Richard Quinn

Hospitalists should be on the lookout for carbapenem-resistant Enterobacteriaceae (CRE) infections, says one author of a CDC report that noted a three-fold increase in the proportion of Enterobacteriaceae bugs that proved resistant to carbapenem within the past decade.

Earlier this month, the CDC's Morbidity and Mortality Weekly Report revealed that the percentage of CRE infections jumped to 4.2% in 2011 from 1.2% in 2001, according to data from the National Nosocomial Infection Surveillance system.

"It is a very serious public health threat," says co-author Alex Kallen, MD, MPH, a medical epidemiologist and outbreak response coordinator in the CDC's Division of Healthcare Quality Promotion. "Maybe it's not that common now, but with no action, it has the potential to become much more common, like a lot of the other MDROs [multidrug-resistant organisms] that hospitalists see regularly. [Hospitalists] have a lot of control over some of the things that could potentially lead to increased transmission."

Dr. Kallen says HM groups can help reduce the spread of CRE through antibiotic stewardship, the review of detailed patient histories to ferret out risk factors, and dedication to contact precautions and hand hygiene. Hospitalists also play a leadership role in coordinating efforts for patients transferring between hospitals and other institutions, such as skilled-nursing or assisted-living facilities, he says.

Dr. Kallen added that hospitalists should not dismiss CRE, even if they rarely encounter it.

"If you're a place that doesn't see this very often, and you see one, that's a big deal," he adds. "It needs to be acted on aggressively. Being proactive is much more effective than waiting until it's common and then trying to intervene."

 

Visit our website for more information on hospital-acquired infections.

 

 

Hospitalists should be on the lookout for carbapenem-resistant Enterobacteriaceae (CRE) infections, says one author of a CDC report that noted a three-fold increase in the proportion of Enterobacteriaceae bugs that proved resistant to carbapenem within the past decade.

Earlier this month, the CDC's Morbidity and Mortality Weekly Report revealed that the percentage of CRE infections jumped to 4.2% in 2011 from 1.2% in 2001, according to data from the National Nosocomial Infection Surveillance system.

"It is a very serious public health threat," says co-author Alex Kallen, MD, MPH, a medical epidemiologist and outbreak response coordinator in the CDC's Division of Healthcare Quality Promotion. "Maybe it's not that common now, but with no action, it has the potential to become much more common, like a lot of the other MDROs [multidrug-resistant organisms] that hospitalists see regularly. [Hospitalists] have a lot of control over some of the things that could potentially lead to increased transmission."

Dr. Kallen says HM groups can help reduce the spread of CRE through antibiotic stewardship, the review of detailed patient histories to ferret out risk factors, and dedication to contact precautions and hand hygiene. Hospitalists also play a leadership role in coordinating efforts for patients transferring between hospitals and other institutions, such as skilled-nursing or assisted-living facilities, he says.

Dr. Kallen added that hospitalists should not dismiss CRE, even if they rarely encounter it.

"If you're a place that doesn't see this very often, and you see one, that's a big deal," he adds. "It needs to be acted on aggressively. Being proactive is much more effective than waiting until it's common and then trying to intervene."

 

Visit our website for more information on hospital-acquired infections.

 

 

Hospitalists should be on the lookout for carbapenem-resistant Enterobacteriaceae (CRE) infections, says one author of a CDC report that noted a three-fold increase in the proportion of Enterobacteriaceae bugs that proved resistant to carbapenem within the past decade.

Earlier this month, the CDC's Morbidity and Mortality Weekly Report revealed that the percentage of CRE infections jumped to 4.2% in 2011 from 1.2% in 2001, according to data from the National Nosocomial Infection Surveillance system.

"It is a very serious public health threat," says co-author Alex Kallen, MD, MPH, a medical epidemiologist and outbreak response coordinator in the CDC's Division of Healthcare Quality Promotion. "Maybe it's not that common now, but with no action, it has the potential to become much more common, like a lot of the other MDROs [multidrug-resistant organisms] that hospitalists see regularly. [Hospitalists] have a lot of control over some of the things that could potentially lead to increased transmission."

Dr. Kallen says HM groups can help reduce the spread of CRE through antibiotic stewardship, the review of detailed patient histories to ferret out risk factors, and dedication to contact precautions and hand hygiene. Hospitalists also play a leadership role in coordinating efforts for patients transferring between hospitals and other institutions, such as skilled-nursing or assisted-living facilities, he says.

Dr. Kallen added that hospitalists should not dismiss CRE, even if they rarely encounter it.

"If you're a place that doesn't see this very often, and you see one, that's a big deal," he adds. "It needs to be acted on aggressively. Being proactive is much more effective than waiting until it's common and then trying to intervene."

 

Visit our website for more information on hospital-acquired infections.

 

 

Click here to listen to Dr. Danielsson

Click here to listen to Dr. Danielsson

Click here to listen to Dr. Danielsson

Ask supporters and detractors of the seven-on/seven-off schedule their favorite (or least favorite) aspect of the model, and they’ll say the same thing: how it impacts work-life balance.

Heads: “For me, I know that there’s that balance,” says Dr. Houser, who works in Rapid City, S.D. “I know that there are going to be some holidays, some weekends where I’m not going to go to the soccer game or go to the volleyball game or see the choir practice. But the other side of me knows that I will be able to make it up to the kids, if it was something that I missed. I’ll be able to devote that time that I really like to devote to my family when I’m off.”

Tails: “I really believe that [seven-on/seven-off] scheduling is probably more desirable to Generation Y, which tends to have a lot more life quality and life balance as part of their mentality,” says Eshbaugh, the administrator in Traverse City, Mich. “I think the older generation of physicians, especially because they came out of the outpatient world, they were used to working five days a week, every week.”

Ask supporters and detractors of the seven-on/seven-off schedule their favorite (or least favorite) aspect of the model, and they’ll say the same thing: how it impacts work-life balance.

Heads: “For me, I know that there’s that balance,” says Dr. Houser, who works in Rapid City, S.D. “I know that there are going to be some holidays, some weekends where I’m not going to go to the soccer game or go to the volleyball game or see the choir practice. But the other side of me knows that I will be able to make it up to the kids, if it was something that I missed. I’ll be able to devote that time that I really like to devote to my family when I’m off.”

Tails: “I really believe that [seven-on/seven-off] scheduling is probably more desirable to Generation Y, which tends to have a lot more life quality and life balance as part of their mentality,” says Eshbaugh, the administrator in Traverse City, Mich. “I think the older generation of physicians, especially because they came out of the outpatient world, they were used to working five days a week, every week.”

Ask supporters and detractors of the seven-on/seven-off schedule their favorite (or least favorite) aspect of the model, and they’ll say the same thing: how it impacts work-life balance.

Heads: “For me, I know that there’s that balance,” says Dr. Houser, who works in Rapid City, S.D. “I know that there are going to be some holidays, some weekends where I’m not going to go to the soccer game or go to the volleyball game or see the choir practice. But the other side of me knows that I will be able to make it up to the kids, if it was something that I missed. I’ll be able to devote that time that I really like to devote to my family when I’m off.”

Tails: “I really believe that [seven-on/seven-off] scheduling is probably more desirable to Generation Y, which tends to have a lot more life quality and life balance as part of their mentality,” says Eshbaugh, the administrator in Traverse City, Mich. “I think the older generation of physicians, especially because they came out of the outpatient world, they were used to working five days a week, every week.”

Robert Houser, MD, MBA, co-medical director of Rapid City Regional Hospital in Rapid City, S.D., left his primary-care practice a little more than 10 years ago to become a hospitalist. At the time, his new schedule—working seven days in a row, then taking off seven days in a row—struck him as odd. But the idea of being able to throw himself completely and alternately into both his job and his family appealed to him. More than a decade later, he still believes his schedule is a perfect mix of personal and professional time.

Bradley Eshbaugh, MBA, FACMPE, chief administrator of Hospitalists of Northern Michigan (HNM) in Traverse City, Mich., and a SHM Administrators’ Committee member, doesn’t see it that way. His hospitalists tell him the work-a-week, skip-a-week schedule is too inflexible for the work-life balance they crave. Even when newly hired physicians accustomed to the week-on/week-off schedule ask if they can continue it, Eshbaugh says, most quickly realize the flexible-schedule option that HNM utilizes offers them a more balanced approach to time off work.

Welcome to the world of seven-on/seven-off scheduling, where detractors and supporters often have the same reasons for their differing viewpoints. Those who favor the model say that its simple-to-implement block approach to scheduling allows physicians to know far in advance when their time off is. That allows clinicians to plan their lives way in advance, a carrot hospitalist groups have used for more than a decade to attract new hires. Those who prefer other scheduling methods say the seven-on/seven-off model’s rigidity leaves little flexibility to deal with the unscheduled inevitabilities of life (sickness, personal time, maternity leave, resignations, etc.) and is not the best construct to match staffing to the busiest admissions periods.

And while everyone agrees that the seven-on/seven-off model is among the most popular, there is as yet no clinical data that show whether its practitioners are more or less likely to provide higher-quality care. So the oft-asked question of whether the schedule is sustainable comes down not to care delivery but financial pressure. Three-quarters of HM groups (HMGs) rely on their host hospitals for financial support, and that support-per-FTE at nonacademic groups serving only adults rose to an median of $140,204 this year, according to SHM’s 2012 State of Hospital Medicine report—a 40% increase over data in the 2010 SHM/MGMA‐ACMPE survey.

 

“When we started in this business 15 years ago, the average hospital might have three to five hospitalists, maybe a subsidy of $300,000 to $500,000,” says Martin Buser, a partner in Hospitalist Management Resources of Del Mar, Calif. “That same program today is probably running 15 to 20 hospitalists, a subsidy of $3 million-plus. It’s really strongly on the radar screen for administrators to look at, ‘Can I keep affording this, or do I need to find less expensive ways to get the same result?’”

Viewpoints Vary

The origins of the seven-on/seven-off schedule are a bit murky. Some believe it was borrowed from the shift-work model in the ED. Others think it has roots in the nursing ranks. Still others think that in the nascent days of HM, two- and three-physician groups developed the schedule by simply splitting monthly schedules by weeks. Regardless of pedigree, the model has grown to be just about the most common schedule for HMGs serving adults only. The State of Hospital Medicine report reported that 41.9% of adult groups use the seven-on/seven-off schedule, with 41.6% reporting their schedule as “variable” and “other.”

SHM has never queried hospitalists specifically about their schedules before, so no comparative data are available for information. Interestingly, the State of Hospital Medicine report found that hospitalist management companies and private HM groups were less likely to use the seven-on/seven-off schedule than hospital-owned or academic groups.

Jeff Taylor, president and chief operating officer of IPC: The Hospitalist Co., a national physician group practice based in North Hollywood, Calif., says just 10% of his 1,400 providers nationwide uses the seven-on/seven-off construct. He argues the model “is economically inefficient.” For example, he says, take a hospital with a census of around 60 inpatients per day. An HM group that wants to limit daily censuses to about 15 patients would need four doctors to staff that patient load. Using the seven-on/seven-off schedule, the group would need eight dayside hospitalists (not counting nocturnists). In a more traditional staffing model of a five-day workweek and call coverage, a group likely could handle the same workload with five FTE hospitalists, Taylor says.

“We have been doing some education with hospitals over the last three or four years of just doing the math,” he adds. “How many doctors would you need to staff this census? … We often give a dual proposal. This is how much it will cost for seven-on/seven-off; this is how much it will cost with the Monday-through-Friday model. Obviously, the Monday-through-Friday model is a lower cost, but it may take a little bit longer to get it staffed.”

Staffing difficulties—particularly recruitment and retention—are a major driver of the popularity of the seven-on/seven-off schedule, says Gregory Martinek, DO, FHM, medical director of Lexington Hospitalists in Altoona, Pa. He says it’s tough to recruit hospitalists to work in a small town in central Pennsylvania, so offering a schedule those physicians want to work is helpful.

In fact, Dr. Martinek offers his hospitalists an extra week of vacation in addition to the 26 weeks they don’t work. That allows some of his foreign-born physicians to take a three-week break from work, which many use as a chance to return to their birth countries.

“We had trouble recruiting when we had a different model,” Dr. Martinek says. “This has really worked for us. It’s allowed us to recruit.”

Cost Concerns

How do HM group leaders answer C-suite questions about whether the expenses associated with the seven-on/seven-off model are worth it? The short answer is data. Know basic metrics on length of stay, cost of care, etc., before having that conversation. For example, a traditional 40-hour workweek is 2,080 hours per annum (and probably less with vacation time). And while some might think that 26 weeks off a year equates to fewer hours, 26 weeks of 12-hour shifts totals 2,184 hours.

 

Per Danielsson, MD, medical director of Swedish Hospital Medicine in Seattle, says his group uses a hybrid seven-on/seven-off schedule that has demonstrated that their cost-of-care delivery is consistently $1,000 to $1,500 less per case than other physicians’ cases at Swedish Medical Center—and those other physicians often take care of patients with the same diagnoses.

“When you have those kinds of numbers, and you’re doing 7,000 admissions per year, the numbers add up quickly,” Dr. Danielsson says.

Kristi Gylten, MBA, director of hospitalist services at Rapid City Regional Hospital and a member of SHM’s Administrators’ Committee, says hospitalist group leaders should urge their administrations to look at more than just financial statements when judging the value of an HM group, particularly in rural areas.

“Our program started with three physicians in 2004 and has grown to over 30 in 2012,” she says. “There has been such great value brought to our community and our medical staff and our patients, just over and above what the bottom line would show on a monthly operational statement, that we don’t have the bean-counters knocking on our door.”

IPC’s Taylor says a complicating factor in moving away from the seven-on/seven-off format is the passion physicians have for their schedules. Or, to use his words: “You make major changes to schedules at great peril.”

John Frehse, managing partner of Core Practice, a Chicago consultancy that designs and implements labor strategies for shift-work operations, says that managers and administrators looking to change schedules often shy away from the upheaval.

“This emotional and potentially disruptive environment is something that makes them say, ‘We’re getting away with it now, so let’s not change it. Why rock the boat?’” Frehse explains. “They should be saying, ‘What is the methodology to get this out of here and put in something that’s financially responsible for the organization?’”

Practice Concerns

Ten years ago, Dr. Houser found the seven-on/seven-off schedule “a little bit unusual.” Now, his workweek of seven 10-hour days in a row seems natural. Even so, he understands those who voice concerns about hospitalized patients who would not be happy to know their hospitalist was on his 60th, 70th, or 80th hour of work that week.

“The physician’s side of me stays in a mode where I know I have to be a resource to the patient and I have to be a resource to my colleagues, and so I don’t think terms of being mentally drained,” he says. “Whether I’m starting or finishing, I just want to be as fresh as I can to approach those problems and mentally stay in the game that way. If I start thinking about being fatigued or tired, I feel like I won’t be able to provide the type of care that I can for that patient.”

Some groups using the seven-on/seven-off model allow physicians to leave the hospital at slow times while requiring they be on call. That allows hospitalists to recharge a bit midweek while ensuring that there is enough staff to provide coverage. Dr. Martinek says there’s no need to “hold them in the hospital if there is no work to do.” Daytime hospitalists also split admission to lighten the workload, he says.

 

Taylor says another practical concern for hospitalists working the seven-on/seven-off schedule is how engaged they can be with their institutions, particularly when they aren’t there half the year for committee meetings, staff gatherings—even water cooler conversation.

“I just have difficulty understanding how if half your workforce is gone every other week, how that group of doctors can become as integrated and ingrained and as part of the fabric of that facility as people who are there every week,” he says. “There are people who disagree with me on that, obviously.”

---

Richard Quinn is a freelance writer in New Jersey.

Robert Houser, MD, MBA, co-medical director of Rapid City Regional Hospital in Rapid City, S.D., left his primary-care practice a little more than 10 years ago to become a hospitalist. At the time, his new schedule—working seven days in a row, then taking off seven days in a row—struck him as odd. But the idea of being able to throw himself completely and alternately into both his job and his family appealed to him. More than a decade later, he still believes his schedule is a perfect mix of personal and professional time.

Bradley Eshbaugh, MBA, FACMPE, chief administrator of Hospitalists of Northern Michigan (HNM) in Traverse City, Mich., and a SHM Administrators’ Committee member, doesn’t see it that way. His hospitalists tell him the work-a-week, skip-a-week schedule is too inflexible for the work-life balance they crave. Even when newly hired physicians accustomed to the week-on/week-off schedule ask if they can continue it, Eshbaugh says, most quickly realize the flexible-schedule option that HNM utilizes offers them a more balanced approach to time off work.

Welcome to the world of seven-on/seven-off scheduling, where detractors and supporters often have the same reasons for their differing viewpoints. Those who favor the model say that its simple-to-implement block approach to scheduling allows physicians to know far in advance when their time off is. That allows clinicians to plan their lives way in advance, a carrot hospitalist groups have used for more than a decade to attract new hires. Those who prefer other scheduling methods say the seven-on/seven-off model’s rigidity leaves little flexibility to deal with the unscheduled inevitabilities of life (sickness, personal time, maternity leave, resignations, etc.) and is not the best construct to match staffing to the busiest admissions periods.

And while everyone agrees that the seven-on/seven-off model is among the most popular, there is as yet no clinical data that show whether its practitioners are more or less likely to provide higher-quality care. So the oft-asked question of whether the schedule is sustainable comes down not to care delivery but financial pressure. Three-quarters of HM groups (HMGs) rely on their host hospitals for financial support, and that support-per-FTE at nonacademic groups serving only adults rose to an median of $140,204 this year, according to SHM’s 2012 State of Hospital Medicine report—a 40% increase over data in the 2010 SHM/MGMA‐ACMPE survey.

 

“When we started in this business 15 years ago, the average hospital might have three to five hospitalists, maybe a subsidy of $300,000 to $500,000,” says Martin Buser, a partner in Hospitalist Management Resources of Del Mar, Calif. “That same program today is probably running 15 to 20 hospitalists, a subsidy of $3 million-plus. It’s really strongly on the radar screen for administrators to look at, ‘Can I keep affording this, or do I need to find less expensive ways to get the same result?’”

Viewpoints Vary

The origins of the seven-on/seven-off schedule are a bit murky. Some believe it was borrowed from the shift-work model in the ED. Others think it has roots in the nursing ranks. Still others think that in the nascent days of HM, two- and three-physician groups developed the schedule by simply splitting monthly schedules by weeks. Regardless of pedigree, the model has grown to be just about the most common schedule for HMGs serving adults only. The State of Hospital Medicine report reported that 41.9% of adult groups use the seven-on/seven-off schedule, with 41.6% reporting their schedule as “variable” and “other.”

SHM has never queried hospitalists specifically about their schedules before, so no comparative data are available for information. Interestingly, the State of Hospital Medicine report found that hospitalist management companies and private HM groups were less likely to use the seven-on/seven-off schedule than hospital-owned or academic groups.

Jeff Taylor, president and chief operating officer of IPC: The Hospitalist Co., a national physician group practice based in North Hollywood, Calif., says just 10% of his 1,400 providers nationwide uses the seven-on/seven-off construct. He argues the model “is economically inefficient.” For example, he says, take a hospital with a census of around 60 inpatients per day. An HM group that wants to limit daily censuses to about 15 patients would need four doctors to staff that patient load. Using the seven-on/seven-off schedule, the group would need eight dayside hospitalists (not counting nocturnists). In a more traditional staffing model of a five-day workweek and call coverage, a group likely could handle the same workload with five FTE hospitalists, Taylor says.

“We have been doing some education with hospitals over the last three or four years of just doing the math,” he adds. “How many doctors would you need to staff this census? … We often give a dual proposal. This is how much it will cost for seven-on/seven-off; this is how much it will cost with the Monday-through-Friday model. Obviously, the Monday-through-Friday model is a lower cost, but it may take a little bit longer to get it staffed.”

Staffing difficulties—particularly recruitment and retention—are a major driver of the popularity of the seven-on/seven-off schedule, says Gregory Martinek, DO, FHM, medical director of Lexington Hospitalists in Altoona, Pa. He says it’s tough to recruit hospitalists to work in a small town in central Pennsylvania, so offering a schedule those physicians want to work is helpful.

In fact, Dr. Martinek offers his hospitalists an extra week of vacation in addition to the 26 weeks they don’t work. That allows some of his foreign-born physicians to take a three-week break from work, which many use as a chance to return to their birth countries.

“We had trouble recruiting when we had a different model,” Dr. Martinek says. “This has really worked for us. It’s allowed us to recruit.”

Cost Concerns

How do HM group leaders answer C-suite questions about whether the expenses associated with the seven-on/seven-off model are worth it? The short answer is data. Know basic metrics on length of stay, cost of care, etc., before having that conversation. For example, a traditional 40-hour workweek is 2,080 hours per annum (and probably less with vacation time). And while some might think that 26 weeks off a year equates to fewer hours, 26 weeks of 12-hour shifts totals 2,184 hours.

 

Per Danielsson, MD, medical director of Swedish Hospital Medicine in Seattle, says his group uses a hybrid seven-on/seven-off schedule that has demonstrated that their cost-of-care delivery is consistently $1,000 to $1,500 less per case than other physicians’ cases at Swedish Medical Center—and those other physicians often take care of patients with the same diagnoses.

“When you have those kinds of numbers, and you’re doing 7,000 admissions per year, the numbers add up quickly,” Dr. Danielsson says.

Kristi Gylten, MBA, director of hospitalist services at Rapid City Regional Hospital and a member of SHM’s Administrators’ Committee, says hospitalist group leaders should urge their administrations to look at more than just financial statements when judging the value of an HM group, particularly in rural areas.

“Our program started with three physicians in 2004 and has grown to over 30 in 2012,” she says. “There has been such great value brought to our community and our medical staff and our patients, just over and above what the bottom line would show on a monthly operational statement, that we don’t have the bean-counters knocking on our door.”

IPC’s Taylor says a complicating factor in moving away from the seven-on/seven-off format is the passion physicians have for their schedules. Or, to use his words: “You make major changes to schedules at great peril.”

John Frehse, managing partner of Core Practice, a Chicago consultancy that designs and implements labor strategies for shift-work operations, says that managers and administrators looking to change schedules often shy away from the upheaval.

“This emotional and potentially disruptive environment is something that makes them say, ‘We’re getting away with it now, so let’s not change it. Why rock the boat?’” Frehse explains. “They should be saying, ‘What is the methodology to get this out of here and put in something that’s financially responsible for the organization?’”

Practice Concerns

Ten years ago, Dr. Houser found the seven-on/seven-off schedule “a little bit unusual.” Now, his workweek of seven 10-hour days in a row seems natural. Even so, he understands those who voice concerns about hospitalized patients who would not be happy to know their hospitalist was on his 60th, 70th, or 80th hour of work that week.

“The physician’s side of me stays in a mode where I know I have to be a resource to the patient and I have to be a resource to my colleagues, and so I don’t think terms of being mentally drained,” he says. “Whether I’m starting or finishing, I just want to be as fresh as I can to approach those problems and mentally stay in the game that way. If I start thinking about being fatigued or tired, I feel like I won’t be able to provide the type of care that I can for that patient.”

Some groups using the seven-on/seven-off model allow physicians to leave the hospital at slow times while requiring they be on call. That allows hospitalists to recharge a bit midweek while ensuring that there is enough staff to provide coverage. Dr. Martinek says there’s no need to “hold them in the hospital if there is no work to do.” Daytime hospitalists also split admission to lighten the workload, he says.

 

Taylor says another practical concern for hospitalists working the seven-on/seven-off schedule is how engaged they can be with their institutions, particularly when they aren’t there half the year for committee meetings, staff gatherings—even water cooler conversation.

“I just have difficulty understanding how if half your workforce is gone every other week, how that group of doctors can become as integrated and ingrained and as part of the fabric of that facility as people who are there every week,” he says. “There are people who disagree with me on that, obviously.”

---

Richard Quinn is a freelance writer in New Jersey.

Robert Houser, MD, MBA, co-medical director of Rapid City Regional Hospital in Rapid City, S.D., left his primary-care practice a little more than 10 years ago to become a hospitalist. At the time, his new schedule—working seven days in a row, then taking off seven days in a row—struck him as odd. But the idea of being able to throw himself completely and alternately into both his job and his family appealed to him. More than a decade later, he still believes his schedule is a perfect mix of personal and professional time.

Bradley Eshbaugh, MBA, FACMPE, chief administrator of Hospitalists of Northern Michigan (HNM) in Traverse City, Mich., and a SHM Administrators’ Committee member, doesn’t see it that way. His hospitalists tell him the work-a-week, skip-a-week schedule is too inflexible for the work-life balance they crave. Even when newly hired physicians accustomed to the week-on/week-off schedule ask if they can continue it, Eshbaugh says, most quickly realize the flexible-schedule option that HNM utilizes offers them a more balanced approach to time off work.

Welcome to the world of seven-on/seven-off scheduling, where detractors and supporters often have the same reasons for their differing viewpoints. Those who favor the model say that its simple-to-implement block approach to scheduling allows physicians to know far in advance when their time off is. That allows clinicians to plan their lives way in advance, a carrot hospitalist groups have used for more than a decade to attract new hires. Those who prefer other scheduling methods say the seven-on/seven-off model’s rigidity leaves little flexibility to deal with the unscheduled inevitabilities of life (sickness, personal time, maternity leave, resignations, etc.) and is not the best construct to match staffing to the busiest admissions periods.

And while everyone agrees that the seven-on/seven-off model is among the most popular, there is as yet no clinical data that show whether its practitioners are more or less likely to provide higher-quality care. So the oft-asked question of whether the schedule is sustainable comes down not to care delivery but financial pressure. Three-quarters of HM groups (HMGs) rely on their host hospitals for financial support, and that support-per-FTE at nonacademic groups serving only adults rose to an median of $140,204 this year, according to SHM’s 2012 State of Hospital Medicine report—a 40% increase over data in the 2010 SHM/MGMA‐ACMPE survey.

 

“When we started in this business 15 years ago, the average hospital might have three to five hospitalists, maybe a subsidy of $300,000 to $500,000,” says Martin Buser, a partner in Hospitalist Management Resources of Del Mar, Calif. “That same program today is probably running 15 to 20 hospitalists, a subsidy of $3 million-plus. It’s really strongly on the radar screen for administrators to look at, ‘Can I keep affording this, or do I need to find less expensive ways to get the same result?’”

Viewpoints Vary

The origins of the seven-on/seven-off schedule are a bit murky. Some believe it was borrowed from the shift-work model in the ED. Others think it has roots in the nursing ranks. Still others think that in the nascent days of HM, two- and three-physician groups developed the schedule by simply splitting monthly schedules by weeks. Regardless of pedigree, the model has grown to be just about the most common schedule for HMGs serving adults only. The State of Hospital Medicine report reported that 41.9% of adult groups use the seven-on/seven-off schedule, with 41.6% reporting their schedule as “variable” and “other.”

SHM has never queried hospitalists specifically about their schedules before, so no comparative data are available for information. Interestingly, the State of Hospital Medicine report found that hospitalist management companies and private HM groups were less likely to use the seven-on/seven-off schedule than hospital-owned or academic groups.

Jeff Taylor, president and chief operating officer of IPC: The Hospitalist Co., a national physician group practice based in North Hollywood, Calif., says just 10% of his 1,400 providers nationwide uses the seven-on/seven-off construct. He argues the model “is economically inefficient.” For example, he says, take a hospital with a census of around 60 inpatients per day. An HM group that wants to limit daily censuses to about 15 patients would need four doctors to staff that patient load. Using the seven-on/seven-off schedule, the group would need eight dayside hospitalists (not counting nocturnists). In a more traditional staffing model of a five-day workweek and call coverage, a group likely could handle the same workload with five FTE hospitalists, Taylor says.

“We have been doing some education with hospitals over the last three or four years of just doing the math,” he adds. “How many doctors would you need to staff this census? … We often give a dual proposal. This is how much it will cost for seven-on/seven-off; this is how much it will cost with the Monday-through-Friday model. Obviously, the Monday-through-Friday model is a lower cost, but it may take a little bit longer to get it staffed.”

Staffing difficulties—particularly recruitment and retention—are a major driver of the popularity of the seven-on/seven-off schedule, says Gregory Martinek, DO, FHM, medical director of Lexington Hospitalists in Altoona, Pa. He says it’s tough to recruit hospitalists to work in a small town in central Pennsylvania, so offering a schedule those physicians want to work is helpful.

In fact, Dr. Martinek offers his hospitalists an extra week of vacation in addition to the 26 weeks they don’t work. That allows some of his foreign-born physicians to take a three-week break from work, which many use as a chance to return to their birth countries.

“We had trouble recruiting when we had a different model,” Dr. Martinek says. “This has really worked for us. It’s allowed us to recruit.”

Cost Concerns

How do HM group leaders answer C-suite questions about whether the expenses associated with the seven-on/seven-off model are worth it? The short answer is data. Know basic metrics on length of stay, cost of care, etc., before having that conversation. For example, a traditional 40-hour workweek is 2,080 hours per annum (and probably less with vacation time). And while some might think that 26 weeks off a year equates to fewer hours, 26 weeks of 12-hour shifts totals 2,184 hours.

 

Per Danielsson, MD, medical director of Swedish Hospital Medicine in Seattle, says his group uses a hybrid seven-on/seven-off schedule that has demonstrated that their cost-of-care delivery is consistently $1,000 to $1,500 less per case than other physicians’ cases at Swedish Medical Center—and those other physicians often take care of patients with the same diagnoses.

“When you have those kinds of numbers, and you’re doing 7,000 admissions per year, the numbers add up quickly,” Dr. Danielsson says.

Kristi Gylten, MBA, director of hospitalist services at Rapid City Regional Hospital and a member of SHM’s Administrators’ Committee, says hospitalist group leaders should urge their administrations to look at more than just financial statements when judging the value of an HM group, particularly in rural areas.

“Our program started with three physicians in 2004 and has grown to over 30 in 2012,” she says. “There has been such great value brought to our community and our medical staff and our patients, just over and above what the bottom line would show on a monthly operational statement, that we don’t have the bean-counters knocking on our door.”

IPC’s Taylor says a complicating factor in moving away from the seven-on/seven-off format is the passion physicians have for their schedules. Or, to use his words: “You make major changes to schedules at great peril.”

John Frehse, managing partner of Core Practice, a Chicago consultancy that designs and implements labor strategies for shift-work operations, says that managers and administrators looking to change schedules often shy away from the upheaval.

“This emotional and potentially disruptive environment is something that makes them say, ‘We’re getting away with it now, so let’s not change it. Why rock the boat?’” Frehse explains. “They should be saying, ‘What is the methodology to get this out of here and put in something that’s financially responsible for the organization?’”

Practice Concerns

Ten years ago, Dr. Houser found the seven-on/seven-off schedule “a little bit unusual.” Now, his workweek of seven 10-hour days in a row seems natural. Even so, he understands those who voice concerns about hospitalized patients who would not be happy to know their hospitalist was on his 60th, 70th, or 80th hour of work that week.

“The physician’s side of me stays in a mode where I know I have to be a resource to the patient and I have to be a resource to my colleagues, and so I don’t think terms of being mentally drained,” he says. “Whether I’m starting or finishing, I just want to be as fresh as I can to approach those problems and mentally stay in the game that way. If I start thinking about being fatigued or tired, I feel like I won’t be able to provide the type of care that I can for that patient.”

Some groups using the seven-on/seven-off model allow physicians to leave the hospital at slow times while requiring they be on call. That allows hospitalists to recharge a bit midweek while ensuring that there is enough staff to provide coverage. Dr. Martinek says there’s no need to “hold them in the hospital if there is no work to do.” Daytime hospitalists also split admission to lighten the workload, he says.

 

Taylor says another practical concern for hospitalists working the seven-on/seven-off schedule is how engaged they can be with their institutions, particularly when they aren’t there half the year for committee meetings, staff gatherings—even water cooler conversation.

“I just have difficulty understanding how if half your workforce is gone every other week, how that group of doctors can become as integrated and ingrained and as part of the fabric of that facility as people who are there every week,” he says. “There are people who disagree with me on that, obviously.”

---

Richard Quinn is a freelance writer in New Jersey.

Whether one prefers the seven-on/seven-off scheduling model or not, it’s universally agreed that a full seven days off in a row is one of the schedule’s big selling points. But what about hospitalists who choose to work on their weeks off?

“That’s a definite concern, too,” says Gregory Martinek, DO, FHM, medical director of Lexington Hospitalists for the Altoona Regional Health System in Altoona, Pa.

In rural areas, such as Dr. Martinek’s workplace in central Pennsylvania, hospitalists often have a chance to pick up additional shifts—some even have two full-time gigs. That work, known as moonlighting, can be at their home institutions or at other hospitals in the region. But the practice raises questions about how well-rested physicians can be if they are working nearly every day.

“If a group of administrators get together and say, ‘Well, my hospitalists are working at your facility and vice versa, it’s like I’m paying them a full-time equivalent … but then on their off-week, when they’re supposed to be off for their quality of life and balance, and they’re off working somewhere,’ that’s a concern,” Dr. Martinek says.

To control the practice, Dr. Martinek has put rules in place to guide hospitalists who are eager to work additional shifts either via moonlighting or locum tenens. His group stipulates that hospitalists designated as the backup person for the week cannot accept additional shifts elsewhere. Additionally, if there are open shifts at Altoona Regiona Health System, hospitalists are encouraged to accept these shifts before accepting shifts outside the health system.

Dr. Martinek says he understands physicians’ desire to take additional shifts for financial benefit, but he urges them to take the long view of their careers before burning themselves out.

“This is a marathon, not a sprint, and they need to pace themselves,” he adds. “It’s OK to want to earn some extra money while it’s there, but you’ve got to think about the longevity of your career and really take your time off.” TH

Richard Quinn is a freelance writer in New Jersey.

Whether one prefers the seven-on/seven-off scheduling model or not, it’s universally agreed that a full seven days off in a row is one of the schedule’s big selling points. But what about hospitalists who choose to work on their weeks off?

“That’s a definite concern, too,” says Gregory Martinek, DO, FHM, medical director of Lexington Hospitalists for the Altoona Regional Health System in Altoona, Pa.

In rural areas, such as Dr. Martinek’s workplace in central Pennsylvania, hospitalists often have a chance to pick up additional shifts—some even have two full-time gigs. That work, known as moonlighting, can be at their home institutions or at other hospitals in the region. But the practice raises questions about how well-rested physicians can be if they are working nearly every day.

“If a group of administrators get together and say, ‘Well, my hospitalists are working at your facility and vice versa, it’s like I’m paying them a full-time equivalent … but then on their off-week, when they’re supposed to be off for their quality of life and balance, and they’re off working somewhere,’ that’s a concern,” Dr. Martinek says.

To control the practice, Dr. Martinek has put rules in place to guide hospitalists who are eager to work additional shifts either via moonlighting or locum tenens. His group stipulates that hospitalists designated as the backup person for the week cannot accept additional shifts elsewhere. Additionally, if there are open shifts at Altoona Regiona Health System, hospitalists are encouraged to accept these shifts before accepting shifts outside the health system.

Dr. Martinek says he understands physicians’ desire to take additional shifts for financial benefit, but he urges them to take the long view of their careers before burning themselves out.

“This is a marathon, not a sprint, and they need to pace themselves,” he adds. “It’s OK to want to earn some extra money while it’s there, but you’ve got to think about the longevity of your career and really take your time off.” TH

Richard Quinn is a freelance writer in New Jersey.

Whether one prefers the seven-on/seven-off scheduling model or not, it’s universally agreed that a full seven days off in a row is one of the schedule’s big selling points. But what about hospitalists who choose to work on their weeks off?

“That’s a definite concern, too,” says Gregory Martinek, DO, FHM, medical director of Lexington Hospitalists for the Altoona Regional Health System in Altoona, Pa.

In rural areas, such as Dr. Martinek’s workplace in central Pennsylvania, hospitalists often have a chance to pick up additional shifts—some even have two full-time gigs. That work, known as moonlighting, can be at their home institutions or at other hospitals in the region. But the practice raises questions about how well-rested physicians can be if they are working nearly every day.

“If a group of administrators get together and say, ‘Well, my hospitalists are working at your facility and vice versa, it’s like I’m paying them a full-time equivalent … but then on their off-week, when they’re supposed to be off for their quality of life and balance, and they’re off working somewhere,’ that’s a concern,” Dr. Martinek says.

To control the practice, Dr. Martinek has put rules in place to guide hospitalists who are eager to work additional shifts either via moonlighting or locum tenens. His group stipulates that hospitalists designated as the backup person for the week cannot accept additional shifts elsewhere. Additionally, if there are open shifts at Altoona Regiona Health System, hospitalists are encouraged to accept these shifts before accepting shifts outside the health system.

Dr. Martinek says he understands physicians’ desire to take additional shifts for financial benefit, but he urges them to take the long view of their careers before burning themselves out.

“This is a marathon, not a sprint, and they need to pace themselves,” he adds. “It’s OK to want to earn some extra money while it’s there, but you’ve got to think about the longevity of your career and really take your time off.” TH

Richard Quinn is a freelance writer in New Jersey.

Some hospitalist groups can expect a bump in total revenue over the next two years, thanks to the Medicaid-to-Medicare parity regulation that was included in the Affordable Care Act. But whether the increase in reimbursement lasts beyond 2014 is anyone’s guess.

The regulation, which the Centers for Medicare & Medicaid Services (CMS) released in November and made effective Jan. 1, increases Medicaid payments for certain primary-care services to 100% of Medicare levels this year and next. States will receive an estimated $11 billion over the next two years to fund the program, according to the American Academy of Family Physicians (AAFP). Eligible providers include physicians, physician assistants (PAs), and nurse practitioners (NPs), who self-attest they are board-certified in family, pediatric, or general internal medicine; it also includes those doctors, PAs, or NPs who self-attest that at least 60% of all Medicaid services they bill or provide in a managed-care environment are for specific evaluation and management (E&M) and vaccine administration codes.¹

The concept is to boost Medicaid participation by improving historically lagging reimbursement rates.² To wit, CMS’ Office of the Actuary estimates the parity rule will add more than 10,000 new primary-care physicians (PCPs) to the Medicaid participation ranks.³

SHM Public Policy Committee member Brad Flansbaum, DO, MPH, SFHM, says that hospitalists who deal with Medicaid populations can expect at least some increase in their revenue over the next two years. For example, he says, take an HM group earning $100,000 a year in Medicaid revenue. Now consider Urban Institute figures that show, in 2012, Medicaid physician fees on average were 66% of Medicare physician fees (with wide state variations). The parity rule now pays that hypothetical HM group about $150,000.

“It’s simple math,” Dr. Flansbaum says. “I would emphasize that the bump in pay is going to be proportional to the percentage of Medicaid patients that you see. There are some doctors who see an awful lot of Medicaid patients in safety-net and public hospitals, and that money, when it comes back to departments and divisions, can be used for things that a lot of these places never had the means to do before. It could be salary, but it could also mean hiring more people, more resources. It makes a difference.”

Public Policy Committee chair Ron Greeno, MD, FCCP, MHM, says SHM advocated for the parity regulation, as Medicaid has historically paid for only about 70% of the healthcare delivered to patients. Although the parity issue has not gathered as much attention as other facets of the healthcare reform movement, having CMS recognize that delivery of primary care is not restricted to traditional offices is one he and SHM are particularly proud of.

“This is a correction long in coming,” Dr. Greeno says. “We’re happy hospitalists were included in the group of people that will achieve that parity.”

 

Dr. Flansbaum, director of hospitalist services at Lenox Hill Hospital in New York City, says few physicians are even aware of the provision, in part because of a widespread frustration with Medicaid’s historic reimbursements rates.

“It’s almost a foregone conclusion that Medicaid never pays, reimbursement always goes down, and the interactions with Medicaid are always increasingly difficult,” Dr. Flansbaum adds.

The question for physicians and policy wonks now is what happens to the parity regulation after its scheduled expiration Dec. 31, 2014. Several medical societies, including SHM and the American College of Physicians (ACP), lobbied Congress to make sure the parity regulation was not impacted by the “fiscal cliff” negotiations. The next step is to craft a permanent funding source to pay for it.

“Unless Congress acts to permanently extend and fund this provision, a sudden return to disparate and inadequate payment for primary services needed by Medicaid patients after only two years will again threaten to restrict their access to such needed services,” AAFP said in a statement after the rule was implemented. “It would once again shut out people who have come to know and depend on their primary care physicians. Only by extending Medicaid parity with Medicare can we ensure that these Americans continue to have uninterrupted medical care in the future.”

SHM recommended that CMS work with the states to facilitate timely data collection designed to determine the effects on the quality and efficiency of care being received under Medicaid as a result of the enhanced fees. CMS agreed with this recommendation and the resulting data, hopefully, will make the case for continuing the enhanced payment following 2014.

Dr. Flansbaum says SHM’s policy team will continue to work on the issue, but given the precarious state of federal budgets and political dysfunction in Washington, it’s too early to know whether a funding source will be identified to pay for parity in 2015 and beyond—especially as politicians have yet to craft long-term solutions to issues including the sustainable-growth rate formula and other specialists, including radiologists and obstetricians, lobby to be eligible for the parity pay. However, he is hopeful that physicians who see the added impact of parity pay in the next two years will lobby Congress to find a way to continue the higher reimbursement.

“I can’t tell you whether or not when you put on the scale of all the priorities whether it’s going to be a new Air Force bomber, another $50 billion into Medicare for physicians, or an educational system upgrade,” he says. “I don’t know where the government is going to assign its priorities. Will the money be there to extend both the two-year Medicaid and the reprieve? And if the answer is yes, will it be extended to other providers beyond just primary-care practitioners? It’s anyone’s guess.”

---

Richard Quinn is a freelance writer in New Jersey.

References

1. FAQ: Medicaid/Medicare Parity Regulation. Society of Hospital Medicine website. Available at: http://www.hospitalmedicine.org/AM/Images/Advocacy_Image/pdf/Parity_FAQ_Final.pdf. Accessed Jan. 27, 2013.
2. Centers for Medicare & Medicaid Services. Medicaid program; payments for services furnished by certain primary care physicians and charges for vaccine administration under the Vaccines for Children program. Federal Register website. Available at: http://www.gpo.gov/fdsys/pkg/FR-2012-11-06/pdf/2012-26507.pdf. Accessed Jan. 15, 2013.
3. Bindman A. JAMA Forum: Warning: Dangerous physician payment cliffs ahead. Journal of the American Medical Association website. Available at: http://newsatjama.jama.com/2013/01/10/jama-forum-warning-dangerous-physician-payment-cliffs-ahead/.Accessed Jan. 15, 2013.

Some hospitalist groups can expect a bump in total revenue over the next two years, thanks to the Medicaid-to-Medicare parity regulation that was included in the Affordable Care Act. But whether the increase in reimbursement lasts beyond 2014 is anyone’s guess.

The regulation, which the Centers for Medicare & Medicaid Services (CMS) released in November and made effective Jan. 1, increases Medicaid payments for certain primary-care services to 100% of Medicare levels this year and next. States will receive an estimated $11 billion over the next two years to fund the program, according to the American Academy of Family Physicians (AAFP). Eligible providers include physicians, physician assistants (PAs), and nurse practitioners (NPs), who self-attest they are board-certified in family, pediatric, or general internal medicine; it also includes those doctors, PAs, or NPs who self-attest that at least 60% of all Medicaid services they bill or provide in a managed-care environment are for specific evaluation and management (E&M) and vaccine administration codes.¹

The concept is to boost Medicaid participation by improving historically lagging reimbursement rates.² To wit, CMS’ Office of the Actuary estimates the parity rule will add more than 10,000 new primary-care physicians (PCPs) to the Medicaid participation ranks.³

SHM Public Policy Committee member Brad Flansbaum, DO, MPH, SFHM, says that hospitalists who deal with Medicaid populations can expect at least some increase in their revenue over the next two years. For example, he says, take an HM group earning $100,000 a year in Medicaid revenue. Now consider Urban Institute figures that show, in 2012, Medicaid physician fees on average were 66% of Medicare physician fees (with wide state variations). The parity rule now pays that hypothetical HM group about $150,000.

“It’s simple math,” Dr. Flansbaum says. “I would emphasize that the bump in pay is going to be proportional to the percentage of Medicaid patients that you see. There are some doctors who see an awful lot of Medicaid patients in safety-net and public hospitals, and that money, when it comes back to departments and divisions, can be used for things that a lot of these places never had the means to do before. It could be salary, but it could also mean hiring more people, more resources. It makes a difference.”

Public Policy Committee chair Ron Greeno, MD, FCCP, MHM, says SHM advocated for the parity regulation, as Medicaid has historically paid for only about 70% of the healthcare delivered to patients. Although the parity issue has not gathered as much attention as other facets of the healthcare reform movement, having CMS recognize that delivery of primary care is not restricted to traditional offices is one he and SHM are particularly proud of.

“This is a correction long in coming,” Dr. Greeno says. “We’re happy hospitalists were included in the group of people that will achieve that parity.”

 

Dr. Flansbaum, director of hospitalist services at Lenox Hill Hospital in New York City, says few physicians are even aware of the provision, in part because of a widespread frustration with Medicaid’s historic reimbursements rates.

“It’s almost a foregone conclusion that Medicaid never pays, reimbursement always goes down, and the interactions with Medicaid are always increasingly difficult,” Dr. Flansbaum adds.

The question for physicians and policy wonks now is what happens to the parity regulation after its scheduled expiration Dec. 31, 2014. Several medical societies, including SHM and the American College of Physicians (ACP), lobbied Congress to make sure the parity regulation was not impacted by the “fiscal cliff” negotiations. The next step is to craft a permanent funding source to pay for it.

“Unless Congress acts to permanently extend and fund this provision, a sudden return to disparate and inadequate payment for primary services needed by Medicaid patients after only two years will again threaten to restrict their access to such needed services,” AAFP said in a statement after the rule was implemented. “It would once again shut out people who have come to know and depend on their primary care physicians. Only by extending Medicaid parity with Medicare can we ensure that these Americans continue to have uninterrupted medical care in the future.”

SHM recommended that CMS work with the states to facilitate timely data collection designed to determine the effects on the quality and efficiency of care being received under Medicaid as a result of the enhanced fees. CMS agreed with this recommendation and the resulting data, hopefully, will make the case for continuing the enhanced payment following 2014.

Dr. Flansbaum says SHM’s policy team will continue to work on the issue, but given the precarious state of federal budgets and political dysfunction in Washington, it’s too early to know whether a funding source will be identified to pay for parity in 2015 and beyond—especially as politicians have yet to craft long-term solutions to issues including the sustainable-growth rate formula and other specialists, including radiologists and obstetricians, lobby to be eligible for the parity pay. However, he is hopeful that physicians who see the added impact of parity pay in the next two years will lobby Congress to find a way to continue the higher reimbursement.

“I can’t tell you whether or not when you put on the scale of all the priorities whether it’s going to be a new Air Force bomber, another $50 billion into Medicare for physicians, or an educational system upgrade,” he says. “I don’t know where the government is going to assign its priorities. Will the money be there to extend both the two-year Medicaid and the reprieve? And if the answer is yes, will it be extended to other providers beyond just primary-care practitioners? It’s anyone’s guess.”

---

Richard Quinn is a freelance writer in New Jersey.

References

1. FAQ: Medicaid/Medicare Parity Regulation. Society of Hospital Medicine website. Available at: http://www.hospitalmedicine.org/AM/Images/Advocacy_Image/pdf/Parity_FAQ_Final.pdf. Accessed Jan. 27, 2013.
2. Centers for Medicare & Medicaid Services. Medicaid program; payments for services furnished by certain primary care physicians and charges for vaccine administration under the Vaccines for Children program. Federal Register website. Available at: http://www.gpo.gov/fdsys/pkg/FR-2012-11-06/pdf/2012-26507.pdf. Accessed Jan. 15, 2013.
3. Bindman A. JAMA Forum: Warning: Dangerous physician payment cliffs ahead. Journal of the American Medical Association website. Available at: http://newsatjama.jama.com/2013/01/10/jama-forum-warning-dangerous-physician-payment-cliffs-ahead/.Accessed Jan. 15, 2013.

Some hospitalist groups can expect a bump in total revenue over the next two years, thanks to the Medicaid-to-Medicare parity regulation that was included in the Affordable Care Act. But whether the increase in reimbursement lasts beyond 2014 is anyone’s guess.

The regulation, which the Centers for Medicare & Medicaid Services (CMS) released in November and made effective Jan. 1, increases Medicaid payments for certain primary-care services to 100% of Medicare levels this year and next. States will receive an estimated $11 billion over the next two years to fund the program, according to the American Academy of Family Physicians (AAFP). Eligible providers include physicians, physician assistants (PAs), and nurse practitioners (NPs), who self-attest they are board-certified in family, pediatric, or general internal medicine; it also includes those doctors, PAs, or NPs who self-attest that at least 60% of all Medicaid services they bill or provide in a managed-care environment are for specific evaluation and management (E&M) and vaccine administration codes.¹

The concept is to boost Medicaid participation by improving historically lagging reimbursement rates.² To wit, CMS’ Office of the Actuary estimates the parity rule will add more than 10,000 new primary-care physicians (PCPs) to the Medicaid participation ranks.³

SHM Public Policy Committee member Brad Flansbaum, DO, MPH, SFHM, says that hospitalists who deal with Medicaid populations can expect at least some increase in their revenue over the next two years. For example, he says, take an HM group earning $100,000 a year in Medicaid revenue. Now consider Urban Institute figures that show, in 2012, Medicaid physician fees on average were 66% of Medicare physician fees (with wide state variations). The parity rule now pays that hypothetical HM group about $150,000.

“It’s simple math,” Dr. Flansbaum says. “I would emphasize that the bump in pay is going to be proportional to the percentage of Medicaid patients that you see. There are some doctors who see an awful lot of Medicaid patients in safety-net and public hospitals, and that money, when it comes back to departments and divisions, can be used for things that a lot of these places never had the means to do before. It could be salary, but it could also mean hiring more people, more resources. It makes a difference.”

Public Policy Committee chair Ron Greeno, MD, FCCP, MHM, says SHM advocated for the parity regulation, as Medicaid has historically paid for only about 70% of the healthcare delivered to patients. Although the parity issue has not gathered as much attention as other facets of the healthcare reform movement, having CMS recognize that delivery of primary care is not restricted to traditional offices is one he and SHM are particularly proud of.

“This is a correction long in coming,” Dr. Greeno says. “We’re happy hospitalists were included in the group of people that will achieve that parity.”

 

Dr. Flansbaum, director of hospitalist services at Lenox Hill Hospital in New York City, says few physicians are even aware of the provision, in part because of a widespread frustration with Medicaid’s historic reimbursements rates.

“It’s almost a foregone conclusion that Medicaid never pays, reimbursement always goes down, and the interactions with Medicaid are always increasingly difficult,” Dr. Flansbaum adds.

The question for physicians and policy wonks now is what happens to the parity regulation after its scheduled expiration Dec. 31, 2014. Several medical societies, including SHM and the American College of Physicians (ACP), lobbied Congress to make sure the parity regulation was not impacted by the “fiscal cliff” negotiations. The next step is to craft a permanent funding source to pay for it.

“Unless Congress acts to permanently extend and fund this provision, a sudden return to disparate and inadequate payment for primary services needed by Medicaid patients after only two years will again threaten to restrict their access to such needed services,” AAFP said in a statement after the rule was implemented. “It would once again shut out people who have come to know and depend on their primary care physicians. Only by extending Medicaid parity with Medicare can we ensure that these Americans continue to have uninterrupted medical care in the future.”

SHM recommended that CMS work with the states to facilitate timely data collection designed to determine the effects on the quality and efficiency of care being received under Medicaid as a result of the enhanced fees. CMS agreed with this recommendation and the resulting data, hopefully, will make the case for continuing the enhanced payment following 2014.

Dr. Flansbaum says SHM’s policy team will continue to work on the issue, but given the precarious state of federal budgets and political dysfunction in Washington, it’s too early to know whether a funding source will be identified to pay for parity in 2015 and beyond—especially as politicians have yet to craft long-term solutions to issues including the sustainable-growth rate formula and other specialists, including radiologists and obstetricians, lobby to be eligible for the parity pay. However, he is hopeful that physicians who see the added impact of parity pay in the next two years will lobby Congress to find a way to continue the higher reimbursement.

“I can’t tell you whether or not when you put on the scale of all the priorities whether it’s going to be a new Air Force bomber, another $50 billion into Medicare for physicians, or an educational system upgrade,” he says. “I don’t know where the government is going to assign its priorities. Will the money be there to extend both the two-year Medicaid and the reprieve? And if the answer is yes, will it be extended to other providers beyond just primary-care practitioners? It’s anyone’s guess.”

---

Richard Quinn is a freelance writer in New Jersey.

References

1. FAQ: Medicaid/Medicare Parity Regulation. Society of Hospital Medicine website. Available at: http://www.hospitalmedicine.org/AM/Images/Advocacy_Image/pdf/Parity_FAQ_Final.pdf. Accessed Jan. 27, 2013.
2. Centers for Medicare & Medicaid Services. Medicaid program; payments for services furnished by certain primary care physicians and charges for vaccine administration under the Vaccines for Children program. Federal Register website. Available at: http://www.gpo.gov/fdsys/pkg/FR-2012-11-06/pdf/2012-26507.pdf. Accessed Jan. 15, 2013.
3. Bindman A. JAMA Forum: Warning: Dangerous physician payment cliffs ahead. Journal of the American Medical Association website. Available at: http://newsatjama.jama.com/2013/01/10/jama-forum-warning-dangerous-physician-payment-cliffs-ahead/.Accessed Jan. 15, 2013.

The lead author of a new report that says hospitalized Medicare patients are happier in facilities using a greater number of hospitalists didn't expect that would be the case.

The study, "Hospitalist Staffing and Patient Satisfaction in the National Medicare Population," which was recently published in the Journal of Hospital Medicine, sprung from the theory that hospitals using a large number of hospitalists generally would rank lower in patient satisfaction than others. In part, the expectation was tied to the belief that patients might prefer to be seen by their primary-care physician (PCP) rather than a hospitalist.

"What we'd like people to take away is that in our study—and it's only one study—hospitals with higher levels of hospitalist care had modestly higher patient satisfaction scores, especially in the areas of discharge planning and overall satisfaction," says Lena Chen, MD, MS, clinical lecturer in the division of general medicine at the University of Michigan in Ann Arbor. "It suggests that there doesn't need to be a tradeoff between greater use of hospitalist services and patient satisfaction."

The retrospective cohort study looked at 2,843 acute-care hospitals and split them into groups ranked by the percentage of patients cared for by hospitalists. Those categorized as "nonhospitalist" hospitals had a median of 0% of general medicine patients cared for by hospitalists; a "mixed" hospital had a median of 39.5% of general medicine patients cared for by hospitalists; and a "hospitalist" hospital had a median of 76.5% cared for by hospitalists, according to the report. "Hospitalist" hospitals scored better (65.6%) on global measures of satisfaction than "mixed" (63.9%) or "nonhospitalist" (63.9%) hospitals (P<0.001), the study found. Hospitalist care was not associated with patient satisfaction in the areas of room cleanliness or communication with a physician.

Dr. Chen says she would like to see the research prompt more investigation into why hospitalist care is associated with patient satisfaction.

"We all want to have satisfied patients," she adds. "It would be important to have research that explores what the factors are that lead to greater patient satisfaction. This is a first step, but it's definitely not the end of the road."

Visit our website for more information about patient satisfaction.

The lead author of a new report that says hospitalized Medicare patients are happier in facilities using a greater number of hospitalists didn't expect that would be the case.

The study, "Hospitalist Staffing and Patient Satisfaction in the National Medicare Population," which was recently published in the Journal of Hospital Medicine, sprung from the theory that hospitals using a large number of hospitalists generally would rank lower in patient satisfaction than others. In part, the expectation was tied to the belief that patients might prefer to be seen by their primary-care physician (PCP) rather than a hospitalist.

"What we'd like people to take away is that in our study—and it's only one study—hospitals with higher levels of hospitalist care had modestly higher patient satisfaction scores, especially in the areas of discharge planning and overall satisfaction," says Lena Chen, MD, MS, clinical lecturer in the division of general medicine at the University of Michigan in Ann Arbor. "It suggests that there doesn't need to be a tradeoff between greater use of hospitalist services and patient satisfaction."

The retrospective cohort study looked at 2,843 acute-care hospitals and split them into groups ranked by the percentage of patients cared for by hospitalists. Those categorized as "nonhospitalist" hospitals had a median of 0% of general medicine patients cared for by hospitalists; a "mixed" hospital had a median of 39.5% of general medicine patients cared for by hospitalists; and a "hospitalist" hospital had a median of 76.5% cared for by hospitalists, according to the report. "Hospitalist" hospitals scored better (65.6%) on global measures of satisfaction than "mixed" (63.9%) or "nonhospitalist" (63.9%) hospitals (P<0.001), the study found. Hospitalist care was not associated with patient satisfaction in the areas of room cleanliness or communication with a physician.

Dr. Chen says she would like to see the research prompt more investigation into why hospitalist care is associated with patient satisfaction.

"We all want to have satisfied patients," she adds. "It would be important to have research that explores what the factors are that lead to greater patient satisfaction. This is a first step, but it's definitely not the end of the road."

Visit our website for more information about patient satisfaction.

The lead author of a new report that says hospitalized Medicare patients are happier in facilities using a greater number of hospitalists didn't expect that would be the case.

The study, "Hospitalist Staffing and Patient Satisfaction in the National Medicare Population," which was recently published in the Journal of Hospital Medicine, sprung from the theory that hospitals using a large number of hospitalists generally would rank lower in patient satisfaction than others. In part, the expectation was tied to the belief that patients might prefer to be seen by their primary-care physician (PCP) rather than a hospitalist.

"What we'd like people to take away is that in our study—and it's only one study—hospitals with higher levels of hospitalist care had modestly higher patient satisfaction scores, especially in the areas of discharge planning and overall satisfaction," says Lena Chen, MD, MS, clinical lecturer in the division of general medicine at the University of Michigan in Ann Arbor. "It suggests that there doesn't need to be a tradeoff between greater use of hospitalist services and patient satisfaction."

The retrospective cohort study looked at 2,843 acute-care hospitals and split them into groups ranked by the percentage of patients cared for by hospitalists. Those categorized as "nonhospitalist" hospitals had a median of 0% of general medicine patients cared for by hospitalists; a "mixed" hospital had a median of 39.5% of general medicine patients cared for by hospitalists; and a "hospitalist" hospital had a median of 76.5% cared for by hospitalists, according to the report. "Hospitalist" hospitals scored better (65.6%) on global measures of satisfaction than "mixed" (63.9%) or "nonhospitalist" (63.9%) hospitals (P<0.001), the study found. Hospitalist care was not associated with patient satisfaction in the areas of room cleanliness or communication with a physician.

Dr. Chen says she would like to see the research prompt more investigation into why hospitalist care is associated with patient satisfaction.

"We all want to have satisfied patients," she adds. "It would be important to have research that explores what the factors are that lead to greater patient satisfaction. This is a first step, but it's definitely not the end of the road."

Visit our website for more information about patient satisfaction.

A recent study in which 36% of hospitalists reported that their workload exceeds safe patient census levels at least once a week could spur serious discussions on productivity and quality of care, according to one of its authors.

Daniel Brotman, MD, FACP, FHM, director of the hospitalist program at Johns Hopkins Hospital in Baltimore and one of the study's authors, says the results highlight the delicate balance between pushing hospitalists to generate revenue and maintaining patient safety.

"It's certainly not in the best interest of our patients or our healthcare system to fix financial stress by expecting more clinical productivity of doctors year over year,” he says. "At some point, and it's self-evident—at least in my mind—quality starts to suffer when workload gets excessive."

The report, "Impact of Attending Physician Workload on Patient Care: A Survey of Hospitalists," details findings of the first study to assess perception of unsafe workloads by directly questioning physicians, according to its authors. They electronically queried 506 hospitalists enrolled in the physicians' online network and information site QuantiaMD.com.

As many as 40% of physicians reported their typical inpatient census exceeded safe levels at least once monthly, the report noted, and physicians pegged 15 as the optimal number of patients to see on a shift dedicated to clinical work.

John Nelson, MD, MHM, a principal in Nelson Flores Hospital Medicine Consultants in La Quinta, Calif., says staffing shortages are likely the most common cause of heavy workloads, and that the high number of physicians reporting overloaded censuses is evidence that hospitalists are concerned their job performance is adversely affected.

"I suspect that as belt-tightening continues to occur," Dr. Brotman adds, "we're going to see the importance of [research] like this increasing, because we're going to see more and more stressed-out, overextended doctors who are having trouble delivering the care that they know they can deliver if they had more time."

 

Visit our website for more information on hospital medicine workloads.

 

A recent study in which 36% of hospitalists reported that their workload exceeds safe patient census levels at least once a week could spur serious discussions on productivity and quality of care, according to one of its authors.

Daniel Brotman, MD, FACP, FHM, director of the hospitalist program at Johns Hopkins Hospital in Baltimore and one of the study's authors, says the results highlight the delicate balance between pushing hospitalists to generate revenue and maintaining patient safety.

"It's certainly not in the best interest of our patients or our healthcare system to fix financial stress by expecting more clinical productivity of doctors year over year,” he says. "At some point, and it's self-evident—at least in my mind—quality starts to suffer when workload gets excessive."

The report, "Impact of Attending Physician Workload on Patient Care: A Survey of Hospitalists," details findings of the first study to assess perception of unsafe workloads by directly questioning physicians, according to its authors. They electronically queried 506 hospitalists enrolled in the physicians' online network and information site QuantiaMD.com.

As many as 40% of physicians reported their typical inpatient census exceeded safe levels at least once monthly, the report noted, and physicians pegged 15 as the optimal number of patients to see on a shift dedicated to clinical work.

John Nelson, MD, MHM, a principal in Nelson Flores Hospital Medicine Consultants in La Quinta, Calif., says staffing shortages are likely the most common cause of heavy workloads, and that the high number of physicians reporting overloaded censuses is evidence that hospitalists are concerned their job performance is adversely affected.

"I suspect that as belt-tightening continues to occur," Dr. Brotman adds, "we're going to see the importance of [research] like this increasing, because we're going to see more and more stressed-out, overextended doctors who are having trouble delivering the care that they know they can deliver if they had more time."

 

Visit our website for more information on hospital medicine workloads.

 

A recent study in which 36% of hospitalists reported that their workload exceeds safe patient census levels at least once a week could spur serious discussions on productivity and quality of care, according to one of its authors.

Daniel Brotman, MD, FACP, FHM, director of the hospitalist program at Johns Hopkins Hospital in Baltimore and one of the study's authors, says the results highlight the delicate balance between pushing hospitalists to generate revenue and maintaining patient safety.

"It's certainly not in the best interest of our patients or our healthcare system to fix financial stress by expecting more clinical productivity of doctors year over year,” he says. "At some point, and it's self-evident—at least in my mind—quality starts to suffer when workload gets excessive."

The report, "Impact of Attending Physician Workload on Patient Care: A Survey of Hospitalists," details findings of the first study to assess perception of unsafe workloads by directly questioning physicians, according to its authors. They electronically queried 506 hospitalists enrolled in the physicians' online network and information site QuantiaMD.com.

As many as 40% of physicians reported their typical inpatient census exceeded safe levels at least once monthly, the report noted, and physicians pegged 15 as the optimal number of patients to see on a shift dedicated to clinical work.

John Nelson, MD, MHM, a principal in Nelson Flores Hospital Medicine Consultants in La Quinta, Calif., says staffing shortages are likely the most common cause of heavy workloads, and that the high number of physicians reporting overloaded censuses is evidence that hospitalists are concerned their job performance is adversely affected.

"I suspect that as belt-tightening continues to occur," Dr. Brotman adds, "we're going to see the importance of [research] like this increasing, because we're going to see more and more stressed-out, overextended doctors who are having trouble delivering the care that they know they can deliver if they had more time."

 

Visit our website for more information on hospital medicine workloads.

 

Hospitalists aren’t urban planners, but it doesn’t take a zoning expert to realize that when a community sees hundreds of new homes built, some of the residents of those homes will end up in the hospital. The same logic applies when a company moves thousands of jobs to an office building a few blocks away from a hospital.

HM group leaders might not normally think about such things when analyzing whether they need to add staff, but at least one practice consultant says they should.

“If you fail to look outside the building, you will fail,” says Kenneth Hertz, FACMPE, principal of MGMA’s Health Care Consulting Group. “I think the outside metrics are almost more important. You’ve got to stay on top of what’s happening outside in your community, because the people you serve are your market, and if all you do is look within the four walls of the hospital, you will not see what’s coming.”

Hospitals often have community data available, Hertz says, but group leaders don’t always think to access it. He suggests they view the information as a routine part of their strategic planning.

Of course, Hertz adds, it’s not the only information that goes into the expansion equation, but administrators often respect group leaders who come armed with data from inside and outside the hospital about why it is necessary to make a new hire.

“It’s about open, honest discussion,” he says. “It’s about looking at information both inside the four walls and outside in the community. It’s not easy, but it can be done. But you’ve got to plan.”

Hertz says HM group leaders should plan at least 12 to 18 months out for a hire, “which I know is hard these days,” he says. But, he adds, short-term forecasting makes it “very difficult” to know when and how best to grow your group. TH

Richard Quinn is a freelance writer in New Jersey.

 

Hospitalists aren’t urban planners, but it doesn’t take a zoning expert to realize that when a community sees hundreds of new homes built, some of the residents of those homes will end up in the hospital. The same logic applies when a company moves thousands of jobs to an office building a few blocks away from a hospital.

HM group leaders might not normally think about such things when analyzing whether they need to add staff, but at least one practice consultant says they should.

“If you fail to look outside the building, you will fail,” says Kenneth Hertz, FACMPE, principal of MGMA’s Health Care Consulting Group. “I think the outside metrics are almost more important. You’ve got to stay on top of what’s happening outside in your community, because the people you serve are your market, and if all you do is look within the four walls of the hospital, you will not see what’s coming.”

Hospitals often have community data available, Hertz says, but group leaders don’t always think to access it. He suggests they view the information as a routine part of their strategic planning.

Of course, Hertz adds, it’s not the only information that goes into the expansion equation, but administrators often respect group leaders who come armed with data from inside and outside the hospital about why it is necessary to make a new hire.

“It’s about open, honest discussion,” he says. “It’s about looking at information both inside the four walls and outside in the community. It’s not easy, but it can be done. But you’ve got to plan.”

Hertz says HM group leaders should plan at least 12 to 18 months out for a hire, “which I know is hard these days,” he says. But, he adds, short-term forecasting makes it “very difficult” to know when and how best to grow your group. TH

Richard Quinn is a freelance writer in New Jersey.

 

Hospitalists aren’t urban planners, but it doesn’t take a zoning expert to realize that when a community sees hundreds of new homes built, some of the residents of those homes will end up in the hospital. The same logic applies when a company moves thousands of jobs to an office building a few blocks away from a hospital.

HM group leaders might not normally think about such things when analyzing whether they need to add staff, but at least one practice consultant says they should.

“If you fail to look outside the building, you will fail,” says Kenneth Hertz, FACMPE, principal of MGMA’s Health Care Consulting Group. “I think the outside metrics are almost more important. You’ve got to stay on top of what’s happening outside in your community, because the people you serve are your market, and if all you do is look within the four walls of the hospital, you will not see what’s coming.”

Hospitals often have community data available, Hertz says, but group leaders don’t always think to access it. He suggests they view the information as a routine part of their strategic planning.

Of course, Hertz adds, it’s not the only information that goes into the expansion equation, but administrators often respect group leaders who come armed with data from inside and outside the hospital about why it is necessary to make a new hire.

“It’s about open, honest discussion,” he says. “It’s about looking at information both inside the four walls and outside in the community. It’s not easy, but it can be done. But you’ve got to plan.”

Hertz says HM group leaders should plan at least 12 to 18 months out for a hire, “which I know is hard these days,” he says. But, he adds, short-term forecasting makes it “very difficult” to know when and how best to grow your group. TH

Richard Quinn is a freelance writer in New Jersey.

 

SHM board member Burke Kealey, MD, SFHM, medical director of hospital specialties at HealthPartners Medical Group in St. Paul, Minn., says there is no easy way to know when it is the right time to grow. He offers four tips to hospitalist group leaders grappling with the question:

• Benchmark: Use the SHM survey, MGMA data, or local analyses to determine best practices. But don’t be a slave to data that don’t account for the particulars of your payor mix, patient population, etc.
• Network: Meet with group leaders in nearby practices. Talk to administrators. Understand the competitive set for your hospital and know what their data sets are.
• Communicate: Talk to doctors, C-suite executives, and everyone in between. Front-line physicians and nurses often know better than practice heads which resources are needed, and where.
• Stay flexible: Don’t be wedded to needing to grow. Maybe a group has physicians who want extra shifts to handle a new schedule. Maybe the installation of new technology will improve efficiency and eliminate the need for a new physician.

SHM board member Burke Kealey, MD, SFHM, medical director of hospital specialties at HealthPartners Medical Group in St. Paul, Minn., says there is no easy way to know when it is the right time to grow. He offers four tips to hospitalist group leaders grappling with the question:

• Benchmark: Use the SHM survey, MGMA data, or local analyses to determine best practices. But don’t be a slave to data that don’t account for the particulars of your payor mix, patient population, etc.
• Network: Meet with group leaders in nearby practices. Talk to administrators. Understand the competitive set for your hospital and know what their data sets are.
• Communicate: Talk to doctors, C-suite executives, and everyone in between. Front-line physicians and nurses often know better than practice heads which resources are needed, and where.
• Stay flexible: Don’t be wedded to needing to grow. Maybe a group has physicians who want extra shifts to handle a new schedule. Maybe the installation of new technology will improve efficiency and eliminate the need for a new physician.

SHM board member Burke Kealey, MD, SFHM, medical director of hospital specialties at HealthPartners Medical Group in St. Paul, Minn., says there is no easy way to know when it is the right time to grow. He offers four tips to hospitalist group leaders grappling with the question:

• Benchmark: Use the SHM survey, MGMA data, or local analyses to determine best practices. But don’t be a slave to data that don’t account for the particulars of your payor mix, patient population, etc.
• Network: Meet with group leaders in nearby practices. Talk to administrators. Understand the competitive set for your hospital and know what their data sets are.
• Communicate: Talk to doctors, C-suite executives, and everyone in between. Front-line physicians and nurses often know better than practice heads which resources are needed, and where.
• Stay flexible: Don’t be wedded to needing to grow. Maybe a group has physicians who want extra shifts to handle a new schedule. Maybe the installation of new technology will improve efficiency and eliminate the need for a new physician.