Jin Park, MD, is worried. She worries about the health of her patients, her hospital, and her HM group. She frets that the U.S. healthcare system will be too slow to implement must-needed change—the kind of national transformation that will improve care, contain costs, and eliminate political jousting.
“I’m a doctor with more than a decade of experience; I don’t have a personal concern. I have a community concern, a societal concern,” says Dr. Park, one of 17 hospitalists at Adventist Health in Portland, Ore. “I think adversity is good, and given the magnetism of the change, I feel like only the monsters are going to be able to survive. But you can’t just have the Kaiser [Permanentes] and the Monarch [Healthcares] and all these other examples take over the entire country. I mean, that’s not going to happen, right?”
Dr. Park wasn’t the only anxious hospitalist at HM12, held last month at the San Diego Convention Center. She and more than 150 others listened to SHM Public Policy Committee Chair Ron Greeno, MD, MHM, explain in detail the Accountable Care Organization (ACO) program being ramped up by the Centers for Medicare & Medicaid Services (CMS). Dr. Greeno, chief medical officer for Brentwood, Tenn.-based Cogent HMG, outlined how ACOs are designed to change the healthcare payment paradigm.
“They want to change doctors, hospitals, nursing homes, everybody that provides healthcare, from being profit centers to being cost centers,” Dr. Greeno said. “Right now, we’re profit centers. We do something, we get paid; we don’t do it, we don’t get paid. You see a patient, you get paid for that; your hospital admits a patient, you get paid for that. They’re a profit center. Under a [capitation] methodology, everything’s flipped on its head. If we admit a patient, we have to pay for that. We use those dollars; we’re now a cost center.”
For hospitalists, he added, that means making themselves more valuable by providing cost-effective care that translates into a healthier population.
On the Horizon: Systematic Change
While payment reform was a central theme of the annual meeting, another main takeaway was the shift of Medicare from a payor for quantity (fee-for-service) to a payor for quality (value-based purchasing).
It’s “systematically linking quality to payment,” said Patrick Conway, MD, MSc, FAAP, SFHM, a pediatric hospitalist, chief medical officer of CMS, and director of the Office of Clinical Standards and Quality at the U.S. Department of Health and Human Services in Washington, D.C. “We are transitioning to a more value-based purchaser, an active purchaser, and a catalyst for health system change. Our aims: better care for individuals, better health for populations, and lower cost for improvement.”
One in 3 Americans uses Medicare or Medicaid, the nation’s largest provider of healthcare coverage. And that number could rise when health exchanges launch in 2014 as part of the Affordable Care Act (ACA), Dr. Conway said. Combined, the two agencies spend about $800 billion annually. Medicare alone spends more than $1.5 billion per day.
Dr. Conway acknowledged the difficulty in changing the system, especially at the “ground level.” In addition to outlining key CMS’ initiatives, he indicated one of the main goals of his position is to “learn how to scale and spread successful interventions.”
—Ron Greeno, MD, MHM
“Quality can be measured and improved at multiple levels,” he told more than 2,000 hospitalists at the opening keynote address. “We’ve got the individual physician level, the group level, and then the community level. So we’re thinking about these three levels of measurement and how we align across those three levels.”
Dr. Conway, who volunteers for pediatric HM shifts on weekends, said CMS is especially excited about the Center for Medicare and Medicaid Innovation, an ACA creation that is gaining momentum with its Petri-dish-like efforts to improve quality and contain costs.
“We haven’t scaled any of these yet. We’re in testing mode,” Dr. Conway said. “I think the important point is that we have to figure out pre-testing mode, agree on evaluation models, without actuaries, that if these things work, we’re actually able to scale them to the program. This has so much robust support and applications, one could argue that we’re going to have so much interest that, one, it will be difficult to evaluate, but also, depending on how much interest you have, it could almost be at scale out of the gate.”
The Perfect Storm
National elections, Supreme Court activism, and public outrage at an “utterly dysfunctional” Congress: That’s how Norm Ornstein, PhD, MA, resident scholar at the American Enterprise Institute for Public Policy Research and a policy analyst for CBS News, views the day-to-day workings inside the Beltway.
Ornstein explained that “tribalism” is worse now than during any of his 40-plus years in Washington. He doesn’t see it getting any better, either, and wouldn’t be surprised if another wave of voter dissent tips the scales of power this November.
“We are a fairly evenly divided country,” Ornstein said, using a football analogy to describe the major political parties. “The basic reality is the Democratic Party has gravitated over to its own 20- or 25-yard line from its normal place, which was around its 40-yard line. The Republican Party, however, has moved behind its goalpost right now.”
Ornstein said he doesn’t think the U.S. Supreme Court will declare the ACA unconstitutional. Even though he’s skeptical of the conservative-leaning court’s motives, he said, “overturning even the individual mandate doesn’t make a lot of sense.”
Even so, he told hospitalists that the ever-increasing cost of healthcare, combined with America’s aging population, translates into a hostile political climate.
“All of that makes your challenge that much greater,” he said.
No matter what happens in the 2012 elections, Ornstein explained that at the end of December, a political “perfect storm” is brewing.
“Barack Obama will still be the president until Jan. 20, 2013. All of the Bush tax cuts expire the last day of December. The agreement that extended the payroll tax cut, unemployment insurance, and the doc-pay fix also expire at the end of December,” he explained. “Jan. 1, 2013, the Draconian sequesters—mindless, across-the-board cuts in defense and discretionary spending, not sparing any programs, designed to try and force them to the table to reach a broader budget deal but they couldn’t reach—all begin. And that’s $50 billion taken from what is already a pretty tight discretionary domestic budget.
“So fasten your seat belts for what’s going to be an extremely bumpy ride over the next several months, and a very murky picture for what will follow.”
Don’t Give Up
Many hospitalists think advocacy is beyond their pay grade, assuming their voice or idea will get lost in the bureaucracy that is the nation’s capital. Dr. Conway exhorted hospitalists to stay in the fight, partner with hospital administration, and champion quality initiatives.
“We’re all in this together,” he said. “You can understand your hospital’s performance statement, share data within and outside your hospital, be actively engaged in your hospital value-based purchasing programs and inpatient quality reporting. Physician leadership and professionalism, I think, is incredibly important.”