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Affordable Care Act Calls on Hospitalists to Hone Skills


Specifically, What the ACA Means to Hospitalists

Many of the buzzwords being bandied about in discussions of the Affordable Care Act, or ACA, already are familiar to hospitalists. HM providers regularly operate in an interdisciplinary environment and have been leading the charge in quality improvement initiatives over the past few years. But as the ACA kicks into high gear, hospitalists say it will ramp up the emphasis on tighter cost controls (especially identifying and eliminating waste), greater efficiency, and smoother transitions of care.

Supporters of the law have advanced the moral and ethical argument that everyone deserves at least basic healthcare.

“Money is not going to magically appear to pay for that,”

Dr. Hilger says. “So we’re all responsible for looking at what we do and where’s the waste in the system to help improve the care for the most at-risk patients.”

Some fundamentals of the work environment haven’t changed dramatically.

“Even before the ACA, there were core measures and coding and documentation requirements,” Dr. Hilger says. What’s different now, he says, is an added sense of urgency in scrutinizing quality and cost. That expectation may be especially acute for HM providers. “I think there’s a lot of pressure on hospitalists because organizations and hospitals are expecting us to be the primary care doctors in the hospital and to eliminate waste,” he says. That mandate dovetails with campaigns like Choosing Wisely that ask doctors to ponder the necessity of often overused or misused tests and procedures.

There’s going to be two steps forward, one step back, but the simple question is: Was it ever OK to have tens of millions of patients who had no insurance or were underinsured and were using the emergency room as their primary care? I think, no matter what your political affiliation, that, in general, the answer is no.

—Rick Hilger, MD, SFHM,medical director for care management, Regions Hospital, St. Paul, Minn., hospitalist, HealthPartners, member, SHM Public Policy Committee.

Another area of added emphasis is transitioning patients out of the hospital in a high-quality, low-cost way.

“That’s something we should have been doing 10 years ago,” Dr. Hilger says. “So that’s definitely a trend in the right direction that the ACA is helping to further.”

In effect, the heightened profile of ACOs, the rise of quality-based metrics, and the shift toward pay-for-performance models are extending the expectations around what happens to patients before, during, and after a hospital stay.

“We’re expected to not only provide excellent care to the patient while they’re in the hospital, but we’re expected to make sure that there is a good transition plan at discharge,” Dr. Hilger explains. “We’re expected to make sure that the patient has appropriate appointments lined up, that they’re getting appropriate services either at home or that we try to get them appropriately to a skilled nursing facility.”

Dr. Lenchus says a major objective of healthcare reform—at least in principle—is to devote more energy to preventive care to help ward off more expensive acute care.

“If we assume the hypothesis that the ACA really tries to keep people out of the hospital, that makes their time in the hospital that much more focused and concentrated, to the point where quality, cost control, and efficiency are really going to come into play,” he says.

And, at least initially, patients who have chronic conditions or were excluded from the healthcare system due to pre-existing illnesses or an inability to pay are likely to be clamoring for access the most. Consequently, those who do end up in the hospital will require more complex care.

“With respect to the workload, I believe we’ll see patients who are farther along in their disease process, in more acute, more dire need for healthcare,” Dr. Lenchus says.

Providers already accustomed to working in teams to improve quality and to communicating with a hospital’s chief medical officer and other C-suite executives over matters of cost will have a clear advantage.

“The ACA is not perfect, and it’s going to take time to figure out what works and what doesn’t, but what we have control over on a daily basis is to really focus on high-quality, low-cost, standardized best practices,” Dr. Hilger says.

What does that mean in practice? “Really work on perfecting or maximizing your transitions of care,” he says. “Really work with care management and social workers, and work with your hospital to try to develop relationships—if you haven’t already—with the primary care systems in your community.”

Bryn Nelson is a freelance medical writer in Seattle.

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