Lucrative Changes to E&M Codes
One provision directly impacting hospitalists is MIPPA’s changes to payments for inpatient evaluation and management codes (E&M codes). According to Laura Allendorf, SHM’s senior advisor for advocacy and government affairs, this change will result in an estimated 3% average gain in total Medicare payments to hospitalists, or $5,000 to $6,000 annually—on top of the 1.1% payment update. (It’s important to note the final 2009 physician fee schedule, published in November, could change the overall impact for individual members.) E&M payments from some private payers also could increase, since many base their fees on Medicare’s fee schedule.
Quality Research Initiatives
MIPPA requires the establishment or continuation of several quality research initiatives, designed to help CMS determine new models of efficiency of care and cost efficiency.
One of these initiatives is Patient-Centered Medical Home (PCMH), a care model that facilitates partnerships between individual patients and their personal physicians, and when appropriate, the patient’s family. Care is facilitated by registries, information technology, health information exchange, and other means to assure patients get the indicated care when and where they need and want it in a culturally and linguistically appropriate manner. MIPPA grants new funding and expanded authority for CMS’ Medical Home Demonstration Project—if certain quality and/or savings targets are achieved.
“We’ve talked a bit about Patient-Centered Medical Home,” says Dr. Flansbaum of SHM’s Public Policy Committee. “From a political standpoint, it’s a feel-good agenda item with a lot of bipartisan support. The notion of this is here, but operationalizing it—getting it to work—is an entirely different story.” By definition, PCMH will revolve around primary care physicians, and the role and responsibilities of any hospitalists involved is yet unknown—as is the reimbursement model. “This is so far away right now, it’s a notion that needs to be turned into a theory that needs to be turned into a paradigm, to paraphrase Woody Allen,” Dr. Flansbaum says.
Another initiative greenlighted by MIPPA is comparative effectiveness research, or CER. It examines the effectiveness of different therapies for a specific medical condition, or for a specific set of patients, to determine the best option. It may involve comparing competing medications, or may analyze different treatment approaches such as surgery, devices, and drug therapies. MIPPA requires the Institute of Medicine report on best practices for the review of comparative effectiveness research and the development of clinical protocols.
“Obviously, the medical device companies and the pharmaceutical companies are against this,” Dr. Flansbaum says. “But it would be helpful for physicians, because it would give some guidance in certain gray-area treatments, such as: Is this drug appropriate in treating an end-stage cancer patient?” And as far as the nation’s health care system goes, he explains, “I think we need comparative effectiveness. We can’t continue as we are—on the net, we’re going broke—our current healthcare system can’t afford to keep going.”
Not the Only Game in Town
One interesting provision of MIPPA revokes “the unique authority of the Joint Commission to deem hospitals in compliance with the Medicare Conditions of Participation,” meaning hospital compliance is an open market—subject to approval from CMS, of course.
“The Joint Commission has been the gold standard for hospitals for a long, long time,” Dr. Flansbaum points out. “Now that they’ve opened that up, DNV (Det Norske Veritas Healthcare, Inc.) [for example], can compete with the Joint Commission to certify hospitals.”
What will this mean for hospitals? Probably not much in the short term. “I believe only 15 hospitals have DNV certifications, and that all of those also have a Joint Commission certification,” Dr. Flansbaum says, adding “[DNV and the Joint Commission] have a different approach; it’s like the ACT and the SAT. Both are used for college entrance exams, but the SAT is still mostly the gold standard, like the Joint Commission. But who knows? That could change … and if it does, well, competition is good.”