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How policy illustrates the value of SHM membership
Federal programs can be enormously complicated, and the Medicare value-based payment programs, such as the Physician Quality Reporting System, the physician value-based payment modifier, and the new Merit-Based Incentive Payment System, are no exception.
It can be a challenge to navigate the rules, to identify how and which measures to report, and to determine how to integrate those requirements into your practice. Furthermore, the feedback from these programs to providers can be difficult to read and interpret.
Part of the value of being a member of the Society of Hospital Medicine (SHM) is having another set of eyes – particularly those that spend a significant amount of time immersed in federal regulations – to parse the policy-practice nexus. SHM hears from members all over the country, many in different practice types and with different policy needs. This knowledge can be shared, both with other members and with policymakers. A recent example highlights the power of this relationship.
Your membership contributes directly to the advocacy efforts of SHM, and the engagement of members with SHM staff on policy issues is a force multiplier for the effect SHM can have on policy decisions. There is a lot of value for belonging to SHM, and sometimes, we can put an exact number on it.
A solo-practicing hospitalist called seeking perspective on why he received a letter indicating he would be receiving a penalty in 2018 for failing the requirements of Physician Quality Reporting System reporting. This hospitalist had successfully reported on as many measures as he possibly could, so he could not understand why he would be receiving a penalty.
All told, a different read of the feedback reports, and some strategic questions from SHM staff, helped this hospitalist understand why he was being penalized and how, in this case, he could ask Centers for Medicare & Medicaid Services for reconsideration. Upon second review by CMS, the penalties were overturned, and this provider should save nearly $30,000 in Medicare payments in 2018.
SHM helped the provider by being a sounding board and by sharing information learned from experiences other members had had with these programs. In turn, the knowledge gained from this interaction will be used to fine-tune SHM’s educational materials and outreach efforts about these programs. It has also already contributed to advocacy efforts with CMS policymakers regarding how they can improve the programs to be more transparent and equitable. The learning is shared in both directions.
Want to learn more about SHM’s advocacy efforts and how policy affects hospitalists? Stop by sessions at Hospital Medicine 2018 in Orlando; there will be one on pay-for-performance programs on Monday, April 9, at 3:15 p.m. and others on health policy throughout the day on Wednesday, April 11. Learn more at www.shmannualconference.org.
Mr. Lapps is the government relations manager at the Society of Hospital Medicine.
Federal programs can be enormously complicated, and the Medicare value-based payment programs, such as the Physician Quality Reporting System, the physician value-based payment modifier, and the new Merit-Based Incentive Payment System, are no exception.
It can be a challenge to navigate the rules, to identify how and which measures to report, and to determine how to integrate those requirements into your practice. Furthermore, the feedback from these programs to providers can be difficult to read and interpret.
Part of the value of being a member of the Society of Hospital Medicine (SHM) is having another set of eyes – particularly those that spend a significant amount of time immersed in federal regulations – to parse the policy-practice nexus. SHM hears from members all over the country, many in different practice types and with different policy needs. This knowledge can be shared, both with other members and with policymakers. A recent example highlights the power of this relationship.
Your membership contributes directly to the advocacy efforts of SHM, and the engagement of members with SHM staff on policy issues is a force multiplier for the effect SHM can have on policy decisions. There is a lot of value for belonging to SHM, and sometimes, we can put an exact number on it.
A solo-practicing hospitalist called seeking perspective on why he received a letter indicating he would be receiving a penalty in 2018 for failing the requirements of Physician Quality Reporting System reporting. This hospitalist had successfully reported on as many measures as he possibly could, so he could not understand why he would be receiving a penalty.
All told, a different read of the feedback reports, and some strategic questions from SHM staff, helped this hospitalist understand why he was being penalized and how, in this case, he could ask Centers for Medicare & Medicaid Services for reconsideration. Upon second review by CMS, the penalties were overturned, and this provider should save nearly $30,000 in Medicare payments in 2018.
SHM helped the provider by being a sounding board and by sharing information learned from experiences other members had had with these programs. In turn, the knowledge gained from this interaction will be used to fine-tune SHM’s educational materials and outreach efforts about these programs. It has also already contributed to advocacy efforts with CMS policymakers regarding how they can improve the programs to be more transparent and equitable. The learning is shared in both directions.
Want to learn more about SHM’s advocacy efforts and how policy affects hospitalists? Stop by sessions at Hospital Medicine 2018 in Orlando; there will be one on pay-for-performance programs on Monday, April 9, at 3:15 p.m. and others on health policy throughout the day on Wednesday, April 11. Learn more at www.shmannualconference.org.
Mr. Lapps is the government relations manager at the Society of Hospital Medicine.
Federal programs can be enormously complicated, and the Medicare value-based payment programs, such as the Physician Quality Reporting System, the physician value-based payment modifier, and the new Merit-Based Incentive Payment System, are no exception.
It can be a challenge to navigate the rules, to identify how and which measures to report, and to determine how to integrate those requirements into your practice. Furthermore, the feedback from these programs to providers can be difficult to read and interpret.
Part of the value of being a member of the Society of Hospital Medicine (SHM) is having another set of eyes – particularly those that spend a significant amount of time immersed in federal regulations – to parse the policy-practice nexus. SHM hears from members all over the country, many in different practice types and with different policy needs. This knowledge can be shared, both with other members and with policymakers. A recent example highlights the power of this relationship.
Your membership contributes directly to the advocacy efforts of SHM, and the engagement of members with SHM staff on policy issues is a force multiplier for the effect SHM can have on policy decisions. There is a lot of value for belonging to SHM, and sometimes, we can put an exact number on it.
A solo-practicing hospitalist called seeking perspective on why he received a letter indicating he would be receiving a penalty in 2018 for failing the requirements of Physician Quality Reporting System reporting. This hospitalist had successfully reported on as many measures as he possibly could, so he could not understand why he would be receiving a penalty.
All told, a different read of the feedback reports, and some strategic questions from SHM staff, helped this hospitalist understand why he was being penalized and how, in this case, he could ask Centers for Medicare & Medicaid Services for reconsideration. Upon second review by CMS, the penalties were overturned, and this provider should save nearly $30,000 in Medicare payments in 2018.
SHM helped the provider by being a sounding board and by sharing information learned from experiences other members had had with these programs. In turn, the knowledge gained from this interaction will be used to fine-tune SHM’s educational materials and outreach efforts about these programs. It has also already contributed to advocacy efforts with CMS policymakers regarding how they can improve the programs to be more transparent and equitable. The learning is shared in both directions.
Want to learn more about SHM’s advocacy efforts and how policy affects hospitalists? Stop by sessions at Hospital Medicine 2018 in Orlando; there will be one on pay-for-performance programs on Monday, April 9, at 3:15 p.m. and others on health policy throughout the day on Wednesday, April 11. Learn more at www.shmannualconference.org.
Mr. Lapps is the government relations manager at the Society of Hospital Medicine.
Quick Byte: U.S. health care can still innovate
“The United States health care system has many problems, but it also promotes more innovation than its counterparts in other nations. … It has more clinical trials than any other country. It has the most Nobel laureates in physiology or medicine. It has won more patents. At least one publication ranks it No. 1 in overall scientific innovation. … The nation’s innovation advantage arises from a first-class research university system, along with robust intellectual property laws and significant public and private investment in research and development. Perhaps most important, this country offers a large market in which patients, organizations, and government spend a lot on health and companies are able to profit greatly from health care innovation.”
Reference
1. Carroll AE et al. “Can the U.S. repair its health care while keeping its innovation edge?” The New York Times. Oct 9, 2017.
. Accessed Oct 10, 2017.
“The United States health care system has many problems, but it also promotes more innovation than its counterparts in other nations. … It has more clinical trials than any other country. It has the most Nobel laureates in physiology or medicine. It has won more patents. At least one publication ranks it No. 1 in overall scientific innovation. … The nation’s innovation advantage arises from a first-class research university system, along with robust intellectual property laws and significant public and private investment in research and development. Perhaps most important, this country offers a large market in which patients, organizations, and government spend a lot on health and companies are able to profit greatly from health care innovation.”
Reference
1. Carroll AE et al. “Can the U.S. repair its health care while keeping its innovation edge?” The New York Times. Oct 9, 2017.
. Accessed Oct 10, 2017.
“The United States health care system has many problems, but it also promotes more innovation than its counterparts in other nations. … It has more clinical trials than any other country. It has the most Nobel laureates in physiology or medicine. It has won more patents. At least one publication ranks it No. 1 in overall scientific innovation. … The nation’s innovation advantage arises from a first-class research university system, along with robust intellectual property laws and significant public and private investment in research and development. Perhaps most important, this country offers a large market in which patients, organizations, and government spend a lot on health and companies are able to profit greatly from health care innovation.”
Reference
1. Carroll AE et al. “Can the U.S. repair its health care while keeping its innovation edge?” The New York Times. Oct 9, 2017.
. Accessed Oct 10, 2017.
Building a better U.S. health care system
Since 2010, when Democrats passed the Affordable Care Act – also known as Obamacare – without a single Republican vote, the GOP has vowed to repeal and replace it. With the election of Donald Trump in November 2016, Republicans gained control of the presidency and Congress and hoped to put Obamacare on the chopping block.
Although the Affordable Care Act’s (ACA’s) individual mandate was eliminated in the Tax Cuts and Jobs Act passed in late 2017, Republican leaders have been unable to secure the votes they need for a full repeal of Obamacare and a complete reboot of the American health care system. That may be, in part, because in the search for a better American health care system, there is no single right answer. In few places is that more clear than when making comparisons of health care systems across the world.
“Comparisons are fun, and everyone loves rankings,” said Ashish Jha, MD, MPH, a physician with the Harvard T.H. Chan School of Public Health and director of the Harvard Global Health Institute in Cambridge, Mass. Last fall Shah published an analysis on his personal blog comparing health care in the United States with that in seven high-income nations.1 It was prompted by a similar side-by-side comparison he participated in with other experts for the New York Times.2 “The most important part is we get to ask questions about things we care about, like ‘What do other countries do when they’re better than us?’ We’re not going to adopt any country’s model wholesale, but we can learn from them,” he said.
For instance, just 7.4% of people in Switzerland (according to data from the Organisation for Economic Cooperation and Development) skip medical tests, treatments, or follow-ups because of costs, compared with 21.3% in the United States. Meanwhile, the United States leads in innovation, producing 57% of new drugs (according to the Milken Institute), which is more than Switzerland’s 13% and Germany’s 6%.1
Although many Americans tend to think that health care in other developed nations is entirely single payer or government run, systems across Europe and the rest of the globe vary immensely in how they approach health care. One thing common among high-income nations, however, is some form of universal health care. In Canada, for example, the government funds health insurance for care delivered in the private sector. In Australia, public hospitals provide free inpatient care. In France, the Ministry of Health sets prices, budgets, and funding levels.2
“There are really two main purposes” when it comes to international comparisons, said Eric Schneider, MD, senior vice president for policy and research for the Commonwealth Fund. “The first is to understand how other countries perform, and the second is what lessons can we learn from the way care is financed, organized, and delivered in other nations and how we might import some of those ideas to the U.S. and improve policies here.”
The Affordable Care Act, Dr. Jha said, was something of the ultimate test for applying lessons learned in other countries and those put forward over the past decades in the United States by policy experts and leaders in health care thinking.
“The Affordable Care Act includes several ideas that are prevalent in other countries, particularly around how to expand insurance coverage and how to subsidize the poor so they can have good insurance coverage, too,” said Dr. Schneider. “The notion of essential health benefits, the mandate for insurance, the notion of subsidies, in some ways, these were all borrowed from abroad.”
For instance, health care in The Netherlands – which, like the United States, also relies on private health insurers – ranked among the highest of other high-income countries in the world in The Commonwealth Fund’s 2017 international comparison, published in July 2017.3 The Dutch have standardized their health benefits, reducing administrative burden for providers and making copayments more predictable for patients.
Dr. Schneider believes that the United States should continue to build on the progress of the Affordable Care Act – particularly since more than 20 million Americans have gained insurance coverage since the passage of the law (91% of Americans are insured today).4 And the ACA has renewed focus in the United States on improving and strengthening primary care and changing the incentives around care delivery.
Some Democrats and Republicans in Congress have started working on bipartisan solutions to solve some of the problems inherent in the ACA – or those engineered by those who oppose it.
That direction is, at least in part, a health care system with spending that continues to rank among the highest in the world.1,3 The United States spends more than 17% of its GDP on health care, compared with the 11.4% spent by Switzerland, which Jha ranked as having the best health care system among the high-income nations he evaluated.1Craig Garthwaite, a conservative health economist at Northwestern University’s Kellogg School of Management in Evanston, Ill., called the Swiss health care system a “better-functioning version of the Affordable Care Act” in the New York Times’ head-to-head debate.2
However, Dr. Lenchus noted that Switzerland’s system may not be scalable to a country the size of the United States. At 8.5 million people, Switzerland’s population is on par with that of New York City. The U.S. system must support more than 323 million people.
And international comparisons can be challenging for other reasons, as Dr. Jha wrote in a JAMA Viewpoint piece in August 2017 with coauthor Irene Papanicolas, PhD, of the London School of Economics, because they must account for the limitations of data, consider different values in national systems, and define the boundaries of the health system.5 For instance, Dr. Schneider said, some other high-income countries also invest more in housing, nutrition, and transportation than does the United States, which reduces the detrimental impact of social determinants of health, like poverty, poor nutrition, and homelessness.
Dr. Lenchus believes better health care in the United States hinges on more community-level investments and partnerships and on more focus on the social determinants of health. “To some degree, this country should be able to leverage the resources we have at a community level to improve the health of that community’s population,” he said. “Hospitalists are in a prime position to do that.”
Indeed, the Commonwealth Fund report concluded the United States excels on measures that involve the doctor-patient relationship – like end-of-life discussions and chronic disease management – and on preventive measures like screening mammography and adult influenza vaccination.
In a New England Journal of Medicine Perspective published in July 2017, Dr. Schneider and a coauthor outlined four strategies to improve health care in the United States, gleaned from comparisons abroad: ensure universal and adequate health insurance coverage, strengthen primary care, reduce administrative burden, and reduce income-related disparities.6
Regardless of how the United States goes about achieving a better health care system, Dr. Jha said we should stop the partisan rhetoric.
“Where I find a lot of consensus is we should have more competition and less monopoly,” he said. “Liberals and conservatives should be able to get together and say: We are really going to have competitive markets, and we should see the prices of health care services fall; we should see premiums come down, and it would make the coverage problem a lot easier to solve.”
References
1. Jha A. Judging health systems: focusing on what matters. An Ounce of Evidence. Published Sep 18, 2017. Last accessed Oct 19, 2017. https://blogs.sph.harvard.edu/ashish-jha/.
2. Carroll AE et al. The best health care system in the world: Which one would you pick? New York Times. Published Sep 18, 2017. Accessed Oct 19, 2017. https://www.nytimes.com/interactive/2017/09/18/upshot/best-health-care-system-country-bracket.html?action=click&contentCollection=upshot®ion=rank&module=package&version=highlights&contentPlacement=1&pgtype=sectionfront.
3. Schneider EC et al. Mirror, mirror 2017: International comparison reflects flaws and opportunities for better U.S. health care. The Commonwealth Fund. Published Jul 14, 2017. Accessed Oct 19, 2017. http://www.commonwealthfund.org/publications/fund-reports/2017/jul/mirror-mirror-international-comparisons-2017.
4. Martinez ME et al. Health insurance coverage: Early release of estimates from the national health interview survey, January-September 2016. Centers for Disease Control and Prevention, Division of Health Interview Statistics, National Center for Health Statistics. Published Feb, 2017. Accessed Oct 19, 2017. https://www.cdc.gov/nchs/data/nhis/earlyrelease/insur201702.pdf.
5. Papanicolas I et al. Challenges in international comparison of health care systems. JAMA. 2017 Aug 8;318(6):515-6. https://jamanetwork.com/journals/jama/article-abstract/2646461.
6. Schneider EC et al. From last to first – Could the U.S. health care system become the best in the world? N Engl J Med. 2017 Sep 7; 377(10):901-4.
Since 2010, when Democrats passed the Affordable Care Act – also known as Obamacare – without a single Republican vote, the GOP has vowed to repeal and replace it. With the election of Donald Trump in November 2016, Republicans gained control of the presidency and Congress and hoped to put Obamacare on the chopping block.
Although the Affordable Care Act’s (ACA’s) individual mandate was eliminated in the Tax Cuts and Jobs Act passed in late 2017, Republican leaders have been unable to secure the votes they need for a full repeal of Obamacare and a complete reboot of the American health care system. That may be, in part, because in the search for a better American health care system, there is no single right answer. In few places is that more clear than when making comparisons of health care systems across the world.
“Comparisons are fun, and everyone loves rankings,” said Ashish Jha, MD, MPH, a physician with the Harvard T.H. Chan School of Public Health and director of the Harvard Global Health Institute in Cambridge, Mass. Last fall Shah published an analysis on his personal blog comparing health care in the United States with that in seven high-income nations.1 It was prompted by a similar side-by-side comparison he participated in with other experts for the New York Times.2 “The most important part is we get to ask questions about things we care about, like ‘What do other countries do when they’re better than us?’ We’re not going to adopt any country’s model wholesale, but we can learn from them,” he said.
For instance, just 7.4% of people in Switzerland (according to data from the Organisation for Economic Cooperation and Development) skip medical tests, treatments, or follow-ups because of costs, compared with 21.3% in the United States. Meanwhile, the United States leads in innovation, producing 57% of new drugs (according to the Milken Institute), which is more than Switzerland’s 13% and Germany’s 6%.1
Although many Americans tend to think that health care in other developed nations is entirely single payer or government run, systems across Europe and the rest of the globe vary immensely in how they approach health care. One thing common among high-income nations, however, is some form of universal health care. In Canada, for example, the government funds health insurance for care delivered in the private sector. In Australia, public hospitals provide free inpatient care. In France, the Ministry of Health sets prices, budgets, and funding levels.2
“There are really two main purposes” when it comes to international comparisons, said Eric Schneider, MD, senior vice president for policy and research for the Commonwealth Fund. “The first is to understand how other countries perform, and the second is what lessons can we learn from the way care is financed, organized, and delivered in other nations and how we might import some of those ideas to the U.S. and improve policies here.”
The Affordable Care Act, Dr. Jha said, was something of the ultimate test for applying lessons learned in other countries and those put forward over the past decades in the United States by policy experts and leaders in health care thinking.
“The Affordable Care Act includes several ideas that are prevalent in other countries, particularly around how to expand insurance coverage and how to subsidize the poor so they can have good insurance coverage, too,” said Dr. Schneider. “The notion of essential health benefits, the mandate for insurance, the notion of subsidies, in some ways, these were all borrowed from abroad.”
For instance, health care in The Netherlands – which, like the United States, also relies on private health insurers – ranked among the highest of other high-income countries in the world in The Commonwealth Fund’s 2017 international comparison, published in July 2017.3 The Dutch have standardized their health benefits, reducing administrative burden for providers and making copayments more predictable for patients.
Dr. Schneider believes that the United States should continue to build on the progress of the Affordable Care Act – particularly since more than 20 million Americans have gained insurance coverage since the passage of the law (91% of Americans are insured today).4 And the ACA has renewed focus in the United States on improving and strengthening primary care and changing the incentives around care delivery.
Some Democrats and Republicans in Congress have started working on bipartisan solutions to solve some of the problems inherent in the ACA – or those engineered by those who oppose it.
That direction is, at least in part, a health care system with spending that continues to rank among the highest in the world.1,3 The United States spends more than 17% of its GDP on health care, compared with the 11.4% spent by Switzerland, which Jha ranked as having the best health care system among the high-income nations he evaluated.1Craig Garthwaite, a conservative health economist at Northwestern University’s Kellogg School of Management in Evanston, Ill., called the Swiss health care system a “better-functioning version of the Affordable Care Act” in the New York Times’ head-to-head debate.2
However, Dr. Lenchus noted that Switzerland’s system may not be scalable to a country the size of the United States. At 8.5 million people, Switzerland’s population is on par with that of New York City. The U.S. system must support more than 323 million people.
And international comparisons can be challenging for other reasons, as Dr. Jha wrote in a JAMA Viewpoint piece in August 2017 with coauthor Irene Papanicolas, PhD, of the London School of Economics, because they must account for the limitations of data, consider different values in national systems, and define the boundaries of the health system.5 For instance, Dr. Schneider said, some other high-income countries also invest more in housing, nutrition, and transportation than does the United States, which reduces the detrimental impact of social determinants of health, like poverty, poor nutrition, and homelessness.
Dr. Lenchus believes better health care in the United States hinges on more community-level investments and partnerships and on more focus on the social determinants of health. “To some degree, this country should be able to leverage the resources we have at a community level to improve the health of that community’s population,” he said. “Hospitalists are in a prime position to do that.”
Indeed, the Commonwealth Fund report concluded the United States excels on measures that involve the doctor-patient relationship – like end-of-life discussions and chronic disease management – and on preventive measures like screening mammography and adult influenza vaccination.
In a New England Journal of Medicine Perspective published in July 2017, Dr. Schneider and a coauthor outlined four strategies to improve health care in the United States, gleaned from comparisons abroad: ensure universal and adequate health insurance coverage, strengthen primary care, reduce administrative burden, and reduce income-related disparities.6
Regardless of how the United States goes about achieving a better health care system, Dr. Jha said we should stop the partisan rhetoric.
“Where I find a lot of consensus is we should have more competition and less monopoly,” he said. “Liberals and conservatives should be able to get together and say: We are really going to have competitive markets, and we should see the prices of health care services fall; we should see premiums come down, and it would make the coverage problem a lot easier to solve.”
References
1. Jha A. Judging health systems: focusing on what matters. An Ounce of Evidence. Published Sep 18, 2017. Last accessed Oct 19, 2017. https://blogs.sph.harvard.edu/ashish-jha/.
2. Carroll AE et al. The best health care system in the world: Which one would you pick? New York Times. Published Sep 18, 2017. Accessed Oct 19, 2017. https://www.nytimes.com/interactive/2017/09/18/upshot/best-health-care-system-country-bracket.html?action=click&contentCollection=upshot®ion=rank&module=package&version=highlights&contentPlacement=1&pgtype=sectionfront.
3. Schneider EC et al. Mirror, mirror 2017: International comparison reflects flaws and opportunities for better U.S. health care. The Commonwealth Fund. Published Jul 14, 2017. Accessed Oct 19, 2017. http://www.commonwealthfund.org/publications/fund-reports/2017/jul/mirror-mirror-international-comparisons-2017.
4. Martinez ME et al. Health insurance coverage: Early release of estimates from the national health interview survey, January-September 2016. Centers for Disease Control and Prevention, Division of Health Interview Statistics, National Center for Health Statistics. Published Feb, 2017. Accessed Oct 19, 2017. https://www.cdc.gov/nchs/data/nhis/earlyrelease/insur201702.pdf.
5. Papanicolas I et al. Challenges in international comparison of health care systems. JAMA. 2017 Aug 8;318(6):515-6. https://jamanetwork.com/journals/jama/article-abstract/2646461.
6. Schneider EC et al. From last to first – Could the U.S. health care system become the best in the world? N Engl J Med. 2017 Sep 7; 377(10):901-4.
Since 2010, when Democrats passed the Affordable Care Act – also known as Obamacare – without a single Republican vote, the GOP has vowed to repeal and replace it. With the election of Donald Trump in November 2016, Republicans gained control of the presidency and Congress and hoped to put Obamacare on the chopping block.
Although the Affordable Care Act’s (ACA’s) individual mandate was eliminated in the Tax Cuts and Jobs Act passed in late 2017, Republican leaders have been unable to secure the votes they need for a full repeal of Obamacare and a complete reboot of the American health care system. That may be, in part, because in the search for a better American health care system, there is no single right answer. In few places is that more clear than when making comparisons of health care systems across the world.
“Comparisons are fun, and everyone loves rankings,” said Ashish Jha, MD, MPH, a physician with the Harvard T.H. Chan School of Public Health and director of the Harvard Global Health Institute in Cambridge, Mass. Last fall Shah published an analysis on his personal blog comparing health care in the United States with that in seven high-income nations.1 It was prompted by a similar side-by-side comparison he participated in with other experts for the New York Times.2 “The most important part is we get to ask questions about things we care about, like ‘What do other countries do when they’re better than us?’ We’re not going to adopt any country’s model wholesale, but we can learn from them,” he said.
For instance, just 7.4% of people in Switzerland (according to data from the Organisation for Economic Cooperation and Development) skip medical tests, treatments, or follow-ups because of costs, compared with 21.3% in the United States. Meanwhile, the United States leads in innovation, producing 57% of new drugs (according to the Milken Institute), which is more than Switzerland’s 13% and Germany’s 6%.1
Although many Americans tend to think that health care in other developed nations is entirely single payer or government run, systems across Europe and the rest of the globe vary immensely in how they approach health care. One thing common among high-income nations, however, is some form of universal health care. In Canada, for example, the government funds health insurance for care delivered in the private sector. In Australia, public hospitals provide free inpatient care. In France, the Ministry of Health sets prices, budgets, and funding levels.2
“There are really two main purposes” when it comes to international comparisons, said Eric Schneider, MD, senior vice president for policy and research for the Commonwealth Fund. “The first is to understand how other countries perform, and the second is what lessons can we learn from the way care is financed, organized, and delivered in other nations and how we might import some of those ideas to the U.S. and improve policies here.”
The Affordable Care Act, Dr. Jha said, was something of the ultimate test for applying lessons learned in other countries and those put forward over the past decades in the United States by policy experts and leaders in health care thinking.
“The Affordable Care Act includes several ideas that are prevalent in other countries, particularly around how to expand insurance coverage and how to subsidize the poor so they can have good insurance coverage, too,” said Dr. Schneider. “The notion of essential health benefits, the mandate for insurance, the notion of subsidies, in some ways, these were all borrowed from abroad.”
For instance, health care in The Netherlands – which, like the United States, also relies on private health insurers – ranked among the highest of other high-income countries in the world in The Commonwealth Fund’s 2017 international comparison, published in July 2017.3 The Dutch have standardized their health benefits, reducing administrative burden for providers and making copayments more predictable for patients.
Dr. Schneider believes that the United States should continue to build on the progress of the Affordable Care Act – particularly since more than 20 million Americans have gained insurance coverage since the passage of the law (91% of Americans are insured today).4 And the ACA has renewed focus in the United States on improving and strengthening primary care and changing the incentives around care delivery.
Some Democrats and Republicans in Congress have started working on bipartisan solutions to solve some of the problems inherent in the ACA – or those engineered by those who oppose it.
That direction is, at least in part, a health care system with spending that continues to rank among the highest in the world.1,3 The United States spends more than 17% of its GDP on health care, compared with the 11.4% spent by Switzerland, which Jha ranked as having the best health care system among the high-income nations he evaluated.1Craig Garthwaite, a conservative health economist at Northwestern University’s Kellogg School of Management in Evanston, Ill., called the Swiss health care system a “better-functioning version of the Affordable Care Act” in the New York Times’ head-to-head debate.2
However, Dr. Lenchus noted that Switzerland’s system may not be scalable to a country the size of the United States. At 8.5 million people, Switzerland’s population is on par with that of New York City. The U.S. system must support more than 323 million people.
And international comparisons can be challenging for other reasons, as Dr. Jha wrote in a JAMA Viewpoint piece in August 2017 with coauthor Irene Papanicolas, PhD, of the London School of Economics, because they must account for the limitations of data, consider different values in national systems, and define the boundaries of the health system.5 For instance, Dr. Schneider said, some other high-income countries also invest more in housing, nutrition, and transportation than does the United States, which reduces the detrimental impact of social determinants of health, like poverty, poor nutrition, and homelessness.
Dr. Lenchus believes better health care in the United States hinges on more community-level investments and partnerships and on more focus on the social determinants of health. “To some degree, this country should be able to leverage the resources we have at a community level to improve the health of that community’s population,” he said. “Hospitalists are in a prime position to do that.”
Indeed, the Commonwealth Fund report concluded the United States excels on measures that involve the doctor-patient relationship – like end-of-life discussions and chronic disease management – and on preventive measures like screening mammography and adult influenza vaccination.
In a New England Journal of Medicine Perspective published in July 2017, Dr. Schneider and a coauthor outlined four strategies to improve health care in the United States, gleaned from comparisons abroad: ensure universal and adequate health insurance coverage, strengthen primary care, reduce administrative burden, and reduce income-related disparities.6
Regardless of how the United States goes about achieving a better health care system, Dr. Jha said we should stop the partisan rhetoric.
“Where I find a lot of consensus is we should have more competition and less monopoly,” he said. “Liberals and conservatives should be able to get together and say: We are really going to have competitive markets, and we should see the prices of health care services fall; we should see premiums come down, and it would make the coverage problem a lot easier to solve.”
References
1. Jha A. Judging health systems: focusing on what matters. An Ounce of Evidence. Published Sep 18, 2017. Last accessed Oct 19, 2017. https://blogs.sph.harvard.edu/ashish-jha/.
2. Carroll AE et al. The best health care system in the world: Which one would you pick? New York Times. Published Sep 18, 2017. Accessed Oct 19, 2017. https://www.nytimes.com/interactive/2017/09/18/upshot/best-health-care-system-country-bracket.html?action=click&contentCollection=upshot®ion=rank&module=package&version=highlights&contentPlacement=1&pgtype=sectionfront.
3. Schneider EC et al. Mirror, mirror 2017: International comparison reflects flaws and opportunities for better U.S. health care. The Commonwealth Fund. Published Jul 14, 2017. Accessed Oct 19, 2017. http://www.commonwealthfund.org/publications/fund-reports/2017/jul/mirror-mirror-international-comparisons-2017.
4. Martinez ME et al. Health insurance coverage: Early release of estimates from the national health interview survey, January-September 2016. Centers for Disease Control and Prevention, Division of Health Interview Statistics, National Center for Health Statistics. Published Feb, 2017. Accessed Oct 19, 2017. https://www.cdc.gov/nchs/data/nhis/earlyrelease/insur201702.pdf.
5. Papanicolas I et al. Challenges in international comparison of health care systems. JAMA. 2017 Aug 8;318(6):515-6. https://jamanetwork.com/journals/jama/article-abstract/2646461.
6. Schneider EC et al. From last to first – Could the U.S. health care system become the best in the world? N Engl J Med. 2017 Sep 7; 377(10):901-4.
MedPAC: Medicare hospital readmissions program is working
WASHINGTON – The Medicare Hospital Readmissions Reduction Program is working, according to an original analysis of Medicare claims data presented at a meeting of the Medicare Payment Advisory Commission.
“First, readmissions declined,” MedPAC staff member Jeff Stensland, PhD, said during a congressionally mandated staff report to the commissioners. “Second, while observation stays increased, they did not fully offset the decrease in readmissions. Third, while [emergency department] visits also increased, those increases appear to largely be due to factors other than the readmission program. And fourth, in addition, all the evidence we examined suggests that the readmissions program did not result in increased mortality.”
including a reduction in readmissions and patients spending less time in the hospital with “at least equal outcomes,” Dr. Stensland said at the meeting.
Taxpayers benefited from a $2 billion reduction in spending on readmissions, which will “help extend the viability of the Medicare Trust Fund.” He noted that improvements to the program will be discussed at future MedPAC meetings.
Not all MedPAC commissioners agreed with the staff analysis.
David Nerenz, PhD, of the Henry Ford Health System, Detroit, also was not convinced the program was having an impact, noting that hospital readmissions began to decline even before the program started.
In looking at a graph presented that showed this trend, “I was impressed by the fact that the trend line started coming down all the way to the left side of the graph, and what my eye was impressed with was more just the continuation rather than a change, so I guess I feel cautious saying the program had certain effects because they certainly don’t jump off the graph visually,” Dr. Nerenz said. “I’m not disputing the numbers, but to say just as a clear unqualified conclusion the program reduced readmissions, I’m not so sure.”
It is likely premature to make any firm conclusions about how effectively this program decreases unnecessary utilization of hospitals. However, it is heartening to know that it did not increase mortality. The one variable that would best control readmissions is patient education. What constitutes an emergency requiring hospital evaluation and potential admission is often not explained to the patient by you and me. 
It is likely premature to make any firm conclusions about how effectively this program decreases unnecessary utilization of hospitals. However, it is heartening to know that it did not increase mortality. The one variable that would best control readmissions is patient education. What constitutes an emergency requiring hospital evaluation and potential admission is often not explained to the patient by you and me.
It is likely premature to make any firm conclusions about how effectively this program decreases unnecessary utilization of hospitals. However, it is heartening to know that it did not increase mortality. The one variable that would best control readmissions is patient education. What constitutes an emergency requiring hospital evaluation and potential admission is often not explained to the patient by you and me.
WASHINGTON – The Medicare Hospital Readmissions Reduction Program is working, according to an original analysis of Medicare claims data presented at a meeting of the Medicare Payment Advisory Commission.
“First, readmissions declined,” MedPAC staff member Jeff Stensland, PhD, said during a congressionally mandated staff report to the commissioners. “Second, while observation stays increased, they did not fully offset the decrease in readmissions. Third, while [emergency department] visits also increased, those increases appear to largely be due to factors other than the readmission program. And fourth, in addition, all the evidence we examined suggests that the readmissions program did not result in increased mortality.”
including a reduction in readmissions and patients spending less time in the hospital with “at least equal outcomes,” Dr. Stensland said at the meeting.
Taxpayers benefited from a $2 billion reduction in spending on readmissions, which will “help extend the viability of the Medicare Trust Fund.” He noted that improvements to the program will be discussed at future MedPAC meetings.
Not all MedPAC commissioners agreed with the staff analysis.
David Nerenz, PhD, of the Henry Ford Health System, Detroit, also was not convinced the program was having an impact, noting that hospital readmissions began to decline even before the program started.
In looking at a graph presented that showed this trend, “I was impressed by the fact that the trend line started coming down all the way to the left side of the graph, and what my eye was impressed with was more just the continuation rather than a change, so I guess I feel cautious saying the program had certain effects because they certainly don’t jump off the graph visually,” Dr. Nerenz said. “I’m not disputing the numbers, but to say just as a clear unqualified conclusion the program reduced readmissions, I’m not so sure.”
WASHINGTON – The Medicare Hospital Readmissions Reduction Program is working, according to an original analysis of Medicare claims data presented at a meeting of the Medicare Payment Advisory Commission.
“First, readmissions declined,” MedPAC staff member Jeff Stensland, PhD, said during a congressionally mandated staff report to the commissioners. “Second, while observation stays increased, they did not fully offset the decrease in readmissions. Third, while [emergency department] visits also increased, those increases appear to largely be due to factors other than the readmission program. And fourth, in addition, all the evidence we examined suggests that the readmissions program did not result in increased mortality.”
including a reduction in readmissions and patients spending less time in the hospital with “at least equal outcomes,” Dr. Stensland said at the meeting.
Taxpayers benefited from a $2 billion reduction in spending on readmissions, which will “help extend the viability of the Medicare Trust Fund.” He noted that improvements to the program will be discussed at future MedPAC meetings.
Not all MedPAC commissioners agreed with the staff analysis.
David Nerenz, PhD, of the Henry Ford Health System, Detroit, also was not convinced the program was having an impact, noting that hospital readmissions began to decline even before the program started.
In looking at a graph presented that showed this trend, “I was impressed by the fact that the trend line started coming down all the way to the left side of the graph, and what my eye was impressed with was more just the continuation rather than a change, so I guess I feel cautious saying the program had certain effects because they certainly don’t jump off the graph visually,” Dr. Nerenz said. “I’m not disputing the numbers, but to say just as a clear unqualified conclusion the program reduced readmissions, I’m not so sure.”
REPORTING FROM MEDPAC
Is it time for health policy M&Ms?
What would happen if hospitalists began to incorporate health policy into morbidity and mortality (M&M) conferences? That was a question Chris Moriates, MD, explored in an entry for SHM’s The Hospital Leader blog1 and an idea that caused a minor stir on Twitter when he proposed it last summer.
In late July 2017, the U.S. Senate was debating a bill to repeal the Affordable Care Act, without a clear vision for replacing it. In response, physicians around the country took to Twitter to share their sentiments about repeal under the hashtag #DoctorsSpeakOut. In one such tweet, Dr. Moriates, assistant dean for health care value and an associate professor of internal medicine at Dell Medical School at the University of Texas, Austin, said this, in 140 characters: “We recently had idea: health policy M&M for residents to discuss adverse outcomes we see as result of lack of access.”
The idea began with a conversation Dr. Moriates had with Beth Miller, MD, program director for the Dell Medical School Internal Medicine Residency Program. “We were meeting and talking about revamping the [resident] M&M conference to have more learning objectives and put in place best practices,” Dr. Moriates said. “Dr. Miller suggested it could be a good forum [for health policy] because it’s an area where we all come together and there’s a natural hook to it, since it is case-based, thus we can use it to recognize the drivers within the system that lead to bad outcomes.”
In his SHM blog post, Dr. Moriates said he has increasingly observed adverse events that result from issues related to health policy. He provided an example: “A patient I admitted for ‘expedited work-up’ for rectal bleeding after he told me he had been trying to get a recommended colonoscopy for many months but could not get it scheduled due to his lack of insurance. He had colon cancer that had spread.”
In another example, he conjured a hypothetical (though not impractical) case where a patient prescribed blood thinners upon hospital discharge returns to the hospital soon after with a blood clot. Unable to afford the medication, or seek primary care follow-up, this kind of patient is readmitted through no direct fault of his physicians. Yet, the patient is worse off and the hospital takes the hit on readmissions penalties.
Dr. Moriates believes that viewing a case like this through a health policy lens is not only moving, but critical to better understanding health care delivery, particularly in an environment where physician performance is measured, in part, by outcomes. He now believes health policy M&Ms would be valuable to all hospital-based physicians, not just residents.
“Hospitalists are being asked to hit these value-based performance metrics, like readmissions and length of stay, and while we deal with the consequences, we are not always the best informed” with respect to policy, he said. “We could use this forum to teach health policy topics and continually update people and contribute, in real time, to all these different discussions and understand how things are changing or could change and impact our patients.”
“It’s important for physicians to know the policies that are aligned with, and the policies that may undermine, what they’re doing in their practice to improve their patients’ health,” Pourat said.
This knowledge can benefit physicians, too, Pourat added, because health policy M&Ms could help providers understand the goals of particular policies and in turn adjust their own behaviors and expectations.
“Physicians could discuss, what are the underlying issues or root causes, like the decision not to expand Medicaid here in Texas,” Dr. Moriates said. “Not all of these things you can fix, but you’re exposing those stories and perhaps we can come up with some actionable steps. How do we ensure in the future that our patients are able to fulfill their prescription so we’re not just sending someone out assuming they will but not knowing they’re unable to afford it?”
Similar to other domains in which physician leaders become champions, such as antibiotic stewardship, Dr. Pourat suggested that hospitalists could champion policy awareness through the kind of M&Ms Dr. Moriates proposed.
While journal clubs and lectures are great ways for hospitalists to learn more about health policy, the emotionally gripping nature of M&Ms could inspire more physicians to act in favor of policies that benefit their patients and themselves, Dr. Moriates said.
For example, physicians may write to or visit legislative offices, or author op-eds in their local newspapers. This collective action carries the potential to effect change. And it need not be partisan.
“I believe that if health policy issues were more explicitly integrated into M&Ms then clinicians would be more inclined and prepared to effectively advocate for specific policy changes,” he wrote in his blog post. “Perhaps entire groups would be moved to engage in the political process.”
On Twitter, even before Dr. Moriates’ first tweet about health policy M&Ms, New Jersey–based Jennifer Chuang, MD, an adolescent medicine physician, wrote: “M&M is heart-wrenching in academic hospitals. I dare @SenateGOP to present their role in M&M’s to come if ACA is repealed.”
While Dr. Moriates believes the chances are quite small that legislators and policymakers would attend health policy M&Ms, he called the notion “provocative and intriguing.”
In his blog post, Dr. Moriates invites state legislators and local members of Congress to join him in reviewing M&M cases where patients have been negatively affected by policy. He also emphasized that, like most modern M&Ms, the point should not be derision or finger-pointing, but an opportunity to learn how policy translates into practice.
Physicians may learn from legislators, too, he said in his blog post. “Just as policymakers could see legislation through the eyes of practitioners and their patients, this is where we as physicians could possibly learn from our legislators,” he wrote. “We may recognize the potential trade-offs, downsides, and barriers to proposals that to us may have seemed like no-brainers.”
What’s clear, said Dr. Pourat, who is also a professor in the UCLA Fielding School of Public Health and the School of Dentistry, is that Dr. Moriates’ blog post and tweet are “touching an important point for a lot of physicians during this whole debate over health reform.”
President Donald Trump campaigned on a promise to fully repeal and replace the Affordable Care Act but Republican efforts have thus far been stymied. In the meantime, some physicians are watching closely, knowing that whatever comes next will continue to affect them and their patients.
Source
1. Moriates C. Is it time for health policy M&Ms? The Hospital Leader. Aug 16, 2017. http://thehospitalleader.org/is-it-time-for-health-policy-mms/. Accessed 2017 Sep 14.
What would happen if hospitalists began to incorporate health policy into morbidity and mortality (M&M) conferences? That was a question Chris Moriates, MD, explored in an entry for SHM’s The Hospital Leader blog1 and an idea that caused a minor stir on Twitter when he proposed it last summer.
In late July 2017, the U.S. Senate was debating a bill to repeal the Affordable Care Act, without a clear vision for replacing it. In response, physicians around the country took to Twitter to share their sentiments about repeal under the hashtag #DoctorsSpeakOut. In one such tweet, Dr. Moriates, assistant dean for health care value and an associate professor of internal medicine at Dell Medical School at the University of Texas, Austin, said this, in 140 characters: “We recently had idea: health policy M&M for residents to discuss adverse outcomes we see as result of lack of access.”
The idea began with a conversation Dr. Moriates had with Beth Miller, MD, program director for the Dell Medical School Internal Medicine Residency Program. “We were meeting and talking about revamping the [resident] M&M conference to have more learning objectives and put in place best practices,” Dr. Moriates said. “Dr. Miller suggested it could be a good forum [for health policy] because it’s an area where we all come together and there’s a natural hook to it, since it is case-based, thus we can use it to recognize the drivers within the system that lead to bad outcomes.”
In his SHM blog post, Dr. Moriates said he has increasingly observed adverse events that result from issues related to health policy. He provided an example: “A patient I admitted for ‘expedited work-up’ for rectal bleeding after he told me he had been trying to get a recommended colonoscopy for many months but could not get it scheduled due to his lack of insurance. He had colon cancer that had spread.”
In another example, he conjured a hypothetical (though not impractical) case where a patient prescribed blood thinners upon hospital discharge returns to the hospital soon after with a blood clot. Unable to afford the medication, or seek primary care follow-up, this kind of patient is readmitted through no direct fault of his physicians. Yet, the patient is worse off and the hospital takes the hit on readmissions penalties.
Dr. Moriates believes that viewing a case like this through a health policy lens is not only moving, but critical to better understanding health care delivery, particularly in an environment where physician performance is measured, in part, by outcomes. He now believes health policy M&Ms would be valuable to all hospital-based physicians, not just residents.
“Hospitalists are being asked to hit these value-based performance metrics, like readmissions and length of stay, and while we deal with the consequences, we are not always the best informed” with respect to policy, he said. “We could use this forum to teach health policy topics and continually update people and contribute, in real time, to all these different discussions and understand how things are changing or could change and impact our patients.”
“It’s important for physicians to know the policies that are aligned with, and the policies that may undermine, what they’re doing in their practice to improve their patients’ health,” Pourat said.
This knowledge can benefit physicians, too, Pourat added, because health policy M&Ms could help providers understand the goals of particular policies and in turn adjust their own behaviors and expectations.
“Physicians could discuss, what are the underlying issues or root causes, like the decision not to expand Medicaid here in Texas,” Dr. Moriates said. “Not all of these things you can fix, but you’re exposing those stories and perhaps we can come up with some actionable steps. How do we ensure in the future that our patients are able to fulfill their prescription so we’re not just sending someone out assuming they will but not knowing they’re unable to afford it?”
Similar to other domains in which physician leaders become champions, such as antibiotic stewardship, Dr. Pourat suggested that hospitalists could champion policy awareness through the kind of M&Ms Dr. Moriates proposed.
While journal clubs and lectures are great ways for hospitalists to learn more about health policy, the emotionally gripping nature of M&Ms could inspire more physicians to act in favor of policies that benefit their patients and themselves, Dr. Moriates said.
For example, physicians may write to or visit legislative offices, or author op-eds in their local newspapers. This collective action carries the potential to effect change. And it need not be partisan.
“I believe that if health policy issues were more explicitly integrated into M&Ms then clinicians would be more inclined and prepared to effectively advocate for specific policy changes,” he wrote in his blog post. “Perhaps entire groups would be moved to engage in the political process.”
On Twitter, even before Dr. Moriates’ first tweet about health policy M&Ms, New Jersey–based Jennifer Chuang, MD, an adolescent medicine physician, wrote: “M&M is heart-wrenching in academic hospitals. I dare @SenateGOP to present their role in M&M’s to come if ACA is repealed.”
While Dr. Moriates believes the chances are quite small that legislators and policymakers would attend health policy M&Ms, he called the notion “provocative and intriguing.”
In his blog post, Dr. Moriates invites state legislators and local members of Congress to join him in reviewing M&M cases where patients have been negatively affected by policy. He also emphasized that, like most modern M&Ms, the point should not be derision or finger-pointing, but an opportunity to learn how policy translates into practice.
Physicians may learn from legislators, too, he said in his blog post. “Just as policymakers could see legislation through the eyes of practitioners and their patients, this is where we as physicians could possibly learn from our legislators,” he wrote. “We may recognize the potential trade-offs, downsides, and barriers to proposals that to us may have seemed like no-brainers.”
What’s clear, said Dr. Pourat, who is also a professor in the UCLA Fielding School of Public Health and the School of Dentistry, is that Dr. Moriates’ blog post and tweet are “touching an important point for a lot of physicians during this whole debate over health reform.”
President Donald Trump campaigned on a promise to fully repeal and replace the Affordable Care Act but Republican efforts have thus far been stymied. In the meantime, some physicians are watching closely, knowing that whatever comes next will continue to affect them and their patients.
Source
1. Moriates C. Is it time for health policy M&Ms? The Hospital Leader. Aug 16, 2017. http://thehospitalleader.org/is-it-time-for-health-policy-mms/. Accessed 2017 Sep 14.
What would happen if hospitalists began to incorporate health policy into morbidity and mortality (M&M) conferences? That was a question Chris Moriates, MD, explored in an entry for SHM’s The Hospital Leader blog1 and an idea that caused a minor stir on Twitter when he proposed it last summer.
In late July 2017, the U.S. Senate was debating a bill to repeal the Affordable Care Act, without a clear vision for replacing it. In response, physicians around the country took to Twitter to share their sentiments about repeal under the hashtag #DoctorsSpeakOut. In one such tweet, Dr. Moriates, assistant dean for health care value and an associate professor of internal medicine at Dell Medical School at the University of Texas, Austin, said this, in 140 characters: “We recently had idea: health policy M&M for residents to discuss adverse outcomes we see as result of lack of access.”
The idea began with a conversation Dr. Moriates had with Beth Miller, MD, program director for the Dell Medical School Internal Medicine Residency Program. “We were meeting and talking about revamping the [resident] M&M conference to have more learning objectives and put in place best practices,” Dr. Moriates said. “Dr. Miller suggested it could be a good forum [for health policy] because it’s an area where we all come together and there’s a natural hook to it, since it is case-based, thus we can use it to recognize the drivers within the system that lead to bad outcomes.”
In his SHM blog post, Dr. Moriates said he has increasingly observed adverse events that result from issues related to health policy. He provided an example: “A patient I admitted for ‘expedited work-up’ for rectal bleeding after he told me he had been trying to get a recommended colonoscopy for many months but could not get it scheduled due to his lack of insurance. He had colon cancer that had spread.”
In another example, he conjured a hypothetical (though not impractical) case where a patient prescribed blood thinners upon hospital discharge returns to the hospital soon after with a blood clot. Unable to afford the medication, or seek primary care follow-up, this kind of patient is readmitted through no direct fault of his physicians. Yet, the patient is worse off and the hospital takes the hit on readmissions penalties.
Dr. Moriates believes that viewing a case like this through a health policy lens is not only moving, but critical to better understanding health care delivery, particularly in an environment where physician performance is measured, in part, by outcomes. He now believes health policy M&Ms would be valuable to all hospital-based physicians, not just residents.
“Hospitalists are being asked to hit these value-based performance metrics, like readmissions and length of stay, and while we deal with the consequences, we are not always the best informed” with respect to policy, he said. “We could use this forum to teach health policy topics and continually update people and contribute, in real time, to all these different discussions and understand how things are changing or could change and impact our patients.”
“It’s important for physicians to know the policies that are aligned with, and the policies that may undermine, what they’re doing in their practice to improve their patients’ health,” Pourat said.
This knowledge can benefit physicians, too, Pourat added, because health policy M&Ms could help providers understand the goals of particular policies and in turn adjust their own behaviors and expectations.
“Physicians could discuss, what are the underlying issues or root causes, like the decision not to expand Medicaid here in Texas,” Dr. Moriates said. “Not all of these things you can fix, but you’re exposing those stories and perhaps we can come up with some actionable steps. How do we ensure in the future that our patients are able to fulfill their prescription so we’re not just sending someone out assuming they will but not knowing they’re unable to afford it?”
Similar to other domains in which physician leaders become champions, such as antibiotic stewardship, Dr. Pourat suggested that hospitalists could champion policy awareness through the kind of M&Ms Dr. Moriates proposed.
While journal clubs and lectures are great ways for hospitalists to learn more about health policy, the emotionally gripping nature of M&Ms could inspire more physicians to act in favor of policies that benefit their patients and themselves, Dr. Moriates said.
For example, physicians may write to or visit legislative offices, or author op-eds in their local newspapers. This collective action carries the potential to effect change. And it need not be partisan.
“I believe that if health policy issues were more explicitly integrated into M&Ms then clinicians would be more inclined and prepared to effectively advocate for specific policy changes,” he wrote in his blog post. “Perhaps entire groups would be moved to engage in the political process.”
On Twitter, even before Dr. Moriates’ first tweet about health policy M&Ms, New Jersey–based Jennifer Chuang, MD, an adolescent medicine physician, wrote: “M&M is heart-wrenching in academic hospitals. I dare @SenateGOP to present their role in M&M’s to come if ACA is repealed.”
While Dr. Moriates believes the chances are quite small that legislators and policymakers would attend health policy M&Ms, he called the notion “provocative and intriguing.”
In his blog post, Dr. Moriates invites state legislators and local members of Congress to join him in reviewing M&M cases where patients have been negatively affected by policy. He also emphasized that, like most modern M&Ms, the point should not be derision or finger-pointing, but an opportunity to learn how policy translates into practice.
Physicians may learn from legislators, too, he said in his blog post. “Just as policymakers could see legislation through the eyes of practitioners and their patients, this is where we as physicians could possibly learn from our legislators,” he wrote. “We may recognize the potential trade-offs, downsides, and barriers to proposals that to us may have seemed like no-brainers.”
What’s clear, said Dr. Pourat, who is also a professor in the UCLA Fielding School of Public Health and the School of Dentistry, is that Dr. Moriates’ blog post and tweet are “touching an important point for a lot of physicians during this whole debate over health reform.”
President Donald Trump campaigned on a promise to fully repeal and replace the Affordable Care Act but Republican efforts have thus far been stymied. In the meantime, some physicians are watching closely, knowing that whatever comes next will continue to affect them and their patients.
Source
1. Moriates C. Is it time for health policy M&Ms? The Hospital Leader. Aug 16, 2017. http://thehospitalleader.org/is-it-time-for-health-policy-mms/. Accessed 2017 Sep 14.
MedPAC recommends scrapping MIPS, gets pushback from doctors
WASHINGTON – As unpopular as the new Quality Payment Program may be, repealing all or part of it at this stage will be a tough sell.
That was the message heard by members of the Medicare Payment Advisory Commission (MedPAC) during public comments at their Jan. 11 meeting. Comments followed a 14-2 vote by commissioners in favor of recommending that Congress scrap the Merit-Based Incentive Payment System (MIPS) track of the QPP.
“We do agree that there are problems with MIPS,” said Sharon McIlrath, assistant director of federal affairs and coalitions at the American Medical Association. “We would like to fix it rather than kill it, and partly that’s because we don’t want to send shifting messages to physicians. Are they going to invest in building an infrastructure on shifting ground?”
She also questioned whether this proposal could gain any traction at all in Congress.
“We don’t think that it is politically viable to think that you are going to go up there and get the Hill to kill MIPS,” she said.
The Alliance of Specialty Medicine in a Jan. 9 letter to MedPAC also voiced its objections to the commission’s plan to recommend the end of MIPS.
“Our efforts to work with CMS and congressional leaders to improve MIPS and allow for more meaningful and robust engagement are ongoing. We urge you to withdraw your forthcoming recommendation, which diminishes the important role of specialty medicine in Medicare,” alliance members wrote to MedPAC Chairman Francis J. Crosson, MD. “Instead, the commission and staff, under your leadership, should work toward a new recommendation that would improve aspects of the MIPS program that remain a challenge for all clinicians.”
MedPAC had been working on its recommendations regarding MIPS since the program was launched, but ultimately came to the conclusion that it was not fixable. During a presentation on the draft recommendation, MedPAC staff listed a variety of reasons why MIPS “cannot succeed,” including how it replicates flaws of previous value-based purchasing plans and is burdensome and complex, the information reported is not meaningful, scores are not comparable across clinicians, and the payment adjustments, while minimal early on, could vary widely from year to year with even the smallest of MIPS score changes.
Instead, current draft MedPAC recommendations put forward a voluntary value program (VVP) to replace MIPS. VVP would withhold a specific percentage of Medicare pay for physicians who are not involved in a QPP advanced Alternative Payment Model (APM).
Physicians would be able to earn back the withheld pay, plus be eligible for potential bonuses by voluntarily participating in virtual groups. Those groups would be scored on population-based measures.
As was the case across previous meetings where this was discussed, commissioners David Nerenz, PhD, of the Henry Ford Health System of Detroit, and Alice Coombs, MD, of South Shore Hospital, Weymouth, Mass., continued to voice their objections about repealing MIPS and ultimately voted against the recommendation.
The MIPS recommendation will be included in MedPAC’s June report to Congress; it then will be up to Congress to decide whether to act on it.
WASHINGTON – As unpopular as the new Quality Payment Program may be, repealing all or part of it at this stage will be a tough sell.
That was the message heard by members of the Medicare Payment Advisory Commission (MedPAC) during public comments at their Jan. 11 meeting. Comments followed a 14-2 vote by commissioners in favor of recommending that Congress scrap the Merit-Based Incentive Payment System (MIPS) track of the QPP.
“We do agree that there are problems with MIPS,” said Sharon McIlrath, assistant director of federal affairs and coalitions at the American Medical Association. “We would like to fix it rather than kill it, and partly that’s because we don’t want to send shifting messages to physicians. Are they going to invest in building an infrastructure on shifting ground?”
She also questioned whether this proposal could gain any traction at all in Congress.
“We don’t think that it is politically viable to think that you are going to go up there and get the Hill to kill MIPS,” she said.
The Alliance of Specialty Medicine in a Jan. 9 letter to MedPAC also voiced its objections to the commission’s plan to recommend the end of MIPS.
“Our efforts to work with CMS and congressional leaders to improve MIPS and allow for more meaningful and robust engagement are ongoing. We urge you to withdraw your forthcoming recommendation, which diminishes the important role of specialty medicine in Medicare,” alliance members wrote to MedPAC Chairman Francis J. Crosson, MD. “Instead, the commission and staff, under your leadership, should work toward a new recommendation that would improve aspects of the MIPS program that remain a challenge for all clinicians.”
MedPAC had been working on its recommendations regarding MIPS since the program was launched, but ultimately came to the conclusion that it was not fixable. During a presentation on the draft recommendation, MedPAC staff listed a variety of reasons why MIPS “cannot succeed,” including how it replicates flaws of previous value-based purchasing plans and is burdensome and complex, the information reported is not meaningful, scores are not comparable across clinicians, and the payment adjustments, while minimal early on, could vary widely from year to year with even the smallest of MIPS score changes.
Instead, current draft MedPAC recommendations put forward a voluntary value program (VVP) to replace MIPS. VVP would withhold a specific percentage of Medicare pay for physicians who are not involved in a QPP advanced Alternative Payment Model (APM).
Physicians would be able to earn back the withheld pay, plus be eligible for potential bonuses by voluntarily participating in virtual groups. Those groups would be scored on population-based measures.
As was the case across previous meetings where this was discussed, commissioners David Nerenz, PhD, of the Henry Ford Health System of Detroit, and Alice Coombs, MD, of South Shore Hospital, Weymouth, Mass., continued to voice their objections about repealing MIPS and ultimately voted against the recommendation.
The MIPS recommendation will be included in MedPAC’s June report to Congress; it then will be up to Congress to decide whether to act on it.
WASHINGTON – As unpopular as the new Quality Payment Program may be, repealing all or part of it at this stage will be a tough sell.
That was the message heard by members of the Medicare Payment Advisory Commission (MedPAC) during public comments at their Jan. 11 meeting. Comments followed a 14-2 vote by commissioners in favor of recommending that Congress scrap the Merit-Based Incentive Payment System (MIPS) track of the QPP.
“We do agree that there are problems with MIPS,” said Sharon McIlrath, assistant director of federal affairs and coalitions at the American Medical Association. “We would like to fix it rather than kill it, and partly that’s because we don’t want to send shifting messages to physicians. Are they going to invest in building an infrastructure on shifting ground?”
She also questioned whether this proposal could gain any traction at all in Congress.
“We don’t think that it is politically viable to think that you are going to go up there and get the Hill to kill MIPS,” she said.
The Alliance of Specialty Medicine in a Jan. 9 letter to MedPAC also voiced its objections to the commission’s plan to recommend the end of MIPS.
“Our efforts to work with CMS and congressional leaders to improve MIPS and allow for more meaningful and robust engagement are ongoing. We urge you to withdraw your forthcoming recommendation, which diminishes the important role of specialty medicine in Medicare,” alliance members wrote to MedPAC Chairman Francis J. Crosson, MD. “Instead, the commission and staff, under your leadership, should work toward a new recommendation that would improve aspects of the MIPS program that remain a challenge for all clinicians.”
MedPAC had been working on its recommendations regarding MIPS since the program was launched, but ultimately came to the conclusion that it was not fixable. During a presentation on the draft recommendation, MedPAC staff listed a variety of reasons why MIPS “cannot succeed,” including how it replicates flaws of previous value-based purchasing plans and is burdensome and complex, the information reported is not meaningful, scores are not comparable across clinicians, and the payment adjustments, while minimal early on, could vary widely from year to year with even the smallest of MIPS score changes.
Instead, current draft MedPAC recommendations put forward a voluntary value program (VVP) to replace MIPS. VVP would withhold a specific percentage of Medicare pay for physicians who are not involved in a QPP advanced Alternative Payment Model (APM).
Physicians would be able to earn back the withheld pay, plus be eligible for potential bonuses by voluntarily participating in virtual groups. Those groups would be scored on population-based measures.
As was the case across previous meetings where this was discussed, commissioners David Nerenz, PhD, of the Henry Ford Health System of Detroit, and Alice Coombs, MD, of South Shore Hospital, Weymouth, Mass., continued to voice their objections about repealing MIPS and ultimately voted against the recommendation.
The MIPS recommendation will be included in MedPAC’s June report to Congress; it then will be up to Congress to decide whether to act on it.
REPORTING FROM A MEDPAC MEETING
CMS launches advanced APM focused on bundled payments
The Centers for Medicare & Medicaid Services is launching a new voluntary bundled payment demonstration project that for the first time will qualify as an advanced alternative payment model under the Quality Payment Program.
The Bundled Payments for Care Improvement Advanced (BPCI Advanced) “builds on the earlier success of bundled payment models and is an important step in the move away from fee-for-service and towards paying for value,” CMS Administrator Seema Verma said in a statement. “Under this model, providers will have an incentive to deliver high-quality care.”
Both categories of participants may enter into agreements with individual physicians and nonphysician providers to furnish care under the bundled payment model.
It will cover 29 in-patient episodes and three outpatient clinical episodes. Payment will be tied to performance on quality measures.
The 29 in-patient clinical episodes cover a range of conditions, including liver disorders (excluding malignancy, cirrhosis, and alcoholic hepatitis); various cardiac conditions; chronic obstructive pulmonary disease, bronchitis, and asthma; spinal fusion; joint replacements; femur, hip, or pelvis fractures; gastrointestinal hemorrhage or obstruction; renal failure; sepsis; simple pneumonia and respiratory infections; stroke; and urinary tract infections.
The three outpatient clinical episodes include percutaneous coronary intervention, cardiac defibrillator implantation, and back and neck surgery except spinal fusion.
Seven quality measures will be tracked as part of the payment. For all clinical episodes, measurement of all-cause hospital readmissions and advance care plan will be required.
The other five will be applied to the payment when appropriate, as follows:
- Perioperative care: selection of prophylactic antibiotic: first- or second-generation cephalosporin.
- Hospital-level risk-standardized complication rate following elective primary total hip arthroplasty and/or total knee arthroplasty.
- Hospital 30-day, all-cause, risk-standardized mortality rate following coronary artery bypass graft surgery.
- Excess days in acute care after hospitalization for acute myocardial infarction; and AHRQ patient safety indicators.
CMS has scheduled an open-door forum for those interested in participating in BPCI Advanced on Jan. 30.
Applications for participation will be accepted through March 12.
The Centers for Medicare & Medicaid Services is launching a new voluntary bundled payment demonstration project that for the first time will qualify as an advanced alternative payment model under the Quality Payment Program.
The Bundled Payments for Care Improvement Advanced (BPCI Advanced) “builds on the earlier success of bundled payment models and is an important step in the move away from fee-for-service and towards paying for value,” CMS Administrator Seema Verma said in a statement. “Under this model, providers will have an incentive to deliver high-quality care.”
Both categories of participants may enter into agreements with individual physicians and nonphysician providers to furnish care under the bundled payment model.
It will cover 29 in-patient episodes and three outpatient clinical episodes. Payment will be tied to performance on quality measures.
The 29 in-patient clinical episodes cover a range of conditions, including liver disorders (excluding malignancy, cirrhosis, and alcoholic hepatitis); various cardiac conditions; chronic obstructive pulmonary disease, bronchitis, and asthma; spinal fusion; joint replacements; femur, hip, or pelvis fractures; gastrointestinal hemorrhage or obstruction; renal failure; sepsis; simple pneumonia and respiratory infections; stroke; and urinary tract infections.
The three outpatient clinical episodes include percutaneous coronary intervention, cardiac defibrillator implantation, and back and neck surgery except spinal fusion.
Seven quality measures will be tracked as part of the payment. For all clinical episodes, measurement of all-cause hospital readmissions and advance care plan will be required.
The other five will be applied to the payment when appropriate, as follows:
- Perioperative care: selection of prophylactic antibiotic: first- or second-generation cephalosporin.
- Hospital-level risk-standardized complication rate following elective primary total hip arthroplasty and/or total knee arthroplasty.
- Hospital 30-day, all-cause, risk-standardized mortality rate following coronary artery bypass graft surgery.
- Excess days in acute care after hospitalization for acute myocardial infarction; and AHRQ patient safety indicators.
CMS has scheduled an open-door forum for those interested in participating in BPCI Advanced on Jan. 30.
Applications for participation will be accepted through March 12.
The Centers for Medicare & Medicaid Services is launching a new voluntary bundled payment demonstration project that for the first time will qualify as an advanced alternative payment model under the Quality Payment Program.
The Bundled Payments for Care Improvement Advanced (BPCI Advanced) “builds on the earlier success of bundled payment models and is an important step in the move away from fee-for-service and towards paying for value,” CMS Administrator Seema Verma said in a statement. “Under this model, providers will have an incentive to deliver high-quality care.”
Both categories of participants may enter into agreements with individual physicians and nonphysician providers to furnish care under the bundled payment model.
It will cover 29 in-patient episodes and three outpatient clinical episodes. Payment will be tied to performance on quality measures.
The 29 in-patient clinical episodes cover a range of conditions, including liver disorders (excluding malignancy, cirrhosis, and alcoholic hepatitis); various cardiac conditions; chronic obstructive pulmonary disease, bronchitis, and asthma; spinal fusion; joint replacements; femur, hip, or pelvis fractures; gastrointestinal hemorrhage or obstruction; renal failure; sepsis; simple pneumonia and respiratory infections; stroke; and urinary tract infections.
The three outpatient clinical episodes include percutaneous coronary intervention, cardiac defibrillator implantation, and back and neck surgery except spinal fusion.
Seven quality measures will be tracked as part of the payment. For all clinical episodes, measurement of all-cause hospital readmissions and advance care plan will be required.
The other five will be applied to the payment when appropriate, as follows:
- Perioperative care: selection of prophylactic antibiotic: first- or second-generation cephalosporin.
- Hospital-level risk-standardized complication rate following elective primary total hip arthroplasty and/or total knee arthroplasty.
- Hospital 30-day, all-cause, risk-standardized mortality rate following coronary artery bypass graft surgery.
- Excess days in acute care after hospitalization for acute myocardial infarction; and AHRQ patient safety indicators.
CMS has scheduled an open-door forum for those interested in participating in BPCI Advanced on Jan. 30.
Applications for participation will be accepted through March 12.
Homelessness: Whose job is it?
Despite programs to end homelessness, it remains a substantial and growing problem in many cities in the United States.1,2 In 2016, there were an estimated 10,550 homeless people living in my home state of Colorado, a 6% increase from the prior year.2 A recent point-estimate study found that there were more than 5,000 homeless individuals in the Denver metropolitan area on a single night in January 2017.3 Because of the relative scarcity of housing, a growing number of cities like Denver now utilize a practice known as vulnerability indexing to prioritize homeless persons at high risk of mortality from medical conditions for placement in permanent supportive housing.4
Although hospitalists like myself frequently care for vulnerable homeless patients in the hospital, most have little formal training in how best to care for and advocate for these individuals beyond treating their acute medical need, and little direct contact with community organizations with expertise in doing so. Instead, we have learned informally through experience. Hospital providers are often frustrated by the perceived lack of services and support available to these patients, and there is substantial variability in the extent to which providers engage patients and community partners during and after hospitalization. Despite the growing practice of vulnerability indexing in the community, hospital-based providers do not routinely assess vulnerability with respect to housing. Previous research indicates that housing status is assessed in only a minority of homeless patients during their hospital stay.12 Thus, hospitalization often represents a missed opportunity to identify vulnerability and utilize it to connect patients with housing and other resources.
Addressing the significant known health disparities faced by homeless persons is one of the greatest health equity challenges of our time.13 We need better ways of understanding, identifying, and addressing vulnerability among homeless patients who are hospitalized, paired with improved integration with local community organizations. This will require moving beyond the idea that homelessness is the social worker’s job to one of shared responsibility and advocacy.
Collaborative research and other partnerships that engage both community organizations and individuals affected by homelessness are crucial to further understand the specific needs, barriers, challenges, and opportunities for improving hospital care and care transitions in this population. As well-respected community members and systems thinkers who witness these inequities on a daily basis, hospitalists are well positioned to help lead this work.
Dr. Stella is a hospitalist at Denver Health and Hospital Authority, and an associate professor of medicine at the University of Colorado. She is a member of The Hospitalist editorial advisory board.
References
1. Ending Chronic Homelessness. (Aug 2017). U.S. Interagency Council on Homelessness. Available at: https://www.usich.gov/goals/chronicsness. Accessed: Oct 21, 2017.
2. 2016 Annual Homeless Assessment Report (AHAR) to Congress. (Nov 2016). U.S. Department of Housing and Urban Development Office of Community Planning and Development, Part 1. Available at: https://www.hudexchange.info/resources/documents/2016-AHAR-Part-1.pdf. Accessed: Oct 21, 2017.
3. 2017 Point-In-Time Report, Seven-County Metro Denver Region. Metro Denver Homeless Initiative. Available at: http://www.mdhi.org/2017_pit. Accessed Oct 22, 2017.
4. Henwood BF et al. Examining mortality among formerly homeless adults enrolled in Housing First: An observational study. BMC Public Health. 2015;15:1209.
5. Weinstein LC et al. Moving from street to home: Health status of entrants to a Housing First program. J Prim Care Community Health. 2011;2:11–5.
6. Kushel MB et al. Factors associated with the health care utilization of homeless persons. JAMA. 2001;285(2):200-6.
7. Kushel MB et al. Emergency department use among the homeless and marginally housed: Results from a community-based study. Am J Public Health. 2002;92(5):778-84.
8. Baggett TP et al. Mortality among homeless adults in Boston: Shifts in causes of death over a 15-year period. JAMA Intern Med. 2013 Feb 11;173(3):189–95.
9. Johnson et al. For many patients who use large amounts of health care services, the need is intense yet temporary. Health Aff (Millwood). 2015 Aug;34(8):1312-9.
10. Durfee J et al. The impact of tailored intervention services on charges and mortality for adult super-utilizers. Healthc (Amst). 2017 Aug 25. pii: S2213-0764(17)30057-X. doi: 10.1016/j.hjdsi.2017.08.004. [Epub ahead of print]
11. Rinehart DJ et al. Identifying subgroups of adult super utilizers in an urban safety-net system using latent class analysis: Implications for clinical practice. Med Care. 2016 Sep 14. doi: 10.1097/MLR.0000000000000628. [Epub ahead of print]
12. Greysen RS et al. Understanding transitions of care from hospital to homeless shelter: A mixed-methods, community-based participatory approach. J Gen Intern Med. 2012;27(11):1484-91.
13. National Health Care for the Homeless Council. (Oct 2012). Improving Care Transitions for People Experiencing Homelessness. (Lead author: Sabrina Edgington, policy and program specialist.) Available at: www.nhchc.org/wp-content/uploads/2012/12/Policy_Brief_Care_Transitions.pdf. Accessed Oct 21, 2017.
14. Koh HK et al. Improving healthcare for homeless people. JAMA. 2016;316(24):2586-7.
Despite programs to end homelessness, it remains a substantial and growing problem in many cities in the United States.1,2 In 2016, there were an estimated 10,550 homeless people living in my home state of Colorado, a 6% increase from the prior year.2 A recent point-estimate study found that there were more than 5,000 homeless individuals in the Denver metropolitan area on a single night in January 2017.3 Because of the relative scarcity of housing, a growing number of cities like Denver now utilize a practice known as vulnerability indexing to prioritize homeless persons at high risk of mortality from medical conditions for placement in permanent supportive housing.4
Although hospitalists like myself frequently care for vulnerable homeless patients in the hospital, most have little formal training in how best to care for and advocate for these individuals beyond treating their acute medical need, and little direct contact with community organizations with expertise in doing so. Instead, we have learned informally through experience. Hospital providers are often frustrated by the perceived lack of services and support available to these patients, and there is substantial variability in the extent to which providers engage patients and community partners during and after hospitalization. Despite the growing practice of vulnerability indexing in the community, hospital-based providers do not routinely assess vulnerability with respect to housing. Previous research indicates that housing status is assessed in only a minority of homeless patients during their hospital stay.12 Thus, hospitalization often represents a missed opportunity to identify vulnerability and utilize it to connect patients with housing and other resources.
Addressing the significant known health disparities faced by homeless persons is one of the greatest health equity challenges of our time.13 We need better ways of understanding, identifying, and addressing vulnerability among homeless patients who are hospitalized, paired with improved integration with local community organizations. This will require moving beyond the idea that homelessness is the social worker’s job to one of shared responsibility and advocacy.
Collaborative research and other partnerships that engage both community organizations and individuals affected by homelessness are crucial to further understand the specific needs, barriers, challenges, and opportunities for improving hospital care and care transitions in this population. As well-respected community members and systems thinkers who witness these inequities on a daily basis, hospitalists are well positioned to help lead this work.
Dr. Stella is a hospitalist at Denver Health and Hospital Authority, and an associate professor of medicine at the University of Colorado. She is a member of The Hospitalist editorial advisory board.
References
1. Ending Chronic Homelessness. (Aug 2017). U.S. Interagency Council on Homelessness. Available at: https://www.usich.gov/goals/chronicsness. Accessed: Oct 21, 2017.
2. 2016 Annual Homeless Assessment Report (AHAR) to Congress. (Nov 2016). U.S. Department of Housing and Urban Development Office of Community Planning and Development, Part 1. Available at: https://www.hudexchange.info/resources/documents/2016-AHAR-Part-1.pdf. Accessed: Oct 21, 2017.
3. 2017 Point-In-Time Report, Seven-County Metro Denver Region. Metro Denver Homeless Initiative. Available at: http://www.mdhi.org/2017_pit. Accessed Oct 22, 2017.
4. Henwood BF et al. Examining mortality among formerly homeless adults enrolled in Housing First: An observational study. BMC Public Health. 2015;15:1209.
5. Weinstein LC et al. Moving from street to home: Health status of entrants to a Housing First program. J Prim Care Community Health. 2011;2:11–5.
6. Kushel MB et al. Factors associated with the health care utilization of homeless persons. JAMA. 2001;285(2):200-6.
7. Kushel MB et al. Emergency department use among the homeless and marginally housed: Results from a community-based study. Am J Public Health. 2002;92(5):778-84.
8. Baggett TP et al. Mortality among homeless adults in Boston: Shifts in causes of death over a 15-year period. JAMA Intern Med. 2013 Feb 11;173(3):189–95.
9. Johnson et al. For many patients who use large amounts of health care services, the need is intense yet temporary. Health Aff (Millwood). 2015 Aug;34(8):1312-9.
10. Durfee J et al. The impact of tailored intervention services on charges and mortality for adult super-utilizers. Healthc (Amst). 2017 Aug 25. pii: S2213-0764(17)30057-X. doi: 10.1016/j.hjdsi.2017.08.004. [Epub ahead of print]
11. Rinehart DJ et al. Identifying subgroups of adult super utilizers in an urban safety-net system using latent class analysis: Implications for clinical practice. Med Care. 2016 Sep 14. doi: 10.1097/MLR.0000000000000628. [Epub ahead of print]
12. Greysen RS et al. Understanding transitions of care from hospital to homeless shelter: A mixed-methods, community-based participatory approach. J Gen Intern Med. 2012;27(11):1484-91.
13. National Health Care for the Homeless Council. (Oct 2012). Improving Care Transitions for People Experiencing Homelessness. (Lead author: Sabrina Edgington, policy and program specialist.) Available at: www.nhchc.org/wp-content/uploads/2012/12/Policy_Brief_Care_Transitions.pdf. Accessed Oct 21, 2017.
14. Koh HK et al. Improving healthcare for homeless people. JAMA. 2016;316(24):2586-7.
Despite programs to end homelessness, it remains a substantial and growing problem in many cities in the United States.1,2 In 2016, there were an estimated 10,550 homeless people living in my home state of Colorado, a 6% increase from the prior year.2 A recent point-estimate study found that there were more than 5,000 homeless individuals in the Denver metropolitan area on a single night in January 2017.3 Because of the relative scarcity of housing, a growing number of cities like Denver now utilize a practice known as vulnerability indexing to prioritize homeless persons at high risk of mortality from medical conditions for placement in permanent supportive housing.4
Although hospitalists like myself frequently care for vulnerable homeless patients in the hospital, most have little formal training in how best to care for and advocate for these individuals beyond treating their acute medical need, and little direct contact with community organizations with expertise in doing so. Instead, we have learned informally through experience. Hospital providers are often frustrated by the perceived lack of services and support available to these patients, and there is substantial variability in the extent to which providers engage patients and community partners during and after hospitalization. Despite the growing practice of vulnerability indexing in the community, hospital-based providers do not routinely assess vulnerability with respect to housing. Previous research indicates that housing status is assessed in only a minority of homeless patients during their hospital stay.12 Thus, hospitalization often represents a missed opportunity to identify vulnerability and utilize it to connect patients with housing and other resources.
Addressing the significant known health disparities faced by homeless persons is one of the greatest health equity challenges of our time.13 We need better ways of understanding, identifying, and addressing vulnerability among homeless patients who are hospitalized, paired with improved integration with local community organizations. This will require moving beyond the idea that homelessness is the social worker’s job to one of shared responsibility and advocacy.
Collaborative research and other partnerships that engage both community organizations and individuals affected by homelessness are crucial to further understand the specific needs, barriers, challenges, and opportunities for improving hospital care and care transitions in this population. As well-respected community members and systems thinkers who witness these inequities on a daily basis, hospitalists are well positioned to help lead this work.
Dr. Stella is a hospitalist at Denver Health and Hospital Authority, and an associate professor of medicine at the University of Colorado. She is a member of The Hospitalist editorial advisory board.
References
1. Ending Chronic Homelessness. (Aug 2017). U.S. Interagency Council on Homelessness. Available at: https://www.usich.gov/goals/chronicsness. Accessed: Oct 21, 2017.
2. 2016 Annual Homeless Assessment Report (AHAR) to Congress. (Nov 2016). U.S. Department of Housing and Urban Development Office of Community Planning and Development, Part 1. Available at: https://www.hudexchange.info/resources/documents/2016-AHAR-Part-1.pdf. Accessed: Oct 21, 2017.
3. 2017 Point-In-Time Report, Seven-County Metro Denver Region. Metro Denver Homeless Initiative. Available at: http://www.mdhi.org/2017_pit. Accessed Oct 22, 2017.
4. Henwood BF et al. Examining mortality among formerly homeless adults enrolled in Housing First: An observational study. BMC Public Health. 2015;15:1209.
5. Weinstein LC et al. Moving from street to home: Health status of entrants to a Housing First program. J Prim Care Community Health. 2011;2:11–5.
6. Kushel MB et al. Factors associated with the health care utilization of homeless persons. JAMA. 2001;285(2):200-6.
7. Kushel MB et al. Emergency department use among the homeless and marginally housed: Results from a community-based study. Am J Public Health. 2002;92(5):778-84.
8. Baggett TP et al. Mortality among homeless adults in Boston: Shifts in causes of death over a 15-year period. JAMA Intern Med. 2013 Feb 11;173(3):189–95.
9. Johnson et al. For many patients who use large amounts of health care services, the need is intense yet temporary. Health Aff (Millwood). 2015 Aug;34(8):1312-9.
10. Durfee J et al. The impact of tailored intervention services on charges and mortality for adult super-utilizers. Healthc (Amst). 2017 Aug 25. pii: S2213-0764(17)30057-X. doi: 10.1016/j.hjdsi.2017.08.004. [Epub ahead of print]
11. Rinehart DJ et al. Identifying subgroups of adult super utilizers in an urban safety-net system using latent class analysis: Implications for clinical practice. Med Care. 2016 Sep 14. doi: 10.1097/MLR.0000000000000628. [Epub ahead of print]
12. Greysen RS et al. Understanding transitions of care from hospital to homeless shelter: A mixed-methods, community-based participatory approach. J Gen Intern Med. 2012;27(11):1484-91.
13. National Health Care for the Homeless Council. (Oct 2012). Improving Care Transitions for People Experiencing Homelessness. (Lead author: Sabrina Edgington, policy and program specialist.) Available at: www.nhchc.org/wp-content/uploads/2012/12/Policy_Brief_Care_Transitions.pdf. Accessed Oct 21, 2017.
14. Koh HK et al. Improving healthcare for homeless people. JAMA. 2016;316(24):2586-7.
Analysis: Hospital pay for performance not significantly improving Medicare outcomes
for Medicare beneficiaries, according to an analysis of Medicare claims data.
“No evidence that hospitals [that were] operating under pay for performance programs for more than a decade had better process scores or lower mortality than other hospitals was found,” Igna Bonfrer, PhD, of Erasmus University, Rotterdam, the Netherlands, and colleagues wrote in a study published Jan. 4, 2018, in BMJ.
Researchers looked at Medicare claims data from nearly 1.4 million patients aged 65 years and older across 1,189 hospitals. That total included 214 hospitals that were early adopters of pay for performance (PFP) programs, including the Hospital Quality Incentive Demonstration (HQID) and the current Hospital Value-Based Purchasing (HVBP) program, and 975 hospitals that adopted the programs at a later date. The study authors examined clinical process scores and 30-day mortality rates from 2003 to 2013.
Hospitals that were early adopters of a PFP program typically started from a higher baseline process measure score (91.5), compared with late adopters (89.9).
However, improvements among the early adopters “were smaller during the HQID period, although early adopters continued to perform at a slightly higher level than the late adopters during the pre-HVBP period,” the researchers explained. “Over the HVBP period, early and late adopters no longer differed in their clinical process scores.”
Indeed, a ceiling was ultimately reached, with early and late adopters approaching the same level (98.5 vs. 98.2).
For the 30-day mortality rates, both groups “started from a similar baseline (14.9% and 14.8% for the early and late adopters in the fourth quarter of 2003) and ended at the same rate of 9.9% for both groups in the fourth quarter of 2013,” Dr. Bonfrer and colleagues wrote.
The researchers suggested that the programs did not yield better results because of small financial incentives, coupled with program complexities that made it “difficult for hospitals to meaningfully engage in the program.” They also suggested that having to wait until year end to receive any financial incentives could have limited the impact.
“We found that hospitals that have been under financial incentives for more than a decade have not been able to reduce patient mortality more than late adopters, which had only been under financial incentives for less than 3 years,” the researchers concluded. “Given its cost, policymakers in the [United States] should consider one of two things: revise the current program or potentially end it.”
The changes suggested include increasing financial incentives and focusing on process measures that matter most to patients (mortality, patient experience, and functional status), rather than the current measure set that is larger and more difficult to track.
The researchers did not report any financial conflicts of interest.
gtwachtman@frontlinemedcom.com
SOURCE: Dr. Igna Bonfrer et al. BMJ 2018;360:j5622.
for Medicare beneficiaries, according to an analysis of Medicare claims data.
“No evidence that hospitals [that were] operating under pay for performance programs for more than a decade had better process scores or lower mortality than other hospitals was found,” Igna Bonfrer, PhD, of Erasmus University, Rotterdam, the Netherlands, and colleagues wrote in a study published Jan. 4, 2018, in BMJ.
Researchers looked at Medicare claims data from nearly 1.4 million patients aged 65 years and older across 1,189 hospitals. That total included 214 hospitals that were early adopters of pay for performance (PFP) programs, including the Hospital Quality Incentive Demonstration (HQID) and the current Hospital Value-Based Purchasing (HVBP) program, and 975 hospitals that adopted the programs at a later date. The study authors examined clinical process scores and 30-day mortality rates from 2003 to 2013.
Hospitals that were early adopters of a PFP program typically started from a higher baseline process measure score (91.5), compared with late adopters (89.9).
However, improvements among the early adopters “were smaller during the HQID period, although early adopters continued to perform at a slightly higher level than the late adopters during the pre-HVBP period,” the researchers explained. “Over the HVBP period, early and late adopters no longer differed in their clinical process scores.”
Indeed, a ceiling was ultimately reached, with early and late adopters approaching the same level (98.5 vs. 98.2).
For the 30-day mortality rates, both groups “started from a similar baseline (14.9% and 14.8% for the early and late adopters in the fourth quarter of 2003) and ended at the same rate of 9.9% for both groups in the fourth quarter of 2013,” Dr. Bonfrer and colleagues wrote.
The researchers suggested that the programs did not yield better results because of small financial incentives, coupled with program complexities that made it “difficult for hospitals to meaningfully engage in the program.” They also suggested that having to wait until year end to receive any financial incentives could have limited the impact.
“We found that hospitals that have been under financial incentives for more than a decade have not been able to reduce patient mortality more than late adopters, which had only been under financial incentives for less than 3 years,” the researchers concluded. “Given its cost, policymakers in the [United States] should consider one of two things: revise the current program or potentially end it.”
The changes suggested include increasing financial incentives and focusing on process measures that matter most to patients (mortality, patient experience, and functional status), rather than the current measure set that is larger and more difficult to track.
The researchers did not report any financial conflicts of interest.
gtwachtman@frontlinemedcom.com
SOURCE: Dr. Igna Bonfrer et al. BMJ 2018;360:j5622.
for Medicare beneficiaries, according to an analysis of Medicare claims data.
“No evidence that hospitals [that were] operating under pay for performance programs for more than a decade had better process scores or lower mortality than other hospitals was found,” Igna Bonfrer, PhD, of Erasmus University, Rotterdam, the Netherlands, and colleagues wrote in a study published Jan. 4, 2018, in BMJ.
Researchers looked at Medicare claims data from nearly 1.4 million patients aged 65 years and older across 1,189 hospitals. That total included 214 hospitals that were early adopters of pay for performance (PFP) programs, including the Hospital Quality Incentive Demonstration (HQID) and the current Hospital Value-Based Purchasing (HVBP) program, and 975 hospitals that adopted the programs at a later date. The study authors examined clinical process scores and 30-day mortality rates from 2003 to 2013.
Hospitals that were early adopters of a PFP program typically started from a higher baseline process measure score (91.5), compared with late adopters (89.9).
However, improvements among the early adopters “were smaller during the HQID period, although early adopters continued to perform at a slightly higher level than the late adopters during the pre-HVBP period,” the researchers explained. “Over the HVBP period, early and late adopters no longer differed in their clinical process scores.”
Indeed, a ceiling was ultimately reached, with early and late adopters approaching the same level (98.5 vs. 98.2).
For the 30-day mortality rates, both groups “started from a similar baseline (14.9% and 14.8% for the early and late adopters in the fourth quarter of 2003) and ended at the same rate of 9.9% for both groups in the fourth quarter of 2013,” Dr. Bonfrer and colleagues wrote.
The researchers suggested that the programs did not yield better results because of small financial incentives, coupled with program complexities that made it “difficult for hospitals to meaningfully engage in the program.” They also suggested that having to wait until year end to receive any financial incentives could have limited the impact.
“We found that hospitals that have been under financial incentives for more than a decade have not been able to reduce patient mortality more than late adopters, which had only been under financial incentives for less than 3 years,” the researchers concluded. “Given its cost, policymakers in the [United States] should consider one of two things: revise the current program or potentially end it.”
The changes suggested include increasing financial incentives and focusing on process measures that matter most to patients (mortality, patient experience, and functional status), rather than the current measure set that is larger and more difficult to track.
The researchers did not report any financial conflicts of interest.
gtwachtman@frontlinemedcom.com
SOURCE: Dr. Igna Bonfrer et al. BMJ 2018;360:j5622.
FROM BMJ
How will SNF readmissions penalties affect hospitalists?
Starting in 2018, skilled nursing facilities (SNFs), like acute care hospitals before them, will be subject to a penalty of up to 2% of their Medicare reimbursement for posting higher-than-average rates of hospital readmissions.
The Protecting Access to Medicare Act of 2014 established a value-based purchasing component for SNFs, including incentives for high-performing facilities and a measure for all-cause, all-condition readmissions to any hospital from the SNF within 30 days following hospital discharge – designed to recognize and reward, or punish, facilities’ performance on preventing unnecessary readmissions. Public reporting of SNF quality data, including readmission rates, started in October 2017. Penalties follow a year later. Some patients’ readmissions could trigger penalties for both the hospital and the SNF.
According to 2010 data, 23.5% of patients discharged from acute care hospitals to SNFs were readmitted to the hospital within 30 days, at a financial cost of $10,362 per readmission or $4.34 billion per year.1 Seventy eight percent of these readmissions were labeled avoidable. More recent evidence suggests that hospitalization rates for dual-eligible patients living in long-term care facilities decreased by 31% between 2010 and 2015.2As increasing numbers of hospitalists spend some or all of their work week in post-acute care settings, how will the SNF readmission penalty affect their relationships with post-acute facilities?
Experts say SNFs – as with hospitals before them – lack the ability to allocate rewards or penalties for readmission rate performance to individual doctors. But increasingly close collaborative relationships between post-acute facilities and the hospitalists who work in post-acute care mean that the hospitalist has an important role in helping the SNF to manage its readmissions exposure.
“Hospitals and hospitalists want to keep good relationships with the SNFs they partner with, for a variety of reasons,” Dr. Frizner said. “We believe that the best way to reduce readmissions and unplanned transfers from the SNF is for the doctor to know the patient. We need dedicated doctors in the facility. We want hospitalists who already know the patient to come to the facility and see the patient there.”
The hospitalist’s role in post-acute care
Hospitalists who work in post-acute care typically make scheduled, billable medical visits to patients in long-term care facilities, and may also take on roles such as facility medical director or contribute to quality improvement. Relationships may be initiated by a facility seeking more medical coverage, by a hospitalist group seeking additional work or an ability to impact on the post-acute care delivered to hospital patients discharged to the facility, or by health systems, health plans, or accountable care organizations seeking to better manage the quality of care transitions for their beneficiaries.
“What I’m seeing is that with opportunities for bundled payments, we all have new incentives for moving patients along and reducing waste,” Dr. Boutwell said. “For hospitalists practicing in SNFs, it’s going to be a much bigger phenomenon. They’ll be called to reevaluate patients and make more visits than they have been accustomed to.” She hopes SNFs are studying what happened with hospitals’ readmission penalties, and will respond more quickly and effectively to their own penalty exposure.
“What we are seeing is an effort to shift folks to lower cost – but still clinically appropriate – levels of care,” he said. “These dynamics will force SNFs to reevaluate and improve their clinical competencies, to accept patients and then treat them in place. It’s no longer acceptable for the medical director to make rounds in person twice a month and do the rest by telephone.”
Instead, someone needs to be on site several times a week, working with nursing staff and developing protocols and pathways to control variability, Dr. Harrington said. “And in many cases that will be a hospitalist. Hospitalists are finding ways to partner and provide that level of care. I believe good hospitalist groups can change the facility for the better, and fairly quickly.”
What happens in post-acute care
Cari Levy, MD, PhD, who does hospital coverage and post-acute care for a number of facilities and home health agencies in the Denver area, calls the changes coming to SNFs a thrilling time for post-acute care.
“Suddenly medical professionals care about what happens in the post-acute world,” she said. “Everyone is now looking at the same measures. If this works the way it should, there would be a lot more mutual respect between providers.”
SNFs that are concerned about their readmissions rates will want to do root cause analysis to figure out what’s going on, Dr. Levy said. “Maybe the doctor didn’t do a good assessment. Maybe it was just a tough case. Once you start talking, you’ll develop systems to help everyone responsible. Hospitalists can be part of that conversation,” she said.
“You can have a good outcome at Shady Oaks and a terrible outcome at Whispering Pines, for all sorts of reasons. The hospital wants to make sure we’re sending patients to facilities that produce good outcomes,” he explained. “But there has to be communication between providers – the SNF medical director, the hospitalists, and the emergency department.”
A TeamHealth doctor in Phoenix has convened a consortium of providers from different care settings to meet and talk about cases and how they could have gone better. “The reality is, these conversations are going on all over,” Dr. Wilborn said. “What’s driving them is the realization of what we all need to do in this new environment.”
Opportunities from reforms
Robert Burke, MD, FHM, assistant chief of Hospital Medicine at the Denver VA Medical Center, is lead author of a study in the Journal of Hospital Medicine highlighting implications and opportunities from reforms in post-acute care.3 Hospitalists may not appreciate that post-acute care is poised to undergo transformative change from the recently legislated reforms, opening opportunities for hospitalists to improve health care value by improving transitions of care, he noted.
“My sense is that payment reform will put pressure on physicians to use home health care more often than institutional care, because of the cost pressures. We know that hospitalists choose long-term care facility placements less often when participating in bundled payment,” Dr. Burke said. “I think few hospitalists really know what happens on a day-to-day basis in SNFs – or in patients’ homes, for that matter.”
According to Dr. Burke, there’s just not enough data currently to guide these decisions. He said that, based on his research, the best thing hospitalists can do is try to understand what’s available in post-acute spaces, and build relationships with post-acute facilities.
“Find ways to get feedback on your discharge decisions,” he said. “Here in Colorado, we met recently with the local chapter of the Society for Post-Acute and Long-Term Care Medicine, also known as AMDA. It’s been revealing for everyone involved.”
He recommends AMDA’s learning modules – which are designed for doctors who are new to long-term care – to any hospitalist who is entering the post-acute world.
References
1. Mor V et al. The revolving door of rehospitalization from skilled nursing facilities. Health Aff (Millwood). 2010 Jan-Feb;29(1):57-64.
2. Brennan N et al. Data Brief: Sharp reduction in avoidable hospitalizations among long-term care facility residents. The CMS Blog, 2017 Jan 17.
3. Burke RE et al. Post-acute care reform: Implications and opportunities for hospitalists. J Hosp Med. 2017 Jan;12(1);46-51.
Starting in 2018, skilled nursing facilities (SNFs), like acute care hospitals before them, will be subject to a penalty of up to 2% of their Medicare reimbursement for posting higher-than-average rates of hospital readmissions.
The Protecting Access to Medicare Act of 2014 established a value-based purchasing component for SNFs, including incentives for high-performing facilities and a measure for all-cause, all-condition readmissions to any hospital from the SNF within 30 days following hospital discharge – designed to recognize and reward, or punish, facilities’ performance on preventing unnecessary readmissions. Public reporting of SNF quality data, including readmission rates, started in October 2017. Penalties follow a year later. Some patients’ readmissions could trigger penalties for both the hospital and the SNF.
According to 2010 data, 23.5% of patients discharged from acute care hospitals to SNFs were readmitted to the hospital within 30 days, at a financial cost of $10,362 per readmission or $4.34 billion per year.1 Seventy eight percent of these readmissions were labeled avoidable. More recent evidence suggests that hospitalization rates for dual-eligible patients living in long-term care facilities decreased by 31% between 2010 and 2015.2As increasing numbers of hospitalists spend some or all of their work week in post-acute care settings, how will the SNF readmission penalty affect their relationships with post-acute facilities?
Experts say SNFs – as with hospitals before them – lack the ability to allocate rewards or penalties for readmission rate performance to individual doctors. But increasingly close collaborative relationships between post-acute facilities and the hospitalists who work in post-acute care mean that the hospitalist has an important role in helping the SNF to manage its readmissions exposure.
“Hospitals and hospitalists want to keep good relationships with the SNFs they partner with, for a variety of reasons,” Dr. Frizner said. “We believe that the best way to reduce readmissions and unplanned transfers from the SNF is for the doctor to know the patient. We need dedicated doctors in the facility. We want hospitalists who already know the patient to come to the facility and see the patient there.”
The hospitalist’s role in post-acute care
Hospitalists who work in post-acute care typically make scheduled, billable medical visits to patients in long-term care facilities, and may also take on roles such as facility medical director or contribute to quality improvement. Relationships may be initiated by a facility seeking more medical coverage, by a hospitalist group seeking additional work or an ability to impact on the post-acute care delivered to hospital patients discharged to the facility, or by health systems, health plans, or accountable care organizations seeking to better manage the quality of care transitions for their beneficiaries.
“What I’m seeing is that with opportunities for bundled payments, we all have new incentives for moving patients along and reducing waste,” Dr. Boutwell said. “For hospitalists practicing in SNFs, it’s going to be a much bigger phenomenon. They’ll be called to reevaluate patients and make more visits than they have been accustomed to.” She hopes SNFs are studying what happened with hospitals’ readmission penalties, and will respond more quickly and effectively to their own penalty exposure.
“What we are seeing is an effort to shift folks to lower cost – but still clinically appropriate – levels of care,” he said. “These dynamics will force SNFs to reevaluate and improve their clinical competencies, to accept patients and then treat them in place. It’s no longer acceptable for the medical director to make rounds in person twice a month and do the rest by telephone.”
Instead, someone needs to be on site several times a week, working with nursing staff and developing protocols and pathways to control variability, Dr. Harrington said. “And in many cases that will be a hospitalist. Hospitalists are finding ways to partner and provide that level of care. I believe good hospitalist groups can change the facility for the better, and fairly quickly.”
What happens in post-acute care
Cari Levy, MD, PhD, who does hospital coverage and post-acute care for a number of facilities and home health agencies in the Denver area, calls the changes coming to SNFs a thrilling time for post-acute care.
“Suddenly medical professionals care about what happens in the post-acute world,” she said. “Everyone is now looking at the same measures. If this works the way it should, there would be a lot more mutual respect between providers.”
SNFs that are concerned about their readmissions rates will want to do root cause analysis to figure out what’s going on, Dr. Levy said. “Maybe the doctor didn’t do a good assessment. Maybe it was just a tough case. Once you start talking, you’ll develop systems to help everyone responsible. Hospitalists can be part of that conversation,” she said.
“You can have a good outcome at Shady Oaks and a terrible outcome at Whispering Pines, for all sorts of reasons. The hospital wants to make sure we’re sending patients to facilities that produce good outcomes,” he explained. “But there has to be communication between providers – the SNF medical director, the hospitalists, and the emergency department.”
A TeamHealth doctor in Phoenix has convened a consortium of providers from different care settings to meet and talk about cases and how they could have gone better. “The reality is, these conversations are going on all over,” Dr. Wilborn said. “What’s driving them is the realization of what we all need to do in this new environment.”
Opportunities from reforms
Robert Burke, MD, FHM, assistant chief of Hospital Medicine at the Denver VA Medical Center, is lead author of a study in the Journal of Hospital Medicine highlighting implications and opportunities from reforms in post-acute care.3 Hospitalists may not appreciate that post-acute care is poised to undergo transformative change from the recently legislated reforms, opening opportunities for hospitalists to improve health care value by improving transitions of care, he noted.
“My sense is that payment reform will put pressure on physicians to use home health care more often than institutional care, because of the cost pressures. We know that hospitalists choose long-term care facility placements less often when participating in bundled payment,” Dr. Burke said. “I think few hospitalists really know what happens on a day-to-day basis in SNFs – or in patients’ homes, for that matter.”
According to Dr. Burke, there’s just not enough data currently to guide these decisions. He said that, based on his research, the best thing hospitalists can do is try to understand what’s available in post-acute spaces, and build relationships with post-acute facilities.
“Find ways to get feedback on your discharge decisions,” he said. “Here in Colorado, we met recently with the local chapter of the Society for Post-Acute and Long-Term Care Medicine, also known as AMDA. It’s been revealing for everyone involved.”
He recommends AMDA’s learning modules – which are designed for doctors who are new to long-term care – to any hospitalist who is entering the post-acute world.
References
1. Mor V et al. The revolving door of rehospitalization from skilled nursing facilities. Health Aff (Millwood). 2010 Jan-Feb;29(1):57-64.
2. Brennan N et al. Data Brief: Sharp reduction in avoidable hospitalizations among long-term care facility residents. The CMS Blog, 2017 Jan 17.
3. Burke RE et al. Post-acute care reform: Implications and opportunities for hospitalists. J Hosp Med. 2017 Jan;12(1);46-51.
Starting in 2018, skilled nursing facilities (SNFs), like acute care hospitals before them, will be subject to a penalty of up to 2% of their Medicare reimbursement for posting higher-than-average rates of hospital readmissions.
The Protecting Access to Medicare Act of 2014 established a value-based purchasing component for SNFs, including incentives for high-performing facilities and a measure for all-cause, all-condition readmissions to any hospital from the SNF within 30 days following hospital discharge – designed to recognize and reward, or punish, facilities’ performance on preventing unnecessary readmissions. Public reporting of SNF quality data, including readmission rates, started in October 2017. Penalties follow a year later. Some patients’ readmissions could trigger penalties for both the hospital and the SNF.
According to 2010 data, 23.5% of patients discharged from acute care hospitals to SNFs were readmitted to the hospital within 30 days, at a financial cost of $10,362 per readmission or $4.34 billion per year.1 Seventy eight percent of these readmissions were labeled avoidable. More recent evidence suggests that hospitalization rates for dual-eligible patients living in long-term care facilities decreased by 31% between 2010 and 2015.2As increasing numbers of hospitalists spend some or all of their work week in post-acute care settings, how will the SNF readmission penalty affect their relationships with post-acute facilities?
Experts say SNFs – as with hospitals before them – lack the ability to allocate rewards or penalties for readmission rate performance to individual doctors. But increasingly close collaborative relationships between post-acute facilities and the hospitalists who work in post-acute care mean that the hospitalist has an important role in helping the SNF to manage its readmissions exposure.
“Hospitals and hospitalists want to keep good relationships with the SNFs they partner with, for a variety of reasons,” Dr. Frizner said. “We believe that the best way to reduce readmissions and unplanned transfers from the SNF is for the doctor to know the patient. We need dedicated doctors in the facility. We want hospitalists who already know the patient to come to the facility and see the patient there.”
The hospitalist’s role in post-acute care
Hospitalists who work in post-acute care typically make scheduled, billable medical visits to patients in long-term care facilities, and may also take on roles such as facility medical director or contribute to quality improvement. Relationships may be initiated by a facility seeking more medical coverage, by a hospitalist group seeking additional work or an ability to impact on the post-acute care delivered to hospital patients discharged to the facility, or by health systems, health plans, or accountable care organizations seeking to better manage the quality of care transitions for their beneficiaries.
“What I’m seeing is that with opportunities for bundled payments, we all have new incentives for moving patients along and reducing waste,” Dr. Boutwell said. “For hospitalists practicing in SNFs, it’s going to be a much bigger phenomenon. They’ll be called to reevaluate patients and make more visits than they have been accustomed to.” She hopes SNFs are studying what happened with hospitals’ readmission penalties, and will respond more quickly and effectively to their own penalty exposure.
“What we are seeing is an effort to shift folks to lower cost – but still clinically appropriate – levels of care,” he said. “These dynamics will force SNFs to reevaluate and improve their clinical competencies, to accept patients and then treat them in place. It’s no longer acceptable for the medical director to make rounds in person twice a month and do the rest by telephone.”
Instead, someone needs to be on site several times a week, working with nursing staff and developing protocols and pathways to control variability, Dr. Harrington said. “And in many cases that will be a hospitalist. Hospitalists are finding ways to partner and provide that level of care. I believe good hospitalist groups can change the facility for the better, and fairly quickly.”
What happens in post-acute care
Cari Levy, MD, PhD, who does hospital coverage and post-acute care for a number of facilities and home health agencies in the Denver area, calls the changes coming to SNFs a thrilling time for post-acute care.
“Suddenly medical professionals care about what happens in the post-acute world,” she said. “Everyone is now looking at the same measures. If this works the way it should, there would be a lot more mutual respect between providers.”
SNFs that are concerned about their readmissions rates will want to do root cause analysis to figure out what’s going on, Dr. Levy said. “Maybe the doctor didn’t do a good assessment. Maybe it was just a tough case. Once you start talking, you’ll develop systems to help everyone responsible. Hospitalists can be part of that conversation,” she said.
“You can have a good outcome at Shady Oaks and a terrible outcome at Whispering Pines, for all sorts of reasons. The hospital wants to make sure we’re sending patients to facilities that produce good outcomes,” he explained. “But there has to be communication between providers – the SNF medical director, the hospitalists, and the emergency department.”
A TeamHealth doctor in Phoenix has convened a consortium of providers from different care settings to meet and talk about cases and how they could have gone better. “The reality is, these conversations are going on all over,” Dr. Wilborn said. “What’s driving them is the realization of what we all need to do in this new environment.”
Opportunities from reforms
Robert Burke, MD, FHM, assistant chief of Hospital Medicine at the Denver VA Medical Center, is lead author of a study in the Journal of Hospital Medicine highlighting implications and opportunities from reforms in post-acute care.3 Hospitalists may not appreciate that post-acute care is poised to undergo transformative change from the recently legislated reforms, opening opportunities for hospitalists to improve health care value by improving transitions of care, he noted.
“My sense is that payment reform will put pressure on physicians to use home health care more often than institutional care, because of the cost pressures. We know that hospitalists choose long-term care facility placements less often when participating in bundled payment,” Dr. Burke said. “I think few hospitalists really know what happens on a day-to-day basis in SNFs – or in patients’ homes, for that matter.”
According to Dr. Burke, there’s just not enough data currently to guide these decisions. He said that, based on his research, the best thing hospitalists can do is try to understand what’s available in post-acute spaces, and build relationships with post-acute facilities.
“Find ways to get feedback on your discharge decisions,” he said. “Here in Colorado, we met recently with the local chapter of the Society for Post-Acute and Long-Term Care Medicine, also known as AMDA. It’s been revealing for everyone involved.”
He recommends AMDA’s learning modules – which are designed for doctors who are new to long-term care – to any hospitalist who is entering the post-acute world.
References
1. Mor V et al. The revolving door of rehospitalization from skilled nursing facilities. Health Aff (Millwood). 2010 Jan-Feb;29(1):57-64.
2. Brennan N et al. Data Brief: Sharp reduction in avoidable hospitalizations among long-term care facility residents. The CMS Blog, 2017 Jan 17.
3. Burke RE et al. Post-acute care reform: Implications and opportunities for hospitalists. J Hosp Med. 2017 Jan;12(1);46-51.