Nelson, however, says that the future of support will be tied to payment reform, as bundled payments, value-based purchasing (VBP), and other initiatives to reduce overall healthcare spending are implemented. He said HM and other specialties should keep in mind that the point of reform is less overall spending, which translates to less support for everyone.
“When the pie shrinks, the table manners change,” he adds. “People are going to have to figure out how to slice that pie.”
Accountable-care organizations (ACOs) could be one answer. An ACO is a type of healthcare delivery model being piloted by the Centers for Medicare & Medicaid Services (CMS), in which a group of providers band together to coordinate the care of beneficiaries (see “Quality over Quantity,” December 2009, p. 23). Reimbursement is shared by the group and is tied to the quality of care provided. Nelson says the model could significantly cut the need for support, as HM groups are allowed to share in the upside created by the ACO.
The program is set to go live Jan. 1, 2012, but a leading hospitalist already has questioned whether the proposed rules provide enough capitated risk and, therefore, whether the incentive is enough to spur adoption of the model and the potential support reductions it would bring.
“You can certainly start by taking a lower amount of risk, just upside risk,” Cogent HMG chief medical officer Ron Greeno, MD, FCCP, SFHM, told The Hospitalist eWire in April, when the proposed rules were issued. “But your plan should be not to stay there. Your plan should be to take more and more risk as soon as you can, as soon as you’re capable.”
Nelson says that the support can continue in some form or fashion in the new models as long as the hospital and its practitioners are integrated and looking to achieve the same goal.
“The reality is, from the hospital perspective, you need to make sure you’re getting some value,” he says. “What are they buying in exchange for that [payment]?” TH
Richard Quinn is a freelance writer based in New Jersey.
Pay to Play?
When St. Peter’s Hospital in Helena, Mont., proposed charging an outpatient clinic nearly $400,000 a year to use its in-house HM group, it prompted a new question from the hospitalist field: Will hospitals begin charging a fee for HM services?
The near-universal answer from hospitalists is no.
“At the end of the day, what the hospital wants is to keep peace in the valley and drive volume,” says John Laverty, DHA, vice president of hospital-based physicians at HCA Physician Services in Nashville, Tenn. “Any way that they encourage volume by going out and adding subscribing physicians, or docs that want to turn their patients over to hospitalists, I can’t see a hospital charging a fee for that service. Obviously, they’re cutting their nose off because they’re going to limit [referrals].”
Hospitalists have heard about institutions attempting to institute a fee, but pushback from stakeholders usually makes the paradigm unworkable.
Hospitals usually value their relationships with primary-care physicians (PCPs) too much to alienate them, says hospitalist John Bulger, DO, FACP, FHM, of Geisinger Medical Center in Danville, Pa. This is particularly so, he says, when PCPs point out that should they object to paying such a fee to use HM services, many of their patients would end up in a hospital regardless of referrals.
In that context, the attempt by St. Peter’s to charge a fee is the perfect example of the failed premise: The idea was raised but never executed.
“PCPs love hospitalists,” Dr. Bulger says. “But part of the reason they love HM is it’s free.”—RQ