Ron Greeno, MD, FCCP, MHM

From the beginning, SHM has consciously and consistently taken a unique approach to its advocacy efforts with the federal government. The advocacy priorities of SHM most often concern issues that we feel have an impact on our patients and the broader delivery system, as opposed to a focus on issues that have direct financial benefit to our members.

This strategy has served SHM well. It has earned respect among policymakers and we have seen significant success for a young and relatively small medical society. The issues where we spend the bulk of our time and effort include advocating for issues like alternative payment models (APMs), which reward care quality as opposed to volume, as well as issues related to data integrity that APMs require. We have advocated strongly for changes to dysfunctional observation status rules, for workforce adequacy and sustainability, and for recognition of the importance of hospital medicine’s contribution to the redesign of our nations delivery system. And SHM will continue to advocate for many other issues identified as being important to hospital medicine and our patients.

This year, for the first time in the two decades that I have served on the SHM Public Policy Committee, Medicare has proposed changes that would create unprecedented financial hardship for hospital medicine groups. Each year, as a part of its advocacy agenda, SHM reviews and comments on proposed changes to the Medicare Physician Fee Schedule (PFS). Among other things, the PFS adjusts payment rates to physicians for specific services. Changes under the PFS are required to be budget neutral. In effect, budget neutrality means that whenever certain services receive an increased payment rate, CMS is required to offset these changes by making cuts to other services. This year, in an effort to correct the long-standing underfunding of primary care services, CMS has increased payment for many Evaluation and Management (E&M) codes associated with outpatient primary care services. However, due to budget neutrality requirements, many inpatient E&M care services will be receiving significant cuts.

The goal of increasing payment rates for primary care services is laudable, as many of these cognitive services have been long underfunded. However, the proposed payment increases will only apply to outpatient E&M codes and not their corresponding inpatient codes. While our outpatient Internal Medicine and Family Practice colleagues will benefit from these changes, inpatient providers, including hospitalists, stand to lose a significant amount revenue. SHM and the hospitalists we represent estimate that the proposed budget neutrality adjustment will lead to an approximate 8 percent decrease in Medicare Fee for Services (FFS) revenue. Hospitalists are among the specialties that will be most impacted from these proposed changes. If put into effect, these proposals will leave hospital medicine behind.

These changes have been proposed at a time when hospitalists, along with their colleagues in critical care and emergency medicine, have been caring for patients on the frontlines of the COVID-19 pandemic at great risk to themselves at their families. While hospitalists are working tirelessly to provide lifesaving care to COVID-positive patients throughout the country, hospitalist groups have struggled financially as a result of the pandemic. Inpatient volumes, and therefore care reimbursement, has dropped significantly. Many hospitalists have already reported pay reductions of 20% or more. Others have seen their shifts reduced, resulting in understaffing, which may compromise the quality of care. For many groups, a Medicare reimbursement cut of this magnitude add fuel to an already strained revenue stream and will not be financially sustainable.

SHM is, of course, fighting back. We are not asking CMS to completely abandon the increases in reimbursement for primary care outpatient codes, and we support properly valuing outpatient care services. However, we are asking CMS to find a solution that does not come at the expense of hospital medicine and the other specialties that care for acutely ill hospitalized patients, including patients with COVID-19. If a better solution requires holding off on the proposal for another year, CMS should do so. Furthermore, SHM is asking Congress to abandon the statutory requirement for budget neutrality in these extraordinary times as CMS and Congress work to find towards a solution that properly values both inpatient and outpatient care services.

To send a message to your representatives urging them to stop these payment cuts, please visit SHM’s Legislative Action Center at www.votervoice.net/SHM/campaigns/77226/respond. You can read our full comments on the Medicare Physician Fee Schedule Proposed Rule at www.hospitalmedicine.org/policy--advocacy/letters/2021-physician-fee-schedule-proposed-rule/.

From the beginning, SHM has consciously and consistently taken a unique approach to its advocacy efforts with the federal government. The advocacy priorities of SHM most often concern issues that we feel have an impact on our patients and the broader delivery system, as opposed to a focus on issues that have direct financial benefit to our members.

This strategy has served SHM well. It has earned respect among policymakers and we have seen significant success for a young and relatively small medical society. The issues where we spend the bulk of our time and effort include advocating for issues like alternative payment models (APMs), which reward care quality as opposed to volume, as well as issues related to data integrity that APMs require. We have advocated strongly for changes to dysfunctional observation status rules, for workforce adequacy and sustainability, and for recognition of the importance of hospital medicine’s contribution to the redesign of our nations delivery system. And SHM will continue to advocate for many other issues identified as being important to hospital medicine and our patients.

This year, for the first time in the two decades that I have served on the SHM Public Policy Committee, Medicare has proposed changes that would create unprecedented financial hardship for hospital medicine groups. Each year, as a part of its advocacy agenda, SHM reviews and comments on proposed changes to the Medicare Physician Fee Schedule (PFS). Among other things, the PFS adjusts payment rates to physicians for specific services. Changes under the PFS are required to be budget neutral. In effect, budget neutrality means that whenever certain services receive an increased payment rate, CMS is required to offset these changes by making cuts to other services. This year, in an effort to correct the long-standing underfunding of primary care services, CMS has increased payment for many Evaluation and Management (E&M) codes associated with outpatient primary care services. However, due to budget neutrality requirements, many inpatient E&M care services will be receiving significant cuts.

The goal of increasing payment rates for primary care services is laudable, as many of these cognitive services have been long underfunded. However, the proposed payment increases will only apply to outpatient E&M codes and not their corresponding inpatient codes. While our outpatient Internal Medicine and Family Practice colleagues will benefit from these changes, inpatient providers, including hospitalists, stand to lose a significant amount revenue. SHM and the hospitalists we represent estimate that the proposed budget neutrality adjustment will lead to an approximate 8 percent decrease in Medicare Fee for Services (FFS) revenue. Hospitalists are among the specialties that will be most impacted from these proposed changes. If put into effect, these proposals will leave hospital medicine behind.

These changes have been proposed at a time when hospitalists, along with their colleagues in critical care and emergency medicine, have been caring for patients on the frontlines of the COVID-19 pandemic at great risk to themselves at their families. While hospitalists are working tirelessly to provide lifesaving care to COVID-positive patients throughout the country, hospitalist groups have struggled financially as a result of the pandemic. Inpatient volumes, and therefore care reimbursement, has dropped significantly. Many hospitalists have already reported pay reductions of 20% or more. Others have seen their shifts reduced, resulting in understaffing, which may compromise the quality of care. For many groups, a Medicare reimbursement cut of this magnitude add fuel to an already strained revenue stream and will not be financially sustainable.

SHM is, of course, fighting back. We are not asking CMS to completely abandon the increases in reimbursement for primary care outpatient codes, and we support properly valuing outpatient care services. However, we are asking CMS to find a solution that does not come at the expense of hospital medicine and the other specialties that care for acutely ill hospitalized patients, including patients with COVID-19. If a better solution requires holding off on the proposal for another year, CMS should do so. Furthermore, SHM is asking Congress to abandon the statutory requirement for budget neutrality in these extraordinary times as CMS and Congress work to find towards a solution that properly values both inpatient and outpatient care services.

To send a message to your representatives urging them to stop these payment cuts, please visit SHM’s Legislative Action Center at www.votervoice.net/SHM/campaigns/77226/respond. You can read our full comments on the Medicare Physician Fee Schedule Proposed Rule at www.hospitalmedicine.org/policy--advocacy/letters/2021-physician-fee-schedule-proposed-rule/.

From the beginning, SHM has consciously and consistently taken a unique approach to its advocacy efforts with the federal government. The advocacy priorities of SHM most often concern issues that we feel have an impact on our patients and the broader delivery system, as opposed to a focus on issues that have direct financial benefit to our members.

This strategy has served SHM well. It has earned respect among policymakers and we have seen significant success for a young and relatively small medical society. The issues where we spend the bulk of our time and effort include advocating for issues like alternative payment models (APMs), which reward care quality as opposed to volume, as well as issues related to data integrity that APMs require. We have advocated strongly for changes to dysfunctional observation status rules, for workforce adequacy and sustainability, and for recognition of the importance of hospital medicine’s contribution to the redesign of our nations delivery system. And SHM will continue to advocate for many other issues identified as being important to hospital medicine and our patients.

This year, for the first time in the two decades that I have served on the SHM Public Policy Committee, Medicare has proposed changes that would create unprecedented financial hardship for hospital medicine groups. Each year, as a part of its advocacy agenda, SHM reviews and comments on proposed changes to the Medicare Physician Fee Schedule (PFS). Among other things, the PFS adjusts payment rates to physicians for specific services. Changes under the PFS are required to be budget neutral. In effect, budget neutrality means that whenever certain services receive an increased payment rate, CMS is required to offset these changes by making cuts to other services. This year, in an effort to correct the long-standing underfunding of primary care services, CMS has increased payment for many Evaluation and Management (E&M) codes associated with outpatient primary care services. However, due to budget neutrality requirements, many inpatient E&M care services will be receiving significant cuts.

The goal of increasing payment rates for primary care services is laudable, as many of these cognitive services have been long underfunded. However, the proposed payment increases will only apply to outpatient E&M codes and not their corresponding inpatient codes. While our outpatient Internal Medicine and Family Practice colleagues will benefit from these changes, inpatient providers, including hospitalists, stand to lose a significant amount revenue. SHM and the hospitalists we represent estimate that the proposed budget neutrality adjustment will lead to an approximate 8 percent decrease in Medicare Fee for Services (FFS) revenue. Hospitalists are among the specialties that will be most impacted from these proposed changes. If put into effect, these proposals will leave hospital medicine behind.

These changes have been proposed at a time when hospitalists, along with their colleagues in critical care and emergency medicine, have been caring for patients on the frontlines of the COVID-19 pandemic at great risk to themselves at their families. While hospitalists are working tirelessly to provide lifesaving care to COVID-positive patients throughout the country, hospitalist groups have struggled financially as a result of the pandemic. Inpatient volumes, and therefore care reimbursement, has dropped significantly. Many hospitalists have already reported pay reductions of 20% or more. Others have seen their shifts reduced, resulting in understaffing, which may compromise the quality of care. For many groups, a Medicare reimbursement cut of this magnitude add fuel to an already strained revenue stream and will not be financially sustainable.

SHM is, of course, fighting back. We are not asking CMS to completely abandon the increases in reimbursement for primary care outpatient codes, and we support properly valuing outpatient care services. However, we are asking CMS to find a solution that does not come at the expense of hospital medicine and the other specialties that care for acutely ill hospitalized patients, including patients with COVID-19. If a better solution requires holding off on the proposal for another year, CMS should do so. Furthermore, SHM is asking Congress to abandon the statutory requirement for budget neutrality in these extraordinary times as CMS and Congress work to find towards a solution that properly values both inpatient and outpatient care services.

To send a message to your representatives urging them to stop these payment cuts, please visit SHM’s Legislative Action Center at www.votervoice.net/SHM/campaigns/77226/respond. You can read our full comments on the Medicare Physician Fee Schedule Proposed Rule at www.hospitalmedicine.org/policy--advocacy/letters/2021-physician-fee-schedule-proposed-rule/.

Editor’s note: The “Legacies of Hospital Medicine” is a recurring opinion column submitted by some of the best and brightest hospitalists in the field, who have helped shape our specialty into what it is today. It is a series of articles that reflect on Hospital Medicine and its evolution over time, from a variety of unique and innovative perspectives.
 

Medical professional societies have many goals and serve numerous functions. Some of these include education and training, professional development, and shaping the perception of their specialty both in the medical world and the public arena. Advocacy and governmental affairs are also on that list. SHM is no exception to that rule, although we have taken what is clearly an unorthodox approach to those efforts and our strategy has resulted in an unusual amount of success for a society of our size and age.

As my contribution to the “Legacies” series, I am calling upon my 20-year history of participation in SHM’s advocacy and policy efforts to describe that approach, recount some of the history of our efforts, and to talk a bit about our current activities, goals, and strategies.

In 1999 the leadership of SHM decided to create the Public Policy Committee and to provide resources for what was, at the time, a single dedicated staff position to support the work of the committee. As nascent as our efforts were, the strategy for entering into the Washington fray was clear. We decided our priorities were first and foremost to educate our “targets” on exactly what a hospitalist was and on the increasing role hospitalists were playing in the American health care system.

The target audience was (and has remained) Congress, the Centers for Medicare and Medicaid Services, and the Medicare Payment Advisory Committee, which is the advisory board tasked to recommend to Congress how Medicare should spend its resources. The goal of this education was to establish our credibility and to advance the notion that we were the experts on care design for acutely ill patients in the inpatient setting. To this end, we decided that, when we met with folks on the Hill, we would ask for nothing for ourselves or our members, an approach that was virtually unheard of in the halls of Congress.

When responding to questions as to why we were not bringing “asks” to our Hill meetings, we would simply comment that we were only offering our services. And whenever they decided to try to make the health care system better and expertise was required regarding redesign of care in the hospital, they should think about us. Our stated goal: improve the delivery system and provide better and more cost-effective care for our patients.

We also exercised what I will call “issue discipline.” With very limited resources it was critical that we limit our issues to ones on which we could have significant impact, and had enough expertise to shape an effective argument. In addition, as we were going to be operating within a highly partisan system and representing members with varying political views, it was highly important that we did not approach issues in a way that resulted in our appearing politically motivated.

That approach took a lot of time and patience. But as a small and relatively under-resourced organization, we saw it as the only way that we could eventually have our message heard. So for many years the small contingent of SHM staff and the members of the Public Policy Committee (PPC) worked quietly to have our specialty and society recognized by policy makers in Washington and Baltimore (where CMS resides). But in the years just prior to and since the passage of the Affordable Care Act, when serious redesign of the American health care system began, our patience started to pay dividends and policy makers actually reached out for our input on issues related to the care of patients admitted to acute care hospitals. In addition, our advocacy efforts started to gain more traction.

Today, our specialty and society are well known by the key health care policymakers at CMS, MedPAC, and the Center for Medicare and Medicaid Innovation (CMMI), the latter of which was created by the ACA and whose role is to test the new alternative payment models (like accountable care organizations and bundled payments) to find out if they actually lead to better outcomes and lower costs. In the halls of Congress, especially with the health care staff for the committees of jurisdiction for federal health care legislation, our society is seen as an “honest broker” and as an organization committed not just to the issues that impact our members, but one that has the improvement of the entire health care system at the top of its priority list. We have been told that this perception gives us a voice that is much more influential than would be expected for a society of our age, size, and resources.

Along the way, the PPC has grown to a committee of 20 select members led by committee chair Joshua Lenchus, DO, RPh, SFHM. The committee is known to be among the most difficult committees to get on, and members commit to hours of work monthly to support our efforts. Our government relations staff in Philadelphia is still small at just three, but they are extremely bright and productive. Director Josh Boswell serves as their extremely capable leader. Josh Lapps and Ellen Boyer round out the incredibly strong team. Recently, my role evolved from being the long-term chairman of the PPC to one of volunteer staff, as the senior advisor for government relations. In this role I hope to support our full time staff, especially in our Washington-facing efforts.

The SHM staff has brought several systemic improvements to our advocacy work, including execution of several highly successful “Hill Days” and, more recently, the establishment of our “Grassroots Network” that allows a wider swath of our membership to get involved in the field. The Hill Days occur during years when the SHM Annual Conference is in Washington, and one of the days includes busing hundreds of hospitalists to Capitol Hill for meetings with their representatives to discuss our advocacy issues. Our next Hill Day will be at the 2019 annual conference, and we will be signing up volunteer members for this unique experience.

The success of our advocacy can be seen in several high-level “wins” over the last few years. Some of the more notable include:

• Successful application to CMS for a specialty code for Hospital Medicine (the C6 designation), so that performance data for hospitalists will be fairly compared with other hospitalists and not with our outpatient colleagues’ performance.
• Successful support of risk adjustment of readmission rates for safety net hospitals.
• Creation of a hardship exemption of Meaningful Use penalties for hospitalists, an initiative that saved our membership approximately $37 million of unfair penalties per year; this ensured a permanent exemption from these penalties within the Medicare Access and CHIP Reauthorization Act.
• Implementation of Advanced Care Planning CPT codes to encourage appropriate use of “end of life” discussions.
• Establishment of a Hospitalist Measure set with CMS.
• Repeal of the Independent Advisory Board earlier this year.
• Creation of the “Facility Based Option” to replace Merit-Based Incentive Payment System reporting for hospital-based physicians including hospitalists. This voluntary method to replace MIPS reporting was first suggested to CMS by SHM, was developed in partnership with CMS, and will be available in 2019.

SHM continues to take the lead on issues that impact the U.S. health care system and our patients. For several years we have been explaining to CMS and Congress the complete dysfunction of observation status, and its negative impact on elderly patients and hospitals. We have taken advantage of the expertise of several members of the PPC, including research currently being done by member Ann Sheehy, MD, SFHM, to publish two iterations of a white paper on the subject, which was widely read by Hill staff and resulted in Dr. Sheehy testifying on the subject to Congress.

More recently, SHM released a consensus statement on the use of opioids in the inpatient setting, along with a policy statement on opioid abuse, both of which have been widely lauded after being distributed to key committees of both chambers of Congress. Our recommendations will undoubtedly be addressed in an opioid bill which, at the time of this writing, is moving to a vote on the Hill.

As the U.S. health care system undergoes a necessary transformation to one in which value creation is tantamount, hospitalists – by the nature of our work – are in a propitious position to guide the development of better federal policy. We still must be judicious in the use of our limited resources and circumspect in our selection of issues. And we must jealously guard the reputation we have cultivated as a medical society that is looking out for the entire health care system and its patients, while we also support our members and their work.

We want to continue to be an organization that, rather than resisting change, is focused on driving positive change through better ideas and intelligent advocacy.
 

Dr. Greeno is senior advisor for government affairs and past president of the Society of Hospital Medicine.

Editor’s note: The “Legacies of Hospital Medicine” is a recurring opinion column submitted by some of the best and brightest hospitalists in the field, who have helped shape our specialty into what it is today. It is a series of articles that reflect on Hospital Medicine and its evolution over time, from a variety of unique and innovative perspectives.
 

Medical professional societies have many goals and serve numerous functions. Some of these include education and training, professional development, and shaping the perception of their specialty both in the medical world and the public arena. Advocacy and governmental affairs are also on that list. SHM is no exception to that rule, although we have taken what is clearly an unorthodox approach to those efforts and our strategy has resulted in an unusual amount of success for a society of our size and age.

As my contribution to the “Legacies” series, I am calling upon my 20-year history of participation in SHM’s advocacy and policy efforts to describe that approach, recount some of the history of our efforts, and to talk a bit about our current activities, goals, and strategies.

In 1999 the leadership of SHM decided to create the Public Policy Committee and to provide resources for what was, at the time, a single dedicated staff position to support the work of the committee. As nascent as our efforts were, the strategy for entering into the Washington fray was clear. We decided our priorities were first and foremost to educate our “targets” on exactly what a hospitalist was and on the increasing role hospitalists were playing in the American health care system.

The target audience was (and has remained) Congress, the Centers for Medicare and Medicaid Services, and the Medicare Payment Advisory Committee, which is the advisory board tasked to recommend to Congress how Medicare should spend its resources. The goal of this education was to establish our credibility and to advance the notion that we were the experts on care design for acutely ill patients in the inpatient setting. To this end, we decided that, when we met with folks on the Hill, we would ask for nothing for ourselves or our members, an approach that was virtually unheard of in the halls of Congress.

When responding to questions as to why we were not bringing “asks” to our Hill meetings, we would simply comment that we were only offering our services. And whenever they decided to try to make the health care system better and expertise was required regarding redesign of care in the hospital, they should think about us. Our stated goal: improve the delivery system and provide better and more cost-effective care for our patients.

We also exercised what I will call “issue discipline.” With very limited resources it was critical that we limit our issues to ones on which we could have significant impact, and had enough expertise to shape an effective argument. In addition, as we were going to be operating within a highly partisan system and representing members with varying political views, it was highly important that we did not approach issues in a way that resulted in our appearing politically motivated.

That approach took a lot of time and patience. But as a small and relatively under-resourced organization, we saw it as the only way that we could eventually have our message heard. So for many years the small contingent of SHM staff and the members of the Public Policy Committee (PPC) worked quietly to have our specialty and society recognized by policy makers in Washington and Baltimore (where CMS resides). But in the years just prior to and since the passage of the Affordable Care Act, when serious redesign of the American health care system began, our patience started to pay dividends and policy makers actually reached out for our input on issues related to the care of patients admitted to acute care hospitals. In addition, our advocacy efforts started to gain more traction.

Today, our specialty and society are well known by the key health care policymakers at CMS, MedPAC, and the Center for Medicare and Medicaid Innovation (CMMI), the latter of which was created by the ACA and whose role is to test the new alternative payment models (like accountable care organizations and bundled payments) to find out if they actually lead to better outcomes and lower costs. In the halls of Congress, especially with the health care staff for the committees of jurisdiction for federal health care legislation, our society is seen as an “honest broker” and as an organization committed not just to the issues that impact our members, but one that has the improvement of the entire health care system at the top of its priority list. We have been told that this perception gives us a voice that is much more influential than would be expected for a society of our age, size, and resources.

Along the way, the PPC has grown to a committee of 20 select members led by committee chair Joshua Lenchus, DO, RPh, SFHM. The committee is known to be among the most difficult committees to get on, and members commit to hours of work monthly to support our efforts. Our government relations staff in Philadelphia is still small at just three, but they are extremely bright and productive. Director Josh Boswell serves as their extremely capable leader. Josh Lapps and Ellen Boyer round out the incredibly strong team. Recently, my role evolved from being the long-term chairman of the PPC to one of volunteer staff, as the senior advisor for government relations. In this role I hope to support our full time staff, especially in our Washington-facing efforts.

The SHM staff has brought several systemic improvements to our advocacy work, including execution of several highly successful “Hill Days” and, more recently, the establishment of our “Grassroots Network” that allows a wider swath of our membership to get involved in the field. The Hill Days occur during years when the SHM Annual Conference is in Washington, and one of the days includes busing hundreds of hospitalists to Capitol Hill for meetings with their representatives to discuss our advocacy issues. Our next Hill Day will be at the 2019 annual conference, and we will be signing up volunteer members for this unique experience.

The success of our advocacy can be seen in several high-level “wins” over the last few years. Some of the more notable include:

• Successful application to CMS for a specialty code for Hospital Medicine (the C6 designation), so that performance data for hospitalists will be fairly compared with other hospitalists and not with our outpatient colleagues’ performance.
• Successful support of risk adjustment of readmission rates for safety net hospitals.
• Creation of a hardship exemption of Meaningful Use penalties for hospitalists, an initiative that saved our membership approximately $37 million of unfair penalties per year; this ensured a permanent exemption from these penalties within the Medicare Access and CHIP Reauthorization Act.
• Implementation of Advanced Care Planning CPT codes to encourage appropriate use of “end of life” discussions.
• Establishment of a Hospitalist Measure set with CMS.
• Repeal of the Independent Advisory Board earlier this year.
• Creation of the “Facility Based Option” to replace Merit-Based Incentive Payment System reporting for hospital-based physicians including hospitalists. This voluntary method to replace MIPS reporting was first suggested to CMS by SHM, was developed in partnership with CMS, and will be available in 2019.

SHM continues to take the lead on issues that impact the U.S. health care system and our patients. For several years we have been explaining to CMS and Congress the complete dysfunction of observation status, and its negative impact on elderly patients and hospitals. We have taken advantage of the expertise of several members of the PPC, including research currently being done by member Ann Sheehy, MD, SFHM, to publish two iterations of a white paper on the subject, which was widely read by Hill staff and resulted in Dr. Sheehy testifying on the subject to Congress.

More recently, SHM released a consensus statement on the use of opioids in the inpatient setting, along with a policy statement on opioid abuse, both of which have been widely lauded after being distributed to key committees of both chambers of Congress. Our recommendations will undoubtedly be addressed in an opioid bill which, at the time of this writing, is moving to a vote on the Hill.

As the U.S. health care system undergoes a necessary transformation to one in which value creation is tantamount, hospitalists – by the nature of our work – are in a propitious position to guide the development of better federal policy. We still must be judicious in the use of our limited resources and circumspect in our selection of issues. And we must jealously guard the reputation we have cultivated as a medical society that is looking out for the entire health care system and its patients, while we also support our members and their work.

We want to continue to be an organization that, rather than resisting change, is focused on driving positive change through better ideas and intelligent advocacy.
 

Dr. Greeno is senior advisor for government affairs and past president of the Society of Hospital Medicine.

Editor’s note: The “Legacies of Hospital Medicine” is a recurring opinion column submitted by some of the best and brightest hospitalists in the field, who have helped shape our specialty into what it is today. It is a series of articles that reflect on Hospital Medicine and its evolution over time, from a variety of unique and innovative perspectives.
 

Medical professional societies have many goals and serve numerous functions. Some of these include education and training, professional development, and shaping the perception of their specialty both in the medical world and the public arena. Advocacy and governmental affairs are also on that list. SHM is no exception to that rule, although we have taken what is clearly an unorthodox approach to those efforts and our strategy has resulted in an unusual amount of success for a society of our size and age.

As my contribution to the “Legacies” series, I am calling upon my 20-year history of participation in SHM’s advocacy and policy efforts to describe that approach, recount some of the history of our efforts, and to talk a bit about our current activities, goals, and strategies.

In 1999 the leadership of SHM decided to create the Public Policy Committee and to provide resources for what was, at the time, a single dedicated staff position to support the work of the committee. As nascent as our efforts were, the strategy for entering into the Washington fray was clear. We decided our priorities were first and foremost to educate our “targets” on exactly what a hospitalist was and on the increasing role hospitalists were playing in the American health care system.

The target audience was (and has remained) Congress, the Centers for Medicare and Medicaid Services, and the Medicare Payment Advisory Committee, which is the advisory board tasked to recommend to Congress how Medicare should spend its resources. The goal of this education was to establish our credibility and to advance the notion that we were the experts on care design for acutely ill patients in the inpatient setting. To this end, we decided that, when we met with folks on the Hill, we would ask for nothing for ourselves or our members, an approach that was virtually unheard of in the halls of Congress.

When responding to questions as to why we were not bringing “asks” to our Hill meetings, we would simply comment that we were only offering our services. And whenever they decided to try to make the health care system better and expertise was required regarding redesign of care in the hospital, they should think about us. Our stated goal: improve the delivery system and provide better and more cost-effective care for our patients.

We also exercised what I will call “issue discipline.” With very limited resources it was critical that we limit our issues to ones on which we could have significant impact, and had enough expertise to shape an effective argument. In addition, as we were going to be operating within a highly partisan system and representing members with varying political views, it was highly important that we did not approach issues in a way that resulted in our appearing politically motivated.

That approach took a lot of time and patience. But as a small and relatively under-resourced organization, we saw it as the only way that we could eventually have our message heard. So for many years the small contingent of SHM staff and the members of the Public Policy Committee (PPC) worked quietly to have our specialty and society recognized by policy makers in Washington and Baltimore (where CMS resides). But in the years just prior to and since the passage of the Affordable Care Act, when serious redesign of the American health care system began, our patience started to pay dividends and policy makers actually reached out for our input on issues related to the care of patients admitted to acute care hospitals. In addition, our advocacy efforts started to gain more traction.

Today, our specialty and society are well known by the key health care policymakers at CMS, MedPAC, and the Center for Medicare and Medicaid Innovation (CMMI), the latter of which was created by the ACA and whose role is to test the new alternative payment models (like accountable care organizations and bundled payments) to find out if they actually lead to better outcomes and lower costs. In the halls of Congress, especially with the health care staff for the committees of jurisdiction for federal health care legislation, our society is seen as an “honest broker” and as an organization committed not just to the issues that impact our members, but one that has the improvement of the entire health care system at the top of its priority list. We have been told that this perception gives us a voice that is much more influential than would be expected for a society of our age, size, and resources.

Along the way, the PPC has grown to a committee of 20 select members led by committee chair Joshua Lenchus, DO, RPh, SFHM. The committee is known to be among the most difficult committees to get on, and members commit to hours of work monthly to support our efforts. Our government relations staff in Philadelphia is still small at just three, but they are extremely bright and productive. Director Josh Boswell serves as their extremely capable leader. Josh Lapps and Ellen Boyer round out the incredibly strong team. Recently, my role evolved from being the long-term chairman of the PPC to one of volunteer staff, as the senior advisor for government relations. In this role I hope to support our full time staff, especially in our Washington-facing efforts.

The SHM staff has brought several systemic improvements to our advocacy work, including execution of several highly successful “Hill Days” and, more recently, the establishment of our “Grassroots Network” that allows a wider swath of our membership to get involved in the field. The Hill Days occur during years when the SHM Annual Conference is in Washington, and one of the days includes busing hundreds of hospitalists to Capitol Hill for meetings with their representatives to discuss our advocacy issues. Our next Hill Day will be at the 2019 annual conference, and we will be signing up volunteer members for this unique experience.

The success of our advocacy can be seen in several high-level “wins” over the last few years. Some of the more notable include:

• Successful application to CMS for a specialty code for Hospital Medicine (the C6 designation), so that performance data for hospitalists will be fairly compared with other hospitalists and not with our outpatient colleagues’ performance.
• Successful support of risk adjustment of readmission rates for safety net hospitals.
• Creation of a hardship exemption of Meaningful Use penalties for hospitalists, an initiative that saved our membership approximately $37 million of unfair penalties per year; this ensured a permanent exemption from these penalties within the Medicare Access and CHIP Reauthorization Act.
• Implementation of Advanced Care Planning CPT codes to encourage appropriate use of “end of life” discussions.
• Establishment of a Hospitalist Measure set with CMS.
• Repeal of the Independent Advisory Board earlier this year.
• Creation of the “Facility Based Option” to replace Merit-Based Incentive Payment System reporting for hospital-based physicians including hospitalists. This voluntary method to replace MIPS reporting was first suggested to CMS by SHM, was developed in partnership with CMS, and will be available in 2019.

SHM continues to take the lead on issues that impact the U.S. health care system and our patients. For several years we have been explaining to CMS and Congress the complete dysfunction of observation status, and its negative impact on elderly patients and hospitals. We have taken advantage of the expertise of several members of the PPC, including research currently being done by member Ann Sheehy, MD, SFHM, to publish two iterations of a white paper on the subject, which was widely read by Hill staff and resulted in Dr. Sheehy testifying on the subject to Congress.

More recently, SHM released a consensus statement on the use of opioids in the inpatient setting, along with a policy statement on opioid abuse, both of which have been widely lauded after being distributed to key committees of both chambers of Congress. Our recommendations will undoubtedly be addressed in an opioid bill which, at the time of this writing, is moving to a vote on the Hill.

As the U.S. health care system undergoes a necessary transformation to one in which value creation is tantamount, hospitalists – by the nature of our work – are in a propitious position to guide the development of better federal policy. We still must be judicious in the use of our limited resources and circumspect in our selection of issues. And we must jealously guard the reputation we have cultivated as a medical society that is looking out for the entire health care system and its patients, while we also support our members and their work.

We want to continue to be an organization that, rather than resisting change, is focused on driving positive change through better ideas and intelligent advocacy.
 

Dr. Greeno is senior advisor for government affairs and past president of the Society of Hospital Medicine.

I hope all of you enjoyed Day 1 as much as I did. The quality and variety of the presentations yesterday were stellar, and I am sure today will be the same.

The day begins with the Best of Research and Innovations, where the cream of the crop from the hundreds of submitted projects will be presented and recognized. Following that will be the Awards of Excellence, Society of Hospital Medicine’s annual celebration of the very best of our members for their years of stellar contributions in areas such as teaching, clinical excellence, and service to hospital medicine. You will be inspired by the accomplishments of our colleagues who are receiving these awards. They demonstrate to all of us how our specialty improves the health care delivered in our nation’s hospitals.

Dr. Greeno is president of the Society of Hospital Medicine and chief strategy officer at IPC Healthcare.

I hope all of you enjoyed Day 1 as much as I did. The quality and variety of the presentations yesterday were stellar, and I am sure today will be the same.

The day begins with the Best of Research and Innovations, where the cream of the crop from the hundreds of submitted projects will be presented and recognized. Following that will be the Awards of Excellence, Society of Hospital Medicine’s annual celebration of the very best of our members for their years of stellar contributions in areas such as teaching, clinical excellence, and service to hospital medicine. You will be inspired by the accomplishments of our colleagues who are receiving these awards. They demonstrate to all of us how our specialty improves the health care delivered in our nation’s hospitals.

Dr. Greeno is president of the Society of Hospital Medicine and chief strategy officer at IPC Healthcare.

I hope all of you enjoyed Day 1 as much as I did. The quality and variety of the presentations yesterday were stellar, and I am sure today will be the same.

The day begins with the Best of Research and Innovations, where the cream of the crop from the hundreds of submitted projects will be presented and recognized. Following that will be the Awards of Excellence, Society of Hospital Medicine’s annual celebration of the very best of our members for their years of stellar contributions in areas such as teaching, clinical excellence, and service to hospital medicine. You will be inspired by the accomplishments of our colleagues who are receiving these awards. They demonstrate to all of us how our specialty improves the health care delivered in our nation’s hospitals.

Dr. Greeno is president of the Society of Hospital Medicine and chief strategy officer at IPC Healthcare.