Life in the Gap

This year will be a pivotal one in the brave new world of healthcare reform. While fee-for-service and volume-based reimbursement will not disappear, most would concede that those programs’ days are numbered, as public and private payors inexorably migrate to value-based payment mechanisms that hold physicians and hospitals increasingly accountable for more coordinated, safer, higher-quality, and more efficient care.

The Centers for Medicare & Medicaid Services (CMS) is busy putting more provider skin in the game as its shifts from volume to value. It has ramped up its Hospital Value-Based Purchasing Plan (VBP) by adding a third performance domain—quality outcome metrics—to the existing domains of core measure care processes and patient satisfaction scores. VBP will penalize hospitals for preventable readmissions. Armed with a new innovation center established by the Affordable Care Act, CMS is accelerating its experiments with such care and reimbursement models as bundled payments, accountable-care organizations (ACOs), and medical homes. Can it be very long before invitations for provider participation become subpoenas?

While the brunt of value-based reimbursement incentives have so far been directed at hospitals, “At what point will this shift begin putting the practicing physician at risk?” asks Sean Muldoon, MD, MPH, FCCP, FACPM, senior vice president and chief medical officer of Louisville, Ky.-based Kindred Healthcare’s hospital division.

“We’re living in a time of great uncertainty—from the economic, regulatory, and legislative standpoints—and we have to make the best decisions based on what we currently believe is coming,” says Ron Greeno, MD, FCCP, MHM, chief medical officer of Cogent HMG and chair of SHM’s Public Policy Committee.

As change un-folds, some see great opportunity. “Hospitalists are in an enviable position as drivers of change,” says David B. Nash, MD, MBA, professor of health policy and dean of Thomas Jefferson University’s School of Population Health in Philadelphia. “As frontline troops of hospital-based care, they are going to play a critical role in ensuring the most efficient patient stay possible to help hospitals survive under new reimbursement models.”

Evolving Environment

Priorities in an age of reform

  1. Patient satisfaction. These scores continue to weigh heavily in Medicare’s VBP program, comprising 30% of a hospital’s overall quality score. HM needs to weigh in on industry concerns that patient satisfaction survey data are poor measures of quality, Dr. Greeno says. Even so, because hospitalists account for a lot of face time with a lot of patients, they will continue to be on the hook for ensuring that patients have a satisfying experience.
  2. Readmissions and hospital-acquired conditions. As government and private payors increasingly penalize hospitals for preventable readmissions and hospital-acquired conditions, hospitalists are going to be held accountable by their institutions for putting into place process measures that are proven to reduce these problems—DVT prevention protocols, Project BOOST interventions, and other care-transition-improvement programs, Dr. Greeno says.
  3. Greener pastures? Be prepared for another potential impact of health reform: competition for patients. As coverage is extended to millions, voluntary medical staff who previously did not want to take charity-care patients may now be more willing to take ED call, Muldoon says. A hospitalist’s patient pool may shrink further if ACOs catch on, as one of the goals of that model is to prevent hospitalization. In response, Muldoon believes that more hospitalists might look to other care settings (i.e. skilled nursing facilities), where he says reimbursement is approaching that of short-term care hospitals.

Confidence that HM is well-positioned to drive value is especially welcome as the field looks back on 15 years of its existence in a soul-searching appraisal of just how much value it has driven thus far. The evidence is mixed. The profession’s clearest documented success has been preventing delays in patient discharge. That achievement has yet to be buttressed by clear evidence of concomitant gains in quality attributable to hospitalist care.

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