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.