For some hospitals, the net effect on revenue might not be materially different, though Dr. Williams sees a potentially sizable benefit for “safety net” hospitals that care for a large proportion of uninsured patients and excel in making the most of limited resources. Some investors apparently agree. Last December, Nashville, Tenn.-based Vanguard Health Systems finalized a deal to buy Detroit Medical Center, with a total investment of nearly $1.5 billion. Dr. Williams says the expectation is that the medical center will suddenly see many more insured patients via an HIE. The result could be a dramatic boost to its finances.
Wealthier hospitals, by contrast, have had less incentive to maximize efficiency—and now are worried by the potential financial impacts of insurance exchanges. “Your classic, highly profitable community hospital that has a good payor mix loses money on Medicare patients and tends to subsidize that with their private patients,” Dr. Williams says. “The wealthier hospitals are nervous because they’re worried that this entire health insurance exchange is going to put downward pressure on reimbursements from the private insurers.”
The wealthier hospitals are nervous because they’re worried that this entire health insurance exchange is going to put downward pressure on reimbursements from the private insurers.
—Mark Williams, MD, FACP, SFHM, chief, division of hospital medicine, Feinberg School of Medicine, Northwestern University, Chicago
Satisfaction Times Two
With Medicare’s value-based purchasing initiative on its way, hospitals are ramping up their attention to patient satisfaction scores. So how will an influx of potentially older and sicker patients insured through the exchanges affect hospitalists’ scores? No one knows, but because hospitalists already are known for their expertise in treating this very demographic, some experts expect hospitals to lean on them more for leading quality and satisfaction initiatives. This reliance could represent a major opportunity for HM, but faulty performance metrics could also bring danger (read more about this topic in next month’s The Hospitalist).
Cherilyn Murer, president and CEO of Joliet, Ill.-based Murer Consultants Inc., says the expected shift in the nature of inpatients could accelerate efforts to be more accurate about physicians’ performance measures. “Patients who may be in the ICU are at a higher level of crisis than a person who’s in and out for an appendectomy, and yet we’re using the same tool of satisfaction,” she says. Furthermore, she adds, many factors that contribute to patient satisfaction are highly subjective and have nothing to do with a specific physician. “We have to really question the tools now, moreso than only questioning the participation and the outcome,” she says. As with other aspects of healthcare reform, Murer says, the looming arrival of exchanges also should be prompting hospitalists to ask themselves: “What’s our game plan now?” One compelling answer, she contends, is a clinical comanagement agreement that takes a longer-term view of doctors’ relationships with hospitals and gives them more control over decision-making. After all, if HM is taking care of “the sickest of the sick patients,” she says, a comanagement agreement can mean more say in factors that will directly impact their jobs over the long haul. Strategic direction of product lines, space, and equipment-buying decisions are just a few examples.
Murer ultimately sees clinical comanagement as a precursor to more widespread bundling of payments to hospitals and physicians. The mix of private and public insurance reimbursements, already in flux, might be further clouded by the arrival of HIEs. But solidifying hospital-hospitalist alignment with a flexible comanagement agreement, she says, can offer some reassurance over job structure, rewards, and authority as healthcare continues hurtling toward profound change.