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Hospital Medicine’s Role in Healthcare System Under Affordable Care Act Takes Shape


 

David Longworth, MD, Cleveland Clinic, speaks during a breakout session called “Accountable Care Organizations and Hospital Medicine.

David Longworth, MD, Cleveland Clinic, speaks during a breakout session called “Accountable Care Organizations and Hospital Medicine.”

LAS VEGAS—As America’s favorite pastime began a new season, hospitalists from all parts of the country engaged in a variety of healthcare policy discussions at HM14. That’s why the baseball analogy that SHM advocacy guru Ron Greeno, MD, MHM, used to describe how far along the industry is in implementing the Affordable Care Act (ACA) was particularly fitting: “We’re in the first inning,” he said.

So, while hospitalists are dealing with myriad policy issues stemming from the generational healthcare reform legislation colloquially referred to as “Obamacare,” policy experts at HM14 noted that hospitalists can help control how changes will be incorporated into day-to-day care delivery.

“I want to decrease people’s fear about the role of hospitalists in the healthcare system of the future,” said Dr. Greeno, chief medical officer of Cogent Healthcare in Brentwood, Tenn., and chair of SHM’s Public Policy Committee. “They should feel just the opposite of fear. There is unbelievable opportunity for hospitalists in the realigned healthcare system.”

At a base level, the ACA is codifying and prodding healthcare’s move away from fee-for-service payments to compensation based on the health of a given population. Over time, that shift will reward value, not simply pay up for procedures and tests, Dr. Greeno said.

As an example, he explained, “If we prevent a readmission in a fee-for-service world, there are hospitals that tell us that that actually hurts them; they need that admission. In a population health environment ... if you prevent a readmission, that’s wonderful thing. That’s a hospitalization that did not occur. That creates tremendous value.”

SHM CEO Larry Wellikson, MD, SFHM, said hospitalists not only provide that value on the ground, but also have a strong voice in Washington, D.C. That is especially true with hospitalist Patrick Conway, MD, MSc, FAAP, MHM, who serves as chief medical officer for the Centers for Medicare & Medicaid Services (CMS). Dr. Conway is the former chair of SHM’s Public Policy Committee.

“We’re a young organization with no budget and no power, and we get to have a face-to-face conversation with the guy that’s running Medicare,” Dr. Wellikson said. “Five or six hospitalists from SHM sit on our Public Policy Committee and think about how to fix the observation unit, and the next thing you know it becomes [part] of the regulations and changes things. We’re not your ordinary society.”

Robert Wachter, MD, MHM, also noted that the specialty is waiting to see if the U.S. Senate will approve President Obama’s nomination of Boston hospitalist Vivek Murthy, MD, MBA, as surgeon general of the United States. Dr. Murthy has been a strong supporter of the ACA, but a vote on his approval is being held up by Congress members who are concerned he will use the position as a bully pulpit against gun control, a claim he has denied.

Dr. Wachter explains why Congress might hold up hospitalist Vivek Murthy’s nomination to be next U.S. Surgeon General.

Dr. Wachter explains why Congress might hold up hospitalist Vivek Murthy’s nomination to be next U.S. Surgeon General.

Dr. Wellikson added that when lobbying for continued changes to healthcare rules, SHM tries to focus on providing assistance, not asking for handouts. That will likely be a big focus next year, as the annual meeting returns to a suburb of Washington, D.C., with an expectation that hundreds of hospitalists will participate in the “Hospitalists on the Hill” advocacy event.

“We never go to Washington and ask for more power for hospitals or more money for hospitalists,” Dr. Wellikson said. “When we go to Washington, we say, ‘Things are changing in the system. How can we be a part of that change?’

“And that makes us very, very different.”

To be sure, not everyone at HM14 had the rosiest view on Obamacare and how it will play out in the next few years from a policy perspective. Scott Gottlieb, MD, a practicing physician, U.S. Food and Drug Administration alumni, and American Enterprise Institute fellow, said that the financial repercussions of reforms will reduce costs.

“That might affect hospitalist employment, or the hospitalists are going to have to take on new responsibilities to try to make up for services that hospitals might be shedding,” Dr. Gottlieb said. “But if I were trying to pick a growth industry right now, it would be restructuring distressed hospitals. That’s what’s going to happen in five years.”

Dr. Gottlieb, a frequent contributor to Fox News, said that while many political conservatives argue that Obamacare is driving all of the healthcare problems, many underlying components of the ACA have support from Republicans and Democrats, including proposed reforms to Medicare’s sustainable growth rate (SGR) formula.

“It’s hard to just blame Obamacare for this,” he said. “The SGR bill, which is coming out of a Republican-led House and has bipartisan support, codifies major elements of Obamacare that, frankly, I’ve been criticizing for the last four years.”

Dr. Gottlieb believes that risk sharing has to improve for healthcare reform to be embraced by the best-performing doctors. Bundled payments, for example, shift nearly all of the payment risk onto physicians, because their revenue will be capped at a point, regardless of the cost of services rendered, Dr. Gottlieb said.

“I think, ultimately, as physicians, we should be fearful of payment models that put a lot of the financial risk on physicians without ways to offset some of that risk and without tools to manage it well,” he added.

“I want to decrease people’s fear about the role of hospitalists in the healthcare system of the future. They should feel just the opposite of fear. There is unbelievable opportunity for hospitalists in the realigned healthcare system.”

—Dr. Greeno

HM14 keynote speaker and healthcare futurist Ian Morrison, PhD, said he believes that Obamacare will spur local health systems to merge, until just 100 to 200 regional or super-regional systems exist. Consolidation, he noted, ultimately will reduce the number of health systems to between 50 and 75 nationwide.

“Everybody understands we need to reform the delivery system,” Dr. Morrison said, adding that he wants hospitalists to “have an increased interest in public policy and advocate for the things that we believe in, which is better patient care and better outcomes for patients.”

With reference to Dr. Greeno’s analogy that Obamacare is a baseball game in the first inning, Dr. Morrison said he believes that all HM14 attendees will deal with policy implications of the ACA until the end of their careers. And while those changes are often frustrating, he said one of the core themes—a more unified healthcare delivery system focused on value—is for the greater good.

“The unintended consequences are going to be felt for decades,” he said. “But there are parts of it that would be very hard for anybody to disagree with: that we need to have more alignment in terms of other providers and with hospitals.”

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