And this brings me back to value-based purchasing.
The Next Phase: Purchasing Value
For those of you, like me, who struggle to comprehend what buying value actually means, take a few minutes to peruse Bryn Nelson’s cover story this month. Not only will it help you understand the healthcare reform bill, it will help you understand the future of our field. I’ve personally witnessed HM traverse three distinct phases.
In the late 1990s and early 2000s, HM growth was driven by the need to improve efficiency. In most ways, this was code for reducing costs. Hospital executives recognized that hospitalists could reduce the overall costs of a patient admission, thus turning the balance of the prospective payment into profit. In other words, the amount of money a hospital receives for a patient stay is most often fixed and determined up front (prospectively), such that more efficiently moving patients through the system equates to more profit (or less loss).
This growth phase was quickly supplanted by the volume phase—a phase that was driven by the relative departure of primary-care physicians and subspecialists from the hospital. Although some of these doctors still admit their own patients, most of them now take advantage of hospitalist programs to focus their own practice to the outpatient or procedural arenas. Effectively, many of the other doctors have left the house, and hospitalists have had to back-fill this patient volume. To a certain degree, we are all still filling this need.
Connect the Dots
However, it is clear that the next HM driver is going to be quality. And it is programs like VBP that will drive it. Essentially, VBP means that hospitals will be competing with each other to be the best. By best, I mean “most able” to achieve pre-determined quality, safety, and patient-satisfaction indicators. By competing, I mean the reimbursement pie is fixed and those who achieve will get more, and those who fall short will get less.
When you consider that as much as 2% of a hospital’s Medicare reimbursement will soon be at risk, we are talking about millions of dollars per hospital per year. To hospitals with a 1% to 2% profit margin, this is the difference between being in or out of business. It also is interestingly close to the amount of support most hospitals give their HM groups; the exact groups that touch the majority of the patients that will determine their VBP outcomes. Connect the dots, and you can see that your hospitalist group—indeed, your paycheck—is very much at risk.
Which brings me back to the FPHM. In a serendipitous turn of events, the FPHM not only recognizes hospitalists as “special,” but, more important, it also gives us the opportunity to simultaneously enhance both our patients’ outcomes and our compensation. If we get this right, the every-three-year improvement projects required to maintain your certification are exactly the type of work you’ll need to be doing to achieve the outcomes your hospital needs to maintain its Medicare payments. In turn, this will ensure your group maintains its hospital support, and you, your paycheck.
It’s the kind of work that will ensure the best possible outcomes for our patients. And in the end, that, more than an ABIM certificate, is what truly makes us special. TH
Dr. Glasheen is associate professor of medicine at the University of Colorado Denver, where he serves as director of the Hospital Medicine Program and the Hospitalist Training Program, and as associate program director of the Internal Medicine Residency Program.