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• Filed under: Columns, SHM Point of View, SHM

• Keywords: patient-care advocate, performance, bundle, quality improvement (QI), reimbursement, value-based purchasing

We’re All in This Together

From: The Hospitalist, November 2008

by Larry Wellikson, MD, FHM

I have been spending quite a lot of time “outside” of hospital medicine recently. I have spoken to a group of hospital CEOs in New York about the hospital of the future, and I have created a Webcast for hospital executives for the Ohio Hospital Association. Society of Hospital Medicine staff and I have met with senior leaders at the American College of Physician Executives (ACPE) and the Medical Group Management Association (MGMA) regarding partnerships with SHM and hospitalists. We have worked with the critical care societies about a common approach to the “never events” that Medicare has been proposing. And we have met with the American College of Physicians (ACP) and the American Association of Family Physicians (AAFP) about the Patient-Centered Medical Home (PCMH) that they hope will transform primary care.

There are common themes that seem to percolate through many of these meetings. Hospitalists are now practicing at many of our nation’s hospitals. More importantly, as medical care and hospital-based care are being transformed, hospitalists are central to this change on many levels.

Change is taking the form of new payment models. Medicare’s decision not to pay for conditions that are not present on admission (POA) and that should never (or rarely) occur in the hospital is driving hospital CEOs to change their hospital’s culture and processes out of financial necessity. This is a huge step up the quality improvement ladder from one or two patient safety nurses with clipboards and a checklist “documenting” that a specific quality improvement measure has been met. These changes might transform the very way hospitals view themselves and their critical mission. The new payment model will affect how hospitals are rewarded and perceived by their communities and, in the end, will change their business.

It is clear that hospital CEOs think pay for performance has been a distraction, bringing about no additional funding and failing to arouse hospital leadership to move forward to significantly improve clinical performance. It appears rewarding key hospital executives based on patient satisfaction scores, along with publishing hospital specific information in Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) data on the internet, has been more effective in driving tangible change at many hospitals.

More radical approaches are being considered in Washington. Some would fundamentally change the way payment flows to hospitals (and doctors). Sen. Max Baucus, chairman of the Senate Finance Committee, the group that determines Medicare funding, has held hearings on value based purchasing (VBP). SHM leaders have been there and testified. MedPAC, which advises Congress and Medicare, also is considering VBP as one of its recommendations for the future of payment reform. At its core, VBP would move away from simply paying because a visit was made or a procedure was performed to rewarding documented performance and outcomes.

VBP plays to the strengths of the mature hospital medicine group, where data collection, analysis, systems improvement, and change leadership are part of our DNA. It moves hospitalists from simply replacing the clinical roles previously performed by other physicians, be it primary care physicians (PCPs) or surgeons or subspecialists, to partnering with their hospitals and allied health team members to change the culture and performance of their institutions. This moves hospital medicine from a subsidized health profession to a core group of clinicians central to the hospital’s mission, reputation, and financial future.

Other payment changes, including bundling of both the facility fee (Medicare Part A) and the professional fee (Medicare Part B), further plants the hospitalist group firmly in the middle of hospital funding and allocation of manpower. Bundled payments would not necessarily flow to the hospital to distribute to the physicians, but more likely would be managed by a joint physician-hospital partnership. The entire enterprise (doctors and the hospital) would be rewarded for efficient and effective care (i.e., using the appropriate resources to generate the best outcomes.) Decisions would need to be made and negotiated to allocate funds to the hospital and to each physician who participated in the patient’s care, based on time, skill, and performance. With hospitalists taking an important role in most inpatient care, one can see how central they will be in this new system of payment.

But it would be naïve to think that today all hospitalists are ready to step up to the new challenges brought on by payment reform and the increasing demand for documented performance improvement and patient safety. That is where SHM and some of the partnerships we are entertaining come in.

SHM has seen hospitalists coming out of their residency training or from a previous practice mode entering hospital medicine as a career with enthusiasm and drive, but needing key new skills if they are to step up to and into new roles as change leaders at their hospitals. With this in mind, SHM has created our Practice Management Institute with training in starting, managing, growing, and improving a hospital medicine group, including front-end skills in billing and collecting, as well as dashboards for data collection and analysis, and taking the hospitalist enterprise to the next level.

Knowing that helping create the next generation of hospital medicine leaders and hospital leaders is a key competency for hospital medicine, SHM’s successful Leadership Academy already has started nearly 1,000 hospital medicine leaders in the right direction in the last four years. Understanding the growing need for trained leaders in quality improvement and patient safety, SHM has been providing courses for quality improvement leaders, as well as practical implementation tools and strategies in quality improvement and patient safety in Web based resource rooms, as well as mentored implementation strategies and expert training that gets results on a local level on the fronts lines where care is delivered and results matter.

Several things are clear right now.

• Hospital CEOs, the rest of the C-suite, medical staffs, and allied health recognize that hospitalists are not only part of their medical landscape, but a potential partner in many of the acute care changes coming to their hospitals.
• We are moving to a time where there is more action than talk about changing the way hospitals and their doctors are paid and what level of performance is expected, to a time where CMS and the Blues are making incremental changes that will reshape the way hospitals function.
• While the first steps may be CMS not paying for “never events” or CEO compensation being tied to patient satisfaction, more likely sooner than later we will see coverage for the 47 million uninsured, a revamping of primary care, a shift to value based purchasing, and with a bundling of payment for inpatient care.
• Some who are near the end of their professional careers may have the luxury of playing out the string and waiting out any changes. For hospitalists who are by and large at the beginning of their careers, and by the very virtue of their practice styles right smack in the middle of the hospital, literally and figuratively, this is not a choice but a destiny. We need to embrace change, prepare for our role, and create a future that works for our patients, our health communities, and ourselves.

And that is why SHM is seeking partners who can accelerate our production of training and strategies for our hospitalists on the front lines. It is why we are talking to hospitals at the American Hospital Association (AHA) and the C-suite at American College of Healthcare Executives (ACHE) and in New York and in Ohio and in the publications they read. It is why SHM is meeting with the PCP community at ACP and AAFP, and why we are trying to shape the rules of the road in quality improvement and patient safety at the ABIM and other certifying boards, at the Joint Commission, National Quality Forum (NQF), and the AMA’s Physician Consortium on Performance Improvement (PCPI). It is why we are looking to the MGMA and the ACPE and others who have a track record of educating, measuring, and credentialing physician leaders and administrators to help SHM craft the next set of resources you need.

There is no status quo any longer in health care. You are either moving forward or out of date and out of touch. Hospital medicine was born into these times of change (some would even say bred because of the necessity to do things differently.) This is our calling and our destiny. This won’t be easy. It never is. And SHM will be with you every step of the way. Just continue to tell us what you need and we will look for innovative ways to do our part on this incredible journey. TH

Dr. Wellikson is the CEO of SHM