Quality

A paper published in the May/June issue of the Journal of Hospital Medicine shows that a collaborative approach to medication reconciliation ("med rec") appears to both prevent adverse drug events and pay for itself.

The paper, "Nurse-Pharmacist Collaboration on Medication Reconciliation Prevents Potential Harm," found that 225 of 500 surveyed patients had at least one unintended discrepancy in their house medication list (HML) on admission or discharge. And 162 of those patients had a discrepancy ranked on the upper end of the study's risk scale.

However, having nurses and pharmacists work together "allowed many discrepancies to be reconciled before causing harm," the study concluded.

"It absolutely supports the idea that we need to approach medicine as a team game," says hospitalist and lead author Lenny Feldman, MD, FACP, FAAP, SFHM, of John Hopkins School of Medicine in Baltimore. "We can't do this alone, and patients don't do better when we do this alone."

The study noted that it cost $113.64 to find one potentially harmful medication discrepancy. To offset those costs, an institution would have to prevent one discrepancy for every 290 patient encounters. The Johns Hopkins team averted 81 such events, but Dr. Feldman notes that without a control group, it’s difficult to say how many of those potential issues would have been caught at some other point in a patient's stay.

Still, he says, part of the value of a multidisciplinary approach to med rec is that it can help hospitalists improve patient care. By having nurses, physicians, and pharmacists working together, more potential adverse drug events could be prevented, Dr. Feldman says.

"That data-gathering is difficult and time-consuming, and it is not something hospitalists need do on their own," he adds.

A paper published in the May/June issue of the Journal of Hospital Medicine shows that a collaborative approach to medication reconciliation ("med rec") appears to both prevent adverse drug events and pay for itself.

The paper, "Nurse-Pharmacist Collaboration on Medication Reconciliation Prevents Potential Harm," found that 225 of 500 surveyed patients had at least one unintended discrepancy in their house medication list (HML) on admission or discharge. And 162 of those patients had a discrepancy ranked on the upper end of the study's risk scale.

However, having nurses and pharmacists work together "allowed many discrepancies to be reconciled before causing harm," the study concluded.

"It absolutely supports the idea that we need to approach medicine as a team game," says hospitalist and lead author Lenny Feldman, MD, FACP, FAAP, SFHM, of John Hopkins School of Medicine in Baltimore. "We can't do this alone, and patients don't do better when we do this alone."

The study noted that it cost $113.64 to find one potentially harmful medication discrepancy. To offset those costs, an institution would have to prevent one discrepancy for every 290 patient encounters. The Johns Hopkins team averted 81 such events, but Dr. Feldman notes that without a control group, it’s difficult to say how many of those potential issues would have been caught at some other point in a patient's stay.

Still, he says, part of the value of a multidisciplinary approach to med rec is that it can help hospitalists improve patient care. By having nurses, physicians, and pharmacists working together, more potential adverse drug events could be prevented, Dr. Feldman says.

"That data-gathering is difficult and time-consuming, and it is not something hospitalists need do on their own," he adds.

A paper published in the May/June issue of the Journal of Hospital Medicine shows that a collaborative approach to medication reconciliation ("med rec") appears to both prevent adverse drug events and pay for itself.

The paper, "Nurse-Pharmacist Collaboration on Medication Reconciliation Prevents Potential Harm," found that 225 of 500 surveyed patients had at least one unintended discrepancy in their house medication list (HML) on admission or discharge. And 162 of those patients had a discrepancy ranked on the upper end of the study's risk scale.

However, having nurses and pharmacists work together "allowed many discrepancies to be reconciled before causing harm," the study concluded.

"It absolutely supports the idea that we need to approach medicine as a team game," says hospitalist and lead author Lenny Feldman, MD, FACP, FAAP, SFHM, of John Hopkins School of Medicine in Baltimore. "We can't do this alone, and patients don't do better when we do this alone."

The study noted that it cost $113.64 to find one potentially harmful medication discrepancy. To offset those costs, an institution would have to prevent one discrepancy for every 290 patient encounters. The Johns Hopkins team averted 81 such events, but Dr. Feldman notes that without a control group, it’s difficult to say how many of those potential issues would have been caught at some other point in a patient's stay.

Still, he says, part of the value of a multidisciplinary approach to med rec is that it can help hospitalists improve patient care. By having nurses, physicians, and pharmacists working together, more potential adverse drug events could be prevented, Dr. Feldman says.

"That data-gathering is difficult and time-consuming, and it is not something hospitalists need do on their own," he adds.

At first blush, some hospitalists might see it as bad news that a recent report found a pharmacist-assisted medication reconciliation ("med rec") intervention did not significantly reduce clinically important medication errors after discharge. But a deeper reading of the study tells a different story, says a hospitalist who worked on the report.

"This is the latest in our growing understanding of the roles of certain interventions on transitions of care," says Jeffrey Schnipper, MD, MPH, FHM, director of clinical research and an associate physician in the general medicine division at Brigham and Women's Hospitalist Service in Boston, and co-author of the study "Effect of a Pharmacist Intervention on Clinically Important Medication Errors after Hospital Discharge." "What I don't want to have happen is for people to read this article ... and say, 'Oh, pharmacists don't make a difference.' They absolutely make a difference. This is a more nuanced issue of who do they have the biggest impact with, and 'On top of what other interventions are you doing this?'"

The researchers set out to determine whether a pharmacist-delivered intervention on patients with low health literacy (including a post-discharge telephone call) would lower adverse drug events and other clinically important medication errors. They concluded that it did not (unadjusted incidence rate ratio, 0.92 [95% CI, 0.77 to 1.10]).

Dr. Schnipper says the impact was likely muted because the patients studied had higher health-literacy levels than researchers expected. Also, because most follow-up phone calls occurred within a few days of discharge, the intervention failed to capture any events that happened in the 30 days after discharge.

He also notes that the institutions that participated in the study have already implemented multiple med-rec interventions over the past few years. Hospitals that have not focused intently on the issue could find much larger gains from implementing pharmacist-led programs.

"If you're a hospital that has not been fixated on improving medication safety and transitions of care, I think pharmacists are huge," Dr. Schnipper says. "The key, then, is to focus them on the highest-risk patients."

At first blush, some hospitalists might see it as bad news that a recent report found a pharmacist-assisted medication reconciliation ("med rec") intervention did not significantly reduce clinically important medication errors after discharge. But a deeper reading of the study tells a different story, says a hospitalist who worked on the report.

"This is the latest in our growing understanding of the roles of certain interventions on transitions of care," says Jeffrey Schnipper, MD, MPH, FHM, director of clinical research and an associate physician in the general medicine division at Brigham and Women's Hospitalist Service in Boston, and co-author of the study "Effect of a Pharmacist Intervention on Clinically Important Medication Errors after Hospital Discharge." "What I don't want to have happen is for people to read this article ... and say, 'Oh, pharmacists don't make a difference.' They absolutely make a difference. This is a more nuanced issue of who do they have the biggest impact with, and 'On top of what other interventions are you doing this?'"

The researchers set out to determine whether a pharmacist-delivered intervention on patients with low health literacy (including a post-discharge telephone call) would lower adverse drug events and other clinically important medication errors. They concluded that it did not (unadjusted incidence rate ratio, 0.92 [95% CI, 0.77 to 1.10]).

Dr. Schnipper says the impact was likely muted because the patients studied had higher health-literacy levels than researchers expected. Also, because most follow-up phone calls occurred within a few days of discharge, the intervention failed to capture any events that happened in the 30 days after discharge.

He also notes that the institutions that participated in the study have already implemented multiple med-rec interventions over the past few years. Hospitals that have not focused intently on the issue could find much larger gains from implementing pharmacist-led programs.

"If you're a hospital that has not been fixated on improving medication safety and transitions of care, I think pharmacists are huge," Dr. Schnipper says. "The key, then, is to focus them on the highest-risk patients."

At first blush, some hospitalists might see it as bad news that a recent report found a pharmacist-assisted medication reconciliation ("med rec") intervention did not significantly reduce clinically important medication errors after discharge. But a deeper reading of the study tells a different story, says a hospitalist who worked on the report.

"This is the latest in our growing understanding of the roles of certain interventions on transitions of care," says Jeffrey Schnipper, MD, MPH, FHM, director of clinical research and an associate physician in the general medicine division at Brigham and Women's Hospitalist Service in Boston, and co-author of the study "Effect of a Pharmacist Intervention on Clinically Important Medication Errors after Hospital Discharge." "What I don't want to have happen is for people to read this article ... and say, 'Oh, pharmacists don't make a difference.' They absolutely make a difference. This is a more nuanced issue of who do they have the biggest impact with, and 'On top of what other interventions are you doing this?'"

The researchers set out to determine whether a pharmacist-delivered intervention on patients with low health literacy (including a post-discharge telephone call) would lower adverse drug events and other clinically important medication errors. They concluded that it did not (unadjusted incidence rate ratio, 0.92 [95% CI, 0.77 to 1.10]).

Dr. Schnipper says the impact was likely muted because the patients studied had higher health-literacy levels than researchers expected. Also, because most follow-up phone calls occurred within a few days of discharge, the intervention failed to capture any events that happened in the 30 days after discharge.

He also notes that the institutions that participated in the study have already implemented multiple med-rec interventions over the past few years. Hospitals that have not focused intently on the issue could find much larger gains from implementing pharmacist-led programs.

"If you're a hospital that has not been fixated on improving medication safety and transitions of care, I think pharmacists are huge," Dr. Schnipper says. "The key, then, is to focus them on the highest-risk patients."

Although Medicare's looming financial penalties for hospitals with excessive readmissions might seem like a blunt weapon, private health plans often have the flexibility to negotiate with partnering hospitals around incentives for readmissions prevention.

"We have arrangements with private insurance companies where we put at risk future compensation, based on achieving negotiated readmissions results," says Mark Carley, vice president of managed care and network development for Centura Health, a 13-hospital system in Colorado.

Payors, including United Healthcare, have developed their own readmissions programs and reporting mechanisms, although each program’s incentives are a little different, Carley says. Target rates are negotiated based on each hospital's readmissions in the previous 12-month period and national averages. The plan can also provide helpful data on its beneficiaries and other forms of assistance, because it wants to see the hospital hit the target, he adds. "If the target has been set too high, they may be willing to renegotiate."

But the plan doesn't tell the hospital how to reach that target.

"Where the complexity comes in is how we as a system implement internal policies and procedures to improve our care coordination, discharge processes, follow-up, and communication with downstream providers," says Carley. Centura Health's approach to readmissions has included close study of past performance data in search of opportunities for improvement, fine-tuning of the discharge planning process, and follow-up phone calls to patients and providers.

"In addition, we are working with post-acute providers to provide smoother transitions in the discharge process," he says.

Although Medicare's looming financial penalties for hospitals with excessive readmissions might seem like a blunt weapon, private health plans often have the flexibility to negotiate with partnering hospitals around incentives for readmissions prevention.

"We have arrangements with private insurance companies where we put at risk future compensation, based on achieving negotiated readmissions results," says Mark Carley, vice president of managed care and network development for Centura Health, a 13-hospital system in Colorado.

Payors, including United Healthcare, have developed their own readmissions programs and reporting mechanisms, although each program’s incentives are a little different, Carley says. Target rates are negotiated based on each hospital's readmissions in the previous 12-month period and national averages. The plan can also provide helpful data on its beneficiaries and other forms of assistance, because it wants to see the hospital hit the target, he adds. "If the target has been set too high, they may be willing to renegotiate."

But the plan doesn't tell the hospital how to reach that target.

"Where the complexity comes in is how we as a system implement internal policies and procedures to improve our care coordination, discharge processes, follow-up, and communication with downstream providers," says Carley. Centura Health's approach to readmissions has included close study of past performance data in search of opportunities for improvement, fine-tuning of the discharge planning process, and follow-up phone calls to patients and providers.

"In addition, we are working with post-acute providers to provide smoother transitions in the discharge process," he says.

Although Medicare's looming financial penalties for hospitals with excessive readmissions might seem like a blunt weapon, private health plans often have the flexibility to negotiate with partnering hospitals around incentives for readmissions prevention.

"We have arrangements with private insurance companies where we put at risk future compensation, based on achieving negotiated readmissions results," says Mark Carley, vice president of managed care and network development for Centura Health, a 13-hospital system in Colorado.

Payors, including United Healthcare, have developed their own readmissions programs and reporting mechanisms, although each program’s incentives are a little different, Carley says. Target rates are negotiated based on each hospital's readmissions in the previous 12-month period and national averages. The plan can also provide helpful data on its beneficiaries and other forms of assistance, because it wants to see the hospital hit the target, he adds. "If the target has been set too high, they may be willing to renegotiate."

But the plan doesn't tell the hospital how to reach that target.

"Where the complexity comes in is how we as a system implement internal policies and procedures to improve our care coordination, discharge processes, follow-up, and communication with downstream providers," says Carley. Centura Health's approach to readmissions has included close study of past performance data in search of opportunities for improvement, fine-tuning of the discharge planning process, and follow-up phone calls to patients and providers.

"In addition, we are working with post-acute providers to provide smoother transitions in the discharge process," he says.

Clinical question: Can a quality-improvement (QI) collaborative decrease patient identification (ID) band errors?

Background: ID band errors often result in medication errors and unsafe care. Consequently, correct patient identification, through the use of at least two identifiers, has been an ongoing Joint Commission National Patient Safety Goal. Although individual sites have demonstrated improvement in accuracy of patient identification, there have not been reports of dissemination of successful practices.

Study design: Collaborative quality-improvement initiative.

Setting: Six hospitals.

Synopsis: ID band audits in 11,377 patients were performed in the learning collaborative’s six participating hospitals.

The audits were organized primarily around monthly conference calls. The hospital settings were diverse: community hospitals, hospitals within an academic medical center, and freestanding children’s hospitals. The aim of the collaborative was to reduce ID band errors by 50% within a one-year time frame across the collective sites.

Key interventions included transparent data collection and reporting; engagement of staff, families and leadership; voluntary event reporting; and auditing of failures. The mean combined ID band failure rate decreased to 4% from 22% within 13 months, representing a 77% relative reduction (P<0.001).

QI collaboratives are not designed to specifically result in generalizable knowledge, yet they might produce widespread improvement, as this effort demonstrates. The careful documentation of iterative factors implemented across sites in this initiative provides a blueprint for hospitals looking to replicate this success. Additionally, the interventions represent feasible and logical concepts within the basic constructs of improvement science methodology.

Bottom line: A QI collaborative might result in rapid and significant reductions in ID band errors.

Citation: Phillips SC, Saysana M, Worley S, Hain PD. Reduction in pediatric identification band errors: a quality collaborative. Pediatrics. 2012;129(6):e1587-e1593.

Reviewed by Pediatric Editor Mark Shen, MD, SFHM, medical director of hospital medicine at Dell Children's Medical Center, Austin, Texas.

Clinical question: Can a quality-improvement (QI) collaborative decrease patient identification (ID) band errors?

Background: ID band errors often result in medication errors and unsafe care. Consequently, correct patient identification, through the use of at least two identifiers, has been an ongoing Joint Commission National Patient Safety Goal. Although individual sites have demonstrated improvement in accuracy of patient identification, there have not been reports of dissemination of successful practices.

Study design: Collaborative quality-improvement initiative.

Setting: Six hospitals.

Synopsis: ID band audits in 11,377 patients were performed in the learning collaborative’s six participating hospitals.

The audits were organized primarily around monthly conference calls. The hospital settings were diverse: community hospitals, hospitals within an academic medical center, and freestanding children’s hospitals. The aim of the collaborative was to reduce ID band errors by 50% within a one-year time frame across the collective sites.

Key interventions included transparent data collection and reporting; engagement of staff, families and leadership; voluntary event reporting; and auditing of failures. The mean combined ID band failure rate decreased to 4% from 22% within 13 months, representing a 77% relative reduction (P<0.001).

QI collaboratives are not designed to specifically result in generalizable knowledge, yet they might produce widespread improvement, as this effort demonstrates. The careful documentation of iterative factors implemented across sites in this initiative provides a blueprint for hospitals looking to replicate this success. Additionally, the interventions represent feasible and logical concepts within the basic constructs of improvement science methodology.

Bottom line: A QI collaborative might result in rapid and significant reductions in ID band errors.

Citation: Phillips SC, Saysana M, Worley S, Hain PD. Reduction in pediatric identification band errors: a quality collaborative. Pediatrics. 2012;129(6):e1587-e1593.

Reviewed by Pediatric Editor Mark Shen, MD, SFHM, medical director of hospital medicine at Dell Children's Medical Center, Austin, Texas.

Clinical question: Can a quality-improvement (QI) collaborative decrease patient identification (ID) band errors?

Background: ID band errors often result in medication errors and unsafe care. Consequently, correct patient identification, through the use of at least two identifiers, has been an ongoing Joint Commission National Patient Safety Goal. Although individual sites have demonstrated improvement in accuracy of patient identification, there have not been reports of dissemination of successful practices.

Study design: Collaborative quality-improvement initiative.

Setting: Six hospitals.

Synopsis: ID band audits in 11,377 patients were performed in the learning collaborative’s six participating hospitals.

The audits were organized primarily around monthly conference calls. The hospital settings were diverse: community hospitals, hospitals within an academic medical center, and freestanding children’s hospitals. The aim of the collaborative was to reduce ID band errors by 50% within a one-year time frame across the collective sites.

Key interventions included transparent data collection and reporting; engagement of staff, families and leadership; voluntary event reporting; and auditing of failures. The mean combined ID band failure rate decreased to 4% from 22% within 13 months, representing a 77% relative reduction (P<0.001).

QI collaboratives are not designed to specifically result in generalizable knowledge, yet they might produce widespread improvement, as this effort demonstrates. The careful documentation of iterative factors implemented across sites in this initiative provides a blueprint for hospitals looking to replicate this success. Additionally, the interventions represent feasible and logical concepts within the basic constructs of improvement science methodology.

Bottom line: A QI collaborative might result in rapid and significant reductions in ID band errors.

Citation: Phillips SC, Saysana M, Worley S, Hain PD. Reduction in pediatric identification band errors: a quality collaborative. Pediatrics. 2012;129(6):e1587-e1593.

Reviewed by Pediatric Editor Mark Shen, MD, SFHM, medical director of hospital medicine at Dell Children's Medical Center, Austin, Texas.

More than 100 hospitals across the country have used Project BOOST to reduce readmissions and improve their discharge processes. You and your hospital can be next by applying for Project BOOST. The deadline for the next national cohort of Project BOOST is Sept. 1.

To improve your chances of acceptance, start soon. In addition to an online form, the application requires a letter of support from an executive sponsor from each institution.

In October, accepted Project BOOST sites will receive:

• A comprehensive intervention developed by a panel of nationally recognized experts based on the best available evidence;
• A comprehensive implementation guide that provides step-by-step instructions and project management tools, such as the “teachback” training curriculum, to help interdisciplinary teams redesign work flow and plan, implement, and evaluate the intervention;
• Longitudinal technical assistance that provides face-to-face training and a year of expert mentoring and coaching to implement BOOST interventions that build a culture that supports safe and complete transitions. The mentoring program provides a “train-the-trainer” DVD and curriculum for nurses and case managers on using the teachback process, and webinars targeting the educational needs of other team members, including administrators, data analysts, physicians, nurses; and others;
• A collaboration that allows sites to communicate with and learn from each other via the BOOST listserv, BOOST community site, and quarterly all-site teleconferences and webinars; and
• Access to the BOOST data center, an online resource center that allows sites to store and benchmark data against control units and other sites and generate reports.

To start the application process, visit www.hospitalmedicine.org/boost.

Brendon Shank is SHM’s associate vice president for communications.

More than 100 hospitals across the country have used Project BOOST to reduce readmissions and improve their discharge processes. You and your hospital can be next by applying for Project BOOST. The deadline for the next national cohort of Project BOOST is Sept. 1.

To improve your chances of acceptance, start soon. In addition to an online form, the application requires a letter of support from an executive sponsor from each institution.

In October, accepted Project BOOST sites will receive:

• A comprehensive intervention developed by a panel of nationally recognized experts based on the best available evidence;
• A comprehensive implementation guide that provides step-by-step instructions and project management tools, such as the “teachback” training curriculum, to help interdisciplinary teams redesign work flow and plan, implement, and evaluate the intervention;
• Longitudinal technical assistance that provides face-to-face training and a year of expert mentoring and coaching to implement BOOST interventions that build a culture that supports safe and complete transitions. The mentoring program provides a “train-the-trainer” DVD and curriculum for nurses and case managers on using the teachback process, and webinars targeting the educational needs of other team members, including administrators, data analysts, physicians, nurses; and others;
• A collaboration that allows sites to communicate with and learn from each other via the BOOST listserv, BOOST community site, and quarterly all-site teleconferences and webinars; and
• Access to the BOOST data center, an online resource center that allows sites to store and benchmark data against control units and other sites and generate reports.

To start the application process, visit www.hospitalmedicine.org/boost.

Brendon Shank is SHM’s associate vice president for communications.

More than 100 hospitals across the country have used Project BOOST to reduce readmissions and improve their discharge processes. You and your hospital can be next by applying for Project BOOST. The deadline for the next national cohort of Project BOOST is Sept. 1.

To improve your chances of acceptance, start soon. In addition to an online form, the application requires a letter of support from an executive sponsor from each institution.

In October, accepted Project BOOST sites will receive:

• A comprehensive intervention developed by a panel of nationally recognized experts based on the best available evidence;
• A comprehensive implementation guide that provides step-by-step instructions and project management tools, such as the “teachback” training curriculum, to help interdisciplinary teams redesign work flow and plan, implement, and evaluate the intervention;
• Longitudinal technical assistance that provides face-to-face training and a year of expert mentoring and coaching to implement BOOST interventions that build a culture that supports safe and complete transitions. The mentoring program provides a “train-the-trainer” DVD and curriculum for nurses and case managers on using the teachback process, and webinars targeting the educational needs of other team members, including administrators, data analysts, physicians, nurses; and others;
• A collaboration that allows sites to communicate with and learn from each other via the BOOST listserv, BOOST community site, and quarterly all-site teleconferences and webinars; and
• Access to the BOOST data center, an online resource center that allows sites to store and benchmark data against control units and other sites and generate reports.

To start the application process, visit www.hospitalmedicine.org/boost.

Brendon Shank is SHM’s associate vice president for communications.

We need to be focused more on measures that encourage joint responsibility and cooperation among providers, and are important to patients across hospital, post-acute, and ambulatory settings.

—Thomas B. Valuck, MD, JD, senior vice president of strategic partnerships, National Quality Forum, former CMS adviser

No longer content to be a passive purchaser of healthcare services, the Centers for Medicare & Medicaid Services (CMS) is becoming a savvier shopper, holding providers increasingly accountable for the quality and efficiency of the care they deliver. With its value-based purchasing (VPB) program for hospitals already in place, now it’s the physicians’ turn.

CMS is marching toward a value-based payment modifier program that will adjust physician reimbursement based on the relative quality and efficiency of care that physicians provide to Medicare fee-for-service patients. The program will begin January 2015 and will extend to all physicians in 2017. Like the hospital VBP program, it will be budget-neutral—meaning that payment will increase for some physicians but decrease for others.

The coming months mark a pivotal period for physicians as CMS tweaks its accountability apparatus in ways that will determine how reimbursement will rise and fall, for whom, and for what.

Menu of Metrics

In crafting the payment modifier program, CMS can tap performance metrics from several of its existing programs, including the Physician Quality Reporting System (PQRS), the soon-to-be-expanded Physician Compare website (www.medicare.gov/find-a-doctor/provider-search.aspx), and the Physician Feedback Program.

“These agendas are part of a continuum, and of equal importance, in the evolution toward physician value-based purchasing,” says Patrick J. Torcson, MD, MMM, FACP, SFHM, chair of SHM’s Performance Measurement and Reporting Committee, and director of hospital medicine at St. Tammany Parish Hospital in Covington, La.

PQRS began as a voluntary “pay for reporting” system that gave physicians a modest financial bonus (currently 0.5% of allowable Medicare charges) for submitting quality data (left). The Affordable Care Act (ACA) has since authorized CMS to penalize physicians who do not participate—1.5% of allowable Medicare charges beginning in 2015, and 2% in 2016.

The Physician Compare website, launched at the end of 2010, currently contains such rudimentary information as education, gender, and whether a physician is enrolled in Medicare and satisfactorily reports data to the PQRS. But as of January, the site will begin reporting some PQRS data, as well as other metrics.

CMS’ Physician Feedback Program provides quality and cost information to physicians in an effort to encourage them to improve the care they provide and its efficiency. CMS recently combined the program with its value-based payment modifier program as it moves toward physician reimbursement that it says will reward “value rather than volume.” The program, currently being piloted in Iowa, Nebraska, Kansas, and Missouri, issues to physicians confidential quality and resource use reports (QRURs) that compare their performance to peer groups in similar specialties by tracking PQRS results, Healthcare Effectiveness Data and Information Set (HEDIS) measures, and per-capita cost data and preventable hospital admission rates for various medical conditions. CMS will roll out the program nationwide next year.

Metrics Lack Relevance

Developing performance measures that capture the most relevant activities of physicians across many different specialties with equal validity is notoriously difficult—something that CMS acknowledges.¹

Assigning the right patient to the right physician (i.e. figuring out who contributed what care, in what proportion, to which patient) also is fraught with complications, especially in the inpatient care setting, where a patient is likely to see many different physicians during a hospitalization.

SHM president Shaun Frost, MD, SFHM, highlighted these challenges in a letter sent in May to acting CMS administrator Marilyn B. Tavenner in which he pointed to dramatic data deficiencies in the initial round of QRURs sent to Physician Feedback Program participants that included hospitalists in Iowa, Nebraska, Kansas and Missouri. Because hospitalists were categorized as general internal-medicine physicians in the reports, their per-capita cost of care was dramatically higher (73% higher, in one case study) than the average cost of all internal-medicine physicians. No allowance was made for distinguishing the outpatient-oriented practice of a general internist from the inherently more expensive inpatient-focused hospitalist practice.

In the case study reviewed by SHM, the hospitalist’s patients saw, on average, 28 different physicians over the course of a year, during which the hospitalist contributed to the care of many patients but did not direct the care of any one of them—facts that clearly highlight the difficulty of assigning responsibility and accountability for a patient’s care when comparing physician performance.

“Based on the measurement used in the QRUR, it seems likely that a hospitalist would be severely disadvantaged with the introduction of a value-based modifier based on the present QRUR methodology,” Dr. Frost wrote.

SHM is similarly critical of the PQRS measures, which Dr. Torcson says lack relevance to hospitalist practices. “We want to be defined as HM physicians with our own unique measures of quality and cost,” he says. “Our results will look very different from those of an internist with a primarily outpatient practice.”

Dr. Torcson notes that SHM is an active participant in providing feedback during CMS rule proposals and has offered to work with the CMS on further refining the measures. For example, SHM proposed adding additional measures related to care transitions, given their particular relevance to hospitalist practices.

Rule-Changing Reform

The disruptive innovation of CMS’ healthcare reform agenda might wind up being a game-changer that dramatically affects the contours of all provider performance reporting and incentive systems, redefining the issues of physician accountability and patient assignment.

“We’re going to need to figure out how to restructure our measurement systems to match our evolving healthcare delivery and payment systems,” says Thomas B. Valuck, MD, JD, senior vice president of strategic partnerships for the National Quality Forum and former CMS adviser to the VBP program. Healthcare quality reporting should focus more on measures that cut across care contexts and assess whether the care provided truly made a difference for patients—metrics such as health improvement, return to functional status, level of patient involvement in the management of their care, provider team coordination, and other patient needs and preferences, Dr. Valuck believes.

“We need to be focused more on measures that encourage joint responsibility and cooperation among providers, and are important to patients across hospital, post-acute, and ambulatory settings, rather than those that are compartmentalized to one setting or relevant only to specific diseases or subspecialties,” Dr. Valuck says.

Such measure sets, while still retaining some disease- and physician-specific metrics, ideally would be complementary with families of related measures at the community, state, and national levels, Dr. Valuck says. “Such a multidimensional framework can begin to tell a meaningful story about what’s happening to the patient, and how well our system is delivering the right care,” he adds.

Dr. Torcson says HM has a pioneering role to play in this evolution, and he notes that SHM has proposed that CMS harmonize measures that align hospital-based physician activities (e.g. hospital medicine, emergency medicine, anesthesia, radiology) with hospital-level performance agendas so that physicians practicing together in the hospital setting can report on measures that are relevant to both.

Christopher Guadagnino is a freelance medical writer in Philadelphia.

Reference

1. Centers for Medicare & Medicaid Services. Physician Quality Reporting System Town Hall Meeting. Available at: http://www.usqualitymeasures.org/shared/content/C4M_PQRS_transcript.pdf. Accessed July 3, 2012.

We need to be focused more on measures that encourage joint responsibility and cooperation among providers, and are important to patients across hospital, post-acute, and ambulatory settings.

—Thomas B. Valuck, MD, JD, senior vice president of strategic partnerships, National Quality Forum, former CMS adviser

No longer content to be a passive purchaser of healthcare services, the Centers for Medicare & Medicaid Services (CMS) is becoming a savvier shopper, holding providers increasingly accountable for the quality and efficiency of the care they deliver. With its value-based purchasing (VPB) program for hospitals already in place, now it’s the physicians’ turn.

CMS is marching toward a value-based payment modifier program that will adjust physician reimbursement based on the relative quality and efficiency of care that physicians provide to Medicare fee-for-service patients. The program will begin January 2015 and will extend to all physicians in 2017. Like the hospital VBP program, it will be budget-neutral—meaning that payment will increase for some physicians but decrease for others.

The coming months mark a pivotal period for physicians as CMS tweaks its accountability apparatus in ways that will determine how reimbursement will rise and fall, for whom, and for what.

Menu of Metrics

In crafting the payment modifier program, CMS can tap performance metrics from several of its existing programs, including the Physician Quality Reporting System (PQRS), the soon-to-be-expanded Physician Compare website (www.medicare.gov/find-a-doctor/provider-search.aspx), and the Physician Feedback Program.

“These agendas are part of a continuum, and of equal importance, in the evolution toward physician value-based purchasing,” says Patrick J. Torcson, MD, MMM, FACP, SFHM, chair of SHM’s Performance Measurement and Reporting Committee, and director of hospital medicine at St. Tammany Parish Hospital in Covington, La.

PQRS began as a voluntary “pay for reporting” system that gave physicians a modest financial bonus (currently 0.5% of allowable Medicare charges) for submitting quality data (left). The Affordable Care Act (ACA) has since authorized CMS to penalize physicians who do not participate—1.5% of allowable Medicare charges beginning in 2015, and 2% in 2016.

The Physician Compare website, launched at the end of 2010, currently contains such rudimentary information as education, gender, and whether a physician is enrolled in Medicare and satisfactorily reports data to the PQRS. But as of January, the site will begin reporting some PQRS data, as well as other metrics.

CMS’ Physician Feedback Program provides quality and cost information to physicians in an effort to encourage them to improve the care they provide and its efficiency. CMS recently combined the program with its value-based payment modifier program as it moves toward physician reimbursement that it says will reward “value rather than volume.” The program, currently being piloted in Iowa, Nebraska, Kansas, and Missouri, issues to physicians confidential quality and resource use reports (QRURs) that compare their performance to peer groups in similar specialties by tracking PQRS results, Healthcare Effectiveness Data and Information Set (HEDIS) measures, and per-capita cost data and preventable hospital admission rates for various medical conditions. CMS will roll out the program nationwide next year.

Metrics Lack Relevance

Developing performance measures that capture the most relevant activities of physicians across many different specialties with equal validity is notoriously difficult—something that CMS acknowledges.¹

Assigning the right patient to the right physician (i.e. figuring out who contributed what care, in what proportion, to which patient) also is fraught with complications, especially in the inpatient care setting, where a patient is likely to see many different physicians during a hospitalization.

SHM president Shaun Frost, MD, SFHM, highlighted these challenges in a letter sent in May to acting CMS administrator Marilyn B. Tavenner in which he pointed to dramatic data deficiencies in the initial round of QRURs sent to Physician Feedback Program participants that included hospitalists in Iowa, Nebraska, Kansas and Missouri. Because hospitalists were categorized as general internal-medicine physicians in the reports, their per-capita cost of care was dramatically higher (73% higher, in one case study) than the average cost of all internal-medicine physicians. No allowance was made for distinguishing the outpatient-oriented practice of a general internist from the inherently more expensive inpatient-focused hospitalist practice.

In the case study reviewed by SHM, the hospitalist’s patients saw, on average, 28 different physicians over the course of a year, during which the hospitalist contributed to the care of many patients but did not direct the care of any one of them—facts that clearly highlight the difficulty of assigning responsibility and accountability for a patient’s care when comparing physician performance.

“Based on the measurement used in the QRUR, it seems likely that a hospitalist would be severely disadvantaged with the introduction of a value-based modifier based on the present QRUR methodology,” Dr. Frost wrote.

SHM is similarly critical of the PQRS measures, which Dr. Torcson says lack relevance to hospitalist practices. “We want to be defined as HM physicians with our own unique measures of quality and cost,” he says. “Our results will look very different from those of an internist with a primarily outpatient practice.”

Dr. Torcson notes that SHM is an active participant in providing feedback during CMS rule proposals and has offered to work with the CMS on further refining the measures. For example, SHM proposed adding additional measures related to care transitions, given their particular relevance to hospitalist practices.

Rule-Changing Reform

The disruptive innovation of CMS’ healthcare reform agenda might wind up being a game-changer that dramatically affects the contours of all provider performance reporting and incentive systems, redefining the issues of physician accountability and patient assignment.

“We’re going to need to figure out how to restructure our measurement systems to match our evolving healthcare delivery and payment systems,” says Thomas B. Valuck, MD, JD, senior vice president of strategic partnerships for the National Quality Forum and former CMS adviser to the VBP program. Healthcare quality reporting should focus more on measures that cut across care contexts and assess whether the care provided truly made a difference for patients—metrics such as health improvement, return to functional status, level of patient involvement in the management of their care, provider team coordination, and other patient needs and preferences, Dr. Valuck believes.

“We need to be focused more on measures that encourage joint responsibility and cooperation among providers, and are important to patients across hospital, post-acute, and ambulatory settings, rather than those that are compartmentalized to one setting or relevant only to specific diseases or subspecialties,” Dr. Valuck says.

Such measure sets, while still retaining some disease- and physician-specific metrics, ideally would be complementary with families of related measures at the community, state, and national levels, Dr. Valuck says. “Such a multidimensional framework can begin to tell a meaningful story about what’s happening to the patient, and how well our system is delivering the right care,” he adds.

Dr. Torcson says HM has a pioneering role to play in this evolution, and he notes that SHM has proposed that CMS harmonize measures that align hospital-based physician activities (e.g. hospital medicine, emergency medicine, anesthesia, radiology) with hospital-level performance agendas so that physicians practicing together in the hospital setting can report on measures that are relevant to both.

Christopher Guadagnino is a freelance medical writer in Philadelphia.

Reference

1. Centers for Medicare & Medicaid Services. Physician Quality Reporting System Town Hall Meeting. Available at: http://www.usqualitymeasures.org/shared/content/C4M_PQRS_transcript.pdf. Accessed July 3, 2012.

We need to be focused more on measures that encourage joint responsibility and cooperation among providers, and are important to patients across hospital, post-acute, and ambulatory settings.

—Thomas B. Valuck, MD, JD, senior vice president of strategic partnerships, National Quality Forum, former CMS adviser

No longer content to be a passive purchaser of healthcare services, the Centers for Medicare & Medicaid Services (CMS) is becoming a savvier shopper, holding providers increasingly accountable for the quality and efficiency of the care they deliver. With its value-based purchasing (VPB) program for hospitals already in place, now it’s the physicians’ turn.

CMS is marching toward a value-based payment modifier program that will adjust physician reimbursement based on the relative quality and efficiency of care that physicians provide to Medicare fee-for-service patients. The program will begin January 2015 and will extend to all physicians in 2017. Like the hospital VBP program, it will be budget-neutral—meaning that payment will increase for some physicians but decrease for others.

The coming months mark a pivotal period for physicians as CMS tweaks its accountability apparatus in ways that will determine how reimbursement will rise and fall, for whom, and for what.

Menu of Metrics

In crafting the payment modifier program, CMS can tap performance metrics from several of its existing programs, including the Physician Quality Reporting System (PQRS), the soon-to-be-expanded Physician Compare website (www.medicare.gov/find-a-doctor/provider-search.aspx), and the Physician Feedback Program.

“These agendas are part of a continuum, and of equal importance, in the evolution toward physician value-based purchasing,” says Patrick J. Torcson, MD, MMM, FACP, SFHM, chair of SHM’s Performance Measurement and Reporting Committee, and director of hospital medicine at St. Tammany Parish Hospital in Covington, La.

PQRS began as a voluntary “pay for reporting” system that gave physicians a modest financial bonus (currently 0.5% of allowable Medicare charges) for submitting quality data (left). The Affordable Care Act (ACA) has since authorized CMS to penalize physicians who do not participate—1.5% of allowable Medicare charges beginning in 2015, and 2% in 2016.

The Physician Compare website, launched at the end of 2010, currently contains such rudimentary information as education, gender, and whether a physician is enrolled in Medicare and satisfactorily reports data to the PQRS. But as of January, the site will begin reporting some PQRS data, as well as other metrics.

CMS’ Physician Feedback Program provides quality and cost information to physicians in an effort to encourage them to improve the care they provide and its efficiency. CMS recently combined the program with its value-based payment modifier program as it moves toward physician reimbursement that it says will reward “value rather than volume.” The program, currently being piloted in Iowa, Nebraska, Kansas, and Missouri, issues to physicians confidential quality and resource use reports (QRURs) that compare their performance to peer groups in similar specialties by tracking PQRS results, Healthcare Effectiveness Data and Information Set (HEDIS) measures, and per-capita cost data and preventable hospital admission rates for various medical conditions. CMS will roll out the program nationwide next year.

Metrics Lack Relevance

Developing performance measures that capture the most relevant activities of physicians across many different specialties with equal validity is notoriously difficult—something that CMS acknowledges.¹

Assigning the right patient to the right physician (i.e. figuring out who contributed what care, in what proportion, to which patient) also is fraught with complications, especially in the inpatient care setting, where a patient is likely to see many different physicians during a hospitalization.

SHM president Shaun Frost, MD, SFHM, highlighted these challenges in a letter sent in May to acting CMS administrator Marilyn B. Tavenner in which he pointed to dramatic data deficiencies in the initial round of QRURs sent to Physician Feedback Program participants that included hospitalists in Iowa, Nebraska, Kansas and Missouri. Because hospitalists were categorized as general internal-medicine physicians in the reports, their per-capita cost of care was dramatically higher (73% higher, in one case study) than the average cost of all internal-medicine physicians. No allowance was made for distinguishing the outpatient-oriented practice of a general internist from the inherently more expensive inpatient-focused hospitalist practice.

In the case study reviewed by SHM, the hospitalist’s patients saw, on average, 28 different physicians over the course of a year, during which the hospitalist contributed to the care of many patients but did not direct the care of any one of them—facts that clearly highlight the difficulty of assigning responsibility and accountability for a patient’s care when comparing physician performance.

“Based on the measurement used in the QRUR, it seems likely that a hospitalist would be severely disadvantaged with the introduction of a value-based modifier based on the present QRUR methodology,” Dr. Frost wrote.

SHM is similarly critical of the PQRS measures, which Dr. Torcson says lack relevance to hospitalist practices. “We want to be defined as HM physicians with our own unique measures of quality and cost,” he says. “Our results will look very different from those of an internist with a primarily outpatient practice.”

Dr. Torcson notes that SHM is an active participant in providing feedback during CMS rule proposals and has offered to work with the CMS on further refining the measures. For example, SHM proposed adding additional measures related to care transitions, given their particular relevance to hospitalist practices.

Rule-Changing Reform

The disruptive innovation of CMS’ healthcare reform agenda might wind up being a game-changer that dramatically affects the contours of all provider performance reporting and incentive systems, redefining the issues of physician accountability and patient assignment.

“We’re going to need to figure out how to restructure our measurement systems to match our evolving healthcare delivery and payment systems,” says Thomas B. Valuck, MD, JD, senior vice president of strategic partnerships for the National Quality Forum and former CMS adviser to the VBP program. Healthcare quality reporting should focus more on measures that cut across care contexts and assess whether the care provided truly made a difference for patients—metrics such as health improvement, return to functional status, level of patient involvement in the management of their care, provider team coordination, and other patient needs and preferences, Dr. Valuck believes.

“We need to be focused more on measures that encourage joint responsibility and cooperation among providers, and are important to patients across hospital, post-acute, and ambulatory settings, rather than those that are compartmentalized to one setting or relevant only to specific diseases or subspecialties,” Dr. Valuck says.

Such measure sets, while still retaining some disease- and physician-specific metrics, ideally would be complementary with families of related measures at the community, state, and national levels, Dr. Valuck says. “Such a multidimensional framework can begin to tell a meaningful story about what’s happening to the patient, and how well our system is delivering the right care,” he adds.

Dr. Torcson says HM has a pioneering role to play in this evolution, and he notes that SHM has proposed that CMS harmonize measures that align hospital-based physician activities (e.g. hospital medicine, emergency medicine, anesthesia, radiology) with hospital-level performance agendas so that physicians practicing together in the hospital setting can report on measures that are relevant to both.

Christopher Guadagnino is a freelance medical writer in Philadelphia.

Reference

1. Centers for Medicare & Medicaid Services. Physician Quality Reporting System Town Hall Meeting. Available at: http://www.usqualitymeasures.org/shared/content/C4M_PQRS_transcript.pdf. Accessed July 3, 2012.

Hospitalists often are involved in the postoperative care of the surgical patient. However, HM is emerging in the admitting/attending role for procedural patients. Confusion can arise as to the nature of the hospitalist service, and whether it is deemed billable. Knowing the surgical package requirements can help hospitalists consider the issues.

Global Surgical Package Period¹

Surgical procedures, categorized as major or minor surgery, are reimbursed for pre-, intra-, and postoperative care. Postoperative care varies according to the procedure’s assigned global period, which designates zero, 10, or 90 postoperative days. (Physicians can review the global period for any given CPT code in the Medicare Physician Fee Schedule, available at www.cms.gov/apps/physician-fee-schedule/search/search-criteria.aspx.)

Services classified with “XXX” do not have the global period concept. “ZZZ” services denote an “add-on” procedure code that must always be reported with a primary procedure code and assumes the global period assigned to the primary procedure performed.

Major surgery allocates a 90-day global period in which the surgeon is responsible for all related surgical care one day before surgery through 90 postoperative days with no additional charge. Minor surgery, including endoscopy, appoints a zero-day or 10-day postoperative period. The zero-day global period encompasses only services provided on the surgical day, whereas 10-day global periods include services on the surgical day through 10 postoperative days.

Global Surgical Package Components²

The global surgical package comprises a host of responsibilities that include standard facility requirements of filling out all necessary paperwork involved in surgical cases (e.g. preoperative H&P, operative consent forms, preoperative orders). Additionally, the surgeon’s packaged payment includes (at no extra charge):

• Preoperative visits after making the decision for surgery beginning one day prior to surgery;
• All additional postoperative medical or surgical services provided by the surgeon related to complications but not requiring additional trips to the operating room;
• Postoperative visits by the surgeon related to recovery from surgery, including but not limited to dressing changes; local incisional care; removal of cutaneous sutures and staples; line removals; changes and removal of tracheostomy tubes; and discharge services; and
• Postoperative pain management provided by the surgeon.
• Examples of services that are not included in the global surgical package, (i.e. are separately billable and may require an appropriate modifier) are:
• The initial consultation or evaluation of the problem by the surgeon to determine the need for surgery;
• Services of other physicians except where the other physicians are providing coverage for the surgeon or agree on a transfer of care (i.e. a formal agreement in the form of a letter or an annotation in the discharge summary, hospital record, or ASC record);
• Postoperative visits by the surgeon unrelated to the diagnosis for which the surgical procedure is performed, unless the visits occur due to complications of the surgery;
• Diagnostic tests and procedures, including diagnostic radiological procedures;
• Clearly distinct surgical procedures during the postoperative period that do not result in repeat operations or treatment for complications;
• Treatment for postoperative complications that requires a return trip to the operating room (OR), catheterization lab or endoscopy suite;
• Immunosuppressive therapy for organ transplants; and
• Critical-care services (CPT codes 99291 and 99292) unrelated to the surgery where a seriously injured or burned patient is critically ill and requires constant attendance of the surgeon.

Classification of “Surgeon”

For billing purposes, the “surgeon” is a qualified physician who can perform “surgical” services within their scope of practice. All physicians with the same specialty designation in the same group practice as the “surgeon” (i.e. reporting services under the same tax identification number) are considered a single entity and must adhere to the global period billing rules initiated by the “surgeon.”

Alternately, physicians with different specialty designations in the same group practice (e.g. a hospitalist and a cardiologist in a multispecialty group who report services under the same tax identification number) or different group practices can perform and separately report medically necessary services during the surgeon’s global period, as long as a formal (mutually agreed-upon) transfer of care did not occur.

Medical Necessity

With the growth of HM programs and the admission/attending role expansion, involvement in surgical cases comes under scrutiny for medical necessity. Admitting a patient who has active medical conditions (e.g. hypertension, diabetes, emphysema) is reasonable and necessary because the patient has a well-defined need for medical management by the hospitalist. Participation in the care of these patients is separately billable from the surgeon’s global period package.

Alternatively, a hospitalist might be required to admit and follow surgical patients who have no other identifiable chronic or acute conditions aside from the surgical problem. In these cases, hospitalist involvement may satisfy facility policy (quality of care, risk reduction, etc.) and administrative functions (discharge services or coordination of care) rather than active clinical management. This “medical management” will not be considered “medically necessary” by the payor, and may be denied as incidental to the surgeon’s perioperative services. Erroneous payment can occur, which will result in refund requests, as payors do not want to pay twice for duplicate services. Hospitalists can attempt to negotiate other terms with facilities to account for the unpaid time and effort directed toward these types of cases.

Consider the Case

A patient with numerous medical comorbidities is admitted to the hospitalist service for stabilization prior to surgery, which will occur the next day. The hospitalist can report the appropriate admission code (99221-99223) without need for modifiers because the hospitalist is the attending of record and in a different specialty group. If a private insurer denies the claim as inclusive to the surgical service, the hospitalist can appeal with notes and a cover letter, along with the Medicare guidelines for global surgical package. The hospitalist may continue to provide postoperative daily care, as needed, to manage the patient’s chronic conditions, and report each service as subsequent hospital care (99231-99233) without modifier until the day of discharge (99238-99239). Again, if a payor issues a denial (inclusive to surgery), appealing with notes might be necessary.

Carol Pohlig is a billing and coding expert with the University of Pennsylvania Medical Center, Philadelphia. She is faculty for SHM’s inpatient coding course.

References

1. Centers for Medicare & Medicaid Services. Medicare Claims Processing Manual: Chapter 12, Section 40. Centers for Medicare & Medicaid Services website. Available at: http://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/clm104c12.pdf. Accessed May 5, 2012.
2. Centers for Medicare & Medicaid Services. ICD-10: HHS proposes one-year delay of ICD-10 compliance date. Centers for Medicare & Medicaid Services website. Available at: http://www.cms.gov/Medicare/Coding/ICD10/index.html?redirect=/ICD10. Accessed May 5, 2012.
3. Abraham M, Ahlman J, Anderson C, Boudreau A, Connelly J. Current Procedural Terminology 2012 Professional Edition. Chicago: American Medical Association Press; 2011.

Hospitalists often are involved in the postoperative care of the surgical patient. However, HM is emerging in the admitting/attending role for procedural patients. Confusion can arise as to the nature of the hospitalist service, and whether it is deemed billable. Knowing the surgical package requirements can help hospitalists consider the issues.

Global Surgical Package Period¹

Surgical procedures, categorized as major or minor surgery, are reimbursed for pre-, intra-, and postoperative care. Postoperative care varies according to the procedure’s assigned global period, which designates zero, 10, or 90 postoperative days. (Physicians can review the global period for any given CPT code in the Medicare Physician Fee Schedule, available at www.cms.gov/apps/physician-fee-schedule/search/search-criteria.aspx.)

Services classified with “XXX” do not have the global period concept. “ZZZ” services denote an “add-on” procedure code that must always be reported with a primary procedure code and assumes the global period assigned to the primary procedure performed.

Major surgery allocates a 90-day global period in which the surgeon is responsible for all related surgical care one day before surgery through 90 postoperative days with no additional charge. Minor surgery, including endoscopy, appoints a zero-day or 10-day postoperative period. The zero-day global period encompasses only services provided on the surgical day, whereas 10-day global periods include services on the surgical day through 10 postoperative days.

Global Surgical Package Components²

The global surgical package comprises a host of responsibilities that include standard facility requirements of filling out all necessary paperwork involved in surgical cases (e.g. preoperative H&P, operative consent forms, preoperative orders). Additionally, the surgeon’s packaged payment includes (at no extra charge):

• Preoperative visits after making the decision for surgery beginning one day prior to surgery;
• All additional postoperative medical or surgical services provided by the surgeon related to complications but not requiring additional trips to the operating room;
• Postoperative visits by the surgeon related to recovery from surgery, including but not limited to dressing changes; local incisional care; removal of cutaneous sutures and staples; line removals; changes and removal of tracheostomy tubes; and discharge services; and
• Postoperative pain management provided by the surgeon.
• Examples of services that are not included in the global surgical package, (i.e. are separately billable and may require an appropriate modifier) are:
• The initial consultation or evaluation of the problem by the surgeon to determine the need for surgery;
• Services of other physicians except where the other physicians are providing coverage for the surgeon or agree on a transfer of care (i.e. a formal agreement in the form of a letter or an annotation in the discharge summary, hospital record, or ASC record);
• Postoperative visits by the surgeon unrelated to the diagnosis for which the surgical procedure is performed, unless the visits occur due to complications of the surgery;
• Diagnostic tests and procedures, including diagnostic radiological procedures;
• Clearly distinct surgical procedures during the postoperative period that do not result in repeat operations or treatment for complications;
• Treatment for postoperative complications that requires a return trip to the operating room (OR), catheterization lab or endoscopy suite;
• Immunosuppressive therapy for organ transplants; and
• Critical-care services (CPT codes 99291 and 99292) unrelated to the surgery where a seriously injured or burned patient is critically ill and requires constant attendance of the surgeon.

Classification of “Surgeon”

For billing purposes, the “surgeon” is a qualified physician who can perform “surgical” services within their scope of practice. All physicians with the same specialty designation in the same group practice as the “surgeon” (i.e. reporting services under the same tax identification number) are considered a single entity and must adhere to the global period billing rules initiated by the “surgeon.”

Alternately, physicians with different specialty designations in the same group practice (e.g. a hospitalist and a cardiologist in a multispecialty group who report services under the same tax identification number) or different group practices can perform and separately report medically necessary services during the surgeon’s global period, as long as a formal (mutually agreed-upon) transfer of care did not occur.

Medical Necessity

With the growth of HM programs and the admission/attending role expansion, involvement in surgical cases comes under scrutiny for medical necessity. Admitting a patient who has active medical conditions (e.g. hypertension, diabetes, emphysema) is reasonable and necessary because the patient has a well-defined need for medical management by the hospitalist. Participation in the care of these patients is separately billable from the surgeon’s global period package.

Alternatively, a hospitalist might be required to admit and follow surgical patients who have no other identifiable chronic or acute conditions aside from the surgical problem. In these cases, hospitalist involvement may satisfy facility policy (quality of care, risk reduction, etc.) and administrative functions (discharge services or coordination of care) rather than active clinical management. This “medical management” will not be considered “medically necessary” by the payor, and may be denied as incidental to the surgeon’s perioperative services. Erroneous payment can occur, which will result in refund requests, as payors do not want to pay twice for duplicate services. Hospitalists can attempt to negotiate other terms with facilities to account for the unpaid time and effort directed toward these types of cases.

Consider the Case

A patient with numerous medical comorbidities is admitted to the hospitalist service for stabilization prior to surgery, which will occur the next day. The hospitalist can report the appropriate admission code (99221-99223) without need for modifiers because the hospitalist is the attending of record and in a different specialty group. If a private insurer denies the claim as inclusive to the surgical service, the hospitalist can appeal with notes and a cover letter, along with the Medicare guidelines for global surgical package. The hospitalist may continue to provide postoperative daily care, as needed, to manage the patient’s chronic conditions, and report each service as subsequent hospital care (99231-99233) without modifier until the day of discharge (99238-99239). Again, if a payor issues a denial (inclusive to surgery), appealing with notes might be necessary.

Carol Pohlig is a billing and coding expert with the University of Pennsylvania Medical Center, Philadelphia. She is faculty for SHM’s inpatient coding course.

References

1. Centers for Medicare & Medicaid Services. Medicare Claims Processing Manual: Chapter 12, Section 40. Centers for Medicare & Medicaid Services website. Available at: http://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/clm104c12.pdf. Accessed May 5, 2012.
2. Centers for Medicare & Medicaid Services. ICD-10: HHS proposes one-year delay of ICD-10 compliance date. Centers for Medicare & Medicaid Services website. Available at: http://www.cms.gov/Medicare/Coding/ICD10/index.html?redirect=/ICD10. Accessed May 5, 2012.
3. Abraham M, Ahlman J, Anderson C, Boudreau A, Connelly J. Current Procedural Terminology 2012 Professional Edition. Chicago: American Medical Association Press; 2011.

Hospitalists often are involved in the postoperative care of the surgical patient. However, HM is emerging in the admitting/attending role for procedural patients. Confusion can arise as to the nature of the hospitalist service, and whether it is deemed billable. Knowing the surgical package requirements can help hospitalists consider the issues.

Global Surgical Package Period¹

Surgical procedures, categorized as major or minor surgery, are reimbursed for pre-, intra-, and postoperative care. Postoperative care varies according to the procedure’s assigned global period, which designates zero, 10, or 90 postoperative days. (Physicians can review the global period for any given CPT code in the Medicare Physician Fee Schedule, available at www.cms.gov/apps/physician-fee-schedule/search/search-criteria.aspx.)

Services classified with “XXX” do not have the global period concept. “ZZZ” services denote an “add-on” procedure code that must always be reported with a primary procedure code and assumes the global period assigned to the primary procedure performed.

Major surgery allocates a 90-day global period in which the surgeon is responsible for all related surgical care one day before surgery through 90 postoperative days with no additional charge. Minor surgery, including endoscopy, appoints a zero-day or 10-day postoperative period. The zero-day global period encompasses only services provided on the surgical day, whereas 10-day global periods include services on the surgical day through 10 postoperative days.

Global Surgical Package Components²

The global surgical package comprises a host of responsibilities that include standard facility requirements of filling out all necessary paperwork involved in surgical cases (e.g. preoperative H&P, operative consent forms, preoperative orders). Additionally, the surgeon’s packaged payment includes (at no extra charge):

• Preoperative visits after making the decision for surgery beginning one day prior to surgery;
• All additional postoperative medical or surgical services provided by the surgeon related to complications but not requiring additional trips to the operating room;
• Postoperative visits by the surgeon related to recovery from surgery, including but not limited to dressing changes; local incisional care; removal of cutaneous sutures and staples; line removals; changes and removal of tracheostomy tubes; and discharge services; and
• Postoperative pain management provided by the surgeon.
• Examples of services that are not included in the global surgical package, (i.e. are separately billable and may require an appropriate modifier) are:
• The initial consultation or evaluation of the problem by the surgeon to determine the need for surgery;
• Services of other physicians except where the other physicians are providing coverage for the surgeon or agree on a transfer of care (i.e. a formal agreement in the form of a letter or an annotation in the discharge summary, hospital record, or ASC record);
• Postoperative visits by the surgeon unrelated to the diagnosis for which the surgical procedure is performed, unless the visits occur due to complications of the surgery;
• Diagnostic tests and procedures, including diagnostic radiological procedures;
• Clearly distinct surgical procedures during the postoperative period that do not result in repeat operations or treatment for complications;
• Treatment for postoperative complications that requires a return trip to the operating room (OR), catheterization lab or endoscopy suite;
• Immunosuppressive therapy for organ transplants; and
• Critical-care services (CPT codes 99291 and 99292) unrelated to the surgery where a seriously injured or burned patient is critically ill and requires constant attendance of the surgeon.

Classification of “Surgeon”

For billing purposes, the “surgeon” is a qualified physician who can perform “surgical” services within their scope of practice. All physicians with the same specialty designation in the same group practice as the “surgeon” (i.e. reporting services under the same tax identification number) are considered a single entity and must adhere to the global period billing rules initiated by the “surgeon.”

Alternately, physicians with different specialty designations in the same group practice (e.g. a hospitalist and a cardiologist in a multispecialty group who report services under the same tax identification number) or different group practices can perform and separately report medically necessary services during the surgeon’s global period, as long as a formal (mutually agreed-upon) transfer of care did not occur.

Medical Necessity

With the growth of HM programs and the admission/attending role expansion, involvement in surgical cases comes under scrutiny for medical necessity. Admitting a patient who has active medical conditions (e.g. hypertension, diabetes, emphysema) is reasonable and necessary because the patient has a well-defined need for medical management by the hospitalist. Participation in the care of these patients is separately billable from the surgeon’s global period package.

Alternatively, a hospitalist might be required to admit and follow surgical patients who have no other identifiable chronic or acute conditions aside from the surgical problem. In these cases, hospitalist involvement may satisfy facility policy (quality of care, risk reduction, etc.) and administrative functions (discharge services or coordination of care) rather than active clinical management. This “medical management” will not be considered “medically necessary” by the payor, and may be denied as incidental to the surgeon’s perioperative services. Erroneous payment can occur, which will result in refund requests, as payors do not want to pay twice for duplicate services. Hospitalists can attempt to negotiate other terms with facilities to account for the unpaid time and effort directed toward these types of cases.

Consider the Case

A patient with numerous medical comorbidities is admitted to the hospitalist service for stabilization prior to surgery, which will occur the next day. The hospitalist can report the appropriate admission code (99221-99223) without need for modifiers because the hospitalist is the attending of record and in a different specialty group. If a private insurer denies the claim as inclusive to the surgical service, the hospitalist can appeal with notes and a cover letter, along with the Medicare guidelines for global surgical package. The hospitalist may continue to provide postoperative daily care, as needed, to manage the patient’s chronic conditions, and report each service as subsequent hospital care (99231-99233) without modifier until the day of discharge (99238-99239). Again, if a payor issues a denial (inclusive to surgery), appealing with notes might be necessary.

Carol Pohlig is a billing and coding expert with the University of Pennsylvania Medical Center, Philadelphia. She is faculty for SHM’s inpatient coding course.

References

1. Centers for Medicare & Medicaid Services. Medicare Claims Processing Manual: Chapter 12, Section 40. Centers for Medicare & Medicaid Services website. Available at: http://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/clm104c12.pdf. Accessed May 5, 2012.
2. Centers for Medicare & Medicaid Services. ICD-10: HHS proposes one-year delay of ICD-10 compliance date. Centers for Medicare & Medicaid Services website. Available at: http://www.cms.gov/Medicare/Coding/ICD10/index.html?redirect=/ICD10. Accessed May 5, 2012.
3. Abraham M, Ahlman J, Anderson C, Boudreau A, Connelly J. Current Procedural Terminology 2012 Professional Edition. Chicago: American Medical Association Press; 2011.

The most recent report on hospital quality issued by independent healthcare rating company HealthGrades estimates that 254,000 safety incidents that occurred in U.S. hospitals from 2008 to 2010 could have been prevented, and that 56,367 hospitalized patients who died experienced one or more of those preventable events.¹

Drawing upon consumer-reported quality data in CMS’ Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey, HealthGrades concluded that 15% more patient safety incidents occurred at hospitals who ranked lowest (the bottom 10%) on the quality of their physician communication.

Reference

1. CPM Healthgrades. Patient safety and satisfaction: the state of American hospitals. CPM Healthgrades website. Available at: https://www.cpm.com/CPM/assets/File/HealthGradesPatientSafetySatisfactionReport2012.pdf. Accessed July 8, 2012.

The most recent report on hospital quality issued by independent healthcare rating company HealthGrades estimates that 254,000 safety incidents that occurred in U.S. hospitals from 2008 to 2010 could have been prevented, and that 56,367 hospitalized patients who died experienced one or more of those preventable events.¹

Drawing upon consumer-reported quality data in CMS’ Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey, HealthGrades concluded that 15% more patient safety incidents occurred at hospitals who ranked lowest (the bottom 10%) on the quality of their physician communication.

Reference

1. CPM Healthgrades. Patient safety and satisfaction: the state of American hospitals. CPM Healthgrades website. Available at: https://www.cpm.com/CPM/assets/File/HealthGradesPatientSafetySatisfactionReport2012.pdf. Accessed July 8, 2012.

The most recent report on hospital quality issued by independent healthcare rating company HealthGrades estimates that 254,000 safety incidents that occurred in U.S. hospitals from 2008 to 2010 could have been prevented, and that 56,367 hospitalized patients who died experienced one or more of those preventable events.¹

Drawing upon consumer-reported quality data in CMS’ Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey, HealthGrades concluded that 15% more patient safety incidents occurred at hospitals who ranked lowest (the bottom 10%) on the quality of their physician communication.

Reference

1. CPM Healthgrades. Patient safety and satisfaction: the state of American hospitals. CPM Healthgrades website. Available at: https://www.cpm.com/CPM/assets/File/HealthGradesPatientSafetySatisfactionReport2012.pdf. Accessed July 8, 2012.

EDITOR’S NOTE: An incorrect version of Win Whitcomb’s “On the Horizon” column was published in the July issue of The Hospitalist. We deeply regret the error. The correct version of Dr. Whitcomb’s column appears this month, with proper attribution given to hospitalist Brad Flansbaum, DO, SFHM, who contributed to the column.

Assigning the appropriate status to patients (“inpatient” or “observation”) has emerged as a front-and-center issue for hospitalists. Also known as “medical necessity,” many HM groups have been called upon to help solve the “status” problem for their institutions. With nearly 1 in 5 hospitalized patients on observation status in U.S. hospitals, appropriately assigning status is now a dominant, system-level challenge for hospitalists.

This month, we asked two experts to shed light on the nature of this beast, with a focus on the impact on the patient. Brad Flansbaum, DO, SFHM, hospitalist at Lenox Hill Hospital in New York City, and Patrick Conway, MD, FAAP, MSC, SFHM, chief medical officer at the Centers for Medicare & Medicaid Services (CMS), were kind enough to participate in the interview. We start with Dr. Flansbaum.

Dr. Whitcomb: It appears that patients are caught in the middle of the observation status challenge, at least as it relates to footing the bill. Explain the patient perspective of being unwittingly placed on observation status.

Dr. Flansbaum: Recall your last credit card statement. On it is the hotel charge from your last out-of-town CME excursion. Below the total charge, which you were expecting, is a separate line item for a $75 “recreational fee.” You call the hotel, and they inform you that, because you used the hotel gym and pool—accessed with your room key, they levied the fee. No signs, alerts, or postings denoted the policy, so you expected inclusive use of the facilities as a price of your visit. Capture the emotion of the moment, when you see that bill, feel your heart race, and think to yourself, “Get me the manager!”

WW: Why has assigning appropriate status captured the attention of hospitals?

BF: Out of vigilance for penalties and fraud from recovery audit contractor (RAC) investigations, as well attentiveness to unnecessary readmissions, hospitals increasingly are categorizing patients under observation, rather than inpatient, status to avoid conflict with regulators. Beneficiaries are in the crosshairs because of this designation change, and much in the same way of our hotel charge, our patients experience sticker shock when they receive their bill. It is leading to confusion among providers and consternation within the Medicare recipient community.

WW: Why is there so much confusion around appropriate patient status?

BF: The dilemma stems from Medicare payment, and the key distinction between inpatient coverage (Part A) and outpatient coverage, including pharmaceuticals (Parts B and D). When a patient receives their discharge notification—without an “official” inpatient designation, sometimes staying greater than 24 to 48 hours in the ED or in a specially defined observation unit, beneficiary charges are different. This could result in discrete—and sometimes jolting—enrollee copayments and deductibles for drugs and services.

WW: I’ve heard observation status is having a big, adverse impact on patients who go to skilled nursing facilities. Why?

BF: If a patient requires a skilled nursing facility stay (the “three-day stay” inpatient requirement), Medicare will not pay because the patient never registered “official” hospital time. Patients and caregivers are not prepared for the unexpected bills, and consequently, tempers are rising. The rules for Medicare Advantage enrollees (Part C—commercial payers receive a fixed sum from CMS, and oversee parts A, B, and D for an individual beneficiary), which comprise 25% of the program, differ from conventional Medicare. However, commercial plans often shadow traditional, fee-for-service in their policies and, consequently, no exemplar of success in this realm exits.

WW: Why is the number of patients on observation status growing?

BF: Hospitals have significantly increased both the number of their observation stays, as well as their hourly lengths (>48 hours). Because the definition of “observation status” is vague, and even the one- to two-day window is inflating, hospitals and hospitalists often are navigating without a compass. Again, fear of fraud and penalty places hospitals and, indirectly, hospitalists—who often make judgments on admission grade—in a precarious position.

The responsibility of hospitals to notify beneficiaries of their status hinges on this murky determination milieu, which may change in real time during the stay, and makes for an unsatisfactory standard. Understandably, CMS is attempting to rectify this quandary, taking into account a hospital’s need to clarify its billing and designation practices, as well as the beneficiaries’ desire to obtain clear guidance on their responsibilities both during and after the stay. Hospitalists, of course, want direction on coding, along with an understanding of the impact their decisions will have on patients and subspecialty colleagues.

Let’s now bring in Dr. Conway, a pediatric hospitalist. I thank Dr. Flansbaum, who formulated the following questions.

BF/WW: Is it tenable to keep the current system in place? Would it help to require payors and providers to inform beneficiaries of inpatient versus observation status at time zero in a more rigorous, yet to-be-determined manner?

Dr. Conway: Current regulations only require CMS to inform beneficiaries when they are admitted as an inpatient and not when they are an outpatient receiving observation services. There are important implications for beneficiary coverage post-hospital stay, coverage of self-administered drugs, and beneficiary coinsurance from this distinction. As a hospitalist, I think it is best to inform the patient of their status, especially if it has the potential to impact beneficiary liability, including coverage of post-acute care. CMS prepared a pamphlet in 2009, “Are You a Hospital Inpatient or Outpatient? If You Have Medicare, Ask,” to educate beneficiaries on this issue. (Download a PDF of the pamphlet at www.medicare.gov/Publications/Pubs/pdf/11435.pdf.)

BF/WW: Due to the nature of how hospital care is changing, are admission decisions potentially becoming too conflicted an endeavor for inpatient caregivers?  

PC: We want admission decisions to be based on clinical considerations. The decision to admit a patient should be based on the clinical judgment of the primary-care, emergency medicine, and/or HM clinician.

BF/WW: Before the U.S. healthcare system matures to a more full-out, integrated model with internalized risk, can you envision any near-term code changes that might simplify the difficulties all parties are facing, in a budget-neutral fashion?

PC: CMS is currently investigating options to clarify when it is appropriate to admit the patient as an inpatient versus keeping the patient as an outpatient receiving observation services. We understand that this issue is of concern to hospitals, hospitalists, and patients, and we are considering carefully how to simplify the rules in a way that best meets the needs of patients and providers without increasing costs to the system.

With growing attention to observation status coming from patients and provider groups (the AMA is requesting that CMS revise its coverage rules), we will no doubt be hearing more about this going forward.

Dr. Whitcomb is medical director of healthcare quality at Baystate Medical Center in Springfield, Mass. He is a co-founder and past president of SHM. Email him at wfwhit@comcast.net.

EDITOR’S NOTE: An incorrect version of Win Whitcomb’s “On the Horizon” column was published in the July issue of The Hospitalist. We deeply regret the error. The correct version of Dr. Whitcomb’s column appears this month, with proper attribution given to hospitalist Brad Flansbaum, DO, SFHM, who contributed to the column.

Assigning the appropriate status to patients (“inpatient” or “observation”) has emerged as a front-and-center issue for hospitalists. Also known as “medical necessity,” many HM groups have been called upon to help solve the “status” problem for their institutions. With nearly 1 in 5 hospitalized patients on observation status in U.S. hospitals, appropriately assigning status is now a dominant, system-level challenge for hospitalists.

This month, we asked two experts to shed light on the nature of this beast, with a focus on the impact on the patient. Brad Flansbaum, DO, SFHM, hospitalist at Lenox Hill Hospital in New York City, and Patrick Conway, MD, FAAP, MSC, SFHM, chief medical officer at the Centers for Medicare & Medicaid Services (CMS), were kind enough to participate in the interview. We start with Dr. Flansbaum.

Dr. Whitcomb: It appears that patients are caught in the middle of the observation status challenge, at least as it relates to footing the bill. Explain the patient perspective of being unwittingly placed on observation status.

Dr. Flansbaum: Recall your last credit card statement. On it is the hotel charge from your last out-of-town CME excursion. Below the total charge, which you were expecting, is a separate line item for a $75 “recreational fee.” You call the hotel, and they inform you that, because you used the hotel gym and pool—accessed with your room key, they levied the fee. No signs, alerts, or postings denoted the policy, so you expected inclusive use of the facilities as a price of your visit. Capture the emotion of the moment, when you see that bill, feel your heart race, and think to yourself, “Get me the manager!”

WW: Why has assigning appropriate status captured the attention of hospitals?

BF: Out of vigilance for penalties and fraud from recovery audit contractor (RAC) investigations, as well attentiveness to unnecessary readmissions, hospitals increasingly are categorizing patients under observation, rather than inpatient, status to avoid conflict with regulators. Beneficiaries are in the crosshairs because of this designation change, and much in the same way of our hotel charge, our patients experience sticker shock when they receive their bill. It is leading to confusion among providers and consternation within the Medicare recipient community.

WW: Why is there so much confusion around appropriate patient status?

BF: The dilemma stems from Medicare payment, and the key distinction between inpatient coverage (Part A) and outpatient coverage, including pharmaceuticals (Parts B and D). When a patient receives their discharge notification—without an “official” inpatient designation, sometimes staying greater than 24 to 48 hours in the ED or in a specially defined observation unit, beneficiary charges are different. This could result in discrete—and sometimes jolting—enrollee copayments and deductibles for drugs and services.

WW: I’ve heard observation status is having a big, adverse impact on patients who go to skilled nursing facilities. Why?

BF: If a patient requires a skilled nursing facility stay (the “three-day stay” inpatient requirement), Medicare will not pay because the patient never registered “official” hospital time. Patients and caregivers are not prepared for the unexpected bills, and consequently, tempers are rising. The rules for Medicare Advantage enrollees (Part C—commercial payers receive a fixed sum from CMS, and oversee parts A, B, and D for an individual beneficiary), which comprise 25% of the program, differ from conventional Medicare. However, commercial plans often shadow traditional, fee-for-service in their policies and, consequently, no exemplar of success in this realm exits.

WW: Why is the number of patients on observation status growing?

BF: Hospitals have significantly increased both the number of their observation stays, as well as their hourly lengths (>48 hours). Because the definition of “observation status” is vague, and even the one- to two-day window is inflating, hospitals and hospitalists often are navigating without a compass. Again, fear of fraud and penalty places hospitals and, indirectly, hospitalists—who often make judgments on admission grade—in a precarious position.

The responsibility of hospitals to notify beneficiaries of their status hinges on this murky determination milieu, which may change in real time during the stay, and makes for an unsatisfactory standard. Understandably, CMS is attempting to rectify this quandary, taking into account a hospital’s need to clarify its billing and designation practices, as well as the beneficiaries’ desire to obtain clear guidance on their responsibilities both during and after the stay. Hospitalists, of course, want direction on coding, along with an understanding of the impact their decisions will have on patients and subspecialty colleagues.

Let’s now bring in Dr. Conway, a pediatric hospitalist. I thank Dr. Flansbaum, who formulated the following questions.

BF/WW: Is it tenable to keep the current system in place? Would it help to require payors and providers to inform beneficiaries of inpatient versus observation status at time zero in a more rigorous, yet to-be-determined manner?

Dr. Conway: Current regulations only require CMS to inform beneficiaries when they are admitted as an inpatient and not when they are an outpatient receiving observation services. There are important implications for beneficiary coverage post-hospital stay, coverage of self-administered drugs, and beneficiary coinsurance from this distinction. As a hospitalist, I think it is best to inform the patient of their status, especially if it has the potential to impact beneficiary liability, including coverage of post-acute care. CMS prepared a pamphlet in 2009, “Are You a Hospital Inpatient or Outpatient? If You Have Medicare, Ask,” to educate beneficiaries on this issue. (Download a PDF of the pamphlet at www.medicare.gov/Publications/Pubs/pdf/11435.pdf.)

BF/WW: Due to the nature of how hospital care is changing, are admission decisions potentially becoming too conflicted an endeavor for inpatient caregivers?  

PC: We want admission decisions to be based on clinical considerations. The decision to admit a patient should be based on the clinical judgment of the primary-care, emergency medicine, and/or HM clinician.

BF/WW: Before the U.S. healthcare system matures to a more full-out, integrated model with internalized risk, can you envision any near-term code changes that might simplify the difficulties all parties are facing, in a budget-neutral fashion?

PC: CMS is currently investigating options to clarify when it is appropriate to admit the patient as an inpatient versus keeping the patient as an outpatient receiving observation services. We understand that this issue is of concern to hospitals, hospitalists, and patients, and we are considering carefully how to simplify the rules in a way that best meets the needs of patients and providers without increasing costs to the system.

With growing attention to observation status coming from patients and provider groups (the AMA is requesting that CMS revise its coverage rules), we will no doubt be hearing more about this going forward.

Dr. Whitcomb is medical director of healthcare quality at Baystate Medical Center in Springfield, Mass. He is a co-founder and past president of SHM. Email him at wfwhit@comcast.net.

EDITOR’S NOTE: An incorrect version of Win Whitcomb’s “On the Horizon” column was published in the July issue of The Hospitalist. We deeply regret the error. The correct version of Dr. Whitcomb’s column appears this month, with proper attribution given to hospitalist Brad Flansbaum, DO, SFHM, who contributed to the column.

Assigning the appropriate status to patients (“inpatient” or “observation”) has emerged as a front-and-center issue for hospitalists. Also known as “medical necessity,” many HM groups have been called upon to help solve the “status” problem for their institutions. With nearly 1 in 5 hospitalized patients on observation status in U.S. hospitals, appropriately assigning status is now a dominant, system-level challenge for hospitalists.

This month, we asked two experts to shed light on the nature of this beast, with a focus on the impact on the patient. Brad Flansbaum, DO, SFHM, hospitalist at Lenox Hill Hospital in New York City, and Patrick Conway, MD, FAAP, MSC, SFHM, chief medical officer at the Centers for Medicare & Medicaid Services (CMS), were kind enough to participate in the interview. We start with Dr. Flansbaum.

Dr. Whitcomb: It appears that patients are caught in the middle of the observation status challenge, at least as it relates to footing the bill. Explain the patient perspective of being unwittingly placed on observation status.

Dr. Flansbaum: Recall your last credit card statement. On it is the hotel charge from your last out-of-town CME excursion. Below the total charge, which you were expecting, is a separate line item for a $75 “recreational fee.” You call the hotel, and they inform you that, because you used the hotel gym and pool—accessed with your room key, they levied the fee. No signs, alerts, or postings denoted the policy, so you expected inclusive use of the facilities as a price of your visit. Capture the emotion of the moment, when you see that bill, feel your heart race, and think to yourself, “Get me the manager!”

WW: Why has assigning appropriate status captured the attention of hospitals?

BF: Out of vigilance for penalties and fraud from recovery audit contractor (RAC) investigations, as well attentiveness to unnecessary readmissions, hospitals increasingly are categorizing patients under observation, rather than inpatient, status to avoid conflict with regulators. Beneficiaries are in the crosshairs because of this designation change, and much in the same way of our hotel charge, our patients experience sticker shock when they receive their bill. It is leading to confusion among providers and consternation within the Medicare recipient community.

WW: Why is there so much confusion around appropriate patient status?

BF: The dilemma stems from Medicare payment, and the key distinction between inpatient coverage (Part A) and outpatient coverage, including pharmaceuticals (Parts B and D). When a patient receives their discharge notification—without an “official” inpatient designation, sometimes staying greater than 24 to 48 hours in the ED or in a specially defined observation unit, beneficiary charges are different. This could result in discrete—and sometimes jolting—enrollee copayments and deductibles for drugs and services.

WW: I’ve heard observation status is having a big, adverse impact on patients who go to skilled nursing facilities. Why?

BF: If a patient requires a skilled nursing facility stay (the “three-day stay” inpatient requirement), Medicare will not pay because the patient never registered “official” hospital time. Patients and caregivers are not prepared for the unexpected bills, and consequently, tempers are rising. The rules for Medicare Advantage enrollees (Part C—commercial payers receive a fixed sum from CMS, and oversee parts A, B, and D for an individual beneficiary), which comprise 25% of the program, differ from conventional Medicare. However, commercial plans often shadow traditional, fee-for-service in their policies and, consequently, no exemplar of success in this realm exits.

WW: Why is the number of patients on observation status growing?

BF: Hospitals have significantly increased both the number of their observation stays, as well as their hourly lengths (>48 hours). Because the definition of “observation status” is vague, and even the one- to two-day window is inflating, hospitals and hospitalists often are navigating without a compass. Again, fear of fraud and penalty places hospitals and, indirectly, hospitalists—who often make judgments on admission grade—in a precarious position.

The responsibility of hospitals to notify beneficiaries of their status hinges on this murky determination milieu, which may change in real time during the stay, and makes for an unsatisfactory standard. Understandably, CMS is attempting to rectify this quandary, taking into account a hospital’s need to clarify its billing and designation practices, as well as the beneficiaries’ desire to obtain clear guidance on their responsibilities both during and after the stay. Hospitalists, of course, want direction on coding, along with an understanding of the impact their decisions will have on patients and subspecialty colleagues.

Let’s now bring in Dr. Conway, a pediatric hospitalist. I thank Dr. Flansbaum, who formulated the following questions.

BF/WW: Is it tenable to keep the current system in place? Would it help to require payors and providers to inform beneficiaries of inpatient versus observation status at time zero in a more rigorous, yet to-be-determined manner?

Dr. Conway: Current regulations only require CMS to inform beneficiaries when they are admitted as an inpatient and not when they are an outpatient receiving observation services. There are important implications for beneficiary coverage post-hospital stay, coverage of self-administered drugs, and beneficiary coinsurance from this distinction. As a hospitalist, I think it is best to inform the patient of their status, especially if it has the potential to impact beneficiary liability, including coverage of post-acute care. CMS prepared a pamphlet in 2009, “Are You a Hospital Inpatient or Outpatient? If You Have Medicare, Ask,” to educate beneficiaries on this issue. (Download a PDF of the pamphlet at www.medicare.gov/Publications/Pubs/pdf/11435.pdf.)

BF/WW: Due to the nature of how hospital care is changing, are admission decisions potentially becoming too conflicted an endeavor for inpatient caregivers?  

PC: We want admission decisions to be based on clinical considerations. The decision to admit a patient should be based on the clinical judgment of the primary-care, emergency medicine, and/or HM clinician.

BF/WW: Before the U.S. healthcare system matures to a more full-out, integrated model with internalized risk, can you envision any near-term code changes that might simplify the difficulties all parties are facing, in a budget-neutral fashion?

PC: CMS is currently investigating options to clarify when it is appropriate to admit the patient as an inpatient versus keeping the patient as an outpatient receiving observation services. We understand that this issue is of concern to hospitals, hospitalists, and patients, and we are considering carefully how to simplify the rules in a way that best meets the needs of patients and providers without increasing costs to the system.

With growing attention to observation status coming from patients and provider groups (the AMA is requesting that CMS revise its coverage rules), we will no doubt be hearing more about this going forward.

Dr. Whitcomb is medical director of healthcare quality at Baystate Medical Center in Springfield, Mass. He is a co-founder and past president of SHM. Email him at wfwhit@comcast.net.

When Harbor UCLA Medical Center, a teaching hospital in Torrance, Calif., and a major safety-net facility for Los Angeles County, looked at its 30-day readmissions data, it found that readmissions for heart failure patients had increased by about 25% in just one year.

“We parsed the data and said we’re going have to sort this out,” explains Charles McKay, MD, a cardiologist at the hospital. “Then the opportunity to join Project BOOST came along. It’s been helpful to have their tools, mentors, and the whole collaborative experience.”

Harbor UCLA is one of seven Southern California hospitals participating in the yearlong Readmissions Reduction Collaborative, co-sponsored by SHM and the Hospital Association of Southern California (HASC). The hospitals convened in early June in Montebello, Calif., to report results from their quality initiatives. Four of the hospitals reported reductions in readmissions ranging from 24% to 55%. The other three were slower in implementing their quality processes and are just now starting to see results, executives said.

Project BOOST is a national quality initiative created by SHM to improve hospital discharges and care transitions while reducing readmissions—a growing focus for hospitals and health policy makers. About 100 participating sites across the country have benefited from BOOST’s expert mentoring and collaboration, as well as access to such tools as the “teachback” communication techniques and the “8Ps” comprehensive patient risk assessment.

Harbor UCLA’s multidisciplinary readmissions team, with Dr. McKay as its physician champion, zeroed in on heart failure and developed a Cardiovascular Open Access Rapid Evaluation (CORE) service, which he describes as a sort of observation or clinical decisions unit aimed at relieving pressure on the ED. Open 7 a.m. to 7 p.m., the CORE service coordinates medical interventions—stress tests and trips to the cardiac catheter lab, for example—for patients who have not been admitted to the hospital.

The team also focuses on discharged patients who return to the hospital within 72 hours, before the hospital could place post-discharge follow-up phone calls. Many of these patients could not be reached after they left the hospital.

“These are the patients where the system has failed,” Dr. McKay says. “But you could flip it over and say they are our biggest opportunity. That’s where BOOST comes in, to talk about interventions during hospitalization, implementing teachback, streamlining the coordination of care.”

BOOST aims to accelerate the quality-improvement (QI) process, identifying readmission risks and making them a higher priority for nurses and doctors to mobilize resources in the discharge process. “That’s where BOOST shone at our institution,” Dr. McKay says, “and where we still have a lot to learn.”

Harbor UCLA also brought a home healthcare representative onto the team, engaged a discharge advocate, and referred appropriate patients to a heart failure disease management registry. Over the year of the collaborative, it posted a 5.5% decrease in readmissions of heart failure patients.

Hospitalists do not have prominent roles at most HASC readmissions sites; traditional hospitalist services are less common in Southern California hospitals, in part due to the prevalence of independent practice associations (IPAs), which act as intermediaries between physicians and health plans in the region, explains Z. Joseph Wanski, MD, FACE, medical director of the public L.A. Care Health Plan, which co-sponsored the readmissions collaborative. “The IPA is in charge of its members’ hospital and post-hospital care,” he says.

Dr. Wanski, a practicing endocrinologist and a hospitalist at California Hospital Medical Center in Los Angeles, says L.A. Care is now testing the use of hospitalists at some of its contracted acute-care facilities.

In many cases, readmissions involve avoidable costs, as well as reduce patient satisfaction. “If they do not get rehospitalized, patients are happier, their caretakers are happier, and I feel the quality of their care is better,” Dr. Wanski says. “If you can keep the person well at home, make sure they take their medications, hopefully not go back to the ER, and get on with their lives—all those things together are why we’re supporting this collaborative.”

But hospitalists, especially in larger groups, potentially have the leverage to negotiate access to services and the care coordination needed to reduce hospital costs and preventable readmissions, Dr. McKay notes. “In 2012, hospitalists are key, and we need to find a way to make readmission reduction part of their job description, so that they can direct that,” he says.

At Valley Presbyterian Hospital in Van Nuys, which employs three part-time hospitalists who also maintain busy office practices, “the hospitalists have been very cooperative with our project,” reports Adriana Quintero, MSW, the hospital’s full-time Project BOOST facilitator. “They see a lot of our patients in their offices.” The physicians have agreed to carve out time to see, within seven days, discharge patients going home without scheduled appointments with their primary-care physicians (PCPs).

“We find that many of our discharged patients do not call their primary-care physicians for post-discharge appointments” and decline the hospital team’s offers for help—which makes it important for the discharge coordinator to follow up as soon as possible after the patient goes home, Quintero says.

At the collaborative congress in early June, team member Alice Gunderson reported results for Saint Francis Hospital in Lynwood. Gunderson, who sits on the hospital’s quality and safety board, has been a volunteer patient family advocate (PFA) for the past year and a half; she was inspired by her own experience as a family caregiver for her husband and mother, both of whom were Saint Francis patients. Gunderson challenged those in the audience to bring a PFA from their own hospital to the next BOOST meeting.

“From my point of view, wherever healthcare goes, the patient is becoming more educated, with all of the communication technology that is out there, and claiming that empowerment,” Gunderson says. “We must all work together, not in separate silos, for the best outcomes, and we can all learn from one another.”

Larry Beresford is a freelance writer in Oakland, Calif.

When Harbor UCLA Medical Center, a teaching hospital in Torrance, Calif., and a major safety-net facility for Los Angeles County, looked at its 30-day readmissions data, it found that readmissions for heart failure patients had increased by about 25% in just one year.

“We parsed the data and said we’re going have to sort this out,” explains Charles McKay, MD, a cardiologist at the hospital. “Then the opportunity to join Project BOOST came along. It’s been helpful to have their tools, mentors, and the whole collaborative experience.”

Harbor UCLA is one of seven Southern California hospitals participating in the yearlong Readmissions Reduction Collaborative, co-sponsored by SHM and the Hospital Association of Southern California (HASC). The hospitals convened in early June in Montebello, Calif., to report results from their quality initiatives. Four of the hospitals reported reductions in readmissions ranging from 24% to 55%. The other three were slower in implementing their quality processes and are just now starting to see results, executives said.

Project BOOST is a national quality initiative created by SHM to improve hospital discharges and care transitions while reducing readmissions—a growing focus for hospitals and health policy makers. About 100 participating sites across the country have benefited from BOOST’s expert mentoring and collaboration, as well as access to such tools as the “teachback” communication techniques and the “8Ps” comprehensive patient risk assessment.

Harbor UCLA’s multidisciplinary readmissions team, with Dr. McKay as its physician champion, zeroed in on heart failure and developed a Cardiovascular Open Access Rapid Evaluation (CORE) service, which he describes as a sort of observation or clinical decisions unit aimed at relieving pressure on the ED. Open 7 a.m. to 7 p.m., the CORE service coordinates medical interventions—stress tests and trips to the cardiac catheter lab, for example—for patients who have not been admitted to the hospital.

The team also focuses on discharged patients who return to the hospital within 72 hours, before the hospital could place post-discharge follow-up phone calls. Many of these patients could not be reached after they left the hospital.

“These are the patients where the system has failed,” Dr. McKay says. “But you could flip it over and say they are our biggest opportunity. That’s where BOOST comes in, to talk about interventions during hospitalization, implementing teachback, streamlining the coordination of care.”

BOOST aims to accelerate the quality-improvement (QI) process, identifying readmission risks and making them a higher priority for nurses and doctors to mobilize resources in the discharge process. “That’s where BOOST shone at our institution,” Dr. McKay says, “and where we still have a lot to learn.”

Harbor UCLA also brought a home healthcare representative onto the team, engaged a discharge advocate, and referred appropriate patients to a heart failure disease management registry. Over the year of the collaborative, it posted a 5.5% decrease in readmissions of heart failure patients.

Hospitalists do not have prominent roles at most HASC readmissions sites; traditional hospitalist services are less common in Southern California hospitals, in part due to the prevalence of independent practice associations (IPAs), which act as intermediaries between physicians and health plans in the region, explains Z. Joseph Wanski, MD, FACE, medical director of the public L.A. Care Health Plan, which co-sponsored the readmissions collaborative. “The IPA is in charge of its members’ hospital and post-hospital care,” he says.

Dr. Wanski, a practicing endocrinologist and a hospitalist at California Hospital Medical Center in Los Angeles, says L.A. Care is now testing the use of hospitalists at some of its contracted acute-care facilities.

In many cases, readmissions involve avoidable costs, as well as reduce patient satisfaction. “If they do not get rehospitalized, patients are happier, their caretakers are happier, and I feel the quality of their care is better,” Dr. Wanski says. “If you can keep the person well at home, make sure they take their medications, hopefully not go back to the ER, and get on with their lives—all those things together are why we’re supporting this collaborative.”

But hospitalists, especially in larger groups, potentially have the leverage to negotiate access to services and the care coordination needed to reduce hospital costs and preventable readmissions, Dr. McKay notes. “In 2012, hospitalists are key, and we need to find a way to make readmission reduction part of their job description, so that they can direct that,” he says.

At Valley Presbyterian Hospital in Van Nuys, which employs three part-time hospitalists who also maintain busy office practices, “the hospitalists have been very cooperative with our project,” reports Adriana Quintero, MSW, the hospital’s full-time Project BOOST facilitator. “They see a lot of our patients in their offices.” The physicians have agreed to carve out time to see, within seven days, discharge patients going home without scheduled appointments with their primary-care physicians (PCPs).

“We find that many of our discharged patients do not call their primary-care physicians for post-discharge appointments” and decline the hospital team’s offers for help—which makes it important for the discharge coordinator to follow up as soon as possible after the patient goes home, Quintero says.

At the collaborative congress in early June, team member Alice Gunderson reported results for Saint Francis Hospital in Lynwood. Gunderson, who sits on the hospital’s quality and safety board, has been a volunteer patient family advocate (PFA) for the past year and a half; she was inspired by her own experience as a family caregiver for her husband and mother, both of whom were Saint Francis patients. Gunderson challenged those in the audience to bring a PFA from their own hospital to the next BOOST meeting.

“From my point of view, wherever healthcare goes, the patient is becoming more educated, with all of the communication technology that is out there, and claiming that empowerment,” Gunderson says. “We must all work together, not in separate silos, for the best outcomes, and we can all learn from one another.”

Larry Beresford is a freelance writer in Oakland, Calif.

When Harbor UCLA Medical Center, a teaching hospital in Torrance, Calif., and a major safety-net facility for Los Angeles County, looked at its 30-day readmissions data, it found that readmissions for heart failure patients had increased by about 25% in just one year.

“We parsed the data and said we’re going have to sort this out,” explains Charles McKay, MD, a cardiologist at the hospital. “Then the opportunity to join Project BOOST came along. It’s been helpful to have their tools, mentors, and the whole collaborative experience.”

Harbor UCLA is one of seven Southern California hospitals participating in the yearlong Readmissions Reduction Collaborative, co-sponsored by SHM and the Hospital Association of Southern California (HASC). The hospitals convened in early June in Montebello, Calif., to report results from their quality initiatives. Four of the hospitals reported reductions in readmissions ranging from 24% to 55%. The other three were slower in implementing their quality processes and are just now starting to see results, executives said.

Project BOOST is a national quality initiative created by SHM to improve hospital discharges and care transitions while reducing readmissions—a growing focus for hospitals and health policy makers. About 100 participating sites across the country have benefited from BOOST’s expert mentoring and collaboration, as well as access to such tools as the “teachback” communication techniques and the “8Ps” comprehensive patient risk assessment.

Harbor UCLA’s multidisciplinary readmissions team, with Dr. McKay as its physician champion, zeroed in on heart failure and developed a Cardiovascular Open Access Rapid Evaluation (CORE) service, which he describes as a sort of observation or clinical decisions unit aimed at relieving pressure on the ED. Open 7 a.m. to 7 p.m., the CORE service coordinates medical interventions—stress tests and trips to the cardiac catheter lab, for example—for patients who have not been admitted to the hospital.

The team also focuses on discharged patients who return to the hospital within 72 hours, before the hospital could place post-discharge follow-up phone calls. Many of these patients could not be reached after they left the hospital.

“These are the patients where the system has failed,” Dr. McKay says. “But you could flip it over and say they are our biggest opportunity. That’s where BOOST comes in, to talk about interventions during hospitalization, implementing teachback, streamlining the coordination of care.”

BOOST aims to accelerate the quality-improvement (QI) process, identifying readmission risks and making them a higher priority for nurses and doctors to mobilize resources in the discharge process. “That’s where BOOST shone at our institution,” Dr. McKay says, “and where we still have a lot to learn.”

Harbor UCLA also brought a home healthcare representative onto the team, engaged a discharge advocate, and referred appropriate patients to a heart failure disease management registry. Over the year of the collaborative, it posted a 5.5% decrease in readmissions of heart failure patients.

Hospitalists do not have prominent roles at most HASC readmissions sites; traditional hospitalist services are less common in Southern California hospitals, in part due to the prevalence of independent practice associations (IPAs), which act as intermediaries between physicians and health plans in the region, explains Z. Joseph Wanski, MD, FACE, medical director of the public L.A. Care Health Plan, which co-sponsored the readmissions collaborative. “The IPA is in charge of its members’ hospital and post-hospital care,” he says.

Dr. Wanski, a practicing endocrinologist and a hospitalist at California Hospital Medical Center in Los Angeles, says L.A. Care is now testing the use of hospitalists at some of its contracted acute-care facilities.

In many cases, readmissions involve avoidable costs, as well as reduce patient satisfaction. “If they do not get rehospitalized, patients are happier, their caretakers are happier, and I feel the quality of their care is better,” Dr. Wanski says. “If you can keep the person well at home, make sure they take their medications, hopefully not go back to the ER, and get on with their lives—all those things together are why we’re supporting this collaborative.”

But hospitalists, especially in larger groups, potentially have the leverage to negotiate access to services and the care coordination needed to reduce hospital costs and preventable readmissions, Dr. McKay notes. “In 2012, hospitalists are key, and we need to find a way to make readmission reduction part of their job description, so that they can direct that,” he says.

At Valley Presbyterian Hospital in Van Nuys, which employs three part-time hospitalists who also maintain busy office practices, “the hospitalists have been very cooperative with our project,” reports Adriana Quintero, MSW, the hospital’s full-time Project BOOST facilitator. “They see a lot of our patients in their offices.” The physicians have agreed to carve out time to see, within seven days, discharge patients going home without scheduled appointments with their primary-care physicians (PCPs).

“We find that many of our discharged patients do not call their primary-care physicians for post-discharge appointments” and decline the hospital team’s offers for help—which makes it important for the discharge coordinator to follow up as soon as possible after the patient goes home, Quintero says.

At the collaborative congress in early June, team member Alice Gunderson reported results for Saint Francis Hospital in Lynwood. Gunderson, who sits on the hospital’s quality and safety board, has been a volunteer patient family advocate (PFA) for the past year and a half; she was inspired by her own experience as a family caregiver for her husband and mother, both of whom were Saint Francis patients. Gunderson challenged those in the audience to bring a PFA from their own hospital to the next BOOST meeting.

“From my point of view, wherever healthcare goes, the patient is becoming more educated, with all of the communication technology that is out there, and claiming that empowerment,” Gunderson says. “We must all work together, not in separate silos, for the best outcomes, and we can all learn from one another.”

Larry Beresford is a freelance writer in Oakland, Calif.