In 2015, reimbursement for physicians in large groups is subject to a value modifier that takes into account the cost and quality of services performed under the Medicare Physician Fee Schedule. By 2017, the modifier will apply to all physicians participating in fee-for-service Medicare.
It’s one more way the Centers for Medicare and Medicaid Services (CMS) and the federal government are attempting to tip the scales on skyrocketing healthcare costs. Their end goal is a focus on better efficiency and less waste in the healthcare system.
But in an environment of top-down measures, hospitalists on the front lines are leading the charge to reduce overuse and overtreatment, slow cost growth, and improve both the quality of care and outcomes for their patients.
“I think the hospitalist movement has prided itself on quality improvement and patient safety in the hospital,” says Chris Moriates, MD, assistant clinical professor in the division of hospital medicine at the University of California San Francisco (UCSF) and co-creator of the cost awareness curriculum for UCSF’s internal medicine residents. “Over the last few years…they are more focused and enthusiastic about looking at value.”
Dr. Moriates leads the UCSF hospitalist division’s High Value Care Committee and is director of implementation initiatives at Costs of Care. He’s also part of a UCSF program that invites all employees to submit ideas for cutting waste in the hospital while maintaining or improving patient care quality. Last year, the winning project tackled unnecessary blood transfusions and at the same time realized $1 million in savings due to lower transfusion rates. This year, the hospital will focus on decreasing money spent on surgical supplies, potentially saving millions of dollars, he says.
A 2012 article in the Journal of the American Medical Association (JAMA) estimates wasteful spending costs the U.S. healthcare system at least $600 billion and potentially more than a trillion dollars annually due to such issues as care coordination and care delivery failures and overtreatment.1 Numerous studies also indicate overtreatment can lead to patient harm.2
“Say a patient gets a prophylactic scan for abdominal pain,” says Vineet Arora, MD, MAPP, a hospitalist on faculty in the University of Chicago’s department of medicine and director of education initiatives for Costs of Care. “The patient gets better, but an incidental finding of the scan is a renal mass. Now, there is a work-up of that mass, the patient gets a biopsy, and they have a bleed. A lot of testing leads to more testing, and more testing can lead to harm.”
—LeRoi S. Hicks, MD, MPH
Doing less is often better, says John Bulger, DO, MBA, SFHM, chief quality officer for the Geisinger Health System in Danville, Pa. Dr. Bulger, who has led SHM’s participation in the Choosing Wisely campaign, cites a September 2014 study in JAMA Internal Medicine, in which Christiana Care Health System—an 1,100-bed tertiary care center in northern Delaware—built best practice telemetry guidelines into its electronic ordering system to help physicians determine when monitoring was appropriate.3 The health system also assembled multidisciplinary teams, which identified when medications warranted telemetry, and equipped nurses with tools to determine when telemetry should be stopped.
Appropriate use of telemetry is one of SHM’s five Choosing Wisely recommendations for adult patient care.
In addition to an overall 70% reduction in telemetry use without negative impact to patient safety, Christiana Care saved $4.8 million. Throughout its inpatient units, Christiana Care utilizes a multidisciplinary team approach to coordinate patient care. Daily rounds are attended by hospitalists, nurses, pharmacists, case managers, social workers, and others to ensure timely and appropriate patient care. The health system’s Value Institute evaluates hospital efforts and assesses process design to improve efficiency and, ultimately, outcomes.