Financial Management

CMS, SHM, and the Two-Midnight Rule

We ended the chat and we all felt lost. I am referring to SHM's recent CMS conference call concerning the two-midnight rule.  We wanted to clarify the vague nature in how CMS defines medical necessity—the linchpin of how the rule operates.  (more…)


It’s the New Year, 2014, and it is time for Dr. Kealey’s waving of the hospitalist magic wand.  If I had a magic wand, what would I instantly change about the life of hospitalists or the healthcare systems we work in? This is by no means an exhaustive list and certainly (and hopefully) reflects my own pet peeves.  Now, Abracadabra! SGR--  Well, who wouldn’t wish this to go away? The Medicare Sustainable Growth Rate (SGR) formula, created in 1997 to control Medicare spending.  By 2002 it started to work as the economy slowed and payments to doctors were set to begin falling.  Of course Congress backed down then and has backed down each and every year creating last minute “patches” to prevent the cuts.  Yeah for the patch!  Long live the patch!  Except each year, physicians' fees are made part of a dastardly political game of chicken in Washington, raising anxiety levels…

Readmissions may be more than inpatient stays

"The use of hospital readmissions as a lone metric for post-discharge health care quality may be incomplete without considering the role of the ED." Do you agree? I would probably say yes, providing patients we include in the numerator return to the ED with an issue related to their index trip—be it clinical or ancillary.  We may not like to hear those words, but a return visit, regardless of admission, likely connotes a transition failure. Earlier in the year, JAMA examined HCUP data from three states (CA, FL, and NE) to determine the degree to which ED visits and hospital readmissions contribute to overall use of acute care services within 30 days of discharge from acute care hospitals.  The graph below illustrates the percent of patients returning to the hospital after discharge: (more…)

The rate of MI hospital stays decrease, yet total cost of care goes up?

By reading the headlines recently, practitioners would not know if they saved or tanked the healthcare system.  One day disaster looms, the next we have moderated growth and business can continue as usual (and by business, I mean doing the correct things correctly). A new study, along with some recent data, helps shed some light on the issue. Out in JAMA Internal Medicine this week, Likosky and colleagues sought to determine MI cost growth in Medicare beneficiaries from 1999 to 2008.   While MI's are not representative of the system at large, for the purposes of the post, I will use the diagnosis as the canary in the healthcare system coalmine. (more…)

Leave the outpatient regimen untouched

A great commentary out today in JAMA Internal Medicine.  The topic?  Mucking with established ambulatory medication regimens during hospital stays. I find the sins the authors allude to--confusing patients, wasting money, and chasing artificial outcomes, have the least traction with younger hospitalists, trainees, and those without much ambulatory experience.  The temptation to treat the chart or number holds too much sway. An unfortunate consequence--whatever we do on the inpatient side gets exported right back to the caregiver and primary doc.  They must untangle the chaos we create. Treating HM docs should minimize responses  to ethereal measurements and lab readings.  We must also communicate with PCPs to attenuate any potential risks of acting on those findings.   The following passage conveys the sentiment aptly: "The inpatient clinician may not be aware of, or simply ignore, the patient’s long-term success at disease control in the months and years prior to hospitalization. Second,…