalists are actually employed... and the question is whether there is a change in their compensation structure as a result of a negative score,” said Kavita Patel, MD, a practicing internist and nonresident fellow of the Brookings Institution. “That’s why MACRA is complicated: It’s not just that hospitalists are different, it’s that they’re compensated differently as well.”

Some health policy experts, like Robert Berenson, MD, FACP, Institute Fellow of the Health Policy Center at the Urban Institute, say MACRA could actually drive more hospitalists into employment to avoid the costs associated with complying with the law.

Regardless, there is much about MACRA that hospitalists should familiarize themselves with this year. The CMS has announced 2018 will also be a transition year and, as such, additional rules are forthcoming.

“It’s not an easy piece of legislation to understand and there are still areas that need to be clarified in the coming months,” said Nasim Afsarmanesh, MD, SFHM, a hospitalist and member of the Society for Hospital Medicine’s Public Policy Committee.

Here is what to know for now:
 

MIPS

All providers who receive Medicare Physician Fee Schedule payments and do not participate in an Advanced APM will fall into MIPS, and reporting applies to all patients, not just Medicare beneficiaries.³ There are, however, exemptions: providers in their first year of Medicare, those billing Medicare Part B less than $30,000 annually, and those who see 100 or fewer Medicare patients.⁴

Under MIPS, physicians are scored on a scale of 1 to 100 based on performance across four weighted categories: Quality (60%), Advancing Care Information (25%), Improvement Activities (15%), and Cost (not included for 2017). Hospitalists who provide 75% or more of their services in hospital inpatient or outpatient settings, or in the emergency department, are exempt from Advancing Care Information, which replaced meaningful use. As a result, the Quality category will make up 85% of the overall score in 2017.

The CMS also announced added flexibility for 2017 with regard to reporting under MIPS, intended to give providers who need it extra time to prepare.⁵ Physicians and physician groups can report for a full year, starting January 1, 2017, or report for just 90 days, to be eligible for a positive payment adjustment. To avoid a negative adjustment, they can simply submit more than one quality measure, improvement activity, or advancing care information measure (for those not exempt). Or, providers can choose to report nothing and incur a negative 4% payment.

The approach to MIPS in 2017 will vary widely among SHM members, said Joshua Boswell, SHM’s director of government relations.

“Some are looking to do just the bare minimum, not because of their lack of readiness, but for at least this year, to avoid the time, resources, and cost associated with reporting.” he said. “Other groups are considering jumping in with both feet and fully reporting, their thinking being that they can’t lose, and if there is money on the table for high performers, they might as well go for it.”

For 2017, providers who score 70 or more points are eligible for a performance bonus, drawn from a $500 million pool set aside by CMS. The minimum point threshold defined by CMS is three, which a clinician can earn by submitting just one of the six required quality measures.⁴

The CMS has defined 271 total quality measures under MIPS, 13 of which are designated as hospitalist specialty measures. However, SHM believes just seven are applicable to hospitalists. Public Policy Committee chair and SHM president Ron Greeno, MD, MHM, says most clinicians will only be able to reliably report on four.

“We’re working to ensure the program is structured so that providers can confidently report on just the measures applicable to them, even if it’s fewer than six,” he said. To ensure physicians are not penalized or disadvantaged for being unable to report the required number of measures, Dr. Greeno said CMS is working to develop a validation test, though it has not yet released details.

The measures most applicable to hospitalists include two related to heart failure (ACE inhibitor/angiotensin receptor blocker for left ventricular systolic dysfunction [LVSD] and beta-blocker for LVSD), one stroke measure (DC on antithrombotic therapy), advance care planning, prevention of catheter-related bloodstream infection (central venous catheter insertion protocol), documentation of current medications and appropriate treatment of methicillin-resistant Staphylococcus aureus bacteremia.

“This isn’t one of those things that will impact everybody equally,” said Dr. Afsarmanesh. For example, most hospitalists should be able to easily report on advanced care planning and medication documentation, she said, but in some hospitals the stroke measures may be captured in the emergency department; many hospitalists may not achieve enough reportable stroke management cases.

However, Dr. Afsarmanesh expects hospitalists will shine in the improvement activities category. “It’s part of our DNA,” she said. “Improvement activities... have become part of the core responsibilities for many of us within hospitalist groups, hospitals, and health systems.”

In 2017, CMS requires providers to report four improvement activities, which include: implementation of antibiotic stewardship programs, connecting patients to community chronic-disease management programs, and integrating pharmacists into a patient care team. Dr. Afsarmanesh suggests hospitalists visit SHM’s Quality and Innovation guide for ideas, implementation toolkits, and more.

In the cost category, “for the most part, hospitalists aren’t acquainted with cost and there is not a lot of cost transparency around what we do... In general, medical care needs to be discussed between physicians and patients so they can weigh the cost-benefit,” she said, which includes not just dollars and cents, but the impact associated with procedures, like radiation exposure from a CT scan.

However, Dr. Afsarmanesh acknowledges this is challenging, given the overall lack of cost transparency in the American health care system. “It is disjointed and we don’t have any other system where the professionals who do the work are so far-removed from the actual cost,” she said. “The good thing is, I think we are heading toward an era of more cost-conscious practice.”

In addition, hospitalists are poised to help with overall cost-reduction in the hospital. “I could imagine something relevant around readmissions and total cost,” said Dr. Patel. “But risk-adjustment is key.”

This category will increase to 30% of a provider’s or group’s overall score by payment year 2021, CMS says. It will be determined using claims data to calculate per capita costs for all attributed beneficiaries and a Medicare Spending per Beneficiary measure. The CMS also says it is finalizing 10 episode-based measures determined to be reliable and that will be made available to providers in feedback reports starting in 2018.⁴

Clinicians may report MIPS data as individual providers (a single National Provider Identifier tied to a single Tax Identification Number) by sending data for each category through electronic health records, registries, or qualified clinical data registries. Quality data may be reported through Medicare claims.

Hospitalists who report through a group will receive a single payment adjustment based on the group’s performance, using group-level data for each category. Groups can submit using the same mechanisms as individual providers, or through a CMS web interface (though groups must register by June 30, 2017).⁵

The SHM has also asked CMS to consider allowing employed hospitalists to align with and report with their facilities, though Dr. Greeno says this should be voluntary since not every hospitalist may be interested in reporting through their hospital. Dr. Greeno says CMS is “very interested and receptive” to how it could be done.

“We are trying to create the incentive for everybody to provide care at lower costs,” Dr. Greeno said. “There are two goals: Create alignment, and decrease the reporting burden on hospitalist groups.”

Additionally, CMS recognizes the potential burden MIPS imposes on small practices and is working to allow individuals and groups of 10 or fewer clinicians to combine to create virtual groups. This option is not available in 2017.⁴

The CMS has also authorized $100 million, dispersed over 5 years, for certain organizations to provide technical assistance to MIPS providers with fewer than 15 clinicians, in rural areas and those in health professional shortage areas.⁴

According to Modern Healthcare, projections by CMS, released last May, show that 87% of solo practitioners and 70% of physician groups with two to nine providers will see their reimbursement rates fall in 2019. Meanwhile, 55% of groups with 25 to 99 providers and 81% of those with 100 or more clinicians will see an increase in reimbursement.⁷

“I think it’s going to be pretty tough unless you’re big enough to commit the resources you need to do it right,” Dr. Greeno said. “If I was just a really small group with very little overhead, no infrastructure to support, I’d consider taking the penalty and just living with it because I don’t have many costs and just pay my own salary. But it’s still a hard road.”

Dr. Afsarmanesh says SHM continues to look across the board and advocate for all its members.

In 2019, physicians reporting under MIPS will see up to a 4% increase and as low as a 4% decrease in reimbursement. This rises to plus-or-minus 5% in 2020, 7% in 2021 and 9% thereafter.²

Dr. Patel and many others say it appears to be the intention of CMS to move providers toward alternative payment models. A January 2015 news release from the U.S. Department of Health and Human Services announced a goal of tying 50% of Medicare payments to Accountable Care Organizations (ACO) by the end of 2018 (it’s worth noting this was pre-MACRA, and not all ACOs qualify as Advanced APMs).⁸

“The awkwardness and clunkiness of MIPS needs to be addressed in order to make it successful because many people will be in MIPS,” Dr. Patel said. “I think it’s the intention to move people into Advanced APMs, but how long it takes to get to that point – 3-5 years, it could be 10 – physicians have to thrive in MIPS in order to live.”

One of the most important things, she and Dr. Berenson said, is adequately capturing the quality and scope of the care physicians provide.

“I know hospitalists complain how little their care is reflected in HCAHPS (the Hospital Consumer Assessment of Healthcare Providers and Systems) and the quality measures they have now, and readmission rates don’t reflect what doctors do inside the hospital. My colleagues are telling me they want something better,” Dr. Patel said.
 

 

Advanced APMs

Physicians who participate in Advanced APMs are exempt from MIPS. Advanced APMs must use Certified Electronic Health Record Technology (CEHRT) and take on a minimum amount of risk. For 2017 and 2018, providers must risk losing the lesser of 3% of their total Medicare expenditures or 8% of their revenue.⁹ They are paid based on the parameters of their particular model.

Additionally, for the 2019 payment year, 25% of a provider’s or group’s Medicare payments or 20% of their patients must be through the Advanced APM. This increases to 50% of payments and 35% of patients for 2021 and 2022, and in 2023, to 75% of payments and 50% of patients.

In 2017, APMs that meet the criteria for Advanced include: Comprehensive End-Stage Renal Disease Care, Comprehensive Primary Care Plus, Next Generation ACO Model, Shared Savings Program Tracks 2 and 3, Comprehensive Joint Replacement Payment Model Track 1, the Vermont Medicare ACO Initiative, and the Oncology Care Model. (APMs that do not qualify must report under MIPS.)⁵

The CMS also says that services provided at critical access hospitals, rural health clinics, and federally qualified health centers may qualify using patient counts, and medical home models and the Medicaid Medical Home Model may also be considered Advanced APMs using financial criteria.⁴

At this time, SHM is unable to quantify the number of hospitalists participating in Advanced APMs, and some, Dr. Greeno said, may not know whether they are part of an Advanced APM.

Currently, BPCI (Bundled Payments for Care Improvement) is the only alternative payment model in which hospitalists can directly take risk, Dr. Greeno says, but it does not yet qualify as an Advanced APM. However, that could change.

Prior to the passage of MACRA, Brandeis University worked with CMS to create the Episode Grouper for Medicare (EGM), software that converts claims data into episodes of care based on a patient’s condition or conditions or procedures. The American College of Surgeons (ACS) has since proposed an alternative payment model, called ACS-Brandeis, that would use the diagnostic grouper to take into account all of the work done by every provider on any episode admitted to the hospital and use algorithms to decide who affected a particular patient’s care.

“Anyone who takes care of the patient can take risk or gain share if the episode initiator allows them,” said Dr. Greeno.

For example, if a patient is admitted for surgery, but has an internist on their case because they have diabetes and heart failure, and they also have an anesthesiologist and an infectious disease specialist, everybody has an impact on their care and makes decisions about the resources used on the case. The risk associated with the case is effectively divided.

The ACS submitted the proposal to PTAC (the Physician-Focused Payment Model Technical Advisory Committee) in 2016 and SHM submitted a letter of support.

“In this model, everybody’s taking risk and everybody has the opportunity to gain share if the patient is managed well,” said Dr. Greeno. “It’s a very complicated, very complex model... Theoretically, everybody on that case should be optimally engaged – that’s the beauty of it – but we don’t know if it will work.”

The SHM got involved at the request of ACS, because it would not apply solely to surgical patients. Dr. Greeno says ACS asked SHM to look at common surgical diagnoses and review every medical scenario that could come to pass, from heart failure and pneumonia to infection.

“There’s bundles within bundles, medical bundles within surgical bundles,” he said. “It’s fascinating and it’s daunting but it is truly a big data approach to episodes of care. We’re thrilled to be invited and ACS was very enthusiastic about our involvement.”

Dr. Patel, who sits on PTAC, is heartened by the amount of physician-led innovation taking place. “Proposals are coming directly from doctors; they are telling us what they want,” she said.

For Dr. Greeno, this captures the intent of MACRA: “There is going to be a continual increase in the sophistication of models, and hopefully toward ones that are better and better and create the right incentives for everyone involved in the health care system.”


References

1. S. Findlay. Medicare’s new physician payment system. http://www.healthaffairs.org/healthpolicybriefs/brief.php?brief_id=156. Published April 21, 2016. Accessed March 6, 2017.

2. The Society of Hospital Medicine. Medicare physician payments are changing. http://www.macraforhm.org/. Accessed March 6, 2017.

3. A. Maciejowski. MACRA: What’s really in the final rule. http://blog.ncqa.org/macra-whats-really-in-the-final-rule/. Blog post published November 15, 2016. Accessed March 6, 2017.

4. Department of Health and Human Services, Centers for Medicare and Medicaid Services. Quality Payment Program executive summary. https://qpp.cms.gov/docs/QPP_Executive_Summary_of_Final_Rule.pdf. Published Oct. 14, 2016. Accessed March 6, 2017.

5. Department of Health and Human Services, Centers for Medicare and Medicaid Services. Quality Payment Program: Modernizing Medicare to provide better care and smarter spending for a healthier America. https://qpp.cms.gov/. Accessed March 6, 2017.

6. D. Barkholz. Potential MACRA byproduct: physician consolidation. http://www.modernhealthcare.com/article/20160630/NEWS/160639995. Published June 30, 2016. Accessed March 6, 2017.

7. United States Department of Health and Human Services. Better, smarter, healthier: In historic announcement, HHS sets clear goals and timeline for shifting Medicare reimbursement from volume to value. http://wayback.archive-it.org/3926/20170127185400/https://www.hhs.gov/about/news/2015/01/26/better-smarter-healthier-in-historic-announcement-hhs-sets-clear-goals-and-timeline-for-shifting-medicare-reimbursements-from-volume-to-value.html. Published January 26, 2015. Accessed March 6, 2017.

8. B. Wynne. MACRA Final Rule: CMS strikes a balance; will docs hang on? http://healthaffairs.org/blog/2016/10/17/macra-final-rule-cms-strikes-a-balance-will-docs-hang-on/. Published October 17, 2016. Accessed March 6, 2017.

9. United States Department of Health and Human Services, Office of the Assistant Secretary for Planning and Evaluation. Documents for Public Comment: Physician-Focused Payment Model Technical Advisory Committee. Proposal for a Physician-Focused Payment Model: CAS-Brandeis Advanced Alternative Payment Model, American College of Surgeons. https://aspe.hhs.gov/system/files/pdf/253406/TheACSBrandeisAdvancedAPM-ACS.pdf. Published December 13, 2016. Accessed March 6, 2017.

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

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

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

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

“The Republicans now have a hard issue in their hands,” says Allison Hoffman, JD, professor of law at UCLA School of Law and an expert on health care law and policy. “It was hard before the Affordable Care Act, and it will be hard after. There is not an easy solution.”

By 2016, the ACA had expanded health coverage to 20 million people through Medicaid and private insurance on health care marketplaces. It extended the solvency of the Medicare Hospital Insurance Trust Fund. It accelerated the pace of delivery system and payment reform through creation of the Center for Medicare & Medicaid Innovation.

The law, however, has not been without its challenges.

“It was a strong achievement to get 20 million people insured, but it’s not clear that it bent the cost curve,” says Dr. Eibner. “There are high premiums on the individual market and still 31 million people without coverage. There is still opportunity to improve.”

Where we stand January 2017

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

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

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

Dr. Eibner says there is “a clear implication” that physicians may lose patients, care for a greater share who are uninsured, and see a return of higher rates of uncompensated hospital care. The experts say Republicans are unlikely to restore cuts to disproportionate-share hospitals that were made under the ACA because more patients were insured.

Joshua Lenchus, DO, RPh, FACP, SFHM, a member of SHM’s Public Policy Committee and hospitalist at the University of Miami/Jackson Memorial Hospital in Florida, is no fan of entitlement programs like Medicaid but says, “The safety-net hospital where I work would rather have people covered with something than nothing.”

Dr. Lenchus is optimistic that economic reforms under Trump will lead to more jobs, increasing the number of people covered by employer plans. “The economy drives health care reform,” he says. “He has to up his ante now and show people that he can stimulate job growth in this country so we don’t have this middle class that is continuously squeezed.”

Dr. Greeno and Ms. Hoffman, who is also a faculty associate at the UCLA Center for Health Policy Research and vice chair of the Insurance Law Section of the Association of American Law Schools, suggest hospitalists get involved as rules are being shaped and written.

“We want to help reform the delivery system, and we want it to be done right and to be done fairly. We want to have say in how our patients are treated,” Dr. Greeno says.
 

 

Key provisions: A delicate balance

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

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

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

Additionally, “premiums go way up because many more people can’t afford insurance, so those who choose to buy are the sickest,” says Ms. Hoffman. “Risk pools get extremely expensive, and many more people see it as unaffordable.”

As a result, she says, people may choose high-deductible plans and face high out-of-pocket costs if they do seek care.

“It’s asking individuals to save by deciding how they’re going to ration care, where someone says they’re not going to go to the doctor today or fill a prescription drug they need,” Ms. Hoffman says.

Meanwhile, Mr. Trump has said he would like to keep the provision of the ACA that bans insurers from denying individuals with preexisting conditions. This, experts agree, may not be possible if other parts of the law are repealed and not replaced with similar protections for insurers.

“If you try to keep the rules about not including preexisting conditions and get rid of subsidies and the individual mandate, it just won’t work,” Ms. Hoffman says. “You end up with extraordinarily expensive health insurance.”

Rep. Ryan’s plan would prohibit insurers from denying patients with preexisting conditions but only if patients maintain continuous coverage, with a single open-enrollment period. He has promised to provide at least $25 billion in federal funding for state high-risk pools.

Prior to the passage of the ACA, 35 states offered high-risk pools to people excluded from the individual market. The Kaiser Family Foundation shows the net annual losses in these states averaged $5,510 per enrollee in 2011. Premiums ranged from 100% to 200% higher than non–high-risk group coverage. Government subsidies to cover losses amounted to $1 billion in each state.⁴

Meanwhile, both Mr. Trump and Rep. Ryan have proposed profound changes for Medicaid. Dr. Greeno calls this a “massive political challenge” unless they can provide an alternative way to cover people who currently rely on the federal-state entitlement, as well as those who gained coverage through ACA expansion. Currently, 70 million people are enrolled in Medicaid and the Children’s Health Insurance Program.⁵ Through Mr. Trump’s suggested block grants, states would receive a fixed amount of money to administer their program with increased flexibility. Rep. Ryan’s plan calls for enrollment caps that would distribute a dollar amount to each participant in the program with no limit on the number of enrollees. Either would be adjusted for inflation.

States could implement work requirements for beneficiaries or ask them to pay a small amount toward their premiums. Expansion states could also lower the Medicaid threshold below 138%.

Some states will struggle to provide for all their enrollees, Ms. Hoffman says, particularly since health spending generally outpaces inflation. Dr. Lenchus is more optimistic. “I believe states that didn’t expand Medicaid, one way or another, will figure out a way to deal with that population,” he says.

And … Medicare

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

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

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

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

Seniors may also find themselves rationing or skimping on care.

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

 

MACRA launch

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

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

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

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

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

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

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

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

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

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

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

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

References

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

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

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

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

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

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

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

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

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

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

“The Republicans now have a hard issue in their hands,” says Allison Hoffman, JD, professor of law at UCLA School of Law and an expert on health care law and policy. “It was hard before the Affordable Care Act, and it will be hard after. There is not an easy solution.”

By 2016, the ACA had expanded health coverage to 20 million people through Medicaid and private insurance on health care marketplaces. It extended the solvency of the Medicare Hospital Insurance Trust Fund. It accelerated the pace of delivery system and payment reform through creation of the Center for Medicare & Medicaid Innovation.

The law, however, has not been without its challenges.

“It was a strong achievement to get 20 million people insured, but it’s not clear that it bent the cost curve,” says Dr. Eibner. “There are high premiums on the individual market and still 31 million people without coverage. There is still opportunity to improve.”

Where we stand January 2017

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

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

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

Dr. Eibner says there is “a clear implication” that physicians may lose patients, care for a greater share who are uninsured, and see a return of higher rates of uncompensated hospital care. The experts say Republicans are unlikely to restore cuts to disproportionate-share hospitals that were made under the ACA because more patients were insured.

Joshua Lenchus, DO, RPh, FACP, SFHM, a member of SHM’s Public Policy Committee and hospitalist at the University of Miami/Jackson Memorial Hospital in Florida, is no fan of entitlement programs like Medicaid but says, “The safety-net hospital where I work would rather have people covered with something than nothing.”

Dr. Lenchus is optimistic that economic reforms under Trump will lead to more jobs, increasing the number of people covered by employer plans. “The economy drives health care reform,” he says. “He has to up his ante now and show people that he can stimulate job growth in this country so we don’t have this middle class that is continuously squeezed.”

Dr. Greeno and Ms. Hoffman, who is also a faculty associate at the UCLA Center for Health Policy Research and vice chair of the Insurance Law Section of the Association of American Law Schools, suggest hospitalists get involved as rules are being shaped and written.

“We want to help reform the delivery system, and we want it to be done right and to be done fairly. We want to have say in how our patients are treated,” Dr. Greeno says.
 

 

Key provisions: A delicate balance

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

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

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

Additionally, “premiums go way up because many more people can’t afford insurance, so those who choose to buy are the sickest,” says Ms. Hoffman. “Risk pools get extremely expensive, and many more people see it as unaffordable.”

As a result, she says, people may choose high-deductible plans and face high out-of-pocket costs if they do seek care.

“It’s asking individuals to save by deciding how they’re going to ration care, where someone says they’re not going to go to the doctor today or fill a prescription drug they need,” Ms. Hoffman says.

Meanwhile, Mr. Trump has said he would like to keep the provision of the ACA that bans insurers from denying individuals with preexisting conditions. This, experts agree, may not be possible if other parts of the law are repealed and not replaced with similar protections for insurers.

“If you try to keep the rules about not including preexisting conditions and get rid of subsidies and the individual mandate, it just won’t work,” Ms. Hoffman says. “You end up with extraordinarily expensive health insurance.”

Rep. Ryan’s plan would prohibit insurers from denying patients with preexisting conditions but only if patients maintain continuous coverage, with a single open-enrollment period. He has promised to provide at least $25 billion in federal funding for state high-risk pools.

Prior to the passage of the ACA, 35 states offered high-risk pools to people excluded from the individual market. The Kaiser Family Foundation shows the net annual losses in these states averaged $5,510 per enrollee in 2011. Premiums ranged from 100% to 200% higher than non–high-risk group coverage. Government subsidies to cover losses amounted to $1 billion in each state.⁴

Meanwhile, both Mr. Trump and Rep. Ryan have proposed profound changes for Medicaid. Dr. Greeno calls this a “massive political challenge” unless they can provide an alternative way to cover people who currently rely on the federal-state entitlement, as well as those who gained coverage through ACA expansion. Currently, 70 million people are enrolled in Medicaid and the Children’s Health Insurance Program.⁵ Through Mr. Trump’s suggested block grants, states would receive a fixed amount of money to administer their program with increased flexibility. Rep. Ryan’s plan calls for enrollment caps that would distribute a dollar amount to each participant in the program with no limit on the number of enrollees. Either would be adjusted for inflation.

States could implement work requirements for beneficiaries or ask them to pay a small amount toward their premiums. Expansion states could also lower the Medicaid threshold below 138%.

Some states will struggle to provide for all their enrollees, Ms. Hoffman says, particularly since health spending generally outpaces inflation. Dr. Lenchus is more optimistic. “I believe states that didn’t expand Medicaid, one way or another, will figure out a way to deal with that population,” he says.

And … Medicare

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

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

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

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

Seniors may also find themselves rationing or skimping on care.

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

 

MACRA launch

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

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

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

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

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

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

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

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

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

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

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

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

References

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

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

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

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

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

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

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

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

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

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

“The Republicans now have a hard issue in their hands,” says Allison Hoffman, JD, professor of law at UCLA School of Law and an expert on health care law and policy. “It was hard before the Affordable Care Act, and it will be hard after. There is not an easy solution.”

By 2016, the ACA had expanded health coverage to 20 million people through Medicaid and private insurance on health care marketplaces. It extended the solvency of the Medicare Hospital Insurance Trust Fund. It accelerated the pace of delivery system and payment reform through creation of the Center for Medicare & Medicaid Innovation.

The law, however, has not been without its challenges.

“It was a strong achievement to get 20 million people insured, but it’s not clear that it bent the cost curve,” says Dr. Eibner. “There are high premiums on the individual market and still 31 million people without coverage. There is still opportunity to improve.”

Where we stand January 2017

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

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

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

Dr. Eibner says there is “a clear implication” that physicians may lose patients, care for a greater share who are uninsured, and see a return of higher rates of uncompensated hospital care. The experts say Republicans are unlikely to restore cuts to disproportionate-share hospitals that were made under the ACA because more patients were insured.

Joshua Lenchus, DO, RPh, FACP, SFHM, a member of SHM’s Public Policy Committee and hospitalist at the University of Miami/Jackson Memorial Hospital in Florida, is no fan of entitlement programs like Medicaid but says, “The safety-net hospital where I work would rather have people covered with something than nothing.”

Dr. Lenchus is optimistic that economic reforms under Trump will lead to more jobs, increasing the number of people covered by employer plans. “The economy drives health care reform,” he says. “He has to up his ante now and show people that he can stimulate job growth in this country so we don’t have this middle class that is continuously squeezed.”

Dr. Greeno and Ms. Hoffman, who is also a faculty associate at the UCLA Center for Health Policy Research and vice chair of the Insurance Law Section of the Association of American Law Schools, suggest hospitalists get involved as rules are being shaped and written.

“We want to help reform the delivery system, and we want it to be done right and to be done fairly. We want to have say in how our patients are treated,” Dr. Greeno says.
 

 

Key provisions: A delicate balance

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

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

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

Additionally, “premiums go way up because many more people can’t afford insurance, so those who choose to buy are the sickest,” says Ms. Hoffman. “Risk pools get extremely expensive, and many more people see it as unaffordable.”

As a result, she says, people may choose high-deductible plans and face high out-of-pocket costs if they do seek care.

“It’s asking individuals to save by deciding how they’re going to ration care, where someone says they’re not going to go to the doctor today or fill a prescription drug they need,” Ms. Hoffman says.

Meanwhile, Mr. Trump has said he would like to keep the provision of the ACA that bans insurers from denying individuals with preexisting conditions. This, experts agree, may not be possible if other parts of the law are repealed and not replaced with similar protections for insurers.

“If you try to keep the rules about not including preexisting conditions and get rid of subsidies and the individual mandate, it just won’t work,” Ms. Hoffman says. “You end up with extraordinarily expensive health insurance.”

Rep. Ryan’s plan would prohibit insurers from denying patients with preexisting conditions but only if patients maintain continuous coverage, with a single open-enrollment period. He has promised to provide at least $25 billion in federal funding for state high-risk pools.

Prior to the passage of the ACA, 35 states offered high-risk pools to people excluded from the individual market. The Kaiser Family Foundation shows the net annual losses in these states averaged $5,510 per enrollee in 2011. Premiums ranged from 100% to 200% higher than non–high-risk group coverage. Government subsidies to cover losses amounted to $1 billion in each state.⁴

Meanwhile, both Mr. Trump and Rep. Ryan have proposed profound changes for Medicaid. Dr. Greeno calls this a “massive political challenge” unless they can provide an alternative way to cover people who currently rely on the federal-state entitlement, as well as those who gained coverage through ACA expansion. Currently, 70 million people are enrolled in Medicaid and the Children’s Health Insurance Program.⁵ Through Mr. Trump’s suggested block grants, states would receive a fixed amount of money to administer their program with increased flexibility. Rep. Ryan’s plan calls for enrollment caps that would distribute a dollar amount to each participant in the program with no limit on the number of enrollees. Either would be adjusted for inflation.

States could implement work requirements for beneficiaries or ask them to pay a small amount toward their premiums. Expansion states could also lower the Medicaid threshold below 138%.

Some states will struggle to provide for all their enrollees, Ms. Hoffman says, particularly since health spending generally outpaces inflation. Dr. Lenchus is more optimistic. “I believe states that didn’t expand Medicaid, one way or another, will figure out a way to deal with that population,” he says.

And … Medicare

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

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

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

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

Seniors may also find themselves rationing or skimping on care.

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

 

MACRA launch

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

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

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

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

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

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

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

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

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

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

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

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

References

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

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

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

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

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

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

Editor's Note: Listen to Robert Blendon talk more about the health policy implications of the 2016 election.

In some ways, the national election of 2016 is an unprecedented one for health policy. Six years ago, Democrats passed a massive healthcare reform bill without Republican support, which has been central to partisan ire ever since. “Repeal and replace” has become a GOP mantra synonymous with Obamacare. This could be the year the Affordable Care Act (ACA) is marked to expire or the year it sets course for exponential growth.

One thing is certain: The outcome of this year’s election will usher in profound change for the American healthcare system. It also means a great deal of uncertainty for physicians, hospital systems, insurers, patients, and healthcare providers more broadly for weeks, months, or even years to come.

The Policy Proposals

Democratic presidential nominee Hillary Clinton has vowed to keep, strengthen, and “fix” the ACA, with proposals that include allowing people to begin buying into Medicare at age 55 and eliminating the Cadillac tax, plus a vow to defend access to reproductive healthcare. Republican nominee Donald Trump has the seven-point “Healthcare Reform to Make America Great Again,” which has as its first pillar to “completely replace Obamacare.”

While Clinton’s platform is highly detailed, Trump has offered few specifics with regard to its replacement, “just a set of general principles,” says Robert Blendon, the Richard L. Menschel Professor of Public Health at Harvard T.H. Chan School of Public Health (HSPH) and a professor of health policy and political analysis at HSPH and the Harvard Kennedy School of Government. “His supporters are just not focused on what the healthcare bill of the future would look like,” he adds.

Under majority Republican leadership, “it’s absolutely clear,” Blendon says, that the party would attempt to repeal the ACA. That would mean millions of people could lose insurance coverage or face higher levels of cost-sharing, benefits would be less comprehensive, and government regulation would decrease, leading to fewer directives for physicians and providers, he says.

A Democratic sweep of the executive and legislative branches would likely bring more funding for the National Institutes of Health and the Centers for Disease Control and Prevention. It might also lead to the introduction of a government alternative insurance plan that would compete with private insurance for those under age 65, Blendon explains.

“There’d be more money spent, but there’d be much more government regulation, including discussions of Medicare price limits on certain types of drugs,” he says.

Healthcare, though, has been caught in the middle of a host of broader issues, Blendon says.

“Put very simply, you almost have three parties that are running,” he says. “You have Democratic, which is [the] more liberal-moderate party, which is basically running on a health platform that is continuing Obama’s eight years but enlarging it in a number of areas. You have the party of the Republicans strictly in the Congress, which are running as a conservative party, which is to get rid of part of the ACA, to slow Medicare costs, and very concerned with a tax cut broadly and restraining federal optional expenditures in the future.

“The third is Mr. Trump, but it’s not widely understood unless you follow European political situations a lot,” Blendon says. “Mr. Trump is actually running what would be called in Europe a nationalist party. Their issues are a bit different.”

Key components of Trump’s seven-point healthcare plan embrace some historical or current Republican policy ideas. These include using tax-free health savings accounts, allowing tax deductions for insurance premiums, and providing Medicaid block grants to states (though he has vowed not to cut overall Medicaid spending).

 

But Trump also breaks with the party, promising not to alter Medicare, proposing, like Clinton, to allow Medicare to negotiate pharmaceutical drug prices, and considering the idea of allowing pharmaceuticals to be imported from overseas, also like his Democratic opponent.

“I believe on the healthcare issue, he will be somewhat deferential to what the Republican leaders want their healthcare bill to look like in the future … not necessarily because that’s his particular choice but because he has a whole other agenda, which he says over and over is really important to him, and he needs the Republican leadership [to support it],” Blendon says.

How Will Things Get Done?

According to a Brookings Institution policy document published earlier this year, anyone proposing healthcare policy changes will confront “a daunting negotiation with powerful stakeholders to defend and enhance their varied interests” following the 2016 election.1

Three possible scenarios include a full Democratic president and Congress, a full Republican president and Congress, or a split presidency and Congress (including the two houses going each to the other party).

“If there is a split in the House and Senate, will things get done?” says Bradley Flansbaum, DO, MPH, MHM, a member of SHM’s Public Policy Committee. “Democrats don’t want to indicate the law has flaws and needs fixes. That admission invites the GOP to say, ‘See, it’s broken.’ Conversely, if Republicans do try to work with anyone on the other side of the aisle, they will be branded a pariah.”

One hospitalist sees Congress as the main force behind whether the ACA is kept intact.

“Congress holds the purse strings and has the control to chip away at the financial underpinnings until those toothpicks that hold up the Obamacare elephant break and it comes crashing down,” says Joshua Lenchus, DO, RPh, FACP, SFHM, a hospitalist at the University of Miami/Jackson Memorial Hospital in Florida and a member of SHM’s Public Policy Committee.

ACA Fixes?

One option Clinton has proposed is a federally administered public alternative to private insurers in the ACA marketplace, particularly as more companies leave exchanges across the country. Blendon says there is some concern over the idea’s viability since, while it could help keep pricing competitive, it might just “attract some of the sickest people because they’ll feel it provides more financial security.”

“A very high priority for a Clinton administration and a Democratic Congress [is] to get in there with a rescue team, and this is an issue of providing wraparound protection for [insurance] companies that basically end up with either older or sicker people than they had at all anticipated and some sort of a financial cushion to carry them into other years,” Blendon says.

In its policy paper, the Brookings Institution says any serious Republican idea to repeal the ACA should offer an alternative to replace the healthcare bill’s spending reductions, particularly since the Congressional Budget Office estimates repeal of the ACA would increase direct Medicare spending by $802 billion over the next decade, possibly accelerating the depletion of the program’s trust fund.1

“I think what would happen would be some amount of what the Republican leadership has talked about, some sort of a partial alternative to the ACA, and it would cover less people and less benefits, but there would be an absolute plan that they would try to have in place,” Blendon says.

But only time will tell how the election will affect hospitalists in their day-to-day work.

“Unfortunately, we’re still not at a stage that you could say to somebody, ‘This is what the next five years are going to look like; that’s how you should think about what your hospital and practice should be thinking,’” Blendon says. “You’re much more stuck with, ‘There is uncertainty here.’” TH

 

---

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

Reference

1. Rivlin AM, Reischauer RD. Health policy issues and the 2016 presidential election. Brookings Institution website. Accessed August 31, 2016.

Editor's Note: Listen to Robert Blendon talk more about the health policy implications of the 2016 election.

In some ways, the national election of 2016 is an unprecedented one for health policy. Six years ago, Democrats passed a massive healthcare reform bill without Republican support, which has been central to partisan ire ever since. “Repeal and replace” has become a GOP mantra synonymous with Obamacare. This could be the year the Affordable Care Act (ACA) is marked to expire or the year it sets course for exponential growth.

One thing is certain: The outcome of this year’s election will usher in profound change for the American healthcare system. It also means a great deal of uncertainty for physicians, hospital systems, insurers, patients, and healthcare providers more broadly for weeks, months, or even years to come.

The Policy Proposals

Democratic presidential nominee Hillary Clinton has vowed to keep, strengthen, and “fix” the ACA, with proposals that include allowing people to begin buying into Medicare at age 55 and eliminating the Cadillac tax, plus a vow to defend access to reproductive healthcare. Republican nominee Donald Trump has the seven-point “Healthcare Reform to Make America Great Again,” which has as its first pillar to “completely replace Obamacare.”

While Clinton’s platform is highly detailed, Trump has offered few specifics with regard to its replacement, “just a set of general principles,” says Robert Blendon, the Richard L. Menschel Professor of Public Health at Harvard T.H. Chan School of Public Health (HSPH) and a professor of health policy and political analysis at HSPH and the Harvard Kennedy School of Government. “His supporters are just not focused on what the healthcare bill of the future would look like,” he adds.

Under majority Republican leadership, “it’s absolutely clear,” Blendon says, that the party would attempt to repeal the ACA. That would mean millions of people could lose insurance coverage or face higher levels of cost-sharing, benefits would be less comprehensive, and government regulation would decrease, leading to fewer directives for physicians and providers, he says.

A Democratic sweep of the executive and legislative branches would likely bring more funding for the National Institutes of Health and the Centers for Disease Control and Prevention. It might also lead to the introduction of a government alternative insurance plan that would compete with private insurance for those under age 65, Blendon explains.

“There’d be more money spent, but there’d be much more government regulation, including discussions of Medicare price limits on certain types of drugs,” he says.

Healthcare, though, has been caught in the middle of a host of broader issues, Blendon says.

“Put very simply, you almost have three parties that are running,” he says. “You have Democratic, which is [the] more liberal-moderate party, which is basically running on a health platform that is continuing Obama’s eight years but enlarging it in a number of areas. You have the party of the Republicans strictly in the Congress, which are running as a conservative party, which is to get rid of part of the ACA, to slow Medicare costs, and very concerned with a tax cut broadly and restraining federal optional expenditures in the future.

“The third is Mr. Trump, but it’s not widely understood unless you follow European political situations a lot,” Blendon says. “Mr. Trump is actually running what would be called in Europe a nationalist party. Their issues are a bit different.”

Key components of Trump’s seven-point healthcare plan embrace some historical or current Republican policy ideas. These include using tax-free health savings accounts, allowing tax deductions for insurance premiums, and providing Medicaid block grants to states (though he has vowed not to cut overall Medicaid spending).

 

But Trump also breaks with the party, promising not to alter Medicare, proposing, like Clinton, to allow Medicare to negotiate pharmaceutical drug prices, and considering the idea of allowing pharmaceuticals to be imported from overseas, also like his Democratic opponent.

“I believe on the healthcare issue, he will be somewhat deferential to what the Republican leaders want their healthcare bill to look like in the future … not necessarily because that’s his particular choice but because he has a whole other agenda, which he says over and over is really important to him, and he needs the Republican leadership [to support it],” Blendon says.

How Will Things Get Done?

According to a Brookings Institution policy document published earlier this year, anyone proposing healthcare policy changes will confront “a daunting negotiation with powerful stakeholders to defend and enhance their varied interests” following the 2016 election.1

Three possible scenarios include a full Democratic president and Congress, a full Republican president and Congress, or a split presidency and Congress (including the two houses going each to the other party).

“If there is a split in the House and Senate, will things get done?” says Bradley Flansbaum, DO, MPH, MHM, a member of SHM’s Public Policy Committee. “Democrats don’t want to indicate the law has flaws and needs fixes. That admission invites the GOP to say, ‘See, it’s broken.’ Conversely, if Republicans do try to work with anyone on the other side of the aisle, they will be branded a pariah.”

One hospitalist sees Congress as the main force behind whether the ACA is kept intact.

“Congress holds the purse strings and has the control to chip away at the financial underpinnings until those toothpicks that hold up the Obamacare elephant break and it comes crashing down,” says Joshua Lenchus, DO, RPh, FACP, SFHM, a hospitalist at the University of Miami/Jackson Memorial Hospital in Florida and a member of SHM’s Public Policy Committee.

ACA Fixes?

One option Clinton has proposed is a federally administered public alternative to private insurers in the ACA marketplace, particularly as more companies leave exchanges across the country. Blendon says there is some concern over the idea’s viability since, while it could help keep pricing competitive, it might just “attract some of the sickest people because they’ll feel it provides more financial security.”

“A very high priority for a Clinton administration and a Democratic Congress [is] to get in there with a rescue team, and this is an issue of providing wraparound protection for [insurance] companies that basically end up with either older or sicker people than they had at all anticipated and some sort of a financial cushion to carry them into other years,” Blendon says.

In its policy paper, the Brookings Institution says any serious Republican idea to repeal the ACA should offer an alternative to replace the healthcare bill’s spending reductions, particularly since the Congressional Budget Office estimates repeal of the ACA would increase direct Medicare spending by $802 billion over the next decade, possibly accelerating the depletion of the program’s trust fund.1

“I think what would happen would be some amount of what the Republican leadership has talked about, some sort of a partial alternative to the ACA, and it would cover less people and less benefits, but there would be an absolute plan that they would try to have in place,” Blendon says.

But only time will tell how the election will affect hospitalists in their day-to-day work.

“Unfortunately, we’re still not at a stage that you could say to somebody, ‘This is what the next five years are going to look like; that’s how you should think about what your hospital and practice should be thinking,’” Blendon says. “You’re much more stuck with, ‘There is uncertainty here.’” TH

 

---

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

Reference

1. Rivlin AM, Reischauer RD. Health policy issues and the 2016 presidential election. Brookings Institution website. Accessed August 31, 2016.

Editor's Note: Listen to Robert Blendon talk more about the health policy implications of the 2016 election.

In some ways, the national election of 2016 is an unprecedented one for health policy. Six years ago, Democrats passed a massive healthcare reform bill without Republican support, which has been central to partisan ire ever since. “Repeal and replace” has become a GOP mantra synonymous with Obamacare. This could be the year the Affordable Care Act (ACA) is marked to expire or the year it sets course for exponential growth.

One thing is certain: The outcome of this year’s election will usher in profound change for the American healthcare system. It also means a great deal of uncertainty for physicians, hospital systems, insurers, patients, and healthcare providers more broadly for weeks, months, or even years to come.

The Policy Proposals

Democratic presidential nominee Hillary Clinton has vowed to keep, strengthen, and “fix” the ACA, with proposals that include allowing people to begin buying into Medicare at age 55 and eliminating the Cadillac tax, plus a vow to defend access to reproductive healthcare. Republican nominee Donald Trump has the seven-point “Healthcare Reform to Make America Great Again,” which has as its first pillar to “completely replace Obamacare.”

While Clinton’s platform is highly detailed, Trump has offered few specifics with regard to its replacement, “just a set of general principles,” says Robert Blendon, the Richard L. Menschel Professor of Public Health at Harvard T.H. Chan School of Public Health (HSPH) and a professor of health policy and political analysis at HSPH and the Harvard Kennedy School of Government. “His supporters are just not focused on what the healthcare bill of the future would look like,” he adds.

Under majority Republican leadership, “it’s absolutely clear,” Blendon says, that the party would attempt to repeal the ACA. That would mean millions of people could lose insurance coverage or face higher levels of cost-sharing, benefits would be less comprehensive, and government regulation would decrease, leading to fewer directives for physicians and providers, he says.

A Democratic sweep of the executive and legislative branches would likely bring more funding for the National Institutes of Health and the Centers for Disease Control and Prevention. It might also lead to the introduction of a government alternative insurance plan that would compete with private insurance for those under age 65, Blendon explains.

“There’d be more money spent, but there’d be much more government regulation, including discussions of Medicare price limits on certain types of drugs,” he says.

Healthcare, though, has been caught in the middle of a host of broader issues, Blendon says.

“Put very simply, you almost have three parties that are running,” he says. “You have Democratic, which is [the] more liberal-moderate party, which is basically running on a health platform that is continuing Obama’s eight years but enlarging it in a number of areas. You have the party of the Republicans strictly in the Congress, which are running as a conservative party, which is to get rid of part of the ACA, to slow Medicare costs, and very concerned with a tax cut broadly and restraining federal optional expenditures in the future.

“The third is Mr. Trump, but it’s not widely understood unless you follow European political situations a lot,” Blendon says. “Mr. Trump is actually running what would be called in Europe a nationalist party. Their issues are a bit different.”

Key components of Trump’s seven-point healthcare plan embrace some historical or current Republican policy ideas. These include using tax-free health savings accounts, allowing tax deductions for insurance premiums, and providing Medicaid block grants to states (though he has vowed not to cut overall Medicaid spending).

 

But Trump also breaks with the party, promising not to alter Medicare, proposing, like Clinton, to allow Medicare to negotiate pharmaceutical drug prices, and considering the idea of allowing pharmaceuticals to be imported from overseas, also like his Democratic opponent.

“I believe on the healthcare issue, he will be somewhat deferential to what the Republican leaders want their healthcare bill to look like in the future … not necessarily because that’s his particular choice but because he has a whole other agenda, which he says over and over is really important to him, and he needs the Republican leadership [to support it],” Blendon says.

How Will Things Get Done?

According to a Brookings Institution policy document published earlier this year, anyone proposing healthcare policy changes will confront “a daunting negotiation with powerful stakeholders to defend and enhance their varied interests” following the 2016 election.1

Three possible scenarios include a full Democratic president and Congress, a full Republican president and Congress, or a split presidency and Congress (including the two houses going each to the other party).

“If there is a split in the House and Senate, will things get done?” says Bradley Flansbaum, DO, MPH, MHM, a member of SHM’s Public Policy Committee. “Democrats don’t want to indicate the law has flaws and needs fixes. That admission invites the GOP to say, ‘See, it’s broken.’ Conversely, if Republicans do try to work with anyone on the other side of the aisle, they will be branded a pariah.”

One hospitalist sees Congress as the main force behind whether the ACA is kept intact.

“Congress holds the purse strings and has the control to chip away at the financial underpinnings until those toothpicks that hold up the Obamacare elephant break and it comes crashing down,” says Joshua Lenchus, DO, RPh, FACP, SFHM, a hospitalist at the University of Miami/Jackson Memorial Hospital in Florida and a member of SHM’s Public Policy Committee.

ACA Fixes?

One option Clinton has proposed is a federally administered public alternative to private insurers in the ACA marketplace, particularly as more companies leave exchanges across the country. Blendon says there is some concern over the idea’s viability since, while it could help keep pricing competitive, it might just “attract some of the sickest people because they’ll feel it provides more financial security.”

“A very high priority for a Clinton administration and a Democratic Congress [is] to get in there with a rescue team, and this is an issue of providing wraparound protection for [insurance] companies that basically end up with either older or sicker people than they had at all anticipated and some sort of a financial cushion to carry them into other years,” Blendon says.

In its policy paper, the Brookings Institution says any serious Republican idea to repeal the ACA should offer an alternative to replace the healthcare bill’s spending reductions, particularly since the Congressional Budget Office estimates repeal of the ACA would increase direct Medicare spending by $802 billion over the next decade, possibly accelerating the depletion of the program’s trust fund.1

“I think what would happen would be some amount of what the Republican leadership has talked about, some sort of a partial alternative to the ACA, and it would cover less people and less benefits, but there would be an absolute plan that they would try to have in place,” Blendon says.

But only time will tell how the election will affect hospitalists in their day-to-day work.

“Unfortunately, we’re still not at a stage that you could say to somebody, ‘This is what the next five years are going to look like; that’s how you should think about what your hospital and practice should be thinking,’” Blendon says. “You’re much more stuck with, ‘There is uncertainty here.’” TH

 

---

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

Reference

1. Rivlin AM, Reischauer RD. Health policy issues and the 2016 presidential election. Brookings Institution website. Accessed August 31, 2016.

In 2015, researchers in China announced they had found for the first time a bacterial gene conferring resistance to colistin. The gene was present in samples from agricultural animals and in 1% of tested patients.1 Colistin, an antibiotic from the 1950s, is rarely prescribed; it is often considered an antibiotic of last resort.

In May 2016, the U.S. Department of Defense announced this gene, called mcr-1, had been found in E. coli isolated from the urine of a patient in Pennsylvania presenting with symptoms of a urinary tract infection.2 Subsequent surveillance also found mcr-1 E. coli in a pig.

The news has been met with grave concern by public health officials, scientists, infectious disease specialists, and countless physicians around the U.S. It has also served as a reminder that good antibiotic stewardship is a national, if not international, imperative.

“The recent discovery of a plasmid-borne colistin resistance gene, mcr-1, heralds the emergence of truly pan-drug resistant bacteria,” the authors of the recent U.S. study, from the Walter Reed National Military Medical Center, wrote in their opening sentence.

In November 2015, the Society of Hospital Medicine (SHM) launched an antibiotic stewardship campaign, “Fight the Resistance,” in partnership with the Centers for Disease Control and Prevention (CDC). Hospitalists around the country have taken the lead on confronting the issue head on.

When the CDC and the White House called for action last year, “SHM jumped in with both feet,” says Eric Howell, MD, MHM, SHM’s senior physician advisor, chief of the Division of Hospital Medicine at Johns Hopkins Bayview, and professor of medicine at Johns Hopkins University in Baltimore. The “Fight the Resistance” campaign calls for the nation’s 44,000 hospitalists to commit to responsible antibiotic-prescribing practices.

“While it’s extremely alarming, leading up to this, we knew there was a crisis of antibiotic resistance,” says Megan Mack, MD, a hospitalist and clinical instructor in the University of Michigan Health System in Ann Arbor. “We know more antibiotic use is not the answer, stronger is not the answer. We need to be peeling back antibiotic use, honing when we need them, narrowing how we use them as much as possible, and keeping the duration as short as possible.”

Dr. Mack is first author of a new study in the Journal of Hospital Medicine that examines hospitalist-driven antibiotic stewardship efforts in five hospitals around the country.3

The Institute for Healthcare Improvement, with the CDC, recruited Dr. Mack and her study coauthors, hospitalists Jeff Rohde, MD, and Scott Flanders, MD, MHM, to participate.

“We were interested in the opportunity to put into place interventions in five different hospitals and to be able to share our successes and our barriers, which we did twice monthly,” Dr. Mack says.

Each hospital in the collaborative, which included teaching and non-teaching community hospitals and academic medical centers, focused on its own data and tailored its stewardship interventions to three strategies shown to be quality indicators of successful stewardship programs.

These strategies included:

• Enhanced documentation with regard to antimicrobial prescribing and use
• Improved quality and accessibility of guidelines for common infections
• Adoption of a 72-hour antibiotic timeout to reassess a patient’s antibiotic treatment plan once culture results were available

Each hospital used its own particular antibiotic stewardship practice data to educate and inform its physicians, which Dr. Mack says was important to the success of interventions because it was “concrete and realistic.”

The study found that in two hospitals, complete antibiotic documentation in patient records increased to 51% from 4% and to 65% from 8%. It also recorded 726 antibiotic timeouts, resulting in 218 antibiotic treatment adjustments or discontinuations. It also found several barriers to improved antibiotic stewardship.

 

“[Hospitalists] are stretched for time. We’re constantly being pulled in multiple directions,” Dr. Mack says. “We are bombarded daily with quality improvement initiatives and with constantly meeting metrics deemed to be priorities, so we tried interventions that were easily incorporated into daily workflow.”

The team learned that workflow integration was a requirement for success. For instance, Dr. Mack suggests building antibiotic prescribing into hospitalists’ electronic health records, with automatic stop dates that must be overridden by a physician. “It’s too easy to overlook it, and 10 days later, your patient is still on vancomycin.”

The experience, she says, made her fellow physicians in the collaborative realize that, despite some skepticism, good antimicrobial stewardship can be achieved without significant disruption.

“If we don’t change our practice patterns, there are not enough antibiotics in the pipeline to mitigate the effects,” of resistance, says Dr. Howell, who was not involved in the study. “We can’t stop resistance, but we can change our practice patterns so we slow the rate of resistance and give ourselves time to develop new therapies to treat infections.”

This includes behavioral changes hospitalists can easily incorporate, Dr. Howell says, which align with the strategies assessed in Dr. Mack’s study. These include rethinking the treatment time course, antibiotic timeouts, and adhering to prescribing guidelines.

Hospitalists, he says, are well-positioned to lead antibiotic stewardship efforts.

“We’re quality improvement experts … and there are not enough infectious disease physicians in the country to roll out antibiotic stewardship programs, so there is space for hospitalists,” Dr. Howell explains. “In every hospital, we are prescribing these medications, so we own the problem.” TH

---

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

References

1. Liu YY, Wang Y, Walsh TR, et al. Emergence of plasmid-mediated colistin resistance mechanism MCR-1 in animals and human beings in China: a microbiological and molecular biological study. Lancet Infect Dis. 2016;16(2):161-168. doi:10.1016/S1473-3099(15)00424-7.
2. McGann P, Snesrud E, Maybank R, et al. Escherichia coli harboring mcr-1 and blaCTX-M on a novel IncF plasmid: First report of mcr-1 in the USA. Antimicrob Agents Chemother. 2016;60(7):4420-4421.
3. Mack MR, Rohde JM, Jacobsen D, et al. Engaging hospitalists in antimicrobial stewardship: Lessons from a multihospital collaborative [published online ahead of print on April 30, 2016]. J Hosp Med. doi:10.1002/jhm.2599.

In 2015, researchers in China announced they had found for the first time a bacterial gene conferring resistance to colistin. The gene was present in samples from agricultural animals and in 1% of tested patients.1 Colistin, an antibiotic from the 1950s, is rarely prescribed; it is often considered an antibiotic of last resort.

In May 2016, the U.S. Department of Defense announced this gene, called mcr-1, had been found in E. coli isolated from the urine of a patient in Pennsylvania presenting with symptoms of a urinary tract infection.2 Subsequent surveillance also found mcr-1 E. coli in a pig.

The news has been met with grave concern by public health officials, scientists, infectious disease specialists, and countless physicians around the U.S. It has also served as a reminder that good antibiotic stewardship is a national, if not international, imperative.

“The recent discovery of a plasmid-borne colistin resistance gene, mcr-1, heralds the emergence of truly pan-drug resistant bacteria,” the authors of the recent U.S. study, from the Walter Reed National Military Medical Center, wrote in their opening sentence.

In November 2015, the Society of Hospital Medicine (SHM) launched an antibiotic stewardship campaign, “Fight the Resistance,” in partnership with the Centers for Disease Control and Prevention (CDC). Hospitalists around the country have taken the lead on confronting the issue head on.

When the CDC and the White House called for action last year, “SHM jumped in with both feet,” says Eric Howell, MD, MHM, SHM’s senior physician advisor, chief of the Division of Hospital Medicine at Johns Hopkins Bayview, and professor of medicine at Johns Hopkins University in Baltimore. The “Fight the Resistance” campaign calls for the nation’s 44,000 hospitalists to commit to responsible antibiotic-prescribing practices.

“While it’s extremely alarming, leading up to this, we knew there was a crisis of antibiotic resistance,” says Megan Mack, MD, a hospitalist and clinical instructor in the University of Michigan Health System in Ann Arbor. “We know more antibiotic use is not the answer, stronger is not the answer. We need to be peeling back antibiotic use, honing when we need them, narrowing how we use them as much as possible, and keeping the duration as short as possible.”

Dr. Mack is first author of a new study in the Journal of Hospital Medicine that examines hospitalist-driven antibiotic stewardship efforts in five hospitals around the country.3

The Institute for Healthcare Improvement, with the CDC, recruited Dr. Mack and her study coauthors, hospitalists Jeff Rohde, MD, and Scott Flanders, MD, MHM, to participate.

“We were interested in the opportunity to put into place interventions in five different hospitals and to be able to share our successes and our barriers, which we did twice monthly,” Dr. Mack says.

Each hospital in the collaborative, which included teaching and non-teaching community hospitals and academic medical centers, focused on its own data and tailored its stewardship interventions to three strategies shown to be quality indicators of successful stewardship programs.

These strategies included:

• Enhanced documentation with regard to antimicrobial prescribing and use
• Improved quality and accessibility of guidelines for common infections
• Adoption of a 72-hour antibiotic timeout to reassess a patient’s antibiotic treatment plan once culture results were available

Each hospital used its own particular antibiotic stewardship practice data to educate and inform its physicians, which Dr. Mack says was important to the success of interventions because it was “concrete and realistic.”

The study found that in two hospitals, complete antibiotic documentation in patient records increased to 51% from 4% and to 65% from 8%. It also recorded 726 antibiotic timeouts, resulting in 218 antibiotic treatment adjustments or discontinuations. It also found several barriers to improved antibiotic stewardship.

 

“[Hospitalists] are stretched for time. We’re constantly being pulled in multiple directions,” Dr. Mack says. “We are bombarded daily with quality improvement initiatives and with constantly meeting metrics deemed to be priorities, so we tried interventions that were easily incorporated into daily workflow.”

The team learned that workflow integration was a requirement for success. For instance, Dr. Mack suggests building antibiotic prescribing into hospitalists’ electronic health records, with automatic stop dates that must be overridden by a physician. “It’s too easy to overlook it, and 10 days later, your patient is still on vancomycin.”

The experience, she says, made her fellow physicians in the collaborative realize that, despite some skepticism, good antimicrobial stewardship can be achieved without significant disruption.

“If we don’t change our practice patterns, there are not enough antibiotics in the pipeline to mitigate the effects,” of resistance, says Dr. Howell, who was not involved in the study. “We can’t stop resistance, but we can change our practice patterns so we slow the rate of resistance and give ourselves time to develop new therapies to treat infections.”

This includes behavioral changes hospitalists can easily incorporate, Dr. Howell says, which align with the strategies assessed in Dr. Mack’s study. These include rethinking the treatment time course, antibiotic timeouts, and adhering to prescribing guidelines.

Hospitalists, he says, are well-positioned to lead antibiotic stewardship efforts.

“We’re quality improvement experts … and there are not enough infectious disease physicians in the country to roll out antibiotic stewardship programs, so there is space for hospitalists,” Dr. Howell explains. “In every hospital, we are prescribing these medications, so we own the problem.” TH

---

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

References

1. Liu YY, Wang Y, Walsh TR, et al. Emergence of plasmid-mediated colistin resistance mechanism MCR-1 in animals and human beings in China: a microbiological and molecular biological study. Lancet Infect Dis. 2016;16(2):161-168. doi:10.1016/S1473-3099(15)00424-7.
2. McGann P, Snesrud E, Maybank R, et al. Escherichia coli harboring mcr-1 and blaCTX-M on a novel IncF plasmid: First report of mcr-1 in the USA. Antimicrob Agents Chemother. 2016;60(7):4420-4421.
3. Mack MR, Rohde JM, Jacobsen D, et al. Engaging hospitalists in antimicrobial stewardship: Lessons from a multihospital collaborative [published online ahead of print on April 30, 2016]. J Hosp Med. doi:10.1002/jhm.2599.

In 2015, researchers in China announced they had found for the first time a bacterial gene conferring resistance to colistin. The gene was present in samples from agricultural animals and in 1% of tested patients.1 Colistin, an antibiotic from the 1950s, is rarely prescribed; it is often considered an antibiotic of last resort.

In May 2016, the U.S. Department of Defense announced this gene, called mcr-1, had been found in E. coli isolated from the urine of a patient in Pennsylvania presenting with symptoms of a urinary tract infection.2 Subsequent surveillance also found mcr-1 E. coli in a pig.

The news has been met with grave concern by public health officials, scientists, infectious disease specialists, and countless physicians around the U.S. It has also served as a reminder that good antibiotic stewardship is a national, if not international, imperative.

“The recent discovery of a plasmid-borne colistin resistance gene, mcr-1, heralds the emergence of truly pan-drug resistant bacteria,” the authors of the recent U.S. study, from the Walter Reed National Military Medical Center, wrote in their opening sentence.

In November 2015, the Society of Hospital Medicine (SHM) launched an antibiotic stewardship campaign, “Fight the Resistance,” in partnership with the Centers for Disease Control and Prevention (CDC). Hospitalists around the country have taken the lead on confronting the issue head on.

When the CDC and the White House called for action last year, “SHM jumped in with both feet,” says Eric Howell, MD, MHM, SHM’s senior physician advisor, chief of the Division of Hospital Medicine at Johns Hopkins Bayview, and professor of medicine at Johns Hopkins University in Baltimore. The “Fight the Resistance” campaign calls for the nation’s 44,000 hospitalists to commit to responsible antibiotic-prescribing practices.

“While it’s extremely alarming, leading up to this, we knew there was a crisis of antibiotic resistance,” says Megan Mack, MD, a hospitalist and clinical instructor in the University of Michigan Health System in Ann Arbor. “We know more antibiotic use is not the answer, stronger is not the answer. We need to be peeling back antibiotic use, honing when we need them, narrowing how we use them as much as possible, and keeping the duration as short as possible.”

Dr. Mack is first author of a new study in the Journal of Hospital Medicine that examines hospitalist-driven antibiotic stewardship efforts in five hospitals around the country.3

The Institute for Healthcare Improvement, with the CDC, recruited Dr. Mack and her study coauthors, hospitalists Jeff Rohde, MD, and Scott Flanders, MD, MHM, to participate.

“We were interested in the opportunity to put into place interventions in five different hospitals and to be able to share our successes and our barriers, which we did twice monthly,” Dr. Mack says.

Each hospital in the collaborative, which included teaching and non-teaching community hospitals and academic medical centers, focused on its own data and tailored its stewardship interventions to three strategies shown to be quality indicators of successful stewardship programs.

These strategies included:

• Enhanced documentation with regard to antimicrobial prescribing and use
• Improved quality and accessibility of guidelines for common infections
• Adoption of a 72-hour antibiotic timeout to reassess a patient’s antibiotic treatment plan once culture results were available

Each hospital used its own particular antibiotic stewardship practice data to educate and inform its physicians, which Dr. Mack says was important to the success of interventions because it was “concrete and realistic.”

The study found that in two hospitals, complete antibiotic documentation in patient records increased to 51% from 4% and to 65% from 8%. It also recorded 726 antibiotic timeouts, resulting in 218 antibiotic treatment adjustments or discontinuations. It also found several barriers to improved antibiotic stewardship.

 

“[Hospitalists] are stretched for time. We’re constantly being pulled in multiple directions,” Dr. Mack says. “We are bombarded daily with quality improvement initiatives and with constantly meeting metrics deemed to be priorities, so we tried interventions that were easily incorporated into daily workflow.”

The team learned that workflow integration was a requirement for success. For instance, Dr. Mack suggests building antibiotic prescribing into hospitalists’ electronic health records, with automatic stop dates that must be overridden by a physician. “It’s too easy to overlook it, and 10 days later, your patient is still on vancomycin.”

The experience, she says, made her fellow physicians in the collaborative realize that, despite some skepticism, good antimicrobial stewardship can be achieved without significant disruption.

“If we don’t change our practice patterns, there are not enough antibiotics in the pipeline to mitigate the effects,” of resistance, says Dr. Howell, who was not involved in the study. “We can’t stop resistance, but we can change our practice patterns so we slow the rate of resistance and give ourselves time to develop new therapies to treat infections.”

This includes behavioral changes hospitalists can easily incorporate, Dr. Howell says, which align with the strategies assessed in Dr. Mack’s study. These include rethinking the treatment time course, antibiotic timeouts, and adhering to prescribing guidelines.

Hospitalists, he says, are well-positioned to lead antibiotic stewardship efforts.

“We’re quality improvement experts … and there are not enough infectious disease physicians in the country to roll out antibiotic stewardship programs, so there is space for hospitalists,” Dr. Howell explains. “In every hospital, we are prescribing these medications, so we own the problem.” TH

---

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

References

1. Liu YY, Wang Y, Walsh TR, et al. Emergence of plasmid-mediated colistin resistance mechanism MCR-1 in animals and human beings in China: a microbiological and molecular biological study. Lancet Infect Dis. 2016;16(2):161-168. doi:10.1016/S1473-3099(15)00424-7.
2. McGann P, Snesrud E, Maybank R, et al. Escherichia coli harboring mcr-1 and blaCTX-M on a novel IncF plasmid: First report of mcr-1 in the USA. Antimicrob Agents Chemother. 2016;60(7):4420-4421.
3. Mack MR, Rohde JM, Jacobsen D, et al. Engaging hospitalists in antimicrobial stewardship: Lessons from a multihospital collaborative [published online ahead of print on April 30, 2016]. J Hosp Med. doi:10.1002/jhm.2599.

Last year, Congress put an end to the Sustainable Growth Rate (SGR), which had become a yearly battle fought on behalf of and by physicians to prevent significant last-minute cuts to Medicare reimbursement. Many hoped its replacement would provide more stability and certainty.

However, that replacement, the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA), has been anything but clear. On April 27, 2016, the Centers for Medicare & Medicaid Services (CMS) issued a Notice of Proposed Rulemaking in what it called a “first step” in implementing MACRA. CMS accepted feedback and input on the proposed rule through June 27, 2016.

The Society of Hospital Medicine worked to provide comment on what it sees as the biggest concerns of hospitalists.

For example, it remains unclear what quality markers CMS will use to evaluate hospitalists under MACRA, says Rush University Medical Center’s Suparna Dutta, MD, MPH, a hospitalist, assistant professor of medicine, and member of the SHM Public Policy Committee (PPC). “The biggest piece is, what will be used universally for all hospitalists and attributed to the work that we do?”

MACRA represents “a milestone” in efforts to “advance a healthcare system that rewards better care, smarter spending, and healthier people,” U.S. Department of Health & Human Services Secretary Sylvia M. Burwell said in a statement issued the day the proposed rule was announced.

What it is designed to do, says Ron Greeno, MD, MHM, president-elect of SHM, PPC chair, and senior advisor for medical affairs at TeamHealth, is push physicians to move toward alternative payment models.

To achieve this, MACRA creates a framework called the Quality Payment Program, which offers physicians two paths for value-over-volume-based payments: MIPS, for Merit-Based Incentive Payment System, and APMs, for Advanced Alternative Payment Models. The benchmark period for both pathways begins Jan. 1, 2017, and MACRA reimbursement would begin Jan. 1, 2019.

Under MIPS, current quality measurement programs are streamlined into a single payment adjustment, including the Physician Value-Based Modifier, the Electronic Health Record (EHR) Incentive Program and the Physician Quality Reporting System (PQRS).

Physicians will not assume risk on the MIPS pathway, but payment adjustments will be based on their MIPS score, which grows each year through 2022 and ranges that year from +9% to -9%. It will be budget neutral: The top half of scorers will see increases in payments, while the bottom half will see cuts. Additional adjustments will be given to top performers through 2024.

However, as Dr. Dutta and fellow PPC member Lauren Doctoroff, MD, FHM, a hospitalist at Beth Israel Deaconess Medical Center and instructor at Harvard Medical School, wrote for The Hospitalist in March 2016, it is not yet clear how MIPS scores will be calculated for hospitalists.

“The problem is that there is not a typical hospitalist in terms of the work that we do,” Dr. Dutta says. “It depends on the hospital and the types of responsibilities the hospitalists have and the types of patients they care for.”

CMS says 50% of the MIPS score will come from six reported measures that reflect different specialties and practices; 25% will come from technology use, with a focus on interoperability and information exchange; 15% will come from clinical improvement practices, like care coordination; and 10% will be based on cost, chosen from among 40 episode-specific measures.

The new hospitalist billing code, which has not yet been implemented, should be a tremendous help under MACRA, Dr. Dutta says. “As CMS plans on using peer-comparison groups for quality and cost measures, it is really important that we now have a specialty billing code for hospitalists, which should ensure we have a fair and valid comparison pool for any metrics we are measured on for MIPS.”

 

The second path may be much harder for hospitalists to achieve since it requires that physicians share in risk and reward and participate in alternative payment models like Next Generation ACO or the Comprehensive Primary Care Plus model.

Most hospitalists will not be candidates for taking on risks under APM since physicians need to achieve a threshold for taking on more than nominal financial risk, Dr. Dutta says, noting SHM’s efforts to better understand the implications.

“It depends on the the percentage of patients you’re seeing in an APM, and you might hit your threshold if your market has a lot of Medicare ACOs or risk-sharing, but it’s not something hospitalists can consistently plan on,” Dr. Dutta says.

Most hospitalists have little control over whether their facility participates in an APM, Dr. Dutta says, but allowing the APM to which a patient belongs count toward the care provided by hospitalists—though a patient may align with several APMs—may help reach these thresholds.

Feedback from SHM to CMS also included asking to allow the Bundled Payments for Care Improvement Initiative (BPCI) to qualify for APM and seeking clarification into whether hospitalists can tap into cost and quality metrics hospitals are already reporting to CMS.

“Hospitals are collecting a certain amount of data because they have to for Medicare, and that might be a good indicator of what hospitalists are doing,” Dr. Dutta says. This includes services like DVT prophylaxis after surgery in hospitals where hospitalists provide a majority of post-operative care or safety measures like CLABSI (central line–associated bloodstream infection) rates.

To stay up to date with MACRA, visit SHM’s MACRA website and follow @SHMadvocacy on Twitter. TH

Corrected version July 13, 2016.

---

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

Last year, Congress put an end to the Sustainable Growth Rate (SGR), which had become a yearly battle fought on behalf of and by physicians to prevent significant last-minute cuts to Medicare reimbursement. Many hoped its replacement would provide more stability and certainty.

However, that replacement, the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA), has been anything but clear. On April 27, 2016, the Centers for Medicare & Medicaid Services (CMS) issued a Notice of Proposed Rulemaking in what it called a “first step” in implementing MACRA. CMS accepted feedback and input on the proposed rule through June 27, 2016.

The Society of Hospital Medicine worked to provide comment on what it sees as the biggest concerns of hospitalists.

For example, it remains unclear what quality markers CMS will use to evaluate hospitalists under MACRA, says Rush University Medical Center’s Suparna Dutta, MD, MPH, a hospitalist, assistant professor of medicine, and member of the SHM Public Policy Committee (PPC). “The biggest piece is, what will be used universally for all hospitalists and attributed to the work that we do?”

MACRA represents “a milestone” in efforts to “advance a healthcare system that rewards better care, smarter spending, and healthier people,” U.S. Department of Health & Human Services Secretary Sylvia M. Burwell said in a statement issued the day the proposed rule was announced.

What it is designed to do, says Ron Greeno, MD, MHM, president-elect of SHM, PPC chair, and senior advisor for medical affairs at TeamHealth, is push physicians to move toward alternative payment models.

To achieve this, MACRA creates a framework called the Quality Payment Program, which offers physicians two paths for value-over-volume-based payments: MIPS, for Merit-Based Incentive Payment System, and APMs, for Advanced Alternative Payment Models. The benchmark period for both pathways begins Jan. 1, 2017, and MACRA reimbursement would begin Jan. 1, 2019.

Under MIPS, current quality measurement programs are streamlined into a single payment adjustment, including the Physician Value-Based Modifier, the Electronic Health Record (EHR) Incentive Program and the Physician Quality Reporting System (PQRS).

Physicians will not assume risk on the MIPS pathway, but payment adjustments will be based on their MIPS score, which grows each year through 2022 and ranges that year from +9% to -9%. It will be budget neutral: The top half of scorers will see increases in payments, while the bottom half will see cuts. Additional adjustments will be given to top performers through 2024.

However, as Dr. Dutta and fellow PPC member Lauren Doctoroff, MD, FHM, a hospitalist at Beth Israel Deaconess Medical Center and instructor at Harvard Medical School, wrote for The Hospitalist in March 2016, it is not yet clear how MIPS scores will be calculated for hospitalists.

“The problem is that there is not a typical hospitalist in terms of the work that we do,” Dr. Dutta says. “It depends on the hospital and the types of responsibilities the hospitalists have and the types of patients they care for.”

CMS says 50% of the MIPS score will come from six reported measures that reflect different specialties and practices; 25% will come from technology use, with a focus on interoperability and information exchange; 15% will come from clinical improvement practices, like care coordination; and 10% will be based on cost, chosen from among 40 episode-specific measures.

The new hospitalist billing code, which has not yet been implemented, should be a tremendous help under MACRA, Dr. Dutta says. “As CMS plans on using peer-comparison groups for quality and cost measures, it is really important that we now have a specialty billing code for hospitalists, which should ensure we have a fair and valid comparison pool for any metrics we are measured on for MIPS.”

 

The second path may be much harder for hospitalists to achieve since it requires that physicians share in risk and reward and participate in alternative payment models like Next Generation ACO or the Comprehensive Primary Care Plus model.

Most hospitalists will not be candidates for taking on risks under APM since physicians need to achieve a threshold for taking on more than nominal financial risk, Dr. Dutta says, noting SHM’s efforts to better understand the implications.

“It depends on the the percentage of patients you’re seeing in an APM, and you might hit your threshold if your market has a lot of Medicare ACOs or risk-sharing, but it’s not something hospitalists can consistently plan on,” Dr. Dutta says.

Most hospitalists have little control over whether their facility participates in an APM, Dr. Dutta says, but allowing the APM to which a patient belongs count toward the care provided by hospitalists—though a patient may align with several APMs—may help reach these thresholds.

Feedback from SHM to CMS also included asking to allow the Bundled Payments for Care Improvement Initiative (BPCI) to qualify for APM and seeking clarification into whether hospitalists can tap into cost and quality metrics hospitals are already reporting to CMS.

“Hospitals are collecting a certain amount of data because they have to for Medicare, and that might be a good indicator of what hospitalists are doing,” Dr. Dutta says. This includes services like DVT prophylaxis after surgery in hospitals where hospitalists provide a majority of post-operative care or safety measures like CLABSI (central line–associated bloodstream infection) rates.

To stay up to date with MACRA, visit SHM’s MACRA website and follow @SHMadvocacy on Twitter. TH

Corrected version July 13, 2016.

---

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

Last year, Congress put an end to the Sustainable Growth Rate (SGR), which had become a yearly battle fought on behalf of and by physicians to prevent significant last-minute cuts to Medicare reimbursement. Many hoped its replacement would provide more stability and certainty.

However, that replacement, the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA), has been anything but clear. On April 27, 2016, the Centers for Medicare & Medicaid Services (CMS) issued a Notice of Proposed Rulemaking in what it called a “first step” in implementing MACRA. CMS accepted feedback and input on the proposed rule through June 27, 2016.

The Society of Hospital Medicine worked to provide comment on what it sees as the biggest concerns of hospitalists.

For example, it remains unclear what quality markers CMS will use to evaluate hospitalists under MACRA, says Rush University Medical Center’s Suparna Dutta, MD, MPH, a hospitalist, assistant professor of medicine, and member of the SHM Public Policy Committee (PPC). “The biggest piece is, what will be used universally for all hospitalists and attributed to the work that we do?”

MACRA represents “a milestone” in efforts to “advance a healthcare system that rewards better care, smarter spending, and healthier people,” U.S. Department of Health & Human Services Secretary Sylvia M. Burwell said in a statement issued the day the proposed rule was announced.

What it is designed to do, says Ron Greeno, MD, MHM, president-elect of SHM, PPC chair, and senior advisor for medical affairs at TeamHealth, is push physicians to move toward alternative payment models.

To achieve this, MACRA creates a framework called the Quality Payment Program, which offers physicians two paths for value-over-volume-based payments: MIPS, for Merit-Based Incentive Payment System, and APMs, for Advanced Alternative Payment Models. The benchmark period for both pathways begins Jan. 1, 2017, and MACRA reimbursement would begin Jan. 1, 2019.

Under MIPS, current quality measurement programs are streamlined into a single payment adjustment, including the Physician Value-Based Modifier, the Electronic Health Record (EHR) Incentive Program and the Physician Quality Reporting System (PQRS).

Physicians will not assume risk on the MIPS pathway, but payment adjustments will be based on their MIPS score, which grows each year through 2022 and ranges that year from +9% to -9%. It will be budget neutral: The top half of scorers will see increases in payments, while the bottom half will see cuts. Additional adjustments will be given to top performers through 2024.

However, as Dr. Dutta and fellow PPC member Lauren Doctoroff, MD, FHM, a hospitalist at Beth Israel Deaconess Medical Center and instructor at Harvard Medical School, wrote for The Hospitalist in March 2016, it is not yet clear how MIPS scores will be calculated for hospitalists.

“The problem is that there is not a typical hospitalist in terms of the work that we do,” Dr. Dutta says. “It depends on the hospital and the types of responsibilities the hospitalists have and the types of patients they care for.”

CMS says 50% of the MIPS score will come from six reported measures that reflect different specialties and practices; 25% will come from technology use, with a focus on interoperability and information exchange; 15% will come from clinical improvement practices, like care coordination; and 10% will be based on cost, chosen from among 40 episode-specific measures.

The new hospitalist billing code, which has not yet been implemented, should be a tremendous help under MACRA, Dr. Dutta says. “As CMS plans on using peer-comparison groups for quality and cost measures, it is really important that we now have a specialty billing code for hospitalists, which should ensure we have a fair and valid comparison pool for any metrics we are measured on for MIPS.”

 

The second path may be much harder for hospitalists to achieve since it requires that physicians share in risk and reward and participate in alternative payment models like Next Generation ACO or the Comprehensive Primary Care Plus model.

Most hospitalists will not be candidates for taking on risks under APM since physicians need to achieve a threshold for taking on more than nominal financial risk, Dr. Dutta says, noting SHM’s efforts to better understand the implications.

“It depends on the the percentage of patients you’re seeing in an APM, and you might hit your threshold if your market has a lot of Medicare ACOs or risk-sharing, but it’s not something hospitalists can consistently plan on,” Dr. Dutta says.

Most hospitalists have little control over whether their facility participates in an APM, Dr. Dutta says, but allowing the APM to which a patient belongs count toward the care provided by hospitalists—though a patient may align with several APMs—may help reach these thresholds.

Feedback from SHM to CMS also included asking to allow the Bundled Payments for Care Improvement Initiative (BPCI) to qualify for APM and seeking clarification into whether hospitalists can tap into cost and quality metrics hospitals are already reporting to CMS.

“Hospitals are collecting a certain amount of data because they have to for Medicare, and that might be a good indicator of what hospitalists are doing,” Dr. Dutta says. This includes services like DVT prophylaxis after surgery in hospitals where hospitalists provide a majority of post-operative care or safety measures like CLABSI (central line–associated bloodstream infection) rates.

To stay up to date with MACRA, visit SHM’s MACRA website and follow @SHMadvocacy on Twitter. TH

Corrected version July 13, 2016.

---

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

Concern that the Hospital Readmissions Reduction Program (HRRP) has led to more observation stays in an effort by hospitals to avoid readmission penalties can be put to rest.

A study published in late February in the New England Journal of Medicine shows that while readmission rates dropped dramatically with the passage of the Affordable Care Act (ACA) in 2010, this drop was not correlated with an increase in observation services within the nearly 4,000 individual hospitals assessed.1

“I think we were all really happy to see this paper because it’s really well done and it confirms what our gut feeling was as hospitalists—that the readmissions rate falling wasn’t linked to the increase in the use of observation stays,” says Ann Sheehy, MD, MS, FHM, a hospitalist at the University of Wisconsin School of Medicine and Public Health and member of SHM’s Public Policy Committee. “The paper definitively shows that hospitals are not gaming the system to avoid readmission penalties.”

Potentially avoidable hospital readmissions within 30 days of discharge were estimated in 2009 to cost Medicare more than $17 billion annually and are considered a mark of poor-quality care.2 The ACA established HRRP to penalize hospitals with higher-than-expected 30-day readmission rates for several targeted conditions: heart failure, pneumonia, COPD, acute myocardial infarction, total hip and knee replacement, and coronary artery bypass graft surgery.

“Readmission rates had been rock stable for years and years, and coincidentally they came down as observation status rose,” says Ashish Jha, MD, MPH, hospitalist at the VA Boston Healthcare System and professor of health policy at the Harvard T.H. Chan School of Public Health. “The concerning part was that we thought we were making care better by reducing readmissions, but if we were just shifting readmissions to observation, that’s not a change in care pattern—that’s a change in the classification of billing data.”

Earlier data, including an article and an analysis in the Health Affairs blog, also suggested hospitals were trading observation for readmissions, Dr. Jha says.3,4 But the new data have assuaged his concern.

“They did it right,” he says. “Previous studies lumped hospitals together in categories and were not carefully teasing apart what individual hospitals were doing, and when they looked at the individual level, we see no correlation.”

The study’s lead author, Rachael Zuckerman, an economist in the U.S. Department of Health & Human Services (HHS) Office of the Assistant Secretary for Planning and Evaluation (ASPE), writes in a blog post that approximately 565,000 readmissions were likely prevented for the program’s original targeted conditions—heart failure, pneumonia, and acute myocardial infarction—between 2010 and 2015, compared to the readmission rates in the year before passage of the ACA.5

The study examined within-hospital rates of readmission and observation stays among Medicare beneficiaries from October 2007 through May 2015. Within hospitals, there was no correlation between the decline in readmission rates and an uptick in observation stays based on more than 7 million and 45 million index stays for targeted conditions and non-targeted conditions, respectively.

Readmission rates for HRRP’s original target conditions dropped from 21.5% to 17.8%, while non-targeted conditions dropped from 15.3% to 13.1%.

The most rapid drop for targeted and non-targeted conditions occurred shortly after the ACA’s passage, from March 2010 until October 2012, particularly within the six-month window from March through September 2010. Readmission penalties began in October 2012, based on three year’s worth of baseline data.

“Hospitals were reporting readmission rates and CMS was publishing them before the ACA was passed,” says study co-author Steven Sheingold, APSE director of healthcare financing policy. “Hospitals had a good idea a year or two earlier whether they might be in a penalty situation.”

 

Meanwhile, between 2007 and 2015, observation stays for targeted conditions increased from 2.6% to 4.7% and from 2.5% to 4.2% for non-targeted conditions. There was a steady increase across the entire analysis period, with no significant change pre- and post-ACA.

“Readmissions seem to be more related to passage of the Affordable Care Act than observation,” Zuckerman says. Changes in observation rate are likely due to other factors, such as confusion over Medicare recovery audit contractors, the study authors conclude.

Whether the drop in readmission rates without related increase in observation is tied to improved patient health is still unknown, as Dr. Jha explains in his blog, An Ounce of Evidence. He believes it is “flatly incorrect” to assume lower readmission rates mean better patient outcomes “because readmissions are a utilization measure, a measure of integration and accountability, not a patient outcome measure, not a state of health,” he explains.

While the current study does not address this, Zuckerman says her team is interested in understanding whether overall health measures are changing.

“A hospital is not always a bad thing,” Dr. Jha says. “Sometimes they’re just what a patient needs.”

Dr. Sheehy is particularly interested in why, after October 2012, the steep drop in readmissions slowed down. Probably, she says, much of the low hanging fruit was plucked. But it suggests there is still a population of patients facing higher-than-expected readmissions, and researchers would be wise to understand who they are and how they might be better served.

“The next step is looking at people who are still being readmitted,” she says. TH

---

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

References

1. Zuckerman RB, Sheingold SH, Orav EJ, Ruhter J, Epstein AM. Readmissions, observation, and the Hospital Readmissions Reduction Program [published online ahead of print April 21, 2016]. N Engl J Med. doi:10.1056/NEJMsa1513024.
2. Jencks SF, Williams MV, Coleman EA. Rehospitalizations among patients in the Medicare fee-for-service program. N Engl J Med. 2009;360(14):1418-1428.
3. Himmelstein D, Woolhandler S. Quality improvement: ‘become good at cheating and you never need to become good at anything else.’ Available at: http://healthaffairs.org/blog/2015/08/27/quality-improvement-become-good-at-cheating-and-you-never-need-to-become-good-at-anything-else/. Published August 27, 2015. Accessed April 15, 2016.
4. Noel-Miller C, Lind K. Is observation status substituting for hospital readmission? Available at: http://healthaffairs.org/blog/2015/10/28/is-observation-status-substituting-for-hospital-readmission/. Published October 25, 2016. Accessed April 15, 2016.
5. Zuckerman R. Reducing avoidable hospital readmissions to create a better, safer health care system. Available at: http://www.hhs.gov/blog/2016/02/24/reducing-avoidable-hospital-readmissions.html. Published February 24, 2016. Accessed April 15, 2016.

Concern that the Hospital Readmissions Reduction Program (HRRP) has led to more observation stays in an effort by hospitals to avoid readmission penalties can be put to rest.

A study published in late February in the New England Journal of Medicine shows that while readmission rates dropped dramatically with the passage of the Affordable Care Act (ACA) in 2010, this drop was not correlated with an increase in observation services within the nearly 4,000 individual hospitals assessed.1

“I think we were all really happy to see this paper because it’s really well done and it confirms what our gut feeling was as hospitalists—that the readmissions rate falling wasn’t linked to the increase in the use of observation stays,” says Ann Sheehy, MD, MS, FHM, a hospitalist at the University of Wisconsin School of Medicine and Public Health and member of SHM’s Public Policy Committee. “The paper definitively shows that hospitals are not gaming the system to avoid readmission penalties.”

Potentially avoidable hospital readmissions within 30 days of discharge were estimated in 2009 to cost Medicare more than $17 billion annually and are considered a mark of poor-quality care.2 The ACA established HRRP to penalize hospitals with higher-than-expected 30-day readmission rates for several targeted conditions: heart failure, pneumonia, COPD, acute myocardial infarction, total hip and knee replacement, and coronary artery bypass graft surgery.

“Readmission rates had been rock stable for years and years, and coincidentally they came down as observation status rose,” says Ashish Jha, MD, MPH, hospitalist at the VA Boston Healthcare System and professor of health policy at the Harvard T.H. Chan School of Public Health. “The concerning part was that we thought we were making care better by reducing readmissions, but if we were just shifting readmissions to observation, that’s not a change in care pattern—that’s a change in the classification of billing data.”

Earlier data, including an article and an analysis in the Health Affairs blog, also suggested hospitals were trading observation for readmissions, Dr. Jha says.3,4 But the new data have assuaged his concern.

“They did it right,” he says. “Previous studies lumped hospitals together in categories and were not carefully teasing apart what individual hospitals were doing, and when they looked at the individual level, we see no correlation.”

The study’s lead author, Rachael Zuckerman, an economist in the U.S. Department of Health & Human Services (HHS) Office of the Assistant Secretary for Planning and Evaluation (ASPE), writes in a blog post that approximately 565,000 readmissions were likely prevented for the program’s original targeted conditions—heart failure, pneumonia, and acute myocardial infarction—between 2010 and 2015, compared to the readmission rates in the year before passage of the ACA.5

The study examined within-hospital rates of readmission and observation stays among Medicare beneficiaries from October 2007 through May 2015. Within hospitals, there was no correlation between the decline in readmission rates and an uptick in observation stays based on more than 7 million and 45 million index stays for targeted conditions and non-targeted conditions, respectively.

Readmission rates for HRRP’s original target conditions dropped from 21.5% to 17.8%, while non-targeted conditions dropped from 15.3% to 13.1%.

The most rapid drop for targeted and non-targeted conditions occurred shortly after the ACA’s passage, from March 2010 until October 2012, particularly within the six-month window from March through September 2010. Readmission penalties began in October 2012, based on three year’s worth of baseline data.

“Hospitals were reporting readmission rates and CMS was publishing them before the ACA was passed,” says study co-author Steven Sheingold, APSE director of healthcare financing policy. “Hospitals had a good idea a year or two earlier whether they might be in a penalty situation.”

 

Meanwhile, between 2007 and 2015, observation stays for targeted conditions increased from 2.6% to 4.7% and from 2.5% to 4.2% for non-targeted conditions. There was a steady increase across the entire analysis period, with no significant change pre- and post-ACA.

“Readmissions seem to be more related to passage of the Affordable Care Act than observation,” Zuckerman says. Changes in observation rate are likely due to other factors, such as confusion over Medicare recovery audit contractors, the study authors conclude.

Whether the drop in readmission rates without related increase in observation is tied to improved patient health is still unknown, as Dr. Jha explains in his blog, An Ounce of Evidence. He believes it is “flatly incorrect” to assume lower readmission rates mean better patient outcomes “because readmissions are a utilization measure, a measure of integration and accountability, not a patient outcome measure, not a state of health,” he explains.

While the current study does not address this, Zuckerman says her team is interested in understanding whether overall health measures are changing.

“A hospital is not always a bad thing,” Dr. Jha says. “Sometimes they’re just what a patient needs.”

Dr. Sheehy is particularly interested in why, after October 2012, the steep drop in readmissions slowed down. Probably, she says, much of the low hanging fruit was plucked. But it suggests there is still a population of patients facing higher-than-expected readmissions, and researchers would be wise to understand who they are and how they might be better served.

“The next step is looking at people who are still being readmitted,” she says. TH

---

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

References

1. Zuckerman RB, Sheingold SH, Orav EJ, Ruhter J, Epstein AM. Readmissions, observation, and the Hospital Readmissions Reduction Program [published online ahead of print April 21, 2016]. N Engl J Med. doi:10.1056/NEJMsa1513024.
2. Jencks SF, Williams MV, Coleman EA. Rehospitalizations among patients in the Medicare fee-for-service program. N Engl J Med. 2009;360(14):1418-1428.
3. Himmelstein D, Woolhandler S. Quality improvement: ‘become good at cheating and you never need to become good at anything else.’ Available at: http://healthaffairs.org/blog/2015/08/27/quality-improvement-become-good-at-cheating-and-you-never-need-to-become-good-at-anything-else/. Published August 27, 2015. Accessed April 15, 2016.
4. Noel-Miller C, Lind K. Is observation status substituting for hospital readmission? Available at: http://healthaffairs.org/blog/2015/10/28/is-observation-status-substituting-for-hospital-readmission/. Published October 25, 2016. Accessed April 15, 2016.
5. Zuckerman R. Reducing avoidable hospital readmissions to create a better, safer health care system. Available at: http://www.hhs.gov/blog/2016/02/24/reducing-avoidable-hospital-readmissions.html. Published February 24, 2016. Accessed April 15, 2016.

Concern that the Hospital Readmissions Reduction Program (HRRP) has led to more observation stays in an effort by hospitals to avoid readmission penalties can be put to rest.

A study published in late February in the New England Journal of Medicine shows that while readmission rates dropped dramatically with the passage of the Affordable Care Act (ACA) in 2010, this drop was not correlated with an increase in observation services within the nearly 4,000 individual hospitals assessed.1

“I think we were all really happy to see this paper because it’s really well done and it confirms what our gut feeling was as hospitalists—that the readmissions rate falling wasn’t linked to the increase in the use of observation stays,” says Ann Sheehy, MD, MS, FHM, a hospitalist at the University of Wisconsin School of Medicine and Public Health and member of SHM’s Public Policy Committee. “The paper definitively shows that hospitals are not gaming the system to avoid readmission penalties.”

Potentially avoidable hospital readmissions within 30 days of discharge were estimated in 2009 to cost Medicare more than $17 billion annually and are considered a mark of poor-quality care.2 The ACA established HRRP to penalize hospitals with higher-than-expected 30-day readmission rates for several targeted conditions: heart failure, pneumonia, COPD, acute myocardial infarction, total hip and knee replacement, and coronary artery bypass graft surgery.

“Readmission rates had been rock stable for years and years, and coincidentally they came down as observation status rose,” says Ashish Jha, MD, MPH, hospitalist at the VA Boston Healthcare System and professor of health policy at the Harvard T.H. Chan School of Public Health. “The concerning part was that we thought we were making care better by reducing readmissions, but if we were just shifting readmissions to observation, that’s not a change in care pattern—that’s a change in the classification of billing data.”

Earlier data, including an article and an analysis in the Health Affairs blog, also suggested hospitals were trading observation for readmissions, Dr. Jha says.3,4 But the new data have assuaged his concern.

“They did it right,” he says. “Previous studies lumped hospitals together in categories and were not carefully teasing apart what individual hospitals were doing, and when they looked at the individual level, we see no correlation.”

The study’s lead author, Rachael Zuckerman, an economist in the U.S. Department of Health & Human Services (HHS) Office of the Assistant Secretary for Planning and Evaluation (ASPE), writes in a blog post that approximately 565,000 readmissions were likely prevented for the program’s original targeted conditions—heart failure, pneumonia, and acute myocardial infarction—between 2010 and 2015, compared to the readmission rates in the year before passage of the ACA.5

The study examined within-hospital rates of readmission and observation stays among Medicare beneficiaries from October 2007 through May 2015. Within hospitals, there was no correlation between the decline in readmission rates and an uptick in observation stays based on more than 7 million and 45 million index stays for targeted conditions and non-targeted conditions, respectively.

Readmission rates for HRRP’s original target conditions dropped from 21.5% to 17.8%, while non-targeted conditions dropped from 15.3% to 13.1%.

The most rapid drop for targeted and non-targeted conditions occurred shortly after the ACA’s passage, from March 2010 until October 2012, particularly within the six-month window from March through September 2010. Readmission penalties began in October 2012, based on three year’s worth of baseline data.

“Hospitals were reporting readmission rates and CMS was publishing them before the ACA was passed,” says study co-author Steven Sheingold, APSE director of healthcare financing policy. “Hospitals had a good idea a year or two earlier whether they might be in a penalty situation.”

 

Meanwhile, between 2007 and 2015, observation stays for targeted conditions increased from 2.6% to 4.7% and from 2.5% to 4.2% for non-targeted conditions. There was a steady increase across the entire analysis period, with no significant change pre- and post-ACA.

“Readmissions seem to be more related to passage of the Affordable Care Act than observation,” Zuckerman says. Changes in observation rate are likely due to other factors, such as confusion over Medicare recovery audit contractors, the study authors conclude.

Whether the drop in readmission rates without related increase in observation is tied to improved patient health is still unknown, as Dr. Jha explains in his blog, An Ounce of Evidence. He believes it is “flatly incorrect” to assume lower readmission rates mean better patient outcomes “because readmissions are a utilization measure, a measure of integration and accountability, not a patient outcome measure, not a state of health,” he explains.

While the current study does not address this, Zuckerman says her team is interested in understanding whether overall health measures are changing.

“A hospital is not always a bad thing,” Dr. Jha says. “Sometimes they’re just what a patient needs.”

Dr. Sheehy is particularly interested in why, after October 2012, the steep drop in readmissions slowed down. Probably, she says, much of the low hanging fruit was plucked. But it suggests there is still a population of patients facing higher-than-expected readmissions, and researchers would be wise to understand who they are and how they might be better served.

“The next step is looking at people who are still being readmitted,” she says. TH

---

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

References

1. Zuckerman RB, Sheingold SH, Orav EJ, Ruhter J, Epstein AM. Readmissions, observation, and the Hospital Readmissions Reduction Program [published online ahead of print April 21, 2016]. N Engl J Med. doi:10.1056/NEJMsa1513024.
2. Jencks SF, Williams MV, Coleman EA. Rehospitalizations among patients in the Medicare fee-for-service program. N Engl J Med. 2009;360(14):1418-1428.
3. Himmelstein D, Woolhandler S. Quality improvement: ‘become good at cheating and you never need to become good at anything else.’ Available at: http://healthaffairs.org/blog/2015/08/27/quality-improvement-become-good-at-cheating-and-you-never-need-to-become-good-at-anything-else/. Published August 27, 2015. Accessed April 15, 2016.
4. Noel-Miller C, Lind K. Is observation status substituting for hospital readmission? Available at: http://healthaffairs.org/blog/2015/10/28/is-observation-status-substituting-for-hospital-readmission/. Published October 25, 2016. Accessed April 15, 2016.
5. Zuckerman R. Reducing avoidable hospital readmissions to create a better, safer health care system. Available at: http://www.hhs.gov/blog/2016/02/24/reducing-avoidable-hospital-readmissions.html. Published February 24, 2016. Accessed April 15, 2016.

The Centers for Medicare & Medicaid Services (CMS) recently announced that within the year hospitalists will be assigned their own specialty designation code.

Up to 85% of hospitalists are currently designated internal medicine, says Ron Greeno, MD, MHM, founding member of SHM and chair of SHM’s Public Policy Committee, but when it comes to quality metrics—and resulting penalties and bonuses—without a way to distinguish themselves from their clinic-based peers, hospitalists have been disadvantaged.

“It is almost impossible to look good when compared to a world of mostly outpatient physicians,” says Dr. Greeno, chief strategy officer at IPC Healthcare, based in North Hollywood, Calif., and SHM’s president-elect.

Today, hospitalists get lumped together with their office-based internal medicine or primary care counterparts, says Scott Sears, MD, FHM, CPE, MBA, chief clinical officer for Sound Physicians, based in Tacoma, Wash. Yet, he says, “The quality metrics should be different because it’s a different scope of practice.”

For example, with the Physician Quality Reporting System (PQRS) in recent years, hospitalists have been evaluated based on their patients’ HbA1c, a measure of their diabetic control over the three months prior to admission. But diabetic patients admitted to the hospital are there because they are sick and much less likely to have been well-managed.

“Hospitalists have had no control over their patients’ outpatient diabetes management during the time leading up to admissions, yet these admitted patients are compared to those in an outpatient setting, where their physicians do have control,” Dr. Sears says.

“[This] skews the data and real reporting patterns that are part of that specialty,” says Raemarie Jimenez, CPC, vice president of certifications and member development at AAPC, a professional organization for medical coders and more. “CMS wants the data it is using to be meaningful.”

Once the code is established, the choice to identify as a hospitalist will fall to individual physicians, hospitals, or hospitalist groups, Dr. Greeno says. The designation is noteworthy since hospital medicine does not have a board certification. Today, there are more than 48,000 hospitalists in the U.S., and the announcement comes as hospitalists celebrate 20 years as a specialty. SHM is calling 2016 the “Year of the Hospitalist.”

The decision to seek a hospitalist-specific billing code first arose at SHM several years ago, Dr. Greeno says, with discussions about the advantages, disadvantages, and possible unintended consequences of pursuing it. At the time, SHM chose to hold off, but that changed recently.

“A lot of thought was put into it, and two and a half years later, it’s very clear we made the right decision,” he says. “More and more depends on your data and a lot of different value-based measures. … The Public Policy Committee decided the benefits probably outweigh the potential risks.”

The billing code should make it easier to compare apples to apples, both for hospitalists and hospitals, and Dr. Sears says it should also enable patients to compare hospitalist performance to make better-informed healthcare decisions.

“When you have three or four hospitals in your community, you can compare inpatient hospitalist performance to determine who is providing the most consistent high-quality outcomes,” he says.

It may also enhance reimbursement, says Jimenez. Multiple providers often see patients in the hospital and handle their care. Two providers with the same designation may round on a patient on the same day and appear to CMS and private payors to deliver the same services.

“If a specialist is called in, or their family medicine provider is also seeing the patient, they will not be of the same designation, and that might help with some denials of payments that family or internal medicine physicians are getting,” she says.

 

Dr. Greeno also says the code may more effectively demonstrate to CMS that hospitalists do not have enough PQRS metrics to adequately qualify for value-based purchasing.

Yet challenges will remain that a specialty code cannot address. “A pediatric hospitalist may not want to be compared to an adult hospitalist. A critical-access hospitalist doesn’t want to be compared to a hospitalist in a tertiary academic medical center,” Dr. Sears says. “I don’t think it’s an end-all, be-all, but it’s a place to start.”

SHM will continue to actively push CMS to implement the code, Dr. Greeno says, and it will develop strategies for educating members to help them make the decision that is right for them or their group.

Jimenez believes SHM will be capable of doing much more with the data that emerge through robust use of the code.

“Right now, in the industry, big data is it, and the more you can segregate or report on the specifics of data, the better you are at identifying trends,” she says. “We don’t even know yet about clinical outcomes: Are hospitalists’ patients seeing a better outcome of patient experience versus waiting all day to see a family physician? Are there shorter admission times? Trying to improve patient outcomes and reduce costs are two things CMS is desperately interested in.”

---

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

The Centers for Medicare & Medicaid Services (CMS) recently announced that within the year hospitalists will be assigned their own specialty designation code.

Up to 85% of hospitalists are currently designated internal medicine, says Ron Greeno, MD, MHM, founding member of SHM and chair of SHM’s Public Policy Committee, but when it comes to quality metrics—and resulting penalties and bonuses—without a way to distinguish themselves from their clinic-based peers, hospitalists have been disadvantaged.

“It is almost impossible to look good when compared to a world of mostly outpatient physicians,” says Dr. Greeno, chief strategy officer at IPC Healthcare, based in North Hollywood, Calif., and SHM’s president-elect.

Today, hospitalists get lumped together with their office-based internal medicine or primary care counterparts, says Scott Sears, MD, FHM, CPE, MBA, chief clinical officer for Sound Physicians, based in Tacoma, Wash. Yet, he says, “The quality metrics should be different because it’s a different scope of practice.”

For example, with the Physician Quality Reporting System (PQRS) in recent years, hospitalists have been evaluated based on their patients’ HbA1c, a measure of their diabetic control over the three months prior to admission. But diabetic patients admitted to the hospital are there because they are sick and much less likely to have been well-managed.

“Hospitalists have had no control over their patients’ outpatient diabetes management during the time leading up to admissions, yet these admitted patients are compared to those in an outpatient setting, where their physicians do have control,” Dr. Sears says.

“[This] skews the data and real reporting patterns that are part of that specialty,” says Raemarie Jimenez, CPC, vice president of certifications and member development at AAPC, a professional organization for medical coders and more. “CMS wants the data it is using to be meaningful.”

Once the code is established, the choice to identify as a hospitalist will fall to individual physicians, hospitals, or hospitalist groups, Dr. Greeno says. The designation is noteworthy since hospital medicine does not have a board certification. Today, there are more than 48,000 hospitalists in the U.S., and the announcement comes as hospitalists celebrate 20 years as a specialty. SHM is calling 2016 the “Year of the Hospitalist.”

The decision to seek a hospitalist-specific billing code first arose at SHM several years ago, Dr. Greeno says, with discussions about the advantages, disadvantages, and possible unintended consequences of pursuing it. At the time, SHM chose to hold off, but that changed recently.

“A lot of thought was put into it, and two and a half years later, it’s very clear we made the right decision,” he says. “More and more depends on your data and a lot of different value-based measures. … The Public Policy Committee decided the benefits probably outweigh the potential risks.”

The billing code should make it easier to compare apples to apples, both for hospitalists and hospitals, and Dr. Sears says it should also enable patients to compare hospitalist performance to make better-informed healthcare decisions.

“When you have three or four hospitals in your community, you can compare inpatient hospitalist performance to determine who is providing the most consistent high-quality outcomes,” he says.

It may also enhance reimbursement, says Jimenez. Multiple providers often see patients in the hospital and handle their care. Two providers with the same designation may round on a patient on the same day and appear to CMS and private payors to deliver the same services.

“If a specialist is called in, or their family medicine provider is also seeing the patient, they will not be of the same designation, and that might help with some denials of payments that family or internal medicine physicians are getting,” she says.

 

Dr. Greeno also says the code may more effectively demonstrate to CMS that hospitalists do not have enough PQRS metrics to adequately qualify for value-based purchasing.

Yet challenges will remain that a specialty code cannot address. “A pediatric hospitalist may not want to be compared to an adult hospitalist. A critical-access hospitalist doesn’t want to be compared to a hospitalist in a tertiary academic medical center,” Dr. Sears says. “I don’t think it’s an end-all, be-all, but it’s a place to start.”

SHM will continue to actively push CMS to implement the code, Dr. Greeno says, and it will develop strategies for educating members to help them make the decision that is right for them or their group.

Jimenez believes SHM will be capable of doing much more with the data that emerge through robust use of the code.

“Right now, in the industry, big data is it, and the more you can segregate or report on the specifics of data, the better you are at identifying trends,” she says. “We don’t even know yet about clinical outcomes: Are hospitalists’ patients seeing a better outcome of patient experience versus waiting all day to see a family physician? Are there shorter admission times? Trying to improve patient outcomes and reduce costs are two things CMS is desperately interested in.”

---

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

The Centers for Medicare & Medicaid Services (CMS) recently announced that within the year hospitalists will be assigned their own specialty designation code.

Up to 85% of hospitalists are currently designated internal medicine, says Ron Greeno, MD, MHM, founding member of SHM and chair of SHM’s Public Policy Committee, but when it comes to quality metrics—and resulting penalties and bonuses—without a way to distinguish themselves from their clinic-based peers, hospitalists have been disadvantaged.

“It is almost impossible to look good when compared to a world of mostly outpatient physicians,” says Dr. Greeno, chief strategy officer at IPC Healthcare, based in North Hollywood, Calif., and SHM’s president-elect.

Today, hospitalists get lumped together with their office-based internal medicine or primary care counterparts, says Scott Sears, MD, FHM, CPE, MBA, chief clinical officer for Sound Physicians, based in Tacoma, Wash. Yet, he says, “The quality metrics should be different because it’s a different scope of practice.”

For example, with the Physician Quality Reporting System (PQRS) in recent years, hospitalists have been evaluated based on their patients’ HbA1c, a measure of their diabetic control over the three months prior to admission. But diabetic patients admitted to the hospital are there because they are sick and much less likely to have been well-managed.

“Hospitalists have had no control over their patients’ outpatient diabetes management during the time leading up to admissions, yet these admitted patients are compared to those in an outpatient setting, where their physicians do have control,” Dr. Sears says.

“[This] skews the data and real reporting patterns that are part of that specialty,” says Raemarie Jimenez, CPC, vice president of certifications and member development at AAPC, a professional organization for medical coders and more. “CMS wants the data it is using to be meaningful.”

Once the code is established, the choice to identify as a hospitalist will fall to individual physicians, hospitals, or hospitalist groups, Dr. Greeno says. The designation is noteworthy since hospital medicine does not have a board certification. Today, there are more than 48,000 hospitalists in the U.S., and the announcement comes as hospitalists celebrate 20 years as a specialty. SHM is calling 2016 the “Year of the Hospitalist.”

The decision to seek a hospitalist-specific billing code first arose at SHM several years ago, Dr. Greeno says, with discussions about the advantages, disadvantages, and possible unintended consequences of pursuing it. At the time, SHM chose to hold off, but that changed recently.

“A lot of thought was put into it, and two and a half years later, it’s very clear we made the right decision,” he says. “More and more depends on your data and a lot of different value-based measures. … The Public Policy Committee decided the benefits probably outweigh the potential risks.”

The billing code should make it easier to compare apples to apples, both for hospitalists and hospitals, and Dr. Sears says it should also enable patients to compare hospitalist performance to make better-informed healthcare decisions.

“When you have three or four hospitals in your community, you can compare inpatient hospitalist performance to determine who is providing the most consistent high-quality outcomes,” he says.

It may also enhance reimbursement, says Jimenez. Multiple providers often see patients in the hospital and handle their care. Two providers with the same designation may round on a patient on the same day and appear to CMS and private payors to deliver the same services.

“If a specialist is called in, or their family medicine provider is also seeing the patient, they will not be of the same designation, and that might help with some denials of payments that family or internal medicine physicians are getting,” she says.

 

Dr. Greeno also says the code may more effectively demonstrate to CMS that hospitalists do not have enough PQRS metrics to adequately qualify for value-based purchasing.

Yet challenges will remain that a specialty code cannot address. “A pediatric hospitalist may not want to be compared to an adult hospitalist. A critical-access hospitalist doesn’t want to be compared to a hospitalist in a tertiary academic medical center,” Dr. Sears says. “I don’t think it’s an end-all, be-all, but it’s a place to start.”

SHM will continue to actively push CMS to implement the code, Dr. Greeno says, and it will develop strategies for educating members to help them make the decision that is right for them or their group.

Jimenez believes SHM will be capable of doing much more with the data that emerge through robust use of the code.

“Right now, in the industry, big data is it, and the more you can segregate or report on the specifics of data, the better you are at identifying trends,” she says. “We don’t even know yet about clinical outcomes: Are hospitalists’ patients seeing a better outcome of patient experience versus waiting all day to see a family physician? Are there shorter admission times? Trying to improve patient outcomes and reduce costs are two things CMS is desperately interested in.”

---

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

When Houston Methodist Hospital noticed patients in one particular zip code were failing to make it to follow-up appointments after hospital discharge, they looked into it.

“We found it wasn’t on a bus route,” says Janice Finder, RN, MSN, director of the hospital’s Transitions in Care program and a part of SHM’s Project BOOST, which focuses on successful discharge outcomes. So in collaboration with the Texas Department of Aging and Disability Services, the hospital provided cab vouchers for these patients to travel to and from appointments.

The hospital also realized that to improve the chances its large Hispanic diabetic population remained healthy, it would need to tailor its disease management efforts to their culture, particularly when it came to diet.

“Their eating habits are very different, and we want to ensure they have meals based on what they actually eat,” Finder says.

These are exactly the kinds of approaches a new guide developed for the Centers for Medicare & Medicaid Services (CMS) by the Disparities Solutions Center (DSC), based at Massachusetts General Hospital (MGH) in Boston, is looking to promote in an effort to reduce unnecessary hospital readmissions.1 CMS recently made the Guide to Preventing Readmissions among Racially and Ethnically Diverse Medicare Beneficiaries available on its website.

“We know readmissions is an issue for diverse populations, that they are more likely than their white counterparts to be admitted within 30 days of discharge,” says Aswita Tan-McGrory, MBA, MSPH, deputy director of DSC within the Mongan Institute for Health Policy at MGH. “So there was a good business case for creating this guide.”

Keys to Success

Within the guide is a collection of evidence-based information, case studies, and seven recommendations the DSC team assembled to assist hospital leaders looking to reduce readmissions among some of the nation’s highest-risk populations.

While Tan-McGrory acknowledges it may be impractical for hospitals to adopt each recommendation, she says they can pick and choose which they can most effectively adopt.

“We put together these seven steps and looked for who does this really well, and the honest truth is not very many are,” she says. “It’s a complicated process, but it’s some guidance because there really wasn’t anything out there.”

Included in the recommendations: Create a “strong radar” (engage in robust data collection), identify root causes, begin to think about discharge at admission, deploy a team, consider systems and social determinants, focus on culturally competent communication, and foster community partnerships.

“It’s not just medication reconciliation or discharge instructions in a different language,” Tan-McGrory says. “What happens when a patient gets home?”

These types of questions are important because CMS now penalizes hospitals for what it deems excessive avoidable readmissions within 30 days of discharge. In 2016, hospitals can lose up to 3% of their Medicare payments under the Hospital Readmissions Reduction Program.

In 2014, nearly 18% of Medicare patients were admitted within a month of discharge at a cost of $26 billion.2 According to the new guide, Agency for Healthcare Research and Quality data indicate African-American and Hispanic patients make up a higher share of these readmissions, in part because they are disproportionately affected by chronic high-readmission-risk diseases like congestive heart failure.

Social Determinants

Though it’s challenging for healthcare providers, one way to reduce readmissions is to address the social determinants of health, Tan-McGrory says.

“Hospitals have felt in the past that it’s not their domain, but their patients are coming back,” she says. “How do you address people’s isolation at home? How can you send them from the hospital when no one is there to follow up or take care of them?”

 

The answers may lie in part on building community partnerships, something in which Finder’s hospital has successfully engaged. For example, the hospital has teamed with its local United Way to work with Asian patients on issues related to pain management and palliative care.

At Berkshire Medical Center, a 300-bed community teaching hospital in western Massachusetts, electronic health software helps staff flag patients at admission for potential readmission risks. Looking briefly at the new guide, William DeMarco, DO, SFHM, chief of hospital medicine (and also part of Project BOOST), noticed several new areas they may be able to incorporate into the system.

But adequate data collection and interpretation to help understand these disparities is not always possible, particularly for readmissions, Dr. DeMarco says.

However, as in one of the case studies examined in the DCS guide, Berkshire recently began to identify its high utilizers, pairing multidisciplinary teams with individual primary care providers in order to help meet these patients’ needs.

“It can take several hours for one patient, coordinating and getting a lot of people together,” Dr. DeMarco says. “It’s the only way to accomplish that goal, but it’s very resource intensive.”

Although hospitals traditionally focus on what they can do within their four walls, providers are becoming increasingly aware that the social determinants of health—like transportation, dietary choices, and language barriers—deeply impact some racial and ethnically diverse populations. Now, CMS thinks it’s worth paying closer attention. TH

---

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

References

1. Betancourt JR, Tan-McGrory A, Kenst KS. Guide to preventing readmissions among racially and ethnically diverse medicare beneficiaries. Prepared by the Disparities Solutions Center, Mongan Institute for Health Policy at Massachusetts General Hospital. Baltimore, MD: Centers for Medicare & Medicaid Services Office of Minority Health; September 2015.
2. Rau J. Medicare fines 2,610 hospitals in third round of readmission penalties. Kaiser Health News. Available at: http://kaiserhealthnews.org/news/medicare-readmissions-penalties-2015/. Accessed February 15, 2016.

When Houston Methodist Hospital noticed patients in one particular zip code were failing to make it to follow-up appointments after hospital discharge, they looked into it.

“We found it wasn’t on a bus route,” says Janice Finder, RN, MSN, director of the hospital’s Transitions in Care program and a part of SHM’s Project BOOST, which focuses on successful discharge outcomes. So in collaboration with the Texas Department of Aging and Disability Services, the hospital provided cab vouchers for these patients to travel to and from appointments.

The hospital also realized that to improve the chances its large Hispanic diabetic population remained healthy, it would need to tailor its disease management efforts to their culture, particularly when it came to diet.

“Their eating habits are very different, and we want to ensure they have meals based on what they actually eat,” Finder says.

These are exactly the kinds of approaches a new guide developed for the Centers for Medicare & Medicaid Services (CMS) by the Disparities Solutions Center (DSC), based at Massachusetts General Hospital (MGH) in Boston, is looking to promote in an effort to reduce unnecessary hospital readmissions.1 CMS recently made the Guide to Preventing Readmissions among Racially and Ethnically Diverse Medicare Beneficiaries available on its website.

“We know readmissions is an issue for diverse populations, that they are more likely than their white counterparts to be admitted within 30 days of discharge,” says Aswita Tan-McGrory, MBA, MSPH, deputy director of DSC within the Mongan Institute for Health Policy at MGH. “So there was a good business case for creating this guide.”

Keys to Success

Within the guide is a collection of evidence-based information, case studies, and seven recommendations the DSC team assembled to assist hospital leaders looking to reduce readmissions among some of the nation’s highest-risk populations.

While Tan-McGrory acknowledges it may be impractical for hospitals to adopt each recommendation, she says they can pick and choose which they can most effectively adopt.

“We put together these seven steps and looked for who does this really well, and the honest truth is not very many are,” she says. “It’s a complicated process, but it’s some guidance because there really wasn’t anything out there.”

Included in the recommendations: Create a “strong radar” (engage in robust data collection), identify root causes, begin to think about discharge at admission, deploy a team, consider systems and social determinants, focus on culturally competent communication, and foster community partnerships.

“It’s not just medication reconciliation or discharge instructions in a different language,” Tan-McGrory says. “What happens when a patient gets home?”

These types of questions are important because CMS now penalizes hospitals for what it deems excessive avoidable readmissions within 30 days of discharge. In 2016, hospitals can lose up to 3% of their Medicare payments under the Hospital Readmissions Reduction Program.

In 2014, nearly 18% of Medicare patients were admitted within a month of discharge at a cost of $26 billion.2 According to the new guide, Agency for Healthcare Research and Quality data indicate African-American and Hispanic patients make up a higher share of these readmissions, in part because they are disproportionately affected by chronic high-readmission-risk diseases like congestive heart failure.

Social Determinants

Though it’s challenging for healthcare providers, one way to reduce readmissions is to address the social determinants of health, Tan-McGrory says.

“Hospitals have felt in the past that it’s not their domain, but their patients are coming back,” she says. “How do you address people’s isolation at home? How can you send them from the hospital when no one is there to follow up or take care of them?”

 

The answers may lie in part on building community partnerships, something in which Finder’s hospital has successfully engaged. For example, the hospital has teamed with its local United Way to work with Asian patients on issues related to pain management and palliative care.

At Berkshire Medical Center, a 300-bed community teaching hospital in western Massachusetts, electronic health software helps staff flag patients at admission for potential readmission risks. Looking briefly at the new guide, William DeMarco, DO, SFHM, chief of hospital medicine (and also part of Project BOOST), noticed several new areas they may be able to incorporate into the system.

But adequate data collection and interpretation to help understand these disparities is not always possible, particularly for readmissions, Dr. DeMarco says.

However, as in one of the case studies examined in the DCS guide, Berkshire recently began to identify its high utilizers, pairing multidisciplinary teams with individual primary care providers in order to help meet these patients’ needs.

“It can take several hours for one patient, coordinating and getting a lot of people together,” Dr. DeMarco says. “It’s the only way to accomplish that goal, but it’s very resource intensive.”

Although hospitals traditionally focus on what they can do within their four walls, providers are becoming increasingly aware that the social determinants of health—like transportation, dietary choices, and language barriers—deeply impact some racial and ethnically diverse populations. Now, CMS thinks it’s worth paying closer attention. TH

---

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

References

1. Betancourt JR, Tan-McGrory A, Kenst KS. Guide to preventing readmissions among racially and ethnically diverse medicare beneficiaries. Prepared by the Disparities Solutions Center, Mongan Institute for Health Policy at Massachusetts General Hospital. Baltimore, MD: Centers for Medicare & Medicaid Services Office of Minority Health; September 2015.
2. Rau J. Medicare fines 2,610 hospitals in third round of readmission penalties. Kaiser Health News. Available at: http://kaiserhealthnews.org/news/medicare-readmissions-penalties-2015/. Accessed February 15, 2016.

When Houston Methodist Hospital noticed patients in one particular zip code were failing to make it to follow-up appointments after hospital discharge, they looked into it.

“We found it wasn’t on a bus route,” says Janice Finder, RN, MSN, director of the hospital’s Transitions in Care program and a part of SHM’s Project BOOST, which focuses on successful discharge outcomes. So in collaboration with the Texas Department of Aging and Disability Services, the hospital provided cab vouchers for these patients to travel to and from appointments.

The hospital also realized that to improve the chances its large Hispanic diabetic population remained healthy, it would need to tailor its disease management efforts to their culture, particularly when it came to diet.

“Their eating habits are very different, and we want to ensure they have meals based on what they actually eat,” Finder says.

These are exactly the kinds of approaches a new guide developed for the Centers for Medicare & Medicaid Services (CMS) by the Disparities Solutions Center (DSC), based at Massachusetts General Hospital (MGH) in Boston, is looking to promote in an effort to reduce unnecessary hospital readmissions.1 CMS recently made the Guide to Preventing Readmissions among Racially and Ethnically Diverse Medicare Beneficiaries available on its website.

“We know readmissions is an issue for diverse populations, that they are more likely than their white counterparts to be admitted within 30 days of discharge,” says Aswita Tan-McGrory, MBA, MSPH, deputy director of DSC within the Mongan Institute for Health Policy at MGH. “So there was a good business case for creating this guide.”

Keys to Success

Within the guide is a collection of evidence-based information, case studies, and seven recommendations the DSC team assembled to assist hospital leaders looking to reduce readmissions among some of the nation’s highest-risk populations.

While Tan-McGrory acknowledges it may be impractical for hospitals to adopt each recommendation, she says they can pick and choose which they can most effectively adopt.

“We put together these seven steps and looked for who does this really well, and the honest truth is not very many are,” she says. “It’s a complicated process, but it’s some guidance because there really wasn’t anything out there.”

Included in the recommendations: Create a “strong radar” (engage in robust data collection), identify root causes, begin to think about discharge at admission, deploy a team, consider systems and social determinants, focus on culturally competent communication, and foster community partnerships.

“It’s not just medication reconciliation or discharge instructions in a different language,” Tan-McGrory says. “What happens when a patient gets home?”

These types of questions are important because CMS now penalizes hospitals for what it deems excessive avoidable readmissions within 30 days of discharge. In 2016, hospitals can lose up to 3% of their Medicare payments under the Hospital Readmissions Reduction Program.

In 2014, nearly 18% of Medicare patients were admitted within a month of discharge at a cost of $26 billion.2 According to the new guide, Agency for Healthcare Research and Quality data indicate African-American and Hispanic patients make up a higher share of these readmissions, in part because they are disproportionately affected by chronic high-readmission-risk diseases like congestive heart failure.

Social Determinants

Though it’s challenging for healthcare providers, one way to reduce readmissions is to address the social determinants of health, Tan-McGrory says.

“Hospitals have felt in the past that it’s not their domain, but their patients are coming back,” she says. “How do you address people’s isolation at home? How can you send them from the hospital when no one is there to follow up or take care of them?”

 

The answers may lie in part on building community partnerships, something in which Finder’s hospital has successfully engaged. For example, the hospital has teamed with its local United Way to work with Asian patients on issues related to pain management and palliative care.

At Berkshire Medical Center, a 300-bed community teaching hospital in western Massachusetts, electronic health software helps staff flag patients at admission for potential readmission risks. Looking briefly at the new guide, William DeMarco, DO, SFHM, chief of hospital medicine (and also part of Project BOOST), noticed several new areas they may be able to incorporate into the system.

But adequate data collection and interpretation to help understand these disparities is not always possible, particularly for readmissions, Dr. DeMarco says.

However, as in one of the case studies examined in the DCS guide, Berkshire recently began to identify its high utilizers, pairing multidisciplinary teams with individual primary care providers in order to help meet these patients’ needs.

“It can take several hours for one patient, coordinating and getting a lot of people together,” Dr. DeMarco says. “It’s the only way to accomplish that goal, but it’s very resource intensive.”

Although hospitals traditionally focus on what they can do within their four walls, providers are becoming increasingly aware that the social determinants of health—like transportation, dietary choices, and language barriers—deeply impact some racial and ethnically diverse populations. Now, CMS thinks it’s worth paying closer attention. TH

---

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

References

1. Betancourt JR, Tan-McGrory A, Kenst KS. Guide to preventing readmissions among racially and ethnically diverse medicare beneficiaries. Prepared by the Disparities Solutions Center, Mongan Institute for Health Policy at Massachusetts General Hospital. Baltimore, MD: Centers for Medicare & Medicaid Services Office of Minority Health; September 2015.
2. Rau J. Medicare fines 2,610 hospitals in third round of readmission penalties. Kaiser Health News. Available at: http://kaiserhealthnews.org/news/medicare-readmissions-penalties-2015/. Accessed February 15, 2016.