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Physician Payment Reform, P4P, AHRQ


SHM’s Public Policy Committee (PPC) monitors federal legislation and regulations affecting hospital medicine and recommending appropriate action by SHM. SHM works independently and through coalitions with like-minded organizations in pursuit of its policy objectives. This month, I’ll update you on PPC’s major activities in the past six months.

Physician Payment Reform

Late last year, as Congress debated whether to address pending reductions in 2007 Medicare payments to physicians before adjourning, PPC spearheaded a number of activities to influence debate on the issue. These efforts included:

  • Sending a letter from then-SHM President Mary Jo Gorman, MD, MBA, to members of the key health committees, urging lawmakers to take action to avert the scheduled 5% cut in Medicare physician fees and enact a positive payment update that accurately reflects increases in practice costs;
  • Launching a new advocacy tool that allows SHM members to quickly e-mail their members of Congress in opposition to the pending fee cut. In less than two weeks, 130 members sent nearly 390 messages to the U.S. House of Representatives and the Senate; and
  • Lobbying Congress to ensure that any pay-for-reporting program for physicians be voluntary and based on valid measures developed by the medical profession.

The legislation approved by Congress (H.R. 6111) averted the 5% cut, as advocated by SHM, freezing rates at 2006 levels. Continuation of the current payment rates, combined with increases in evaluation and management services proposed by CMS and supported by SHM as part of the five-year review, translated into an average gain per hospitalist of approximately 8.8% on their Medicare billings.

A scheduled 10% cut in 2008 Medicare payments to physicians will dominate this year’s legislative agenda. The PPC will continue to oppose cuts in the physician update and advocate for a more permanent solution to the annual payment reductions caused by the flawed sustainable growth rate.

Pay for Performance

Together with SHM’s Performance and Standards Task Force (PSTF), the PPC has spent countless hours working to position SHM to influence the debate over pay for performance on Capitol Hill and with CMS. This has involved Hill visits by PPC members and staff in addition to conference calls, meetings, and communications with CMS officials. Part of the committee’s role is also to educate SHM members on how their practices will be affected by legislative and regulatory action in this area.

Under the new Physician Quality Reporting Initiative (PQRI) mandated under H.R. 6111, SHM members and other eligible professionals who successfully report quality measures on claims for dates of service from July 1 to Dec. 31 may earn a bonus payment, subject to a cap, of 1.5% of total allowed charges for covered Medicare physician fee schedule services.

Because measures were not originally developed for hospital medicine, PPC, PSTF, and staff actively lobbied CMS and the AMA’s Physician Consortium for Performance Improvement (PCPI) for changes to the measures that would allow wider reporting by SHM members. Significantly, PCPI accepted SHM’s recommendations, paving the way for hospitalist participation in this voluntary program. Had SHM not been at the table, hospitalists would have had only a limited opportunity to qualify for a 1.5% increase in their Medicare payments through participation in the PQRI program. SHM will also take the lead in developing measures on care transitions through the PCPI for 2009, which will position hospital medicine as the premier advocate for this important issue.

Funding for AHRQ

One of SHM’s legislative priorities is to advocate for increased funding for the Agency for Healthcare Research and Quality (AHRQ), whose mission is to improve the quality, safety, efficiency, and effectiveness of healthcare for all Americans. As part of this effort, we participate in the Friends of AHRQ, a voluntary coalition of more than 130 organizations that supports the AHRQ by sending joint letters to key members of Congress, making joint visits to members of Congress and their staff, and holding briefings to demonstrate the importance of AHRQ research.

In March, SHM and 50 other members of the coalition sent a letter to the chairs and ranking members of the House and Senate Appropriations committees recommending that AHRQ receive $350 million in FY 2008, an increase of $31 million over FY 2007. The groups pointed out that while AHRQ is charged with supporting research to improve healthcare quality, reduce costs, advance patient safety, decrease medical errors, eliminate healthcare disparities, and broaden access to essential services, “precarious funding levels threaten the agency’s ability to achieve this important mission, at a time when healthcare costs are at an all-time high.”

Funding for NIH and Other Agencies

SHM also routinely joins with other organizations in urging Congress to increase funding for the National Institutes of Health (NIH) and other public health programs.

A Feb. 26 letter, signed by SHM and 405 other health organizations, urged Congress to increase FY 2008 funding for public health programs by an additional $4 billion, or 7.8%, above the FY 2007 level. The letter states that this increase in the FY 2008 budget for Function 550 discretionary health programs such as NIH, AHRQ, and CDC will “reverse the erosion of support for the continuum of biomedical, behavioral and health services research, community-based disease prevention and health promotion, basic and targeted services for the medically uninsured and those with disabilities, health professions education, and robust regulation of the nation’s food and drug supply.”

Access to Care

Recognizing SHM member interest—and that of the 110th Congress—in initiatives to expand healthcare coverage to the nation’s 47 million uninsured, the PPC is reviewing legislative proposals being considered in this area.

At the committee’s recommendation, SHM sent a letter of support for the Health Partnership Act (S. 325/H.R. 506), which would establish a grant program to promote the development of innovative health coverage initiatives at the state level. In the letter, then-SHM President Mary Jo Gorman, MD, MBA, commended the sponsors for “giving state and local governments the flexibility to test a variety of options for improving access so they can address the unique needs of their uninsured populations.”

She noted that many hospitalist programs exist to manage the burgeoning population of uninsured and underinsured patients who require hospitalization, and offered SHM’s help in moving the bill through Congress.

Grass-roots Advocacy

Politically active members are an organization’s best resource when it comes to influencing healthcare policy on Capitol Hill. Building on the relationships established during SHM’s first Advocacy Day held during the 2006 annual meeting, PPC members traveled to Washington D.C., in February to brief members of Congress and their staffs on SHM’s 2007 legislative priorities, including support for initiatives designed to improve the quality, safety, and cost effectiveness of inpatient medical care.

More than 30 appointments were scheduled with lawmakers and their staffs, many of whom sit on the key congressional committees with jurisdiction over the Medicare and Medicaid programs. Each PPC member had from five to eight visits. They continued the process of educating Congress about the specialty of hospital medicine that began during Advocacy Day and the role of hospitalists in improving the quality of care provided in our nation’s hospitals. It was time well spent. Lawmakers and their staffs were eager to learn about hospital medicine and our support for increased funding for AHRQ, pay-for-reporting, and legislation like the Health Partnership Act.

Allendorf is senior adviser, advocacy and government relations, for SHM.

Hospital Medicine Fast Facts

Staffing by the Numbers

  • On average, a hospital medicine group employs 8.0 FTE physicians.
  • 16% of hospital medicine groups employ physician assistants (PAs); these groups employ an average of 2.0 FTE PAs.
  • 20% of hospital medicine groups employ nurse practitioners. (NPs); these groups employ an average of 1.9 FTE NPs.
  • 9% of hospital medicine groups employ other clinical staff; these groups employ an average of 3.1 FTE other clinical staff.
  • 51% of hospital medicine groups employ non-clinical staff; these groups employ an average of 1.7 FTE non-clinical staff.
  • Between 2004 and 2005, the average growth in staff was 29%

To order a copy of the “SHM Bi-Annual Survey on the State of the Hospital Medicine Movement,” visit or call toll free: (800) 843-3360.

New Task Force, New Chair, Improved Patient Care

SHM’s HQPS Committee makes tremendous progress

By Shannon Roach

The past year has been successful and productive for the SHM Health Quality and Patient Safety (HQPS) Committee. Under the leadership of Lakshmi Halasyamani, MD, HQPS has strengthened its national leadership role in inpatient quality improvement efforts, most notably in the areas of reducing DVTs, improving glycemic control and management of patients with heart failure. Additionally, HQPS has strengthened relationships with partner organizations and created new alliances. HQPS has participated in the development of training activities and clinical support tools for quality improvement efforts.

Hand-Off Standards

The Hand-Off Standards and Communication Task Force was formed to create a formally recognized set of standards for ensuring optimum communication and continuity of care at the end of a medical professional’s shift or a patient’s change in service. The standards ensure that care is coordinated and that important clinical care issues are effectively managed. The development methodology mirrors that of the Discharge Planning Checklist and includes a literature review, panel of experts, presentation to and input from membership. Vineet Arora, MD, has led this development in collaboration with Sunil Kripalani, MD, Efren Manjarrez, MD, Dan Dressler, MD, Preetha Basaviah, MD, and Lakshmi Halasyamani, MD.

The Hand-Off Standards checklist was unveiled at the 2007 Annual Meeting from May 23-25 in Dallas, where attendees reviewed and voted on the standards in order to provide the Task Force with a final draft to present to the Expert Panel for a final review. Effective hand-offs require program policy, verbal exchange, and content exchange. A research agenda was also proposed to evaluate these standards rigorously, put emphasis on controlled interventions, and to encourage SHM and other organizations to fund research and innovations in this area.

Medication Reconciliation

The Medication Reconciliation Task Force is charged with understanding the state of and leading work related to Medication Reconciliation. In support of that, the Task Force submitted a grant proposal to AHRQ to provide funding for a multidisciplinary conference to identify barriers and develop strategies for Quality Improvement in this area.

Heart Failure

Dr. Halasyamani, former HQPS chair, was a key participant in the development of the Heart Failure Resource Room, which launched in February 2006. As part of the Heart Failure Education and Quality Improvement Initiative, there have been both clinical tools and CME/CE additions to this Web-based resource (visit and click “Quality & Safety” then click “Quality Improvement Resource Rooms”). The Quality Improvement Workbook, the Palliative Care CME Module, and Didactic Slide Sets are all housed in the Resource Room along with the recently developed Clinical Tools focusing on Team Communication, Discharge Planning and Polypharmacy.

The Tools include an Inpatient Goal Sheet, a Hospitalist Admission and Daily Rounding Checklist, a Conceptual Model for Teamwork, two reference guides: Patient Education and High Risk Medications for the Heart Failure Patient, and Heart Failure, specific elements of which were integrated into the SHM Discharge Planning Checklist.

Additional CME/CE modules have also been integrated into the Heart Failure Resource Room: Palliative Care for Patients with Heart Failure and Optimizing the Heart Failure Discharge Transition.

A CD-ROM including all these new resources was given to attendees of the Annual Meeting.

Building Partnerships

HQPS has been strengthening partnerships with other professional, regulatory and advocacy groups. These partnerships are intended to improve safety and take a leadership role in setting the national agenda for key quality improvement areas. We now have official liaisons with Academy of Health-System Pharmacists (AHSP), National Transitions of Care Coalition (NTOCC), Institute for Healthcare Improvement (IHI), and Transforming Care at the Bedside (TCAB).

HQPS members also serve as leaders in national efforts to define and improve care transitions including the American Board of Internal Medicine’s Stepping up to the Plate program, and Hartford’s Safe Steps.

HQPS: New Horizons, New Leadership

By Janet Nagamine, MD

It is an honor to serve as the new chair for SHM’s Health Quality and Patient Safety (HQPS) Committee. Dr. Halasyamani has done a tremendous job of developing the committee and getting current initiatives under way. We will continue to support current initiatives with a emphasis on strengthening the relationships and alliances with partner organizations and hospitals so we can take our work from project-level initiatives to system-level initiatives.

System-Level Improvement

I am often asked by hospital administrators in all types of hospital settings, “How do I get physicians on board and engaged as a partner in our quality and safety initiatives?” My response is that many hospitalist physicians are already active members and leaders of committees and initiatives. Some hospitalists would like to be more involved but find little time because most hospitals lack an infrastructure conducive to making this happen.

Hospitals are our “office,” and we are invested in how well the hospital operates. Although it is common for hospitalists to participate on numerous committees, we often lack formal titles or ties to the Quality Department or formal organizational structure. The traditional hospital structure worked better when our role was limited to the occasional P&T committees or peer review, but our level of involvement has evolved into a much larger scope. We are now integrally involved in The Joint Commission Patient Safety Goals, Core Indicators, Pay For Performance, Get with the Guidelines, Rapid Response Teams, Glycemic Control and VTE Prophylaxis initiatives—to name a few.

It is hard to make a significant impact when you rely solely on volunteer committee time to do the work on major initiatives like medication reconciliation, which crosses many department lines. While I wholeheartedly believe it is our professional responsibility to take interest in and volunteer on committees, the scope of the work to be done makes this model unsustainable. hospitalists spend long hours (often 12 hours a day) taking care of acutely ill patients, which leaves little time to develop initiatives, attend meetings, and implement the work of major quality and safety efforts. Yet they are still very involved.

Alignment and support at the organizational level are critical to physician engagement and success in quality improvement and patient safety efforts. Many hospitalists spend numerous hours trying to get initiatives off the ground, only to hit a stumbling block and not succeed. Experiences such as these will certainly affect their willingness to participate in future initiatives. While most hospital administrators and staff find that hospitalists have greatly improved the work environment, we can find better ways to create opportunities for system-level improvement. TH

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