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SuperDocs and Quality Talks: Notes from the Annual Meeting of the Society of Hospital Medicine

Bob Wachter

I’m just back from the annual meeting of the Society of Hospital Medicine and, as usual, I was blown away. I’ve not seen a medical society meeting that is remotely like it.
As Win Whitcomb, who co-founded SHM, wrote to me, the meeting is “a mix of love, deep sense of purpose, community, mission, changing-the world, and just plain sizzle,” and I completely agree. I was also amazed by the size: having hosted the first hospitalist meeting in 1997, with about 100 people, seeing an audience of 3,600 fill a Las Vegas mega-ballroom was just plain awesome.

This enthusiasm did not equal smugness. Folks know that change is the order of the day, and with it will come upheaval and some unpleasantness. But the general attitude I sensed at the meeting was that change is likelier to be good for patients – and for the specialty – than bad. Whether this will ultimately be true is up in the air, but the mindset is awfully energizing to be around.

Here, in no particular order, is my take on a few of the issues that generated hallway buzz during the SHM meeting.

The Closing of Hospitals

While much is uncertain in the era of health reform, the number of hospitals is clearly going to shrink, perhaps by a lot. A healthcare system that tolerated the inefficiency of having two mediocre 125-bed hospitals in adjacent towns will no longer do so: one 200-bed hospital will be left standing when the dust settles.

If that.

The betting is that 10-20% of hospital bed capacity will be taken out of the system in the next few years. It could be even more, depending on the answers to several questions. Will electronic monitoring and telemedicine allow increasing numbers of sick patients to be cared for at home or in sub-acute settings?

Will payments for non-hospital care (home care, SNFs) be enough to expand their capacity to care for acutely ill patients?

Will ACOs, bundling, and other similar interventions truly flourish? Will a shift to population health and a new focus on wellness make a dent in the prevalence of chronic disease?

These are just some of the known unknowns.

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Unpacking the Doc Fix

If you blinked on Thursday, you might’ve missed the House passing the latest Medicare’doc fix’ (see here for its 30-seconds of deliberation).

After posting the bill in the wee hours of Wednesday morning, House leaders faced opposition over its stop-gap approach and some of the cuts employed to offset the cost of the bill. With some arm-twisting, they managed to suppress objections for the handful of seconds necessary to hammer the gavel and call it done.

The Senate is due to take the bill up Monday evening, and it is highly likely to pass (this time it should actually get a vote). Since it is about to become the law of the land, let’s take a look at what’s inside. There’s a little slice of fun in here for everyone.

First and, theoretically, foremost, the bill blocks the pending cuts to doctors under the long-broken Sustainable Growth Rate (SGR)  formula. It would maintain existing physician pay rates for another twelve months, through March 31, 2015.

Not coincidentally, a vote to raise the debt limit will likely come due again at about that time.

Second, the bill continues, for a comparable period, the package of so-called Medicare extenders: a hodge podge of policies that boost payments in rural areas, suspend caps on certain benefits and other otherwise sunsetting policies that each have their niche constituencies. Many of these items have been reauthorized by Congress for over 15 years.

Third, the bill includes some new policies that put out fires of their own, or effectuate high priority programs for well-placed Members of Congress. These include:

  • An additional six month extension of the Two Midnights Rule, which drew a bright line distinction between presumptive inpatient and outpatient hospital stays but has created significant confusion and objections among many hospitals;
  • A one-year delay of ICD-10 implementation, to October 1, 2015 (this is the second time Congress has acted to delay ICD-10);
  • Elimination of the ACA cap on deductibles for employer-sponsored health plans; and
  • Two provisions aiming to improve mental health services, including the Excellence in Mental Health Act that, among other things, improves funding for community mental health centers.

Woah, some of you are saying. Dial back to that 2nd bullet. While the transition to ICD-10 has been controversial since it was first proposed in 2005, just last month CMS Administrator Tavenner said there would be no more delays (last year, the Administration voluntarily delayed the program from 2013 to 2014).

Healthcare providers have been battening down the hatches and preparing for this colossal transition from ICD-9 and its 14,000 codes to ICD-10 and its 69,000. Word on the street is that the provision was included primarily to earn cred with specialty physician groups, whose support for the bill was in question for concern about other provisions (see the bullet re: misvalued – aka overvalued – codes below).

Turns out, the specialty doc associations by and large opposed the bill anyway, and the healthcare sector is now left grappling with this unexpected turn.

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What the Work of the Inspector General Tells Us about Patient Safety…

March 2nd through the 8th were National Patient Safety Awareness Week – I don’t really know what that means either.  We seem to have a lot of these kinds of days and weeks – my daughters pointed out that March 4 was National Pancake Day – with resultant implications for our family meals.

But back to patient safety and National Patient Safety Awareness Week. In recognition, I thought it would be useful to talk about one organization that is doing so much to raise our awareness of the issues of patient safety.  Which organization is this?  Who seems to be leading the charge, reminding us of the urgent, unfinished agenda around patient safety?

It’s an unlikely one:  The Office of the Inspector General of the Department of Health and Human Services.  Yes, the OIG.  This oversight agency strikes fear into the hearts of bureaucrats: OIG usually goes after improper behavior of federal employees, investigates fraud, and makes sure your tax dollars are being used for the purposes Congress intended.

In 2006, Congress asked the OIG to examine how often “never events” occur and whether the Centers for Medicare and Medicaid Services (CMS) adequately denies payments for them.  The OIG took this Congressional request to heart and has, at least in my mind, used it for far greater good:  to begin to look at issues of patient safety far more broadly.

Taken from one lens, the OIG’s approach makes sense:  the federal government spends hundreds of billions of dollars on healthcare for older and disabled Americans and Congress obviously never intended those dollars pay for harmful care.  So, the OIG thinks patient safety is part of its role in oversight, and thank goodness it does.

Because in a world where patient safety gets a lot of discussion but much less action, the OIG keeps the issue on the front burner, reminding us of the human toll of inaction.

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An “F” for Quality

Huge numbers of older persons transition from hospitals to the nursing home.  Often, an older hospitalized patient needs skilled nursing care before they are ready to return home.  In other cases, a nursing home patient who needed hospitalization is returning to the nursing home.  Older patients and their families certainly hope that great communication between the hospital and nursing home would assure a seamless transition in care.

But a rather stunning study in the Journal of the American Geriatrics Society suggests the quality of communication between the hospital and the nursing home is horrendous.  The study was led by researchers from the University of Wisconsin, including nurse researcher, Dr. Barbara King and Geriatrician Dr. Amy Kind.

The authors conducted interviews and focus groups with 27 front line nurses in skilled nursing facilities.  These nurses noted that very difficult transitions were the norm.  Sadly, when asked to give the details of a good transition, none of the nurses were able to think of an example.

Most of the nurses felt that they were left clueless about what happened to the their patient in the hospital.  They lacked essential details about their patient’s clinical status.  The problem was not the lack of paper work that accompanied the patient.  In fact, nurses often received reams of paper work, often over 80 pages.  The problem is that the paper work was generally full of meaningless gibberish such as surgical flow sheets that told little about what was actually going on.

Often the transfer information had errors, conflicted with what the facility was told before the transfer, and lacked accurate information about medications.

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The Bounce Back Effect

Critically ill Medicare patients, who are battling for stable health at the end of life, are victims of repeated hospitalizations, especially after being discharged to a skilled nursing facility (SNF).  The cycle of hospitalizations is an indicator of poor care coordination and discharge planning – causing the patient to get sicker after every “bounce back” to the hospital.  Total spending for SNF care was approximately $31 billion in 2011; with an estimated one in four patients being re-hospitalized within thirty days of discharge to a SNF.[1]

Each readmission leads to further test and treatments, higher health care costs, and most importantly, patient suffering.  It is hard to imagine that patients would prefer to spend their last few months of life shuttling from one healthcare setting to another and receiving aggressive interventions that have little benefit to their quality and longevity of life.  The heroic potential of medical care should not compromise the patient’s opportunity to die with dignity.   A hospital is not a place to die.

Medicare beneficiaries are eligible to receive post-acute care at SNFs, after a three day hospital admission stay.  SNFs provide skilled services such as post-medical or post-surgical rehabilitation, wound care, intravenous medication and necessities that support basic activities of daily living.  Medicare Part A covers the cost of SNF services for a maximum of 100 days, with a co-payment of $148/day assessed to the patient after the 20th day.  If a patient stops receiving skilled care for more than 30 days, then a new three day hospital stay is required to qualify for the allotted SNF care days that remain on the original 100 day benefit.  However, if the patient stops receiving care for at least 60 days in a row, then the patient is eligible for a new 100 day benefit period after the required three day hospital admission.[1]  It is evident that the eligibility for the Medicare SNF benefit is dependent on hospitalizations – many of which may be a formality and a source of unnecessary costs.

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