Kelly April Tyrrell

Come November 2018, Americans will return to the polls to vote for their representatives in Congress, for governors, and for state legislative seats.

Health care has been a topic of debate since the 2016 elections brought a Republican sweep to the executive and legislative branches, but other issues have since moved to the forefront. Will the midterm elections this year prove health care to be a significant issue at the polls?

Unlikely, said Robert Berenson, MD, FACP, Institute Fellow of the Health Policy Center at the Urban Institute. More likely, the election will be a referendum on President Donald Trump, he said. “Things are so partisan right now and it’s all about Trump. I don’t see serious discussion about health policy.”

Ron Greeno, MD, MHM, FCCP, immediate past president of SHM and former chair of the Public Policy Committee, also doesn’t see health care rising to the top of election year issues. But that doesn’t mean health care doesn’t matter to American voters.

“Whether Democrats control the House or Republicans control the House won’t likely make a big difference in terms of impact on the things we care about,” said Dr. Greeno. “The issues they debate in Washington are not going to save the health care system. They are just debating about who is going to pay for what and for whom. To save our health care system, we have to lower the cost of care and only providers can do that.”

What the government can do, he said, is create the right incentives for providers to move away from fee for service and participate in new models that may lower the cost of care. At the same time, “the economy also has to grow at a robust pace, which will make a huge difference. So, recent increases in economic growth rate are welcomed,” said Dr. Greeno.

In 2015, Republicans and Democrats came together to pass bipartisan legislation aimed at moving the health care system away from fee for service: the Medicare and CHIP Reauthorization Act, or MACRA.

However, the law has not been without frustrations, and these concerns will likely not be part of any candidate campaigns in 2018, Dr. Greeno predicted: “There’s not a lot of appetite to reopen the statute (more than) 2 years after it passed.”

MACRA provides clinicians two pathways to reimbursement. The first track, called MIPS (Merit-Based Incentive Payment System), bases a portion of physician reimbursement on scores measured across several categories, including cost and quality. It still operates largely under a fee-for-service framework but is meant to be budget neutral; for every winner there is a loser.

The second track, called the APMs (Alternative Payment Models), requires physicians to take on substantial risk (with potential for reward), if they can achieve specific patient volumes under approved models. However, few providers qualify, especially among hospitalists, though the structure of the program makes it clear that the Centers for Medicare & Medicaid Services intends to have most providers ultimately transition to APMs.

“There’s growing recognition that MACRA, at least the MIPS portion, was a big mistake but Congress can’t go back and say we blew it,” Dr. Berenson said. “CMS has now exempted somewhere between 550,000 and 900,000 clinicians from MACRA,” because they cannot meet the requirements of either pathway without significant hardship.¹

CMS wasn’t considering hospitalists specifically when implementing the law, though hospitalists admit half of the Medicare patients in the United States, Dr. Greeno said. There are very few hospitalists currently participating in Advanced APMs and those that are, do not see the volume of patients the pathway requires.

“What hospitalists do is very conducive to alternative payment models, and we can help those alternative payment models drive improved quality and lowered costs,” said Dr. Greeno. “Hospitals use hospitalists to help them manage risk, so it’s frustrating that most hospitalists will not meet the thresholds for the APM track and benefit from the incentives created.”

However, the Society of Hospital Medicine continues to work on behalf of hospitalists. Thanks to its efforts, Dr. Greeno explained, CMS is planning in 2019 to allow hospitalists to choose to be scored under MIPS based on their hospital’s performance across reporting categories. Or, they can choose to report on their own and opt out of this new “facility-based” option.

“We are working with (CMS) to figure out how to make this new option work,” said Dr. Greeno.

At the state level, 36 governorships are up for grabs and those outcomes could influence the direction of Medicaid. In Kentucky, the Trump administration approved a waiver allowing the state to enforce work requirements for Medicaid recipients. However, on June 29, 2018, the D.C. federal district court invalidated the Kentucky HEALTH waiver approval (with the exception of Kentucky’s IMD SUD [institutions for mental disease for substance use disorders] payment waiver authority) and sent it back to HHS to reconsider. Ten other states as of August 2018 had applied for similar waivers.² However, Dr. Berenson believes that most of what could happen to Medicaid will be a topic after the midterm elections and not before.

He also believes drug prices could become an issue in national elections, though there will not be an easy solution from either side. “Democrats will be reluctant to say they’re going to negotiate drug prices; they’re going to want the government to negotiate for Medicare-like pricing.” Republicans, on the other hand, will be reluctant to consider government regulation.

As a general principle leading into the midterms: “Democrats want to avoid an internal war about whether they are for Medicare for all or single payer or not,” Dr. Berenson said. “What I’m hoping doesn’t happen is that it becomes a litmus test for purity where you have to be for single payer. I think would be huge mistake because it’s not realistic that it would ever get there.”

However, he cites an idea from left-leaning Princeton University’s Paul Starr, a professor of sociology and public affairs, that Democrats could consider: so-called Midlife Medicare, an option that could be made available to Americans beginning at age 50 years.³ It would represent a new Medicare option, funded by general revenues and premiums, available to people age 50 years and older and those younger than 65 years who are without employer-sponsored health insurance.

Regardless, as the United States catapults toward another election that could disrupt the political system or maintain the relative status quo, Dr. Greeno said hospitalists continue to play key roles in improving American health care.

“There are programs in place where we can get the job done if we in the provider community are creative and participative,” he said. “Some of the most important work being done is coming out of the CMS Innovation Center. Hospitalists continue to be a big part of that, but we knew it would take decades of really hard work and I don’t see anything happening in the midterms to derail this or bring about a massive increase in the pace of change.”
 

References

1. Dickson V. CMS gives more small practices a pass on MACRA. Modern Healthcare. Published June 20, 2017.

2. Medicaid Waiver Tracker: Which States Have Approved and Pending Section 1115 Medicaid Waivers? Kaiser Family Foundation. Published Aug. 8, 2018.

3. Starr P. A new strategy for health care. The American Prospect. Published Jan. 4, 2018. Accessed March 5, 2018.
 

Come November 2018, Americans will return to the polls to vote for their representatives in Congress, for governors, and for state legislative seats.

Health care has been a topic of debate since the 2016 elections brought a Republican sweep to the executive and legislative branches, but other issues have since moved to the forefront. Will the midterm elections this year prove health care to be a significant issue at the polls?

Unlikely, said Robert Berenson, MD, FACP, Institute Fellow of the Health Policy Center at the Urban Institute. More likely, the election will be a referendum on President Donald Trump, he said. “Things are so partisan right now and it’s all about Trump. I don’t see serious discussion about health policy.”

Ron Greeno, MD, MHM, FCCP, immediate past president of SHM and former chair of the Public Policy Committee, also doesn’t see health care rising to the top of election year issues. But that doesn’t mean health care doesn’t matter to American voters.

“Whether Democrats control the House or Republicans control the House won’t likely make a big difference in terms of impact on the things we care about,” said Dr. Greeno. “The issues they debate in Washington are not going to save the health care system. They are just debating about who is going to pay for what and for whom. To save our health care system, we have to lower the cost of care and only providers can do that.”

What the government can do, he said, is create the right incentives for providers to move away from fee for service and participate in new models that may lower the cost of care. At the same time, “the economy also has to grow at a robust pace, which will make a huge difference. So, recent increases in economic growth rate are welcomed,” said Dr. Greeno.

In 2015, Republicans and Democrats came together to pass bipartisan legislation aimed at moving the health care system away from fee for service: the Medicare and CHIP Reauthorization Act, or MACRA.

However, the law has not been without frustrations, and these concerns will likely not be part of any candidate campaigns in 2018, Dr. Greeno predicted: “There’s not a lot of appetite to reopen the statute (more than) 2 years after it passed.”

MACRA provides clinicians two pathways to reimbursement. The first track, called MIPS (Merit-Based Incentive Payment System), bases a portion of physician reimbursement on scores measured across several categories, including cost and quality. It still operates largely under a fee-for-service framework but is meant to be budget neutral; for every winner there is a loser.

The second track, called the APMs (Alternative Payment Models), requires physicians to take on substantial risk (with potential for reward), if they can achieve specific patient volumes under approved models. However, few providers qualify, especially among hospitalists, though the structure of the program makes it clear that the Centers for Medicare & Medicaid Services intends to have most providers ultimately transition to APMs.

“There’s growing recognition that MACRA, at least the MIPS portion, was a big mistake but Congress can’t go back and say we blew it,” Dr. Berenson said. “CMS has now exempted somewhere between 550,000 and 900,000 clinicians from MACRA,” because they cannot meet the requirements of either pathway without significant hardship.¹

CMS wasn’t considering hospitalists specifically when implementing the law, though hospitalists admit half of the Medicare patients in the United States, Dr. Greeno said. There are very few hospitalists currently participating in Advanced APMs and those that are, do not see the volume of patients the pathway requires.

“What hospitalists do is very conducive to alternative payment models, and we can help those alternative payment models drive improved quality and lowered costs,” said Dr. Greeno. “Hospitals use hospitalists to help them manage risk, so it’s frustrating that most hospitalists will not meet the thresholds for the APM track and benefit from the incentives created.”

However, the Society of Hospital Medicine continues to work on behalf of hospitalists. Thanks to its efforts, Dr. Greeno explained, CMS is planning in 2019 to allow hospitalists to choose to be scored under MIPS based on their hospital’s performance across reporting categories. Or, they can choose to report on their own and opt out of this new “facility-based” option.

“We are working with (CMS) to figure out how to make this new option work,” said Dr. Greeno.

At the state level, 36 governorships are up for grabs and those outcomes could influence the direction of Medicaid. In Kentucky, the Trump administration approved a waiver allowing the state to enforce work requirements for Medicaid recipients. However, on June 29, 2018, the D.C. federal district court invalidated the Kentucky HEALTH waiver approval (with the exception of Kentucky’s IMD SUD [institutions for mental disease for substance use disorders] payment waiver authority) and sent it back to HHS to reconsider. Ten other states as of August 2018 had applied for similar waivers.² However, Dr. Berenson believes that most of what could happen to Medicaid will be a topic after the midterm elections and not before.

He also believes drug prices could become an issue in national elections, though there will not be an easy solution from either side. “Democrats will be reluctant to say they’re going to negotiate drug prices; they’re going to want the government to negotiate for Medicare-like pricing.” Republicans, on the other hand, will be reluctant to consider government regulation.

As a general principle leading into the midterms: “Democrats want to avoid an internal war about whether they are for Medicare for all or single payer or not,” Dr. Berenson said. “What I’m hoping doesn’t happen is that it becomes a litmus test for purity where you have to be for single payer. I think would be huge mistake because it’s not realistic that it would ever get there.”

However, he cites an idea from left-leaning Princeton University’s Paul Starr, a professor of sociology and public affairs, that Democrats could consider: so-called Midlife Medicare, an option that could be made available to Americans beginning at age 50 years.³ It would represent a new Medicare option, funded by general revenues and premiums, available to people age 50 years and older and those younger than 65 years who are without employer-sponsored health insurance.

Regardless, as the United States catapults toward another election that could disrupt the political system or maintain the relative status quo, Dr. Greeno said hospitalists continue to play key roles in improving American health care.

“There are programs in place where we can get the job done if we in the provider community are creative and participative,” he said. “Some of the most important work being done is coming out of the CMS Innovation Center. Hospitalists continue to be a big part of that, but we knew it would take decades of really hard work and I don’t see anything happening in the midterms to derail this or bring about a massive increase in the pace of change.”
 

References

1. Dickson V. CMS gives more small practices a pass on MACRA. Modern Healthcare. Published June 20, 2017.

2. Medicaid Waiver Tracker: Which States Have Approved and Pending Section 1115 Medicaid Waivers? Kaiser Family Foundation. Published Aug. 8, 2018.

3. Starr P. A new strategy for health care. The American Prospect. Published Jan. 4, 2018. Accessed March 5, 2018.
 

Come November 2018, Americans will return to the polls to vote for their representatives in Congress, for governors, and for state legislative seats.

Health care has been a topic of debate since the 2016 elections brought a Republican sweep to the executive and legislative branches, but other issues have since moved to the forefront. Will the midterm elections this year prove health care to be a significant issue at the polls?

Unlikely, said Robert Berenson, MD, FACP, Institute Fellow of the Health Policy Center at the Urban Institute. More likely, the election will be a referendum on President Donald Trump, he said. “Things are so partisan right now and it’s all about Trump. I don’t see serious discussion about health policy.”

Ron Greeno, MD, MHM, FCCP, immediate past president of SHM and former chair of the Public Policy Committee, also doesn’t see health care rising to the top of election year issues. But that doesn’t mean health care doesn’t matter to American voters.

“Whether Democrats control the House or Republicans control the House won’t likely make a big difference in terms of impact on the things we care about,” said Dr. Greeno. “The issues they debate in Washington are not going to save the health care system. They are just debating about who is going to pay for what and for whom. To save our health care system, we have to lower the cost of care and only providers can do that.”

What the government can do, he said, is create the right incentives for providers to move away from fee for service and participate in new models that may lower the cost of care. At the same time, “the economy also has to grow at a robust pace, which will make a huge difference. So, recent increases in economic growth rate are welcomed,” said Dr. Greeno.

In 2015, Republicans and Democrats came together to pass bipartisan legislation aimed at moving the health care system away from fee for service: the Medicare and CHIP Reauthorization Act, or MACRA.

However, the law has not been without frustrations, and these concerns will likely not be part of any candidate campaigns in 2018, Dr. Greeno predicted: “There’s not a lot of appetite to reopen the statute (more than) 2 years after it passed.”

MACRA provides clinicians two pathways to reimbursement. The first track, called MIPS (Merit-Based Incentive Payment System), bases a portion of physician reimbursement on scores measured across several categories, including cost and quality. It still operates largely under a fee-for-service framework but is meant to be budget neutral; for every winner there is a loser.

The second track, called the APMs (Alternative Payment Models), requires physicians to take on substantial risk (with potential for reward), if they can achieve specific patient volumes under approved models. However, few providers qualify, especially among hospitalists, though the structure of the program makes it clear that the Centers for Medicare & Medicaid Services intends to have most providers ultimately transition to APMs.

“There’s growing recognition that MACRA, at least the MIPS portion, was a big mistake but Congress can’t go back and say we blew it,” Dr. Berenson said. “CMS has now exempted somewhere between 550,000 and 900,000 clinicians from MACRA,” because they cannot meet the requirements of either pathway without significant hardship.¹

CMS wasn’t considering hospitalists specifically when implementing the law, though hospitalists admit half of the Medicare patients in the United States, Dr. Greeno said. There are very few hospitalists currently participating in Advanced APMs and those that are, do not see the volume of patients the pathway requires.

“What hospitalists do is very conducive to alternative payment models, and we can help those alternative payment models drive improved quality and lowered costs,” said Dr. Greeno. “Hospitals use hospitalists to help them manage risk, so it’s frustrating that most hospitalists will not meet the thresholds for the APM track and benefit from the incentives created.”

However, the Society of Hospital Medicine continues to work on behalf of hospitalists. Thanks to its efforts, Dr. Greeno explained, CMS is planning in 2019 to allow hospitalists to choose to be scored under MIPS based on their hospital’s performance across reporting categories. Or, they can choose to report on their own and opt out of this new “facility-based” option.

“We are working with (CMS) to figure out how to make this new option work,” said Dr. Greeno.

At the state level, 36 governorships are up for grabs and those outcomes could influence the direction of Medicaid. In Kentucky, the Trump administration approved a waiver allowing the state to enforce work requirements for Medicaid recipients. However, on June 29, 2018, the D.C. federal district court invalidated the Kentucky HEALTH waiver approval (with the exception of Kentucky’s IMD SUD [institutions for mental disease for substance use disorders] payment waiver authority) and sent it back to HHS to reconsider. Ten other states as of August 2018 had applied for similar waivers.² However, Dr. Berenson believes that most of what could happen to Medicaid will be a topic after the midterm elections and not before.

He also believes drug prices could become an issue in national elections, though there will not be an easy solution from either side. “Democrats will be reluctant to say they’re going to negotiate drug prices; they’re going to want the government to negotiate for Medicare-like pricing.” Republicans, on the other hand, will be reluctant to consider government regulation.

As a general principle leading into the midterms: “Democrats want to avoid an internal war about whether they are for Medicare for all or single payer or not,” Dr. Berenson said. “What I’m hoping doesn’t happen is that it becomes a litmus test for purity where you have to be for single payer. I think would be huge mistake because it’s not realistic that it would ever get there.”

However, he cites an idea from left-leaning Princeton University’s Paul Starr, a professor of sociology and public affairs, that Democrats could consider: so-called Midlife Medicare, an option that could be made available to Americans beginning at age 50 years.³ It would represent a new Medicare option, funded by general revenues and premiums, available to people age 50 years and older and those younger than 65 years who are without employer-sponsored health insurance.

Regardless, as the United States catapults toward another election that could disrupt the political system or maintain the relative status quo, Dr. Greeno said hospitalists continue to play key roles in improving American health care.

“There are programs in place where we can get the job done if we in the provider community are creative and participative,” he said. “Some of the most important work being done is coming out of the CMS Innovation Center. Hospitalists continue to be a big part of that, but we knew it would take decades of really hard work and I don’t see anything happening in the midterms to derail this or bring about a massive increase in the pace of change.”
 

References

1. Dickson V. CMS gives more small practices a pass on MACRA. Modern Healthcare. Published June 20, 2017.

2. Medicaid Waiver Tracker: Which States Have Approved and Pending Section 1115 Medicaid Waivers? Kaiser Family Foundation. Published Aug. 8, 2018.

3. Starr P. A new strategy for health care. The American Prospect. Published Jan. 4, 2018. Accessed March 5, 2018.
 

In October 2015, the Centers for Medicare & Medicaid Services implemented its first meaningful policy to attempt for addressing sepsis.

The condition – one of the leading causes of mortality among hospitalized patients – afflicts more than a million people each year in the United States, and between 15% and 30% of them die. Sepsis is one of the leading drivers of hospital readmissions, sending more patients back to the hospital than heart failure, pneumonia, and chronic obstructive pulmonary disease.¹

However, while providers seem to agree that time to address sepsis is past due, not everyone has embraced the Sepsis CMS Core Measure program, or SEP-1, as the means to best achieve it. This is, in part, because of discrepancies in how sepsis is defined, the burden of reporting, and what some consider to be arbitrary clinical requirements that may not correlate with better patient outcomes.

“Sepsis is indeed a critical public health problem, and it’s appropriate and valuable that Medicare and other policy makers are focusing on sepsis,” said Jeremy Kahn, MD, professor of critical care medicine and health policy and management at the University of Pittsburgh. “This was really the first approach at that … but at 85-pages long, it really is an enormous effort for hospitals to adhere to this measure.”

This is because of the tension between the “intense desire to improve sepsis outcomes” and the “incredible burden” of keeping up with the necessary documentation while also providing quality care, Dr. Kahn said.

In December 2017, Dr. Kahn helped lead a study published in the Journal of Hospital Medicine aimed at trying to understand hospital perceptions of SEP-1. Over the course of 29 interviews with randomly selected hospital quality leaders across the United States, including physicians and nurses, the results came as a surprise.²

Some, like emergency medicine physician Annahieta Kalantari, DO (who did not participate in the survey), feel that SEP-1 forces providers to practice “check-box” medicine and undermines successful efforts that don’t necessarily align with the CMS policy.

She arrived at her institution, Aria-Jefferson Health in Philadelphia, before CMS adopted SEP-1; at that time, she took note of the fact that the rate of sepsis mortalities in her hospital was, in her words, not great when compared with that at similar institutions. And then she helped do something about it.

“I thought, ‘We’re a Premier reporting hospital,’ so we did a gap analysis as to why and put together protocols for the hospital to follow with our sepsis patients, including a sepsis alert and a lot of education,” said Dr. Kalantari, associate program director for the emergency medicine residency program at Aria-Jefferson and a former chair of its sepsis management committee. “Before you knew it, mortalities were below benchmark.”

But once SEP-1 began, she said, the hospital was unable to check all of the boxes all of the time.

“We kept track, but we weren’t hitting all the bundles exactly within the periods of time recommended, but our mortalities were still amazing,” she said. “CMS basically picked definitions [for sepsis], and most of us don’t know what they’re basing them on because no one can agree on a definition anyway. Now they’re penalizing hospitals if they don’t hit the check marks in time, but we’d already demonstrated that our mortality and patient care was exceptional.”
She added: “I am extremely dissatisfied, as someone who provides frontline patient care, with how CMS is choosing to measure us.”

Dr. Kalantari wrote a piece in the Western Journal of Emergency Medicine in July 2017 in which she and coauthors outline the issues they take with SEP-1. They lay out the tension among the varied definitions of what sepsis is – and isn’t – and they also illuminate the apparent conflict between what CMS has officially defined and what evidence-based studies conducted since 2001 have suggested.³

In particular, CMS defines severe sepsis as an initial lactate above 2 mmol/L and septic shock as an initial lactate presentation of greater than 4 mmol/L. However, Dr. Kalantari and here coauthors argue in the paper that there is no standard definition of sepsis and that decades of attempts to achieve one have failed to reach consensus among providers. CMS, she said, fails to acknowledge this.

Defining sepsis

In fact, in 2016, another new definition of sepsis emerged by way of a 19-member task-force of experts: The Third International Consensus Definitions for Sepsis and Septic Shock, also called Sepsis-3.⁴ In March 2017, the Surviving Sepsis Campaign adopted this definition, which defined sepsis as a “life-threatening organ dysfunction caused by a dysregulated host response to infection.”⁵

“I think the definition has always been a challenging part of sepsis,” said Kencee Graves, MD, a hospitalist at the University of Utah, Salt Lake City. “The definitions came about for research purposes, so … they are not perfectly sensitive nor specific.”

However, Dr. Graves believes SEP-1 is a step in the right direction in that it brings awareness to sepsis and holds providers accountable. Several years ago, she and her colleague Devin Horton, MD, also a hospitalist at the University of Utah, embarked on a massive undertaking to address sepsis in their hospital. It was, at the time, lacking in “sepsis culture,” Dr. Horton said.

“One of the big things that motivated both of us was that we started doing chart review together and – it’s always easier with 20/20 hindsight – we were noticing that residents were missing the signs of sepsis,” Dr. Horton explained. “The clinical criteria would be there, but no one would say the word.” This is important, he said, because sepsis is time critical.

So the pair set out to create a cultural change by sharing data and collecting input from each service and unit, which relied heavily on nursing staff to perpetuate change. They created an early warning system in the medical record and worked with units to achieve flexibility in their criteria.

While the early warning system seemed helpful on the floor, SEP-1 adherence rates changed little in the emergency department. So Dr. Graves and Dr. Horton worked out an ED-specific process map that started at triage and was modeled after myocardial infarction STEMI protocols. From April through December 2016, the ED achieved between 29.5% adherence to the SEP-1 bundles, they said according to CMS abstractor data. After the change, between January and March 2017, the ED saw 52.2% adherence.

Dr. Kalantari would like to see CMS allow hospitals to evaluate and alter their processes more individually, with the required result being lower sepsis mortality. Hospitalists, said Dr. Kahn, are well poised to champion these sepsis improvement efforts.

“Hospitalists are uniquely positioned to lead in this area because they are a visible presence and a link between providers doing multidisciplinary acute care,” he said. “The other thing hospitalists can do is insist on rolling out approaches that are evidence based and not likely to cause harm by leading to over resuscitation, or ensuring patients are receiving central-line insertions only when needed.”

This is currently a moment for hospitals to innovate and provide meaningful feedback to CMS, which, he said, is listening.

“It’s a myth that CMS rolls out policy without listening to the clinical community, but what they want is constructive criticism, not just to hear ‘We’re not ready and we have to push this down the road,’ ” Dr. Kahn said. “The time is now in the era of accountability in health care.”

References

1. Sepsis. National Institute of General Medical Sciences. https://www.nigms.nih.gov/education/pages/factsheet_sepsis.aspx. Updated Sept 2017. Accessed Jan 4, 2018.

2. Barbash I et al. Hospital perceptions of Medicare’s sepsis quality reporting initiative. J Hosp Med. 2017;12;963-8.

3. Kalantari A et al. Sepsis Definitions: The search for gold and what CMS got wrong. West J Emerg Med. 2017 Aug;18(5):951-6.

4. Singer M et. al. The Third International Consensus Definitions for Sepsis and Septic Shock (Sepsis-3). JAMA. 2016 Feb 23;315(8):801-10.

5. Rhodes A et al. Surviving Sepsis Campaign: International Guidelines for Management of Sepsis and Septic Shock: 2016. Intensive Care Med. 2017;43:304.

In October 2015, the Centers for Medicare & Medicaid Services implemented its first meaningful policy to attempt for addressing sepsis.

The condition – one of the leading causes of mortality among hospitalized patients – afflicts more than a million people each year in the United States, and between 15% and 30% of them die. Sepsis is one of the leading drivers of hospital readmissions, sending more patients back to the hospital than heart failure, pneumonia, and chronic obstructive pulmonary disease.¹

However, while providers seem to agree that time to address sepsis is past due, not everyone has embraced the Sepsis CMS Core Measure program, or SEP-1, as the means to best achieve it. This is, in part, because of discrepancies in how sepsis is defined, the burden of reporting, and what some consider to be arbitrary clinical requirements that may not correlate with better patient outcomes.

“Sepsis is indeed a critical public health problem, and it’s appropriate and valuable that Medicare and other policy makers are focusing on sepsis,” said Jeremy Kahn, MD, professor of critical care medicine and health policy and management at the University of Pittsburgh. “This was really the first approach at that … but at 85-pages long, it really is an enormous effort for hospitals to adhere to this measure.”

This is because of the tension between the “intense desire to improve sepsis outcomes” and the “incredible burden” of keeping up with the necessary documentation while also providing quality care, Dr. Kahn said.

In December 2017, Dr. Kahn helped lead a study published in the Journal of Hospital Medicine aimed at trying to understand hospital perceptions of SEP-1. Over the course of 29 interviews with randomly selected hospital quality leaders across the United States, including physicians and nurses, the results came as a surprise.²

Some, like emergency medicine physician Annahieta Kalantari, DO (who did not participate in the survey), feel that SEP-1 forces providers to practice “check-box” medicine and undermines successful efforts that don’t necessarily align with the CMS policy.

She arrived at her institution, Aria-Jefferson Health in Philadelphia, before CMS adopted SEP-1; at that time, she took note of the fact that the rate of sepsis mortalities in her hospital was, in her words, not great when compared with that at similar institutions. And then she helped do something about it.

“I thought, ‘We’re a Premier reporting hospital,’ so we did a gap analysis as to why and put together protocols for the hospital to follow with our sepsis patients, including a sepsis alert and a lot of education,” said Dr. Kalantari, associate program director for the emergency medicine residency program at Aria-Jefferson and a former chair of its sepsis management committee. “Before you knew it, mortalities were below benchmark.”

But once SEP-1 began, she said, the hospital was unable to check all of the boxes all of the time.

“We kept track, but we weren’t hitting all the bundles exactly within the periods of time recommended, but our mortalities were still amazing,” she said. “CMS basically picked definitions [for sepsis], and most of us don’t know what they’re basing them on because no one can agree on a definition anyway. Now they’re penalizing hospitals if they don’t hit the check marks in time, but we’d already demonstrated that our mortality and patient care was exceptional.”
She added: “I am extremely dissatisfied, as someone who provides frontline patient care, with how CMS is choosing to measure us.”

Dr. Kalantari wrote a piece in the Western Journal of Emergency Medicine in July 2017 in which she and coauthors outline the issues they take with SEP-1. They lay out the tension among the varied definitions of what sepsis is – and isn’t – and they also illuminate the apparent conflict between what CMS has officially defined and what evidence-based studies conducted since 2001 have suggested.³

In particular, CMS defines severe sepsis as an initial lactate above 2 mmol/L and septic shock as an initial lactate presentation of greater than 4 mmol/L. However, Dr. Kalantari and here coauthors argue in the paper that there is no standard definition of sepsis and that decades of attempts to achieve one have failed to reach consensus among providers. CMS, she said, fails to acknowledge this.

Defining sepsis

In fact, in 2016, another new definition of sepsis emerged by way of a 19-member task-force of experts: The Third International Consensus Definitions for Sepsis and Septic Shock, also called Sepsis-3.⁴ In March 2017, the Surviving Sepsis Campaign adopted this definition, which defined sepsis as a “life-threatening organ dysfunction caused by a dysregulated host response to infection.”⁵

“I think the definition has always been a challenging part of sepsis,” said Kencee Graves, MD, a hospitalist at the University of Utah, Salt Lake City. “The definitions came about for research purposes, so … they are not perfectly sensitive nor specific.”

However, Dr. Graves believes SEP-1 is a step in the right direction in that it brings awareness to sepsis and holds providers accountable. Several years ago, she and her colleague Devin Horton, MD, also a hospitalist at the University of Utah, embarked on a massive undertaking to address sepsis in their hospital. It was, at the time, lacking in “sepsis culture,” Dr. Horton said.

“One of the big things that motivated both of us was that we started doing chart review together and – it’s always easier with 20/20 hindsight – we were noticing that residents were missing the signs of sepsis,” Dr. Horton explained. “The clinical criteria would be there, but no one would say the word.” This is important, he said, because sepsis is time critical.

So the pair set out to create a cultural change by sharing data and collecting input from each service and unit, which relied heavily on nursing staff to perpetuate change. They created an early warning system in the medical record and worked with units to achieve flexibility in their criteria.

While the early warning system seemed helpful on the floor, SEP-1 adherence rates changed little in the emergency department. So Dr. Graves and Dr. Horton worked out an ED-specific process map that started at triage and was modeled after myocardial infarction STEMI protocols. From April through December 2016, the ED achieved between 29.5% adherence to the SEP-1 bundles, they said according to CMS abstractor data. After the change, between January and March 2017, the ED saw 52.2% adherence.

Dr. Kalantari would like to see CMS allow hospitals to evaluate and alter their processes more individually, with the required result being lower sepsis mortality. Hospitalists, said Dr. Kahn, are well poised to champion these sepsis improvement efforts.

“Hospitalists are uniquely positioned to lead in this area because they are a visible presence and a link between providers doing multidisciplinary acute care,” he said. “The other thing hospitalists can do is insist on rolling out approaches that are evidence based and not likely to cause harm by leading to over resuscitation, or ensuring patients are receiving central-line insertions only when needed.”

This is currently a moment for hospitals to innovate and provide meaningful feedback to CMS, which, he said, is listening.

“It’s a myth that CMS rolls out policy without listening to the clinical community, but what they want is constructive criticism, not just to hear ‘We’re not ready and we have to push this down the road,’ ” Dr. Kahn said. “The time is now in the era of accountability in health care.”

References

1. Sepsis. National Institute of General Medical Sciences. https://www.nigms.nih.gov/education/pages/factsheet_sepsis.aspx. Updated Sept 2017. Accessed Jan 4, 2018.

2. Barbash I et al. Hospital perceptions of Medicare’s sepsis quality reporting initiative. J Hosp Med. 2017;12;963-8.

3. Kalantari A et al. Sepsis Definitions: The search for gold and what CMS got wrong. West J Emerg Med. 2017 Aug;18(5):951-6.

4. Singer M et. al. The Third International Consensus Definitions for Sepsis and Septic Shock (Sepsis-3). JAMA. 2016 Feb 23;315(8):801-10.

5. Rhodes A et al. Surviving Sepsis Campaign: International Guidelines for Management of Sepsis and Septic Shock: 2016. Intensive Care Med. 2017;43:304.

In October 2015, the Centers for Medicare & Medicaid Services implemented its first meaningful policy to attempt for addressing sepsis.

The condition – one of the leading causes of mortality among hospitalized patients – afflicts more than a million people each year in the United States, and between 15% and 30% of them die. Sepsis is one of the leading drivers of hospital readmissions, sending more patients back to the hospital than heart failure, pneumonia, and chronic obstructive pulmonary disease.¹

However, while providers seem to agree that time to address sepsis is past due, not everyone has embraced the Sepsis CMS Core Measure program, or SEP-1, as the means to best achieve it. This is, in part, because of discrepancies in how sepsis is defined, the burden of reporting, and what some consider to be arbitrary clinical requirements that may not correlate with better patient outcomes.

“Sepsis is indeed a critical public health problem, and it’s appropriate and valuable that Medicare and other policy makers are focusing on sepsis,” said Jeremy Kahn, MD, professor of critical care medicine and health policy and management at the University of Pittsburgh. “This was really the first approach at that … but at 85-pages long, it really is an enormous effort for hospitals to adhere to this measure.”

This is because of the tension between the “intense desire to improve sepsis outcomes” and the “incredible burden” of keeping up with the necessary documentation while also providing quality care, Dr. Kahn said.

In December 2017, Dr. Kahn helped lead a study published in the Journal of Hospital Medicine aimed at trying to understand hospital perceptions of SEP-1. Over the course of 29 interviews with randomly selected hospital quality leaders across the United States, including physicians and nurses, the results came as a surprise.²

Some, like emergency medicine physician Annahieta Kalantari, DO (who did not participate in the survey), feel that SEP-1 forces providers to practice “check-box” medicine and undermines successful efforts that don’t necessarily align with the CMS policy.

She arrived at her institution, Aria-Jefferson Health in Philadelphia, before CMS adopted SEP-1; at that time, she took note of the fact that the rate of sepsis mortalities in her hospital was, in her words, not great when compared with that at similar institutions. And then she helped do something about it.

“I thought, ‘We’re a Premier reporting hospital,’ so we did a gap analysis as to why and put together protocols for the hospital to follow with our sepsis patients, including a sepsis alert and a lot of education,” said Dr. Kalantari, associate program director for the emergency medicine residency program at Aria-Jefferson and a former chair of its sepsis management committee. “Before you knew it, mortalities were below benchmark.”

But once SEP-1 began, she said, the hospital was unable to check all of the boxes all of the time.

“We kept track, but we weren’t hitting all the bundles exactly within the periods of time recommended, but our mortalities were still amazing,” she said. “CMS basically picked definitions [for sepsis], and most of us don’t know what they’re basing them on because no one can agree on a definition anyway. Now they’re penalizing hospitals if they don’t hit the check marks in time, but we’d already demonstrated that our mortality and patient care was exceptional.”
She added: “I am extremely dissatisfied, as someone who provides frontline patient care, with how CMS is choosing to measure us.”

Dr. Kalantari wrote a piece in the Western Journal of Emergency Medicine in July 2017 in which she and coauthors outline the issues they take with SEP-1. They lay out the tension among the varied definitions of what sepsis is – and isn’t – and they also illuminate the apparent conflict between what CMS has officially defined and what evidence-based studies conducted since 2001 have suggested.³

In particular, CMS defines severe sepsis as an initial lactate above 2 mmol/L and septic shock as an initial lactate presentation of greater than 4 mmol/L. However, Dr. Kalantari and here coauthors argue in the paper that there is no standard definition of sepsis and that decades of attempts to achieve one have failed to reach consensus among providers. CMS, she said, fails to acknowledge this.

Defining sepsis

In fact, in 2016, another new definition of sepsis emerged by way of a 19-member task-force of experts: The Third International Consensus Definitions for Sepsis and Septic Shock, also called Sepsis-3.⁴ In March 2017, the Surviving Sepsis Campaign adopted this definition, which defined sepsis as a “life-threatening organ dysfunction caused by a dysregulated host response to infection.”⁵

“I think the definition has always been a challenging part of sepsis,” said Kencee Graves, MD, a hospitalist at the University of Utah, Salt Lake City. “The definitions came about for research purposes, so … they are not perfectly sensitive nor specific.”

However, Dr. Graves believes SEP-1 is a step in the right direction in that it brings awareness to sepsis and holds providers accountable. Several years ago, she and her colleague Devin Horton, MD, also a hospitalist at the University of Utah, embarked on a massive undertaking to address sepsis in their hospital. It was, at the time, lacking in “sepsis culture,” Dr. Horton said.

“One of the big things that motivated both of us was that we started doing chart review together and – it’s always easier with 20/20 hindsight – we were noticing that residents were missing the signs of sepsis,” Dr. Horton explained. “The clinical criteria would be there, but no one would say the word.” This is important, he said, because sepsis is time critical.

So the pair set out to create a cultural change by sharing data and collecting input from each service and unit, which relied heavily on nursing staff to perpetuate change. They created an early warning system in the medical record and worked with units to achieve flexibility in their criteria.

While the early warning system seemed helpful on the floor, SEP-1 adherence rates changed little in the emergency department. So Dr. Graves and Dr. Horton worked out an ED-specific process map that started at triage and was modeled after myocardial infarction STEMI protocols. From April through December 2016, the ED achieved between 29.5% adherence to the SEP-1 bundles, they said according to CMS abstractor data. After the change, between January and March 2017, the ED saw 52.2% adherence.

Dr. Kalantari would like to see CMS allow hospitals to evaluate and alter their processes more individually, with the required result being lower sepsis mortality. Hospitalists, said Dr. Kahn, are well poised to champion these sepsis improvement efforts.

“Hospitalists are uniquely positioned to lead in this area because they are a visible presence and a link between providers doing multidisciplinary acute care,” he said. “The other thing hospitalists can do is insist on rolling out approaches that are evidence based and not likely to cause harm by leading to over resuscitation, or ensuring patients are receiving central-line insertions only when needed.”

This is currently a moment for hospitals to innovate and provide meaningful feedback to CMS, which, he said, is listening.

“It’s a myth that CMS rolls out policy without listening to the clinical community, but what they want is constructive criticism, not just to hear ‘We’re not ready and we have to push this down the road,’ ” Dr. Kahn said. “The time is now in the era of accountability in health care.”

References

1. Sepsis. National Institute of General Medical Sciences. https://www.nigms.nih.gov/education/pages/factsheet_sepsis.aspx. Updated Sept 2017. Accessed Jan 4, 2018.

2. Barbash I et al. Hospital perceptions of Medicare’s sepsis quality reporting initiative. J Hosp Med. 2017;12;963-8.

3. Kalantari A et al. Sepsis Definitions: The search for gold and what CMS got wrong. West J Emerg Med. 2017 Aug;18(5):951-6.

4. Singer M et. al. The Third International Consensus Definitions for Sepsis and Septic Shock (Sepsis-3). JAMA. 2016 Feb 23;315(8):801-10.

5. Rhodes A et al. Surviving Sepsis Campaign: International Guidelines for Management of Sepsis and Septic Shock: 2016. Intensive Care Med. 2017;43:304.

It wasn’t something she planned to have happen but about 2 years ago, Vineet Arora, MD, MAPP, MHM, became what she calls an “accidental advocate” for gender parity in medicine.

“I was asked to review a paper around gender pay,” the University of Chicago Medical Center hospitalist said. “It was stunning to me just how different salaries were – between male and female physicians – even when the authors were attempting to control for various factors.”

That paper was published in the Journal of the American Medical Association (JAMA) in September 2016 by researchers at Harvard Medical School and Massachusetts General Hospital (MGH). It found that even after adjustment for age, experience, specialty, faculty rank, research productivity, and clinical revenue, female physicians at 24 public medical schools in 12 states earned nearly $20,000 less per year than their male colleagues.¹

Dr. Arora wrote an editorial to accompany that 2016 paper in JAMA, and in September 2017, she and her colleague at the University of Chicago, Jeanne Farnan, MD, MHPE, coauthored another piece in Annals of Internal Medicine titled, “Inpatient Notes: Gender Equality in Hospital Medicine – Are We There Yet?”²

In the 2017 paper, Dr. Arora and Dr. Farnan assessed recent studies documenting inequity in regard to compensation, discrimination around child-rearing, and gender disparities in medical leadership. They also discussed strategies that might improve the future outlook for female physicians.

“As I approach mid-career, I see these issues affecting my career and my colleagues’ careers and I decided we need to be doing more work in this space,” said Dr. Arora.

Fueling the conversation

When asked whether he thinks his research inspired the current conversation around gender inequity in medicine, Anupam Bapu Jena, MD, PhD – lead author of the September 2016 gender pay paper – said that while he did not initiate it, his work “has fueled the conversation.”

“This is an issue that has been going on in the scientific literature for at least 25-30 years,” said Dr. Jena, the Ruth L. Newhouse Associate Professor of Health Care Policy at Harvard Medical School and a physician in the department of medicine at MGH. “I am sure women in medicine have been feeling this since women entered medicine.”

Many female hospitalists hoped that, as a relatively new field, hospital medicine would avoid some of the time-worn challenges women in other specialties faced.

“The birth of hospital medicine held the promise that, as a new field, it would be immune to the ‘old boys’ club mentality that plagues established specialties,” Dr. Farnan and Dr. Arora wrote in their September 2017 Annals article. And yet, they continued, “gender disparities developed in the areas of leadership and academic productivity.”

Being taken seriously

Expectations around gender norms may also affect relationships female doctors have with their patients. In a June 2017 Washington Post editorial, Faye Reiff-Pasarew, MD, describes being objectified as “cute” and “adorable” and not being taken seriously by her patients.⁴

“I’d had a number of interactions with patients that upset me,” said Dr. Reiff-Pasarew, assistant professor of hospital medicine, director of the humanism in medicine program, and unit medical director at Icahn School of Medicine at Mount Sinai in New York City. “Later, I reflected upon them and realized that bias was a systemic problem. There needs to be a conversation amongst the broader medical community about the effect that these biases have on our patients and our practice.”

In her editorial, Dr. Reiff-Pasarew explained that when a female physician is written off as too young or is not recognized as a physician, it can delay necessary care. She also touches on the challenge of earning the trust of hospitalized patients.

“There’s a lot of evidence that the success of medical therapy is influenced by the context in which it is given, beyond mere adherence to a regimen or medication,” Dr. Reiff-Pasarew said, noting that it is a result of “the very powerful placebo effect.

Equal compensation for equal work

Ultimately, it is in the best interest of all physicians, their employers, and their patients to ensure female physicians are satisfied and fulfilled in their professions, said Dr. Jena, and that includes recognizing and rewarding their value.

“What I am trying to argue in my work is for equal pay – equal compensation for equal work,” Dr. Jena said. “Man or woman, it’s a good idea.”

Dr. Jena, who is also a faculty research fellow at the National Bureau of Economic Research, said that when the contributions of a group of people are systematically undervalued, “you run the risk of having those individuals invest less in their career.” In health care, he said, “if fewer women want to go into academic medicine because they know they are underpaid, what impact does it have on new ideas when you eliminate highly successful, intelligent people from a field?”

Dr. Jena and his colleagues authored a February 2017 study in JAMA Internal Medicine that showed hospitalized Medicare patients treated by female internists have lower 30-day mortality and readmissions rates compared with those treated by male internists, including hospitalists. This included millions of hospitalizations and accounted for myriad confounders.⁵

References

1. Jena AB, Olenski AR, Blumenthal DM. Sex differences in physician salary in US public medical schools. JAMA Intern Med. 2016;176(9):1294-1304. doi: 10.1001/jamainternmed.2016.3284.

2. Farnan JM and Arora VM. Gender equality in hospital medicine – are we there yet? Ann Intern Med. 2017;167(6):HO2-HO3. doi: 10.7326/M17-2119.

3. Burden M, Frank MG, Keniston A, et al. Gender disparities in leadership and scholarly productivity of academic hospitalists. J Hosp Med 2015;8;481-5. doi: 10.1002/jhm.2340.

4. Reiff-Pasarew F. I’m a young, female doctor. Calling me ‘sweetie’ won’t help me save your life. Washington Post. Published June 29, 2017. Accessed Dec. 4, 2017.

5. Tsugawa Y, Jena AB, Figueroa JF, et al. Comparison of hospital mortality and readmission rates for Medicare patients treated by male vs female physicians. JAMA Intern Med. 2017;177(2):206-13. doi: 10.1001/jamainternmed.2016.7875.

It wasn’t something she planned to have happen but about 2 years ago, Vineet Arora, MD, MAPP, MHM, became what she calls an “accidental advocate” for gender parity in medicine.

“I was asked to review a paper around gender pay,” the University of Chicago Medical Center hospitalist said. “It was stunning to me just how different salaries were – between male and female physicians – even when the authors were attempting to control for various factors.”

That paper was published in the Journal of the American Medical Association (JAMA) in September 2016 by researchers at Harvard Medical School and Massachusetts General Hospital (MGH). It found that even after adjustment for age, experience, specialty, faculty rank, research productivity, and clinical revenue, female physicians at 24 public medical schools in 12 states earned nearly $20,000 less per year than their male colleagues.¹

Dr. Arora wrote an editorial to accompany that 2016 paper in JAMA, and in September 2017, she and her colleague at the University of Chicago, Jeanne Farnan, MD, MHPE, coauthored another piece in Annals of Internal Medicine titled, “Inpatient Notes: Gender Equality in Hospital Medicine – Are We There Yet?”²

In the 2017 paper, Dr. Arora and Dr. Farnan assessed recent studies documenting inequity in regard to compensation, discrimination around child-rearing, and gender disparities in medical leadership. They also discussed strategies that might improve the future outlook for female physicians.

“As I approach mid-career, I see these issues affecting my career and my colleagues’ careers and I decided we need to be doing more work in this space,” said Dr. Arora.

Fueling the conversation

When asked whether he thinks his research inspired the current conversation around gender inequity in medicine, Anupam Bapu Jena, MD, PhD – lead author of the September 2016 gender pay paper – said that while he did not initiate it, his work “has fueled the conversation.”

“This is an issue that has been going on in the scientific literature for at least 25-30 years,” said Dr. Jena, the Ruth L. Newhouse Associate Professor of Health Care Policy at Harvard Medical School and a physician in the department of medicine at MGH. “I am sure women in medicine have been feeling this since women entered medicine.”

Many female hospitalists hoped that, as a relatively new field, hospital medicine would avoid some of the time-worn challenges women in other specialties faced.

“The birth of hospital medicine held the promise that, as a new field, it would be immune to the ‘old boys’ club mentality that plagues established specialties,” Dr. Farnan and Dr. Arora wrote in their September 2017 Annals article. And yet, they continued, “gender disparities developed in the areas of leadership and academic productivity.”

Being taken seriously

Expectations around gender norms may also affect relationships female doctors have with their patients. In a June 2017 Washington Post editorial, Faye Reiff-Pasarew, MD, describes being objectified as “cute” and “adorable” and not being taken seriously by her patients.⁴

“I’d had a number of interactions with patients that upset me,” said Dr. Reiff-Pasarew, assistant professor of hospital medicine, director of the humanism in medicine program, and unit medical director at Icahn School of Medicine at Mount Sinai in New York City. “Later, I reflected upon them and realized that bias was a systemic problem. There needs to be a conversation amongst the broader medical community about the effect that these biases have on our patients and our practice.”

In her editorial, Dr. Reiff-Pasarew explained that when a female physician is written off as too young or is not recognized as a physician, it can delay necessary care. She also touches on the challenge of earning the trust of hospitalized patients.

“There’s a lot of evidence that the success of medical therapy is influenced by the context in which it is given, beyond mere adherence to a regimen or medication,” Dr. Reiff-Pasarew said, noting that it is a result of “the very powerful placebo effect.

Equal compensation for equal work

Ultimately, it is in the best interest of all physicians, their employers, and their patients to ensure female physicians are satisfied and fulfilled in their professions, said Dr. Jena, and that includes recognizing and rewarding their value.

“What I am trying to argue in my work is for equal pay – equal compensation for equal work,” Dr. Jena said. “Man or woman, it’s a good idea.”

Dr. Jena, who is also a faculty research fellow at the National Bureau of Economic Research, said that when the contributions of a group of people are systematically undervalued, “you run the risk of having those individuals invest less in their career.” In health care, he said, “if fewer women want to go into academic medicine because they know they are underpaid, what impact does it have on new ideas when you eliminate highly successful, intelligent people from a field?”

Dr. Jena and his colleagues authored a February 2017 study in JAMA Internal Medicine that showed hospitalized Medicare patients treated by female internists have lower 30-day mortality and readmissions rates compared with those treated by male internists, including hospitalists. This included millions of hospitalizations and accounted for myriad confounders.⁵

References

1. Jena AB, Olenski AR, Blumenthal DM. Sex differences in physician salary in US public medical schools. JAMA Intern Med. 2016;176(9):1294-1304. doi: 10.1001/jamainternmed.2016.3284.

2. Farnan JM and Arora VM. Gender equality in hospital medicine – are we there yet? Ann Intern Med. 2017;167(6):HO2-HO3. doi: 10.7326/M17-2119.

3. Burden M, Frank MG, Keniston A, et al. Gender disparities in leadership and scholarly productivity of academic hospitalists. J Hosp Med 2015;8;481-5. doi: 10.1002/jhm.2340.

4. Reiff-Pasarew F. I’m a young, female doctor. Calling me ‘sweetie’ won’t help me save your life. Washington Post. Published June 29, 2017. Accessed Dec. 4, 2017.

5. Tsugawa Y, Jena AB, Figueroa JF, et al. Comparison of hospital mortality and readmission rates for Medicare patients treated by male vs female physicians. JAMA Intern Med. 2017;177(2):206-13. doi: 10.1001/jamainternmed.2016.7875.

It wasn’t something she planned to have happen but about 2 years ago, Vineet Arora, MD, MAPP, MHM, became what she calls an “accidental advocate” for gender parity in medicine.

“I was asked to review a paper around gender pay,” the University of Chicago Medical Center hospitalist said. “It was stunning to me just how different salaries were – between male and female physicians – even when the authors were attempting to control for various factors.”

That paper was published in the Journal of the American Medical Association (JAMA) in September 2016 by researchers at Harvard Medical School and Massachusetts General Hospital (MGH). It found that even after adjustment for age, experience, specialty, faculty rank, research productivity, and clinical revenue, female physicians at 24 public medical schools in 12 states earned nearly $20,000 less per year than their male colleagues.¹

Dr. Arora wrote an editorial to accompany that 2016 paper in JAMA, and in September 2017, she and her colleague at the University of Chicago, Jeanne Farnan, MD, MHPE, coauthored another piece in Annals of Internal Medicine titled, “Inpatient Notes: Gender Equality in Hospital Medicine – Are We There Yet?”²

In the 2017 paper, Dr. Arora and Dr. Farnan assessed recent studies documenting inequity in regard to compensation, discrimination around child-rearing, and gender disparities in medical leadership. They also discussed strategies that might improve the future outlook for female physicians.

“As I approach mid-career, I see these issues affecting my career and my colleagues’ careers and I decided we need to be doing more work in this space,” said Dr. Arora.

Fueling the conversation

When asked whether he thinks his research inspired the current conversation around gender inequity in medicine, Anupam Bapu Jena, MD, PhD – lead author of the September 2016 gender pay paper – said that while he did not initiate it, his work “has fueled the conversation.”

“This is an issue that has been going on in the scientific literature for at least 25-30 years,” said Dr. Jena, the Ruth L. Newhouse Associate Professor of Health Care Policy at Harvard Medical School and a physician in the department of medicine at MGH. “I am sure women in medicine have been feeling this since women entered medicine.”

Many female hospitalists hoped that, as a relatively new field, hospital medicine would avoid some of the time-worn challenges women in other specialties faced.

“The birth of hospital medicine held the promise that, as a new field, it would be immune to the ‘old boys’ club mentality that plagues established specialties,” Dr. Farnan and Dr. Arora wrote in their September 2017 Annals article. And yet, they continued, “gender disparities developed in the areas of leadership and academic productivity.”

Being taken seriously

Expectations around gender norms may also affect relationships female doctors have with their patients. In a June 2017 Washington Post editorial, Faye Reiff-Pasarew, MD, describes being objectified as “cute” and “adorable” and not being taken seriously by her patients.⁴

“I’d had a number of interactions with patients that upset me,” said Dr. Reiff-Pasarew, assistant professor of hospital medicine, director of the humanism in medicine program, and unit medical director at Icahn School of Medicine at Mount Sinai in New York City. “Later, I reflected upon them and realized that bias was a systemic problem. There needs to be a conversation amongst the broader medical community about the effect that these biases have on our patients and our practice.”

In her editorial, Dr. Reiff-Pasarew explained that when a female physician is written off as too young or is not recognized as a physician, it can delay necessary care. She also touches on the challenge of earning the trust of hospitalized patients.

“There’s a lot of evidence that the success of medical therapy is influenced by the context in which it is given, beyond mere adherence to a regimen or medication,” Dr. Reiff-Pasarew said, noting that it is a result of “the very powerful placebo effect.

Equal compensation for equal work

Ultimately, it is in the best interest of all physicians, their employers, and their patients to ensure female physicians are satisfied and fulfilled in their professions, said Dr. Jena, and that includes recognizing and rewarding their value.

“What I am trying to argue in my work is for equal pay – equal compensation for equal work,” Dr. Jena said. “Man or woman, it’s a good idea.”

Dr. Jena, who is also a faculty research fellow at the National Bureau of Economic Research, said that when the contributions of a group of people are systematically undervalued, “you run the risk of having those individuals invest less in their career.” In health care, he said, “if fewer women want to go into academic medicine because they know they are underpaid, what impact does it have on new ideas when you eliminate highly successful, intelligent people from a field?”

Dr. Jena and his colleagues authored a February 2017 study in JAMA Internal Medicine that showed hospitalized Medicare patients treated by female internists have lower 30-day mortality and readmissions rates compared with those treated by male internists, including hospitalists. This included millions of hospitalizations and accounted for myriad confounders.⁵

References

1. Jena AB, Olenski AR, Blumenthal DM. Sex differences in physician salary in US public medical schools. JAMA Intern Med. 2016;176(9):1294-1304. doi: 10.1001/jamainternmed.2016.3284.

2. Farnan JM and Arora VM. Gender equality in hospital medicine – are we there yet? Ann Intern Med. 2017;167(6):HO2-HO3. doi: 10.7326/M17-2119.

3. Burden M, Frank MG, Keniston A, et al. Gender disparities in leadership and scholarly productivity of academic hospitalists. J Hosp Med 2015;8;481-5. doi: 10.1002/jhm.2340.

4. Reiff-Pasarew F. I’m a young, female doctor. Calling me ‘sweetie’ won’t help me save your life. Washington Post. Published June 29, 2017. Accessed Dec. 4, 2017.

5. Tsugawa Y, Jena AB, Figueroa JF, et al. Comparison of hospital mortality and readmission rates for Medicare patients treated by male vs female physicians. JAMA Intern Med. 2017;177(2):206-13. doi: 10.1001/jamainternmed.2016.7875.

In 2014, 33,594 people were killed by firearms in the United States. More than 21,000 of these deaths were suicides. The rest were primarily homicides and accidental shootings. Meanwhile, firearm deaths represented nearly 17% of injury deaths that year.^1,2

In a 2015 Perspective published in the New England Journal of Medicine, author Chana Sacks, MD, pointed out that 20 children and adolescents are sent to the hospital daily for firearm injuries and 2,000 people each year suffer gunshot-related spinal cord injuries and “become lifelong patients.”³

At the same time, Federal Bureau of Investigation data show that the number of active shooter situations rose between 2000 and 2013, with an average of 6.4 incidents a year for the first 7 years of the study, conducted in 2013, and an average of 16.4 in the last 7 years of the study. More than 1,000 people were wounded or killed across 160 active shooter incidents, defined as an individual or individuals actively engaged in killing or trying to kill people in a populous area.⁴

“Gun violence is undeniably a public health issue,” said Dr. Sacks, a hospitalist at Massachusetts General Hospital and instructor at Harvard Medical School, both in Boston, and a vocal proponent of addressing firearms in the public health sphere. Her cousin’s 7-year-old son, Daniel Barden, was fatally shot at Sandy Hook Elementary School in Newtown, Conn., in December 2012.

Yet, the notion of firearm injuries and deaths as a public health issue is, in America, an issue of contention. How can hospitalists and other health care providers avoid wading into the political thicket while also looking out for their patients?

For one, it’s not the only controversial issue with which providers are confronted, Dr. Sacks and others say. From taking sexual histories, counseling patients about abortion and adoption, and discussing end-of-life issues, clinicians may routinely face uncomfortable interactions in the name of patient care.

“It’s not a question about their right to a weapon; it’s about how individuals can stay as safe as possible and keep their families as safe as possible,” said Dr. Sacks, who also wrote in a January 2017 opinion for the American Medical Association that: “Counseling about gun safety is not political – no more so than a physician counseling a patient about cutting down on sugary beverages is an act of declaring support for New York City’s attempted ban on large-sized sodas.”⁵

In 2014, 33,594 people were killed by firearms in the United States. More than 21,000 of these deaths were suicides. The rest were primarily homicides and accidental shootings. Meanwhile, firearm deaths represented nearly 17% of injury deaths that year.^1,2

In a 2015 Perspective published in the New England Journal of Medicine, author Chana Sacks, MD, pointed out that 20 children and adolescents are sent to the hospital daily for firearm injuries and 2,000 people each year suffer gunshot-related spinal cord injuries and “become lifelong patients.”³

At the same time, Federal Bureau of Investigation data show that the number of active shooter situations rose between 2000 and 2013, with an average of 6.4 incidents a year for the first 7 years of the study, conducted in 2013, and an average of 16.4 in the last 7 years of the study. More than 1,000 people were wounded or killed across 160 active shooter incidents, defined as an individual or individuals actively engaged in killing or trying to kill people in a populous area.⁴

“Gun violence is undeniably a public health issue,” said Dr. Sacks, a hospitalist at Massachusetts General Hospital and instructor at Harvard Medical School, both in Boston, and a vocal proponent of addressing firearms in the public health sphere. Her cousin’s 7-year-old son, Daniel Barden, was fatally shot at Sandy Hook Elementary School in Newtown, Conn., in December 2012.

Yet, the notion of firearm injuries and deaths as a public health issue is, in America, an issue of contention. How can hospitalists and other health care providers avoid wading into the political thicket while also looking out for their patients?

For one, it’s not the only controversial issue with which providers are confronted, Dr. Sacks and others say. From taking sexual histories, counseling patients about abortion and adoption, and discussing end-of-life issues, clinicians may routinely face uncomfortable interactions in the name of patient care.

“It’s not a question about their right to a weapon; it’s about how individuals can stay as safe as possible and keep their families as safe as possible,” said Dr. Sacks, who also wrote in a January 2017 opinion for the American Medical Association that: “Counseling about gun safety is not political – no more so than a physician counseling a patient about cutting down on sugary beverages is an act of declaring support for New York City’s attempted ban on large-sized sodas.”⁵

In 2014, 33,594 people were killed by firearms in the United States. More than 21,000 of these deaths were suicides. The rest were primarily homicides and accidental shootings. Meanwhile, firearm deaths represented nearly 17% of injury deaths that year.^1,2

In a 2015 Perspective published in the New England Journal of Medicine, author Chana Sacks, MD, pointed out that 20 children and adolescents are sent to the hospital daily for firearm injuries and 2,000 people each year suffer gunshot-related spinal cord injuries and “become lifelong patients.”³

At the same time, Federal Bureau of Investigation data show that the number of active shooter situations rose between 2000 and 2013, with an average of 6.4 incidents a year for the first 7 years of the study, conducted in 2013, and an average of 16.4 in the last 7 years of the study. More than 1,000 people were wounded or killed across 160 active shooter incidents, defined as an individual or individuals actively engaged in killing or trying to kill people in a populous area.⁴

“Gun violence is undeniably a public health issue,” said Dr. Sacks, a hospitalist at Massachusetts General Hospital and instructor at Harvard Medical School, both in Boston, and a vocal proponent of addressing firearms in the public health sphere. Her cousin’s 7-year-old son, Daniel Barden, was fatally shot at Sandy Hook Elementary School in Newtown, Conn., in December 2012.

Yet, the notion of firearm injuries and deaths as a public health issue is, in America, an issue of contention. How can hospitalists and other health care providers avoid wading into the political thicket while also looking out for their patients?

For one, it’s not the only controversial issue with which providers are confronted, Dr. Sacks and others say. From taking sexual histories, counseling patients about abortion and adoption, and discussing end-of-life issues, clinicians may routinely face uncomfortable interactions in the name of patient care.

“It’s not a question about their right to a weapon; it’s about how individuals can stay as safe as possible and keep their families as safe as possible,” said Dr. Sacks, who also wrote in a January 2017 opinion for the American Medical Association that: “Counseling about gun safety is not political – no more so than a physician counseling a patient about cutting down on sugary beverages is an act of declaring support for New York City’s attempted ban on large-sized sodas.”⁵

Since 2010, when Democrats passed the Affordable Care Act – also known as Obamacare – without a single Republican vote, the GOP has vowed to repeal and replace it. With the election of Donald Trump in November 2016, Republicans gained control of the presidency and Congress and hoped to put Obamacare on the chopping block.

Although the Affordable Care Act’s (ACA’s) individual mandate was eliminated in the Tax Cuts and Jobs Act passed in late 2017, Republican leaders have been unable to secure the votes they need for a full repeal of Obamacare and a complete reboot of the American health care system. That may be, in part, because in the search for a better American health care system, there is no single right answer. In few places is that more clear than when making comparisons of health care systems across the world.

“Comparisons are fun, and everyone loves rankings,” said Ashish Jha, MD, MPH, a physician with the Harvard T.H. Chan School of Public Health and director of the Harvard Global Health Institute in Cambridge, Mass. Last fall Shah published an analysis on his personal blog comparing health care in the United States with that in seven high-income nations.¹ It was prompted by a similar side-by-side comparison he participated in with other experts for the New York Times.² “The most important part is we get to ask questions about things we care about, like ‘What do other countries do when they’re better than us?’ We’re not going to adopt any country’s model wholesale, but we can learn from them,” he said.

For instance, just 7.4% of people in Switzerland (according to data from the Organisation for Economic Cooperation and Development) skip medical tests, treatments, or follow-ups because of costs, compared with 21.3% in the United States. Meanwhile, the United States leads in innovation, producing 57% of new drugs (according to the Milken Institute), which is more than Switzerland’s 13% and Germany’s 6%.¹

Although many Americans tend to think that health care in other developed nations is entirely single payer or government run, systems across Europe and the rest of the globe vary immensely in how they approach health care. One thing common among high-income nations, however, is some form of universal health care. In Canada, for example, the government funds health insurance for care delivered in the private sector. In Australia, public hospitals provide free inpatient care. In France, the Ministry of Health sets prices, budgets, and funding levels.²

“There are really two main purposes” when it comes to international comparisons, said Eric Schneider, MD, senior vice president for policy and research for the Commonwealth Fund. “The first is to understand how other countries perform, and the second is what lessons can we learn from the way care is financed, organized, and delivered in other nations and how we might import some of those ideas to the U.S. and improve policies here.”

The Affordable Care Act, Dr. Jha said, was something of the ultimate test for applying lessons learned in other countries and those put forward over the past decades in the United States by policy experts and leaders in health care thinking.

“The Affordable Care Act includes several ideas that are prevalent in other countries, particularly around how to expand insurance coverage and how to subsidize the poor so they can have good insurance coverage, too,” said Dr. Schneider. “The notion of essential health benefits, the mandate for insurance, the notion of subsidies, in some ways, these were all borrowed from abroad.”

For instance, health care in The Netherlands – which, like the United States, also relies on private health insurers – ranked among the highest of other high-income countries in the world in The Commonwealth Fund’s 2017 international comparison, published in July 2017.³ The Dutch have standardized their health benefits, reducing administrative burden for providers and making copayments more predictable for patients.

Dr. Schneider believes that the United States should continue to build on the progress of the Affordable Care Act – particularly since more than 20 million Americans have gained insurance coverage since the passage of the law (91% of Americans are insured today).⁴ And the ACA has renewed focus in the United States on improving and strengthening primary care and changing the incentives around care delivery.

Some Democrats and Republicans in Congress have started working on bipartisan solutions to solve some of the problems inherent in the ACA – or those engineered by those who oppose it.

References

1. Jha A. Judging health systems: focusing on what matters. An Ounce of Evidence. Published Sep 18, 2017. Last accessed Oct 19, 2017. https://blogs.sph.harvard.edu/ashish-jha/.

2. Carroll AE et al. The best health care system in the world: Which one would you pick? New York Times. Published Sep 18, 2017. Accessed Oct 19, 2017. https://www.nytimes.com/interactive/2017/09/18/upshot/best-health-care-system-country-bracket.html?action=click&contentCollection=upshot&region=rank&module=package&version=highlights&contentPlacement=1&pgtype=sectionfront.

3. Schneider EC et al. Mirror, mirror 2017: International comparison reflects flaws and opportunities for better U.S. health care. The Commonwealth Fund. Published Jul 14, 2017. Accessed Oct 19, 2017. http://www.commonwealthfund.org/publications/fund-reports/2017/jul/mirror-mirror-international-comparisons-2017.

4. Martinez ME et al. Health insurance coverage: Early release of estimates from the national health interview survey, January-September 2016. Centers for Disease Control and Prevention, Division of Health Interview Statistics, National Center for Health Statistics. Published Feb, 2017. Accessed Oct 19, 2017. https://www.cdc.gov/nchs/data/nhis/earlyrelease/insur201702.pdf.

5. Papanicolas I et al. Challenges in international comparison of health care systems. JAMA. 2017 Aug 8;318(6):515-6. https://jamanetwork.com/journals/jama/article-abstract/2646461.

6. Schneider EC et al. From last to first – Could the U.S. health care system become the best in the world? N Engl J Med. 2017 Sep 7; 377(10):901-4.

Since 2010, when Democrats passed the Affordable Care Act – also known as Obamacare – without a single Republican vote, the GOP has vowed to repeal and replace it. With the election of Donald Trump in November 2016, Republicans gained control of the presidency and Congress and hoped to put Obamacare on the chopping block.

Although the Affordable Care Act’s (ACA’s) individual mandate was eliminated in the Tax Cuts and Jobs Act passed in late 2017, Republican leaders have been unable to secure the votes they need for a full repeal of Obamacare and a complete reboot of the American health care system. That may be, in part, because in the search for a better American health care system, there is no single right answer. In few places is that more clear than when making comparisons of health care systems across the world.

“Comparisons are fun, and everyone loves rankings,” said Ashish Jha, MD, MPH, a physician with the Harvard T.H. Chan School of Public Health and director of the Harvard Global Health Institute in Cambridge, Mass. Last fall Shah published an analysis on his personal blog comparing health care in the United States with that in seven high-income nations.¹ It was prompted by a similar side-by-side comparison he participated in with other experts for the New York Times.² “The most important part is we get to ask questions about things we care about, like ‘What do other countries do when they’re better than us?’ We’re not going to adopt any country’s model wholesale, but we can learn from them,” he said.

For instance, just 7.4% of people in Switzerland (according to data from the Organisation for Economic Cooperation and Development) skip medical tests, treatments, or follow-ups because of costs, compared with 21.3% in the United States. Meanwhile, the United States leads in innovation, producing 57% of new drugs (according to the Milken Institute), which is more than Switzerland’s 13% and Germany’s 6%.¹

Although many Americans tend to think that health care in other developed nations is entirely single payer or government run, systems across Europe and the rest of the globe vary immensely in how they approach health care. One thing common among high-income nations, however, is some form of universal health care. In Canada, for example, the government funds health insurance for care delivered in the private sector. In Australia, public hospitals provide free inpatient care. In France, the Ministry of Health sets prices, budgets, and funding levels.²

“There are really two main purposes” when it comes to international comparisons, said Eric Schneider, MD, senior vice president for policy and research for the Commonwealth Fund. “The first is to understand how other countries perform, and the second is what lessons can we learn from the way care is financed, organized, and delivered in other nations and how we might import some of those ideas to the U.S. and improve policies here.”

The Affordable Care Act, Dr. Jha said, was something of the ultimate test for applying lessons learned in other countries and those put forward over the past decades in the United States by policy experts and leaders in health care thinking.

“The Affordable Care Act includes several ideas that are prevalent in other countries, particularly around how to expand insurance coverage and how to subsidize the poor so they can have good insurance coverage, too,” said Dr. Schneider. “The notion of essential health benefits, the mandate for insurance, the notion of subsidies, in some ways, these were all borrowed from abroad.”

For instance, health care in The Netherlands – which, like the United States, also relies on private health insurers – ranked among the highest of other high-income countries in the world in The Commonwealth Fund’s 2017 international comparison, published in July 2017.³ The Dutch have standardized their health benefits, reducing administrative burden for providers and making copayments more predictable for patients.

Dr. Schneider believes that the United States should continue to build on the progress of the Affordable Care Act – particularly since more than 20 million Americans have gained insurance coverage since the passage of the law (91% of Americans are insured today).⁴ And the ACA has renewed focus in the United States on improving and strengthening primary care and changing the incentives around care delivery.

Some Democrats and Republicans in Congress have started working on bipartisan solutions to solve some of the problems inherent in the ACA – or those engineered by those who oppose it.

References

1. Jha A. Judging health systems: focusing on what matters. An Ounce of Evidence. Published Sep 18, 2017. Last accessed Oct 19, 2017. https://blogs.sph.harvard.edu/ashish-jha/.

2. Carroll AE et al. The best health care system in the world: Which one would you pick? New York Times. Published Sep 18, 2017. Accessed Oct 19, 2017. https://www.nytimes.com/interactive/2017/09/18/upshot/best-health-care-system-country-bracket.html?action=click&contentCollection=upshot&region=rank&module=package&version=highlights&contentPlacement=1&pgtype=sectionfront.

3. Schneider EC et al. Mirror, mirror 2017: International comparison reflects flaws and opportunities for better U.S. health care. The Commonwealth Fund. Published Jul 14, 2017. Accessed Oct 19, 2017. http://www.commonwealthfund.org/publications/fund-reports/2017/jul/mirror-mirror-international-comparisons-2017.

4. Martinez ME et al. Health insurance coverage: Early release of estimates from the national health interview survey, January-September 2016. Centers for Disease Control and Prevention, Division of Health Interview Statistics, National Center for Health Statistics. Published Feb, 2017. Accessed Oct 19, 2017. https://www.cdc.gov/nchs/data/nhis/earlyrelease/insur201702.pdf.

5. Papanicolas I et al. Challenges in international comparison of health care systems. JAMA. 2017 Aug 8;318(6):515-6. https://jamanetwork.com/journals/jama/article-abstract/2646461.

6. Schneider EC et al. From last to first – Could the U.S. health care system become the best in the world? N Engl J Med. 2017 Sep 7; 377(10):901-4.

Since 2010, when Democrats passed the Affordable Care Act – also known as Obamacare – without a single Republican vote, the GOP has vowed to repeal and replace it. With the election of Donald Trump in November 2016, Republicans gained control of the presidency and Congress and hoped to put Obamacare on the chopping block.

Although the Affordable Care Act’s (ACA’s) individual mandate was eliminated in the Tax Cuts and Jobs Act passed in late 2017, Republican leaders have been unable to secure the votes they need for a full repeal of Obamacare and a complete reboot of the American health care system. That may be, in part, because in the search for a better American health care system, there is no single right answer. In few places is that more clear than when making comparisons of health care systems across the world.

“Comparisons are fun, and everyone loves rankings,” said Ashish Jha, MD, MPH, a physician with the Harvard T.H. Chan School of Public Health and director of the Harvard Global Health Institute in Cambridge, Mass. Last fall Shah published an analysis on his personal blog comparing health care in the United States with that in seven high-income nations.¹ It was prompted by a similar side-by-side comparison he participated in with other experts for the New York Times.² “The most important part is we get to ask questions about things we care about, like ‘What do other countries do when they’re better than us?’ We’re not going to adopt any country’s model wholesale, but we can learn from them,” he said.

For instance, just 7.4% of people in Switzerland (according to data from the Organisation for Economic Cooperation and Development) skip medical tests, treatments, or follow-ups because of costs, compared with 21.3% in the United States. Meanwhile, the United States leads in innovation, producing 57% of new drugs (according to the Milken Institute), which is more than Switzerland’s 13% and Germany’s 6%.¹

Although many Americans tend to think that health care in other developed nations is entirely single payer or government run, systems across Europe and the rest of the globe vary immensely in how they approach health care. One thing common among high-income nations, however, is some form of universal health care. In Canada, for example, the government funds health insurance for care delivered in the private sector. In Australia, public hospitals provide free inpatient care. In France, the Ministry of Health sets prices, budgets, and funding levels.²

“There are really two main purposes” when it comes to international comparisons, said Eric Schneider, MD, senior vice president for policy and research for the Commonwealth Fund. “The first is to understand how other countries perform, and the second is what lessons can we learn from the way care is financed, organized, and delivered in other nations and how we might import some of those ideas to the U.S. and improve policies here.”

The Affordable Care Act, Dr. Jha said, was something of the ultimate test for applying lessons learned in other countries and those put forward over the past decades in the United States by policy experts and leaders in health care thinking.

“The Affordable Care Act includes several ideas that are prevalent in other countries, particularly around how to expand insurance coverage and how to subsidize the poor so they can have good insurance coverage, too,” said Dr. Schneider. “The notion of essential health benefits, the mandate for insurance, the notion of subsidies, in some ways, these were all borrowed from abroad.”

For instance, health care in The Netherlands – which, like the United States, also relies on private health insurers – ranked among the highest of other high-income countries in the world in The Commonwealth Fund’s 2017 international comparison, published in July 2017.³ The Dutch have standardized their health benefits, reducing administrative burden for providers and making copayments more predictable for patients.

Dr. Schneider believes that the United States should continue to build on the progress of the Affordable Care Act – particularly since more than 20 million Americans have gained insurance coverage since the passage of the law (91% of Americans are insured today).⁴ And the ACA has renewed focus in the United States on improving and strengthening primary care and changing the incentives around care delivery.

Some Democrats and Republicans in Congress have started working on bipartisan solutions to solve some of the problems inherent in the ACA – or those engineered by those who oppose it.

References

1. Jha A. Judging health systems: focusing on what matters. An Ounce of Evidence. Published Sep 18, 2017. Last accessed Oct 19, 2017. https://blogs.sph.harvard.edu/ashish-jha/.

2. Carroll AE et al. The best health care system in the world: Which one would you pick? New York Times. Published Sep 18, 2017. Accessed Oct 19, 2017. https://www.nytimes.com/interactive/2017/09/18/upshot/best-health-care-system-country-bracket.html?action=click&contentCollection=upshot&region=rank&module=package&version=highlights&contentPlacement=1&pgtype=sectionfront.

3. Schneider EC et al. Mirror, mirror 2017: International comparison reflects flaws and opportunities for better U.S. health care. The Commonwealth Fund. Published Jul 14, 2017. Accessed Oct 19, 2017. http://www.commonwealthfund.org/publications/fund-reports/2017/jul/mirror-mirror-international-comparisons-2017.

4. Martinez ME et al. Health insurance coverage: Early release of estimates from the national health interview survey, January-September 2016. Centers for Disease Control and Prevention, Division of Health Interview Statistics, National Center for Health Statistics. Published Feb, 2017. Accessed Oct 19, 2017. https://www.cdc.gov/nchs/data/nhis/earlyrelease/insur201702.pdf.

5. Papanicolas I et al. Challenges in international comparison of health care systems. JAMA. 2017 Aug 8;318(6):515-6. https://jamanetwork.com/journals/jama/article-abstract/2646461.

6. Schneider EC et al. From last to first – Could the U.S. health care system become the best in the world? N Engl J Med. 2017 Sep 7; 377(10):901-4.

What would happen if hospitalists began to incorporate health policy into morbidity and mortality (M&M) conferences? That was a question Chris Moriates, MD, explored in an entry for SHM’s The Hospital Leader blog¹ and an idea that caused a minor stir on Twitter when he proposed it last summer.

In late July 2017, the U.S. Senate was debating a bill to repeal the Affordable Care Act, without a clear vision for replacing it. In response, physicians around the country took to Twitter to share their sentiments about repeal under the hashtag #DoctorsSpeakOut. In one such tweet, Dr. Moriates, assistant dean for health care value and an associate professor of internal medicine at Dell Medical School at the University of Texas, Austin, said this, in 140 characters: “We recently had idea: health policy M&M for residents to discuss adverse outcomes we see as result of lack of access.”

Source

1. Moriates C. Is it time for health policy M&Ms? The Hospital Leader. Aug 16, 2017. http://thehospitalleader.org/is-it-time-for-health-policy-mms/. Accessed 2017 Sep 14.

What would happen if hospitalists began to incorporate health policy into morbidity and mortality (M&M) conferences? That was a question Chris Moriates, MD, explored in an entry for SHM’s The Hospital Leader blog¹ and an idea that caused a minor stir on Twitter when he proposed it last summer.

In late July 2017, the U.S. Senate was debating a bill to repeal the Affordable Care Act, without a clear vision for replacing it. In response, physicians around the country took to Twitter to share their sentiments about repeal under the hashtag #DoctorsSpeakOut. In one such tweet, Dr. Moriates, assistant dean for health care value and an associate professor of internal medicine at Dell Medical School at the University of Texas, Austin, said this, in 140 characters: “We recently had idea: health policy M&M for residents to discuss adverse outcomes we see as result of lack of access.”

Source

1. Moriates C. Is it time for health policy M&Ms? The Hospital Leader. Aug 16, 2017. http://thehospitalleader.org/is-it-time-for-health-policy-mms/. Accessed 2017 Sep 14.

What would happen if hospitalists began to incorporate health policy into morbidity and mortality (M&M) conferences? That was a question Chris Moriates, MD, explored in an entry for SHM’s The Hospital Leader blog¹ and an idea that caused a minor stir on Twitter when he proposed it last summer.

In late July 2017, the U.S. Senate was debating a bill to repeal the Affordable Care Act, without a clear vision for replacing it. In response, physicians around the country took to Twitter to share their sentiments about repeal under the hashtag #DoctorsSpeakOut. In one such tweet, Dr. Moriates, assistant dean for health care value and an associate professor of internal medicine at Dell Medical School at the University of Texas, Austin, said this, in 140 characters: “We recently had idea: health policy M&M for residents to discuss adverse outcomes we see as result of lack of access.”

Source

1. Moriates C. Is it time for health policy M&Ms? The Hospital Leader. Aug 16, 2017. http://thehospitalleader.org/is-it-time-for-health-policy-mms/. Accessed 2017 Sep 14.

Earlier this year, the Centers for Medicare and Medicaid Services finalized fundamental changes to how it reimburses hospitals for uncompensated care costs. When first proposed, the move raised alarm among physicians, hospitals, health systems, state health departments, and others around the country, and even prompted a lawsuit in New Hampshire.

In the months since the official adoption by the CMS, it remains unclear how the change will affect hospitals around the country, particularly the safety net hospitals that rely on these payments most.

How will hospitals adapt?

The CMS did not give hospitals transition time. The reinterpretation became effective in June 2017, just 60 days after the agency issued the final rule. Dr. McHugh said he is not sure why the agency did not build in time for hospitals to adapt, particularly given the uncertainty around the national uninsured rate going forward, with so many potential changes to the American health care system under a new administration.

How any of these changes trickle down to hospitalists remains to be seen, said Dr. Flansbaum. Dr. McHugh believes it could lead to increased patient loads, higher turnover and churn, and fewer experienced physicians in safety net hospitals as younger doctors are hired and burn out. “At the end of the day, that feeds into patient care and patient satisfaction and quality,” he said.

However, hospitals across the country have been living with this “slow burn” for a long time, said Dr. Flansbaum, though not necessarily due to inadequate DSH payments. At least in some areas, reimbursements have gone down, hospital occupancy rates have declined, rural hospitals have closed, hospitals have consolidated, and people have been laid off.

It’s important to ensure the hospitals providing care for high levels of uninsured or underinsured patients receive the help they need, he said, and it’s also important to examine the role hospitals play as a whole in the American health care system.

“It’s an expensive system,” he said. “We have we created a system where, unlike other countries that have developed more vigorous primary or outpatient care, we have created an inpatient health system.”

With the CMS’ change, the government is the only entity that seems to win across the board, Dr. McHugh said. He said he would not be surprised if analysts looked to see how hospitals were affected by it in coming months.

But, he remains optimistic. In fact, the final rule also came with an $800 million increase in the amount of uncompensated care payments for acute care hospitals in fiscal year 2018, the CMS says.⁴

“Hospitals are adaptable,” Dr. McHugh said. “I think what you’ll see is this will spur some innovation in terms of patient care maybe a few years down the road. It may hit some stumbling blocks in the early going but there may be some positive changes in the future.”
 

References

1. Medicaid Program; Disproportionate Share Hospital Payments –Treatment of Third Party Payers in Calculating Uncompensated Care Costs. Centers for Medicare and Medicaid Services final rule. Citation 82 FR 16114. Published April 3, 2017. Last accessed August 14, 2017. https://www.federalregister.gov/documents/2017/04/03/2017-06538/medicaid-program-disproportionate-share-hospital-payments-treatment-of-third-party-payers-in

2. Kugler E. 2016-09-14 NAUH Medicaid Program DSH Payments – Treatment of Third Party Payer in Calculating Uncompensated Care Costs. September 14, 2016. Last accessed August 14, 2017. https://www.regulations.gov/document?D=CMS-2016-0144-0020

3. Berg A. Proposed Rule on Disproportionate Share Hospital Payments – Treatment of Third Party Payers in Calculating Uncompensated Care Costs, CMS-2399-P. September 14, 2016. Last accessed August 14, 2017. https://www.regulations.gov/document?D=CMS-2016-0144-0046

4. CMS finalizes 2018 payment and policy updates for Medicare hospital admissions. Published August 2, 2017. Last accessed August 14, 2017. https://www.cms.gov/Newsroom/MediaReleaseDatabase/Press-releases/2017-Press-releases-items/2017-08-02.html

Earlier this year, the Centers for Medicare and Medicaid Services finalized fundamental changes to how it reimburses hospitals for uncompensated care costs. When first proposed, the move raised alarm among physicians, hospitals, health systems, state health departments, and others around the country, and even prompted a lawsuit in New Hampshire.

In the months since the official adoption by the CMS, it remains unclear how the change will affect hospitals around the country, particularly the safety net hospitals that rely on these payments most.

How will hospitals adapt?

The CMS did not give hospitals transition time. The reinterpretation became effective in June 2017, just 60 days after the agency issued the final rule. Dr. McHugh said he is not sure why the agency did not build in time for hospitals to adapt, particularly given the uncertainty around the national uninsured rate going forward, with so many potential changes to the American health care system under a new administration.

How any of these changes trickle down to hospitalists remains to be seen, said Dr. Flansbaum. Dr. McHugh believes it could lead to increased patient loads, higher turnover and churn, and fewer experienced physicians in safety net hospitals as younger doctors are hired and burn out. “At the end of the day, that feeds into patient care and patient satisfaction and quality,” he said.

However, hospitals across the country have been living with this “slow burn” for a long time, said Dr. Flansbaum, though not necessarily due to inadequate DSH payments. At least in some areas, reimbursements have gone down, hospital occupancy rates have declined, rural hospitals have closed, hospitals have consolidated, and people have been laid off.

It’s important to ensure the hospitals providing care for high levels of uninsured or underinsured patients receive the help they need, he said, and it’s also important to examine the role hospitals play as a whole in the American health care system.

“It’s an expensive system,” he said. “We have we created a system where, unlike other countries that have developed more vigorous primary or outpatient care, we have created an inpatient health system.”

With the CMS’ change, the government is the only entity that seems to win across the board, Dr. McHugh said. He said he would not be surprised if analysts looked to see how hospitals were affected by it in coming months.

But, he remains optimistic. In fact, the final rule also came with an $800 million increase in the amount of uncompensated care payments for acute care hospitals in fiscal year 2018, the CMS says.⁴

“Hospitals are adaptable,” Dr. McHugh said. “I think what you’ll see is this will spur some innovation in terms of patient care maybe a few years down the road. It may hit some stumbling blocks in the early going but there may be some positive changes in the future.”
 

References

1. Medicaid Program; Disproportionate Share Hospital Payments –Treatment of Third Party Payers in Calculating Uncompensated Care Costs. Centers for Medicare and Medicaid Services final rule. Citation 82 FR 16114. Published April 3, 2017. Last accessed August 14, 2017. https://www.federalregister.gov/documents/2017/04/03/2017-06538/medicaid-program-disproportionate-share-hospital-payments-treatment-of-third-party-payers-in

2. Kugler E. 2016-09-14 NAUH Medicaid Program DSH Payments – Treatment of Third Party Payer in Calculating Uncompensated Care Costs. September 14, 2016. Last accessed August 14, 2017. https://www.regulations.gov/document?D=CMS-2016-0144-0020

3. Berg A. Proposed Rule on Disproportionate Share Hospital Payments – Treatment of Third Party Payers in Calculating Uncompensated Care Costs, CMS-2399-P. September 14, 2016. Last accessed August 14, 2017. https://www.regulations.gov/document?D=CMS-2016-0144-0046

4. CMS finalizes 2018 payment and policy updates for Medicare hospital admissions. Published August 2, 2017. Last accessed August 14, 2017. https://www.cms.gov/Newsroom/MediaReleaseDatabase/Press-releases/2017-Press-releases-items/2017-08-02.html

Earlier this year, the Centers for Medicare and Medicaid Services finalized fundamental changes to how it reimburses hospitals for uncompensated care costs. When first proposed, the move raised alarm among physicians, hospitals, health systems, state health departments, and others around the country, and even prompted a lawsuit in New Hampshire.

In the months since the official adoption by the CMS, it remains unclear how the change will affect hospitals around the country, particularly the safety net hospitals that rely on these payments most.

How will hospitals adapt?

The CMS did not give hospitals transition time. The reinterpretation became effective in June 2017, just 60 days after the agency issued the final rule. Dr. McHugh said he is not sure why the agency did not build in time for hospitals to adapt, particularly given the uncertainty around the national uninsured rate going forward, with so many potential changes to the American health care system under a new administration.

How any of these changes trickle down to hospitalists remains to be seen, said Dr. Flansbaum. Dr. McHugh believes it could lead to increased patient loads, higher turnover and churn, and fewer experienced physicians in safety net hospitals as younger doctors are hired and burn out. “At the end of the day, that feeds into patient care and patient satisfaction and quality,” he said.

However, hospitals across the country have been living with this “slow burn” for a long time, said Dr. Flansbaum, though not necessarily due to inadequate DSH payments. At least in some areas, reimbursements have gone down, hospital occupancy rates have declined, rural hospitals have closed, hospitals have consolidated, and people have been laid off.

It’s important to ensure the hospitals providing care for high levels of uninsured or underinsured patients receive the help they need, he said, and it’s also important to examine the role hospitals play as a whole in the American health care system.

“It’s an expensive system,” he said. “We have we created a system where, unlike other countries that have developed more vigorous primary or outpatient care, we have created an inpatient health system.”

With the CMS’ change, the government is the only entity that seems to win across the board, Dr. McHugh said. He said he would not be surprised if analysts looked to see how hospitals were affected by it in coming months.

But, he remains optimistic. In fact, the final rule also came with an $800 million increase in the amount of uncompensated care payments for acute care hospitals in fiscal year 2018, the CMS says.⁴

“Hospitals are adaptable,” Dr. McHugh said. “I think what you’ll see is this will spur some innovation in terms of patient care maybe a few years down the road. It may hit some stumbling blocks in the early going but there may be some positive changes in the future.”
 

References

1. Medicaid Program; Disproportionate Share Hospital Payments –Treatment of Third Party Payers in Calculating Uncompensated Care Costs. Centers for Medicare and Medicaid Services final rule. Citation 82 FR 16114. Published April 3, 2017. Last accessed August 14, 2017. https://www.federalregister.gov/documents/2017/04/03/2017-06538/medicaid-program-disproportionate-share-hospital-payments-treatment-of-third-party-payers-in

2. Kugler E. 2016-09-14 NAUH Medicaid Program DSH Payments – Treatment of Third Party Payer in Calculating Uncompensated Care Costs. September 14, 2016. Last accessed August 14, 2017. https://www.regulations.gov/document?D=CMS-2016-0144-0020

3. Berg A. Proposed Rule on Disproportionate Share Hospital Payments – Treatment of Third Party Payers in Calculating Uncompensated Care Costs, CMS-2399-P. September 14, 2016. Last accessed August 14, 2017. https://www.regulations.gov/document?D=CMS-2016-0144-0046

4. CMS finalizes 2018 payment and policy updates for Medicare hospital admissions. Published August 2, 2017. Last accessed August 14, 2017. https://www.cms.gov/Newsroom/MediaReleaseDatabase/Press-releases/2017-Press-releases-items/2017-08-02.html

A decade ago, most hospitalists and hospital leaders were not thinking about health equity, let alone discussing it.

“It used to be we could say: ‘We saved your life but everything else is beyond our control,’ ” said Nick Fitterman, MD, FACP, SFHM, vice chair of Hospital Medicine at Northwell Health in New York, and associate professor of medicine at Hofstra Northwell School of Medicine and Long Island Jewish Medical Center.

But today?

”We have a better understanding that what affects the health of most of our patients is what happens outside the four walls of the hospital,” he said. “Now, we can work with case managers and community-based organizations to help address housing and food. We can at least steer our patients to resources and help them with the social determinants of their health.”

• Choose to practice at a hospital that serves large numbers of socially disadvantaged people;

• Put particular effort into helping the most socially disadvantaged patients in their hospitals.

This should include understanding the conditions that bring disadvantaged people to the hospital in disproportionate numbers, Dr. Braveman said, and getting involved in initiatives intended to address them. For example, after observing that disproportionate numbers of poor kids are hospitalized with asthma, hospitalists might connect with community groups that can help address pest abatement in low-income housing.

Health equity efforts should not just focus on socioeconomically or racially disadvantaged groups either, Dr. Braveman and Dr. Fitterman argue. They must also address others who are marginalized, like patients who are disabled, elderly, obese, non–English speaking, or gender nonconforming.

Dr. Fitterman said his hospital leadership has made health equity a priority and believes successful health equity practices involve good leadership, becoming aware of and addressing unconscious bias, and efforts to address the social determinants that can cut through health disparities.

“The focus of our last leadership retreat was diversity and health disparities,” Dr. Fitterman said. “It starts at the top down. I bring that to our faculty and site directors: everyone takes an online test to raise their awareness of unconscious bias.”

Dr. Smothers serves on the board of the Center for Health Equity and Wellness at Adventist HealthCare, which works to improve access to “culturally appropriate care, and provides community wellness outreach and education.” He said that, in addition to programs at the Center which address disparities, his hospital has also established teams of doctors, nurses, case managers, and transitional care nurses to help redirect patients to “more appropriate, less costly services, such as primary care, urgent care, home care, and subacute care,” when it is in the patient’s best interest.

Not only are Adventist’s hospitalists aware of community resources available to their patients, they are also culturally diverse, Dr. Smothers said, noting that they are “well equipped to manage our diverse patient population, including those who lack adequate health care.”

Additionally, Dr. Smothers said: “We engage our hospitalists in care coordination, encouraging them to make recommendations on alternative treatment locations and/or options at the point of entry.” And all admitted patients with chronic conditions are provided with a month’s supply of medication and schedule transportation for their follow-up appointment upon discharge.

“We need to inquire about social determinants that may prohibit our success with our patients,” said Dr. Fitterman. “You are not always going to be able to fix it, but it doesn’t mean you shouldn’t try.”
 

References

1. Braveman P, et al. What is health equity? And what difference does a definition make? Robert Wood Johnson Foundation. Published May 2017. Accessed July 15, 2017.

2. Communities in Action: Pathways to Health Equity. National Academies of Sciences, Engineering and Medicine. Published Jan. 11, 2017. Accessed July 15, 2017.

A decade ago, most hospitalists and hospital leaders were not thinking about health equity, let alone discussing it.

“It used to be we could say: ‘We saved your life but everything else is beyond our control,’ ” said Nick Fitterman, MD, FACP, SFHM, vice chair of Hospital Medicine at Northwell Health in New York, and associate professor of medicine at Hofstra Northwell School of Medicine and Long Island Jewish Medical Center.

But today?

”We have a better understanding that what affects the health of most of our patients is what happens outside the four walls of the hospital,” he said. “Now, we can work with case managers and community-based organizations to help address housing and food. We can at least steer our patients to resources and help them with the social determinants of their health.”

• Choose to practice at a hospital that serves large numbers of socially disadvantaged people;

• Put particular effort into helping the most socially disadvantaged patients in their hospitals.

This should include understanding the conditions that bring disadvantaged people to the hospital in disproportionate numbers, Dr. Braveman said, and getting involved in initiatives intended to address them. For example, after observing that disproportionate numbers of poor kids are hospitalized with asthma, hospitalists might connect with community groups that can help address pest abatement in low-income housing.

Health equity efforts should not just focus on socioeconomically or racially disadvantaged groups either, Dr. Braveman and Dr. Fitterman argue. They must also address others who are marginalized, like patients who are disabled, elderly, obese, non–English speaking, or gender nonconforming.

Dr. Fitterman said his hospital leadership has made health equity a priority and believes successful health equity practices involve good leadership, becoming aware of and addressing unconscious bias, and efforts to address the social determinants that can cut through health disparities.

“The focus of our last leadership retreat was diversity and health disparities,” Dr. Fitterman said. “It starts at the top down. I bring that to our faculty and site directors: everyone takes an online test to raise their awareness of unconscious bias.”

Dr. Smothers serves on the board of the Center for Health Equity and Wellness at Adventist HealthCare, which works to improve access to “culturally appropriate care, and provides community wellness outreach and education.” He said that, in addition to programs at the Center which address disparities, his hospital has also established teams of doctors, nurses, case managers, and transitional care nurses to help redirect patients to “more appropriate, less costly services, such as primary care, urgent care, home care, and subacute care,” when it is in the patient’s best interest.

Not only are Adventist’s hospitalists aware of community resources available to their patients, they are also culturally diverse, Dr. Smothers said, noting that they are “well equipped to manage our diverse patient population, including those who lack adequate health care.”

Additionally, Dr. Smothers said: “We engage our hospitalists in care coordination, encouraging them to make recommendations on alternative treatment locations and/or options at the point of entry.” And all admitted patients with chronic conditions are provided with a month’s supply of medication and schedule transportation for their follow-up appointment upon discharge.

“We need to inquire about social determinants that may prohibit our success with our patients,” said Dr. Fitterman. “You are not always going to be able to fix it, but it doesn’t mean you shouldn’t try.”
 

References

1. Braveman P, et al. What is health equity? And what difference does a definition make? Robert Wood Johnson Foundation. Published May 2017. Accessed July 15, 2017.

2. Communities in Action: Pathways to Health Equity. National Academies of Sciences, Engineering and Medicine. Published Jan. 11, 2017. Accessed July 15, 2017.

A decade ago, most hospitalists and hospital leaders were not thinking about health equity, let alone discussing it.

“It used to be we could say: ‘We saved your life but everything else is beyond our control,’ ” said Nick Fitterman, MD, FACP, SFHM, vice chair of Hospital Medicine at Northwell Health in New York, and associate professor of medicine at Hofstra Northwell School of Medicine and Long Island Jewish Medical Center.

But today?

”We have a better understanding that what affects the health of most of our patients is what happens outside the four walls of the hospital,” he said. “Now, we can work with case managers and community-based organizations to help address housing and food. We can at least steer our patients to resources and help them with the social determinants of their health.”

• Choose to practice at a hospital that serves large numbers of socially disadvantaged people;

• Put particular effort into helping the most socially disadvantaged patients in their hospitals.

This should include understanding the conditions that bring disadvantaged people to the hospital in disproportionate numbers, Dr. Braveman said, and getting involved in initiatives intended to address them. For example, after observing that disproportionate numbers of poor kids are hospitalized with asthma, hospitalists might connect with community groups that can help address pest abatement in low-income housing.

Health equity efforts should not just focus on socioeconomically or racially disadvantaged groups either, Dr. Braveman and Dr. Fitterman argue. They must also address others who are marginalized, like patients who are disabled, elderly, obese, non–English speaking, or gender nonconforming.

Dr. Fitterman said his hospital leadership has made health equity a priority and believes successful health equity practices involve good leadership, becoming aware of and addressing unconscious bias, and efforts to address the social determinants that can cut through health disparities.

“The focus of our last leadership retreat was diversity and health disparities,” Dr. Fitterman said. “It starts at the top down. I bring that to our faculty and site directors: everyone takes an online test to raise their awareness of unconscious bias.”

Dr. Smothers serves on the board of the Center for Health Equity and Wellness at Adventist HealthCare, which works to improve access to “culturally appropriate care, and provides community wellness outreach and education.” He said that, in addition to programs at the Center which address disparities, his hospital has also established teams of doctors, nurses, case managers, and transitional care nurses to help redirect patients to “more appropriate, less costly services, such as primary care, urgent care, home care, and subacute care,” when it is in the patient’s best interest.

Not only are Adventist’s hospitalists aware of community resources available to their patients, they are also culturally diverse, Dr. Smothers said, noting that they are “well equipped to manage our diverse patient population, including those who lack adequate health care.”

Additionally, Dr. Smothers said: “We engage our hospitalists in care coordination, encouraging them to make recommendations on alternative treatment locations and/or options at the point of entry.” And all admitted patients with chronic conditions are provided with a month’s supply of medication and schedule transportation for their follow-up appointment upon discharge.

“We need to inquire about social determinants that may prohibit our success with our patients,” said Dr. Fitterman. “You are not always going to be able to fix it, but it doesn’t mean you shouldn’t try.”
 

References

1. Braveman P, et al. What is health equity? And what difference does a definition make? Robert Wood Johnson Foundation. Published May 2017. Accessed July 15, 2017.

2. Communities in Action: Pathways to Health Equity. National Academies of Sciences, Engineering and Medicine. Published Jan. 11, 2017. Accessed July 15, 2017.

When Carol Glaser, MD, was in training, the philosophy around antibiotic prescribing often went something like this: “Ten days of antibiotics is good, but let’s do a few more days just to be sure,” she said.

Today, however, the new mantra is “less is more.” Dr. Glaser is an experienced pediatric infectious disease physician and the lead physician for pediatric antimicrobial stewardship at The Permanente Medical Group, Kaiser Permanente, at the Oakland (Calif.) Medical Center. While antibiotic stewardship is an issue relevant to nearly all hospitalists, for pediatric patients, the considerations can be unique and particularly serious.

References

1. Keren R, Shah SS, Srivastava R, et al. Comparative effectiveness of intravenous vs oral antibiotics for postdischarge treatment of acute osteomyelitis in children. JAMA Pediatr. 2015 Feb:169(2):120-8.

2. Shah SS, Srivastava R, Wu S, et al. Intravenous versus oral antibiotics for postdischarge treatment of complicated pneumonia. Pediatrics. 2016 Dec;138(6). pii: e20161692.

When Carol Glaser, MD, was in training, the philosophy around antibiotic prescribing often went something like this: “Ten days of antibiotics is good, but let’s do a few more days just to be sure,” she said.

Today, however, the new mantra is “less is more.” Dr. Glaser is an experienced pediatric infectious disease physician and the lead physician for pediatric antimicrobial stewardship at The Permanente Medical Group, Kaiser Permanente, at the Oakland (Calif.) Medical Center. While antibiotic stewardship is an issue relevant to nearly all hospitalists, for pediatric patients, the considerations can be unique and particularly serious.

References

1. Keren R, Shah SS, Srivastava R, et al. Comparative effectiveness of intravenous vs oral antibiotics for postdischarge treatment of acute osteomyelitis in children. JAMA Pediatr. 2015 Feb:169(2):120-8.

2. Shah SS, Srivastava R, Wu S, et al. Intravenous versus oral antibiotics for postdischarge treatment of complicated pneumonia. Pediatrics. 2016 Dec;138(6). pii: e20161692.

When Carol Glaser, MD, was in training, the philosophy around antibiotic prescribing often went something like this: “Ten days of antibiotics is good, but let’s do a few more days just to be sure,” she said.

Today, however, the new mantra is “less is more.” Dr. Glaser is an experienced pediatric infectious disease physician and the lead physician for pediatric antimicrobial stewardship at The Permanente Medical Group, Kaiser Permanente, at the Oakland (Calif.) Medical Center. While antibiotic stewardship is an issue relevant to nearly all hospitalists, for pediatric patients, the considerations can be unique and particularly serious.

References

1. Keren R, Shah SS, Srivastava R, et al. Comparative effectiveness of intravenous vs oral antibiotics for postdischarge treatment of acute osteomyelitis in children. JAMA Pediatr. 2015 Feb:169(2):120-8.

2. Shah SS, Srivastava R, Wu S, et al. Intravenous versus oral antibiotics for postdischarge treatment of complicated pneumonia. Pediatrics. 2016 Dec;138(6). pii: e20161692.

In 2016, a series of studies showed the impact of Medicaid expansion on hospitals.¹ The news was good: Hospitals in states that accepted Medicaid expansion through the Affordable Care Act saw dramatic reductions in their uninsured patient populations, increases in their Medicaid stays, and reductions in uncompensated care costs.^1,2

In 2017, additional data continue to show that Medicaid expansion has been a boon to hospitals, including an April 2017 report published by the Urban Institute and a May 2017 analysis from The Commonwealth Fund.^3,4 Both show that some of the hospitals that need it most are reaping the greatest benefits of expansion.

References

1. Tyrrell K. Benefits of Medicaid Expansion for Hospitalists. The Hospitalist. 2016 March;2016(3). http://www.the-hospitalist.org/hospitalist/article/121832/benefits-medicaid-expansion-hospitalists. Accessed May 25, 2017.

2. Dranove D., Garthwaite C., Ody C. Uncompensated Care Decreased at Hospitals in Medicaid Expansion States but Not at Hospitals in Nonexpansion States. Health Affairs, Aug. 2016 35(8):1471-9. http://content.healthaffairs.org/content/35/8/1471.abstract. Accessed May 25, 2017.

3. Blavin F. How Has the ACA Changed Finances for Different Types of Hospitals? Updated Insights from 2015 Cost Report Data. Urban Institute. Published April 2017. Accessed May 25, 2017. http://www.urban.org/sites/default/files/publication/89446/2001215-how-has-the-aca-changed-finances-for-different-types-of-hospitals.pdf.

4. Dranove D., Garthwaite C., Ody C. The Impact of the ACA’s Medicaid Expansion on Hospitals’ Uncompensated Care Burden and the Potential Effects of Repeal. Published May 3, 2017. Accessed May 25, 2017. http://www.commonwealthfund.org/publications/issue-briefs/2017/may/aca-medicaid-expansion-hospital-uncompensated-care.

5. Blavin F. Association Between the 2014 Medicaid Expansion and US Hospital Finances. http://jamanetwork.com/journals/jama/fullarticle/2565750. JAMA 2016;316(14):1475-1483. doi:10.1001/jama.2016.14765

6. President Trump’s 2018 Budget Proposal Reduces Federal Funding for Coverage of Children in Medicaid and CHIP. Kaiser Family Foundation. Published March 23, 2017. Accessed May 25, 2017. http://kff.org/medicaid/fact-sheet/presidents-2018-budget-proposal-reduces-federal-funding-for-coverage-of-children-in-medicaid-and-chip/

7. Paradise J. Restructuring Medicaid in the American Health Care Act: Five Key Considerations. Kaiser Family Foundation. Published March 15, 2017. Accessed May 25, 2017. http://kff.org/medicaid/issue-brief/restructuring-medicaid-in-the-american-health-care-act-five-key-considerations/

8. Medicaid Hospital Payment: A comparison across states and to Medicare. MACPAC Issue Brief. Published April 2017.

9. Levin Becker A. Hospitals blast Malloy’s proposal to subject them to property taxes. Published Feb. 8, 2017. Accessed May 25, 2017. https://ctmirror.org/2017/02/08/hospitals-blast-malloys-proposal-to-subject-them-to-property-taxes/

In 2016, a series of studies showed the impact of Medicaid expansion on hospitals.¹ The news was good: Hospitals in states that accepted Medicaid expansion through the Affordable Care Act saw dramatic reductions in their uninsured patient populations, increases in their Medicaid stays, and reductions in uncompensated care costs.^1,2

In 2017, additional data continue to show that Medicaid expansion has been a boon to hospitals, including an April 2017 report published by the Urban Institute and a May 2017 analysis from The Commonwealth Fund.^3,4 Both show that some of the hospitals that need it most are reaping the greatest benefits of expansion.

References

1. Tyrrell K. Benefits of Medicaid Expansion for Hospitalists. The Hospitalist. 2016 March;2016(3). http://www.the-hospitalist.org/hospitalist/article/121832/benefits-medicaid-expansion-hospitalists. Accessed May 25, 2017.

2. Dranove D., Garthwaite C., Ody C. Uncompensated Care Decreased at Hospitals in Medicaid Expansion States but Not at Hospitals in Nonexpansion States. Health Affairs, Aug. 2016 35(8):1471-9. http://content.healthaffairs.org/content/35/8/1471.abstract. Accessed May 25, 2017.

3. Blavin F. How Has the ACA Changed Finances for Different Types of Hospitals? Updated Insights from 2015 Cost Report Data. Urban Institute. Published April 2017. Accessed May 25, 2017. http://www.urban.org/sites/default/files/publication/89446/2001215-how-has-the-aca-changed-finances-for-different-types-of-hospitals.pdf.

4. Dranove D., Garthwaite C., Ody C. The Impact of the ACA’s Medicaid Expansion on Hospitals’ Uncompensated Care Burden and the Potential Effects of Repeal. Published May 3, 2017. Accessed May 25, 2017. http://www.commonwealthfund.org/publications/issue-briefs/2017/may/aca-medicaid-expansion-hospital-uncompensated-care.

5. Blavin F. Association Between the 2014 Medicaid Expansion and US Hospital Finances. http://jamanetwork.com/journals/jama/fullarticle/2565750. JAMA 2016;316(14):1475-1483. doi:10.1001/jama.2016.14765

6. President Trump’s 2018 Budget Proposal Reduces Federal Funding for Coverage of Children in Medicaid and CHIP. Kaiser Family Foundation. Published March 23, 2017. Accessed May 25, 2017. http://kff.org/medicaid/fact-sheet/presidents-2018-budget-proposal-reduces-federal-funding-for-coverage-of-children-in-medicaid-and-chip/

7. Paradise J. Restructuring Medicaid in the American Health Care Act: Five Key Considerations. Kaiser Family Foundation. Published March 15, 2017. Accessed May 25, 2017. http://kff.org/medicaid/issue-brief/restructuring-medicaid-in-the-american-health-care-act-five-key-considerations/

8. Medicaid Hospital Payment: A comparison across states and to Medicare. MACPAC Issue Brief. Published April 2017.

9. Levin Becker A. Hospitals blast Malloy’s proposal to subject them to property taxes. Published Feb. 8, 2017. Accessed May 25, 2017. https://ctmirror.org/2017/02/08/hospitals-blast-malloys-proposal-to-subject-them-to-property-taxes/

In 2016, a series of studies showed the impact of Medicaid expansion on hospitals.¹ The news was good: Hospitals in states that accepted Medicaid expansion through the Affordable Care Act saw dramatic reductions in their uninsured patient populations, increases in their Medicaid stays, and reductions in uncompensated care costs.^1,2

In 2017, additional data continue to show that Medicaid expansion has been a boon to hospitals, including an April 2017 report published by the Urban Institute and a May 2017 analysis from The Commonwealth Fund.^3,4 Both show that some of the hospitals that need it most are reaping the greatest benefits of expansion.

References

1. Tyrrell K. Benefits of Medicaid Expansion for Hospitalists. The Hospitalist. 2016 March;2016(3). http://www.the-hospitalist.org/hospitalist/article/121832/benefits-medicaid-expansion-hospitalists. Accessed May 25, 2017.

2. Dranove D., Garthwaite C., Ody C. Uncompensated Care Decreased at Hospitals in Medicaid Expansion States but Not at Hospitals in Nonexpansion States. Health Affairs, Aug. 2016 35(8):1471-9. http://content.healthaffairs.org/content/35/8/1471.abstract. Accessed May 25, 2017.

3. Blavin F. How Has the ACA Changed Finances for Different Types of Hospitals? Updated Insights from 2015 Cost Report Data. Urban Institute. Published April 2017. Accessed May 25, 2017. http://www.urban.org/sites/default/files/publication/89446/2001215-how-has-the-aca-changed-finances-for-different-types-of-hospitals.pdf.

4. Dranove D., Garthwaite C., Ody C. The Impact of the ACA’s Medicaid Expansion on Hospitals’ Uncompensated Care Burden and the Potential Effects of Repeal. Published May 3, 2017. Accessed May 25, 2017. http://www.commonwealthfund.org/publications/issue-briefs/2017/may/aca-medicaid-expansion-hospital-uncompensated-care.

5. Blavin F. Association Between the 2014 Medicaid Expansion and US Hospital Finances. http://jamanetwork.com/journals/jama/fullarticle/2565750. JAMA 2016;316(14):1475-1483. doi:10.1001/jama.2016.14765

6. President Trump’s 2018 Budget Proposal Reduces Federal Funding for Coverage of Children in Medicaid and CHIP. Kaiser Family Foundation. Published March 23, 2017. Accessed May 25, 2017. http://kff.org/medicaid/fact-sheet/presidents-2018-budget-proposal-reduces-federal-funding-for-coverage-of-children-in-medicaid-and-chip/

7. Paradise J. Restructuring Medicaid in the American Health Care Act: Five Key Considerations. Kaiser Family Foundation. Published March 15, 2017. Accessed May 25, 2017. http://kff.org/medicaid/issue-brief/restructuring-medicaid-in-the-american-health-care-act-five-key-considerations/

8. Medicaid Hospital Payment: A comparison across states and to Medicare. MACPAC Issue Brief. Published April 2017.

9. Levin Becker A. Hospitals blast Malloy’s proposal to subject them to property taxes. Published Feb. 8, 2017. Accessed May 25, 2017. https://ctmirror.org/2017/02/08/hospitals-blast-malloys-proposal-to-subject-them-to-property-taxes/