In fact, a widely publicized study in the Annals of Internal Medicine this year has caused a good deal of hand-wringing, as it suggests that HM-driven efficiency improvements may simply be attributable to shifting costs elsewhere because their patients tend to have higher readmission rates.1
That finding highlights a defining challenge of healthcare reform: how to achieve better value (quality per unit cost) within a care delivery and payment infrastructure that still pays for fragmented care. That infrastructure is trying to achieve the integration that is needed—both in the hospital and post-discharge, with preventive and acute care, at the individual patient and population levels.
“We’re being asked to prepare for an entirely different system, one which cares for populations of patients and tries to keep them out of the hospital,” Dr. Greeno says, “but our payment encourages just the opposite.”
Transitioning to value-based models while still functioning largely in a volume-based, fee-for-service environment is much like having one foot on the dock and one foot on a boat that is leaving the dock. That’s how the American Hospital Association put it in a report it released in September, “Hospitals and Care Systems of the Future.” Providers are struggling to navigate “life in the gap” between a volume-based “first curve” environment that inadequately rewards innovation and a “second curve” environment in which reimbursement is integrally tied to delivering coordinated care that demonstrates value, the AHA notes, using terminology coined by healthcare futurist Ian Morrison.
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Hospitalists will need to seize collaborative opportunities with hospitals to develop strategies to navigate this “life in the gap” during the transition to value-based reimbursement models of the second curve. As Jeff Glasheen, MD, SFHM, physician editor of The Hospitalist, provocatively wrote in his September 2011 column: “We must improve the quality of care to levels that, if necessary, Medicare would happily pay more for. This must be our singular goal” (see “Fiddling As HM Burns,” The Hospitalist). Assuming that money will follow quality, hospitals should be willing to invest in hospitalist-led processes and safety improvement activities, which likely will be the standard of care tomorrow, even if they do not turn a profit today.
Hospitalists will be the “effector arm” of crucial care-management practices under new payment models, Dr. Nash predicts. He says HM should focus on helping to make the model work—for example, championing evidence-based protocols and approved drug formularies, eliminating wasteful tests, and promoting better medication reconciliation and care transitions (see “Reconciliation Act,”).“Because they are on-site full-time, hospitalists are in the cat-bird seat to teach other attending physicians about the importance of reading from the same hymnal on these best practices,” he adds.
Dr. Greeno agrees reform needs to be cost-effective as well as patient-focused.
“The pressure on hospitalists to demonstrate our value has never been higher,” he says, urging hospitalists to pay particular attention to key features of reform to which they are already accountable, such as improving patient satisfaction and promoting evidence-based interventions that prevent readmissions and hospital-acquired conditions (see “Priorities in an Age of Reform,” left).
Dr. Greeno notes that SHM’s advocacy activities have been ramped up significantly to stay on top of reform developments—and ensure that policymakers hear hospitalists’ voices. “If we want to have a positive impact, we must track these changes, understand them, influence them, implement them, and make them successful,” he says. “That’s the challenge our field faces. There’s no physician organization that knows more about what goes on in a hospital than we do, and we will help policymakers and hospitals to make intelligent decisions.”