Clinical question: Is lung ultrasound a useful tool for helping to diagnose acute decompensated heart failure (ADHF)?

Background: Lung ultrasound is an emerging bedside tool that has been promoted to help evaluate lung water content to help clinicians differentiate ADHF from other causes of dyspnea.

Study design: Prospective, multicenter, observational cohort study.

Setting: Seven EDs in Italy.

Synopsis: A total of 1,005 patients were enrolled in the study. Upon presentation to the ED, patients received a standard workup, including history, physical examination, EKG, and arterial blood gas sampling. Physicians were asked to render a diagnosis of ADHF or noncardiogenic dyspnea. The same physician then performed a lung ultrasound and rendered a revised diagnosis based on the ultrasound findings. A second ED physician and cardiologist, blinded to the ultrasound results, reviewed the medical record and rendered a final diagnosis as to the cause of the patient’s dyspnea.

The ultrasound approach had a higher accuracy than clinical evaluation alone in differentiating ADHF from noncardiac causes of dyspnea (97% vs. 85.3%). The authors also report a higher sensitivity compared to chest X-ray alone (69.5%) and natriuretic peptide testing (85%).

Bottom line: Lung ultrasound combined with clinical evaluation may improve the accuracy of ADHF diagnosis, but its usefulness may be limited by the need for ED physicians to have some degree of expertise in the use of ultrasound.

Citation: Pivetta E, Goffi A, Lupia E, et al. Lung ultrasound-implemented diagnosis of acute decompensated heart failure in the ED: a SIMEU multicenter study. Chest. 2015;148(1):202-210.

Clinical question: Is lung ultrasound a useful tool for helping to diagnose acute decompensated heart failure (ADHF)?

Background: Lung ultrasound is an emerging bedside tool that has been promoted to help evaluate lung water content to help clinicians differentiate ADHF from other causes of dyspnea.

Study design: Prospective, multicenter, observational cohort study.

Setting: Seven EDs in Italy.

Synopsis: A total of 1,005 patients were enrolled in the study. Upon presentation to the ED, patients received a standard workup, including history, physical examination, EKG, and arterial blood gas sampling. Physicians were asked to render a diagnosis of ADHF or noncardiogenic dyspnea. The same physician then performed a lung ultrasound and rendered a revised diagnosis based on the ultrasound findings. A second ED physician and cardiologist, blinded to the ultrasound results, reviewed the medical record and rendered a final diagnosis as to the cause of the patient’s dyspnea.

The ultrasound approach had a higher accuracy than clinical evaluation alone in differentiating ADHF from noncardiac causes of dyspnea (97% vs. 85.3%). The authors also report a higher sensitivity compared to chest X-ray alone (69.5%) and natriuretic peptide testing (85%).

Bottom line: Lung ultrasound combined with clinical evaluation may improve the accuracy of ADHF diagnosis, but its usefulness may be limited by the need for ED physicians to have some degree of expertise in the use of ultrasound.

Citation: Pivetta E, Goffi A, Lupia E, et al. Lung ultrasound-implemented diagnosis of acute decompensated heart failure in the ED: a SIMEU multicenter study. Chest. 2015;148(1):202-210.

Clinical question: Is lung ultrasound a useful tool for helping to diagnose acute decompensated heart failure (ADHF)?

Background: Lung ultrasound is an emerging bedside tool that has been promoted to help evaluate lung water content to help clinicians differentiate ADHF from other causes of dyspnea.

Study design: Prospective, multicenter, observational cohort study.

Setting: Seven EDs in Italy.

Synopsis: A total of 1,005 patients were enrolled in the study. Upon presentation to the ED, patients received a standard workup, including history, physical examination, EKG, and arterial blood gas sampling. Physicians were asked to render a diagnosis of ADHF or noncardiogenic dyspnea. The same physician then performed a lung ultrasound and rendered a revised diagnosis based on the ultrasound findings. A second ED physician and cardiologist, blinded to the ultrasound results, reviewed the medical record and rendered a final diagnosis as to the cause of the patient’s dyspnea.

The ultrasound approach had a higher accuracy than clinical evaluation alone in differentiating ADHF from noncardiac causes of dyspnea (97% vs. 85.3%). The authors also report a higher sensitivity compared to chest X-ray alone (69.5%) and natriuretic peptide testing (85%).

Bottom line: Lung ultrasound combined with clinical evaluation may improve the accuracy of ADHF diagnosis, but its usefulness may be limited by the need for ED physicians to have some degree of expertise in the use of ultrasound.

Citation: Pivetta E, Goffi A, Lupia E, et al. Lung ultrasound-implemented diagnosis of acute decompensated heart failure in the ED: a SIMEU multicenter study. Chest. 2015;148(1):202-210.

Clinical question: When evaluating the intermediate-risk patient with chest pain, should coronary computed tomography angiography (CCTA) be used instead of myocardial perfusion imaging (MPI)?

Background: CCTA has been shown in prior randomized controlled trials to save time and money compared to other protocols, including stress ECG, echocardiogram, and MPI. Less information is available as to whether CCTA provides a better selection of patients for cardiac catheterization compared to MPI.

Study design: Randomized, controlled, comparative effectiveness trial.

Setting: Telemetry ward of an urban medical center.

Synopsis: Four hundred patients admitted with chest pain and an intermediate, pre-test probability of coronary artery disease were randomized to either CCTA or MPI. Patients were predominantly female, were ethnically varied, and had a mean age of 57 years.

Study results showed no significant difference in rates of cardiac catheterization that did not lead to revascularization at one-year follow-up. Specifically, 7.5% of patients in the CCTA group underwent catheterization not leading to revascularization, compared to 10% in the MPI group.

One limitation of the study is that it was conducted at a single site. Furthermore, the decision to proceed to catheterization was made clinically and not based on a predefined algorithm.

Bottom line: CCTA and MPI are both acceptable choices to determine the need for invasive testing in patients admitted with chest pain.

Citation: Levsky JM, Spevack DM, Travin MI, et al. Coronary computed tomography angiography versus radionuclide myocardial perfusion imaging in patients with chest pain admitted to telemetry: a randomized trial. Ann Intern Med. 2015;163(3):174-183.

Clinical question: When evaluating the intermediate-risk patient with chest pain, should coronary computed tomography angiography (CCTA) be used instead of myocardial perfusion imaging (MPI)?

Background: CCTA has been shown in prior randomized controlled trials to save time and money compared to other protocols, including stress ECG, echocardiogram, and MPI. Less information is available as to whether CCTA provides a better selection of patients for cardiac catheterization compared to MPI.

Study design: Randomized, controlled, comparative effectiveness trial.

Setting: Telemetry ward of an urban medical center.

Synopsis: Four hundred patients admitted with chest pain and an intermediate, pre-test probability of coronary artery disease were randomized to either CCTA or MPI. Patients were predominantly female, were ethnically varied, and had a mean age of 57 years.

Study results showed no significant difference in rates of cardiac catheterization that did not lead to revascularization at one-year follow-up. Specifically, 7.5% of patients in the CCTA group underwent catheterization not leading to revascularization, compared to 10% in the MPI group.

One limitation of the study is that it was conducted at a single site. Furthermore, the decision to proceed to catheterization was made clinically and not based on a predefined algorithm.

Bottom line: CCTA and MPI are both acceptable choices to determine the need for invasive testing in patients admitted with chest pain.

Citation: Levsky JM, Spevack DM, Travin MI, et al. Coronary computed tomography angiography versus radionuclide myocardial perfusion imaging in patients with chest pain admitted to telemetry: a randomized trial. Ann Intern Med. 2015;163(3):174-183.

Clinical question: When evaluating the intermediate-risk patient with chest pain, should coronary computed tomography angiography (CCTA) be used instead of myocardial perfusion imaging (MPI)?

Background: CCTA has been shown in prior randomized controlled trials to save time and money compared to other protocols, including stress ECG, echocardiogram, and MPI. Less information is available as to whether CCTA provides a better selection of patients for cardiac catheterization compared to MPI.

Study design: Randomized, controlled, comparative effectiveness trial.

Setting: Telemetry ward of an urban medical center.

Synopsis: Four hundred patients admitted with chest pain and an intermediate, pre-test probability of coronary artery disease were randomized to either CCTA or MPI. Patients were predominantly female, were ethnically varied, and had a mean age of 57 years.

Study results showed no significant difference in rates of cardiac catheterization that did not lead to revascularization at one-year follow-up. Specifically, 7.5% of patients in the CCTA group underwent catheterization not leading to revascularization, compared to 10% in the MPI group.

One limitation of the study is that it was conducted at a single site. Furthermore, the decision to proceed to catheterization was made clinically and not based on a predefined algorithm.

Bottom line: CCTA and MPI are both acceptable choices to determine the need for invasive testing in patients admitted with chest pain.

Citation: Levsky JM, Spevack DM, Travin MI, et al. Coronary computed tomography angiography versus radionuclide myocardial perfusion imaging in patients with chest pain admitted to telemetry: a randomized trial. Ann Intern Med. 2015;163(3):174-183.

Clinical question: Can a low-risk patient newly diagnosed with VTE in the ED be immediately discharged home on a direct factor Xa inhibitor?

Background: Studies have shown that rivaroxaban incurs a risk of 2.1% in VTE recurrence and of 9.4% in clinically relevant major and non-major bleeding (in an average 208 days follow-up). More information is required to determine if similar success can be achieved by discharging low-risk patients from the ED.

Study design: Prospective, observational study.

Setting: EDs at two urban, teaching hospitals.

Synopsis: After fulfilling the criteria for low risk, 106 patients were discharged from the ED with DVT, pulmonary embolism (PE), or both. Most patients were 50 years or younger and had unprovoked VTE. Three of the 106 patients had recurrence of VTE (2.8%, 95% CI=0.6% to 8%) at a mean duration of 389 days. No patient had a major bleeding event.

In this small study, fewer than 80% of patients discharged had at least one clinic follow-up; the majority of these patients (75%) followed up in a clinic staffed by ED physicians. Therefore, ability for close follow-up must be taken into consideration prior to discharge from the ED.

Moreover, one to two days post-discharge, a member of the care team called the patient to confirm their ability to fill the rivaroxaban prescription and to answer other questions related to the new diagnosis.

Bottom line: With close follow-up and confirmation of the ability to fill a rivaroxaban prescription, patients with low-risk VTE may be discharged home from the ED.

Citation: Beam DM, Kahler ZP, Kline JA. Immediate discharge and home treatment with rivaroxaban of low-risk venous thromboembolism diagnosed in two U.S. emergency departments: a one-year preplanned analysis. Acad Emerg Med. 2015;22(7):788-795.

Clinical question: Can a low-risk patient newly diagnosed with VTE in the ED be immediately discharged home on a direct factor Xa inhibitor?

Background: Studies have shown that rivaroxaban incurs a risk of 2.1% in VTE recurrence and of 9.4% in clinically relevant major and non-major bleeding (in an average 208 days follow-up). More information is required to determine if similar success can be achieved by discharging low-risk patients from the ED.

Study design: Prospective, observational study.

Setting: EDs at two urban, teaching hospitals.

Synopsis: After fulfilling the criteria for low risk, 106 patients were discharged from the ED with DVT, pulmonary embolism (PE), or both. Most patients were 50 years or younger and had unprovoked VTE. Three of the 106 patients had recurrence of VTE (2.8%, 95% CI=0.6% to 8%) at a mean duration of 389 days. No patient had a major bleeding event.

In this small study, fewer than 80% of patients discharged had at least one clinic follow-up; the majority of these patients (75%) followed up in a clinic staffed by ED physicians. Therefore, ability for close follow-up must be taken into consideration prior to discharge from the ED.

Moreover, one to two days post-discharge, a member of the care team called the patient to confirm their ability to fill the rivaroxaban prescription and to answer other questions related to the new diagnosis.

Bottom line: With close follow-up and confirmation of the ability to fill a rivaroxaban prescription, patients with low-risk VTE may be discharged home from the ED.

Citation: Beam DM, Kahler ZP, Kline JA. Immediate discharge and home treatment with rivaroxaban of low-risk venous thromboembolism diagnosed in two U.S. emergency departments: a one-year preplanned analysis. Acad Emerg Med. 2015;22(7):788-795.

Clinical question: Can a low-risk patient newly diagnosed with VTE in the ED be immediately discharged home on a direct factor Xa inhibitor?

Background: Studies have shown that rivaroxaban incurs a risk of 2.1% in VTE recurrence and of 9.4% in clinically relevant major and non-major bleeding (in an average 208 days follow-up). More information is required to determine if similar success can be achieved by discharging low-risk patients from the ED.

Study design: Prospective, observational study.

Setting: EDs at two urban, teaching hospitals.

Synopsis: After fulfilling the criteria for low risk, 106 patients were discharged from the ED with DVT, pulmonary embolism (PE), or both. Most patients were 50 years or younger and had unprovoked VTE. Three of the 106 patients had recurrence of VTE (2.8%, 95% CI=0.6% to 8%) at a mean duration of 389 days. No patient had a major bleeding event.

In this small study, fewer than 80% of patients discharged had at least one clinic follow-up; the majority of these patients (75%) followed up in a clinic staffed by ED physicians. Therefore, ability for close follow-up must be taken into consideration prior to discharge from the ED.

Moreover, one to two days post-discharge, a member of the care team called the patient to confirm their ability to fill the rivaroxaban prescription and to answer other questions related to the new diagnosis.

Bottom line: With close follow-up and confirmation of the ability to fill a rivaroxaban prescription, patients with low-risk VTE may be discharged home from the ED.

Citation: Beam DM, Kahler ZP, Kline JA. Immediate discharge and home treatment with rivaroxaban of low-risk venous thromboembolism diagnosed in two U.S. emergency departments: a one-year preplanned analysis. Acad Emerg Med. 2015;22(7):788-795.

Clinical question: How would an evidence-based clinical pathway for cellulitis affect process metrics, patient outcomes, and clinical cost?

Background: Cellulitis is a common hospital problem, but its evaluation and treatment vary widely. Specifically, broad-spectrum antibiotics and imaging studies are overutilized when compared to recommended guidelines. A standardized clinical pathway is proposed as a possible solution.

Study design: Retrospective, observational, pre-/post-intervention study.

Setting: University of Utah Health Sciences Center, Salt Lake City.

Synopsis: A multidisciplinary team created a guideline-based care pathway for cellulitis and enrolled 677 adult patients for retrospective analysis during a two-year period. The study showed an overall 59% decrease in the odds of ordering broad-spectrum antibiotics, 23% decrease in pharmacy cost, 44% decrease in laboratory cost, and 13% decrease in overall facility cost, pre-/post-intervention. It also demonstrated no adverse effect on length of stay or 30-day readmission rates.

Given the retrospective, single-center nature of this study, as well as some baseline characteristic differences between enrolled patients, careful conclusions regarding external validity on diverse patient populations must be considered; however, the history of clinical care pathways supports many of the study’s findings. The results make a compelling case for hospitalist groups to implement similar cellulitis pathways and research their effectiveness.

Bottom line: Clinical care pathways for cellulitis provide an opportunity to improve antibiotic stewardship and lower hospital costs without compromising quality of care.

Citation: Yarbrough PM, Kukhareva PV, Spivak ES, Hopkins C, Kawamoto K. Evidence-based care pathway for cellulitis improves process, clinical, and cost outcomes [published online ahead of print July 28, 2015]. J Hosp Med. doi: 10.1002/jhm.2433.

Clinical question: How would an evidence-based clinical pathway for cellulitis affect process metrics, patient outcomes, and clinical cost?

Background: Cellulitis is a common hospital problem, but its evaluation and treatment vary widely. Specifically, broad-spectrum antibiotics and imaging studies are overutilized when compared to recommended guidelines. A standardized clinical pathway is proposed as a possible solution.

Study design: Retrospective, observational, pre-/post-intervention study.

Setting: University of Utah Health Sciences Center, Salt Lake City.

Synopsis: A multidisciplinary team created a guideline-based care pathway for cellulitis and enrolled 677 adult patients for retrospective analysis during a two-year period. The study showed an overall 59% decrease in the odds of ordering broad-spectrum antibiotics, 23% decrease in pharmacy cost, 44% decrease in laboratory cost, and 13% decrease in overall facility cost, pre-/post-intervention. It also demonstrated no adverse effect on length of stay or 30-day readmission rates.

Given the retrospective, single-center nature of this study, as well as some baseline characteristic differences between enrolled patients, careful conclusions regarding external validity on diverse patient populations must be considered; however, the history of clinical care pathways supports many of the study’s findings. The results make a compelling case for hospitalist groups to implement similar cellulitis pathways and research their effectiveness.

Bottom line: Clinical care pathways for cellulitis provide an opportunity to improve antibiotic stewardship and lower hospital costs without compromising quality of care.

Citation: Yarbrough PM, Kukhareva PV, Spivak ES, Hopkins C, Kawamoto K. Evidence-based care pathway for cellulitis improves process, clinical, and cost outcomes [published online ahead of print July 28, 2015]. J Hosp Med. doi: 10.1002/jhm.2433.

Clinical question: How would an evidence-based clinical pathway for cellulitis affect process metrics, patient outcomes, and clinical cost?

Background: Cellulitis is a common hospital problem, but its evaluation and treatment vary widely. Specifically, broad-spectrum antibiotics and imaging studies are overutilized when compared to recommended guidelines. A standardized clinical pathway is proposed as a possible solution.

Study design: Retrospective, observational, pre-/post-intervention study.

Setting: University of Utah Health Sciences Center, Salt Lake City.

Synopsis: A multidisciplinary team created a guideline-based care pathway for cellulitis and enrolled 677 adult patients for retrospective analysis during a two-year period. The study showed an overall 59% decrease in the odds of ordering broad-spectrum antibiotics, 23% decrease in pharmacy cost, 44% decrease in laboratory cost, and 13% decrease in overall facility cost, pre-/post-intervention. It also demonstrated no adverse effect on length of stay or 30-day readmission rates.

Given the retrospective, single-center nature of this study, as well as some baseline characteristic differences between enrolled patients, careful conclusions regarding external validity on diverse patient populations must be considered; however, the history of clinical care pathways supports many of the study’s findings. The results make a compelling case for hospitalist groups to implement similar cellulitis pathways and research their effectiveness.

Bottom line: Clinical care pathways for cellulitis provide an opportunity to improve antibiotic stewardship and lower hospital costs without compromising quality of care.

Citation: Yarbrough PM, Kukhareva PV, Spivak ES, Hopkins C, Kawamoto K. Evidence-based care pathway for cellulitis improves process, clinical, and cost outcomes [published online ahead of print July 28, 2015]. J Hosp Med. doi: 10.1002/jhm.2433.

When you ask Tiffani Panek, division administrator for the division of hospital medicine at Johns Hopkins Bayview Medical Center (BMC) in Baltimore, Md., about her thoughts on the future of hospital medicine, her passion and enthusiasm are immediately apparent. After earning SHM’s Certificate of Leadership in Hospital Medicine, Panek was elected vice president of SHM’s Maryland chapter. She is the only practice administrator currently in chapter leadership.

Her motto? “I’m a hospitalist who happens not to be a clinician.”

The Hospitalist recently spoke with Panek about the future of the HM movement and the roles nonphysician staff play in advancing hospital medicine.

Question: Tell us about your role as division administrator for BMC’s division of hospital medicine.

Answer: As part of the executive leadership team, I serve as the administrative counterpart to site director Flora Kisuule, MD, MPH. I am also the program coordinator for the Academic Hospitalist Fellowship Program and partner with Dr. Kisuule and SHM board member and senior physician advisor Eric Howell, MD, SFHM, on the program’s growing international work to train academic hospitalists and future leaders of hospitalist programs.

Q: What led you to join SHM and get involved in the Practice Administrators Committee?

A: I had never heard of hospital medicine before I started with [my] division, and I really wanted to learn all I could. I was fortunate enough that Dr. Howell was a part of SHM very early, and as my director, he encouraged me to get involved. In the beginning, it was really about educating myself, but after a few years, when I was immersed and truly in love with hospital medicine, I wanted to get more involved and be a part of the change and innovation that SHM and hospital medicine represent. The movement touches so many people in such a direct way. We are in the trenches, taking care of people when they are at their most vulnerable.

Q: How were you able to take what you learned from SHM Leadership Academy and apply it to your professional life and new chapter leader position?

A: I should make a cross-stitch of one of my favorite takeaways: “They won’t care what you know until they know that you care!” The personality and communication lessons have not only helped me develop my own communication skills, but they have helped me become a better supervisor and mentor. I often return to my notes about leading through adversity when faced with challenges at our own facility. I want to bring all of that to the table as the new Maryland chapter vice president, to help us improve the diversity of the chapter and ultimately the hospital medicine movement.

Q: Moving forward, how do you see your role in SHM—and SHM as an organization— impacting positive change for hospitalized patients and the hospitalists who serve them?

A: As an active member, I am excited to leverage SHM, the Practice Administrators Committee, the local chapter, and other meetings to unite talented people working in hospital medicine and work towards the same mission: improving care of hospitalized patients. In addition to bringing our subspecialty colleagues into the fold, we also must improve our inclusivity of nurse practitioners, physician assistants, pharmacists, nurses, and, of course, our administrators. Every single person should feel invested and valued. The diversity of hospital medicine, and of SHM, sets our specialty apart from many others, and we are much stronger for it. There are no healthcare professionals better situated to improve the quality and cost of care than hospitalists.

 

---

Brett Radler is SHM’s communications coordinator.

When you ask Tiffani Panek, division administrator for the division of hospital medicine at Johns Hopkins Bayview Medical Center (BMC) in Baltimore, Md., about her thoughts on the future of hospital medicine, her passion and enthusiasm are immediately apparent. After earning SHM’s Certificate of Leadership in Hospital Medicine, Panek was elected vice president of SHM’s Maryland chapter. She is the only practice administrator currently in chapter leadership.

Her motto? “I’m a hospitalist who happens not to be a clinician.”

The Hospitalist recently spoke with Panek about the future of the HM movement and the roles nonphysician staff play in advancing hospital medicine.

Question: Tell us about your role as division administrator for BMC’s division of hospital medicine.

Answer: As part of the executive leadership team, I serve as the administrative counterpart to site director Flora Kisuule, MD, MPH. I am also the program coordinator for the Academic Hospitalist Fellowship Program and partner with Dr. Kisuule and SHM board member and senior physician advisor Eric Howell, MD, SFHM, on the program’s growing international work to train academic hospitalists and future leaders of hospitalist programs.

Q: What led you to join SHM and get involved in the Practice Administrators Committee?

A: I had never heard of hospital medicine before I started with [my] division, and I really wanted to learn all I could. I was fortunate enough that Dr. Howell was a part of SHM very early, and as my director, he encouraged me to get involved. In the beginning, it was really about educating myself, but after a few years, when I was immersed and truly in love with hospital medicine, I wanted to get more involved and be a part of the change and innovation that SHM and hospital medicine represent. The movement touches so many people in such a direct way. We are in the trenches, taking care of people when they are at their most vulnerable.

Q: How were you able to take what you learned from SHM Leadership Academy and apply it to your professional life and new chapter leader position?

A: I should make a cross-stitch of one of my favorite takeaways: “They won’t care what you know until they know that you care!” The personality and communication lessons have not only helped me develop my own communication skills, but they have helped me become a better supervisor and mentor. I often return to my notes about leading through adversity when faced with challenges at our own facility. I want to bring all of that to the table as the new Maryland chapter vice president, to help us improve the diversity of the chapter and ultimately the hospital medicine movement.

Q: Moving forward, how do you see your role in SHM—and SHM as an organization— impacting positive change for hospitalized patients and the hospitalists who serve them?

A: As an active member, I am excited to leverage SHM, the Practice Administrators Committee, the local chapter, and other meetings to unite talented people working in hospital medicine and work towards the same mission: improving care of hospitalized patients. In addition to bringing our subspecialty colleagues into the fold, we also must improve our inclusivity of nurse practitioners, physician assistants, pharmacists, nurses, and, of course, our administrators. Every single person should feel invested and valued. The diversity of hospital medicine, and of SHM, sets our specialty apart from many others, and we are much stronger for it. There are no healthcare professionals better situated to improve the quality and cost of care than hospitalists.

 

---

Brett Radler is SHM’s communications coordinator.

When you ask Tiffani Panek, division administrator for the division of hospital medicine at Johns Hopkins Bayview Medical Center (BMC) in Baltimore, Md., about her thoughts on the future of hospital medicine, her passion and enthusiasm are immediately apparent. After earning SHM’s Certificate of Leadership in Hospital Medicine, Panek was elected vice president of SHM’s Maryland chapter. She is the only practice administrator currently in chapter leadership.

Her motto? “I’m a hospitalist who happens not to be a clinician.”

The Hospitalist recently spoke with Panek about the future of the HM movement and the roles nonphysician staff play in advancing hospital medicine.

Question: Tell us about your role as division administrator for BMC’s division of hospital medicine.

Answer: As part of the executive leadership team, I serve as the administrative counterpart to site director Flora Kisuule, MD, MPH. I am also the program coordinator for the Academic Hospitalist Fellowship Program and partner with Dr. Kisuule and SHM board member and senior physician advisor Eric Howell, MD, SFHM, on the program’s growing international work to train academic hospitalists and future leaders of hospitalist programs.

Q: What led you to join SHM and get involved in the Practice Administrators Committee?

A: I had never heard of hospital medicine before I started with [my] division, and I really wanted to learn all I could. I was fortunate enough that Dr. Howell was a part of SHM very early, and as my director, he encouraged me to get involved. In the beginning, it was really about educating myself, but after a few years, when I was immersed and truly in love with hospital medicine, I wanted to get more involved and be a part of the change and innovation that SHM and hospital medicine represent. The movement touches so many people in such a direct way. We are in the trenches, taking care of people when they are at their most vulnerable.

Q: How were you able to take what you learned from SHM Leadership Academy and apply it to your professional life and new chapter leader position?

A: I should make a cross-stitch of one of my favorite takeaways: “They won’t care what you know until they know that you care!” The personality and communication lessons have not only helped me develop my own communication skills, but they have helped me become a better supervisor and mentor. I often return to my notes about leading through adversity when faced with challenges at our own facility. I want to bring all of that to the table as the new Maryland chapter vice president, to help us improve the diversity of the chapter and ultimately the hospital medicine movement.

Q: Moving forward, how do you see your role in SHM—and SHM as an organization— impacting positive change for hospitalized patients and the hospitalists who serve them?

A: As an active member, I am excited to leverage SHM, the Practice Administrators Committee, the local chapter, and other meetings to unite talented people working in hospital medicine and work towards the same mission: improving care of hospitalized patients. In addition to bringing our subspecialty colleagues into the fold, we also must improve our inclusivity of nurse practitioners, physician assistants, pharmacists, nurses, and, of course, our administrators. Every single person should feel invested and valued. The diversity of hospital medicine, and of SHM, sets our specialty apart from many others, and we are much stronger for it. There are no healthcare professionals better situated to improve the quality and cost of care than hospitalists.

 

---

Brett Radler is SHM’s communications coordinator.

As the senior physician advisor to SHM’s Center for Hospital Innovation and Improvement, Eric Howell, MD, SFHM, bridges the gap between clinical expertise and project support and development. The Hospitalist recently had a conversation with Dr. Howell, a past president of SHM, to learn more about his role and how the Center for Hospital Innovation and Improvement is revolutionizing quality improvement (QI) in hospital medicine.

Question: What is your role as the senior physician advisor to The Center for Hospital Innovation and Improvement?

Answer: I see my role as the intersection of a Venn diagram; one circle involves my clinical know-how, and the other includes the proposals brought to the Center for Hospital Innovation and Improvement by hospitalists and healthcare professionals. Where those two circles intersect is where I am able to use my experience from the front line of patient care to validate potential projects.

In addition to project assessment, I monitor the pulse of healthcare professionals and hospital leadership to ensure we are meeting their needs, including our efforts of convening a recent summit, where hospitalist clinicians … weighed in on how our team could help them improve. I plan to share this feedback in an upcoming feature, centered on emerging topics in hospital medicine, including care transitions, high-risk medications, advance care planning, and others.

Q: Given your clinical experience and involvement with SHM, how would you say hospitalists are positioned to improve quality, safety, and patient outcomes?

A: We possess the necessary ingredients to develop a recipe for success in QI from both a clinical and an operational perspective. Hospital medicine is still a young, innovative field that is extremely open to change. Anyone who knows QI knows that it is all about effectively managing and responding to change. Hospitalists also are aware of how to operate in a highly matrixed environment and to collaborate as part of an interdisciplinary team, which are invaluable assets to implementing QI initiatives successfully and proactively monitoring their impact.

Q: What are the biggest assets the Center for Hospital Innovation and Improvement can offer hospitalists in their mission to improve patient care?

A: Our team has resources to help hospitalists improve their skills at whatever stage they are in their careers. If you are just beginning or trying to learn new things independently, you can explore the web-based materials and resource rooms. They are publicly accessible resources that can assist in informing quality improvement efforts in the hospital. For those looking to expand their skills in a more hands-on way, we offer a mentored implementation program, where hospitalists can receive guidance from expert mentors in a number of different clinical areas.

Q: How can the Center for Hospital Innovation and Improvement help hospitalists address emerging challenges in hospital medicine?

A: You cannot talk about the Center for Hospital Innovation and Improvement without mentioning signature mentored implementation programs like Project BOOST, focused on effective care transitions, and glycemic control—they are juggernauts for SHM’s portfolio because of their proven track records and sustainable frameworks for driving positive change. These two alone have already been implemented at over 400 facilities, with more inquiries each day.

With support from The Milbank Foundation, The Hastings Center and SHM have joined forces and will create new skills-based training resources and a QI framework to improve end-of-life care in the hospital. Our goal is to equip hospital clinicians with the requisite tools to provide adequate palliative care, especially given the policy landscape related to advance care planning discussions.

 

As antibiotic resistance emerges as a global issue, antibiotic stewardship has continued to be a high priority for hospitalists. After attending the related White House forum earlier this year, SHM committed to cultivating initiatives that emphasize appropriate prescribing practices, which will aid in slowing the emergence of antibiotic-resistant bacteria and prevent the spread of resistant infections. SHM looks forward to making noteworthy contributions to this initiative, promoting awareness and behavior change through the “Fight the Resistance” campaign.

Q: What is one major takeaway about The Center for Hospital Innovation and Improvement hospitalists should know?

A: The Center for Hospital Innovation and Improvement is not an exclusive club—rather, it is like an open farmers’ market. Anyone with any amount of expertise can get resources through collaboration and partnership. Whether it is residents trying to improve the house staff or professors at major academic centers looking for research partners, The Center for Hospital Innovation and Improvement will welcome you to collaborate and link you to valuable resources.

---

Brett Radler is SHM’s communications coordinator.

As the senior physician advisor to SHM’s Center for Hospital Innovation and Improvement, Eric Howell, MD, SFHM, bridges the gap between clinical expertise and project support and development. The Hospitalist recently had a conversation with Dr. Howell, a past president of SHM, to learn more about his role and how the Center for Hospital Innovation and Improvement is revolutionizing quality improvement (QI) in hospital medicine.

Question: What is your role as the senior physician advisor to The Center for Hospital Innovation and Improvement?

Answer: I see my role as the intersection of a Venn diagram; one circle involves my clinical know-how, and the other includes the proposals brought to the Center for Hospital Innovation and Improvement by hospitalists and healthcare professionals. Where those two circles intersect is where I am able to use my experience from the front line of patient care to validate potential projects.

In addition to project assessment, I monitor the pulse of healthcare professionals and hospital leadership to ensure we are meeting their needs, including our efforts of convening a recent summit, where hospitalist clinicians … weighed in on how our team could help them improve. I plan to share this feedback in an upcoming feature, centered on emerging topics in hospital medicine, including care transitions, high-risk medications, advance care planning, and others.

Q: Given your clinical experience and involvement with SHM, how would you say hospitalists are positioned to improve quality, safety, and patient outcomes?

A: We possess the necessary ingredients to develop a recipe for success in QI from both a clinical and an operational perspective. Hospital medicine is still a young, innovative field that is extremely open to change. Anyone who knows QI knows that it is all about effectively managing and responding to change. Hospitalists also are aware of how to operate in a highly matrixed environment and to collaborate as part of an interdisciplinary team, which are invaluable assets to implementing QI initiatives successfully and proactively monitoring their impact.

Q: What are the biggest assets the Center for Hospital Innovation and Improvement can offer hospitalists in their mission to improve patient care?

A: Our team has resources to help hospitalists improve their skills at whatever stage they are in their careers. If you are just beginning or trying to learn new things independently, you can explore the web-based materials and resource rooms. They are publicly accessible resources that can assist in informing quality improvement efforts in the hospital. For those looking to expand their skills in a more hands-on way, we offer a mentored implementation program, where hospitalists can receive guidance from expert mentors in a number of different clinical areas.

Q: How can the Center for Hospital Innovation and Improvement help hospitalists address emerging challenges in hospital medicine?

A: You cannot talk about the Center for Hospital Innovation and Improvement without mentioning signature mentored implementation programs like Project BOOST, focused on effective care transitions, and glycemic control—they are juggernauts for SHM’s portfolio because of their proven track records and sustainable frameworks for driving positive change. These two alone have already been implemented at over 400 facilities, with more inquiries each day.

With support from The Milbank Foundation, The Hastings Center and SHM have joined forces and will create new skills-based training resources and a QI framework to improve end-of-life care in the hospital. Our goal is to equip hospital clinicians with the requisite tools to provide adequate palliative care, especially given the policy landscape related to advance care planning discussions.

 

As antibiotic resistance emerges as a global issue, antibiotic stewardship has continued to be a high priority for hospitalists. After attending the related White House forum earlier this year, SHM committed to cultivating initiatives that emphasize appropriate prescribing practices, which will aid in slowing the emergence of antibiotic-resistant bacteria and prevent the spread of resistant infections. SHM looks forward to making noteworthy contributions to this initiative, promoting awareness and behavior change through the “Fight the Resistance” campaign.

Q: What is one major takeaway about The Center for Hospital Innovation and Improvement hospitalists should know?

A: The Center for Hospital Innovation and Improvement is not an exclusive club—rather, it is like an open farmers’ market. Anyone with any amount of expertise can get resources through collaboration and partnership. Whether it is residents trying to improve the house staff or professors at major academic centers looking for research partners, The Center for Hospital Innovation and Improvement will welcome you to collaborate and link you to valuable resources.

---

Brett Radler is SHM’s communications coordinator.

As the senior physician advisor to SHM’s Center for Hospital Innovation and Improvement, Eric Howell, MD, SFHM, bridges the gap between clinical expertise and project support and development. The Hospitalist recently had a conversation with Dr. Howell, a past president of SHM, to learn more about his role and how the Center for Hospital Innovation and Improvement is revolutionizing quality improvement (QI) in hospital medicine.

Question: What is your role as the senior physician advisor to The Center for Hospital Innovation and Improvement?

Answer: I see my role as the intersection of a Venn diagram; one circle involves my clinical know-how, and the other includes the proposals brought to the Center for Hospital Innovation and Improvement by hospitalists and healthcare professionals. Where those two circles intersect is where I am able to use my experience from the front line of patient care to validate potential projects.

In addition to project assessment, I monitor the pulse of healthcare professionals and hospital leadership to ensure we are meeting their needs, including our efforts of convening a recent summit, where hospitalist clinicians … weighed in on how our team could help them improve. I plan to share this feedback in an upcoming feature, centered on emerging topics in hospital medicine, including care transitions, high-risk medications, advance care planning, and others.

Q: Given your clinical experience and involvement with SHM, how would you say hospitalists are positioned to improve quality, safety, and patient outcomes?

A: We possess the necessary ingredients to develop a recipe for success in QI from both a clinical and an operational perspective. Hospital medicine is still a young, innovative field that is extremely open to change. Anyone who knows QI knows that it is all about effectively managing and responding to change. Hospitalists also are aware of how to operate in a highly matrixed environment and to collaborate as part of an interdisciplinary team, which are invaluable assets to implementing QI initiatives successfully and proactively monitoring their impact.

Q: What are the biggest assets the Center for Hospital Innovation and Improvement can offer hospitalists in their mission to improve patient care?

A: Our team has resources to help hospitalists improve their skills at whatever stage they are in their careers. If you are just beginning or trying to learn new things independently, you can explore the web-based materials and resource rooms. They are publicly accessible resources that can assist in informing quality improvement efforts in the hospital. For those looking to expand their skills in a more hands-on way, we offer a mentored implementation program, where hospitalists can receive guidance from expert mentors in a number of different clinical areas.

Q: How can the Center for Hospital Innovation and Improvement help hospitalists address emerging challenges in hospital medicine?

A: You cannot talk about the Center for Hospital Innovation and Improvement without mentioning signature mentored implementation programs like Project BOOST, focused on effective care transitions, and glycemic control—they are juggernauts for SHM’s portfolio because of their proven track records and sustainable frameworks for driving positive change. These two alone have already been implemented at over 400 facilities, with more inquiries each day.

With support from The Milbank Foundation, The Hastings Center and SHM have joined forces and will create new skills-based training resources and a QI framework to improve end-of-life care in the hospital. Our goal is to equip hospital clinicians with the requisite tools to provide adequate palliative care, especially given the policy landscape related to advance care planning discussions.

 

As antibiotic resistance emerges as a global issue, antibiotic stewardship has continued to be a high priority for hospitalists. After attending the related White House forum earlier this year, SHM committed to cultivating initiatives that emphasize appropriate prescribing practices, which will aid in slowing the emergence of antibiotic-resistant bacteria and prevent the spread of resistant infections. SHM looks forward to making noteworthy contributions to this initiative, promoting awareness and behavior change through the “Fight the Resistance” campaign.

Q: What is one major takeaway about The Center for Hospital Innovation and Improvement hospitalists should know?

A: The Center for Hospital Innovation and Improvement is not an exclusive club—rather, it is like an open farmers’ market. Anyone with any amount of expertise can get resources through collaboration and partnership. Whether it is residents trying to improve the house staff or professors at major academic centers looking for research partners, The Center for Hospital Innovation and Improvement will welcome you to collaborate and link you to valuable resources.

---

Brett Radler is SHM’s communications coordinator.

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

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

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

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

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

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

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

---

Joshua Lapps is SHM’s government relations manager.

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

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

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

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

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

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

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

---

Joshua Lapps is SHM’s government relations manager.

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

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

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

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

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

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

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

---

Joshua Lapps is SHM’s government relations manager.

During a facility stay, a patient could be attended to by more than one hospitalist. For example, perhaps one hospitalist is the admitting physician, but the patient has a three-day stay and may be seen by three different hospitalists. Are there any guidelines as to which physician should be billed on the facility claim? Thank you for any remarks, suggestions, or references.

—Anonymous

Dr. Hospitalist responds:

Most of us can definitely relate to the concerns you have about properly billing during the patient’s hospital stay. By facility claim, I’m assuming you mean the physician’s bill for services rendered to a hospitalized patient. After querying the Centers for Medicare and Medicaid (CMS) website and discussing the question with several of our coding and billing gurus, as far as I can tell, there are no specific guidelines pertaining to which physician in a multiphysician group should bill. CMS guidelines are clear that you should only bill for the services you provide. CMS is very specific about allowing only one physician of the same specialty billing per day (reference the CMS Manual, Chapter 12, 30.6.9-Payment for Inpatient Hospital Visits).

In our very large group, we bill daily for the individual inpatient services we provide. That way, when the bill goes out, the clinician author is responsible for its validity and can support the level of care as documented.

Billing and coding is such an arduous process, I can’t imagine attempting it without an electronic interface. Most hospitalist groups have some form of electronic billing software that has integrated checks and balances to catch the common mistakes. Improper billing done by anyone in the group can expose the entire group to an audit. With ICD-10 now upon us, this becomes ever more important.

Good luck!

---

Do you have a problem or concern that you’d like Dr. Hospitalist to address? Email your questions to drhospit@wiley.com.

During a facility stay, a patient could be attended to by more than one hospitalist. For example, perhaps one hospitalist is the admitting physician, but the patient has a three-day stay and may be seen by three different hospitalists. Are there any guidelines as to which physician should be billed on the facility claim? Thank you for any remarks, suggestions, or references.

—Anonymous

Dr. Hospitalist responds:

Most of us can definitely relate to the concerns you have about properly billing during the patient’s hospital stay. By facility claim, I’m assuming you mean the physician’s bill for services rendered to a hospitalized patient. After querying the Centers for Medicare and Medicaid (CMS) website and discussing the question with several of our coding and billing gurus, as far as I can tell, there are no specific guidelines pertaining to which physician in a multiphysician group should bill. CMS guidelines are clear that you should only bill for the services you provide. CMS is very specific about allowing only one physician of the same specialty billing per day (reference the CMS Manual, Chapter 12, 30.6.9-Payment for Inpatient Hospital Visits).

In our very large group, we bill daily for the individual inpatient services we provide. That way, when the bill goes out, the clinician author is responsible for its validity and can support the level of care as documented.

Billing and coding is such an arduous process, I can’t imagine attempting it without an electronic interface. Most hospitalist groups have some form of electronic billing software that has integrated checks and balances to catch the common mistakes. Improper billing done by anyone in the group can expose the entire group to an audit. With ICD-10 now upon us, this becomes ever more important.

Good luck!

---

Do you have a problem or concern that you’d like Dr. Hospitalist to address? Email your questions to drhospit@wiley.com.

During a facility stay, a patient could be attended to by more than one hospitalist. For example, perhaps one hospitalist is the admitting physician, but the patient has a three-day stay and may be seen by three different hospitalists. Are there any guidelines as to which physician should be billed on the facility claim? Thank you for any remarks, suggestions, or references.

—Anonymous

Dr. Hospitalist responds:

Most of us can definitely relate to the concerns you have about properly billing during the patient’s hospital stay. By facility claim, I’m assuming you mean the physician’s bill for services rendered to a hospitalized patient. After querying the Centers for Medicare and Medicaid (CMS) website and discussing the question with several of our coding and billing gurus, as far as I can tell, there are no specific guidelines pertaining to which physician in a multiphysician group should bill. CMS guidelines are clear that you should only bill for the services you provide. CMS is very specific about allowing only one physician of the same specialty billing per day (reference the CMS Manual, Chapter 12, 30.6.9-Payment for Inpatient Hospital Visits).

In our very large group, we bill daily for the individual inpatient services we provide. That way, when the bill goes out, the clinician author is responsible for its validity and can support the level of care as documented.

Billing and coding is such an arduous process, I can’t imagine attempting it without an electronic interface. Most hospitalist groups have some form of electronic billing software that has integrated checks and balances to catch the common mistakes. Improper billing done by anyone in the group can expose the entire group to an audit. With ICD-10 now upon us, this becomes ever more important.

Good luck!

---

Do you have a problem or concern that you’d like Dr. Hospitalist to address? Email your questions to drhospit@wiley.com.

Editor’s note: Second in a continuing series of articles exploring ways hospitalist groups can cut back.

In last month’s column, I made the case that most hospitalist groups should think about doing away with a morning meeting to distribute overnight admissions and changing a daytime admitter shift into another rounder and having all of the day rounders share admissions. Here I’ll describe additional things in place at some hospitalist groups that should probably be eliminated.

Obscuring Attending Hospitalist Name

Some hospitalist groups admit patients to the “blue team” or “gold team” or use a similar system. I encountered one place that had a fuchsia team. Such designations typically take the place of the attending physician’s name and can be convenient when one hospitalist goes off service and is replaced by another; the team name stays the same. Even if the attending hospitalist makes up the entire team (i.e., no residents or students), some groups use the “team” name rather than the attending hospitalist name.

But when the patient’s chart, sign on the door, and other identifying materials all refer only to the team that is caring for the patient, the patients, their families, and most hospital staff don’t have an easy way to identify the responsible physician. Say a worried daughter steps into the hall to ask the nurse, “Which doctor is taking care of my dad?” The nurse might readily see that the blue team is responsible but may not know which hospitalist is working on the blue team today and might have to walk back to the nursing station to look over a sheet of paper (a “decoder ring”) to figure out the hospitalist’s name.

This scenario has all kinds of drawbacks. To the daughter, the name of the doctor in charge is a big deal. It doesn’t inspire confidence if the nurse can’t readily say who that is. And the busy nurse might forget to investigate and provide the name to the daughter in a timely way.

I think groups using a system like this should seriously consider replacing team names with the attending hospitalist name and updating that name in the medical record, whether that is an EHR, a paper chart, or some other form, every time that doctor rotates off service and is replaced by another. Hospital staff, patients, and families should always see the name of the attending physician and not an uninformative color or nondescript team name.

It will require work for someone, the hospitalist in many cases, to go into the EHR and write an order or send a message to ensure that the hospitalist name is kept current every time one doctor replaces another. But it’s worth the effort.

Day Hospitalists Should Round on Patients Admitted after Midnight

Although not exactly common, I’ve come across this scenario often enough that it’s worth mentioning.

Hospitalists, sometimes with a hint of indignity or even chest thumping, have told me they don’t visit or round on patients admitted after midnight by their night doctor. “You can’t bill for a second visit on the same calendar day,” they explain, firmly. “So if I can’t get paid to see the patient, then I won’t.”

This is just crazy.

For one thing, these same doctors are typically employed by the hospital and are being paid to provide whatever care patients need. I think they’ve just latched onto the “can’t bill another visit” as an excuse to get out of some work.

 

Don’t forget that many of these patients may wait over 30 hours from their admitting visit to the first follow-up visit; this delay is at the beginning of their hospital stay, when they might be most unstable. And it delays initiation of discharge planning and other important steps in patient care.

I don’t see any room for meaningful debate on this. The rounder who picks up a patient admitted the night before should always make a full rounding visit, even if the admission was after midnight.

But if the visit isn’t billable, you are freed from the typical billing-related documentation requirements. No need to document detail in the note that doesn’t meaningfully contribute to the care of the patient. For example, you might omit a chief complaint for this encounter.

Daytime Triage Doctor

Practices larger than about 20 full-time equivalents often have one daytime doctor hold a “triage” or “hot” pager, which others call to make a new referral. This triage doctor will hear about all referrals and keep track of and contact the hospitalist responsible for the next new patient. This can be a very busy job and often comes on top of a full clinical load for that doctor.

As I mentioned in my July 2015 and December 2010 articles, in many or most groups, a clerical person could take over this function, at least during business hours.

Vacation Time

In many or most cases, hospitalists that have specified vacation time are not getting a better deal than those that have no vacation time. What really matters is how many shifts you’re responsible for in a year. For the days you aren’t on shift, in most hospitalist groups it really doesn’t matter whether you label some of them as vacation days or CME days.

I discussed this issue in greater detail in my March 2007 article.

But if you’re in the 30% of hospitalist groups that have a vacation (or PTO) provision currently and it works well, then there certainly isn’t a compelling reason to change or do away with it.

---

Dr. Nelson has been a practicing hospitalist since 1988. He is co-founder and past president of SHM, and principal in Nelson Flores Hospital Medicine Consultants. He is co-director for SHM’s “Best Practices in Managing a Hospital Medicine Program” course. Write to him at john.nelson@nelsonflores.com.

Editor’s note: Second in a continuing series of articles exploring ways hospitalist groups can cut back.

In last month’s column, I made the case that most hospitalist groups should think about doing away with a morning meeting to distribute overnight admissions and changing a daytime admitter shift into another rounder and having all of the day rounders share admissions. Here I’ll describe additional things in place at some hospitalist groups that should probably be eliminated.

Obscuring Attending Hospitalist Name

Some hospitalist groups admit patients to the “blue team” or “gold team” or use a similar system. I encountered one place that had a fuchsia team. Such designations typically take the place of the attending physician’s name and can be convenient when one hospitalist goes off service and is replaced by another; the team name stays the same. Even if the attending hospitalist makes up the entire team (i.e., no residents or students), some groups use the “team” name rather than the attending hospitalist name.

But when the patient’s chart, sign on the door, and other identifying materials all refer only to the team that is caring for the patient, the patients, their families, and most hospital staff don’t have an easy way to identify the responsible physician. Say a worried daughter steps into the hall to ask the nurse, “Which doctor is taking care of my dad?” The nurse might readily see that the blue team is responsible but may not know which hospitalist is working on the blue team today and might have to walk back to the nursing station to look over a sheet of paper (a “decoder ring”) to figure out the hospitalist’s name.

This scenario has all kinds of drawbacks. To the daughter, the name of the doctor in charge is a big deal. It doesn’t inspire confidence if the nurse can’t readily say who that is. And the busy nurse might forget to investigate and provide the name to the daughter in a timely way.

I think groups using a system like this should seriously consider replacing team names with the attending hospitalist name and updating that name in the medical record, whether that is an EHR, a paper chart, or some other form, every time that doctor rotates off service and is replaced by another. Hospital staff, patients, and families should always see the name of the attending physician and not an uninformative color or nondescript team name.

It will require work for someone, the hospitalist in many cases, to go into the EHR and write an order or send a message to ensure that the hospitalist name is kept current every time one doctor replaces another. But it’s worth the effort.

Day Hospitalists Should Round on Patients Admitted after Midnight

Although not exactly common, I’ve come across this scenario often enough that it’s worth mentioning.

Hospitalists, sometimes with a hint of indignity or even chest thumping, have told me they don’t visit or round on patients admitted after midnight by their night doctor. “You can’t bill for a second visit on the same calendar day,” they explain, firmly. “So if I can’t get paid to see the patient, then I won’t.”

This is just crazy.

For one thing, these same doctors are typically employed by the hospital and are being paid to provide whatever care patients need. I think they’ve just latched onto the “can’t bill another visit” as an excuse to get out of some work.

 

Don’t forget that many of these patients may wait over 30 hours from their admitting visit to the first follow-up visit; this delay is at the beginning of their hospital stay, when they might be most unstable. And it delays initiation of discharge planning and other important steps in patient care.

I don’t see any room for meaningful debate on this. The rounder who picks up a patient admitted the night before should always make a full rounding visit, even if the admission was after midnight.

But if the visit isn’t billable, you are freed from the typical billing-related documentation requirements. No need to document detail in the note that doesn’t meaningfully contribute to the care of the patient. For example, you might omit a chief complaint for this encounter.

Daytime Triage Doctor

Practices larger than about 20 full-time equivalents often have one daytime doctor hold a “triage” or “hot” pager, which others call to make a new referral. This triage doctor will hear about all referrals and keep track of and contact the hospitalist responsible for the next new patient. This can be a very busy job and often comes on top of a full clinical load for that doctor.

As I mentioned in my July 2015 and December 2010 articles, in many or most groups, a clerical person could take over this function, at least during business hours.

Vacation Time

In many or most cases, hospitalists that have specified vacation time are not getting a better deal than those that have no vacation time. What really matters is how many shifts you’re responsible for in a year. For the days you aren’t on shift, in most hospitalist groups it really doesn’t matter whether you label some of them as vacation days or CME days.

I discussed this issue in greater detail in my March 2007 article.

But if you’re in the 30% of hospitalist groups that have a vacation (or PTO) provision currently and it works well, then there certainly isn’t a compelling reason to change or do away with it.

---

Dr. Nelson has been a practicing hospitalist since 1988. He is co-founder and past president of SHM, and principal in Nelson Flores Hospital Medicine Consultants. He is co-director for SHM’s “Best Practices in Managing a Hospital Medicine Program” course. Write to him at john.nelson@nelsonflores.com.

Editor’s note: Second in a continuing series of articles exploring ways hospitalist groups can cut back.

In last month’s column, I made the case that most hospitalist groups should think about doing away with a morning meeting to distribute overnight admissions and changing a daytime admitter shift into another rounder and having all of the day rounders share admissions. Here I’ll describe additional things in place at some hospitalist groups that should probably be eliminated.

Obscuring Attending Hospitalist Name

Some hospitalist groups admit patients to the “blue team” or “gold team” or use a similar system. I encountered one place that had a fuchsia team. Such designations typically take the place of the attending physician’s name and can be convenient when one hospitalist goes off service and is replaced by another; the team name stays the same. Even if the attending hospitalist makes up the entire team (i.e., no residents or students), some groups use the “team” name rather than the attending hospitalist name.

But when the patient’s chart, sign on the door, and other identifying materials all refer only to the team that is caring for the patient, the patients, their families, and most hospital staff don’t have an easy way to identify the responsible physician. Say a worried daughter steps into the hall to ask the nurse, “Which doctor is taking care of my dad?” The nurse might readily see that the blue team is responsible but may not know which hospitalist is working on the blue team today and might have to walk back to the nursing station to look over a sheet of paper (a “decoder ring”) to figure out the hospitalist’s name.

This scenario has all kinds of drawbacks. To the daughter, the name of the doctor in charge is a big deal. It doesn’t inspire confidence if the nurse can’t readily say who that is. And the busy nurse might forget to investigate and provide the name to the daughter in a timely way.

I think groups using a system like this should seriously consider replacing team names with the attending hospitalist name and updating that name in the medical record, whether that is an EHR, a paper chart, or some other form, every time that doctor rotates off service and is replaced by another. Hospital staff, patients, and families should always see the name of the attending physician and not an uninformative color or nondescript team name.

It will require work for someone, the hospitalist in many cases, to go into the EHR and write an order or send a message to ensure that the hospitalist name is kept current every time one doctor replaces another. But it’s worth the effort.

Day Hospitalists Should Round on Patients Admitted after Midnight

Although not exactly common, I’ve come across this scenario often enough that it’s worth mentioning.

Hospitalists, sometimes with a hint of indignity or even chest thumping, have told me they don’t visit or round on patients admitted after midnight by their night doctor. “You can’t bill for a second visit on the same calendar day,” they explain, firmly. “So if I can’t get paid to see the patient, then I won’t.”

This is just crazy.

For one thing, these same doctors are typically employed by the hospital and are being paid to provide whatever care patients need. I think they’ve just latched onto the “can’t bill another visit” as an excuse to get out of some work.

 

Don’t forget that many of these patients may wait over 30 hours from their admitting visit to the first follow-up visit; this delay is at the beginning of their hospital stay, when they might be most unstable. And it delays initiation of discharge planning and other important steps in patient care.

I don’t see any room for meaningful debate on this. The rounder who picks up a patient admitted the night before should always make a full rounding visit, even if the admission was after midnight.

But if the visit isn’t billable, you are freed from the typical billing-related documentation requirements. No need to document detail in the note that doesn’t meaningfully contribute to the care of the patient. For example, you might omit a chief complaint for this encounter.

Daytime Triage Doctor

Practices larger than about 20 full-time equivalents often have one daytime doctor hold a “triage” or “hot” pager, which others call to make a new referral. This triage doctor will hear about all referrals and keep track of and contact the hospitalist responsible for the next new patient. This can be a very busy job and often comes on top of a full clinical load for that doctor.

As I mentioned in my July 2015 and December 2010 articles, in many or most groups, a clerical person could take over this function, at least during business hours.

Vacation Time

In many or most cases, hospitalists that have specified vacation time are not getting a better deal than those that have no vacation time. What really matters is how many shifts you’re responsible for in a year. For the days you aren’t on shift, in most hospitalist groups it really doesn’t matter whether you label some of them as vacation days or CME days.

I discussed this issue in greater detail in my March 2007 article.

But if you’re in the 30% of hospitalist groups that have a vacation (or PTO) provision currently and it works well, then there certainly isn’t a compelling reason to change or do away with it.

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Dr. Nelson has been a practicing hospitalist since 1988. He is co-founder and past president of SHM, and principal in Nelson Flores Hospital Medicine Consultants. He is co-director for SHM’s “Best Practices in Managing a Hospital Medicine Program” course. Write to him at john.nelson@nelsonflores.com.

It’s that time of year again … the time when hospitals around the country are being notified of their 30-day readmission penalties from the Centers for Medicare and Medicaid Services (CMS). Now in the fourth year of the program, many hospitals have come to dread the announcement of how much they are being penalized each year.¹

This year, the readmission reduction program will decrease Medicare payments within a total of 2,592 U.S. hospitals, for a combined total of $420 million. This year’s program included readmissions from July 2011 to June 2014; the program uses a three-year rolling average for its calculations.²

The readmission program, which initially was implemented through the Affordable Care Act in 2012, aimed to penalize hospitals with higher than expected 30-day readmission rates on select conditions (currently heart attack, heart failure, pneumonia, COPD, and hip/knee replacements). Medicare estimates that it spends $17 billion a year in avoidable readmissions, which prompted the initial support for the program. For each condition, CMS calculates expected readmission rates (based on risk adjustment models that include age, severity of illness, and comorbid conditions) and observed rates, and then calculates an “excess readmission ratio” for each hospital. Based on the overall ratio, the hospital is penalized up to 3% of its Medicare payments for all inpatient stays for that fiscal year. Each year, CMS reassesses the readmission rates for hospitals and readjusts the magnitude of the penalty. The purpose of the program is to incent hospitals to invest in discharge planning and care coordination efforts and do everything possible to avoid readmissions.¹

Who Gets Penalized?

This year, most eligible hospitals were penalized to some extent, and all but 209 of the hospitals that were penalized last year were penalized again.

The average Medicare payment reduction will be 0.61% per patient stay.

A total of 506 hospitals will lose at least 1% of their Medicare payments, and 38 hospitals will receive the maximum 3% penalty.

Unfortunately, safety net hospitals were about 60% more likely than other hospitals to have been penalized in all three years of the program. In addition, hospitals with the lowest profit margins were 36% more likely to be penalized than those with higher margins.

Some states were disproportionately affected, with at least three-quarters of hospitals affected in Alabama, Connecticut, Florida, Massachusetts, New Jersey, New York, Rhode Island, South Carolina, Virginia, and the District of Columbia. States that fared the best were Idaho, Iowa, Kansas, Montana, Nebraska, North Dakota, and South Dakota.

Most of the 2,232 hospitals that avoided a penalty were spared because they were exempted from the program (Veterans Affairs hospitals, children’s hospitals, critical access hospitals, or those with too few Medicare patients), not because of exceptional performance.

Does the Program Work?

Despite criticism, there is no doubt that this program has forced hospitals to pay keen attention to transitions of care and avoidable readmissions. And it does appear to be an effective strategy for CMS to achieve its goals; there has been an overall decrease in 30-day readmission rates among Medicare recipients since the program began, in all types of hospitals.

Compared to 2012, there were 100,000 fewer readmissions among Medicare beneficiaries in the U.S. in 2013. As such, there is no evidence that the program will be discontinued, although it will hopefully be altered in some key aspects.³

What the Future Holds

The program has been criticized on many fronts. For one, it recalculates a three-year rolling average each year, which makes it incredibly difficult to “wash out” older (poor) performance and get off the penalty list.

 

In addition, critics have pointed out that the program fails to take into account the socioeconomic background of patients when assessing readmission penalties. Many argue that social determinants of readmissions that are beyond the immediate control of a hospital system can have a huge impact on readmission rates.

The National Quality Forum is examining the impact of these factors on readmissions, but this evaluation likely will take years.

In the meantime, the Hospital Readmissions Program Accuracy and Accountability Act of 2014 has been introduced as a bill that would require CMS to factor socioeconomic status into the equation when determining readmission penalties.

What All This Means for Hospitalists

All of us working within the confines of the current program can do a few things to improve our understanding and our hospitals’ performance:

• If your hospital is one that incurred a penalty, know that most “eligible” hospitals also incurred a penalty.
• Look at how your hospital fared within your state and find out if you are above or below average in the amount.³
• Continue to focus on exemplary care transition protocols, policies, and programs within your hospital system, because the penalties are unlikely to go away and are very likely to expand over time.
• Support any advocacy efforts toward improving risk adjustment methodologies for readmissions; all hospitals are likely to benefit from more accurate risk adjustments.

---

Dr. Scheurer is a hospitalist and chief quality officer at the Medical University of South Carolina in Charleston. She is physician editor of The Hospitalist. Email her at scheured@musc.edu.

References

1. Centers for Medicare and Medicaid Services. Readmissions reduction program. Accessed October 3, 2015.
2. Rau J. Half of nation’s hospitals fail again to escape Medicare’s readmissions penalties. August 3, 2015. Accessed October 3, 2015.
3. Medpac. The hospital readmission penalty: how well is it working?. Accessed October 3, 2015.

It’s that time of year again … the time when hospitals around the country are being notified of their 30-day readmission penalties from the Centers for Medicare and Medicaid Services (CMS). Now in the fourth year of the program, many hospitals have come to dread the announcement of how much they are being penalized each year.¹

This year, the readmission reduction program will decrease Medicare payments within a total of 2,592 U.S. hospitals, for a combined total of $420 million. This year’s program included readmissions from July 2011 to June 2014; the program uses a three-year rolling average for its calculations.²

The readmission program, which initially was implemented through the Affordable Care Act in 2012, aimed to penalize hospitals with higher than expected 30-day readmission rates on select conditions (currently heart attack, heart failure, pneumonia, COPD, and hip/knee replacements). Medicare estimates that it spends $17 billion a year in avoidable readmissions, which prompted the initial support for the program. For each condition, CMS calculates expected readmission rates (based on risk adjustment models that include age, severity of illness, and comorbid conditions) and observed rates, and then calculates an “excess readmission ratio” for each hospital. Based on the overall ratio, the hospital is penalized up to 3% of its Medicare payments for all inpatient stays for that fiscal year. Each year, CMS reassesses the readmission rates for hospitals and readjusts the magnitude of the penalty. The purpose of the program is to incent hospitals to invest in discharge planning and care coordination efforts and do everything possible to avoid readmissions.¹

Who Gets Penalized?

This year, most eligible hospitals were penalized to some extent, and all but 209 of the hospitals that were penalized last year were penalized again.

The average Medicare payment reduction will be 0.61% per patient stay.

A total of 506 hospitals will lose at least 1% of their Medicare payments, and 38 hospitals will receive the maximum 3% penalty.

Unfortunately, safety net hospitals were about 60% more likely than other hospitals to have been penalized in all three years of the program. In addition, hospitals with the lowest profit margins were 36% more likely to be penalized than those with higher margins.

Some states were disproportionately affected, with at least three-quarters of hospitals affected in Alabama, Connecticut, Florida, Massachusetts, New Jersey, New York, Rhode Island, South Carolina, Virginia, and the District of Columbia. States that fared the best were Idaho, Iowa, Kansas, Montana, Nebraska, North Dakota, and South Dakota.

Most of the 2,232 hospitals that avoided a penalty were spared because they were exempted from the program (Veterans Affairs hospitals, children’s hospitals, critical access hospitals, or those with too few Medicare patients), not because of exceptional performance.

Does the Program Work?

Despite criticism, there is no doubt that this program has forced hospitals to pay keen attention to transitions of care and avoidable readmissions. And it does appear to be an effective strategy for CMS to achieve its goals; there has been an overall decrease in 30-day readmission rates among Medicare recipients since the program began, in all types of hospitals.

Compared to 2012, there were 100,000 fewer readmissions among Medicare beneficiaries in the U.S. in 2013. As such, there is no evidence that the program will be discontinued, although it will hopefully be altered in some key aspects.³

What the Future Holds

The program has been criticized on many fronts. For one, it recalculates a three-year rolling average each year, which makes it incredibly difficult to “wash out” older (poor) performance and get off the penalty list.

 

In addition, critics have pointed out that the program fails to take into account the socioeconomic background of patients when assessing readmission penalties. Many argue that social determinants of readmissions that are beyond the immediate control of a hospital system can have a huge impact on readmission rates.

The National Quality Forum is examining the impact of these factors on readmissions, but this evaluation likely will take years.

In the meantime, the Hospital Readmissions Program Accuracy and Accountability Act of 2014 has been introduced as a bill that would require CMS to factor socioeconomic status into the equation when determining readmission penalties.

What All This Means for Hospitalists

All of us working within the confines of the current program can do a few things to improve our understanding and our hospitals’ performance:

• If your hospital is one that incurred a penalty, know that most “eligible” hospitals also incurred a penalty.
• Look at how your hospital fared within your state and find out if you are above or below average in the amount.³
• Continue to focus on exemplary care transition protocols, policies, and programs within your hospital system, because the penalties are unlikely to go away and are very likely to expand over time.
• Support any advocacy efforts toward improving risk adjustment methodologies for readmissions; all hospitals are likely to benefit from more accurate risk adjustments.

---

Dr. Scheurer is a hospitalist and chief quality officer at the Medical University of South Carolina in Charleston. She is physician editor of The Hospitalist. Email her at scheured@musc.edu.

References

1. Centers for Medicare and Medicaid Services. Readmissions reduction program. Accessed October 3, 2015.
2. Rau J. Half of nation’s hospitals fail again to escape Medicare’s readmissions penalties. August 3, 2015. Accessed October 3, 2015.
3. Medpac. The hospital readmission penalty: how well is it working?. Accessed October 3, 2015.

It’s that time of year again … the time when hospitals around the country are being notified of their 30-day readmission penalties from the Centers for Medicare and Medicaid Services (CMS). Now in the fourth year of the program, many hospitals have come to dread the announcement of how much they are being penalized each year.¹

This year, the readmission reduction program will decrease Medicare payments within a total of 2,592 U.S. hospitals, for a combined total of $420 million. This year’s program included readmissions from July 2011 to June 2014; the program uses a three-year rolling average for its calculations.²

The readmission program, which initially was implemented through the Affordable Care Act in 2012, aimed to penalize hospitals with higher than expected 30-day readmission rates on select conditions (currently heart attack, heart failure, pneumonia, COPD, and hip/knee replacements). Medicare estimates that it spends $17 billion a year in avoidable readmissions, which prompted the initial support for the program. For each condition, CMS calculates expected readmission rates (based on risk adjustment models that include age, severity of illness, and comorbid conditions) and observed rates, and then calculates an “excess readmission ratio” for each hospital. Based on the overall ratio, the hospital is penalized up to 3% of its Medicare payments for all inpatient stays for that fiscal year. Each year, CMS reassesses the readmission rates for hospitals and readjusts the magnitude of the penalty. The purpose of the program is to incent hospitals to invest in discharge planning and care coordination efforts and do everything possible to avoid readmissions.¹

Who Gets Penalized?

This year, most eligible hospitals were penalized to some extent, and all but 209 of the hospitals that were penalized last year were penalized again.

The average Medicare payment reduction will be 0.61% per patient stay.

A total of 506 hospitals will lose at least 1% of their Medicare payments, and 38 hospitals will receive the maximum 3% penalty.

Unfortunately, safety net hospitals were about 60% more likely than other hospitals to have been penalized in all three years of the program. In addition, hospitals with the lowest profit margins were 36% more likely to be penalized than those with higher margins.

Some states were disproportionately affected, with at least three-quarters of hospitals affected in Alabama, Connecticut, Florida, Massachusetts, New Jersey, New York, Rhode Island, South Carolina, Virginia, and the District of Columbia. States that fared the best were Idaho, Iowa, Kansas, Montana, Nebraska, North Dakota, and South Dakota.

Most of the 2,232 hospitals that avoided a penalty were spared because they were exempted from the program (Veterans Affairs hospitals, children’s hospitals, critical access hospitals, or those with too few Medicare patients), not because of exceptional performance.

Does the Program Work?

Despite criticism, there is no doubt that this program has forced hospitals to pay keen attention to transitions of care and avoidable readmissions. And it does appear to be an effective strategy for CMS to achieve its goals; there has been an overall decrease in 30-day readmission rates among Medicare recipients since the program began, in all types of hospitals.

Compared to 2012, there were 100,000 fewer readmissions among Medicare beneficiaries in the U.S. in 2013. As such, there is no evidence that the program will be discontinued, although it will hopefully be altered in some key aspects.³

What the Future Holds

The program has been criticized on many fronts. For one, it recalculates a three-year rolling average each year, which makes it incredibly difficult to “wash out” older (poor) performance and get off the penalty list.

 

In addition, critics have pointed out that the program fails to take into account the socioeconomic background of patients when assessing readmission penalties. Many argue that social determinants of readmissions that are beyond the immediate control of a hospital system can have a huge impact on readmission rates.

The National Quality Forum is examining the impact of these factors on readmissions, but this evaluation likely will take years.

In the meantime, the Hospital Readmissions Program Accuracy and Accountability Act of 2014 has been introduced as a bill that would require CMS to factor socioeconomic status into the equation when determining readmission penalties.

What All This Means for Hospitalists

All of us working within the confines of the current program can do a few things to improve our understanding and our hospitals’ performance:

• If your hospital is one that incurred a penalty, know that most “eligible” hospitals also incurred a penalty.
• Look at how your hospital fared within your state and find out if you are above or below average in the amount.³
• Continue to focus on exemplary care transition protocols, policies, and programs within your hospital system, because the penalties are unlikely to go away and are very likely to expand over time.
• Support any advocacy efforts toward improving risk adjustment methodologies for readmissions; all hospitals are likely to benefit from more accurate risk adjustments.

---

Dr. Scheurer is a hospitalist and chief quality officer at the Medical University of South Carolina in Charleston. She is physician editor of The Hospitalist. Email her at scheured@musc.edu.

References

1. Centers for Medicare and Medicaid Services. Readmissions reduction program. Accessed October 3, 2015.
2. Rau J. Half of nation’s hospitals fail again to escape Medicare’s readmissions penalties. August 3, 2015. Accessed October 3, 2015.
3. Medpac. The hospital readmission penalty: how well is it working?. Accessed October 3, 2015.