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Special Issue Assesses Strengthening Our Soldiers
ABS Survey Finds Increased Caseloads Among General Surgeons
BOCA RATON, FLA. – General surgeons are working harder than ever, with significantly bigger annual operative case totals than a decade ago, and the overload is expected to worsen, based on findings of a new American Board of Surgery analysis of general surgery workloads and practice patterns during 2007-2009.
"My sense is that there’s a worsening shortage of general surgeons that’s causing them to work harder. There’s more need for them. I don’t know what is the maximum number of operations a general surgeon can do in a year, but I bet it’s pretty close to where we are right now," Dr. R. James Valentine said in presenting the ABS survey findings at the annual meeting of the American Surgical Association.
Nearly 80% of trainees completing general surgery residencies now opt to obtain additional surgical subspecialty fellowship training, which means that the number of general surgeons going directly into practice is decreasing and the number of surgical subspecialists is climbing.
The ABS survey showed that these subspecialist surgeons perform roughly 25% of all core general surgery procedures being done in the United States. But as these subspecialist surgeons narrow their practices over time – which is the norm in response to patient demands and practice referral patterns – the core general surgery procedures that they will no longer be doing will fall squarely on the shoulders of already-overworked general surgeons, explained Dr. Valentine, professor and vice chairman of the department of surgery at the University of Texas Southwestern Medical Center, Dallas.
The ABS study involved analysis of the surgical operative logs of 4,968 surgeons who took the recertification exam in 2007-2009. Some 68% of them were certified only in general surgery, whereas the rest had one or more additional American Board of Medical Specialties certificates.
In all, 88% of all general surgeons seeking recertification were men. They performed an average of 506 operative cases per year, compared with 375 for female general surgeons. These operative caseloads were significantly higher than those reflected in a similar ABS survey conducted a decade earlier. Moreover, in 2007-2009, general surgeons performed more procedures in all areas – abdominal, alimentary, breast, endoscopy, vascular, and laparoscopy – than in 1997-1999.
Among other key study findings were the following:
• Female general surgeons performed far more breast operations and significantly fewer abdominal, alimentary, and laparoscopic operations than did their male counterparts.
• Subspecialist surgeons did 26% of all core general surgery alimentary operations such as appendectomies and cholecystectomies, 10% of all breast operations, 13% of abdominal, 15% of laparoscopic, and 26% of endoscopic procedures.
General surgeons performed 46% of all vascular, 16% of thoracic, 30% of pediatric, and 33% of plastic surgery operations.
• A huge difference in practice patterns between urban and rural general surgeons was identified. Rural general surgeons performed far more endoscopic procedures and significantly fewer abdominal, alimentary, and laparoscopic procedures than did their urban counterparts.
• Within the field of vascular surgery, general surgeons performed 35% of all carotid endarterectomies, 27% of leg bypass procedures, 25% of aneurysm repairs, and 24% of all endovascular procedures.
• U.S. medical school graduates and international medical graduates had similar workloads and distribution of operations.
"We conclude from these data that the reduced general surgery operative experience in residencies with coexisting fellowship programs may negatively impact access to general surgery care. Similarly, narrowing general surgery residency operative experience may impair access to specialty operations," Dr. Valentine said.
Discussant Dr. George F. Sheldon said the message of this and other studies is that there remains a clear need to train general surgeons who are able to care for a wide range of surgical conditions.
"The type of practice and some of the tools may differ, and the setting in which we work may be changing, but I really think the fundamental concept of a broadly trained general surgeon is validated by all of the studies that have been done," said Dr. Sheldon, professor of surgery and social medicine at the University of North Carolina at Chapel Hill.
Dr. E. Christopher Ellison, chair of the ABS, drew attention to the large number of endoscopic procedures being performed by general surgeons, particularly those in rural practice.
"I think with the recent debate about the role of general surgeons in endoscopy, your evidence presents a case that we need to continue a high level of endoscopy training in our general surgery programs. In our rural and less populated areas, the general surgeon provides ready access to endoscopy of the upper and lower GI tract. Certainly, this is a benefit to the patients living in those areas," commented Dr. Ellison, professor and chair of the department of surgery and associate vice president for health sciences at the Ohio State University, Columbus.
Dr. Valentine concurred.
"It certainly looks like general surgeons are doing a lot of endoscopy without the help of our GI colleagues, especially in rural areas. That’s something that we need to remember when we’re challenged by those societies," according to Dr. Valentine.
He said he had no financial conflicts.
I would interpret the data regarding vascular surgery slightly differently. First, we see a growing number of women entering the general surgery career path, with a practice pattern suggesting an interest in doing fewer and less complex procedures. Second, general surgeons now perform less than half of all "vascular" cases, but for index cases such as AAA repair (open or EVAR), CEA or lower extremity bypass, their contribution is now closer to 25% of overall volumes. These percentages represent a decline from prior reports, and I
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suspect this trend will continue. Second, as vascular interventions continue to evolve into endovascular procedures requiring advanced imaging suites and a complete endovascular toolbox of treatment options instantly available, rural physicians and hospital simply will not have the financial structure or training to provide state of the art care. Our analysis (presented at VAM 2011, SS 26) demonstrated that vascular surgical inpatient procedures increased 22% over from 1997 to 2008. Furthermore, compared with 2008 levels, inpatient case volumes are predicted to grow by 18% by 2015, 34% by 2020, and 72% by 2030. Obviously, outpatient procedural growth will continue to expand the vascular workload even more. I can only conclude that general surgeons will play a diminishing role in the care of patients with vascular disease, and that the vascular surgeon specialist will face continued growth in practice volumes for the foreseeable future.
Dr Brian Rubin is a professor of the department of surgery at the Washington University School of Medicine, St. Louis, and an associate medical editor of Vascular Specialist.
I would interpret the data regarding vascular surgery slightly differently. First, we see a growing number of women entering the general surgery career path, with a practice pattern suggesting an interest in doing fewer and less complex procedures. Second, general surgeons now perform less than half of all "vascular" cases, but for index cases such as AAA repair (open or EVAR), CEA or lower extremity bypass, their contribution is now closer to 25% of overall volumes. These percentages represent a decline from prior reports, and I
|
suspect this trend will continue. Second, as vascular interventions continue to evolve into endovascular procedures requiring advanced imaging suites and a complete endovascular toolbox of treatment options instantly available, rural physicians and hospital simply will not have the financial structure or training to provide state of the art care. Our analysis (presented at VAM 2011, SS 26) demonstrated that vascular surgical inpatient procedures increased 22% over from 1997 to 2008. Furthermore, compared with 2008 levels, inpatient case volumes are predicted to grow by 18% by 2015, 34% by 2020, and 72% by 2030. Obviously, outpatient procedural growth will continue to expand the vascular workload even more. I can only conclude that general surgeons will play a diminishing role in the care of patients with vascular disease, and that the vascular surgeon specialist will face continued growth in practice volumes for the foreseeable future.
Dr Brian Rubin is a professor of the department of surgery at the Washington University School of Medicine, St. Louis, and an associate medical editor of Vascular Specialist.
I would interpret the data regarding vascular surgery slightly differently. First, we see a growing number of women entering the general surgery career path, with a practice pattern suggesting an interest in doing fewer and less complex procedures. Second, general surgeons now perform less than half of all "vascular" cases, but for index cases such as AAA repair (open or EVAR), CEA or lower extremity bypass, their contribution is now closer to 25% of overall volumes. These percentages represent a decline from prior reports, and I
|
suspect this trend will continue. Second, as vascular interventions continue to evolve into endovascular procedures requiring advanced imaging suites and a complete endovascular toolbox of treatment options instantly available, rural physicians and hospital simply will not have the financial structure or training to provide state of the art care. Our analysis (presented at VAM 2011, SS 26) demonstrated that vascular surgical inpatient procedures increased 22% over from 1997 to 2008. Furthermore, compared with 2008 levels, inpatient case volumes are predicted to grow by 18% by 2015, 34% by 2020, and 72% by 2030. Obviously, outpatient procedural growth will continue to expand the vascular workload even more. I can only conclude that general surgeons will play a diminishing role in the care of patients with vascular disease, and that the vascular surgeon specialist will face continued growth in practice volumes for the foreseeable future.
Dr Brian Rubin is a professor of the department of surgery at the Washington University School of Medicine, St. Louis, and an associate medical editor of Vascular Specialist.
BOCA RATON, FLA. – General surgeons are working harder than ever, with significantly bigger annual operative case totals than a decade ago, and the overload is expected to worsen, based on findings of a new American Board of Surgery analysis of general surgery workloads and practice patterns during 2007-2009.
"My sense is that there’s a worsening shortage of general surgeons that’s causing them to work harder. There’s more need for them. I don’t know what is the maximum number of operations a general surgeon can do in a year, but I bet it’s pretty close to where we are right now," Dr. R. James Valentine said in presenting the ABS survey findings at the annual meeting of the American Surgical Association.
Nearly 80% of trainees completing general surgery residencies now opt to obtain additional surgical subspecialty fellowship training, which means that the number of general surgeons going directly into practice is decreasing and the number of surgical subspecialists is climbing.
The ABS survey showed that these subspecialist surgeons perform roughly 25% of all core general surgery procedures being done in the United States. But as these subspecialist surgeons narrow their practices over time – which is the norm in response to patient demands and practice referral patterns – the core general surgery procedures that they will no longer be doing will fall squarely on the shoulders of already-overworked general surgeons, explained Dr. Valentine, professor and vice chairman of the department of surgery at the University of Texas Southwestern Medical Center, Dallas.
The ABS study involved analysis of the surgical operative logs of 4,968 surgeons who took the recertification exam in 2007-2009. Some 68% of them were certified only in general surgery, whereas the rest had one or more additional American Board of Medical Specialties certificates.
In all, 88% of all general surgeons seeking recertification were men. They performed an average of 506 operative cases per year, compared with 375 for female general surgeons. These operative caseloads were significantly higher than those reflected in a similar ABS survey conducted a decade earlier. Moreover, in 2007-2009, general surgeons performed more procedures in all areas – abdominal, alimentary, breast, endoscopy, vascular, and laparoscopy – than in 1997-1999.
Among other key study findings were the following:
• Female general surgeons performed far more breast operations and significantly fewer abdominal, alimentary, and laparoscopic operations than did their male counterparts.
• Subspecialist surgeons did 26% of all core general surgery alimentary operations such as appendectomies and cholecystectomies, 10% of all breast operations, 13% of abdominal, 15% of laparoscopic, and 26% of endoscopic procedures.
General surgeons performed 46% of all vascular, 16% of thoracic, 30% of pediatric, and 33% of plastic surgery operations.
• A huge difference in practice patterns between urban and rural general surgeons was identified. Rural general surgeons performed far more endoscopic procedures and significantly fewer abdominal, alimentary, and laparoscopic procedures than did their urban counterparts.
• Within the field of vascular surgery, general surgeons performed 35% of all carotid endarterectomies, 27% of leg bypass procedures, 25% of aneurysm repairs, and 24% of all endovascular procedures.
• U.S. medical school graduates and international medical graduates had similar workloads and distribution of operations.
"We conclude from these data that the reduced general surgery operative experience in residencies with coexisting fellowship programs may negatively impact access to general surgery care. Similarly, narrowing general surgery residency operative experience may impair access to specialty operations," Dr. Valentine said.
Discussant Dr. George F. Sheldon said the message of this and other studies is that there remains a clear need to train general surgeons who are able to care for a wide range of surgical conditions.
"The type of practice and some of the tools may differ, and the setting in which we work may be changing, but I really think the fundamental concept of a broadly trained general surgeon is validated by all of the studies that have been done," said Dr. Sheldon, professor of surgery and social medicine at the University of North Carolina at Chapel Hill.
Dr. E. Christopher Ellison, chair of the ABS, drew attention to the large number of endoscopic procedures being performed by general surgeons, particularly those in rural practice.
"I think with the recent debate about the role of general surgeons in endoscopy, your evidence presents a case that we need to continue a high level of endoscopy training in our general surgery programs. In our rural and less populated areas, the general surgeon provides ready access to endoscopy of the upper and lower GI tract. Certainly, this is a benefit to the patients living in those areas," commented Dr. Ellison, professor and chair of the department of surgery and associate vice president for health sciences at the Ohio State University, Columbus.
Dr. Valentine concurred.
"It certainly looks like general surgeons are doing a lot of endoscopy without the help of our GI colleagues, especially in rural areas. That’s something that we need to remember when we’re challenged by those societies," according to Dr. Valentine.
He said he had no financial conflicts.
BOCA RATON, FLA. – General surgeons are working harder than ever, with significantly bigger annual operative case totals than a decade ago, and the overload is expected to worsen, based on findings of a new American Board of Surgery analysis of general surgery workloads and practice patterns during 2007-2009.
"My sense is that there’s a worsening shortage of general surgeons that’s causing them to work harder. There’s more need for them. I don’t know what is the maximum number of operations a general surgeon can do in a year, but I bet it’s pretty close to where we are right now," Dr. R. James Valentine said in presenting the ABS survey findings at the annual meeting of the American Surgical Association.
Nearly 80% of trainees completing general surgery residencies now opt to obtain additional surgical subspecialty fellowship training, which means that the number of general surgeons going directly into practice is decreasing and the number of surgical subspecialists is climbing.
The ABS survey showed that these subspecialist surgeons perform roughly 25% of all core general surgery procedures being done in the United States. But as these subspecialist surgeons narrow their practices over time – which is the norm in response to patient demands and practice referral patterns – the core general surgery procedures that they will no longer be doing will fall squarely on the shoulders of already-overworked general surgeons, explained Dr. Valentine, professor and vice chairman of the department of surgery at the University of Texas Southwestern Medical Center, Dallas.
The ABS study involved analysis of the surgical operative logs of 4,968 surgeons who took the recertification exam in 2007-2009. Some 68% of them were certified only in general surgery, whereas the rest had one or more additional American Board of Medical Specialties certificates.
In all, 88% of all general surgeons seeking recertification were men. They performed an average of 506 operative cases per year, compared with 375 for female general surgeons. These operative caseloads were significantly higher than those reflected in a similar ABS survey conducted a decade earlier. Moreover, in 2007-2009, general surgeons performed more procedures in all areas – abdominal, alimentary, breast, endoscopy, vascular, and laparoscopy – than in 1997-1999.
Among other key study findings were the following:
• Female general surgeons performed far more breast operations and significantly fewer abdominal, alimentary, and laparoscopic operations than did their male counterparts.
• Subspecialist surgeons did 26% of all core general surgery alimentary operations such as appendectomies and cholecystectomies, 10% of all breast operations, 13% of abdominal, 15% of laparoscopic, and 26% of endoscopic procedures.
General surgeons performed 46% of all vascular, 16% of thoracic, 30% of pediatric, and 33% of plastic surgery operations.
• A huge difference in practice patterns between urban and rural general surgeons was identified. Rural general surgeons performed far more endoscopic procedures and significantly fewer abdominal, alimentary, and laparoscopic procedures than did their urban counterparts.
• Within the field of vascular surgery, general surgeons performed 35% of all carotid endarterectomies, 27% of leg bypass procedures, 25% of aneurysm repairs, and 24% of all endovascular procedures.
• U.S. medical school graduates and international medical graduates had similar workloads and distribution of operations.
"We conclude from these data that the reduced general surgery operative experience in residencies with coexisting fellowship programs may negatively impact access to general surgery care. Similarly, narrowing general surgery residency operative experience may impair access to specialty operations," Dr. Valentine said.
Discussant Dr. George F. Sheldon said the message of this and other studies is that there remains a clear need to train general surgeons who are able to care for a wide range of surgical conditions.
"The type of practice and some of the tools may differ, and the setting in which we work may be changing, but I really think the fundamental concept of a broadly trained general surgeon is validated by all of the studies that have been done," said Dr. Sheldon, professor of surgery and social medicine at the University of North Carolina at Chapel Hill.
Dr. E. Christopher Ellison, chair of the ABS, drew attention to the large number of endoscopic procedures being performed by general surgeons, particularly those in rural practice.
"I think with the recent debate about the role of general surgeons in endoscopy, your evidence presents a case that we need to continue a high level of endoscopy training in our general surgery programs. In our rural and less populated areas, the general surgeon provides ready access to endoscopy of the upper and lower GI tract. Certainly, this is a benefit to the patients living in those areas," commented Dr. Ellison, professor and chair of the department of surgery and associate vice president for health sciences at the Ohio State University, Columbus.
Dr. Valentine concurred.
"It certainly looks like general surgeons are doing a lot of endoscopy without the help of our GI colleagues, especially in rural areas. That’s something that we need to remember when we’re challenged by those societies," according to Dr. Valentine.
He said he had no financial conflicts.
SCIP Hasn't Improved Key SSI Outcomes
BOCA RATON, FLA. – Adherence to Surgical Care Improvement Program measures that are aimed at preventing surgical site infections has not had the desired effect, according to a large national Veterans Affairs study.
There is widespread agreement that reducing surgical site infections is a worthy quality improvement goal. These infections are associated with a twofold increase in mortality, a 60% increase in ICU admission, and a fivefold greater likelihood of hospital readmission after discharge.
But the VA study results showing that the SCIP hasn’t reduced surgical site infection rates call into question whether the program is worth continuing.
"SCIP adherence is not informative to third-party payers, administrators, or patients. The policy of continued SCIP measurement for public reporting and payment should be reevaluated," Dr. Mary T. Hawn declared in presenting the VA study findings at the annual meeting of the American Surgical Association.
SCIP is a multiyear partnership that was initiated in 2003 with the goal of reducing surgical morbidity and mortality at U.S. hospitals. Among the 10 national organizations that are represented on the SCIP steering committee are the American College of Surgeons, the American Hospital Association, the U.S. Department of Veterans Affairs, the Centers for Medicare and Medicaid Services, the Agency for Healthcare Research and Quality, the Centers for Disease Control and Prevention, and the Joint Commission.
Dr. Hawn presented a retrospective study of 60,853 procedures performed at 112 VA hospitals during 2005-2009. The outcome measure was the combined rate of superficial and deep surgical site infections (SSIs) occurring within 30 days of surgery.
The independent variables were adherence to each of five SCIP surgical site infection prevention measures that hospitals are required to collect and report. The five measures are timely administration of a prophylactic antibiotic, timely discontinuation of the antibiotic, appropriate antibiotic coverage, hair removal, and normothermia for colon procedures.
In addition, investigators tracked the impact of rates of adherence to all five measures in a given case, a combined metric they called composite SCIP.
This was the first study to use individual patient-level data for evaluating SCIP. Investigators were able to adjust for the presence of comorbid conditions that are known to affect the risk of SSIs, such as diabetes, dyspnea, and corticosteroid use, noted Dr. Hawn of the University of Alabama at Birmingham.
The overall SSI rate was 6.2%. It didn’t vary significantly over the 5-year study period, which began when the SCIP measures were first implemented in the VA system. Rates of adherence to the five SCIP measures quickly climbed to high levels during the first 6 months, probably because of the VA’s pay-for-performance incentives, she explained.
A first look at the data suggested that SCIP might be performing as intended. For example, there was an 81% adherence rate to the composite SCIP measure, and surgical cases meeting that standard had a 45% lower SSI rate than did those in which all five measures weren’t met. However, when patient-level SSI risk factors were introduced in a multivariate logistic regression analysis, there was no longer any association between SCIP adherence and SSI rates.
SCIP adherence rates ranged from a high of 86.4% for orthopedic surgery to a low of 60.4% for colorectal procedures. Adherence rates for gynecologic and vascular procedures were 85.9% and 81.6%, respectively.
In a separate analysis, Dr. Hawn and her colleagues looked at the relationship between a hospital’s adherence to SCIP measures and the institutional SSI rate. Once again, they found that there was none. The difference in hospital rates of SCIP adherence accounted for a mere 2% of the variation in hospital-wide SSI rates.
Dr. Hawn said that it is particularly troubling, in light of the VA data, to consider that public reporting of the SCIP adherence rates is being used to guide patients to what are supposed to be high-quality hospitals. "Are we really guiding patients to the right hospitals?" she asked.
Discussant Dr. David B. Hoyt noted that the collection of SCIP data constitutes a huge cost for American hospitals.
"It’s essential that quality measurement systems put in place actually correlate with improvement in quality. This study today is a critical example of how a well-intended process can in fact fail to reduce surgical infections. Overall, the SCIP program does not achieve its goal," said Dr. Hoyt, executive director of the American College of Surgeons.
"The data collection burden has increased in the last several years, and unless indicators that are ineffective are dropped, the expense of adding new indicators cannot be accommodated," he added.
Dr. Donald E. Fry commented that the SCIP measures are valid. The trouble is, they’re not inclusive.
"To paraphrase Paul Simon, ‘There must be 50 ways to get an SSI.’ And antibiotics are only a small portion of that," said Dr. Fry, executive vice president at Michael Pine and Associates, Chicago, an analytic health care consulting firm.
"I hope that this presentation will be a significant stimulus for us to go forward with not measuring silly process measures. This is not synchronized swimming. We need to be measuring outcomes. We need objective measures of what it is we’re trying to do, looking at how good hospitals do it well and bad ones don’t do it so well, and coming up with an entire strategy for SSIs," he said.
The SCIP study was funded by the VA. Dr. Hawn declared having no relevant financial interests. ☐
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BOCA RATON, FLA. – Adherence to Surgical Care Improvement Program measures that are aimed at preventing surgical site infections has not had the desired effect, according to a large national Veterans Affairs study.
There is widespread agreement that reducing surgical site infections is a worthy quality improvement goal. These infections are associated with a twofold increase in mortality, a 60% increase in ICU admission, and a fivefold greater likelihood of hospital readmission after discharge.
But the VA study results showing that the SCIP hasn’t reduced surgical site infection rates call into question whether the program is worth continuing.
"SCIP adherence is not informative to third-party payers, administrators, or patients. The policy of continued SCIP measurement for public reporting and payment should be reevaluated," Dr. Mary T. Hawn declared in presenting the VA study findings at the annual meeting of the American Surgical Association.
SCIP is a multiyear partnership that was initiated in 2003 with the goal of reducing surgical morbidity and mortality at U.S. hospitals. Among the 10 national organizations that are represented on the SCIP steering committee are the American College of Surgeons, the American Hospital Association, the U.S. Department of Veterans Affairs, the Centers for Medicare and Medicaid Services, the Agency for Healthcare Research and Quality, the Centers for Disease Control and Prevention, and the Joint Commission.
Dr. Hawn presented a retrospective study of 60,853 procedures performed at 112 VA hospitals during 2005-2009. The outcome measure was the combined rate of superficial and deep surgical site infections (SSIs) occurring within 30 days of surgery.
The independent variables were adherence to each of five SCIP surgical site infection prevention measures that hospitals are required to collect and report. The five measures are timely administration of a prophylactic antibiotic, timely discontinuation of the antibiotic, appropriate antibiotic coverage, hair removal, and normothermia for colon procedures.
In addition, investigators tracked the impact of rates of adherence to all five measures in a given case, a combined metric they called composite SCIP.
This was the first study to use individual patient-level data for evaluating SCIP. Investigators were able to adjust for the presence of comorbid conditions that are known to affect the risk of SSIs, such as diabetes, dyspnea, and corticosteroid use, noted Dr. Hawn of the University of Alabama at Birmingham.
The overall SSI rate was 6.2%. It didn’t vary significantly over the 5-year study period, which began when the SCIP measures were first implemented in the VA system. Rates of adherence to the five SCIP measures quickly climbed to high levels during the first 6 months, probably because of the VA’s pay-for-performance incentives, she explained.
A first look at the data suggested that SCIP might be performing as intended. For example, there was an 81% adherence rate to the composite SCIP measure, and surgical cases meeting that standard had a 45% lower SSI rate than did those in which all five measures weren’t met. However, when patient-level SSI risk factors were introduced in a multivariate logistic regression analysis, there was no longer any association between SCIP adherence and SSI rates.
SCIP adherence rates ranged from a high of 86.4% for orthopedic surgery to a low of 60.4% for colorectal procedures. Adherence rates for gynecologic and vascular procedures were 85.9% and 81.6%, respectively.
In a separate analysis, Dr. Hawn and her colleagues looked at the relationship between a hospital’s adherence to SCIP measures and the institutional SSI rate. Once again, they found that there was none. The difference in hospital rates of SCIP adherence accounted for a mere 2% of the variation in hospital-wide SSI rates.
Dr. Hawn said that it is particularly troubling, in light of the VA data, to consider that public reporting of the SCIP adherence rates is being used to guide patients to what are supposed to be high-quality hospitals. "Are we really guiding patients to the right hospitals?" she asked.
Discussant Dr. David B. Hoyt noted that the collection of SCIP data constitutes a huge cost for American hospitals.
"It’s essential that quality measurement systems put in place actually correlate with improvement in quality. This study today is a critical example of how a well-intended process can in fact fail to reduce surgical infections. Overall, the SCIP program does not achieve its goal," said Dr. Hoyt, executive director of the American College of Surgeons.
"The data collection burden has increased in the last several years, and unless indicators that are ineffective are dropped, the expense of adding new indicators cannot be accommodated," he added.
Dr. Donald E. Fry commented that the SCIP measures are valid. The trouble is, they’re not inclusive.
"To paraphrase Paul Simon, ‘There must be 50 ways to get an SSI.’ And antibiotics are only a small portion of that," said Dr. Fry, executive vice president at Michael Pine and Associates, Chicago, an analytic health care consulting firm.
"I hope that this presentation will be a significant stimulus for us to go forward with not measuring silly process measures. This is not synchronized swimming. We need to be measuring outcomes. We need objective measures of what it is we’re trying to do, looking at how good hospitals do it well and bad ones don’t do it so well, and coming up with an entire strategy for SSIs," he said.
The SCIP study was funded by the VA. Dr. Hawn declared having no relevant financial interests. ☐
BOCA RATON, FLA. – Adherence to Surgical Care Improvement Program measures that are aimed at preventing surgical site infections has not had the desired effect, according to a large national Veterans Affairs study.
There is widespread agreement that reducing surgical site infections is a worthy quality improvement goal. These infections are associated with a twofold increase in mortality, a 60% increase in ICU admission, and a fivefold greater likelihood of hospital readmission after discharge.
But the VA study results showing that the SCIP hasn’t reduced surgical site infection rates call into question whether the program is worth continuing.
"SCIP adherence is not informative to third-party payers, administrators, or patients. The policy of continued SCIP measurement for public reporting and payment should be reevaluated," Dr. Mary T. Hawn declared in presenting the VA study findings at the annual meeting of the American Surgical Association.
SCIP is a multiyear partnership that was initiated in 2003 with the goal of reducing surgical morbidity and mortality at U.S. hospitals. Among the 10 national organizations that are represented on the SCIP steering committee are the American College of Surgeons, the American Hospital Association, the U.S. Department of Veterans Affairs, the Centers for Medicare and Medicaid Services, the Agency for Healthcare Research and Quality, the Centers for Disease Control and Prevention, and the Joint Commission.
Dr. Hawn presented a retrospective study of 60,853 procedures performed at 112 VA hospitals during 2005-2009. The outcome measure was the combined rate of superficial and deep surgical site infections (SSIs) occurring within 30 days of surgery.
The independent variables were adherence to each of five SCIP surgical site infection prevention measures that hospitals are required to collect and report. The five measures are timely administration of a prophylactic antibiotic, timely discontinuation of the antibiotic, appropriate antibiotic coverage, hair removal, and normothermia for colon procedures.
In addition, investigators tracked the impact of rates of adherence to all five measures in a given case, a combined metric they called composite SCIP.
This was the first study to use individual patient-level data for evaluating SCIP. Investigators were able to adjust for the presence of comorbid conditions that are known to affect the risk of SSIs, such as diabetes, dyspnea, and corticosteroid use, noted Dr. Hawn of the University of Alabama at Birmingham.
The overall SSI rate was 6.2%. It didn’t vary significantly over the 5-year study period, which began when the SCIP measures were first implemented in the VA system. Rates of adherence to the five SCIP measures quickly climbed to high levels during the first 6 months, probably because of the VA’s pay-for-performance incentives, she explained.
A first look at the data suggested that SCIP might be performing as intended. For example, there was an 81% adherence rate to the composite SCIP measure, and surgical cases meeting that standard had a 45% lower SSI rate than did those in which all five measures weren’t met. However, when patient-level SSI risk factors were introduced in a multivariate logistic regression analysis, there was no longer any association between SCIP adherence and SSI rates.
SCIP adherence rates ranged from a high of 86.4% for orthopedic surgery to a low of 60.4% for colorectal procedures. Adherence rates for gynecologic and vascular procedures were 85.9% and 81.6%, respectively.
In a separate analysis, Dr. Hawn and her colleagues looked at the relationship between a hospital’s adherence to SCIP measures and the institutional SSI rate. Once again, they found that there was none. The difference in hospital rates of SCIP adherence accounted for a mere 2% of the variation in hospital-wide SSI rates.
Dr. Hawn said that it is particularly troubling, in light of the VA data, to consider that public reporting of the SCIP adherence rates is being used to guide patients to what are supposed to be high-quality hospitals. "Are we really guiding patients to the right hospitals?" she asked.
Discussant Dr. David B. Hoyt noted that the collection of SCIP data constitutes a huge cost for American hospitals.
"It’s essential that quality measurement systems put in place actually correlate with improvement in quality. This study today is a critical example of how a well-intended process can in fact fail to reduce surgical infections. Overall, the SCIP program does not achieve its goal," said Dr. Hoyt, executive director of the American College of Surgeons.
"The data collection burden has increased in the last several years, and unless indicators that are ineffective are dropped, the expense of adding new indicators cannot be accommodated," he added.
Dr. Donald E. Fry commented that the SCIP measures are valid. The trouble is, they’re not inclusive.
"To paraphrase Paul Simon, ‘There must be 50 ways to get an SSI.’ And antibiotics are only a small portion of that," said Dr. Fry, executive vice president at Michael Pine and Associates, Chicago, an analytic health care consulting firm.
"I hope that this presentation will be a significant stimulus for us to go forward with not measuring silly process measures. This is not synchronized swimming. We need to be measuring outcomes. We need objective measures of what it is we’re trying to do, looking at how good hospitals do it well and bad ones don’t do it so well, and coming up with an entire strategy for SSIs," he said.
The SCIP study was funded by the VA. Dr. Hawn declared having no relevant financial interests. ☐
Major Finding: The overall surgical site infection rate of 6.2% did not vary significantly over the 5-year study period, regardless of adherence to SCIP measures.
Data Source: A retrospective study of 60,853 procedures performed at 112 VA hospitals.
Disclosures: Dr. Hawn declared having no relevant financial interests.
Marriage of Necessity
Doctors and hospitals need each other. Healthcare reform is requiring hospitals to rely more heavily on physicians to help them meet quality, safety, and efficiency goals. But in return, doctors are demanding more financial security and a larger role in hospital leadership.
Just how far are they willing to take their mutual relationship to meet their individual needs? A new report by professional services company PwC (formerly PricewaterhouseCoopers) examines the mindsets of potential partners, including an online survey of more than 1,000 doctors and in-depth interviews with 28 healthcare executives. The results suggest plenty of opportunities for alignment, though perhaps also the need for serious pre-marriage counseling.
“From Courtship to Marriage Part II” (www.PwC.com/us/PhysicianHospitalAlignment) follows an initial report that emphasizes the element of trust that’s necessary for any doctor-hospital alignment to succeed. This time around, the sequel is focusing on more concrete steps needed to take the budding relationship to the next level and sustain it. In particular, the new report focuses on sharing power (governance), sharing resources (compensation), and sharing outcomes (guidelines).
The PwC report preempts the naysayers by acknowledging at the outset that “hospitals and physicians have been to the altar before, but many of those marriages ended in divorce.” So what’s different from the 1990s, that decade of broken marriages doomed by the irreconcilable differences over capitation?
“Number one is that back in the ’90s, there wasn’t a clear consensus in defining and determining what is quality,” says Warren Skea, a director in the PwC Health Enterprise Growth Practice. In the intervening years, he says, membership societies—SHM among them—and nonprofit organizations, such as the National Quality Forum, have helped address the need to define and measure healthcare quality. The Centers for Medicare & Medicaid Services (CMS) followed up by adopting and implementing some of those measures in programs, including hospital value-based purchasing (see “Value-Based Purchasing Raises the Stakes,” May 2011, p. 1).
Another missing component in the ’90s, Skea says, was an adequate set of tools for gauging quality. “Even if we did agree what quality was, we couldn’t go back in there and measure it in a valid way,” he explains. “We just didn’t have that capacity.”
A third lesson learned the hard way is that decision-making should involve all physicians, from primary-care doctors to specialists. That power-sharing will be critical, Skea says, as reimbursement models move away from fee-for-service, transaction-based compensation methods and toward paying for outcomes and quality. Silos of care are out, and transitioning patients across a continuum of care is definitely in.
Sound familiar? It should, and the similarity to the hospitalist job description isn’t lost on Skea. “I think hospitalists have served as a very good illustrative example of how physicians can add value to that efficiency equation, improve quality, increase [good] outcomes—all of those things,” he says. In fact, Skea says, the question now is how the quarterback role assumed by hospitalists can be translated or projected to the larger industry and other settings (e.g. outpatient clinics, home care rehabilitation, and continuing care facilities).
Accountable-care organizations (ACOs) are a hot topic in any discussion of better patient transitions and closer doctor-hospital alignments, but they’re hardly the only wedding chapels in town. The new report sketches out the corresponding amenities of a comanagement model and provider-owned plan, and Skea notes that part of the new Center for Medicare & Medicaid Innovation’s mandate will be to investigate other promising methods for encouraging providers to work together.
Leaders, Partners
For most doctors, according to the survey, working together means making joint decisions. More than 90% said they should be involved in “hospital governance activities such as serving on boards, being in management, and taking part in performance.”
“That didn’t surprise me at all; there’s a huge appetite for physicians to be involved in strategic governance and oversight,” Skea says. “That’s where hospitalists have been really good: taking it to that next level of strategy and leadership.”
Next to compensation, he says, governance is the biggest issue for many hospital-affiliated physicians. One wrinkle, however, is what the report’s authors heard from hospital executives. “There’s a recognition by hospital executives that they need those physicians in those governance roles,” Skea says. But the executives felt that more physicians should be trained and educated in business and financial decision-making.
Some of the training strategies, he says, are homegrown. One hospital client, for example, is providing its physicians with courses in statistical analysis, financial modeling, and change management, and referring to the educational package as “MBA in a box.” Other hospitals are steering their physicians toward outside sources of instruction. SHM’s four-day Leadership Academy (www.hospitalmedicine.org/leadership) offers another resource for hospitalists seeking more prominent roles within their institutions.
Along with a desire for more power-sharing, doctors looking to a hospital setting have clearly indicated that they expect to hold their own financially. According to the survey, 83% of doctors considering hospital employment expect to be paid as much as or more than they are currently earning.
And therein lies another potential sticking point. Based on past experience, doctors might expect that hospitals’ financial resources will still allow them to maximize their compensation. But as health reform plays out, Skea cautions, “everybody is going to have to do more with less.”
Compromise Ahead
But other survey results hint at the potential for compromise. According to the report, physicians agreed that half of their compensation should be a fixed salary, while the remaining half could be based on meeting productivity, quality, patient satisfaction, and cost-of-care goals, with the potential for performance rewards. “This shows that physicians realize the health system is changing to track and reward performance and that they can influence the quality and cost of care delivery at the institutional level,” the report states.
And as for the guidelines doctors follow while delivering healthcare, 62% of those surveyed believe nationally accepted guidelines should guide the way they practice medicine; 30% prefer local guidelines.
Skea says he was a bit surprised that nearly 1 in 3 doctors are still resistant to national guidelines, though he believes that number is on the wane. After an initial pushback, he says, doctors seem to be gravitating toward the national standards, due in part to physician societies taking active roles in the discussions.
So what should hospitalists take away from all of this? Skea says they should continue to highlight and demonstrate the value they provide in standardizing care, measuring quality, and improving efficiencies in the four walls of the hospital. “They’ve had a track record, I think they have the mindset, and they’ve had the relationship with hospital executives,” he says.
Hospitalists likely will be called upon to help educate their physician colleagues in other specialties. Because of their background and history of success, Skea says, “they could be one of the real leaders and catalysts for change within an ACO or some of these other more integrated and aligned delivery models, and then move into governance.”
With a little assistance, perhaps this marriage might work after all. TH
Bryn Nelson is a freelance medical writer based in Seattle.
Doctors and hospitals need each other. Healthcare reform is requiring hospitals to rely more heavily on physicians to help them meet quality, safety, and efficiency goals. But in return, doctors are demanding more financial security and a larger role in hospital leadership.
Just how far are they willing to take their mutual relationship to meet their individual needs? A new report by professional services company PwC (formerly PricewaterhouseCoopers) examines the mindsets of potential partners, including an online survey of more than 1,000 doctors and in-depth interviews with 28 healthcare executives. The results suggest plenty of opportunities for alignment, though perhaps also the need for serious pre-marriage counseling.
“From Courtship to Marriage Part II” (www.PwC.com/us/PhysicianHospitalAlignment) follows an initial report that emphasizes the element of trust that’s necessary for any doctor-hospital alignment to succeed. This time around, the sequel is focusing on more concrete steps needed to take the budding relationship to the next level and sustain it. In particular, the new report focuses on sharing power (governance), sharing resources (compensation), and sharing outcomes (guidelines).
The PwC report preempts the naysayers by acknowledging at the outset that “hospitals and physicians have been to the altar before, but many of those marriages ended in divorce.” So what’s different from the 1990s, that decade of broken marriages doomed by the irreconcilable differences over capitation?
“Number one is that back in the ’90s, there wasn’t a clear consensus in defining and determining what is quality,” says Warren Skea, a director in the PwC Health Enterprise Growth Practice. In the intervening years, he says, membership societies—SHM among them—and nonprofit organizations, such as the National Quality Forum, have helped address the need to define and measure healthcare quality. The Centers for Medicare & Medicaid Services (CMS) followed up by adopting and implementing some of those measures in programs, including hospital value-based purchasing (see “Value-Based Purchasing Raises the Stakes,” May 2011, p. 1).
Another missing component in the ’90s, Skea says, was an adequate set of tools for gauging quality. “Even if we did agree what quality was, we couldn’t go back in there and measure it in a valid way,” he explains. “We just didn’t have that capacity.”
A third lesson learned the hard way is that decision-making should involve all physicians, from primary-care doctors to specialists. That power-sharing will be critical, Skea says, as reimbursement models move away from fee-for-service, transaction-based compensation methods and toward paying for outcomes and quality. Silos of care are out, and transitioning patients across a continuum of care is definitely in.
Sound familiar? It should, and the similarity to the hospitalist job description isn’t lost on Skea. “I think hospitalists have served as a very good illustrative example of how physicians can add value to that efficiency equation, improve quality, increase [good] outcomes—all of those things,” he says. In fact, Skea says, the question now is how the quarterback role assumed by hospitalists can be translated or projected to the larger industry and other settings (e.g. outpatient clinics, home care rehabilitation, and continuing care facilities).
Accountable-care organizations (ACOs) are a hot topic in any discussion of better patient transitions and closer doctor-hospital alignments, but they’re hardly the only wedding chapels in town. The new report sketches out the corresponding amenities of a comanagement model and provider-owned plan, and Skea notes that part of the new Center for Medicare & Medicaid Innovation’s mandate will be to investigate other promising methods for encouraging providers to work together.
Leaders, Partners
For most doctors, according to the survey, working together means making joint decisions. More than 90% said they should be involved in “hospital governance activities such as serving on boards, being in management, and taking part in performance.”
“That didn’t surprise me at all; there’s a huge appetite for physicians to be involved in strategic governance and oversight,” Skea says. “That’s where hospitalists have been really good: taking it to that next level of strategy and leadership.”
Next to compensation, he says, governance is the biggest issue for many hospital-affiliated physicians. One wrinkle, however, is what the report’s authors heard from hospital executives. “There’s a recognition by hospital executives that they need those physicians in those governance roles,” Skea says. But the executives felt that more physicians should be trained and educated in business and financial decision-making.
Some of the training strategies, he says, are homegrown. One hospital client, for example, is providing its physicians with courses in statistical analysis, financial modeling, and change management, and referring to the educational package as “MBA in a box.” Other hospitals are steering their physicians toward outside sources of instruction. SHM’s four-day Leadership Academy (www.hospitalmedicine.org/leadership) offers another resource for hospitalists seeking more prominent roles within their institutions.
Along with a desire for more power-sharing, doctors looking to a hospital setting have clearly indicated that they expect to hold their own financially. According to the survey, 83% of doctors considering hospital employment expect to be paid as much as or more than they are currently earning.
And therein lies another potential sticking point. Based on past experience, doctors might expect that hospitals’ financial resources will still allow them to maximize their compensation. But as health reform plays out, Skea cautions, “everybody is going to have to do more with less.”
Compromise Ahead
But other survey results hint at the potential for compromise. According to the report, physicians agreed that half of their compensation should be a fixed salary, while the remaining half could be based on meeting productivity, quality, patient satisfaction, and cost-of-care goals, with the potential for performance rewards. “This shows that physicians realize the health system is changing to track and reward performance and that they can influence the quality and cost of care delivery at the institutional level,” the report states.
And as for the guidelines doctors follow while delivering healthcare, 62% of those surveyed believe nationally accepted guidelines should guide the way they practice medicine; 30% prefer local guidelines.
Skea says he was a bit surprised that nearly 1 in 3 doctors are still resistant to national guidelines, though he believes that number is on the wane. After an initial pushback, he says, doctors seem to be gravitating toward the national standards, due in part to physician societies taking active roles in the discussions.
So what should hospitalists take away from all of this? Skea says they should continue to highlight and demonstrate the value they provide in standardizing care, measuring quality, and improving efficiencies in the four walls of the hospital. “They’ve had a track record, I think they have the mindset, and they’ve had the relationship with hospital executives,” he says.
Hospitalists likely will be called upon to help educate their physician colleagues in other specialties. Because of their background and history of success, Skea says, “they could be one of the real leaders and catalysts for change within an ACO or some of these other more integrated and aligned delivery models, and then move into governance.”
With a little assistance, perhaps this marriage might work after all. TH
Bryn Nelson is a freelance medical writer based in Seattle.
Doctors and hospitals need each other. Healthcare reform is requiring hospitals to rely more heavily on physicians to help them meet quality, safety, and efficiency goals. But in return, doctors are demanding more financial security and a larger role in hospital leadership.
Just how far are they willing to take their mutual relationship to meet their individual needs? A new report by professional services company PwC (formerly PricewaterhouseCoopers) examines the mindsets of potential partners, including an online survey of more than 1,000 doctors and in-depth interviews with 28 healthcare executives. The results suggest plenty of opportunities for alignment, though perhaps also the need for serious pre-marriage counseling.
“From Courtship to Marriage Part II” (www.PwC.com/us/PhysicianHospitalAlignment) follows an initial report that emphasizes the element of trust that’s necessary for any doctor-hospital alignment to succeed. This time around, the sequel is focusing on more concrete steps needed to take the budding relationship to the next level and sustain it. In particular, the new report focuses on sharing power (governance), sharing resources (compensation), and sharing outcomes (guidelines).
The PwC report preempts the naysayers by acknowledging at the outset that “hospitals and physicians have been to the altar before, but many of those marriages ended in divorce.” So what’s different from the 1990s, that decade of broken marriages doomed by the irreconcilable differences over capitation?
“Number one is that back in the ’90s, there wasn’t a clear consensus in defining and determining what is quality,” says Warren Skea, a director in the PwC Health Enterprise Growth Practice. In the intervening years, he says, membership societies—SHM among them—and nonprofit organizations, such as the National Quality Forum, have helped address the need to define and measure healthcare quality. The Centers for Medicare & Medicaid Services (CMS) followed up by adopting and implementing some of those measures in programs, including hospital value-based purchasing (see “Value-Based Purchasing Raises the Stakes,” May 2011, p. 1).
Another missing component in the ’90s, Skea says, was an adequate set of tools for gauging quality. “Even if we did agree what quality was, we couldn’t go back in there and measure it in a valid way,” he explains. “We just didn’t have that capacity.”
A third lesson learned the hard way is that decision-making should involve all physicians, from primary-care doctors to specialists. That power-sharing will be critical, Skea says, as reimbursement models move away from fee-for-service, transaction-based compensation methods and toward paying for outcomes and quality. Silos of care are out, and transitioning patients across a continuum of care is definitely in.
Sound familiar? It should, and the similarity to the hospitalist job description isn’t lost on Skea. “I think hospitalists have served as a very good illustrative example of how physicians can add value to that efficiency equation, improve quality, increase [good] outcomes—all of those things,” he says. In fact, Skea says, the question now is how the quarterback role assumed by hospitalists can be translated or projected to the larger industry and other settings (e.g. outpatient clinics, home care rehabilitation, and continuing care facilities).
Accountable-care organizations (ACOs) are a hot topic in any discussion of better patient transitions and closer doctor-hospital alignments, but they’re hardly the only wedding chapels in town. The new report sketches out the corresponding amenities of a comanagement model and provider-owned plan, and Skea notes that part of the new Center for Medicare & Medicaid Innovation’s mandate will be to investigate other promising methods for encouraging providers to work together.
Leaders, Partners
For most doctors, according to the survey, working together means making joint decisions. More than 90% said they should be involved in “hospital governance activities such as serving on boards, being in management, and taking part in performance.”
“That didn’t surprise me at all; there’s a huge appetite for physicians to be involved in strategic governance and oversight,” Skea says. “That’s where hospitalists have been really good: taking it to that next level of strategy and leadership.”
Next to compensation, he says, governance is the biggest issue for many hospital-affiliated physicians. One wrinkle, however, is what the report’s authors heard from hospital executives. “There’s a recognition by hospital executives that they need those physicians in those governance roles,” Skea says. But the executives felt that more physicians should be trained and educated in business and financial decision-making.
Some of the training strategies, he says, are homegrown. One hospital client, for example, is providing its physicians with courses in statistical analysis, financial modeling, and change management, and referring to the educational package as “MBA in a box.” Other hospitals are steering their physicians toward outside sources of instruction. SHM’s four-day Leadership Academy (www.hospitalmedicine.org/leadership) offers another resource for hospitalists seeking more prominent roles within their institutions.
Along with a desire for more power-sharing, doctors looking to a hospital setting have clearly indicated that they expect to hold their own financially. According to the survey, 83% of doctors considering hospital employment expect to be paid as much as or more than they are currently earning.
And therein lies another potential sticking point. Based on past experience, doctors might expect that hospitals’ financial resources will still allow them to maximize their compensation. But as health reform plays out, Skea cautions, “everybody is going to have to do more with less.”
Compromise Ahead
But other survey results hint at the potential for compromise. According to the report, physicians agreed that half of their compensation should be a fixed salary, while the remaining half could be based on meeting productivity, quality, patient satisfaction, and cost-of-care goals, with the potential for performance rewards. “This shows that physicians realize the health system is changing to track and reward performance and that they can influence the quality and cost of care delivery at the institutional level,” the report states.
And as for the guidelines doctors follow while delivering healthcare, 62% of those surveyed believe nationally accepted guidelines should guide the way they practice medicine; 30% prefer local guidelines.
Skea says he was a bit surprised that nearly 1 in 3 doctors are still resistant to national guidelines, though he believes that number is on the wane. After an initial pushback, he says, doctors seem to be gravitating toward the national standards, due in part to physician societies taking active roles in the discussions.
So what should hospitalists take away from all of this? Skea says they should continue to highlight and demonstrate the value they provide in standardizing care, measuring quality, and improving efficiencies in the four walls of the hospital. “They’ve had a track record, I think they have the mindset, and they’ve had the relationship with hospital executives,” he says.
Hospitalists likely will be called upon to help educate their physician colleagues in other specialties. Because of their background and history of success, Skea says, “they could be one of the real leaders and catalysts for change within an ACO or some of these other more integrated and aligned delivery models, and then move into governance.”
With a little assistance, perhaps this marriage might work after all. TH
Bryn Nelson is a freelance medical writer based in Seattle.
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POLICY CORNER: new documentation requirement could burden hospitalists
As of April 1, physicians who order home care services for their Medicare patients are required to document that they had a face-to-face encounter with the patient prior to certifying the patient’s eligibility for home care services. The face-to-face encounter is a mandated provision of the Affordable Care Act (ACA) of 2010, which is intended to reduce fraud and abuse among home health providers.
Despite this goal, the new documentation requirement poses the threat of a significant paperwork burden on practitioners, including hospitalists.
Many providers have remained unaware of this new requirement, but those who are aware have been experiencing confusion as to what, if any, additional paperwork is required of physicians. SHM, along with the American Medical Association (AMA) and other physician groups, have requested clarification from the Centers for Medicare & Medicaid Services (CMS) regarding the documentation requirement. SHM also is advocating that CMS keep the additional paperwork burden to a minimum.
CMS denied a request to extend the implementation deadline to allow for more provider education. Despite denying the extension, CMS has committed to continue monitoring for problems and unintended consequences caused by the new requirement.
CMS also has clarified the face-to-face documentation requirements: “Physicians may attach existing documentation as long as it includes necessary information and evidences the need for home health services.”
An example would be for a physician to attach the patient’s discharge summary or relevant portion of the patient’s medical record that evidences the need for home health services. Instead of creating an entirely new document or filling out an additional form to evidence the face-to-face encounter, physicians will have some flexibility in determining the existing documentation they will use. This is an option that hopefully will reduce some of the burden.
CMS could produce further guidelines in the future. SHM intends to continue following the issue and advocating on behalf of hospitalists. For the most up-to-date information, visit http://questions.cms.hhs.gov and enter the search term “home health face-to-face.” TH
As of April 1, physicians who order home care services for their Medicare patients are required to document that they had a face-to-face encounter with the patient prior to certifying the patient’s eligibility for home care services. The face-to-face encounter is a mandated provision of the Affordable Care Act (ACA) of 2010, which is intended to reduce fraud and abuse among home health providers.
Despite this goal, the new documentation requirement poses the threat of a significant paperwork burden on practitioners, including hospitalists.
Many providers have remained unaware of this new requirement, but those who are aware have been experiencing confusion as to what, if any, additional paperwork is required of physicians. SHM, along with the American Medical Association (AMA) and other physician groups, have requested clarification from the Centers for Medicare & Medicaid Services (CMS) regarding the documentation requirement. SHM also is advocating that CMS keep the additional paperwork burden to a minimum.
CMS denied a request to extend the implementation deadline to allow for more provider education. Despite denying the extension, CMS has committed to continue monitoring for problems and unintended consequences caused by the new requirement.
CMS also has clarified the face-to-face documentation requirements: “Physicians may attach existing documentation as long as it includes necessary information and evidences the need for home health services.”
An example would be for a physician to attach the patient’s discharge summary or relevant portion of the patient’s medical record that evidences the need for home health services. Instead of creating an entirely new document or filling out an additional form to evidence the face-to-face encounter, physicians will have some flexibility in determining the existing documentation they will use. This is an option that hopefully will reduce some of the burden.
CMS could produce further guidelines in the future. SHM intends to continue following the issue and advocating on behalf of hospitalists. For the most up-to-date information, visit http://questions.cms.hhs.gov and enter the search term “home health face-to-face.” TH
As of April 1, physicians who order home care services for their Medicare patients are required to document that they had a face-to-face encounter with the patient prior to certifying the patient’s eligibility for home care services. The face-to-face encounter is a mandated provision of the Affordable Care Act (ACA) of 2010, which is intended to reduce fraud and abuse among home health providers.
Despite this goal, the new documentation requirement poses the threat of a significant paperwork burden on practitioners, including hospitalists.
Many providers have remained unaware of this new requirement, but those who are aware have been experiencing confusion as to what, if any, additional paperwork is required of physicians. SHM, along with the American Medical Association (AMA) and other physician groups, have requested clarification from the Centers for Medicare & Medicaid Services (CMS) regarding the documentation requirement. SHM also is advocating that CMS keep the additional paperwork burden to a minimum.
CMS denied a request to extend the implementation deadline to allow for more provider education. Despite denying the extension, CMS has committed to continue monitoring for problems and unintended consequences caused by the new requirement.
CMS also has clarified the face-to-face documentation requirements: “Physicians may attach existing documentation as long as it includes necessary information and evidences the need for home health services.”
An example would be for a physician to attach the patient’s discharge summary or relevant portion of the patient’s medical record that evidences the need for home health services. Instead of creating an entirely new document or filling out an additional form to evidence the face-to-face encounter, physicians will have some flexibility in determining the existing documentation they will use. This is an option that hopefully will reduce some of the burden.
CMS could produce further guidelines in the future. SHM intends to continue following the issue and advocating on behalf of hospitalists. For the most up-to-date information, visit http://questions.cms.hhs.gov and enter the search term “home health face-to-face.” TH