Medicare

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

1. 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.
2. 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

1. 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.
2. 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

1. 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.
2. 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.

On July 1, 2015, the Centers for Medicare and Medicaid Services (CMS) announced proposed changes to its controversial two-midnight rule. The changes afford physicians more flexibility to determine patient hospitalization status and place primary patient status auditing authority with Quality Improvement Organizations (QIO), rather than the unpopular Recovery Auditor Contractors (RACs).

The original policy was implemented in October 2013 to reduce the number of long observation stays impacting Medicare beneficiaries, which are not payable under Part A and impact coverage for some types of follow-up care. Under the policy, stays under two midnights are considered outpatient while longer stays are considered inpatient. Physicians must decide at time of admission how to designate a patient and provide adequate documentation for the decision. The changes give physicians the authority to designate shorter stays for inpatients based on medical necessity.

According to CMS actuary data published in the 2016 Hospital Outpatient Prospective Payment System and Ambulatory Surgical Center Payment System proposed payment rule, the two-midnight rule is working. Since fiscal year 2013, observation stays longer than two days are down 11%. It also says a related 0.2% reduction in payment for inpatient services is justified based on an increase in the number of inpatient admissions.

The agency has sought public comment on three separate occasions since the policy began but says no suitable alternatives to the rule—other than full repeal—have been offered. While the American Hospital Association has said the changes are a good first step, it and others contend the rule still leaves too much uncertainty.

“There’s so little objectivity, it makes it hard to understand how this is going to be implemented,” says Dr. Lauren Doctoroff, MD, a hospitalist and medical director for utilization management at Beth Israel Deaconess Medical Center in Boston.

While the two-midnight rule has helped Dr. Doctoroff's hospital better determine which stays should be considered inpatient and which observation, when it comes to review of short inpatient stays, CMS has not made clear how much influence RACs will continue to play or how QIOs will be different, she says. The RACs have been unpopular because they share in savings recovered on behalf of CMS even when their aggressive audit decisions are overturned, which studies show happens with frequency. Nor do the changes indicate what constitutes adequate documentation.

“There are so many gray areas,” says Dr. Doctoroff, particularly when physicians treat patients with complex social needs, who may not have a stable situation for discharge. “There are some potential benefits, but it’s unclear how it will work and what role the QIOs take relative to RAs, whether it will be more of the same with a different name. It’s not clear if it’s going to be better.”

Visit our website for more information on CMS' two-midnight rule.

---

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

On July 1, 2015, the Centers for Medicare and Medicaid Services (CMS) announced proposed changes to its controversial two-midnight rule. The changes afford physicians more flexibility to determine patient hospitalization status and place primary patient status auditing authority with Quality Improvement Organizations (QIO), rather than the unpopular Recovery Auditor Contractors (RACs).

The original policy was implemented in October 2013 to reduce the number of long observation stays impacting Medicare beneficiaries, which are not payable under Part A and impact coverage for some types of follow-up care. Under the policy, stays under two midnights are considered outpatient while longer stays are considered inpatient. Physicians must decide at time of admission how to designate a patient and provide adequate documentation for the decision. The changes give physicians the authority to designate shorter stays for inpatients based on medical necessity.

According to CMS actuary data published in the 2016 Hospital Outpatient Prospective Payment System and Ambulatory Surgical Center Payment System proposed payment rule, the two-midnight rule is working. Since fiscal year 2013, observation stays longer than two days are down 11%. It also says a related 0.2% reduction in payment for inpatient services is justified based on an increase in the number of inpatient admissions.

The agency has sought public comment on three separate occasions since the policy began but says no suitable alternatives to the rule—other than full repeal—have been offered. While the American Hospital Association has said the changes are a good first step, it and others contend the rule still leaves too much uncertainty.

“There’s so little objectivity, it makes it hard to understand how this is going to be implemented,” says Dr. Lauren Doctoroff, MD, a hospitalist and medical director for utilization management at Beth Israel Deaconess Medical Center in Boston.

While the two-midnight rule has helped Dr. Doctoroff's hospital better determine which stays should be considered inpatient and which observation, when it comes to review of short inpatient stays, CMS has not made clear how much influence RACs will continue to play or how QIOs will be different, she says. The RACs have been unpopular because they share in savings recovered on behalf of CMS even when their aggressive audit decisions are overturned, which studies show happens with frequency. Nor do the changes indicate what constitutes adequate documentation.

“There are so many gray areas,” says Dr. Doctoroff, particularly when physicians treat patients with complex social needs, who may not have a stable situation for discharge. “There are some potential benefits, but it’s unclear how it will work and what role the QIOs take relative to RAs, whether it will be more of the same with a different name. It’s not clear if it’s going to be better.”

Visit our website for more information on CMS' two-midnight rule.

---

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

On July 1, 2015, the Centers for Medicare and Medicaid Services (CMS) announced proposed changes to its controversial two-midnight rule. The changes afford physicians more flexibility to determine patient hospitalization status and place primary patient status auditing authority with Quality Improvement Organizations (QIO), rather than the unpopular Recovery Auditor Contractors (RACs).

The original policy was implemented in October 2013 to reduce the number of long observation stays impacting Medicare beneficiaries, which are not payable under Part A and impact coverage for some types of follow-up care. Under the policy, stays under two midnights are considered outpatient while longer stays are considered inpatient. Physicians must decide at time of admission how to designate a patient and provide adequate documentation for the decision. The changes give physicians the authority to designate shorter stays for inpatients based on medical necessity.

According to CMS actuary data published in the 2016 Hospital Outpatient Prospective Payment System and Ambulatory Surgical Center Payment System proposed payment rule, the two-midnight rule is working. Since fiscal year 2013, observation stays longer than two days are down 11%. It also says a related 0.2% reduction in payment for inpatient services is justified based on an increase in the number of inpatient admissions.

The agency has sought public comment on three separate occasions since the policy began but says no suitable alternatives to the rule—other than full repeal—have been offered. While the American Hospital Association has said the changes are a good first step, it and others contend the rule still leaves too much uncertainty.

“There’s so little objectivity, it makes it hard to understand how this is going to be implemented,” says Dr. Lauren Doctoroff, MD, a hospitalist and medical director for utilization management at Beth Israel Deaconess Medical Center in Boston.

While the two-midnight rule has helped Dr. Doctoroff's hospital better determine which stays should be considered inpatient and which observation, when it comes to review of short inpatient stays, CMS has not made clear how much influence RACs will continue to play or how QIOs will be different, she says. The RACs have been unpopular because they share in savings recovered on behalf of CMS even when their aggressive audit decisions are overturned, which studies show happens with frequency. Nor do the changes indicate what constitutes adequate documentation.

“There are so many gray areas,” says Dr. Doctoroff, particularly when physicians treat patients with complex social needs, who may not have a stable situation for discharge. “There are some potential benefits, but it’s unclear how it will work and what role the QIOs take relative to RAs, whether it will be more of the same with a different name. It’s not clear if it’s going to be better.”

Visit our website for more information on CMS' two-midnight rule.

---

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

As a hospitalist myself, I have seen firsthand the need for a healthcare system that provides better care, spends dollars more wisely, and keeps people healthier. I practice on weekends taking care of children, many of whom have multiple chronic conditions and fragile social support, and their families. I love patient care; however, too many times, we hospitalists see patients whose fragmented care results in poor outcomes and repeated hospitalizations.

In my current role at the Centers for Medicare and Medicaid Services (CMS), I am pleased to see that Secretary Burwell is confronting these problems head on, with concrete goals for shifting the equation in how we pay for care. Specifically, we announced the goal of moving 30% of payments by 2016 into alternative payment models such as accountable care organizations (ACOs) or bundled payments, where the provider is accountable for total cost of care and quality. We set the goal of 50% of payments in these models by 2018. In 2011, Medicare had essentially zero payments in these models, but by 2014, we have reached 20% and growing in alternative payment models. Hospitalists can play a significant role in this healthcare transformation, and several initiatives in CMS’ Innovation Center, which I lead, are relevant to our work.

Recently, a Department of Health and Human Services (HHS) report showed that an estimated 50,000 fewer patients died in hospitals, 1.3 million fewer adverse events and infections occurred, and approximately $12 billion in healthcare costs were saved as a result of a reduction in hospital-acquired conditions from 2010 to 2013. This progress toward a safer healthcare system occurred during a period of concerted attention directed by hospitals and hospitalists throughout the country at reducing adverse events. These efforts were also due in part to provisions of the Affordable Care Act such as Medicare payment incentives to improve the quality of care and the HHS Partnership for Patients initiative. The Partnership for Patients is a nationwide public-private collaboration that began in April 2011 with two main goals: Reduce preventable hospital-acquired conditions by 40% and 30-day readmissions by 20%. Since the Partnership for Patients was launched, the vast majority of U.S. hospitals and many other stakeholders have joined the collaborative effort and delivered results.

CMS is committed to making even greater progress toward keeping people as safe and healthy as possible. That is why we have launched a second round of Hospital Engagement Network (HEN) contracts to continue reducing preventable hospital-acquired conditions and readmissions. HEN funding will be available to award contracts to national, regional, or state hospital associations, large healthcare organizations, or national affinity organizations that will support hospitals in their efforts to reduce preventable hospital-acquired conditions and readmissions. In February, CMS posted a request for proposals for HEN contracts to continue the success achieved in improving patient safety.

The Partnership for Patients and HENs are just one part of an overall effort by HHS to deliver better care, spend dollars more wisely, and improve health. Initiatives like the Partnership for Patients, accountable care organizations, quality improvement organizations, and others have helped reduce hospital readmissions in Medicare by nearly 8% between January 2012 and December 2013—translating into 150,000 fewer readmissions. Hospitalists have played a major role in these improvements.

On a broader front, CMS is taking action to improve healthcare so patients and their families can get the best care possible. To this end, CMS is focused on three key areas: (1) improving the way providers and hospitals are paid, (2) improving and innovating in care delivery, and (3) sharing information more broadly with providers and hospitals, consumers, and others to support better decisions.

 

When it comes to improving the way providers are paid, we want to reward value and care coordination—rather than volume and care duplication. We have over 25 payment and service delivery models at the CMS Innovation Center, but I will call out three that are particularly relevant to hospitalists. First, the ACO program is demonstrating positive results. Medicare has over 400 ACOs serving almost eight million beneficiaries. The Pioneer ACO program evaluation results demonstrated over $380 million in savings and improved quality—for example, improvement in 28 out of 33 quality measures, including patient experience of care. Based on these results, this model was the first from the CMS Innovation Center to be certified by the CMS actuary, and the Secretary of Health and Human Services announced her intent to expand the model components as a permanent part of the Medicare program through rulemaking. Second, in the Bundled Payments for Care Improvement model, we have thousands of providers (e.g. hospitals, physician groups) in phase 1 determining how they might improve care and considering taking on financial risk. The model includes acute and post-acute care, such as a 90-day episode for hip and knee replacement. We have 500 providers, and more that are willing to take on two-sided financial risk will likely be added in the next quarter. Hospitalists have a large role to play in improving quality and reducing costs in this model. Finally, the State Innovation Model is driving state and local change. In this model, we are funding and partnering with states on comprehensive delivery system reform. Seventeen states are implementing interventions, and 21 states and territories are designing their plans. The state is encouraged to partner with payers, providers, employers, public health entities, and others in the state to strive within the whole state population for better care, smarter spending, and healthier people. Many states are implementing payment models such as ACOs and bundled payments in Medicaid and with private payers. Increasingly, hospital medicine groups are going to value-based in the quality and efficiency of care delivery, both within the hospital walls and for episodes of care. This will entail stronger linkages and teamwork, both within the hospital and with clinicians in the community. It will also require a much stronger focus on predicting which patients are at risk of decompensation and delivering tailored interventions, including care management and technology to monitor patients in the home and other settings.

To improve care delivery, we are supporting providers to find new ways to coordinate and integrate care. For example, discharging a patient from the hospital without clear instructions on how to take care of themselves at home, when they should take their medicines, or when to check back in with the doctor can lead to an unnecessary readmission back into the hospital. This is especially true of individuals who have complex illnesses or diseases that may be more difficult to manage. We are supporting care improvement through a variety of channels, including facilitating hospitals and community groups teaming up to share best practices, and we applaud the Society of Hospital Medicine’s BOOST program, which is focused on peer mentoring and improvement.

Finally, as we look to improve the way information is distributed, we are working to create more transparency on the cost and quality of care, to bring electronic health information to inform care, and to bring the most recent scientific evidence to the point of care so we can bolster clinical decision making. Necessary information needs to be available to the treating physician and patients across settings. We must continue to improve the interoperability and usability of electronic health records so that they can enable improvement and care delivery.

 

I hope that as hospitalists you will take a closer look at the HHS initiatives I’ve described here—and others—and consider becoming a participant. Hospital medicine physicians are already leading many of these initiatives and are a positive force for health system transformation. As I look back on my last four-plus years at CMS (which sometimes feel like 30 years), I am amazed by how much progress we have made in improving the quality of care (e.g. over 95% of measures in CMS quality programs have improved over the last three years), spending dollars more wisely (e.g. lowest cost growth in the last four years in over 50 years), and improving the health of the nation (e.g. decreased smoking rates). Our nation is moving rapidly toward accountable, alternative payment models, including the recent legislation to “fix the SGR,” and I have seen hospitalists lead progress towards adopting these models nationally and locally. A challenge for all of us is to accelerate the pace of positive change and relentlessly pursue improved patient outcomes and a higher performing health system. But I know hospitalists are up to this challenge.

Thank you for all the work that you do every day on behalf of your patients and a better health system.

---

Dr. Conway is a hospitalist, CMS’ chief medical officer, and deputy administrator for innovation and quality. He is a former member of the SHM Public Policy Committee and a frequent speaker at SHM events.

As a hospitalist myself, I have seen firsthand the need for a healthcare system that provides better care, spends dollars more wisely, and keeps people healthier. I practice on weekends taking care of children, many of whom have multiple chronic conditions and fragile social support, and their families. I love patient care; however, too many times, we hospitalists see patients whose fragmented care results in poor outcomes and repeated hospitalizations.

In my current role at the Centers for Medicare and Medicaid Services (CMS), I am pleased to see that Secretary Burwell is confronting these problems head on, with concrete goals for shifting the equation in how we pay for care. Specifically, we announced the goal of moving 30% of payments by 2016 into alternative payment models such as accountable care organizations (ACOs) or bundled payments, where the provider is accountable for total cost of care and quality. We set the goal of 50% of payments in these models by 2018. In 2011, Medicare had essentially zero payments in these models, but by 2014, we have reached 20% and growing in alternative payment models. Hospitalists can play a significant role in this healthcare transformation, and several initiatives in CMS’ Innovation Center, which I lead, are relevant to our work.

Recently, a Department of Health and Human Services (HHS) report showed that an estimated 50,000 fewer patients died in hospitals, 1.3 million fewer adverse events and infections occurred, and approximately $12 billion in healthcare costs were saved as a result of a reduction in hospital-acquired conditions from 2010 to 2013. This progress toward a safer healthcare system occurred during a period of concerted attention directed by hospitals and hospitalists throughout the country at reducing adverse events. These efforts were also due in part to provisions of the Affordable Care Act such as Medicare payment incentives to improve the quality of care and the HHS Partnership for Patients initiative. The Partnership for Patients is a nationwide public-private collaboration that began in April 2011 with two main goals: Reduce preventable hospital-acquired conditions by 40% and 30-day readmissions by 20%. Since the Partnership for Patients was launched, the vast majority of U.S. hospitals and many other stakeholders have joined the collaborative effort and delivered results.

CMS is committed to making even greater progress toward keeping people as safe and healthy as possible. That is why we have launched a second round of Hospital Engagement Network (HEN) contracts to continue reducing preventable hospital-acquired conditions and readmissions. HEN funding will be available to award contracts to national, regional, or state hospital associations, large healthcare organizations, or national affinity organizations that will support hospitals in their efforts to reduce preventable hospital-acquired conditions and readmissions. In February, CMS posted a request for proposals for HEN contracts to continue the success achieved in improving patient safety.

The Partnership for Patients and HENs are just one part of an overall effort by HHS to deliver better care, spend dollars more wisely, and improve health. Initiatives like the Partnership for Patients, accountable care organizations, quality improvement organizations, and others have helped reduce hospital readmissions in Medicare by nearly 8% between January 2012 and December 2013—translating into 150,000 fewer readmissions. Hospitalists have played a major role in these improvements.

On a broader front, CMS is taking action to improve healthcare so patients and their families can get the best care possible. To this end, CMS is focused on three key areas: (1) improving the way providers and hospitals are paid, (2) improving and innovating in care delivery, and (3) sharing information more broadly with providers and hospitals, consumers, and others to support better decisions.

 

When it comes to improving the way providers are paid, we want to reward value and care coordination—rather than volume and care duplication. We have over 25 payment and service delivery models at the CMS Innovation Center, but I will call out three that are particularly relevant to hospitalists. First, the ACO program is demonstrating positive results. Medicare has over 400 ACOs serving almost eight million beneficiaries. The Pioneer ACO program evaluation results demonstrated over $380 million in savings and improved quality—for example, improvement in 28 out of 33 quality measures, including patient experience of care. Based on these results, this model was the first from the CMS Innovation Center to be certified by the CMS actuary, and the Secretary of Health and Human Services announced her intent to expand the model components as a permanent part of the Medicare program through rulemaking. Second, in the Bundled Payments for Care Improvement model, we have thousands of providers (e.g. hospitals, physician groups) in phase 1 determining how they might improve care and considering taking on financial risk. The model includes acute and post-acute care, such as a 90-day episode for hip and knee replacement. We have 500 providers, and more that are willing to take on two-sided financial risk will likely be added in the next quarter. Hospitalists have a large role to play in improving quality and reducing costs in this model. Finally, the State Innovation Model is driving state and local change. In this model, we are funding and partnering with states on comprehensive delivery system reform. Seventeen states are implementing interventions, and 21 states and territories are designing their plans. The state is encouraged to partner with payers, providers, employers, public health entities, and others in the state to strive within the whole state population for better care, smarter spending, and healthier people. Many states are implementing payment models such as ACOs and bundled payments in Medicaid and with private payers. Increasingly, hospital medicine groups are going to value-based in the quality and efficiency of care delivery, both within the hospital walls and for episodes of care. This will entail stronger linkages and teamwork, both within the hospital and with clinicians in the community. It will also require a much stronger focus on predicting which patients are at risk of decompensation and delivering tailored interventions, including care management and technology to monitor patients in the home and other settings.

To improve care delivery, we are supporting providers to find new ways to coordinate and integrate care. For example, discharging a patient from the hospital without clear instructions on how to take care of themselves at home, when they should take their medicines, or when to check back in with the doctor can lead to an unnecessary readmission back into the hospital. This is especially true of individuals who have complex illnesses or diseases that may be more difficult to manage. We are supporting care improvement through a variety of channels, including facilitating hospitals and community groups teaming up to share best practices, and we applaud the Society of Hospital Medicine’s BOOST program, which is focused on peer mentoring and improvement.

Finally, as we look to improve the way information is distributed, we are working to create more transparency on the cost and quality of care, to bring electronic health information to inform care, and to bring the most recent scientific evidence to the point of care so we can bolster clinical decision making. Necessary information needs to be available to the treating physician and patients across settings. We must continue to improve the interoperability and usability of electronic health records so that they can enable improvement and care delivery.

 

I hope that as hospitalists you will take a closer look at the HHS initiatives I’ve described here—and others—and consider becoming a participant. Hospital medicine physicians are already leading many of these initiatives and are a positive force for health system transformation. As I look back on my last four-plus years at CMS (which sometimes feel like 30 years), I am amazed by how much progress we have made in improving the quality of care (e.g. over 95% of measures in CMS quality programs have improved over the last three years), spending dollars more wisely (e.g. lowest cost growth in the last four years in over 50 years), and improving the health of the nation (e.g. decreased smoking rates). Our nation is moving rapidly toward accountable, alternative payment models, including the recent legislation to “fix the SGR,” and I have seen hospitalists lead progress towards adopting these models nationally and locally. A challenge for all of us is to accelerate the pace of positive change and relentlessly pursue improved patient outcomes and a higher performing health system. But I know hospitalists are up to this challenge.

Thank you for all the work that you do every day on behalf of your patients and a better health system.

---

Dr. Conway is a hospitalist, CMS’ chief medical officer, and deputy administrator for innovation and quality. He is a former member of the SHM Public Policy Committee and a frequent speaker at SHM events.

As a hospitalist myself, I have seen firsthand the need for a healthcare system that provides better care, spends dollars more wisely, and keeps people healthier. I practice on weekends taking care of children, many of whom have multiple chronic conditions and fragile social support, and their families. I love patient care; however, too many times, we hospitalists see patients whose fragmented care results in poor outcomes and repeated hospitalizations.

In my current role at the Centers for Medicare and Medicaid Services (CMS), I am pleased to see that Secretary Burwell is confronting these problems head on, with concrete goals for shifting the equation in how we pay for care. Specifically, we announced the goal of moving 30% of payments by 2016 into alternative payment models such as accountable care organizations (ACOs) or bundled payments, where the provider is accountable for total cost of care and quality. We set the goal of 50% of payments in these models by 2018. In 2011, Medicare had essentially zero payments in these models, but by 2014, we have reached 20% and growing in alternative payment models. Hospitalists can play a significant role in this healthcare transformation, and several initiatives in CMS’ Innovation Center, which I lead, are relevant to our work.

Recently, a Department of Health and Human Services (HHS) report showed that an estimated 50,000 fewer patients died in hospitals, 1.3 million fewer adverse events and infections occurred, and approximately $12 billion in healthcare costs were saved as a result of a reduction in hospital-acquired conditions from 2010 to 2013. This progress toward a safer healthcare system occurred during a period of concerted attention directed by hospitals and hospitalists throughout the country at reducing adverse events. These efforts were also due in part to provisions of the Affordable Care Act such as Medicare payment incentives to improve the quality of care and the HHS Partnership for Patients initiative. The Partnership for Patients is a nationwide public-private collaboration that began in April 2011 with two main goals: Reduce preventable hospital-acquired conditions by 40% and 30-day readmissions by 20%. Since the Partnership for Patients was launched, the vast majority of U.S. hospitals and many other stakeholders have joined the collaborative effort and delivered results.

CMS is committed to making even greater progress toward keeping people as safe and healthy as possible. That is why we have launched a second round of Hospital Engagement Network (HEN) contracts to continue reducing preventable hospital-acquired conditions and readmissions. HEN funding will be available to award contracts to national, regional, or state hospital associations, large healthcare organizations, or national affinity organizations that will support hospitals in their efforts to reduce preventable hospital-acquired conditions and readmissions. In February, CMS posted a request for proposals for HEN contracts to continue the success achieved in improving patient safety.

The Partnership for Patients and HENs are just one part of an overall effort by HHS to deliver better care, spend dollars more wisely, and improve health. Initiatives like the Partnership for Patients, accountable care organizations, quality improvement organizations, and others have helped reduce hospital readmissions in Medicare by nearly 8% between January 2012 and December 2013—translating into 150,000 fewer readmissions. Hospitalists have played a major role in these improvements.

On a broader front, CMS is taking action to improve healthcare so patients and their families can get the best care possible. To this end, CMS is focused on three key areas: (1) improving the way providers and hospitals are paid, (2) improving and innovating in care delivery, and (3) sharing information more broadly with providers and hospitals, consumers, and others to support better decisions.

 

When it comes to improving the way providers are paid, we want to reward value and care coordination—rather than volume and care duplication. We have over 25 payment and service delivery models at the CMS Innovation Center, but I will call out three that are particularly relevant to hospitalists. First, the ACO program is demonstrating positive results. Medicare has over 400 ACOs serving almost eight million beneficiaries. The Pioneer ACO program evaluation results demonstrated over $380 million in savings and improved quality—for example, improvement in 28 out of 33 quality measures, including patient experience of care. Based on these results, this model was the first from the CMS Innovation Center to be certified by the CMS actuary, and the Secretary of Health and Human Services announced her intent to expand the model components as a permanent part of the Medicare program through rulemaking. Second, in the Bundled Payments for Care Improvement model, we have thousands of providers (e.g. hospitals, physician groups) in phase 1 determining how they might improve care and considering taking on financial risk. The model includes acute and post-acute care, such as a 90-day episode for hip and knee replacement. We have 500 providers, and more that are willing to take on two-sided financial risk will likely be added in the next quarter. Hospitalists have a large role to play in improving quality and reducing costs in this model. Finally, the State Innovation Model is driving state and local change. In this model, we are funding and partnering with states on comprehensive delivery system reform. Seventeen states are implementing interventions, and 21 states and territories are designing their plans. The state is encouraged to partner with payers, providers, employers, public health entities, and others in the state to strive within the whole state population for better care, smarter spending, and healthier people. Many states are implementing payment models such as ACOs and bundled payments in Medicaid and with private payers. Increasingly, hospital medicine groups are going to value-based in the quality and efficiency of care delivery, both within the hospital walls and for episodes of care. This will entail stronger linkages and teamwork, both within the hospital and with clinicians in the community. It will also require a much stronger focus on predicting which patients are at risk of decompensation and delivering tailored interventions, including care management and technology to monitor patients in the home and other settings.

To improve care delivery, we are supporting providers to find new ways to coordinate and integrate care. For example, discharging a patient from the hospital without clear instructions on how to take care of themselves at home, when they should take their medicines, or when to check back in with the doctor can lead to an unnecessary readmission back into the hospital. This is especially true of individuals who have complex illnesses or diseases that may be more difficult to manage. We are supporting care improvement through a variety of channels, including facilitating hospitals and community groups teaming up to share best practices, and we applaud the Society of Hospital Medicine’s BOOST program, which is focused on peer mentoring and improvement.

Finally, as we look to improve the way information is distributed, we are working to create more transparency on the cost and quality of care, to bring electronic health information to inform care, and to bring the most recent scientific evidence to the point of care so we can bolster clinical decision making. Necessary information needs to be available to the treating physician and patients across settings. We must continue to improve the interoperability and usability of electronic health records so that they can enable improvement and care delivery.

 

I hope that as hospitalists you will take a closer look at the HHS initiatives I’ve described here—and others—and consider becoming a participant. Hospital medicine physicians are already leading many of these initiatives and are a positive force for health system transformation. As I look back on my last four-plus years at CMS (which sometimes feel like 30 years), I am amazed by how much progress we have made in improving the quality of care (e.g. over 95% of measures in CMS quality programs have improved over the last three years), spending dollars more wisely (e.g. lowest cost growth in the last four years in over 50 years), and improving the health of the nation (e.g. decreased smoking rates). Our nation is moving rapidly toward accountable, alternative payment models, including the recent legislation to “fix the SGR,” and I have seen hospitalists lead progress towards adopting these models nationally and locally. A challenge for all of us is to accelerate the pace of positive change and relentlessly pursue improved patient outcomes and a higher performing health system. But I know hospitalists are up to this challenge.

Thank you for all the work that you do every day on behalf of your patients and a better health system.

---

Dr. Conway is a hospitalist, CMS’ chief medical officer, and deputy administrator for innovation and quality. He is a former member of the SHM Public Policy Committee and a frequent speaker at SHM events.

In April, the Centers for Medicare and Medicaid Services (CMS) publicly revealed for the first time which hospitals achieved five stars and which had room for improvement based on patient experience per the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey.

Although these measures are not new, this year CMS assembled the star ratings from HCAHPS survey results and made them available on its consumer-facing website, in an effort to increase transparency.

The decision has not been met without controversy, particularly given the fact that just 251 hospitals out of more than 3,500 received five stars, and only two major teaching hospitals achieved the highest rating. Some professional groups, like the American Hospital Association (AHA), which issued a statement the day CMS released its ratings, believe the rankings risk “oversimplifying the complexity of quality care or misinterpreting what is important to a particular patient, especially since patients seek care for many different reasons.”

Others argue that there is a disconnect between what hospital leaders perceive as important drivers of patient experience and what patients really want. For instance, a 2013 Harvard Business Review article cites a 2012 survey in which C-suite leaders suggested new facilities, private rooms, on-demand food, bedside electronics, and more amenities were necessary to improve patient experience in the hospital.¹

“I am surprised at how much controversy there is on this,” says Ashish Jha, MD, MPH, hospitalist at the VA Boston Healthcare System and professor of health policy at the Harvard T.H. Chan School of Public Health. “Modestly good evidence suggests that hospitals that do well on patient experience scores are also the hospitals that have better patient outcomes on more hard measures, like mortality and evidence-based guidelines.”

Dr. Jha cites a February 2015 study, published in the Journal of Hospital Medicine, in which patients were moved from one clinical building to a newer one with more patient-centered features.² The care team remained the same. The study concluded that patients were able to differentiate between satisfactory clinical care and their surroundings, and that clinical care had a greater impact on patient experience than any other factor.

“Was your pain controlled adequately? Were people responsive to your needs? Were you treated with dignity and respect?” Dr. Jha says. “I think it’s disrespectful to say patients can’t tell the difference between high thread-count bed sheets and being treated with disrespect.”

The HCAHPS survey, Dr. Jha notes, reflects important aspects of healthcare that only patients can report. It encompasses 11 measures that gauge, for example, how well patients felt nurses and physicians communicated with them. It also asks patients to provide an overall hospital rank on a 10-point scale (counting only those that receive a nine or 10), according to Kaiser Health News, and to rate the cleanliness and quietness of the rooms.

Hospitals must send surveys to a random sample of adult patients monthly, including those not on Medicare, within six weeks of discharge, and Inpatient Prospective Payment System hospitals should collect at least 300 surveys every four years, CMS says.

“I think one of the most important things for a hospital to understand is [that] the methodology behind creating the star ratings and the way CMS structures the ratings does make it challenging to achieve the very highest score,” says Akin Demehin, AHA senior associate director of policy.

 

While CMS applies adjustments to account for sampling methods and patient characteristics of hospitals, an analysis by Dr. Jha’s team showed significant disparities between the rankings of large, academic medical centers and those of small, for-profit hospitals, as well as a substantial difference between hospitals that provide for the greatest number of poor patients and those that serve the fewest.³

However, he writes on his blog, "An Ounce of Evidence," that survey methodology is not the problem and that he believes star ratings are a good idea. Although some hospitals might find themselves at score cut-offs—a one-point difference can translate to a full star change—it’s a “small price to pay to make data more accessible to patients,” he writes.

“There is pretty good evidence hospitals are paying attention, and one that gets a one or two-star rating may be motivated to be better,” Dr. Jha says.

“Every hospital is interested in this because it’s part of value-based purchasing,” says Trina Dorrah, MD, MPH, a hospitalist and director of quality at Baylor Scott & White Health in Round Rock, Texas.

Dr. Dorrah has authored two books focused on patient experience, and she suggests simple ways hospitals can work toward improving their HCAHPS scores, and potentially their star ratings, from having nurses round with physicians to installing communication-facilitating whiteboards in every room.

Her hospital also awards bonuses to the hospitalist group for achieving set goals. Some hospitalist programs around the country are also adding questions to their surveys to link individual providers to patient rankings, she said, though many also do it in aggregate, because linking patients to individual physicians can get “very messy.”

CMS advises caution in interpreting star rankings, acknowledging that they are not the only valuable measures of care quality. Despite the concern over the contextual value of the new rankings, Demehin says AHA supports use of the HCAHPS survey and the value of patient experience measures and believes they should be consulted in conjunction with other quality improvement efforts.

“When I’m really sick and I go to the hospital, I want to be treated with dignity and respect and I want my pain treated quickly, but I also want to survive and not develop an infection,” Dr. Jha says. “That’s obviously not in the star ratings.”

---

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

References

1. Merlino J, Raman A. Understanding the drivers of the patient experience. Harvard Business Review. Sept. 17, 2013. Accessed May 14, 2015.
2. Siddiqui Z, Zuccarelli R, Durkin N, Wu AW, Brotman DJ. Changes in patient satisfaction related to hospital renovation: Experience with a new clinical building. J Hosp Med. 2015;10(3):165-171.
3. Jha A. Finding the stars of hospital care in the U.S. An Ounce of Evidence blog. April 20, 2015. Accessed June 4, 2015.

In April, the Centers for Medicare and Medicaid Services (CMS) publicly revealed for the first time which hospitals achieved five stars and which had room for improvement based on patient experience per the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey.

Although these measures are not new, this year CMS assembled the star ratings from HCAHPS survey results and made them available on its consumer-facing website, in an effort to increase transparency.

The decision has not been met without controversy, particularly given the fact that just 251 hospitals out of more than 3,500 received five stars, and only two major teaching hospitals achieved the highest rating. Some professional groups, like the American Hospital Association (AHA), which issued a statement the day CMS released its ratings, believe the rankings risk “oversimplifying the complexity of quality care or misinterpreting what is important to a particular patient, especially since patients seek care for many different reasons.”

Others argue that there is a disconnect between what hospital leaders perceive as important drivers of patient experience and what patients really want. For instance, a 2013 Harvard Business Review article cites a 2012 survey in which C-suite leaders suggested new facilities, private rooms, on-demand food, bedside electronics, and more amenities were necessary to improve patient experience in the hospital.¹

“I am surprised at how much controversy there is on this,” says Ashish Jha, MD, MPH, hospitalist at the VA Boston Healthcare System and professor of health policy at the Harvard T.H. Chan School of Public Health. “Modestly good evidence suggests that hospitals that do well on patient experience scores are also the hospitals that have better patient outcomes on more hard measures, like mortality and evidence-based guidelines.”

Dr. Jha cites a February 2015 study, published in the Journal of Hospital Medicine, in which patients were moved from one clinical building to a newer one with more patient-centered features.² The care team remained the same. The study concluded that patients were able to differentiate between satisfactory clinical care and their surroundings, and that clinical care had a greater impact on patient experience than any other factor.

“Was your pain controlled adequately? Were people responsive to your needs? Were you treated with dignity and respect?” Dr. Jha says. “I think it’s disrespectful to say patients can’t tell the difference between high thread-count bed sheets and being treated with disrespect.”

The HCAHPS survey, Dr. Jha notes, reflects important aspects of healthcare that only patients can report. It encompasses 11 measures that gauge, for example, how well patients felt nurses and physicians communicated with them. It also asks patients to provide an overall hospital rank on a 10-point scale (counting only those that receive a nine or 10), according to Kaiser Health News, and to rate the cleanliness and quietness of the rooms.

Hospitals must send surveys to a random sample of adult patients monthly, including those not on Medicare, within six weeks of discharge, and Inpatient Prospective Payment System hospitals should collect at least 300 surveys every four years, CMS says.

“I think one of the most important things for a hospital to understand is [that] the methodology behind creating the star ratings and the way CMS structures the ratings does make it challenging to achieve the very highest score,” says Akin Demehin, AHA senior associate director of policy.

 

While CMS applies adjustments to account for sampling methods and patient characteristics of hospitals, an analysis by Dr. Jha’s team showed significant disparities between the rankings of large, academic medical centers and those of small, for-profit hospitals, as well as a substantial difference between hospitals that provide for the greatest number of poor patients and those that serve the fewest.³

However, he writes on his blog, "An Ounce of Evidence," that survey methodology is not the problem and that he believes star ratings are a good idea. Although some hospitals might find themselves at score cut-offs—a one-point difference can translate to a full star change—it’s a “small price to pay to make data more accessible to patients,” he writes.

“There is pretty good evidence hospitals are paying attention, and one that gets a one or two-star rating may be motivated to be better,” Dr. Jha says.

“Every hospital is interested in this because it’s part of value-based purchasing,” says Trina Dorrah, MD, MPH, a hospitalist and director of quality at Baylor Scott & White Health in Round Rock, Texas.

Dr. Dorrah has authored two books focused on patient experience, and she suggests simple ways hospitals can work toward improving their HCAHPS scores, and potentially their star ratings, from having nurses round with physicians to installing communication-facilitating whiteboards in every room.

Her hospital also awards bonuses to the hospitalist group for achieving set goals. Some hospitalist programs around the country are also adding questions to their surveys to link individual providers to patient rankings, she said, though many also do it in aggregate, because linking patients to individual physicians can get “very messy.”

CMS advises caution in interpreting star rankings, acknowledging that they are not the only valuable measures of care quality. Despite the concern over the contextual value of the new rankings, Demehin says AHA supports use of the HCAHPS survey and the value of patient experience measures and believes they should be consulted in conjunction with other quality improvement efforts.

“When I’m really sick and I go to the hospital, I want to be treated with dignity and respect and I want my pain treated quickly, but I also want to survive and not develop an infection,” Dr. Jha says. “That’s obviously not in the star ratings.”

---

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

References

1. Merlino J, Raman A. Understanding the drivers of the patient experience. Harvard Business Review. Sept. 17, 2013. Accessed May 14, 2015.
2. Siddiqui Z, Zuccarelli R, Durkin N, Wu AW, Brotman DJ. Changes in patient satisfaction related to hospital renovation: Experience with a new clinical building. J Hosp Med. 2015;10(3):165-171.
3. Jha A. Finding the stars of hospital care in the U.S. An Ounce of Evidence blog. April 20, 2015. Accessed June 4, 2015.

In April, the Centers for Medicare and Medicaid Services (CMS) publicly revealed for the first time which hospitals achieved five stars and which had room for improvement based on patient experience per the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey.

Although these measures are not new, this year CMS assembled the star ratings from HCAHPS survey results and made them available on its consumer-facing website, in an effort to increase transparency.

The decision has not been met without controversy, particularly given the fact that just 251 hospitals out of more than 3,500 received five stars, and only two major teaching hospitals achieved the highest rating. Some professional groups, like the American Hospital Association (AHA), which issued a statement the day CMS released its ratings, believe the rankings risk “oversimplifying the complexity of quality care or misinterpreting what is important to a particular patient, especially since patients seek care for many different reasons.”

Others argue that there is a disconnect between what hospital leaders perceive as important drivers of patient experience and what patients really want. For instance, a 2013 Harvard Business Review article cites a 2012 survey in which C-suite leaders suggested new facilities, private rooms, on-demand food, bedside electronics, and more amenities were necessary to improve patient experience in the hospital.¹

“I am surprised at how much controversy there is on this,” says Ashish Jha, MD, MPH, hospitalist at the VA Boston Healthcare System and professor of health policy at the Harvard T.H. Chan School of Public Health. “Modestly good evidence suggests that hospitals that do well on patient experience scores are also the hospitals that have better patient outcomes on more hard measures, like mortality and evidence-based guidelines.”

Dr. Jha cites a February 2015 study, published in the Journal of Hospital Medicine, in which patients were moved from one clinical building to a newer one with more patient-centered features.² The care team remained the same. The study concluded that patients were able to differentiate between satisfactory clinical care and their surroundings, and that clinical care had a greater impact on patient experience than any other factor.

“Was your pain controlled adequately? Were people responsive to your needs? Were you treated with dignity and respect?” Dr. Jha says. “I think it’s disrespectful to say patients can’t tell the difference between high thread-count bed sheets and being treated with disrespect.”

The HCAHPS survey, Dr. Jha notes, reflects important aspects of healthcare that only patients can report. It encompasses 11 measures that gauge, for example, how well patients felt nurses and physicians communicated with them. It also asks patients to provide an overall hospital rank on a 10-point scale (counting only those that receive a nine or 10), according to Kaiser Health News, and to rate the cleanliness and quietness of the rooms.

Hospitals must send surveys to a random sample of adult patients monthly, including those not on Medicare, within six weeks of discharge, and Inpatient Prospective Payment System hospitals should collect at least 300 surveys every four years, CMS says.

“I think one of the most important things for a hospital to understand is [that] the methodology behind creating the star ratings and the way CMS structures the ratings does make it challenging to achieve the very highest score,” says Akin Demehin, AHA senior associate director of policy.

 

While CMS applies adjustments to account for sampling methods and patient characteristics of hospitals, an analysis by Dr. Jha’s team showed significant disparities between the rankings of large, academic medical centers and those of small, for-profit hospitals, as well as a substantial difference between hospitals that provide for the greatest number of poor patients and those that serve the fewest.³

However, he writes on his blog, "An Ounce of Evidence," that survey methodology is not the problem and that he believes star ratings are a good idea. Although some hospitals might find themselves at score cut-offs—a one-point difference can translate to a full star change—it’s a “small price to pay to make data more accessible to patients,” he writes.

“There is pretty good evidence hospitals are paying attention, and one that gets a one or two-star rating may be motivated to be better,” Dr. Jha says.

“Every hospital is interested in this because it’s part of value-based purchasing,” says Trina Dorrah, MD, MPH, a hospitalist and director of quality at Baylor Scott & White Health in Round Rock, Texas.

Dr. Dorrah has authored two books focused on patient experience, and she suggests simple ways hospitals can work toward improving their HCAHPS scores, and potentially their star ratings, from having nurses round with physicians to installing communication-facilitating whiteboards in every room.

Her hospital also awards bonuses to the hospitalist group for achieving set goals. Some hospitalist programs around the country are also adding questions to their surveys to link individual providers to patient rankings, she said, though many also do it in aggregate, because linking patients to individual physicians can get “very messy.”

CMS advises caution in interpreting star rankings, acknowledging that they are not the only valuable measures of care quality. Despite the concern over the contextual value of the new rankings, Demehin says AHA supports use of the HCAHPS survey and the value of patient experience measures and believes they should be consulted in conjunction with other quality improvement efforts.

“When I’m really sick and I go to the hospital, I want to be treated with dignity and respect and I want my pain treated quickly, but I also want to survive and not develop an infection,” Dr. Jha says. “That’s obviously not in the star ratings.”

---

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

References

1. Merlino J, Raman A. Understanding the drivers of the patient experience. Harvard Business Review. Sept. 17, 2013. Accessed May 14, 2015.
2. Siddiqui Z, Zuccarelli R, Durkin N, Wu AW, Brotman DJ. Changes in patient satisfaction related to hospital renovation: Experience with a new clinical building. J Hosp Med. 2015;10(3):165-171.
3. Jha A. Finding the stars of hospital care in the U.S. An Ounce of Evidence blog. April 20, 2015. Accessed June 4, 2015.

On April 16, President Obama signed into law a bipartisan, bicameral piece of legislation that not only fully repealed the sustainable growth rate (SGR) but also permanently eliminated the recurring threat of physician payment cuts in Medicare.

Along with the SGR repeal, the Medicare Access and CHIP Reauthorization Act, or MACRA, institutes the Merit-based Incentive Payment System (MIPS). Starting in 2019, the MIPS will consolidate all of Medicare’s current quality reporting programs: the Physician Quality Reporting System (PQRS), the Value-Based Payment Modifier (VBPM) Program, and the meaningful use (MU) requirements, and will restructure their associated penalties.

Under current law, however, physicians are still required to participate in PQRS, VBPM, and MU, or face their associated penalties until the MIPS is fully implemented in 2019. MACRA also incentivizes the adoption of alternative payment models (APMs). APMs are broadly defined within the law as models that involve both upside and downside financial risk (e.g. ACOs or bundled payments) or patient-centered medical homes, provided they improve quality without increasing costs or lower costs without decreasing quality. Those participating in and deriving substantial revenue from an approved APM will not only be exempt from reporting within the MIPS, but will also receive an automatic 5% bonus in their Medicare billing.

Pay-for-performance programs lack relevant quality metrics and are structured in ways that do not account for the realities of providing inpatient care, which increasingly result in headaches for hospitalists. MACRA has the potential to alleviate this burden and reshape the way in which hospitalists are measured.

SHM worked closely with key Congressional committees, as they were developing the SGR repeal legislation, to include flexible language that could better align quality measures for hospitalists. As a result, buried deep in the text of MACRA lies a two-sentence section that makes this goal possible. The law authorizes the “use [of] measures used for a payment system other than for physicians, such as measures for inpatient hospitals, for the purposes of the performance categories [quality and resource use].” Permitting the use of measures from other payment systems allows hospitalists to have the opportunity to align their quality and resource use performance with that of their institutions. As this alignment is not allowed under current law, it brings new potential to level the playing field and increase the relevance of hospitalist quality reporting in the future.

SHM has been pressing CMS to pursue this concept for the last three years, and MACRA finally gives CMS clear authority to move ahead.

The law is not overly specific, so it is not exactly clear how this provision will be implemented. SHM will remain vigilant, working with CMS to ensure that the MIPS-related regulations set the stage for more fair assessment of hospitalists when the MIPS goes into effect in 2019.

Although hospitalists face an uphill battle in terms of current PQRS reporting, the flexibility contained in MACRA provides an important first step toward a better pathway to reporting quality measures that are fair and relevant for hospitalists.

---

Ellen Boyer is SHM’s government relations project coordinator.

On April 16, President Obama signed into law a bipartisan, bicameral piece of legislation that not only fully repealed the sustainable growth rate (SGR) but also permanently eliminated the recurring threat of physician payment cuts in Medicare.

Along with the SGR repeal, the Medicare Access and CHIP Reauthorization Act, or MACRA, institutes the Merit-based Incentive Payment System (MIPS). Starting in 2019, the MIPS will consolidate all of Medicare’s current quality reporting programs: the Physician Quality Reporting System (PQRS), the Value-Based Payment Modifier (VBPM) Program, and the meaningful use (MU) requirements, and will restructure their associated penalties.

Under current law, however, physicians are still required to participate in PQRS, VBPM, and MU, or face their associated penalties until the MIPS is fully implemented in 2019. MACRA also incentivizes the adoption of alternative payment models (APMs). APMs are broadly defined within the law as models that involve both upside and downside financial risk (e.g. ACOs or bundled payments) or patient-centered medical homes, provided they improve quality without increasing costs or lower costs without decreasing quality. Those participating in and deriving substantial revenue from an approved APM will not only be exempt from reporting within the MIPS, but will also receive an automatic 5% bonus in their Medicare billing.

Pay-for-performance programs lack relevant quality metrics and are structured in ways that do not account for the realities of providing inpatient care, which increasingly result in headaches for hospitalists. MACRA has the potential to alleviate this burden and reshape the way in which hospitalists are measured.

SHM worked closely with key Congressional committees, as they were developing the SGR repeal legislation, to include flexible language that could better align quality measures for hospitalists. As a result, buried deep in the text of MACRA lies a two-sentence section that makes this goal possible. The law authorizes the “use [of] measures used for a payment system other than for physicians, such as measures for inpatient hospitals, for the purposes of the performance categories [quality and resource use].” Permitting the use of measures from other payment systems allows hospitalists to have the opportunity to align their quality and resource use performance with that of their institutions. As this alignment is not allowed under current law, it brings new potential to level the playing field and increase the relevance of hospitalist quality reporting in the future.

SHM has been pressing CMS to pursue this concept for the last three years, and MACRA finally gives CMS clear authority to move ahead.

The law is not overly specific, so it is not exactly clear how this provision will be implemented. SHM will remain vigilant, working with CMS to ensure that the MIPS-related regulations set the stage for more fair assessment of hospitalists when the MIPS goes into effect in 2019.

Although hospitalists face an uphill battle in terms of current PQRS reporting, the flexibility contained in MACRA provides an important first step toward a better pathway to reporting quality measures that are fair and relevant for hospitalists.

---

Ellen Boyer is SHM’s government relations project coordinator.

On April 16, President Obama signed into law a bipartisan, bicameral piece of legislation that not only fully repealed the sustainable growth rate (SGR) but also permanently eliminated the recurring threat of physician payment cuts in Medicare.

Along with the SGR repeal, the Medicare Access and CHIP Reauthorization Act, or MACRA, institutes the Merit-based Incentive Payment System (MIPS). Starting in 2019, the MIPS will consolidate all of Medicare’s current quality reporting programs: the Physician Quality Reporting System (PQRS), the Value-Based Payment Modifier (VBPM) Program, and the meaningful use (MU) requirements, and will restructure their associated penalties.

Under current law, however, physicians are still required to participate in PQRS, VBPM, and MU, or face their associated penalties until the MIPS is fully implemented in 2019. MACRA also incentivizes the adoption of alternative payment models (APMs). APMs are broadly defined within the law as models that involve both upside and downside financial risk (e.g. ACOs or bundled payments) or patient-centered medical homes, provided they improve quality without increasing costs or lower costs without decreasing quality. Those participating in and deriving substantial revenue from an approved APM will not only be exempt from reporting within the MIPS, but will also receive an automatic 5% bonus in their Medicare billing.

Pay-for-performance programs lack relevant quality metrics and are structured in ways that do not account for the realities of providing inpatient care, which increasingly result in headaches for hospitalists. MACRA has the potential to alleviate this burden and reshape the way in which hospitalists are measured.

SHM worked closely with key Congressional committees, as they were developing the SGR repeal legislation, to include flexible language that could better align quality measures for hospitalists. As a result, buried deep in the text of MACRA lies a two-sentence section that makes this goal possible. The law authorizes the “use [of] measures used for a payment system other than for physicians, such as measures for inpatient hospitals, for the purposes of the performance categories [quality and resource use].” Permitting the use of measures from other payment systems allows hospitalists to have the opportunity to align their quality and resource use performance with that of their institutions. As this alignment is not allowed under current law, it brings new potential to level the playing field and increase the relevance of hospitalist quality reporting in the future.

SHM has been pressing CMS to pursue this concept for the last three years, and MACRA finally gives CMS clear authority to move ahead.

The law is not overly specific, so it is not exactly clear how this provision will be implemented. SHM will remain vigilant, working with CMS to ensure that the MIPS-related regulations set the stage for more fair assessment of hospitalists when the MIPS goes into effect in 2019.

Although hospitalists face an uphill battle in terms of current PQRS reporting, the flexibility contained in MACRA provides an important first step toward a better pathway to reporting quality measures that are fair and relevant for hospitalists.

---

Ellen Boyer is SHM’s government relations project coordinator.

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

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

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

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

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

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

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

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

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

---

Joshua Lapps is SHM’s manager of government relations.

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

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

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

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

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

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

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

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

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

---

Joshua Lapps is SHM’s manager of government relations.

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

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

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

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

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

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

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

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

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

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Joshua Lapps is SHM’s manager of government relations.

NATIONAL HARBOR, Md.—Armed with blue folders chockablock with agendas, talking points, and fact sheets, about 100 hospitalists boarded three charter buses and descended on Capitol Hill last month like a swarm of erudite high schoolers on a class trip.

Clad in state-themed ties, suits, and dresses, the group’s goal was singular: Introduce the concept of hospital medicine to every senator, representative, and Congressional staffer who would take the time to meet them, and let those folks know that SHM and its members stand at the ready to serve as a resource for politicians.

“We don’t go to Washington and say, ‘You need to pay hospitalists more money,’” says SHM CEO Larry Wellikson, MD, MHM. “We go and we say, ‘You have a problem. We have a solution. Why don’t we work together to create the future?’ This is what people need to hear. This is a breath of fresh air, and that’s why we get invited back and we’re part of the discussion.”

This year’s discussion was formally titled Hospitalists on the Hill, version 2015. The turnout always improves when the annual meeting is just across the Potomac River at the Gaylord National Resort & Convention Center, as it has been for three of the past six years. The society ferried hospitalists to the offices of Washington power players with three goals this year:

• Push for support for the Improving Access to Medicare Coverage Act of 2015 (H.R. 1571 and S. 843), as it would adjust Medicare rules to allow observation status to be counted toward the three-day inpatient rule for coverage of care in skilled nursing facilities.
• Ask for support for the Personalize Your Care Act, a soon-to-be-reintroduced bill from U.S. Rep. Earl Blumenauer (D-Ore.) authorizing Medicare to pay for end-of-life care discussions and building in opportunities for patients to participate in their long-term care planning.
• Push for Congress to repeal the sustainable growth rate (SGR) formula and create a “pathway towards payment models that reward quality and efficiency.” This legislative “ask,” to use lobbying parlance, is an evergreen that has been an SHM priority for years.

Jodi Strong, director of operations at Novant Health, a 12-hospital group based in Charlotte, N.C., says that she joined this year’s advocacy pilgrimage for the first time because, in a time of generational upheaval in the American healthcare system, every voice should be heard.

“One vote does make a difference, and I want to be a part of that process,” she says, adding, “Hospitalists are very instrumental in the patient, the care that they receive, where they go after they’ve had a hospital visit, how they connect with the patient’s primary care physician.”

The trick of lobbying is getting those in power to see the world as those in practice do. It helps when the two are friends. H.E. “Chip” Walpole Jr., MS, MD, regional medical director of Select Medical of Greenville, S.C., has known U.S. Rep. Trey Gowdy (R-S.C.) for years. When they talk about medical issues, it helps the congressman get a stethoscope-on-the-ground view.

“He’ll say, ‘I know I can trust Chip and he’ll give me a straight answer for a problem,’” Dr. Walpole says. “Then it’s about inviting them, to say ‘Hey, come and see. You want to learn a little bit more about what we do in the hospital? Come and see our facility.’”

 

And, while many first-time Hill Day attendees get nervous about trying to impress the Beltway, Dr. Walpole views it from the flip side.

“Any time you get to have face-to-face time with one of your Congressional leaders, whether it be a representative or senator, you talk to the people that actually directly influence and impact not only the work that we do, but the work that we do for our patients,” he says. “In that regard, we represent a voice for them, to explain to them who we are and what we do and what our patients’ needs are.

“They depend on us.”

That’s the message that Stephanie Vance, who founded Washington-based Advocacy Associates LLC, pushed as she prepped the laymen lobbyists for more than an hour before sending them off to their meetings. Vance, a 25-year veteran of the political scene, reminded hospitalists during the breakfast prep session that those in Congress are elected to serve—and that means they’re elected to listen.

Hospitalist Gordon Johnson, MD, FACP, FHM, got the message. He’s president of the SHM’s Oregon Chapter, but he had never done a lobbying trip like this before. The appeal was simple and effective to him.

“The more of us that are involved, the more meaningful it is,” he says. “When [members of Congress and their staffs] have people coming from their constituency, that carries a message. It does carry a stronger message.”

But, as with patient discharge, the message is always strongest with good follow-up. Vance, known to many as “the advocacy guru,” urged hospitalists to follow up after their meetings—an occasional phone call or e-mail to let the person know that, should they have any questions, a hospitalist is standing by to provide answers. To Dr. Walpole, a connection like that can be worth more than hiring a white-shoed lobbying firm.

“When you put a face with someone—‘Oh, I know Chip, I know Richard from back home,’—they make a connection with someone that is real and personal to them,” he says. “And, ultimately, that can probably make a bigger difference in influencing how they represent us than anything else.”

---

Richard Quinn is a freelance writer in New Jersey.

NATIONAL HARBOR, Md.—Armed with blue folders chockablock with agendas, talking points, and fact sheets, about 100 hospitalists boarded three charter buses and descended on Capitol Hill last month like a swarm of erudite high schoolers on a class trip.

Clad in state-themed ties, suits, and dresses, the group’s goal was singular: Introduce the concept of hospital medicine to every senator, representative, and Congressional staffer who would take the time to meet them, and let those folks know that SHM and its members stand at the ready to serve as a resource for politicians.

“We don’t go to Washington and say, ‘You need to pay hospitalists more money,’” says SHM CEO Larry Wellikson, MD, MHM. “We go and we say, ‘You have a problem. We have a solution. Why don’t we work together to create the future?’ This is what people need to hear. This is a breath of fresh air, and that’s why we get invited back and we’re part of the discussion.”

This year’s discussion was formally titled Hospitalists on the Hill, version 2015. The turnout always improves when the annual meeting is just across the Potomac River at the Gaylord National Resort & Convention Center, as it has been for three of the past six years. The society ferried hospitalists to the offices of Washington power players with three goals this year:

• Push for support for the Improving Access to Medicare Coverage Act of 2015 (H.R. 1571 and S. 843), as it would adjust Medicare rules to allow observation status to be counted toward the three-day inpatient rule for coverage of care in skilled nursing facilities.
• Ask for support for the Personalize Your Care Act, a soon-to-be-reintroduced bill from U.S. Rep. Earl Blumenauer (D-Ore.) authorizing Medicare to pay for end-of-life care discussions and building in opportunities for patients to participate in their long-term care planning.
• Push for Congress to repeal the sustainable growth rate (SGR) formula and create a “pathway towards payment models that reward quality and efficiency.” This legislative “ask,” to use lobbying parlance, is an evergreen that has been an SHM priority for years.

Jodi Strong, director of operations at Novant Health, a 12-hospital group based in Charlotte, N.C., says that she joined this year’s advocacy pilgrimage for the first time because, in a time of generational upheaval in the American healthcare system, every voice should be heard.

“One vote does make a difference, and I want to be a part of that process,” she says, adding, “Hospitalists are very instrumental in the patient, the care that they receive, where they go after they’ve had a hospital visit, how they connect with the patient’s primary care physician.”

The trick of lobbying is getting those in power to see the world as those in practice do. It helps when the two are friends. H.E. “Chip” Walpole Jr., MS, MD, regional medical director of Select Medical of Greenville, S.C., has known U.S. Rep. Trey Gowdy (R-S.C.) for years. When they talk about medical issues, it helps the congressman get a stethoscope-on-the-ground view.

“He’ll say, ‘I know I can trust Chip and he’ll give me a straight answer for a problem,’” Dr. Walpole says. “Then it’s about inviting them, to say ‘Hey, come and see. You want to learn a little bit more about what we do in the hospital? Come and see our facility.’”

 

And, while many first-time Hill Day attendees get nervous about trying to impress the Beltway, Dr. Walpole views it from the flip side.

“Any time you get to have face-to-face time with one of your Congressional leaders, whether it be a representative or senator, you talk to the people that actually directly influence and impact not only the work that we do, but the work that we do for our patients,” he says. “In that regard, we represent a voice for them, to explain to them who we are and what we do and what our patients’ needs are.

“They depend on us.”

That’s the message that Stephanie Vance, who founded Washington-based Advocacy Associates LLC, pushed as she prepped the laymen lobbyists for more than an hour before sending them off to their meetings. Vance, a 25-year veteran of the political scene, reminded hospitalists during the breakfast prep session that those in Congress are elected to serve—and that means they’re elected to listen.

Hospitalist Gordon Johnson, MD, FACP, FHM, got the message. He’s president of the SHM’s Oregon Chapter, but he had never done a lobbying trip like this before. The appeal was simple and effective to him.

“The more of us that are involved, the more meaningful it is,” he says. “When [members of Congress and their staffs] have people coming from their constituency, that carries a message. It does carry a stronger message.”

But, as with patient discharge, the message is always strongest with good follow-up. Vance, known to many as “the advocacy guru,” urged hospitalists to follow up after their meetings—an occasional phone call or e-mail to let the person know that, should they have any questions, a hospitalist is standing by to provide answers. To Dr. Walpole, a connection like that can be worth more than hiring a white-shoed lobbying firm.

“When you put a face with someone—‘Oh, I know Chip, I know Richard from back home,’—they make a connection with someone that is real and personal to them,” he says. “And, ultimately, that can probably make a bigger difference in influencing how they represent us than anything else.”

---

Richard Quinn is a freelance writer in New Jersey.

NATIONAL HARBOR, Md.—Armed with blue folders chockablock with agendas, talking points, and fact sheets, about 100 hospitalists boarded three charter buses and descended on Capitol Hill last month like a swarm of erudite high schoolers on a class trip.

Clad in state-themed ties, suits, and dresses, the group’s goal was singular: Introduce the concept of hospital medicine to every senator, representative, and Congressional staffer who would take the time to meet them, and let those folks know that SHM and its members stand at the ready to serve as a resource for politicians.

“We don’t go to Washington and say, ‘You need to pay hospitalists more money,’” says SHM CEO Larry Wellikson, MD, MHM. “We go and we say, ‘You have a problem. We have a solution. Why don’t we work together to create the future?’ This is what people need to hear. This is a breath of fresh air, and that’s why we get invited back and we’re part of the discussion.”

This year’s discussion was formally titled Hospitalists on the Hill, version 2015. The turnout always improves when the annual meeting is just across the Potomac River at the Gaylord National Resort & Convention Center, as it has been for three of the past six years. The society ferried hospitalists to the offices of Washington power players with three goals this year:

• Push for support for the Improving Access to Medicare Coverage Act of 2015 (H.R. 1571 and S. 843), as it would adjust Medicare rules to allow observation status to be counted toward the three-day inpatient rule for coverage of care in skilled nursing facilities.
• Ask for support for the Personalize Your Care Act, a soon-to-be-reintroduced bill from U.S. Rep. Earl Blumenauer (D-Ore.) authorizing Medicare to pay for end-of-life care discussions and building in opportunities for patients to participate in their long-term care planning.
• Push for Congress to repeal the sustainable growth rate (SGR) formula and create a “pathway towards payment models that reward quality and efficiency.” This legislative “ask,” to use lobbying parlance, is an evergreen that has been an SHM priority for years.

Jodi Strong, director of operations at Novant Health, a 12-hospital group based in Charlotte, N.C., says that she joined this year’s advocacy pilgrimage for the first time because, in a time of generational upheaval in the American healthcare system, every voice should be heard.

“One vote does make a difference, and I want to be a part of that process,” she says, adding, “Hospitalists are very instrumental in the patient, the care that they receive, where they go after they’ve had a hospital visit, how they connect with the patient’s primary care physician.”

The trick of lobbying is getting those in power to see the world as those in practice do. It helps when the two are friends. H.E. “Chip” Walpole Jr., MS, MD, regional medical director of Select Medical of Greenville, S.C., has known U.S. Rep. Trey Gowdy (R-S.C.) for years. When they talk about medical issues, it helps the congressman get a stethoscope-on-the-ground view.

“He’ll say, ‘I know I can trust Chip and he’ll give me a straight answer for a problem,’” Dr. Walpole says. “Then it’s about inviting them, to say ‘Hey, come and see. You want to learn a little bit more about what we do in the hospital? Come and see our facility.’”

 

And, while many first-time Hill Day attendees get nervous about trying to impress the Beltway, Dr. Walpole views it from the flip side.

“Any time you get to have face-to-face time with one of your Congressional leaders, whether it be a representative or senator, you talk to the people that actually directly influence and impact not only the work that we do, but the work that we do for our patients,” he says. “In that regard, we represent a voice for them, to explain to them who we are and what we do and what our patients’ needs are.

“They depend on us.”

That’s the message that Stephanie Vance, who founded Washington-based Advocacy Associates LLC, pushed as she prepped the laymen lobbyists for more than an hour before sending them off to their meetings. Vance, a 25-year veteran of the political scene, reminded hospitalists during the breakfast prep session that those in Congress are elected to serve—and that means they’re elected to listen.

Hospitalist Gordon Johnson, MD, FACP, FHM, got the message. He’s president of the SHM’s Oregon Chapter, but he had never done a lobbying trip like this before. The appeal was simple and effective to him.

“The more of us that are involved, the more meaningful it is,” he says. “When [members of Congress and their staffs] have people coming from their constituency, that carries a message. It does carry a stronger message.”

But, as with patient discharge, the message is always strongest with good follow-up. Vance, known to many as “the advocacy guru,” urged hospitalists to follow up after their meetings—an occasional phone call or e-mail to let the person know that, should they have any questions, a hospitalist is standing by to provide answers. To Dr. Walpole, a connection like that can be worth more than hiring a white-shoed lobbying firm.

“When you put a face with someone—‘Oh, I know Chip, I know Richard from back home,’—they make a connection with someone that is real and personal to them,” he says. “And, ultimately, that can probably make a bigger difference in influencing how they represent us than anything else.”

---

Richard Quinn is a freelance writer in New Jersey.

The long awaited permanent repeal of the poorly designed Sustainable Growth Rate (SGR) came just in time to avert the 21.2% Medicare physician payment cut that would have taken effect on April 1st, 2015. The SGR formula was first enacted in the Balanced Budget Act of 1997 with the intent to control Medicare spending on physician services. The federal budget sequester in the Budget Control Act of 2011 led to heightened speculation of doom and gloom about the U.S. debt and, ultimately, the necessity of a massive reduction in Medicare payments. Over the past decade, lawmakers have managed to pass 17 various delays and adjustments to keep spending in line with the target SGR. In its place, Congress finally passed H.R. 2, the Medicare Access and CHIP Reauthorization Act (MACRA), which was signed into law by President Obama on April 16, 2015.

What physicians should expect:

(1) The bill includes a 0.5% physician pay increase per year for the next five years beginning July 1, 2015.

(2) It incentivizes physicians to use alternate payment models that focus on care coordination and preventive care.

(3) It consolidates the three existing Medicare quality reporting programs known as the Physician Quality Reporting System (PQRS), Meaningful Use of Electronic Health Records, and the Physician Value-Based Payment Modifier, as well as their associated penalties into a single value-based performance program called the Merit-based Incentive Payment System (MIPS) which starts in 2019.

Is this good for hospitalists? While hospitalists are now protected from the 21% pay cut, we are still faced with increasing burden of legislative mandates on quality metrics. This has created unique challenges for acute inpatient care. The current individual incentive programs will remain in effect until MIPS in 2019, mandating the reporting of PQRS and VBPMs in order to avoid penalties. As such, we will need to continue to focus our efforts on meeting these challenges by aligning our performance measures with that of our institutions. This includes helping to develop alternative payment mechanisms (APMs), such as accountable care organizations (ACOs), patient-centered medical homes, bundled-payment arrangements, and other models. Of note, physicians involved in APMs will not be subject to MIPS assessment and will receive an annual 5% increase from 2019-2024.

The legislation creates other concerns such as the planned enforcement of Medicare's “2-midnight” rule, the requirement of EHR to be interoperable by the end of 2018, and the uncertainty of fairness of CMS in assessing quality and incentive payments. And the question remains, will Congress shift its attention to lowering payments for hospitals and non-physician providers to offset the once expected Medicare cuts? Hospitalists are distinctively qualified to potentially make headway given our already very active involvement in hospital process improvements. It will be in our best interest to stay vocal at the hospital, local, and national level.

The long awaited permanent repeal of the poorly designed Sustainable Growth Rate (SGR) came just in time to avert the 21.2% Medicare physician payment cut that would have taken effect on April 1st, 2015. The SGR formula was first enacted in the Balanced Budget Act of 1997 with the intent to control Medicare spending on physician services. The federal budget sequester in the Budget Control Act of 2011 led to heightened speculation of doom and gloom about the U.S. debt and, ultimately, the necessity of a massive reduction in Medicare payments. Over the past decade, lawmakers have managed to pass 17 various delays and adjustments to keep spending in line with the target SGR. In its place, Congress finally passed H.R. 2, the Medicare Access and CHIP Reauthorization Act (MACRA), which was signed into law by President Obama on April 16, 2015.

What physicians should expect:

(1) The bill includes a 0.5% physician pay increase per year for the next five years beginning July 1, 2015.

(2) It incentivizes physicians to use alternate payment models that focus on care coordination and preventive care.

(3) It consolidates the three existing Medicare quality reporting programs known as the Physician Quality Reporting System (PQRS), Meaningful Use of Electronic Health Records, and the Physician Value-Based Payment Modifier, as well as their associated penalties into a single value-based performance program called the Merit-based Incentive Payment System (MIPS) which starts in 2019.

Is this good for hospitalists? While hospitalists are now protected from the 21% pay cut, we are still faced with increasing burden of legislative mandates on quality metrics. This has created unique challenges for acute inpatient care. The current individual incentive programs will remain in effect until MIPS in 2019, mandating the reporting of PQRS and VBPMs in order to avoid penalties. As such, we will need to continue to focus our efforts on meeting these challenges by aligning our performance measures with that of our institutions. This includes helping to develop alternative payment mechanisms (APMs), such as accountable care organizations (ACOs), patient-centered medical homes, bundled-payment arrangements, and other models. Of note, physicians involved in APMs will not be subject to MIPS assessment and will receive an annual 5% increase from 2019-2024.

The legislation creates other concerns such as the planned enforcement of Medicare's “2-midnight” rule, the requirement of EHR to be interoperable by the end of 2018, and the uncertainty of fairness of CMS in assessing quality and incentive payments. And the question remains, will Congress shift its attention to lowering payments for hospitals and non-physician providers to offset the once expected Medicare cuts? Hospitalists are distinctively qualified to potentially make headway given our already very active involvement in hospital process improvements. It will be in our best interest to stay vocal at the hospital, local, and national level.

The long awaited permanent repeal of the poorly designed Sustainable Growth Rate (SGR) came just in time to avert the 21.2% Medicare physician payment cut that would have taken effect on April 1st, 2015. The SGR formula was first enacted in the Balanced Budget Act of 1997 with the intent to control Medicare spending on physician services. The federal budget sequester in the Budget Control Act of 2011 led to heightened speculation of doom and gloom about the U.S. debt and, ultimately, the necessity of a massive reduction in Medicare payments. Over the past decade, lawmakers have managed to pass 17 various delays and adjustments to keep spending in line with the target SGR. In its place, Congress finally passed H.R. 2, the Medicare Access and CHIP Reauthorization Act (MACRA), which was signed into law by President Obama on April 16, 2015.

What physicians should expect:

(1) The bill includes a 0.5% physician pay increase per year for the next five years beginning July 1, 2015.

(2) It incentivizes physicians to use alternate payment models that focus on care coordination and preventive care.

(3) It consolidates the three existing Medicare quality reporting programs known as the Physician Quality Reporting System (PQRS), Meaningful Use of Electronic Health Records, and the Physician Value-Based Payment Modifier, as well as their associated penalties into a single value-based performance program called the Merit-based Incentive Payment System (MIPS) which starts in 2019.

Is this good for hospitalists? While hospitalists are now protected from the 21% pay cut, we are still faced with increasing burden of legislative mandates on quality metrics. This has created unique challenges for acute inpatient care. The current individual incentive programs will remain in effect until MIPS in 2019, mandating the reporting of PQRS and VBPMs in order to avoid penalties. As such, we will need to continue to focus our efforts on meeting these challenges by aligning our performance measures with that of our institutions. This includes helping to develop alternative payment mechanisms (APMs), such as accountable care organizations (ACOs), patient-centered medical homes, bundled-payment arrangements, and other models. Of note, physicians involved in APMs will not be subject to MIPS assessment and will receive an annual 5% increase from 2019-2024.

The legislation creates other concerns such as the planned enforcement of Medicare's “2-midnight” rule, the requirement of EHR to be interoperable by the end of 2018, and the uncertainty of fairness of CMS in assessing quality and incentive payments. And the question remains, will Congress shift its attention to lowering payments for hospitals and non-physician providers to offset the once expected Medicare cuts? Hospitalists are distinctively qualified to potentially make headway given our already very active involvement in hospital process improvements. It will be in our best interest to stay vocal at the hospital, local, and national level.

HM15 Session: Putting Your Nickel Down: The What, Why, and How of Implementing Physician Value-Based Purchasing in Your Practice

Presenters: Stephen Besch, Simone Karp RPh, Patrick Torcson MD MMM SFHM, Gregory Seymann MD SFHM

Summation: HHS has set a goal of tying increasing percentages of Medicare payments to quality or value through alternative payment models, such as Accountable Care Organizations (ACOs) or bundled payment arrangements. By the end of 2018 the goal is for 50% of Medicare payments to be tied to these alternative payment models.   For the remaining traditional Medicare payment arrangements, 90% of those will be tied to quality/value incentives by 2018.

Medicare is transforming itself from a “passive payer” to an “active purchaser” of high quality, efficient healthcare. As such- active participation by physicians, physician groups, and hospitals is required for payment eligibility.

At the physician/group level, hospitalists should be reporting PQRS measures. Incentive payments for PQRS ended in 2014, Medicare is now making “negative payment adjustments.” Penalties are equal to a percentage of all Medicare Part B FFS (Fee-for-Service) charges and there is a 2-year delay between reporting or performance failure and penalization.

Physician Value-Based Purchasing (P-VBP) affects all Eligible Providers (EPs) in 2015. P4P (Pay for Performance) assesses both quality and cost. Aim is for budget neutrality via “quality tiering” which rewards “high quality/low cost” practices with penalties from “low quality/high cost” practices. As of now (2015) ACPs and therapists can be penalized under P-VBP.

Key Points/HM Takeaways:

• Hospitalists should be reporting PQRS measures- penalty phase has begun
• Key PQRS Changes for 2015:

  • 6 measures applicable to inpatient billing removed
  • no useful inpatient measures added
  • penalty avoidance requires 9 measures at 50% or higher rates, covering at least 3 of the 6 NQS (National Quality Strategy) domains- including 1 cross-cutting measure
  • all 2015 PQRS data will be posted to Physician Compare website in 2016
  • 3 Examples of hospitalist applicable “cross-cutting measures” are

    • 47-advance care plan
    • 130-documentation of current medications
    • 317-preventative care: bp screening

  • PQRS data must be reported with respect to MAV clusters (Measure Applicability Validation)- reporting only measure that have no MAV cluster is a safe strategy so long as one of the measures is “cross-cutting”
  • Maximum P-VBP penalties automatically apply if group does not report enough PQRS data
  • visit CMS website for more information

HM15 Session: Putting Your Nickel Down: The What, Why, and How of Implementing Physician Value-Based Purchasing in Your Practice

Presenters: Stephen Besch, Simone Karp RPh, Patrick Torcson MD MMM SFHM, Gregory Seymann MD SFHM

Summation: HHS has set a goal of tying increasing percentages of Medicare payments to quality or value through alternative payment models, such as Accountable Care Organizations (ACOs) or bundled payment arrangements. By the end of 2018 the goal is for 50% of Medicare payments to be tied to these alternative payment models.   For the remaining traditional Medicare payment arrangements, 90% of those will be tied to quality/value incentives by 2018.

Medicare is transforming itself from a “passive payer” to an “active purchaser” of high quality, efficient healthcare. As such- active participation by physicians, physician groups, and hospitals is required for payment eligibility.

At the physician/group level, hospitalists should be reporting PQRS measures. Incentive payments for PQRS ended in 2014, Medicare is now making “negative payment adjustments.” Penalties are equal to a percentage of all Medicare Part B FFS (Fee-for-Service) charges and there is a 2-year delay between reporting or performance failure and penalization.

Physician Value-Based Purchasing (P-VBP) affects all Eligible Providers (EPs) in 2015. P4P (Pay for Performance) assesses both quality and cost. Aim is for budget neutrality via “quality tiering” which rewards “high quality/low cost” practices with penalties from “low quality/high cost” practices. As of now (2015) ACPs and therapists can be penalized under P-VBP.

Key Points/HM Takeaways:

• Hospitalists should be reporting PQRS measures- penalty phase has begun
• Key PQRS Changes for 2015:

  • 6 measures applicable to inpatient billing removed
  • no useful inpatient measures added
  • penalty avoidance requires 9 measures at 50% or higher rates, covering at least 3 of the 6 NQS (National Quality Strategy) domains- including 1 cross-cutting measure
  • all 2015 PQRS data will be posted to Physician Compare website in 2016
  • 3 Examples of hospitalist applicable “cross-cutting measures” are

    • 47-advance care plan
    • 130-documentation of current medications
    • 317-preventative care: bp screening

  • PQRS data must be reported with respect to MAV clusters (Measure Applicability Validation)- reporting only measure that have no MAV cluster is a safe strategy so long as one of the measures is “cross-cutting”
  • Maximum P-VBP penalties automatically apply if group does not report enough PQRS data
  • visit CMS website for more information

HM15 Session: Putting Your Nickel Down: The What, Why, and How of Implementing Physician Value-Based Purchasing in Your Practice

Presenters: Stephen Besch, Simone Karp RPh, Patrick Torcson MD MMM SFHM, Gregory Seymann MD SFHM

Summation: HHS has set a goal of tying increasing percentages of Medicare payments to quality or value through alternative payment models, such as Accountable Care Organizations (ACOs) or bundled payment arrangements. By the end of 2018 the goal is for 50% of Medicare payments to be tied to these alternative payment models.   For the remaining traditional Medicare payment arrangements, 90% of those will be tied to quality/value incentives by 2018.

Medicare is transforming itself from a “passive payer” to an “active purchaser” of high quality, efficient healthcare. As such- active participation by physicians, physician groups, and hospitals is required for payment eligibility.

At the physician/group level, hospitalists should be reporting PQRS measures. Incentive payments for PQRS ended in 2014, Medicare is now making “negative payment adjustments.” Penalties are equal to a percentage of all Medicare Part B FFS (Fee-for-Service) charges and there is a 2-year delay between reporting or performance failure and penalization.

Physician Value-Based Purchasing (P-VBP) affects all Eligible Providers (EPs) in 2015. P4P (Pay for Performance) assesses both quality and cost. Aim is for budget neutrality via “quality tiering” which rewards “high quality/low cost” practices with penalties from “low quality/high cost” practices. As of now (2015) ACPs and therapists can be penalized under P-VBP.

Key Points/HM Takeaways:

• Hospitalists should be reporting PQRS measures- penalty phase has begun
• Key PQRS Changes for 2015:

  • 6 measures applicable to inpatient billing removed
  • no useful inpatient measures added
  • penalty avoidance requires 9 measures at 50% or higher rates, covering at least 3 of the 6 NQS (National Quality Strategy) domains- including 1 cross-cutting measure
  • all 2015 PQRS data will be posted to Physician Compare website in 2016
  • 3 Examples of hospitalist applicable “cross-cutting measures” are

    • 47-advance care plan
    • 130-documentation of current medications
    • 317-preventative care: bp screening

  • PQRS data must be reported with respect to MAV clusters (Measure Applicability Validation)- reporting only measure that have no MAV cluster is a safe strategy so long as one of the measures is “cross-cutting”
  • Maximum P-VBP penalties automatically apply if group does not report enough PQRS data
  • visit CMS website for more information

HM15 Session  RAPID FIRE PANEL: Hot Topics in Practice Management Updates on Key Issues, Including the Key Characteristics of an Effective HMG

HM15 Presenters: Roy Sittig MD SFHM, Jeffrey Frank MD MBA, Jodi Braun

Summation: Speakers covered timely topics regarding the Accountable Care Act, namely Medicaid Expansion and Bundled Payment arrangements; and reviewed the seminal paper on “Key Principals and Characteristics of an Effective Hospitalist Medicine Group” and lessons learned in implementing those 10 Key Principles.

Medicaid Expansion: EDs serving the 29 Medicaid expansion states are reporting higher volumes, likely due to 11.4million new lives now insured under the ACA. While the ACA does provide for higher Medicaid payment rates thus far, only 34% of providers accept Medicaid, a 21% drop since the ACA went into effect.

Bundled Payment Arrangements:

• Bundled Payment Care Initiative (BPCI) lexicon:

  • Model 2-Episode Anchor (anchor admission) AND 90days post d/c; Medicare pays 98% of usual cost
  • Model 3-90days post d/c AFTER anchor admission; Medicare pays 97% of usual cost
  • Convener-entity that brings providers together and enters into CMS agreement to bear risk for bundles
  • Awardee (entity having agreement with Medicare to assume risk and receive payment via BPCI) and Convener own the Bundle
  • Episode initiator (EI) triggers “bundle period”
  • Bundles based on DRG

10-Key Principles of an Effective Hospitalist Medicine Group:

1. Effective Leadership
2. Engaged Hospitalists
3. Adequate Resources
4. Planning and Management Infrastructure
5. Alignment with Hospital/Health System
6. Care Coordination Across Settings
7. Leadership in Key Clinical Issues in the Hospital/Health System
8. Thoughtful Approach to Scope of Activity
9. Patient/Family-Centered, Team-Based Care; Effective Communication
10. Recruiting/Retaining Qualified Clinicians

Key Points/HM Takeaways:

Medicaid Expansion- many of the 11.4M newly insured lives under the ACA have moved into Medicaid. Only about 1/3 of providers now accept Medicaid- 1 in 5 covered persons now have Medicaid, nearly 20% increase since 2013.

Bundled Payments- Majority of savings opportunity lies in Post-Acute Care. Awardee and Convener make profit is total cost is less than 98% of Target Price. In gainsharing agreements individuals can be reimbursed up to 150% usual Medicare rate. Pay occurs in usual Medicare fashion but is reconciled 60-90 days after end of bundle. For more information: http://innovation.cms.gov/initiatives/bundled-payments/

Effective HM Groups- Three important areas for focus when beginning to address group performance are: engaged hospitalists, planning and management infrastructure, care coordination across settings. These three topics have broad reaching implications into the hospitalist practice and patient care. [Cawley P, et al. Journal of Hospital Medicine 2014; 9(2):123-128]

HM15 Session  RAPID FIRE PANEL: Hot Topics in Practice Management Updates on Key Issues, Including the Key Characteristics of an Effective HMG

HM15 Presenters: Roy Sittig MD SFHM, Jeffrey Frank MD MBA, Jodi Braun

Summation: Speakers covered timely topics regarding the Accountable Care Act, namely Medicaid Expansion and Bundled Payment arrangements; and reviewed the seminal paper on “Key Principals and Characteristics of an Effective Hospitalist Medicine Group” and lessons learned in implementing those 10 Key Principles.

Medicaid Expansion: EDs serving the 29 Medicaid expansion states are reporting higher volumes, likely due to 11.4million new lives now insured under the ACA. While the ACA does provide for higher Medicaid payment rates thus far, only 34% of providers accept Medicaid, a 21% drop since the ACA went into effect.

Bundled Payment Arrangements:

• Bundled Payment Care Initiative (BPCI) lexicon:

  • Model 2-Episode Anchor (anchor admission) AND 90days post d/c; Medicare pays 98% of usual cost
  • Model 3-90days post d/c AFTER anchor admission; Medicare pays 97% of usual cost
  • Convener-entity that brings providers together and enters into CMS agreement to bear risk for bundles
  • Awardee (entity having agreement with Medicare to assume risk and receive payment via BPCI) and Convener own the Bundle
  • Episode initiator (EI) triggers “bundle period”
  • Bundles based on DRG

10-Key Principles of an Effective Hospitalist Medicine Group:

1. Effective Leadership
2. Engaged Hospitalists
3. Adequate Resources
4. Planning and Management Infrastructure
5. Alignment with Hospital/Health System
6. Care Coordination Across Settings
7. Leadership in Key Clinical Issues in the Hospital/Health System
8. Thoughtful Approach to Scope of Activity
9. Patient/Family-Centered, Team-Based Care; Effective Communication
10. Recruiting/Retaining Qualified Clinicians

Key Points/HM Takeaways:

Medicaid Expansion- many of the 11.4M newly insured lives under the ACA have moved into Medicaid. Only about 1/3 of providers now accept Medicaid- 1 in 5 covered persons now have Medicaid, nearly 20% increase since 2013.

Bundled Payments- Majority of savings opportunity lies in Post-Acute Care. Awardee and Convener make profit is total cost is less than 98% of Target Price. In gainsharing agreements individuals can be reimbursed up to 150% usual Medicare rate. Pay occurs in usual Medicare fashion but is reconciled 60-90 days after end of bundle. For more information: http://innovation.cms.gov/initiatives/bundled-payments/

Effective HM Groups- Three important areas for focus when beginning to address group performance are: engaged hospitalists, planning and management infrastructure, care coordination across settings. These three topics have broad reaching implications into the hospitalist practice and patient care. [Cawley P, et al. Journal of Hospital Medicine 2014; 9(2):123-128]

HM15 Session  RAPID FIRE PANEL: Hot Topics in Practice Management Updates on Key Issues, Including the Key Characteristics of an Effective HMG

HM15 Presenters: Roy Sittig MD SFHM, Jeffrey Frank MD MBA, Jodi Braun

Summation: Speakers covered timely topics regarding the Accountable Care Act, namely Medicaid Expansion and Bundled Payment arrangements; and reviewed the seminal paper on “Key Principals and Characteristics of an Effective Hospitalist Medicine Group” and lessons learned in implementing those 10 Key Principles.

Medicaid Expansion: EDs serving the 29 Medicaid expansion states are reporting higher volumes, likely due to 11.4million new lives now insured under the ACA. While the ACA does provide for higher Medicaid payment rates thus far, only 34% of providers accept Medicaid, a 21% drop since the ACA went into effect.

Bundled Payment Arrangements:

• Bundled Payment Care Initiative (BPCI) lexicon:

  • Model 2-Episode Anchor (anchor admission) AND 90days post d/c; Medicare pays 98% of usual cost
  • Model 3-90days post d/c AFTER anchor admission; Medicare pays 97% of usual cost
  • Convener-entity that brings providers together and enters into CMS agreement to bear risk for bundles
  • Awardee (entity having agreement with Medicare to assume risk and receive payment via BPCI) and Convener own the Bundle
  • Episode initiator (EI) triggers “bundle period”
  • Bundles based on DRG

10-Key Principles of an Effective Hospitalist Medicine Group:

1. Effective Leadership
2. Engaged Hospitalists
3. Adequate Resources
4. Planning and Management Infrastructure
5. Alignment with Hospital/Health System
6. Care Coordination Across Settings
7. Leadership in Key Clinical Issues in the Hospital/Health System
8. Thoughtful Approach to Scope of Activity
9. Patient/Family-Centered, Team-Based Care; Effective Communication
10. Recruiting/Retaining Qualified Clinicians

Key Points/HM Takeaways:

Medicaid Expansion- many of the 11.4M newly insured lives under the ACA have moved into Medicaid. Only about 1/3 of providers now accept Medicaid- 1 in 5 covered persons now have Medicaid, nearly 20% increase since 2013.

Bundled Payments- Majority of savings opportunity lies in Post-Acute Care. Awardee and Convener make profit is total cost is less than 98% of Target Price. In gainsharing agreements individuals can be reimbursed up to 150% usual Medicare rate. Pay occurs in usual Medicare fashion but is reconciled 60-90 days after end of bundle. For more information: http://innovation.cms.gov/initiatives/bundled-payments/

Effective HM Groups- Three important areas for focus when beginning to address group performance are: engaged hospitalists, planning and management infrastructure, care coordination across settings. These three topics have broad reaching implications into the hospitalist practice and patient care. [Cawley P, et al. Journal of Hospital Medicine 2014; 9(2):123-128]