Troy Brown

April 03, 2012

April 3, 2012 (San Diego, California) — The Affordable Care Act has changed the delivery of healthcare forever. Specific provisions, such as those concerned with readmissions and the bundling of payments, are being featured here at Hospital Medicine 2012: Society of Hospital Medicine Annual Meeting.

Patrick H. Conway, MD, MSc, FAAP, SFHM, chief medical officer and director of the Office of Clinical Standards and Quality at the Centers for Medicare & Medicaid Services (CMS) in Baltimore, Maryland, spoke to a standing-room-only audience about how the Affordable Care Act affects the practice of hospital medicine and ways that hospitalists can help improve the delivery of healthcare.

The CMS is the largest purchaser of healthcare in the world. Combined, Medicare and Medicaid spend approximately $800 billion a year, insuring about 1 in every 3 Americans and making $1.5 billion in benefit payments each day, said Dr. Conway.

"Historically, Medicare was a large claims-processing shop. We are now...transitioning to more of a value-based purchaser, an active purchaser, and a catalyst for change," said Dr. Conway.

The aims of the National Quality Strategy are to achieve better health for the population, better care for individuals, and lower costs, he explained.

Eliminating Outdated Regulations

One of the accomplishments of the CMS has been to revise conditions of participation for hospitals and 15 other types of providers, removing regulations that no longer make sense. For instance, in the past, when patients were admitted to the hospital, they weren't allowed to take their medications from home. Now patients or their caregivers will be allowed to self-administer medications during hospital stays. The CMS will look at other settings next, including home health and nursing homes.

Removing these types of outdated rules is expected to save more than $1 billion per year and to improve quality and safety standards.

Quality Measurement

The CMS has a wide array of quality reporting and performance programs that address hospital quality, physician quality reporting, postacute care, and other setting quality reporting, payment model reporting, and "population" quality reporting. All of these programs originated from statutes and have statutory authority, explained Dr. Conway.

The CMS is aligning its quality measures with the National Quality Strategy priorities released in 2010. These are clinical quality of care, care coordination, population/community health, efficiency and cost reduction, safety, and person- and caregiver-centered experience.

To achieve the goals of the National Quality Strategy, quality should be measured and improved at the individual physician level, the practice setting level, and the community level. Dr. Conway noted that most improvement happens at the group level rather than at the individual physician level. Quality measures should be aligned across programs whenever possible.

Aligned Payment Incentives and Value-Based Purchasing

"Value-based purchasing is essentially rewarding providers and health systems that provide better outcomes in health and healthcare at lower cost to the beneficiaries and communities they serve," said Dr. Conway. Hospital value-based purchasing has some components that are positive, but there are still opportunities for growth, he said. The program gives performance scores for clinical process of care measures and patient experience of care dimensions, with points awarded for achievement and improvement.

"Congress gave us the flexibility in hospital value-based purchasing to reward improvement or reward achievement, and I think that's critical. [With] other programs...we were not given that flexibility," said Dr. Conway.

"On patient experience, we're also trying to select measures more along the lines of communication and patient discharge planning, and less 'did you like the lobby', etc.," he said.

Readmission Program Overhaul

The readmissions program is much less flexible, with payment reduction for readmissions within 30 days of discharge, rather than financial reward, as its cornerstone. For now, the program focuses on hospitals, but in the future, Dr. Conway believes it should include all healthcare settings, such as postacute care centers. The program currently addresses acute myocardial infarction, congestive heart failure, and pneumonia; more conditions will be added later. The goal is not to eliminate readmissions, but to reduce them overall.

Dr. Conway described other CMS-based programs.

The Community-Based Care Transitions Program, written into legislation, dedicates $500 million over 5 years to improve the transitions of Medicare beneficiaries from inpatient hospital care to home or other healthcare settings.

Accountable care organizations (ACOs) are groups of providers that are concerned with achieving better health and better care at lower costs. The primary ACO is the Medicare Shared Savings Program.

Bundled payment projects comprise a 3-year initiative that was implemented by the Center for Medicare and Medicaid Innovation, and are an effective component of a larger strategy, Dr. Conway explained. "If it works, we can scale it across the country," he said. This program has enjoyed a great deal of interest, and this is encouraging. "Depending on how much interest you have, you could almost be at scale right out of the gates," said Dr. Conway.

In an interview with Medscape Medical News, Dr. Conway explained that "to have the implementation of the Affordable Care Act go as well as possible, I think we need to engage with front-line clinicians and physicians. Conversely, we need clinicians and physicians to engage both in the policy process and in changing their local systems of care."

He explained that incentives and rewards should be part of the approach. "It's essentially making the right thing to do something that is also financially rewarding. If you invest in care coordination and you decrease readmissions, or people have better health outcomes, we should reward you for that, from a payment perspective," Dr. Conway explained.

"Clinicians should go forward with implementing changes in their health system along the lines of better health, better care, and lower cost. Those principles will still be important in our health system going forward," Dr. Conway said.

There are many ways of doing this, he explained. Physicians should partner with their hospitals, using all of the resources at their disposal to improve healthcare delivery. It's important for physicians to continue seeing patients and providing excellent care, but they should also lead system improvements in their local healthcare systems, said Dr. Conway. He encourages physicians to engage in their hospitals' value-based purchasing programs and to work with the Society of Hospital Medicine to develop innovative models for the delivery of healthcare.

Norman J. Ornstein, PhD, MA, BA, from the American Enterprise Institute for Public Policy Research in Washington, DC, followed Dr. Conway's session with a presentation on making health policy in an age of dysfunctional politics. He shared his thoughts on the future of hospital medicine in light of the current uncertainty about the viability of the Affordable Care Act in an interview with Medscape Medical News.

"You have to operate as if the law is going to continue in place. I don't think there's any choice in the matter. We also have to realize that the vast bulk of changes we're going to see in the world of hospital medicine are going to occur whether we have the Affordable Care Act or not. The continuing pressures on cost mean that we're going to see consolidation, and that means probably fewer hospitals. Some of those community hospitals are going to go," said Dr. Ornstein.

"There's going to be more vertical integration and there's going to be a different set of people telling you what to do and how to save money. Almost certainly, compensation is going to go down, as pressures are going to be there on provider pay. It's incumbent on everybody doing this to try to figure out how they can make their own innovations that will enable them to do their jobs and not get ground under in the process," said Dr. Ornstein.

"The other thing to keep in mind is that even if we have some research that shows that health [information technology] is not going to be the magic bullet that people thought, we're going to continue to move forward with technology to try to bring greater efficiencies to this process. Figuring out how to do that and even making some initial investment and commitment makes a lot of sense, too," said Dr. Ornstein.

Dr. Conway has disclosed no relevant financial relationships. Dr. Ornstein is a board member of UCB.

Hospital Medicine 2012: Society of Hospital Medicine (SHM) Annual Meeting. Presented April 2, 2012.

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