Policy experts analyze health care reform

Panel members' views span a wide spectrum of policy and experience.

Bringing together experts from the federal government, a conservative think tank, academia, and the insurance industry to discuss the Affordable Care Act sounds like a recipe for conflict.

But the panelists who opened Hospital Medicine 2014 in Las Vegas in March found agreement on many points, despite their diverse perspectives. They described effects of health care reform that they've already seen and offered predictions of what's ahead for U.S. hospitals and hospitalists.

Panelists left to right Patrick H Conway MD MSc chief medical officer for the Centers for Medicare Medicaid Services CMS Scott Gottlieb MD resident fellow at the American Enterprise Institu
Panelists, left to right: Patrick H. Conway, MD, MSc, chief medical officer for the Centers for Medicare Medicaid Services (CMS); Scott Gottlieb, MD, resident fellow at the American Enterprise Institute; Patrick T. Courneya, MD, medical director of virtuwell for HealthPartners, Inc.; and Patrick Cawley, MD, FACP, chief executive officer of the Medical University of South Carolina Medical Center. Photo courtesy of Society of Hospital Medicine.

The panel included Patrick H. Conway, MD, MSc, chief medical officer for the Centers for Medicare Medicaid Services (CMS); Patrick Cawley, MD, FACP, chief executive officer of the Medical University of South Carolina Medical Center; Patrick T. Courneya, MD, medical director of virtuwell for HealthPartners, Inc.; and Scott Gottlieb, MD, resident fellow at the American Enterprise Institute.

Here are some highlights from their discussion.

On health care costs

Dr. Conway: We are in the lowest cost-growth rate, over the last 4 years, recorded in history, in terms of national health expenditures. We're actually growing lower than the GDP. Our economists are now actually saying that it's some fundamental changes in the delivery system. It's not just the economy.

Dr. Cawley: A lot of us [hospital CEOs] are worried about finances….Three reasons: One is that revenues just keep falling. Part of that is the Affordable Care Act. If you're in a red state not taking Medicaid expansion, you're very worried…. There are a lot of other things happening: the shift from inpatient care to outpatient care, [more] patient responsibility. The last 15 years, the percent of [health care costs] that patients are paying is at its highest. It's hard for hospitals to collect money from patients.

The second reason we're worried about cost is increased cost. Nurses cost more, supplies cost more. But probably the thing that's growing the fastest for all of us is physician services…. Five years ago, in our hospital we were supporting about 5 different physician groups in our hospital [including hospitalists]…. These days we're supporting 25 different groups, including groups I thought would never have to have support: CT surgeons and acute care surgeons. It just continues to expand every single year.

The third reason hospital CEOs are worried about cost is…we hear from local businesses about the cost of health care. They can't take 15% to 20% increases in their health care premiums. They are coming over to me and saying, ‘You've got to cut it out.’

On hospitalists

Dr. Conway: CMS and [the Agency for Healthcare Research and Quality] have measured all-cause patient harm, things like [central line-associated bloodstream infections], [adverse drug events], pressure ulcers, etc. Over the last 2 years, for the first time ever, we've had a dramatic decrease…Through Partnership for Patients, [quality improvement organizations], and other efforts, we've tried to support you in this work, but really credit you in the field….You are improving so fast on process measures for CMS that we actually have to pull them out of the program. We have removed almost half of the measures that were in hospital value-based purchasing and the inpatient quality reporting program over the last 3 years because performance has improved so much. Over 85% of the measures in that program have improved substantially over the last 3 years. ….In summary, you are driving work to transform the health care system of this country.

Dr. Cawley: You'd better be working on decreasing your cost of care delivery. You'd better be working on standardization. If I'm a CEO at your hospital, that's the only way you're going to get on my good side in the next couple years. Because I'm under a lot of pressure, I need you to be under that same pressure. The second thing is you have to prove your value....where you are on quality, where you are on cost. The third thing you have to understand is that in an effort to further save costs and develop economies of scale, there is a lot of consolidation occurring in hospitals. The last…way this is all going to affect you is leadership change. The turnover for hospital CEOs is at its highest in almost 20 years.

On the future

Dr. Cawley: I don't think the fundamentals will change. We're bringing great care to patients. We'll be able to measure that care much better because we have much better analytics. We'll be able to know whether you're giving the right antibiotic or discharging the patient too soon. I don't think any of that's going to change. What I do think will happen to hospital medicine practice is we need to continue to focus on proving our value. Where is your value in your particular hospital? Is it length of stay? Is it quality? Is it both? Do you provide night services to the whole hospita…You need to quantify that. You need to do more of that. We've been doing that for 20 years, but I think the data behind all that will be easier to get at.

Dr. Gottlieb: I think a lot of the consolidation we're seeing in the marketplace is going to end badly, with hospitals going out and buying cardiologists. There's this perception in Washington among some that there's something different this time, that we have better resources and technology and hospitals are better able to manage physicians, [that] they're actually going to be able to perform as health plans and market to consumers. I don't think they're going to be able to do that. They didn't manage it well in the 1990s. I think they're going to fail again. Hospitals shouldn't own physicians. They don't know how to manage risk.

In the move towards capitation and bundled payments, I think it's inevitable that the acute/post-acute portion of care gets more consolidated and bundled. CMS is already moving in that direction. Adding to that, you're going to see more outpatient entities want(ing) to own control of the discharge function….I think you're going to see unconventional types of entities start to try to bid for your services, if not own you, in the marketplace. A lot of outpatient types of providers are going to want to own hospitalists to control that discharge function. That creates a lot of dislocation, but also a lot of opportunities for hospitalists.

Dr. Courneya: There's a fundamental transition. The way that we have traditionally compartmentalized the series of services that we have delivered to patients is going to break down really substantially. Hospital medicine will be quite clearly much more a part of a continuum. Communicating across that continuum in the hospital and post-hospital space will be really quite different. It will require some interesting new skills, interesting new technology, interesting use of the data that we have.