Published in the February 2007 issue of Today’s Hospitalist.
The end of 2006 brought good financial news for hospitalists: an increase in the work component of relative value units (RVUs) for evaluation and management (E/M) services, coupled with Congress averting a scheduled 5% physician pay cut. For hospitalists, that adds up to a roughly 8% increase in Medicare payments for 2007.
The legislation that headed off the cut also launched a pay-for-reporting system that will give a bonus to physicians who submit data on performance measures.
Physicians who, between July and December of 2007, report on at least three of 66 measures through their claims submission process will qualify for a 1.5% bonus. While that should be even more good news, program details so far leave many key questions unanswered. At issue is how fully hospitalists will be able to get reporting credit and bonus payments for care standards they meet every day.
According to Eric M. Siegal, MD, who chairs the public policy committee of the Society of Hospital Medicine, the major challenges stem from the fact that neither the Centers for Medicare and Medicaid Services (CMS), nor the AMA through its billing and reporting mechanisms, have kept pace with the growth of hospital medicine. While the financial stakes now are small, the long-term weight of issues being hashed out may be immense.
"This may set the framework for a much more comprehensive pay-for-performance agenda down the road," says Dr. Siegal. "Individual hospitalists and groups this year will have to decide whether reporting is worth the 1.5% kicker. But if two years from now, it’s a 5% or 10% gradient, that may engender a very different response."
Dr. Siegal spoke with Today’s Hospitalist about the new RVU weights and the increasingly urgent discussion about which physicians will own inpatient quality measures.
As far as the RVU increases, what are the significant changes?
The substantial increases are in the admission and subsequent evaluation codes, which are the bulk of what we do. There are also changes in consult and critical care codes.
The new RVUs reflect a de-emphasis on discharge management, which is a disappointment given the growing attention to managing care transitions. But overall, the changes are very positive.
Generalists have long complained about the RVU imbalance between E/M services and procedures. Can hospitalists expect more re-calculations?
This is a step in the right direction, but I don’t expect many more changes down the road because increasing the weight for E/M services for generalists will be increasingly difficult politically.
Due to budget neutrality provisions, any increase to one constituency must be offset with commensurate decreases elsewhere. Internal medicine represents such a huge percentage of the medical community that a relatively small increase for us has to be offset by potentially large cuts for others.
Do you expect private insurers to follow suit?
Medicare has always been the bellwether, and private insurers are certainly willing to follow when reimbursement goes down! So this should translate into better compensation from commercial payers as well.
Many of Medicare’s new list of performance measures relate to inpatient care. Will hospitalists be able to report on all of those?
There is real confusion over who will be able to report what. We can definitely report on some measures, including prescribing aspirin and beta-blockers for acute myocardial infarction. But there are many others we would like to report on that we can’t right now.
The problem is that physicians currently report these data to the CMS through specific codes known as "G codes." Right now, many measures appropriate for hospitalists to report do not have inpatient G codes linked to them. So if you admit someone to the hospital and put them on an ACE inhibitor, you can’t get credit for that through an inpatient code.
Another problem: Measures for conditions such as pneumonia are tied to codes used only in the emergency department. So you would have to bill an emergency department code, which we can’t do, to report appropriate pneumonia care.
What’s the fix?
There has been a lot of talk about CPT II, codes the AMA developed for data collection and reporting, as a replacement for G codes.
However, nobody yet is using these codes, and we are not sure if or when they will be widely adopted. We’re also not clear on what using CPT II would allow us to do. We have heard everything from "CPT II will apply to any physician, anywhere, for any measure," to "no, it won’t."
Reporting issues aside, do you expect tension between physicians over who gets to claim inpatient measures?
Attribution is another confusing issue we’ve asked the CMS to clarify. Say a patient comes in with heart failure and LV systolic dysfunction and is already on an ACE inhibitor from an outpatient physician. If we continue the ACE inhibitor at discharge, can we report that?
What if the patient wasn’t on an ACE inhibitor and we put him on one; is that different? And if I am seeing the patient and a cardiologist is as well, do we both get to report it?
Another problem: We’d like to align the measures we report to the CMS with Joint Commission core measures. Hospitalists are already helping hospitals report on Joint Commission measures, and it would only make sense for us to report those same data to the CMS.
Will groups need extensive information technology to report on measures?
Any hospitalist group using some kind of computer-based billing application should be able to participate using G-codes.
If we evolve to using CPT II, however, we don’t know how onerous that transition would be. If CPT II requires an enormous amount of work for a 1.5% gain, hospitalists may decide it’s not worth the effort. But that would probably change if more dollars were at stake.
Are these issues an indication that policy-makers haven’t caught up with who’s delivering inpatient care?
The problem right now is that the CMS doesn’t recognize hospital medicine as a specialty and we do not have a seat at the AMA’s House of Delegates. The discussion we’re now having is whether we need to become voting member within the AMA, and how to get a unique seat at the table from the CMS’ perspective. That’s only appropriate given that hospitalists are poised to become the single largest deliverer of inpatient care to Medicare patients.
Until very recently, most of our advocacy efforts have been through proxies, such as the American College of Physicians. But we are at the point that we need to start advocating on our own behalf. Pay for performance has been a galvanizing issue in that regard.
What’s the timeline for getting problems resolved?
The comment period for the measure set ends in April before rollout in July. That is an ambitious timeline, given how many players are involved.
Something will happen in July, but so far, that something has a lot of if’s and maybe’s. The one thing we can say with a high degree of certainty is that pay for performance isn’t going away. What it looks like and what incentives will be used are all in flux. But there is no question that the concept is here to stay.
Phyllis Maguire is Executive Editor of Today’s Hospitalist.