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Kelly April Tyrrell writes about health, science and health policy. She lives in Madison, Wisconsin, where she is usually running, riding her bike, rock climbing or cross-country skiing. Follow her @kellyperil.
Benefits of Medicaid Expansion for Hospitalists
By January 2016, 31 states and the District of Columbia had embraced the Medicaid expansion brought to bear by the Affordable Care Act. Three states had not expanded but were “in active discussion,” while 16 states continued to opt out.1
The impacts of those decisions—on hospitals, on patients, and on physicians—are now beginning to be emerge. Several early studies, published toward the end of 2015 and in early 2016, show how the choice to expand or not expand impacted payor mix, patient access to quality healthcare, and physician reimbursement.
A study published in Health Affairs found states that expanded Medicaid in 2014, including Minnesota, Kentucky, and Arizona, saw a dramatic decrease in uninsured hospital stays and a significant increase in Medicaid stays. In six states that did not expand that year, including Florida, Georgia, and Missouri, there was no significant change in payor mix.2
“What a lot of these early studies are saying is that when you expand Medicaid, people get on Medicaid, and that’s exactly what you hope will happen when you do a major public coverage expansion,” says study lead author Sayeh Nikpay, PhD, MPH, assistant professor of health policy at Vanderbilt University School of Medicine in Nashville, Tenn. “Physicians are grappling with payment issues, and it should be quite a relief that people are coming in the door with some kind of insurance rather than uninsured.”
Instant Impact
Dr. Nikpay and the research team at the University of Michigan Institute for Healthcare Policy & Innovation (where she was previously a postdoctoral researcher) utilized a free online tool, HCUP Fast Stats (Healthcare Cost and Utilization Project), from the Agency for Healthcare Research and Quality. They examined adult discharges by quarter in 2013 and 2014 in each state in the study, controlling for demographic and economic characteristics.
Expansion states, the team learned, experienced a seven percentage point rise in Medicaid shares and a six percentage point drop in uninsured shares, reflecting a respective 20% increase in Medicaid discharges and 50% decrease in uninsured discharges. The effect was particularly profound in Kentucky, which saw a 13.5% drop in uninsured shares.
This underscores the “significant benefits of Medicaid expansion for low-income adults and for the hospitals that serve them,” the study authors concluded.
With positive data from this study and others—and the federal government willing to work with states on alternative expansion models, like in Arkansas, which is using Medicaid dollars to subsidize private insurance for recipients—Colleen M. Grogan, professor in the School of Social Service Administration at The University of Chicago, says the remaining states may feel more pressure to expand.
They are “getting pressure from hospitals and the business sector,” Grogan says. “It has an enormous impact on the economy. I don’t think any state is exempt from economic impact when they give up an infusion of federal funds.”
The federal government currently pays 100% of state Medicaid costs for the newly eligible upon expansion, eventually dropping to 90% by 2020.
A January 2016 Health Affairs study from researchers at Harvard University and Brigham and Women’s Hospital in Boston showed that traditional expansion in Kentucky and the “private option” expansion adopted in Arkansas both led to a decrease in the number of uninsured patients, an increase in access to healthcare, and fewer patients skipping medications or experiencing trouble paying medical bills between 2013 and expansion in 2014. This contrasted with the results in Texas, which has not expanded.3
Hospitalist Concerns
Patrick Cawley, MD, MBA, MHM, is CEO of the Medical University of South Carolina, previously practiced as a hospitalist, and is a past president of the Society of Hospital Medicine. For now, South Carolina is, like Texas, a non-expansion state. Dr. Cawley is concerned for the future of his hospital, an 800-bed academic, tertiary, safety-net hospital in Charleston, because payments to hospitals like his ultimately will drop.
Before a Supreme Court decision that ruled states were not compelled to expand Medicaid, the Affordable Care Act provided for a reduction in payments to safety-net hospitals. This was motivated by the notion that all hospitals would see a significant decrease in uncompensated care. The reduction has been delayed but is still scheduled to start in 2017.
“We couldn’t survive if disproportionate share goes away and something didn’t replace it, like Medicaid expansion,” Dr. Cawley says. But, he adds, over time he expects all or nearly all states will expand.
“When Medicaid first rolled out, it took 10 to 12 years before all states took it. I think expansion is the same way,” he says. “It’s one of those things that probably does work out, but what’s the transition going to be like, and how long is that transition going to last?” TH
Kelly April Tyrrell is a freelance writer in Madison, Wis.
References
- Status of state action on the Medicaid expansion decision. Kaiser Family Foundation website. http://kff.org/health-reform/state-indicator/state-activity-around-expanding-medicaid-under-the-affordable-care-act/. Updated January 12, 2016. Accessed January 14, 2016.
- Nikpay S, Buchmueller T, Levy HG. Affordable Care Act Medicaid expansion reduced uninsured hospital stays in 2014. Health Aff. 2016;35(1):106-110. doi:10.1377/hlthaff.2015.1144.
- Sommers BD, Blendon RJ, Orav EJ. Both the ‘private option’ and traditional Medicaid expansions improved access to care for low-income adults. Health Aff. 2016;35(1):96-105. doi:10.1377/hlthaff.2015.0917.
- Jones CD, Scott SJ, Anoff DL, Pierce RG, Glasheen JJ. Changes in payer mix and physician reimbursement after the Affordable Care Act and Medicaid expansion. Inquiry. 2015;52. doi:10.1177/0046958015602464.
Good News for Hospitalists
An additional 2015 study published by researchers at the University of Colorado Hospital found that Medicaid reimbursement to hospitalists per patient encounter rose 4.2% at the hospital in 2014 upon the state’s Medicaid expansion in January of that year. Medicaid encounters also increased, while uninsured encounters decreased.4
By January 2016, 31 states and the District of Columbia had embraced the Medicaid expansion brought to bear by the Affordable Care Act. Three states had not expanded but were “in active discussion,” while 16 states continued to opt out.1
The impacts of those decisions—on hospitals, on patients, and on physicians—are now beginning to be emerge. Several early studies, published toward the end of 2015 and in early 2016, show how the choice to expand or not expand impacted payor mix, patient access to quality healthcare, and physician reimbursement.
A study published in Health Affairs found states that expanded Medicaid in 2014, including Minnesota, Kentucky, and Arizona, saw a dramatic decrease in uninsured hospital stays and a significant increase in Medicaid stays. In six states that did not expand that year, including Florida, Georgia, and Missouri, there was no significant change in payor mix.2
“What a lot of these early studies are saying is that when you expand Medicaid, people get on Medicaid, and that’s exactly what you hope will happen when you do a major public coverage expansion,” says study lead author Sayeh Nikpay, PhD, MPH, assistant professor of health policy at Vanderbilt University School of Medicine in Nashville, Tenn. “Physicians are grappling with payment issues, and it should be quite a relief that people are coming in the door with some kind of insurance rather than uninsured.”
Instant Impact
Dr. Nikpay and the research team at the University of Michigan Institute for Healthcare Policy & Innovation (where she was previously a postdoctoral researcher) utilized a free online tool, HCUP Fast Stats (Healthcare Cost and Utilization Project), from the Agency for Healthcare Research and Quality. They examined adult discharges by quarter in 2013 and 2014 in each state in the study, controlling for demographic and economic characteristics.
Expansion states, the team learned, experienced a seven percentage point rise in Medicaid shares and a six percentage point drop in uninsured shares, reflecting a respective 20% increase in Medicaid discharges and 50% decrease in uninsured discharges. The effect was particularly profound in Kentucky, which saw a 13.5% drop in uninsured shares.
This underscores the “significant benefits of Medicaid expansion for low-income adults and for the hospitals that serve them,” the study authors concluded.
With positive data from this study and others—and the federal government willing to work with states on alternative expansion models, like in Arkansas, which is using Medicaid dollars to subsidize private insurance for recipients—Colleen M. Grogan, professor in the School of Social Service Administration at The University of Chicago, says the remaining states may feel more pressure to expand.
They are “getting pressure from hospitals and the business sector,” Grogan says. “It has an enormous impact on the economy. I don’t think any state is exempt from economic impact when they give up an infusion of federal funds.”
The federal government currently pays 100% of state Medicaid costs for the newly eligible upon expansion, eventually dropping to 90% by 2020.
A January 2016 Health Affairs study from researchers at Harvard University and Brigham and Women’s Hospital in Boston showed that traditional expansion in Kentucky and the “private option” expansion adopted in Arkansas both led to a decrease in the number of uninsured patients, an increase in access to healthcare, and fewer patients skipping medications or experiencing trouble paying medical bills between 2013 and expansion in 2014. This contrasted with the results in Texas, which has not expanded.3
Hospitalist Concerns
Patrick Cawley, MD, MBA, MHM, is CEO of the Medical University of South Carolina, previously practiced as a hospitalist, and is a past president of the Society of Hospital Medicine. For now, South Carolina is, like Texas, a non-expansion state. Dr. Cawley is concerned for the future of his hospital, an 800-bed academic, tertiary, safety-net hospital in Charleston, because payments to hospitals like his ultimately will drop.
Before a Supreme Court decision that ruled states were not compelled to expand Medicaid, the Affordable Care Act provided for a reduction in payments to safety-net hospitals. This was motivated by the notion that all hospitals would see a significant decrease in uncompensated care. The reduction has been delayed but is still scheduled to start in 2017.
“We couldn’t survive if disproportionate share goes away and something didn’t replace it, like Medicaid expansion,” Dr. Cawley says. But, he adds, over time he expects all or nearly all states will expand.
“When Medicaid first rolled out, it took 10 to 12 years before all states took it. I think expansion is the same way,” he says. “It’s one of those things that probably does work out, but what’s the transition going to be like, and how long is that transition going to last?” TH
Kelly April Tyrrell is a freelance writer in Madison, Wis.
References
- Status of state action on the Medicaid expansion decision. Kaiser Family Foundation website. http://kff.org/health-reform/state-indicator/state-activity-around-expanding-medicaid-under-the-affordable-care-act/. Updated January 12, 2016. Accessed January 14, 2016.
- Nikpay S, Buchmueller T, Levy HG. Affordable Care Act Medicaid expansion reduced uninsured hospital stays in 2014. Health Aff. 2016;35(1):106-110. doi:10.1377/hlthaff.2015.1144.
- Sommers BD, Blendon RJ, Orav EJ. Both the ‘private option’ and traditional Medicaid expansions improved access to care for low-income adults. Health Aff. 2016;35(1):96-105. doi:10.1377/hlthaff.2015.0917.
- Jones CD, Scott SJ, Anoff DL, Pierce RG, Glasheen JJ. Changes in payer mix and physician reimbursement after the Affordable Care Act and Medicaid expansion. Inquiry. 2015;52. doi:10.1177/0046958015602464.
Good News for Hospitalists
An additional 2015 study published by researchers at the University of Colorado Hospital found that Medicaid reimbursement to hospitalists per patient encounter rose 4.2% at the hospital in 2014 upon the state’s Medicaid expansion in January of that year. Medicaid encounters also increased, while uninsured encounters decreased.4
By January 2016, 31 states and the District of Columbia had embraced the Medicaid expansion brought to bear by the Affordable Care Act. Three states had not expanded but were “in active discussion,” while 16 states continued to opt out.1
The impacts of those decisions—on hospitals, on patients, and on physicians—are now beginning to be emerge. Several early studies, published toward the end of 2015 and in early 2016, show how the choice to expand or not expand impacted payor mix, patient access to quality healthcare, and physician reimbursement.
A study published in Health Affairs found states that expanded Medicaid in 2014, including Minnesota, Kentucky, and Arizona, saw a dramatic decrease in uninsured hospital stays and a significant increase in Medicaid stays. In six states that did not expand that year, including Florida, Georgia, and Missouri, there was no significant change in payor mix.2
“What a lot of these early studies are saying is that when you expand Medicaid, people get on Medicaid, and that’s exactly what you hope will happen when you do a major public coverage expansion,” says study lead author Sayeh Nikpay, PhD, MPH, assistant professor of health policy at Vanderbilt University School of Medicine in Nashville, Tenn. “Physicians are grappling with payment issues, and it should be quite a relief that people are coming in the door with some kind of insurance rather than uninsured.”
Instant Impact
Dr. Nikpay and the research team at the University of Michigan Institute for Healthcare Policy & Innovation (where she was previously a postdoctoral researcher) utilized a free online tool, HCUP Fast Stats (Healthcare Cost and Utilization Project), from the Agency for Healthcare Research and Quality. They examined adult discharges by quarter in 2013 and 2014 in each state in the study, controlling for demographic and economic characteristics.
Expansion states, the team learned, experienced a seven percentage point rise in Medicaid shares and a six percentage point drop in uninsured shares, reflecting a respective 20% increase in Medicaid discharges and 50% decrease in uninsured discharges. The effect was particularly profound in Kentucky, which saw a 13.5% drop in uninsured shares.
This underscores the “significant benefits of Medicaid expansion for low-income adults and for the hospitals that serve them,” the study authors concluded.
With positive data from this study and others—and the federal government willing to work with states on alternative expansion models, like in Arkansas, which is using Medicaid dollars to subsidize private insurance for recipients—Colleen M. Grogan, professor in the School of Social Service Administration at The University of Chicago, says the remaining states may feel more pressure to expand.
They are “getting pressure from hospitals and the business sector,” Grogan says. “It has an enormous impact on the economy. I don’t think any state is exempt from economic impact when they give up an infusion of federal funds.”
The federal government currently pays 100% of state Medicaid costs for the newly eligible upon expansion, eventually dropping to 90% by 2020.
A January 2016 Health Affairs study from researchers at Harvard University and Brigham and Women’s Hospital in Boston showed that traditional expansion in Kentucky and the “private option” expansion adopted in Arkansas both led to a decrease in the number of uninsured patients, an increase in access to healthcare, and fewer patients skipping medications or experiencing trouble paying medical bills between 2013 and expansion in 2014. This contrasted with the results in Texas, which has not expanded.3
Hospitalist Concerns
Patrick Cawley, MD, MBA, MHM, is CEO of the Medical University of South Carolina, previously practiced as a hospitalist, and is a past president of the Society of Hospital Medicine. For now, South Carolina is, like Texas, a non-expansion state. Dr. Cawley is concerned for the future of his hospital, an 800-bed academic, tertiary, safety-net hospital in Charleston, because payments to hospitals like his ultimately will drop.
Before a Supreme Court decision that ruled states were not compelled to expand Medicaid, the Affordable Care Act provided for a reduction in payments to safety-net hospitals. This was motivated by the notion that all hospitals would see a significant decrease in uncompensated care. The reduction has been delayed but is still scheduled to start in 2017.
“We couldn’t survive if disproportionate share goes away and something didn’t replace it, like Medicaid expansion,” Dr. Cawley says. But, he adds, over time he expects all or nearly all states will expand.
“When Medicaid first rolled out, it took 10 to 12 years before all states took it. I think expansion is the same way,” he says. “It’s one of those things that probably does work out, but what’s the transition going to be like, and how long is that transition going to last?” TH
Kelly April Tyrrell is a freelance writer in Madison, Wis.
References
- Status of state action on the Medicaid expansion decision. Kaiser Family Foundation website. http://kff.org/health-reform/state-indicator/state-activity-around-expanding-medicaid-under-the-affordable-care-act/. Updated January 12, 2016. Accessed January 14, 2016.
- Nikpay S, Buchmueller T, Levy HG. Affordable Care Act Medicaid expansion reduced uninsured hospital stays in 2014. Health Aff. 2016;35(1):106-110. doi:10.1377/hlthaff.2015.1144.
- Sommers BD, Blendon RJ, Orav EJ. Both the ‘private option’ and traditional Medicaid expansions improved access to care for low-income adults. Health Aff. 2016;35(1):96-105. doi:10.1377/hlthaff.2015.0917.
- Jones CD, Scott SJ, Anoff DL, Pierce RG, Glasheen JJ. Changes in payer mix and physician reimbursement after the Affordable Care Act and Medicaid expansion. Inquiry. 2015;52. doi:10.1177/0046958015602464.
Good News for Hospitalists
An additional 2015 study published by researchers at the University of Colorado Hospital found that Medicaid reimbursement to hospitalists per patient encounter rose 4.2% at the hospital in 2014 upon the state’s Medicaid expansion in January of that year. Medicaid encounters also increased, while uninsured encounters decreased.4
LISTEN NOW: Harvard Health Policy Professor Robert Blendon Discusses Democratic Presidential Candidate Stances
Listen to more of our interview with Robert Blendon, professor of health policy and political analysis at the Harvard T.H. Chan School of Public Health and Harvard Kennedy School of Government.
Listen to more of our interview with Robert Blendon, professor of health policy and political analysis at the Harvard T.H. Chan School of Public Health and Harvard Kennedy School of Government.
Listen to more of our interview with Robert Blendon, professor of health policy and political analysis at the Harvard T.H. Chan School of Public Health and Harvard Kennedy School of Government.
A Look at Democratic Presidential Hopefuls’ Healthcare Ideas
Unlike the crowded Republican primary field heading into this year’s presidential election, just three candidates seek the Democratic nomination: former First Lady and former New York Sen. Hillary Clinton, former Maryland Gov. Martin O’Malley, and U.S. Sen. Bernie Sanders of Vermont.
Although they share numerous ideas, the candidates also differ fundamentally in how they believe the American healthcare system should be run. And they stand in stark contrast to their Republican opponents.
“There really is a philosophical difference between the parties,” says Robert Blendon, professor of health policy and political analysis at the Harvard T.H. Chan School of Public Health and Harvard Kennedy School of Government. “Republicans really feel that if people themselves controlled more of the financial wherewithal, they would shop more and ask more questions.”
Democrats, however, “tend to believe that when people are ill, they are not in particularly good shape to shop,” Blendon says. Nor are they particularly fit to decide what costs are worth incurring or what procedures they may or may not need, he adds.
Listen to more of our interview with Dr. Blendon.
In general, Democrats believe the healthcare system should provide patients structure to make appropriate choices. They do not support reliance on high-deductible health plans and health savings accounts to lower healthcare costs.
“This is why the outcome of the election will matter,” Blendon says, “because it’s a very different view of what the future should look like.”
In 1993, as First Lady, Clinton undertook a failed but massive healthcare reform effort that would have created a universal healthcare system based on private insurance. Today, she supports the Affordable Care Act and says she will continue to build upon and support it, which includes making changes to the law such as repealing the Cadillac tax and further lowering out-of-pocket healthcare costs for most Americans.
Clinton’s view “is that many people have too large deductibles and copays, and for moderate-income people, it’s really deterring care,” Blendon says. “She’s likely to try to see if they can actually increase the government subsidies so the plans offer a wider range of benefits.”
Bradley Flansbaum, DO, MPH, MHM, hospitalist and SHM Public Policy Committee member, says changes must be made.
“We can’t say the direction we’re moving in is the right direction,” he says. “There is a desperate sense in America that what we have been doing is wrong and we need to change … whether the experiments now lead to a system more Americans would prefer remains to be seen.”
Sanders believes in a much bolder shift in direction. He does not think the Affordable Care Act goes far enough and wants to move to a single-payor system.
“I want to end the international embarrassment of the United States of America being the only major country on Earth that doesn’t guarantee healthcare to all people as a right, not a privilege,” he said at the second Democratic debate on Nov. 14, 2015.
However, his vision is unlikely to come to quick fruition if elected, Blendon says. “There’s not going to be—anywhere in the short term—the votes in the U.S. Congress to move in that direction.
“But it would change the level of discussion.”
O’Malley, on the other hand, wants to expand the ACA and envisions an “all-payor system” like that in Maryland, where the state sets medical costs and caps what hospitals can charge. He has vowed to continue to move away from a fee-for-service healthcare system and has said that reform should “eliminate the profit motive” for hospitals CEOs to keep beds filled.
“Regardless of who is elected, I would like to believe they would build off of what already exists,” says Joshua Lenchus, DO, RPh, SFHM, a member of SHM’s Public Policy Committee and a hospitalist at the University of Miami Jackson Memorial Hospital. “The populace doesn’t have the stomach for going through healthcare reform again.”
One of the biggest issues to emerge in the Democratic primaries is drugs: the pricing set by and regulations governing the pharmaceutical industry. Sanders wants to see a higher level of transparency, Clinton wants to require companies receiving federal support to invest in research, and both want to see the skyrocketing costs of prescription drugs reduced dramatically. This includes allowing Medicare to negotiate drug prices and allowing the sale of drugs from other countries that meet FDA standards.
“That resonates with the general public,” Blendon says, “because it’s very hard for people to understand that if we’re free trade in everything, why aren’t we for free trade in pharmaceuticals?”
Dr. Lenchus believes Democrats are going to “double-down” on health reform.
“To ensure the financial underpinnings and some of the partisan concerns are addressed,” he says. “I think with respect to hospitalists, the thing that impacts us the most is how medicine is going to get paid for doing what it does.” TH
Kelly April Tyrrell is a freelance writer in Madison, Wis.
Unlike the crowded Republican primary field heading into this year’s presidential election, just three candidates seek the Democratic nomination: former First Lady and former New York Sen. Hillary Clinton, former Maryland Gov. Martin O’Malley, and U.S. Sen. Bernie Sanders of Vermont.
Although they share numerous ideas, the candidates also differ fundamentally in how they believe the American healthcare system should be run. And they stand in stark contrast to their Republican opponents.
“There really is a philosophical difference between the parties,” says Robert Blendon, professor of health policy and political analysis at the Harvard T.H. Chan School of Public Health and Harvard Kennedy School of Government. “Republicans really feel that if people themselves controlled more of the financial wherewithal, they would shop more and ask more questions.”
Democrats, however, “tend to believe that when people are ill, they are not in particularly good shape to shop,” Blendon says. Nor are they particularly fit to decide what costs are worth incurring or what procedures they may or may not need, he adds.
Listen to more of our interview with Dr. Blendon.
In general, Democrats believe the healthcare system should provide patients structure to make appropriate choices. They do not support reliance on high-deductible health plans and health savings accounts to lower healthcare costs.
“This is why the outcome of the election will matter,” Blendon says, “because it’s a very different view of what the future should look like.”
In 1993, as First Lady, Clinton undertook a failed but massive healthcare reform effort that would have created a universal healthcare system based on private insurance. Today, she supports the Affordable Care Act and says she will continue to build upon and support it, which includes making changes to the law such as repealing the Cadillac tax and further lowering out-of-pocket healthcare costs for most Americans.
Clinton’s view “is that many people have too large deductibles and copays, and for moderate-income people, it’s really deterring care,” Blendon says. “She’s likely to try to see if they can actually increase the government subsidies so the plans offer a wider range of benefits.”
Bradley Flansbaum, DO, MPH, MHM, hospitalist and SHM Public Policy Committee member, says changes must be made.
“We can’t say the direction we’re moving in is the right direction,” he says. “There is a desperate sense in America that what we have been doing is wrong and we need to change … whether the experiments now lead to a system more Americans would prefer remains to be seen.”
Sanders believes in a much bolder shift in direction. He does not think the Affordable Care Act goes far enough and wants to move to a single-payor system.
“I want to end the international embarrassment of the United States of America being the only major country on Earth that doesn’t guarantee healthcare to all people as a right, not a privilege,” he said at the second Democratic debate on Nov. 14, 2015.
However, his vision is unlikely to come to quick fruition if elected, Blendon says. “There’s not going to be—anywhere in the short term—the votes in the U.S. Congress to move in that direction.
“But it would change the level of discussion.”
O’Malley, on the other hand, wants to expand the ACA and envisions an “all-payor system” like that in Maryland, where the state sets medical costs and caps what hospitals can charge. He has vowed to continue to move away from a fee-for-service healthcare system and has said that reform should “eliminate the profit motive” for hospitals CEOs to keep beds filled.
“Regardless of who is elected, I would like to believe they would build off of what already exists,” says Joshua Lenchus, DO, RPh, SFHM, a member of SHM’s Public Policy Committee and a hospitalist at the University of Miami Jackson Memorial Hospital. “The populace doesn’t have the stomach for going through healthcare reform again.”
One of the biggest issues to emerge in the Democratic primaries is drugs: the pricing set by and regulations governing the pharmaceutical industry. Sanders wants to see a higher level of transparency, Clinton wants to require companies receiving federal support to invest in research, and both want to see the skyrocketing costs of prescription drugs reduced dramatically. This includes allowing Medicare to negotiate drug prices and allowing the sale of drugs from other countries that meet FDA standards.
“That resonates with the general public,” Blendon says, “because it’s very hard for people to understand that if we’re free trade in everything, why aren’t we for free trade in pharmaceuticals?”
Dr. Lenchus believes Democrats are going to “double-down” on health reform.
“To ensure the financial underpinnings and some of the partisan concerns are addressed,” he says. “I think with respect to hospitalists, the thing that impacts us the most is how medicine is going to get paid for doing what it does.” TH
Kelly April Tyrrell is a freelance writer in Madison, Wis.
Unlike the crowded Republican primary field heading into this year’s presidential election, just three candidates seek the Democratic nomination: former First Lady and former New York Sen. Hillary Clinton, former Maryland Gov. Martin O’Malley, and U.S. Sen. Bernie Sanders of Vermont.
Although they share numerous ideas, the candidates also differ fundamentally in how they believe the American healthcare system should be run. And they stand in stark contrast to their Republican opponents.
“There really is a philosophical difference between the parties,” says Robert Blendon, professor of health policy and political analysis at the Harvard T.H. Chan School of Public Health and Harvard Kennedy School of Government. “Republicans really feel that if people themselves controlled more of the financial wherewithal, they would shop more and ask more questions.”
Democrats, however, “tend to believe that when people are ill, they are not in particularly good shape to shop,” Blendon says. Nor are they particularly fit to decide what costs are worth incurring or what procedures they may or may not need, he adds.
Listen to more of our interview with Dr. Blendon.
In general, Democrats believe the healthcare system should provide patients structure to make appropriate choices. They do not support reliance on high-deductible health plans and health savings accounts to lower healthcare costs.
“This is why the outcome of the election will matter,” Blendon says, “because it’s a very different view of what the future should look like.”
In 1993, as First Lady, Clinton undertook a failed but massive healthcare reform effort that would have created a universal healthcare system based on private insurance. Today, she supports the Affordable Care Act and says she will continue to build upon and support it, which includes making changes to the law such as repealing the Cadillac tax and further lowering out-of-pocket healthcare costs for most Americans.
Clinton’s view “is that many people have too large deductibles and copays, and for moderate-income people, it’s really deterring care,” Blendon says. “She’s likely to try to see if they can actually increase the government subsidies so the plans offer a wider range of benefits.”
Bradley Flansbaum, DO, MPH, MHM, hospitalist and SHM Public Policy Committee member, says changes must be made.
“We can’t say the direction we’re moving in is the right direction,” he says. “There is a desperate sense in America that what we have been doing is wrong and we need to change … whether the experiments now lead to a system more Americans would prefer remains to be seen.”
Sanders believes in a much bolder shift in direction. He does not think the Affordable Care Act goes far enough and wants to move to a single-payor system.
“I want to end the international embarrassment of the United States of America being the only major country on Earth that doesn’t guarantee healthcare to all people as a right, not a privilege,” he said at the second Democratic debate on Nov. 14, 2015.
However, his vision is unlikely to come to quick fruition if elected, Blendon says. “There’s not going to be—anywhere in the short term—the votes in the U.S. Congress to move in that direction.
“But it would change the level of discussion.”
O’Malley, on the other hand, wants to expand the ACA and envisions an “all-payor system” like that in Maryland, where the state sets medical costs and caps what hospitals can charge. He has vowed to continue to move away from a fee-for-service healthcare system and has said that reform should “eliminate the profit motive” for hospitals CEOs to keep beds filled.
“Regardless of who is elected, I would like to believe they would build off of what already exists,” says Joshua Lenchus, DO, RPh, SFHM, a member of SHM’s Public Policy Committee and a hospitalist at the University of Miami Jackson Memorial Hospital. “The populace doesn’t have the stomach for going through healthcare reform again.”
One of the biggest issues to emerge in the Democratic primaries is drugs: the pricing set by and regulations governing the pharmaceutical industry. Sanders wants to see a higher level of transparency, Clinton wants to require companies receiving federal support to invest in research, and both want to see the skyrocketing costs of prescription drugs reduced dramatically. This includes allowing Medicare to negotiate drug prices and allowing the sale of drugs from other countries that meet FDA standards.
“That resonates with the general public,” Blendon says, “because it’s very hard for people to understand that if we’re free trade in everything, why aren’t we for free trade in pharmaceuticals?”
Dr. Lenchus believes Democrats are going to “double-down” on health reform.
“To ensure the financial underpinnings and some of the partisan concerns are addressed,” he says. “I think with respect to hospitalists, the thing that impacts us the most is how medicine is going to get paid for doing what it does.” TH
Kelly April Tyrrell is a freelance writer in Madison, Wis.
Harvard Professor Robert Blendon, ScD, Discusses the Republican Presidential Candidates
Listen to more of our interview on the GOP candidates with Robert Blendon, ScD, professor of health policy and political analysis at the Harvard School of Public Health and Harvard Kennedy School of Government in Cambridge, Mass.
Listen to more of our interview on the GOP candidates with Robert Blendon, ScD, professor of health policy and political analysis at the Harvard School of Public Health and Harvard Kennedy School of Government in Cambridge, Mass.
Listen to more of our interview on the GOP candidates with Robert Blendon, ScD, professor of health policy and political analysis at the Harvard School of Public Health and Harvard Kennedy School of Government in Cambridge, Mass.
Where Leading GOP Presidential Candidates Stand on Health Policies
As the long 2016 presidential election season draws on, Republican hopefuls strive to stand out among their fellow party candidates; however, many in the running remain tacit about specific policies on issues ranging from immigration to gun control and healthcare.
“Many of these candidates … do not feel like getting involved in an extensive policy discussion will influence whether they win Iowa and New Hampshire,” says Robert Blendon, ScD, professor of health policy and political analysis at the Harvard School of Public Health and Harvard Kennedy School of Government in Cambridge, Mass. “They see it as a distraction, because the people voting are not asking them.”
For physicians and others passionate about healthcare, “it’s very frustrating,” Dr. Blendon says. “People who are on the Republican side want a replacement [for the Affordable Care Act], but they are not driven—I have seen the surveys—to want to really know the details of that replacement.”
GOP candidates share many common ideas about the U.S. health system. Most say they want to allow people under age 26 to remain on their parents’ health plans and believe people with preexisting conditions should have access to coverage, generally through the creation of state-based, high-risk insurance pools. They believe expanded health savings accounts will give patients more skin in the game, and, across the board, they have vowed to “repeal and replace Obamacare.”
Listen to more of our interview with Robert Blendon, ScD
However, “with more than 10 candidates, there is going to be variation,” Dr. Blendon adds.
For instance, former Florida Governor Jeb Bush has proposed the Conservative Plan for 21st Century Health, which aims to “lower costs,” “promote innovation,” and “return power to states.”
Neurosurgeon Ben Carson originally suggested he would “abolish” Medicare and instead provide seniors with a $2,000-a-year federal subsidy to purchase private insurance. He has backtracked that idea and, in December 2015, issued a report highlighting the pillars of his health plan, which include creating “health empowerment accounts” and raising the Medicare age to 70.
New Jersey Governor Chris Christie’s plan suggests a priority for veterans, including the formation of a federal Secretary of Veterans Affairs, while Carly Fiorina says that “every healthcare provider “ought to publish its costs, its prices, its outcomes” so patients know what they are buying.
“As the field on the Republican side narrows, I think we will start to see more pressure on them to flesh those principles out a little bit more,” says Joshua Lenchus, DO, RPh, FACP, SFHM, a hospitalist at the University of Miami (Fla.) Jackson Memorial Hospital and a member of SHM’s Public Policy Committee.
Some GOP candidates, like Kentucky Senator and ophthalmologist Rand Paul, have proposed reforming medical malpractice. Some wish to make insurance portable from one job to the next, like former Arkansas Governor Mike Huckabee, or across state lines, as Ohio Governor John Kasich has proposed.
Some of these ideas, says hospitalist and SHM Public Policy Committee member Bradley Flansbaum, DO, MPH, MHM, “have been adequately dismembered, and they’re not going to carry weight.
“Buying insurance across state lines, fixing malpractice—that is not going to fix the healthcare system,” says Dr. Flansbaum, clinical professor of medicine at NYU School of Medicine in New York City.
Overall, a Republican-sponsored healthcare system will not guarantee the same level of comprehensive benefits patients have now under the ACA, Dr. Blendon says, and, in general, subsidies and tax credits will be less generous than they are today, in turn reducing federal expenditures.
Most Republican candidates are in favor of some version of free market healthcare, but Dr. Flansbaum points out that “there are so many imperfections in the market, everything from people having asymmetric information—a physician knows a lot more than a patient does—to opaque pricing,” he says. “It’s not exchanging goods like we are used to.”
Republicans are generally committed to “less federal government, less expenditures, more choices, and less expensive benefits,” in healthcare, but Dr. Blendon says the system “would not go back to 2009.”
For hospitalists interested in election-year or other healthcare policy issues, Dr. Flansbaum suggests getting involved in the SHM committee, visiting the advocacy section of the SHM website, and reaching out to local representatives and others who write and vote on laws.
“How do you affect change?” he asks. “It’s not sitting in the breakfast lounge at the hospital bellyaching to your colleagues.” TH
Editor's note: update Jan. 4, 2016.
Kelly April Tyrrell is a freelance writer in Madison, Wis.
As the long 2016 presidential election season draws on, Republican hopefuls strive to stand out among their fellow party candidates; however, many in the running remain tacit about specific policies on issues ranging from immigration to gun control and healthcare.
“Many of these candidates … do not feel like getting involved in an extensive policy discussion will influence whether they win Iowa and New Hampshire,” says Robert Blendon, ScD, professor of health policy and political analysis at the Harvard School of Public Health and Harvard Kennedy School of Government in Cambridge, Mass. “They see it as a distraction, because the people voting are not asking them.”
For physicians and others passionate about healthcare, “it’s very frustrating,” Dr. Blendon says. “People who are on the Republican side want a replacement [for the Affordable Care Act], but they are not driven—I have seen the surveys—to want to really know the details of that replacement.”
GOP candidates share many common ideas about the U.S. health system. Most say they want to allow people under age 26 to remain on their parents’ health plans and believe people with preexisting conditions should have access to coverage, generally through the creation of state-based, high-risk insurance pools. They believe expanded health savings accounts will give patients more skin in the game, and, across the board, they have vowed to “repeal and replace Obamacare.”
Listen to more of our interview with Robert Blendon, ScD
However, “with more than 10 candidates, there is going to be variation,” Dr. Blendon adds.
For instance, former Florida Governor Jeb Bush has proposed the Conservative Plan for 21st Century Health, which aims to “lower costs,” “promote innovation,” and “return power to states.”
Neurosurgeon Ben Carson originally suggested he would “abolish” Medicare and instead provide seniors with a $2,000-a-year federal subsidy to purchase private insurance. He has backtracked that idea and, in December 2015, issued a report highlighting the pillars of his health plan, which include creating “health empowerment accounts” and raising the Medicare age to 70.
New Jersey Governor Chris Christie’s plan suggests a priority for veterans, including the formation of a federal Secretary of Veterans Affairs, while Carly Fiorina says that “every healthcare provider “ought to publish its costs, its prices, its outcomes” so patients know what they are buying.
“As the field on the Republican side narrows, I think we will start to see more pressure on them to flesh those principles out a little bit more,” says Joshua Lenchus, DO, RPh, FACP, SFHM, a hospitalist at the University of Miami (Fla.) Jackson Memorial Hospital and a member of SHM’s Public Policy Committee.
Some GOP candidates, like Kentucky Senator and ophthalmologist Rand Paul, have proposed reforming medical malpractice. Some wish to make insurance portable from one job to the next, like former Arkansas Governor Mike Huckabee, or across state lines, as Ohio Governor John Kasich has proposed.
Some of these ideas, says hospitalist and SHM Public Policy Committee member Bradley Flansbaum, DO, MPH, MHM, “have been adequately dismembered, and they’re not going to carry weight.
“Buying insurance across state lines, fixing malpractice—that is not going to fix the healthcare system,” says Dr. Flansbaum, clinical professor of medicine at NYU School of Medicine in New York City.
Overall, a Republican-sponsored healthcare system will not guarantee the same level of comprehensive benefits patients have now under the ACA, Dr. Blendon says, and, in general, subsidies and tax credits will be less generous than they are today, in turn reducing federal expenditures.
Most Republican candidates are in favor of some version of free market healthcare, but Dr. Flansbaum points out that “there are so many imperfections in the market, everything from people having asymmetric information—a physician knows a lot more than a patient does—to opaque pricing,” he says. “It’s not exchanging goods like we are used to.”
Republicans are generally committed to “less federal government, less expenditures, more choices, and less expensive benefits,” in healthcare, but Dr. Blendon says the system “would not go back to 2009.”
For hospitalists interested in election-year or other healthcare policy issues, Dr. Flansbaum suggests getting involved in the SHM committee, visiting the advocacy section of the SHM website, and reaching out to local representatives and others who write and vote on laws.
“How do you affect change?” he asks. “It’s not sitting in the breakfast lounge at the hospital bellyaching to your colleagues.” TH
Editor's note: update Jan. 4, 2016.
Kelly April Tyrrell is a freelance writer in Madison, Wis.
As the long 2016 presidential election season draws on, Republican hopefuls strive to stand out among their fellow party candidates; however, many in the running remain tacit about specific policies on issues ranging from immigration to gun control and healthcare.
“Many of these candidates … do not feel like getting involved in an extensive policy discussion will influence whether they win Iowa and New Hampshire,” says Robert Blendon, ScD, professor of health policy and political analysis at the Harvard School of Public Health and Harvard Kennedy School of Government in Cambridge, Mass. “They see it as a distraction, because the people voting are not asking them.”
For physicians and others passionate about healthcare, “it’s very frustrating,” Dr. Blendon says. “People who are on the Republican side want a replacement [for the Affordable Care Act], but they are not driven—I have seen the surveys—to want to really know the details of that replacement.”
GOP candidates share many common ideas about the U.S. health system. Most say they want to allow people under age 26 to remain on their parents’ health plans and believe people with preexisting conditions should have access to coverage, generally through the creation of state-based, high-risk insurance pools. They believe expanded health savings accounts will give patients more skin in the game, and, across the board, they have vowed to “repeal and replace Obamacare.”
Listen to more of our interview with Robert Blendon, ScD
However, “with more than 10 candidates, there is going to be variation,” Dr. Blendon adds.
For instance, former Florida Governor Jeb Bush has proposed the Conservative Plan for 21st Century Health, which aims to “lower costs,” “promote innovation,” and “return power to states.”
Neurosurgeon Ben Carson originally suggested he would “abolish” Medicare and instead provide seniors with a $2,000-a-year federal subsidy to purchase private insurance. He has backtracked that idea and, in December 2015, issued a report highlighting the pillars of his health plan, which include creating “health empowerment accounts” and raising the Medicare age to 70.
New Jersey Governor Chris Christie’s plan suggests a priority for veterans, including the formation of a federal Secretary of Veterans Affairs, while Carly Fiorina says that “every healthcare provider “ought to publish its costs, its prices, its outcomes” so patients know what they are buying.
“As the field on the Republican side narrows, I think we will start to see more pressure on them to flesh those principles out a little bit more,” says Joshua Lenchus, DO, RPh, FACP, SFHM, a hospitalist at the University of Miami (Fla.) Jackson Memorial Hospital and a member of SHM’s Public Policy Committee.
Some GOP candidates, like Kentucky Senator and ophthalmologist Rand Paul, have proposed reforming medical malpractice. Some wish to make insurance portable from one job to the next, like former Arkansas Governor Mike Huckabee, or across state lines, as Ohio Governor John Kasich has proposed.
Some of these ideas, says hospitalist and SHM Public Policy Committee member Bradley Flansbaum, DO, MPH, MHM, “have been adequately dismembered, and they’re not going to carry weight.
“Buying insurance across state lines, fixing malpractice—that is not going to fix the healthcare system,” says Dr. Flansbaum, clinical professor of medicine at NYU School of Medicine in New York City.
Overall, a Republican-sponsored healthcare system will not guarantee the same level of comprehensive benefits patients have now under the ACA, Dr. Blendon says, and, in general, subsidies and tax credits will be less generous than they are today, in turn reducing federal expenditures.
Most Republican candidates are in favor of some version of free market healthcare, but Dr. Flansbaum points out that “there are so many imperfections in the market, everything from people having asymmetric information—a physician knows a lot more than a patient does—to opaque pricing,” he says. “It’s not exchanging goods like we are used to.”
Republicans are generally committed to “less federal government, less expenditures, more choices, and less expensive benefits,” in healthcare, but Dr. Blendon says the system “would not go back to 2009.”
For hospitalists interested in election-year or other healthcare policy issues, Dr. Flansbaum suggests getting involved in the SHM committee, visiting the advocacy section of the SHM website, and reaching out to local representatives and others who write and vote on laws.
“How do you affect change?” he asks. “It’s not sitting in the breakfast lounge at the hospital bellyaching to your colleagues.” TH
Editor's note: update Jan. 4, 2016.
Kelly April Tyrrell is a freelance writer in Madison, Wis.
Policy Changes Hospitalists May See in 2016
The year 2015 brought the repeal of the sustainable growth rate (SGR) and new rules for advanced care planning reimbursement. It saw hospitalists take the lead on improving the two-midnight rule and respond to a global infectious disease scare.
The Hospitalist caught up with Dr. Greeno, chief strategy officer at North Hollywood, Calif.-based IPC Healthcare, to ask him about what he sees for the year ahead in policy.
Question: What are the biggest changes in store for 2016 that stand to impact hospitalists?
Answer: Much of it is just a magnification of the things that most hospitalists are already feeling or sensing. Clearly, there is a very solid movement toward alternative payment methodologies. BPCI (the Bundled Payments for Care Improvement initiative) has been embraced by hospitalists and other physicians all over the country at a scale that has surprised everybody.
There is also more consolidation in the healthcare industry as a whole. Hospital organizations are getting bigger, and we’re seeing consolidation of hospitalist groups. We will see cross-integration in the healthcare system that occurs at a rapid pace: hospitals buying physician groups, health systems and providers starting health plans, health plans acquiring hospital systems. In the not-too-distant future, we are all going to be in the population health business. This is a complete realignment of the healthcare system, and we haven’t seen the half of it yet. We have to be prepared to do it all, or a very big piece of it. The good news is, we are an absolute necessity for success in the future.
Q: It’s a presidential election year. How much weight should physicians put on claims made by candidates?
A: I encourage people to be politically engaged, but I don’t think the majority of what’s happening in healthcare is being driven by politics. It’s being driven by dispassionate economic forces that aren’t going to go away, no matter who is president. We have to figure out how to care for our population more cost-effectively. The ACA (Affordable Care Act) has driven a lot of the political environment in D.C. since its passage, including a big divide between the two parties, but it’s about three things: insurance reform, expanded access, and, particularly, delivery system reform. That’s the part we really care about and can influence the most, I think. Both parties feel like the delivery system needs to be reformed. I don’t think the election will have a major impact on hospitalists and what we do.
The ACA created an environment where things moved faster, created the (CMS) Innovation Center that drives alternative payment methodologies. It created a burning platform for things that already needed to happen.
Q: Is there anything new for meaningful use/EHR in 2016?
A: There are implications of meaningful use for hospitalists. Last year was the first that meaningful use penalties for physician groups came into effect. The way it was written, there was an exception to meaningful use requirements for hospital-based physicians, but a majority of SHM’s membership does not qualify for exemption and are subject to penalties. It’s not small: $2,500 to $5,000 per doctor. The Public Policy Committee at SHM has been working in Washington the last couple of years. We were able to get a one-year exemption, and now they’ve given us a second year, but we can only do five years according to law, and we have to apply every year. We have applied to CMS for a specialty code for hospitalists, and if that gets approved, it will be used to identify who is a hospitalist and who is not. If we submit under that code, then we’re not subject to penalty.
–Dr. Greeno
Q: What is the future of the two-midnight rule?
A: The committee and SHM took that on several years ago at my urging because it didn’t seem like other specialties were leading that issue. It doesn’t affect hospitalists in terms of how we’re paid, but it does affect the patients we care for. I think we’ll have a better solution in the coming years.
Q: What should hospitalists be thinking about heading into 2016?
A: They should be starting to prepare for a world where they no longer get paid with fee-for-service. Hospitalists are in the post-acute setting, where a lot of the action takes place, and it’s the high-cost action. My lesson is to embrace the changes; don’t fight it. As a hospitalist, your job is going to be different a year from now. We might as well get ready for the change, because there’s going to be a lot of change in the system.
Kelly April Tyrrell is a freelance writer in Madison, Wis.
The year 2015 brought the repeal of the sustainable growth rate (SGR) and new rules for advanced care planning reimbursement. It saw hospitalists take the lead on improving the two-midnight rule and respond to a global infectious disease scare.
The Hospitalist caught up with Dr. Greeno, chief strategy officer at North Hollywood, Calif.-based IPC Healthcare, to ask him about what he sees for the year ahead in policy.
Question: What are the biggest changes in store for 2016 that stand to impact hospitalists?
Answer: Much of it is just a magnification of the things that most hospitalists are already feeling or sensing. Clearly, there is a very solid movement toward alternative payment methodologies. BPCI (the Bundled Payments for Care Improvement initiative) has been embraced by hospitalists and other physicians all over the country at a scale that has surprised everybody.
There is also more consolidation in the healthcare industry as a whole. Hospital organizations are getting bigger, and we’re seeing consolidation of hospitalist groups. We will see cross-integration in the healthcare system that occurs at a rapid pace: hospitals buying physician groups, health systems and providers starting health plans, health plans acquiring hospital systems. In the not-too-distant future, we are all going to be in the population health business. This is a complete realignment of the healthcare system, and we haven’t seen the half of it yet. We have to be prepared to do it all, or a very big piece of it. The good news is, we are an absolute necessity for success in the future.
Q: It’s a presidential election year. How much weight should physicians put on claims made by candidates?
A: I encourage people to be politically engaged, but I don’t think the majority of what’s happening in healthcare is being driven by politics. It’s being driven by dispassionate economic forces that aren’t going to go away, no matter who is president. We have to figure out how to care for our population more cost-effectively. The ACA (Affordable Care Act) has driven a lot of the political environment in D.C. since its passage, including a big divide between the two parties, but it’s about three things: insurance reform, expanded access, and, particularly, delivery system reform. That’s the part we really care about and can influence the most, I think. Both parties feel like the delivery system needs to be reformed. I don’t think the election will have a major impact on hospitalists and what we do.
The ACA created an environment where things moved faster, created the (CMS) Innovation Center that drives alternative payment methodologies. It created a burning platform for things that already needed to happen.
Q: Is there anything new for meaningful use/EHR in 2016?
A: There are implications of meaningful use for hospitalists. Last year was the first that meaningful use penalties for physician groups came into effect. The way it was written, there was an exception to meaningful use requirements for hospital-based physicians, but a majority of SHM’s membership does not qualify for exemption and are subject to penalties. It’s not small: $2,500 to $5,000 per doctor. The Public Policy Committee at SHM has been working in Washington the last couple of years. We were able to get a one-year exemption, and now they’ve given us a second year, but we can only do five years according to law, and we have to apply every year. We have applied to CMS for a specialty code for hospitalists, and if that gets approved, it will be used to identify who is a hospitalist and who is not. If we submit under that code, then we’re not subject to penalty.
–Dr. Greeno
Q: What is the future of the two-midnight rule?
A: The committee and SHM took that on several years ago at my urging because it didn’t seem like other specialties were leading that issue. It doesn’t affect hospitalists in terms of how we’re paid, but it does affect the patients we care for. I think we’ll have a better solution in the coming years.
Q: What should hospitalists be thinking about heading into 2016?
A: They should be starting to prepare for a world where they no longer get paid with fee-for-service. Hospitalists are in the post-acute setting, where a lot of the action takes place, and it’s the high-cost action. My lesson is to embrace the changes; don’t fight it. As a hospitalist, your job is going to be different a year from now. We might as well get ready for the change, because there’s going to be a lot of change in the system.
Kelly April Tyrrell is a freelance writer in Madison, Wis.
The year 2015 brought the repeal of the sustainable growth rate (SGR) and new rules for advanced care planning reimbursement. It saw hospitalists take the lead on improving the two-midnight rule and respond to a global infectious disease scare.
The Hospitalist caught up with Dr. Greeno, chief strategy officer at North Hollywood, Calif.-based IPC Healthcare, to ask him about what he sees for the year ahead in policy.
Question: What are the biggest changes in store for 2016 that stand to impact hospitalists?
Answer: Much of it is just a magnification of the things that most hospitalists are already feeling or sensing. Clearly, there is a very solid movement toward alternative payment methodologies. BPCI (the Bundled Payments for Care Improvement initiative) has been embraced by hospitalists and other physicians all over the country at a scale that has surprised everybody.
There is also more consolidation in the healthcare industry as a whole. Hospital organizations are getting bigger, and we’re seeing consolidation of hospitalist groups. We will see cross-integration in the healthcare system that occurs at a rapid pace: hospitals buying physician groups, health systems and providers starting health plans, health plans acquiring hospital systems. In the not-too-distant future, we are all going to be in the population health business. This is a complete realignment of the healthcare system, and we haven’t seen the half of it yet. We have to be prepared to do it all, or a very big piece of it. The good news is, we are an absolute necessity for success in the future.
Q: It’s a presidential election year. How much weight should physicians put on claims made by candidates?
A: I encourage people to be politically engaged, but I don’t think the majority of what’s happening in healthcare is being driven by politics. It’s being driven by dispassionate economic forces that aren’t going to go away, no matter who is president. We have to figure out how to care for our population more cost-effectively. The ACA (Affordable Care Act) has driven a lot of the political environment in D.C. since its passage, including a big divide between the two parties, but it’s about three things: insurance reform, expanded access, and, particularly, delivery system reform. That’s the part we really care about and can influence the most, I think. Both parties feel like the delivery system needs to be reformed. I don’t think the election will have a major impact on hospitalists and what we do.
The ACA created an environment where things moved faster, created the (CMS) Innovation Center that drives alternative payment methodologies. It created a burning platform for things that already needed to happen.
Q: Is there anything new for meaningful use/EHR in 2016?
A: There are implications of meaningful use for hospitalists. Last year was the first that meaningful use penalties for physician groups came into effect. The way it was written, there was an exception to meaningful use requirements for hospital-based physicians, but a majority of SHM’s membership does not qualify for exemption and are subject to penalties. It’s not small: $2,500 to $5,000 per doctor. The Public Policy Committee at SHM has been working in Washington the last couple of years. We were able to get a one-year exemption, and now they’ve given us a second year, but we can only do five years according to law, and we have to apply every year. We have applied to CMS for a specialty code for hospitalists, and if that gets approved, it will be used to identify who is a hospitalist and who is not. If we submit under that code, then we’re not subject to penalty.
–Dr. Greeno
Q: What is the future of the two-midnight rule?
A: The committee and SHM took that on several years ago at my urging because it didn’t seem like other specialties were leading that issue. It doesn’t affect hospitalists in terms of how we’re paid, but it does affect the patients we care for. I think we’ll have a better solution in the coming years.
Q: What should hospitalists be thinking about heading into 2016?
A: They should be starting to prepare for a world where they no longer get paid with fee-for-service. Hospitalists are in the post-acute setting, where a lot of the action takes place, and it’s the high-cost action. My lesson is to embrace the changes; don’t fight it. As a hospitalist, your job is going to be different a year from now. We might as well get ready for the change, because there’s going to be a lot of change in the system.
Kelly April Tyrrell is a freelance writer in Madison, Wis.
Hospitalists Support Medicare’s Plan to Reimburse Advance Care Planning
On July 8, following on the heels of the sustainable growth rate repeal, the Centers for Medicare and Medicaid Services released a proposed update to the 2016 Physician Fee Schedule that would reimburse physicians and other qualified providers for conversations with patients and patient families about end-of-life care.
It is yet another move toward higher quality patient-centered care, CMS said in a news release on its website the day the proposed rule change was published. The comment period, which spanned 90 days, closes Nov. 1. The final rule will take effect Jan. 1, 2016.
Although CMS specifically cites the recommendation made by the American Medical Association to make advance care planning a separate, payable service, many physician groups, including the Society of Hospital Medicine, have championed and continue to actively advocate for reimbursement for end-of-life conversations with patients and their families.
“We think that palliative care and hospice services are underutilized, so we support anything we can do to make sure there is more appropriate use of these services,” says Ronald A. Greeno, MD, FCCP, MHM, a founding member of SHM, a longtime SHM Public Policy Committee member, and a current member of its board of directors. “We think it’s important to encourage providers to take the time to have those discussions, and one way is getting reimbursement for that time.”
When CMS considered reimbursement for advance care planning last year but did not propose a rule, SHM wrote a letter in December 2014 to U.S. Department of Health and Human Services (HHS) acting administrator Marilynn Tavenner urging the agency to consider adopting the two codes for complex advance care planning developed by the AMA’s CPT Editorial Panel.1 In May 2015, SHM joined 65 other medical specialty and professional societies in signing a letter to HHS Secretary Sylvia Mathews Burwell asking for these codes to be formalized in CY 2016.2
In the more recent letter, the authors mention peer-reviewed research demonstrating that advance care planning leads to “better care, higher patient and family satisfaction, fewer unwanted hospitalizations and lower rates of caregiver distress, depression and lost productivity.” SHM also cites a 2014 Institute of Medicine report, Dying in America, in which advance care planning is listed as one of five key recommendations.3
—Dr. Greeno
Pending final rule adoption, the codes 99487 and 99498 will become payable starting in January 2016.
“We (hospitalists) are in this position pretty much every day, working with people in late life and at the end of life, cycling in and out of the hospital with end-stage chronic diseases,” says Howard Epstein, MD, FHM, CHIE, executive vice president and chief medical officer at PreferredOne Health Plans in Minnesota and a hospice and palliative medicine-certified hospitalist. “I’ll be quite honest: I don’t think reimbursement is going to pay for the time and expertise for these procedures; it’s more offsetting the costs of doing the right thing for patients and families.”
What reimbursement does is lend credibility to the goals of care and advance care planning discussions patients and providers are already having, Dr. Epstein says.
“Having a specific CPT code for this legitimizes it,” he says, “like the field of palliative medicine when it became a board-certified specialty; these kinds of things really matter. They say, ‘This is our procedure.’”
It also enables providers to take the time to have these conversations with patients and families. In a post on the SHM blog in July 2015, Dr. Epstein, also a member of the SHM board of directors, cites a New England Journal of Medicine study indicating that most of the 2.5 million deaths each year in the U.S. are due to progressive health conditions and another that found that a quarter of elderly Americans lack the ability to make critical decisions at the end of life.4,5 The proposed rule, he says, reflects a change in our culture.
“As our society ages, and more and more people go through the experience with loved ones, they are demanding this care,” Dr. Epstein says.
But simply providing reimbursement is not enough, nor should the onus fall squarely on physicians, Dr. Epstein says. Rather, he believes physicians should take advantage of resources provided by SHM, hospital systems, and other organizations that offer training in advance care planning, and all members of a patient care and support team should be well versed in how to have these conversations.
The rule comes just over five years after attempts to include advance care planning in health reform efforts failed, and SHM plans to continue to advocate for national consistency in applying the measure and to work to ensure there are no limits to the timing of advance care planning conversations or where they take place.
“It was just a matter of time. It was bound to happen,” Dr. Greeno says of the rule. “We held out during the discussions of death panels and things like that. There are always lots of political issues with misinformation on both sides. We’ve tried to really communicate how and why we are supportive, and the benefits for our patients and our healthcare system, which is always our goal.”
Kelly April Tyrrell is a freelance writer in Madison, Wis.
References
- Kealey BT. Re: Medicare Program; Revisions to Payment Policies under the Physician Fee Schedule, Clinical Laboratory Fee Schedule, Access to Identifiable Data for the Center for Medicare and Medicaid Innovation Models and Other Revisions to Part B for CY 2015; Final Rule (CMS-1612-FC). Letter to Administrator Marilyn Tavenner, Centers for Medicare and Medicaid Services, Department of Health and Human Services. December 8, 2014. Accessed September 14, 2015.
- Letter to The Honorable Sylvia Mathews Burwell, Secretary of Health and Human Services. May 12, 2015. Accessed September 14, 2015.
- Institute of Medicine. Dying in America: improving quality and honoring individual preferences near the end of life. September 17, 2014. Accessed September 14, 2015.
- Wolf SM, Berlinger N, Jennings B. Forty years of work on end-of-life care - from patient’s rights to systemic reform. N Engl J Med. 2015;372(7):678-682. doi: 10.1056/NEJMms1410321.
- Silveira MJ, Kim SY, Langa KM. Advance directives and outcomes of surrogate decision making before death. N Engl J Med. 2010;362(13):1211-1218. doi: 10.1056/NEJMsa0907901.
On July 8, following on the heels of the sustainable growth rate repeal, the Centers for Medicare and Medicaid Services released a proposed update to the 2016 Physician Fee Schedule that would reimburse physicians and other qualified providers for conversations with patients and patient families about end-of-life care.
It is yet another move toward higher quality patient-centered care, CMS said in a news release on its website the day the proposed rule change was published. The comment period, which spanned 90 days, closes Nov. 1. The final rule will take effect Jan. 1, 2016.
Although CMS specifically cites the recommendation made by the American Medical Association to make advance care planning a separate, payable service, many physician groups, including the Society of Hospital Medicine, have championed and continue to actively advocate for reimbursement for end-of-life conversations with patients and their families.
“We think that palliative care and hospice services are underutilized, so we support anything we can do to make sure there is more appropriate use of these services,” says Ronald A. Greeno, MD, FCCP, MHM, a founding member of SHM, a longtime SHM Public Policy Committee member, and a current member of its board of directors. “We think it’s important to encourage providers to take the time to have those discussions, and one way is getting reimbursement for that time.”
When CMS considered reimbursement for advance care planning last year but did not propose a rule, SHM wrote a letter in December 2014 to U.S. Department of Health and Human Services (HHS) acting administrator Marilynn Tavenner urging the agency to consider adopting the two codes for complex advance care planning developed by the AMA’s CPT Editorial Panel.1 In May 2015, SHM joined 65 other medical specialty and professional societies in signing a letter to HHS Secretary Sylvia Mathews Burwell asking for these codes to be formalized in CY 2016.2
In the more recent letter, the authors mention peer-reviewed research demonstrating that advance care planning leads to “better care, higher patient and family satisfaction, fewer unwanted hospitalizations and lower rates of caregiver distress, depression and lost productivity.” SHM also cites a 2014 Institute of Medicine report, Dying in America, in which advance care planning is listed as one of five key recommendations.3
—Dr. Greeno
Pending final rule adoption, the codes 99487 and 99498 will become payable starting in January 2016.
“We (hospitalists) are in this position pretty much every day, working with people in late life and at the end of life, cycling in and out of the hospital with end-stage chronic diseases,” says Howard Epstein, MD, FHM, CHIE, executive vice president and chief medical officer at PreferredOne Health Plans in Minnesota and a hospice and palliative medicine-certified hospitalist. “I’ll be quite honest: I don’t think reimbursement is going to pay for the time and expertise for these procedures; it’s more offsetting the costs of doing the right thing for patients and families.”
What reimbursement does is lend credibility to the goals of care and advance care planning discussions patients and providers are already having, Dr. Epstein says.
“Having a specific CPT code for this legitimizes it,” he says, “like the field of palliative medicine when it became a board-certified specialty; these kinds of things really matter. They say, ‘This is our procedure.’”
It also enables providers to take the time to have these conversations with patients and families. In a post on the SHM blog in July 2015, Dr. Epstein, also a member of the SHM board of directors, cites a New England Journal of Medicine study indicating that most of the 2.5 million deaths each year in the U.S. are due to progressive health conditions and another that found that a quarter of elderly Americans lack the ability to make critical decisions at the end of life.4,5 The proposed rule, he says, reflects a change in our culture.
“As our society ages, and more and more people go through the experience with loved ones, they are demanding this care,” Dr. Epstein says.
But simply providing reimbursement is not enough, nor should the onus fall squarely on physicians, Dr. Epstein says. Rather, he believes physicians should take advantage of resources provided by SHM, hospital systems, and other organizations that offer training in advance care planning, and all members of a patient care and support team should be well versed in how to have these conversations.
The rule comes just over five years after attempts to include advance care planning in health reform efforts failed, and SHM plans to continue to advocate for national consistency in applying the measure and to work to ensure there are no limits to the timing of advance care planning conversations or where they take place.
“It was just a matter of time. It was bound to happen,” Dr. Greeno says of the rule. “We held out during the discussions of death panels and things like that. There are always lots of political issues with misinformation on both sides. We’ve tried to really communicate how and why we are supportive, and the benefits for our patients and our healthcare system, which is always our goal.”
Kelly April Tyrrell is a freelance writer in Madison, Wis.
References
- Kealey BT. Re: Medicare Program; Revisions to Payment Policies under the Physician Fee Schedule, Clinical Laboratory Fee Schedule, Access to Identifiable Data for the Center for Medicare and Medicaid Innovation Models and Other Revisions to Part B for CY 2015; Final Rule (CMS-1612-FC). Letter to Administrator Marilyn Tavenner, Centers for Medicare and Medicaid Services, Department of Health and Human Services. December 8, 2014. Accessed September 14, 2015.
- Letter to The Honorable Sylvia Mathews Burwell, Secretary of Health and Human Services. May 12, 2015. Accessed September 14, 2015.
- Institute of Medicine. Dying in America: improving quality and honoring individual preferences near the end of life. September 17, 2014. Accessed September 14, 2015.
- Wolf SM, Berlinger N, Jennings B. Forty years of work on end-of-life care - from patient’s rights to systemic reform. N Engl J Med. 2015;372(7):678-682. doi: 10.1056/NEJMms1410321.
- Silveira MJ, Kim SY, Langa KM. Advance directives and outcomes of surrogate decision making before death. N Engl J Med. 2010;362(13):1211-1218. doi: 10.1056/NEJMsa0907901.
On July 8, following on the heels of the sustainable growth rate repeal, the Centers for Medicare and Medicaid Services released a proposed update to the 2016 Physician Fee Schedule that would reimburse physicians and other qualified providers for conversations with patients and patient families about end-of-life care.
It is yet another move toward higher quality patient-centered care, CMS said in a news release on its website the day the proposed rule change was published. The comment period, which spanned 90 days, closes Nov. 1. The final rule will take effect Jan. 1, 2016.
Although CMS specifically cites the recommendation made by the American Medical Association to make advance care planning a separate, payable service, many physician groups, including the Society of Hospital Medicine, have championed and continue to actively advocate for reimbursement for end-of-life conversations with patients and their families.
“We think that palliative care and hospice services are underutilized, so we support anything we can do to make sure there is more appropriate use of these services,” says Ronald A. Greeno, MD, FCCP, MHM, a founding member of SHM, a longtime SHM Public Policy Committee member, and a current member of its board of directors. “We think it’s important to encourage providers to take the time to have those discussions, and one way is getting reimbursement for that time.”
When CMS considered reimbursement for advance care planning last year but did not propose a rule, SHM wrote a letter in December 2014 to U.S. Department of Health and Human Services (HHS) acting administrator Marilynn Tavenner urging the agency to consider adopting the two codes for complex advance care planning developed by the AMA’s CPT Editorial Panel.1 In May 2015, SHM joined 65 other medical specialty and professional societies in signing a letter to HHS Secretary Sylvia Mathews Burwell asking for these codes to be formalized in CY 2016.2
In the more recent letter, the authors mention peer-reviewed research demonstrating that advance care planning leads to “better care, higher patient and family satisfaction, fewer unwanted hospitalizations and lower rates of caregiver distress, depression and lost productivity.” SHM also cites a 2014 Institute of Medicine report, Dying in America, in which advance care planning is listed as one of five key recommendations.3
—Dr. Greeno
Pending final rule adoption, the codes 99487 and 99498 will become payable starting in January 2016.
“We (hospitalists) are in this position pretty much every day, working with people in late life and at the end of life, cycling in and out of the hospital with end-stage chronic diseases,” says Howard Epstein, MD, FHM, CHIE, executive vice president and chief medical officer at PreferredOne Health Plans in Minnesota and a hospice and palliative medicine-certified hospitalist. “I’ll be quite honest: I don’t think reimbursement is going to pay for the time and expertise for these procedures; it’s more offsetting the costs of doing the right thing for patients and families.”
What reimbursement does is lend credibility to the goals of care and advance care planning discussions patients and providers are already having, Dr. Epstein says.
“Having a specific CPT code for this legitimizes it,” he says, “like the field of palliative medicine when it became a board-certified specialty; these kinds of things really matter. They say, ‘This is our procedure.’”
It also enables providers to take the time to have these conversations with patients and families. In a post on the SHM blog in July 2015, Dr. Epstein, also a member of the SHM board of directors, cites a New England Journal of Medicine study indicating that most of the 2.5 million deaths each year in the U.S. are due to progressive health conditions and another that found that a quarter of elderly Americans lack the ability to make critical decisions at the end of life.4,5 The proposed rule, he says, reflects a change in our culture.
“As our society ages, and more and more people go through the experience with loved ones, they are demanding this care,” Dr. Epstein says.
But simply providing reimbursement is not enough, nor should the onus fall squarely on physicians, Dr. Epstein says. Rather, he believes physicians should take advantage of resources provided by SHM, hospital systems, and other organizations that offer training in advance care planning, and all members of a patient care and support team should be well versed in how to have these conversations.
The rule comes just over five years after attempts to include advance care planning in health reform efforts failed, and SHM plans to continue to advocate for national consistency in applying the measure and to work to ensure there are no limits to the timing of advance care planning conversations or where they take place.
“It was just a matter of time. It was bound to happen,” Dr. Greeno says of the rule. “We held out during the discussions of death panels and things like that. There are always lots of political issues with misinformation on both sides. We’ve tried to really communicate how and why we are supportive, and the benefits for our patients and our healthcare system, which is always our goal.”
Kelly April Tyrrell is a freelance writer in Madison, Wis.
References
- Kealey BT. Re: Medicare Program; Revisions to Payment Policies under the Physician Fee Schedule, Clinical Laboratory Fee Schedule, Access to Identifiable Data for the Center for Medicare and Medicaid Innovation Models and Other Revisions to Part B for CY 2015; Final Rule (CMS-1612-FC). Letter to Administrator Marilyn Tavenner, Centers for Medicare and Medicaid Services, Department of Health and Human Services. December 8, 2014. Accessed September 14, 2015.
- Letter to The Honorable Sylvia Mathews Burwell, Secretary of Health and Human Services. May 12, 2015. Accessed September 14, 2015.
- Institute of Medicine. Dying in America: improving quality and honoring individual preferences near the end of life. September 17, 2014. Accessed September 14, 2015.
- Wolf SM, Berlinger N, Jennings B. Forty years of work on end-of-life care - from patient’s rights to systemic reform. N Engl J Med. 2015;372(7):678-682. doi: 10.1056/NEJMms1410321.
- Silveira MJ, Kim SY, Langa KM. Advance directives and outcomes of surrogate decision making before death. N Engl J Med. 2010;362(13):1211-1218. doi: 10.1056/NEJMsa0907901.
Physicians Critical of Proposed Changes to Medicare's Two-Midnight Rule
In the wake of proposed changes to the Centers for Medicare and Medicaid Services’ two-midnight rule, physicians say new flexibilities and changes to the policy’s auditing mechanism add more uncertainty and ambiguity.
The 2016 Hospital Outpatient Prospective Payment System and Ambulatory Surgical Center Payment System proposed rule was published on July 1, 2015, and included changes in response to concerns about portions of the original two-midnight rule.1 By classifying an inpatient stay as any hospitalization lasting more than two midnights, the rule, which attempted to clarify which services warranted billing under Part B and which qualified for Part A, initially was intended to limit the long observation stays negatively impacting Medicare beneficiaries. However, aggressive reviews by recovery auditors (RAs) and the notion that physician judgment was taking a backseat to arbitrary CMS policy caused a backlash.
In 2014, CMS solicited feedback on the two-midnight rule. SHM suggested a two-tiered approach to address immediate and long-term patient care needs.
“SHM suggests CMS pursue broader solutions to observation status instead of making minor adjustments to the two-midnight rule,” wrote then-SHM President Burke Kealey, MD, SFHM, in a public comment letter to CMS in June 2014. “However, SHM does recognize that in the interim, the two-midnight policy needs to be refined in order to reflect the realities of patient care. Some situations may not be appropriate for classification as outpatient, regardless of the length of stay.”
The proposed changes were supposed to be a solution, but some are saying that CMS has missed the mark. In trying to give physicians more flexibility to determine patient status at the time of admissions, the rule instead may leave physician judgment open to additional scrutiny. Also, the nature of short inpatient stay reviews by Quality Improvement Organizations (QIOs), rather than RAs, remains unclear, and an additional point of concern involves the question of how RAs will factor in.
“My personal opinion is that it will only muddy the waters, in terms of payment for [and] documentation and reviews of short stays for Medicare beneficiaries,” says Jeannine Engel, MD, FACP, in a statement she wrote and shared by email. Dr. Engel is an internist and physician advisor for billing compliance at University of Utah Health Care in Salt Lake City. “No matter who reviews medical documentation, when subjective criteria are used, there is room for interpretation.”
CMS has not defined what constitutes adequate documentation to justify short inpatient stays, nor has it indicated the threshold for “high rates of denials” that would kick reviews over to RAs.
“Details are lacking, and then what makes it even more confusing is what they’ve done with the tweak in policy is further muddied the definition of inpatient,” says Charles Locke, MD, internist and senior physician advisor at Johns Hopkins University School of Medicine in Baltimore. “Whether you agree or disagree with the two-midnight rule, it actually made more clear what inpatient should be.”
According to CMS, the two-midnight rule has reduced observation stays lasting longer than two midnights by 11%, and inpatient admissions are anticipated to increase. But, physicians say, it’s a billing distinction rather than one that impacts patient care.
“The reality is when you take someone in the hospital as outpatient, they can receive every service and care identical to inpatient,” Dr. Locke says. “CMS seems hung up on the idea that in the hospital there are two levels of care.”
In fact, with the changes, “CMS had all but abandoned the term ‘inpatient hospital care’ in favor of simply ‘hospital care.’ Now it is back,” says Dr. Engel, who is also a professor of medicine at Huntsman Cancer Institute. “The two-midnight rule was a payment policy, not a ‘care policy.’ Now we may be back to debating what constitutes ‘inpatient care’ versus what could have been ‘safely delivered in a different/lower status such as observation.’”
Dr. Engel and Dr. Locke recently published a study of RAs and the two-midnight rule in the Journal of Hospital Medicine, with University of Wisconsin-Madison School of Medicine and Public Health hospitalist Ann Sheehy, MD.2
The AHA-CMS Quarrel
In addition to SHM, other organizations are heartened by CMS’s responsiveness. Priya Bathija, senior associate director of policy at the American Hospital Association, called them a “step in the right direction,” but also highlighted some of the group’s lingering concerns.
“We think it’s a good thing they’re using QIOs as first-line medical review as opposed to RAs, but we still want to make sure RAs will not make inappropriate denials of claims,” Bathija says.
The AHA is fighting a legal battle against the U.S. Department of Health and Human Services over a 0.2% reduction in inpatient payments through the two-midnight rule, maintained in the proposed changes, which CMS says are warranted based on a projected increase in inpatient service claims.3 The AHA disputes these actuarial values, Bathija says.
The AHA is calling upon CMS to make changes to short stay payments and submitted a letter to CMS outlining six models.4 The agency accepted comment on the proposed changes through August 30.
The fundamental issue, however, is that the Medicare payment system is vastly out of date, Dr. Locke says. “What I have advocated is to get rid of Part A and Part B distinction, just like private insurance,” he says, “so when you’re hospitalized, you’re hospitalized, and there is no distinction except inpatient extended, recovery outpatient, or extended outpatient observation.”
If the proposed rule changes are finalized, hospitals are going to have to learn to live with them, despite ambiguous guidance, and adjust their workflow, Dr. Locke says.
“It costs a lot of money and time, and hospitals don’t want to do something thinking they’re doing it in good faith but then the Inspector General says you owe $10 million,” he says. “In general, I and others don’t see this fixing any fundamental problems.”
Kelly April Tyrrell is a freelance writer in Madison, Wis.
References
- U.S. Department of Health and Human Services. Medicare program: Hospital Outpatient Prospective Payment and Ambulatory Surgical Center payment systems and quality reporting programs; short inpatient hospital stays; transition for certain Medicare-dependent, small rural hospitals under the Hospital Inpatient Prospective Payment System. July 1, 2015. Accessed July 29, 2015.
- Sheehy AM, Locke C, Engel JZ, et al. Recovery audit contractor audits and appeals at three academic medical centers. J Hosp Med. 2015;10(4):212-219. doi: 10.1002/jhm.2332.
- American Hospital Association. Associations, hospitals challenge two-midnight rule in federal court. April 14, 2014. Accessed July 29, 2015.
- Fishman LE. RE: Two-midnight policy and potential short stay payment solutions [letter]. American Hospital Association. February 13, 2015. Accessed July 29, 2015.
In the wake of proposed changes to the Centers for Medicare and Medicaid Services’ two-midnight rule, physicians say new flexibilities and changes to the policy’s auditing mechanism add more uncertainty and ambiguity.
The 2016 Hospital Outpatient Prospective Payment System and Ambulatory Surgical Center Payment System proposed rule was published on July 1, 2015, and included changes in response to concerns about portions of the original two-midnight rule.1 By classifying an inpatient stay as any hospitalization lasting more than two midnights, the rule, which attempted to clarify which services warranted billing under Part B and which qualified for Part A, initially was intended to limit the long observation stays negatively impacting Medicare beneficiaries. However, aggressive reviews by recovery auditors (RAs) and the notion that physician judgment was taking a backseat to arbitrary CMS policy caused a backlash.
In 2014, CMS solicited feedback on the two-midnight rule. SHM suggested a two-tiered approach to address immediate and long-term patient care needs.
“SHM suggests CMS pursue broader solutions to observation status instead of making minor adjustments to the two-midnight rule,” wrote then-SHM President Burke Kealey, MD, SFHM, in a public comment letter to CMS in June 2014. “However, SHM does recognize that in the interim, the two-midnight policy needs to be refined in order to reflect the realities of patient care. Some situations may not be appropriate for classification as outpatient, regardless of the length of stay.”
The proposed changes were supposed to be a solution, but some are saying that CMS has missed the mark. In trying to give physicians more flexibility to determine patient status at the time of admissions, the rule instead may leave physician judgment open to additional scrutiny. Also, the nature of short inpatient stay reviews by Quality Improvement Organizations (QIOs), rather than RAs, remains unclear, and an additional point of concern involves the question of how RAs will factor in.
“My personal opinion is that it will only muddy the waters, in terms of payment for [and] documentation and reviews of short stays for Medicare beneficiaries,” says Jeannine Engel, MD, FACP, in a statement she wrote and shared by email. Dr. Engel is an internist and physician advisor for billing compliance at University of Utah Health Care in Salt Lake City. “No matter who reviews medical documentation, when subjective criteria are used, there is room for interpretation.”
CMS has not defined what constitutes adequate documentation to justify short inpatient stays, nor has it indicated the threshold for “high rates of denials” that would kick reviews over to RAs.
“Details are lacking, and then what makes it even more confusing is what they’ve done with the tweak in policy is further muddied the definition of inpatient,” says Charles Locke, MD, internist and senior physician advisor at Johns Hopkins University School of Medicine in Baltimore. “Whether you agree or disagree with the two-midnight rule, it actually made more clear what inpatient should be.”
According to CMS, the two-midnight rule has reduced observation stays lasting longer than two midnights by 11%, and inpatient admissions are anticipated to increase. But, physicians say, it’s a billing distinction rather than one that impacts patient care.
“The reality is when you take someone in the hospital as outpatient, they can receive every service and care identical to inpatient,” Dr. Locke says. “CMS seems hung up on the idea that in the hospital there are two levels of care.”
In fact, with the changes, “CMS had all but abandoned the term ‘inpatient hospital care’ in favor of simply ‘hospital care.’ Now it is back,” says Dr. Engel, who is also a professor of medicine at Huntsman Cancer Institute. “The two-midnight rule was a payment policy, not a ‘care policy.’ Now we may be back to debating what constitutes ‘inpatient care’ versus what could have been ‘safely delivered in a different/lower status such as observation.’”
Dr. Engel and Dr. Locke recently published a study of RAs and the two-midnight rule in the Journal of Hospital Medicine, with University of Wisconsin-Madison School of Medicine and Public Health hospitalist Ann Sheehy, MD.2
The AHA-CMS Quarrel
In addition to SHM, other organizations are heartened by CMS’s responsiveness. Priya Bathija, senior associate director of policy at the American Hospital Association, called them a “step in the right direction,” but also highlighted some of the group’s lingering concerns.
“We think it’s a good thing they’re using QIOs as first-line medical review as opposed to RAs, but we still want to make sure RAs will not make inappropriate denials of claims,” Bathija says.
The AHA is fighting a legal battle against the U.S. Department of Health and Human Services over a 0.2% reduction in inpatient payments through the two-midnight rule, maintained in the proposed changes, which CMS says are warranted based on a projected increase in inpatient service claims.3 The AHA disputes these actuarial values, Bathija says.
The AHA is calling upon CMS to make changes to short stay payments and submitted a letter to CMS outlining six models.4 The agency accepted comment on the proposed changes through August 30.
The fundamental issue, however, is that the Medicare payment system is vastly out of date, Dr. Locke says. “What I have advocated is to get rid of Part A and Part B distinction, just like private insurance,” he says, “so when you’re hospitalized, you’re hospitalized, and there is no distinction except inpatient extended, recovery outpatient, or extended outpatient observation.”
If the proposed rule changes are finalized, hospitals are going to have to learn to live with them, despite ambiguous guidance, and adjust their workflow, Dr. Locke says.
“It costs a lot of money and time, and hospitals don’t want to do something thinking they’re doing it in good faith but then the Inspector General says you owe $10 million,” he says. “In general, I and others don’t see this fixing any fundamental problems.”
Kelly April Tyrrell is a freelance writer in Madison, Wis.
References
- U.S. Department of Health and Human Services. Medicare program: Hospital Outpatient Prospective Payment and Ambulatory Surgical Center payment systems and quality reporting programs; short inpatient hospital stays; transition for certain Medicare-dependent, small rural hospitals under the Hospital Inpatient Prospective Payment System. July 1, 2015. Accessed July 29, 2015.
- Sheehy AM, Locke C, Engel JZ, et al. Recovery audit contractor audits and appeals at three academic medical centers. J Hosp Med. 2015;10(4):212-219. doi: 10.1002/jhm.2332.
- American Hospital Association. Associations, hospitals challenge two-midnight rule in federal court. April 14, 2014. Accessed July 29, 2015.
- Fishman LE. RE: Two-midnight policy and potential short stay payment solutions [letter]. American Hospital Association. February 13, 2015. Accessed July 29, 2015.
In the wake of proposed changes to the Centers for Medicare and Medicaid Services’ two-midnight rule, physicians say new flexibilities and changes to the policy’s auditing mechanism add more uncertainty and ambiguity.
The 2016 Hospital Outpatient Prospective Payment System and Ambulatory Surgical Center Payment System proposed rule was published on July 1, 2015, and included changes in response to concerns about portions of the original two-midnight rule.1 By classifying an inpatient stay as any hospitalization lasting more than two midnights, the rule, which attempted to clarify which services warranted billing under Part B and which qualified for Part A, initially was intended to limit the long observation stays negatively impacting Medicare beneficiaries. However, aggressive reviews by recovery auditors (RAs) and the notion that physician judgment was taking a backseat to arbitrary CMS policy caused a backlash.
In 2014, CMS solicited feedback on the two-midnight rule. SHM suggested a two-tiered approach to address immediate and long-term patient care needs.
“SHM suggests CMS pursue broader solutions to observation status instead of making minor adjustments to the two-midnight rule,” wrote then-SHM President Burke Kealey, MD, SFHM, in a public comment letter to CMS in June 2014. “However, SHM does recognize that in the interim, the two-midnight policy needs to be refined in order to reflect the realities of patient care. Some situations may not be appropriate for classification as outpatient, regardless of the length of stay.”
The proposed changes were supposed to be a solution, but some are saying that CMS has missed the mark. In trying to give physicians more flexibility to determine patient status at the time of admissions, the rule instead may leave physician judgment open to additional scrutiny. Also, the nature of short inpatient stay reviews by Quality Improvement Organizations (QIOs), rather than RAs, remains unclear, and an additional point of concern involves the question of how RAs will factor in.
“My personal opinion is that it will only muddy the waters, in terms of payment for [and] documentation and reviews of short stays for Medicare beneficiaries,” says Jeannine Engel, MD, FACP, in a statement she wrote and shared by email. Dr. Engel is an internist and physician advisor for billing compliance at University of Utah Health Care in Salt Lake City. “No matter who reviews medical documentation, when subjective criteria are used, there is room for interpretation.”
CMS has not defined what constitutes adequate documentation to justify short inpatient stays, nor has it indicated the threshold for “high rates of denials” that would kick reviews over to RAs.
“Details are lacking, and then what makes it even more confusing is what they’ve done with the tweak in policy is further muddied the definition of inpatient,” says Charles Locke, MD, internist and senior physician advisor at Johns Hopkins University School of Medicine in Baltimore. “Whether you agree or disagree with the two-midnight rule, it actually made more clear what inpatient should be.”
According to CMS, the two-midnight rule has reduced observation stays lasting longer than two midnights by 11%, and inpatient admissions are anticipated to increase. But, physicians say, it’s a billing distinction rather than one that impacts patient care.
“The reality is when you take someone in the hospital as outpatient, they can receive every service and care identical to inpatient,” Dr. Locke says. “CMS seems hung up on the idea that in the hospital there are two levels of care.”
In fact, with the changes, “CMS had all but abandoned the term ‘inpatient hospital care’ in favor of simply ‘hospital care.’ Now it is back,” says Dr. Engel, who is also a professor of medicine at Huntsman Cancer Institute. “The two-midnight rule was a payment policy, not a ‘care policy.’ Now we may be back to debating what constitutes ‘inpatient care’ versus what could have been ‘safely delivered in a different/lower status such as observation.’”
Dr. Engel and Dr. Locke recently published a study of RAs and the two-midnight rule in the Journal of Hospital Medicine, with University of Wisconsin-Madison School of Medicine and Public Health hospitalist Ann Sheehy, MD.2
The AHA-CMS Quarrel
In addition to SHM, other organizations are heartened by CMS’s responsiveness. Priya Bathija, senior associate director of policy at the American Hospital Association, called them a “step in the right direction,” but also highlighted some of the group’s lingering concerns.
“We think it’s a good thing they’re using QIOs as first-line medical review as opposed to RAs, but we still want to make sure RAs will not make inappropriate denials of claims,” Bathija says.
The AHA is fighting a legal battle against the U.S. Department of Health and Human Services over a 0.2% reduction in inpatient payments through the two-midnight rule, maintained in the proposed changes, which CMS says are warranted based on a projected increase in inpatient service claims.3 The AHA disputes these actuarial values, Bathija says.
The AHA is calling upon CMS to make changes to short stay payments and submitted a letter to CMS outlining six models.4 The agency accepted comment on the proposed changes through August 30.
The fundamental issue, however, is that the Medicare payment system is vastly out of date, Dr. Locke says. “What I have advocated is to get rid of Part A and Part B distinction, just like private insurance,” he says, “so when you’re hospitalized, you’re hospitalized, and there is no distinction except inpatient extended, recovery outpatient, or extended outpatient observation.”
If the proposed rule changes are finalized, hospitals are going to have to learn to live with them, despite ambiguous guidance, and adjust their workflow, Dr. Locke says.
“It costs a lot of money and time, and hospitals don’t want to do something thinking they’re doing it in good faith but then the Inspector General says you owe $10 million,” he says. “In general, I and others don’t see this fixing any fundamental problems.”
Kelly April Tyrrell is a freelance writer in Madison, Wis.
References
- U.S. Department of Health and Human Services. Medicare program: Hospital Outpatient Prospective Payment and Ambulatory Surgical Center payment systems and quality reporting programs; short inpatient hospital stays; transition for certain Medicare-dependent, small rural hospitals under the Hospital Inpatient Prospective Payment System. July 1, 2015. Accessed July 29, 2015.
- Sheehy AM, Locke C, Engel JZ, et al. Recovery audit contractor audits and appeals at three academic medical centers. J Hosp Med. 2015;10(4):212-219. doi: 10.1002/jhm.2332.
- American Hospital Association. Associations, hospitals challenge two-midnight rule in federal court. April 14, 2014. Accessed July 29, 2015.
- Fishman LE. RE: Two-midnight policy and potential short stay payment solutions [letter]. American Hospital Association. February 13, 2015. Accessed July 29, 2015.
Experts Urge Extension to Medicaid's Parity Program
On the last day of 2014, a provision of the Affordable Care Act (ACA) that increased payments to some physicians providing primary care services to the country’s poorest patients expired. The Medicaid payment parity program, under section 1202 of the ACA, increased to Medicare levels Medicaid reimbursement for primary care services rendered by internists, pediatricians, family medicine physicians, some subspecialists, and hospitalists in all states in 2013 and 2014.
A bill introduced in 2015, the Ensuring Access to Primary Care for Women and Children Act—sponsored by Sherrod Brown (D-Ohio) and Patty Murray, (D-W. Va.) in the Senate and Kathy Castor (D-Fla.) in the House—seeks to extend the parity program another two years and expand it to other providers, like obstetricians and nurse practitioners.
The parity program was intended to improve access to healthcare for the millions of Americans newly eligible for Medicaid under the ACA. Currently, one in five Americans is on Medicaid.
Fewer physicians in the U.S. participate in Medicaid than in Medicare or private insurance, and low reimbursement rates are sometimes cited as a cause.1,2 In 2012, fee-for-service Medicaid reimbursement for primary care averaged just 59% of Medicare fee levels nationally, but during the years of increased payment, eligible physicians saw a 73% boost in reimbursement for Medicaid primary care services.1,2
The new bill is similar to one introduced unsuccessfully last year in the Senate, which sought to avoid a lapse in the program. Initially beset by delays, some experts say the program did not last long enough to gather sufficient data or to demonstrate its effectiveness. Others say the short duration of the program prevented new providers from accepting Medicaid patients.3
An extension “would give people the chance to get more data and show the payment increase resulted in a more cost-effective healthcare system,” says Ron Greeno, MD, FCCP, MHM, an SHM board member, chair of SHM’s Public Policy Committee, and chief strategy officer at IPC Healthcare. “Ideally, there would be permanent parity.”
–Dr. Greeno
In February, Dan Polsky, PhD, the Robert D. Eilers professor in healthcare management and economics at the University of Pennsylvania Perelman School of Medicine in Philadelphia, and colleagues published a study in the New England Journal of Medicine that showed an increase in primary care appointments for new Medicaid patients correlating with the temporary increase in reimbursement.4
“We saw a 10% increase in the number of providers willing to see new Medicaid patients,” Dr. Polsky says. “It was an economic behavior test to see how physicians respond to changes in payment rates, because in a lot of states, policy makers are being asked to extend parity, and the typical comment was: ‘We don’t know if it works; it’s not cheap.’”
Indeed, the Congressional Budget Office estimated that the two-year pay increase would cost between $11 and $12 billion.1
“We came up with evidence it works,” Dr. Polsky says.
However, further measures of the parity program’s success remain a challenge, according to the author of a Kaiser Family Foundation brief, because it’s difficult to separate it from other elements of the healthcare law. Studies have also conflicted with regard to the ability of payment boosts to improve access, and the reimbursement increase may not be compatible with a shift away from the fee-for-service model.1
Yet, experts like Dr. Polsky say that to encourage greater participation in Medicaid, some type of parity is needed. “If we’re going to maintain better provider availability, I think you would need something like this,” he says.
For hospitalists, the two-year boost meant the ability to provide better care for hospitalized patients, Dr. Greeno says. Anecdotally, hospitalists reported that it was easier to discharge Medicaid patients to primary care follow-up in the community, he says, and better pay meant better staffing ratios were possible.
As of Jan. 1, 2015, 16 states and the District of Columbia reported that they will continue to reimburse Medicaid primary care services at Medicare levels.2 Dr. Greeno says the disparity between states that reimburse at higher rates for Medicaid and those that won’t could start changing the macroeconomics of medical practice, similar to the situation that occurred when states differentially imposed caps on malpractice liability.
A May 2015 Health Affairs policy brief indicates that, despite the House and Senate bill, Congress is unlikely to act soon on increasing Medicaid reimbursement rates again. Dr. Greeno believes this a mistake.
“From a healthcare policy standpoint, it seems intellectually inconsistent, and from a public health standpoint, is it really justifiable?” he asks. “At the end of the day, the fundamental question is, do we really want to have two classes of access to American healthcare?”
Kelly April Tyrrell is a freelance writer in Madison, Wis.
References
- Paradise J. Henry J. Kaiser Family Foundation. The Kaiser Commission on Medicaid and the Uninsured. Medicaid moving forward. March 9, 2015. Accessed July 7, 2015.
- Tollen L. Medicaid primary care parity. May 11, 2015. Health Affairs online. Accessed July 7, 2015.
- Medicaid and CHIP Payment and Access Commission (MACPAC). March 2015 report to Congress on Medicaid and CHIP, chapter 8: an update on the Medicaid primary care payment increase. Accessed July 7, 2015.
- Polsky D, Richards M, Basseyn S, et al. Appointment availability after increases in Medicaid payments for primary care. N Engl J Med. 2015;372:537-545. doi: 10.1056/NEJMsa1413299.
On the last day of 2014, a provision of the Affordable Care Act (ACA) that increased payments to some physicians providing primary care services to the country’s poorest patients expired. The Medicaid payment parity program, under section 1202 of the ACA, increased to Medicare levels Medicaid reimbursement for primary care services rendered by internists, pediatricians, family medicine physicians, some subspecialists, and hospitalists in all states in 2013 and 2014.
A bill introduced in 2015, the Ensuring Access to Primary Care for Women and Children Act—sponsored by Sherrod Brown (D-Ohio) and Patty Murray, (D-W. Va.) in the Senate and Kathy Castor (D-Fla.) in the House—seeks to extend the parity program another two years and expand it to other providers, like obstetricians and nurse practitioners.
The parity program was intended to improve access to healthcare for the millions of Americans newly eligible for Medicaid under the ACA. Currently, one in five Americans is on Medicaid.
Fewer physicians in the U.S. participate in Medicaid than in Medicare or private insurance, and low reimbursement rates are sometimes cited as a cause.1,2 In 2012, fee-for-service Medicaid reimbursement for primary care averaged just 59% of Medicare fee levels nationally, but during the years of increased payment, eligible physicians saw a 73% boost in reimbursement for Medicaid primary care services.1,2
The new bill is similar to one introduced unsuccessfully last year in the Senate, which sought to avoid a lapse in the program. Initially beset by delays, some experts say the program did not last long enough to gather sufficient data or to demonstrate its effectiveness. Others say the short duration of the program prevented new providers from accepting Medicaid patients.3
An extension “would give people the chance to get more data and show the payment increase resulted in a more cost-effective healthcare system,” says Ron Greeno, MD, FCCP, MHM, an SHM board member, chair of SHM’s Public Policy Committee, and chief strategy officer at IPC Healthcare. “Ideally, there would be permanent parity.”
–Dr. Greeno
In February, Dan Polsky, PhD, the Robert D. Eilers professor in healthcare management and economics at the University of Pennsylvania Perelman School of Medicine in Philadelphia, and colleagues published a study in the New England Journal of Medicine that showed an increase in primary care appointments for new Medicaid patients correlating with the temporary increase in reimbursement.4
“We saw a 10% increase in the number of providers willing to see new Medicaid patients,” Dr. Polsky says. “It was an economic behavior test to see how physicians respond to changes in payment rates, because in a lot of states, policy makers are being asked to extend parity, and the typical comment was: ‘We don’t know if it works; it’s not cheap.’”
Indeed, the Congressional Budget Office estimated that the two-year pay increase would cost between $11 and $12 billion.1
“We came up with evidence it works,” Dr. Polsky says.
However, further measures of the parity program’s success remain a challenge, according to the author of a Kaiser Family Foundation brief, because it’s difficult to separate it from other elements of the healthcare law. Studies have also conflicted with regard to the ability of payment boosts to improve access, and the reimbursement increase may not be compatible with a shift away from the fee-for-service model.1
Yet, experts like Dr. Polsky say that to encourage greater participation in Medicaid, some type of parity is needed. “If we’re going to maintain better provider availability, I think you would need something like this,” he says.
For hospitalists, the two-year boost meant the ability to provide better care for hospitalized patients, Dr. Greeno says. Anecdotally, hospitalists reported that it was easier to discharge Medicaid patients to primary care follow-up in the community, he says, and better pay meant better staffing ratios were possible.
As of Jan. 1, 2015, 16 states and the District of Columbia reported that they will continue to reimburse Medicaid primary care services at Medicare levels.2 Dr. Greeno says the disparity between states that reimburse at higher rates for Medicaid and those that won’t could start changing the macroeconomics of medical practice, similar to the situation that occurred when states differentially imposed caps on malpractice liability.
A May 2015 Health Affairs policy brief indicates that, despite the House and Senate bill, Congress is unlikely to act soon on increasing Medicaid reimbursement rates again. Dr. Greeno believes this a mistake.
“From a healthcare policy standpoint, it seems intellectually inconsistent, and from a public health standpoint, is it really justifiable?” he asks. “At the end of the day, the fundamental question is, do we really want to have two classes of access to American healthcare?”
Kelly April Tyrrell is a freelance writer in Madison, Wis.
References
- Paradise J. Henry J. Kaiser Family Foundation. The Kaiser Commission on Medicaid and the Uninsured. Medicaid moving forward. March 9, 2015. Accessed July 7, 2015.
- Tollen L. Medicaid primary care parity. May 11, 2015. Health Affairs online. Accessed July 7, 2015.
- Medicaid and CHIP Payment and Access Commission (MACPAC). March 2015 report to Congress on Medicaid and CHIP, chapter 8: an update on the Medicaid primary care payment increase. Accessed July 7, 2015.
- Polsky D, Richards M, Basseyn S, et al. Appointment availability after increases in Medicaid payments for primary care. N Engl J Med. 2015;372:537-545. doi: 10.1056/NEJMsa1413299.
On the last day of 2014, a provision of the Affordable Care Act (ACA) that increased payments to some physicians providing primary care services to the country’s poorest patients expired. The Medicaid payment parity program, under section 1202 of the ACA, increased to Medicare levels Medicaid reimbursement for primary care services rendered by internists, pediatricians, family medicine physicians, some subspecialists, and hospitalists in all states in 2013 and 2014.
A bill introduced in 2015, the Ensuring Access to Primary Care for Women and Children Act—sponsored by Sherrod Brown (D-Ohio) and Patty Murray, (D-W. Va.) in the Senate and Kathy Castor (D-Fla.) in the House—seeks to extend the parity program another two years and expand it to other providers, like obstetricians and nurse practitioners.
The parity program was intended to improve access to healthcare for the millions of Americans newly eligible for Medicaid under the ACA. Currently, one in five Americans is on Medicaid.
Fewer physicians in the U.S. participate in Medicaid than in Medicare or private insurance, and low reimbursement rates are sometimes cited as a cause.1,2 In 2012, fee-for-service Medicaid reimbursement for primary care averaged just 59% of Medicare fee levels nationally, but during the years of increased payment, eligible physicians saw a 73% boost in reimbursement for Medicaid primary care services.1,2
The new bill is similar to one introduced unsuccessfully last year in the Senate, which sought to avoid a lapse in the program. Initially beset by delays, some experts say the program did not last long enough to gather sufficient data or to demonstrate its effectiveness. Others say the short duration of the program prevented new providers from accepting Medicaid patients.3
An extension “would give people the chance to get more data and show the payment increase resulted in a more cost-effective healthcare system,” says Ron Greeno, MD, FCCP, MHM, an SHM board member, chair of SHM’s Public Policy Committee, and chief strategy officer at IPC Healthcare. “Ideally, there would be permanent parity.”
–Dr. Greeno
In February, Dan Polsky, PhD, the Robert D. Eilers professor in healthcare management and economics at the University of Pennsylvania Perelman School of Medicine in Philadelphia, and colleagues published a study in the New England Journal of Medicine that showed an increase in primary care appointments for new Medicaid patients correlating with the temporary increase in reimbursement.4
“We saw a 10% increase in the number of providers willing to see new Medicaid patients,” Dr. Polsky says. “It was an economic behavior test to see how physicians respond to changes in payment rates, because in a lot of states, policy makers are being asked to extend parity, and the typical comment was: ‘We don’t know if it works; it’s not cheap.’”
Indeed, the Congressional Budget Office estimated that the two-year pay increase would cost between $11 and $12 billion.1
“We came up with evidence it works,” Dr. Polsky says.
However, further measures of the parity program’s success remain a challenge, according to the author of a Kaiser Family Foundation brief, because it’s difficult to separate it from other elements of the healthcare law. Studies have also conflicted with regard to the ability of payment boosts to improve access, and the reimbursement increase may not be compatible with a shift away from the fee-for-service model.1
Yet, experts like Dr. Polsky say that to encourage greater participation in Medicaid, some type of parity is needed. “If we’re going to maintain better provider availability, I think you would need something like this,” he says.
For hospitalists, the two-year boost meant the ability to provide better care for hospitalized patients, Dr. Greeno says. Anecdotally, hospitalists reported that it was easier to discharge Medicaid patients to primary care follow-up in the community, he says, and better pay meant better staffing ratios were possible.
As of Jan. 1, 2015, 16 states and the District of Columbia reported that they will continue to reimburse Medicaid primary care services at Medicare levels.2 Dr. Greeno says the disparity between states that reimburse at higher rates for Medicaid and those that won’t could start changing the macroeconomics of medical practice, similar to the situation that occurred when states differentially imposed caps on malpractice liability.
A May 2015 Health Affairs policy brief indicates that, despite the House and Senate bill, Congress is unlikely to act soon on increasing Medicaid reimbursement rates again. Dr. Greeno believes this a mistake.
“From a healthcare policy standpoint, it seems intellectually inconsistent, and from a public health standpoint, is it really justifiable?” he asks. “At the end of the day, the fundamental question is, do we really want to have two classes of access to American healthcare?”
Kelly April Tyrrell is a freelance writer in Madison, Wis.
References
- Paradise J. Henry J. Kaiser Family Foundation. The Kaiser Commission on Medicaid and the Uninsured. Medicaid moving forward. March 9, 2015. Accessed July 7, 2015.
- Tollen L. Medicaid primary care parity. May 11, 2015. Health Affairs online. Accessed July 7, 2015.
- Medicaid and CHIP Payment and Access Commission (MACPAC). March 2015 report to Congress on Medicaid and CHIP, chapter 8: an update on the Medicaid primary care payment increase. Accessed July 7, 2015.
- Polsky D, Richards M, Basseyn S, et al. Appointment availability after increases in Medicaid payments for primary care. N Engl J Med. 2015;372:537-545. doi: 10.1056/NEJMsa1413299.
Hospitalist's Study Cited in Federal Recovery Audit Legislation Passed by Senate
Society of Hospital Medicine members have a real impact.
A paper published in the Journal of Hospital Medicine in April by Ann Sheehy, MD, MS, and colleagues was recently cited in Sen. Ben Cardin’s (D-Md.) amendment to the Audit and Appeal Fairness, Integrity, and Reforms in Medicare Act of 2015.1,2 The act aims to improve the accuracy and transparency of recovery audits (RA), which were the subject of testimony given by Dr. Sheehy—a hospitalist at the University of Wisconsin-Madison—by invitation before Congress twice in 2014.
Formally called recovery audit contractors, or RACS, RAs evaluate whether hospitals were overpaid for hospitalizations improperly deemed inpatient rather than outpatient via observation status. In the study cited before the Senate Finance Committee, Dr. Sheehy’s group found a three-fold increase in RA overpayment determinations from 2010 to 2013; concurrently, the number of decisions overturned in favor of cited hospitals, either in discussion or appeal, doubled, going from 36% in 2010 to nearly 70% in 2013.
RAs share a percentage of the money they recover for the Centers for Medicare and Medicaid Services, even when decisions are appealed and won by hospitals. As Dr. Sheehy testified last year: “Unfortunately, these contingency incentives favor aggressive auditing, without transparency, accountability, or repercussions for cases that should never have been audited.”
The bill passed the Senate on June 5, 2015.
References
- Sheehy AM, Locke C, Engel JZ, et al. Recovery audit contractor audits and appeals at three academic medical centers. J Hosp Med. 2015;10(4):212-219. doi: 10.1002/jhm.2332.
- United States Senate Committee on Finance. Master Amendments of the Audit and Appeal Fairness, Integrity, and Reforms in Medicare Act of 2015. Accessed July 7, 2015.
Society of Hospital Medicine members have a real impact.
A paper published in the Journal of Hospital Medicine in April by Ann Sheehy, MD, MS, and colleagues was recently cited in Sen. Ben Cardin’s (D-Md.) amendment to the Audit and Appeal Fairness, Integrity, and Reforms in Medicare Act of 2015.1,2 The act aims to improve the accuracy and transparency of recovery audits (RA), which were the subject of testimony given by Dr. Sheehy—a hospitalist at the University of Wisconsin-Madison—by invitation before Congress twice in 2014.
Formally called recovery audit contractors, or RACS, RAs evaluate whether hospitals were overpaid for hospitalizations improperly deemed inpatient rather than outpatient via observation status. In the study cited before the Senate Finance Committee, Dr. Sheehy’s group found a three-fold increase in RA overpayment determinations from 2010 to 2013; concurrently, the number of decisions overturned in favor of cited hospitals, either in discussion or appeal, doubled, going from 36% in 2010 to nearly 70% in 2013.
RAs share a percentage of the money they recover for the Centers for Medicare and Medicaid Services, even when decisions are appealed and won by hospitals. As Dr. Sheehy testified last year: “Unfortunately, these contingency incentives favor aggressive auditing, without transparency, accountability, or repercussions for cases that should never have been audited.”
The bill passed the Senate on June 5, 2015.
References
- Sheehy AM, Locke C, Engel JZ, et al. Recovery audit contractor audits and appeals at three academic medical centers. J Hosp Med. 2015;10(4):212-219. doi: 10.1002/jhm.2332.
- United States Senate Committee on Finance. Master Amendments of the Audit and Appeal Fairness, Integrity, and Reforms in Medicare Act of 2015. Accessed July 7, 2015.
Society of Hospital Medicine members have a real impact.
A paper published in the Journal of Hospital Medicine in April by Ann Sheehy, MD, MS, and colleagues was recently cited in Sen. Ben Cardin’s (D-Md.) amendment to the Audit and Appeal Fairness, Integrity, and Reforms in Medicare Act of 2015.1,2 The act aims to improve the accuracy and transparency of recovery audits (RA), which were the subject of testimony given by Dr. Sheehy—a hospitalist at the University of Wisconsin-Madison—by invitation before Congress twice in 2014.
Formally called recovery audit contractors, or RACS, RAs evaluate whether hospitals were overpaid for hospitalizations improperly deemed inpatient rather than outpatient via observation status. In the study cited before the Senate Finance Committee, Dr. Sheehy’s group found a three-fold increase in RA overpayment determinations from 2010 to 2013; concurrently, the number of decisions overturned in favor of cited hospitals, either in discussion or appeal, doubled, going from 36% in 2010 to nearly 70% in 2013.
RAs share a percentage of the money they recover for the Centers for Medicare and Medicaid Services, even when decisions are appealed and won by hospitals. As Dr. Sheehy testified last year: “Unfortunately, these contingency incentives favor aggressive auditing, without transparency, accountability, or repercussions for cases that should never have been audited.”
The bill passed the Senate on June 5, 2015.
References
- Sheehy AM, Locke C, Engel JZ, et al. Recovery audit contractor audits and appeals at three academic medical centers. J Hosp Med. 2015;10(4):212-219. doi: 10.1002/jhm.2332.
- United States Senate Committee on Finance. Master Amendments of the Audit and Appeal Fairness, Integrity, and Reforms in Medicare Act of 2015. Accessed July 7, 2015.