Categories
Inpatient Practice

Medicare’s Stars Don’t Shine Brightly

starThis week, Medicare released its new hospital rating system, The Hospital Compare Overall Hospital Quality Star Ratings. Using this system, Medicare rates hospitals by their quality using a 5 star system with 1 representing the lowest quality hospital and 5 representing the highest quality hospital. In reviewing the methodology, I believe that Medicare has failed epically.

The rating is based on 64 quality measures that Medicare tracks for all hospitals in the United States. Because not all 64 measures will apply to every hospital, Medicare only uses those applicable to a given hospital so that for any given hospital, the quality measures reviewed can be as many as 64 but as few as 9 with an average of 40 per hospital. The full listing of all of the specific quality measures can be found on the CMS website here. The 64 quality measures are grouped into 7 categories including:

  1. Mortality
  2. Safety of care
  3. Readmissions
  4. Patient experience
  5. Effectiveness of care
  6. Timeliness of care
  7. Efficient use of medical imaging

The Comprehensive Methodology Report published by Medicare details exactly how these quality measures are incorporated into the final rating. I would challenge anyone reading this blog to read the report and try to understand it. It is incomprehensible.

From the ratings, 2.2% of U.S. hospitals got a 5-star rating, 20.3% a 4-star rating, 38.5% a 3-star rating, 15.7% a 2-star rating, 2.9% a 1-star rating, and 20.4% were unrated.

So here is the problem. By using mortality measures as one of the main determinants of the rating system, hospitals that take care of sicker patients are going to be ranked lower; for example, tertiary care hospitals, those that have a high percentage of their inpatients admitted through emergency departments, and those that do higher risk procedures such as coronary artery bypass and graft surgery will be ranked lower simply because of the population of patients that they care for.

Even more concerning is the use of 8 quality measures that have to do with readmissions. It is well-established that risks for readmission to the hospital within 30 days of discharge is correlated with lower income patients, older patients, socioeconomically disadvantaged racial groups, and availability of primary care physicians in the community. Hospitals that care for these patients will have a lower ranking.

When the rankings of U.S. hospitals was released this week, there were some surprising (or maybe not so surprising) findings. Hospitals that do not manage complex patients and those that do not do high-risk procedures and surgeries fared very well and were highly ranked. Hospitals that care for the underserved and care for more medically complex patients fared poorly and were ranked very low. As an example, academic teaching hospitals were uniformly ranked low whereas non-teaching hospitals (which tend to manage less medically complicated patients) were ranked quite highly. The Ohio State University Medical Center came in at a 3-star rating which puts it among the top-performing academic medical centers in the nation but I know those other academic medical centers and they are not poor quality hospitals.

Hospital star rating Medicare

So what does this mean to a hospital that would like to have a high Medicare star ranking? Well, in the spirit of Jonathan Swift’s treatise “A Modest Proposal”, here are the steps a hospital can take to improve its Medicare ranking:

  1. Eliminate the emergency room. You must avoid sick patients from being in your hospital at all costs and since sick patients come to the emergency room, if you don’t have one, those undesirable patients will go elsewhere.
  2. Do not allow any patient > 65 years old to be admitted to your hospital. First, if the patients are not over 65, they likely won’t have Medicare so Medicare will not track them and second, patients over 65 are more likely to be sicker so you do not want them in your hospital.
  3. Do not admit anyone with an income of less than $24,250 per year. This is the Federal poverty limit for a family of 4 in the United States. Many studies have shown that patients with lower income have higher 30-day readmission rates. Therefore, make them go elsewhere.
  4. Do not admit patients who belong to socioeconomically disadvantaged races. These patients have also been shown to have higher 30-day readmission rates to the hospital. African Americans, Hispanic Americans, and Native Americans should be told to go elsewhere if your hospital wants to be ranked higher by Medicare.
  5. Stop taking trauma patients and close your trauma center if you have one.
  6. If you have an obstetric unit, only take care of wealthy women. Since one of the measures is “Elective delivery prior to 39 completed weeks gestation” and it is known that socioeconomically disadvantaged women have a higher premature birth rate, a hospital wanting to improve its Medicare ratings should not deliver disadvantaged women. Preferably, your hospital should only deliver upper class, non-smoking, caucasian women between the ages of 18-35 with a body mass index of < 30 and no diabetes, no prior history of pre-eclampsia, and no history of being physically or sexually abused. Do not permit twins or triplets to be delivered at your hospital.
  7. Fire anyone who works in your hospital who refuses to get a flu shot. “Healthcare personnel influenza vaccination” is one of the quality measures so if your nurses or doctors don’t get a vaccine, get rid of them in order to improve your rating.
  8. Get rid of all trainees such as residents, medical students, and fellows since hospitals with trainees have a substantially worse rating by Medicare’s criteria.
  9. Above all, do not ever, ever, ever admit patients with chronic pain such as patients with sickle cell anemia or chronic wounds. “Pain management” is one of the quality measures and specifically it revolves around how well pain was controlled. As an alternative, an equally effective strategy is to prescribe ad lib oxycontin to any patient who asks for it in order to improve the pain questions on the Medicare-required patient questionaires.

Obviously, this is absurd. Hospitals exist to take care of sick patients and those hospitals that care for the sickest patients and those that are the most socioeconomically disadvantaged have been unfairly penalized by the new Medicare star ranking system. At best, this system is flawed. At worst, it is discriminatory on a racial, economic, and age basis.

July 29, 2016

Categories
Hospital Finances Inpatient Practice

The Three Most Valuable Specialists In Your Hospital

book and stethescopeFrom reading the title of this post, you’re probably thinking that I am going to list some surgical specialties, interventional cardiology, or gastroenterology since these specialties bring in financially lucrative procedure volume to the hospital. So what I am going to say is going to surprise you. I’m going to make the argument that the 3 most valuable specialists in your hospital are geriatrics, infectious disease, and nephrology. I know what’s going through your mind right now: “What in the world is he thinking about?”. Well, let me make my case and then you decide. And it all starts with CPT.

CPT codes, or the Current Procedural Terminology codes, are the coding numbers that are assigned to every service and procedure that a physician does, from an office visit to an appendectomy. So for example, CPT 99221-99223 code for the 3 different levels of new inpatient encounters and CPT 99251-99255 code for the 5 different levels of inpatient consultation encounters. For decades, those consultation codes charged by a specialist paid more than the standard new patient encounter codes that would be charged for an admission history and physical examination by a generalist. This makes sense – if you are a specialist and providing a specialty consult opinion drawing from your additional years of training and experience, you should be paid more than the generalist doing a standard history and physical exam.

But on January 1, 2010, Medicare got rid of the consultation codes and required specialists to use the same CPT codes that the generalists were using for the admission history and physical exam. The net result of that decision was that cognitive specialists (i.e., those that do not have a procedure that they do) saw a significant drop in their income compared to the procedural specialists (i.e., those that do a procedure, like cardiac stress testing or colonoscopy). The three subspecialties that were affected the most were infectious disease, nephrology, and geriatrics.

Every year, the Medical Group Management Association (MGMA) publishes the starting salaries for physicians in their first year after completing training. In the past, specialists made more money than generalists. It makes sense… if you do an extra 2-3 years of training as a subspecialty fellow, you should expect a return on investment for that training and so you should expect a higher salary. But since the elimination of the consult codes by Medicare, some specialists, namely those that don’t involve doing lucrative procedures, have seen their salaries drop to the point that there is no longer any return on the investment of the extra years of subspecialty fellowship. Here is the most recent data from the annual MGMA salary survey from 2015 (based on data from 2014).

Physician salary

 

With general internal medicine, family practice, and hospitalist medicine, all you need is 3 years of residency and you are ready to start practicing. For all of the other specialties, you have to do 2-3 years of additional fellowship training. For infectious disease and nephrology, there is no salary advantage to doing those additional years of fellowship training (geriatrics is not listed in the MGMA report but their salary is typically similar to general internal medicine). In fact, the cost of doing the additional years of fellowship training is that you are going to make less than a family physician or a hospitalist who stopped after 3 years of residency.

For any of my colleagues in academic medicine who are looking at these numbers and saying, “I don’t make anywhere near that amount even though I’ve been practicing for years”, relax. The MGMA data is largely derived from private practice physicians and not academic physicians and as has always been the case, you make a lot more in private practice than you do in academics.

All of this has not gone unnoticed by medical students and residents when choosing a subspecialty. Recently, the National Residency Match Program released the results of the 2016 resident and fellow match. The results paint a frightening picture for the future of the cognitive specialties.

NMRP

This graph shows the percentage of available fellowship positions that were filled by graduates of American medical schools (blue) and the percentage of fellowship positions filled by all applicants, including foreign medical graduates (orange). In keeping with the starting salary data, residents just are not going into geriatrics, nephrology, or infectious disease. There is simply no return on the time investment of doing a fellowship.

So what does this mean for hospital medical directors? Geriatricians, nephrologists, and infectious disease specialists are going to become increasingly scarce. It is going to be harder and harder to recruit these specialists. Of equal concern, there is a danger that the best and smartest residents will be drawn to the other specialties, resulting in an overall drop in the caliber of the new cognitive specialists in future years compared to past years.

We are fortunate at our hospital. The Director of the Division of General Internal Medicine and the Chairman of Internal Medicine have placed a high value on geriatrics. We have great nephrologists and one of the premier interventional nephrology programs in the country. And 2 years ago, the Director of the Division of Infectious Disease recruited one of the best clinicians I know as our hospital’s lead infectious disease specialist and director of hospital epidemiology.

If you have a good geriatrician, a good nephrologist, or a good infectious disease specialist, take good care of him or her because he or she is going to be hard to replace. And when you have strategic planning meetings with your hospital business leaders, speak up for these specialties because hiring them now before their supply drops further is going to be a good long-term business decision. For medical students who have always dreamed of a career in one of these specialties, take heart, because in a few years the invisible hand that governs the law of supply and demand in capitalism will cause their salaries to rise again in the future.

July 23, 2016

Categories
Inpatient Practice

The Ten Commandments Of Consultation

Thirty years ago, Dr. Lee Goldman wrote an article titled “Ten Commandments for Effective Consultation”. I’ve taken some liberties with his recommendations in the context of practice in an era of the electronic medical record.

  1. No consult question is too small. If a physician requests a consultation, it is usually because he or she believes that they and their patient will benefit from your expertise.
  2. Weekends are the same as weekdays. Patients should expect the same level of physician care no matter what day of the week they happen to be in the hospital. New consults on Saturdays and Sundays should be seen promptly.
  3. Follow up your test results. Advising what test to order is one half of your responsibility as a consultant. Interpreting that test result in the context of the patient’s illness is the other half. As a consultant, you share responsibility for the tests that you recommend to the primary service.
  4. A consult is a gift. In the business of medicine, consultants survive by providing consultation. Refusing a consult is like refusing a birthday present.
  5. It’s not a request for consultation, it’s a request for collaboration. The admitting physician may not see your note until the next day and so tests or important medication changes may not be ordered for >24 hours unless you ensure that they happen promptly. On teaching services (with residents), call the resident to let him/her know what you want done. On non-teaching services, enter your own orders for tests or medication changes for the problem that you were asked to assist with or call the attending physician with your recommendations. Inpatient medicine has become a team sport and the patient who wins is the one who has the strongest team of physicians, not just a single strong player.
  6. Availability trumps ability. A consultant succeeds by providing the best customer service and the physician requesting consultation is the customer. Consults requested before 10:00 AM should be seen that day. Seeing patients promptly and being available by phone/pager to the primary service is best practice. If you need your car’s oil changed, would you give your business to the garage that is only open from 9 AM to noon or would you go to the garage that is open from 7 AM to 7 PM?
  7. The discharge is the most dangerous procedure in medicine. As a specialist, you are in the best position to know what is needed in follow up. Assist by scheduling outpatient testing or clinic appointments. Give specific recommendations for medication doses and duration after discharge (especially antibiotics). If monitoring labs are necessary for the treatment that you have recommended, either have those labs sent to you for action/review or make sure that there is a clear hand off to another physician who will take responsibility for those lab test results.
  8. Answer the question that you are asked. You may find additional medical problems that need to be addressed but never forget to respond to the initial question.
  9. Distillation is more important than regurgitation. With electronic medical records, it is easy to import pages and pages of test results. The physician requesting your consultation is not requesting you to restate all of the data retrievable from the computer, that physician is requesting your analysis of all of the data. Make your assessment and analysis easy to locate in your note. When it comes to background data in your consultation note, in general, less is more.
  10. Don’t be a one and done. Your initial impression and recommendation are valuable but your follow up of those recommendations is often even more valuable. See your consults daily until the problem that you were asked to address is resolved or stabilized. Consult follow ups should be seen daily, whether that day is a weekday or a weekend.
  11. And the Golden Rule of consultation: Consult unto your neighbor as you would want your neighbor to consult unto you. Enough said.

July 22, 2016