The Congressional Budget Office in May sharply lowered its projections for the next decade’s outlays on Medicare, Medicaid, and the extension of coverage for 25 million uninsured Americans under the Affordable Care Act.¹

“During the past several years, health-care spending has grown much more slowly, both nationally and for federal programs, than it did historically and more slowly than CBO had projected,” according to the CBO report.

Health-care spending in 2012 was 5% below the amount the nonpartisan budgetary analysts had estimated in a 2010 projection for 2012. If these trends continue, commentators note, that could lessen budgetary pressures and perhaps strengthen the economy, as well as reduce the urgency for Congress to achieve a “grand bargain” confronting national debt issues.

However, CBO notes, budgetary shortfalls are expected to increase later this decade under the pressures of an aging population, expanded federal subsidies for health insurance, and the resumption of health-care cost inflation.

Larry Beresford is a freelance writer in San Francisco.

Reference

1. Congressional Budget Office. Updated budget projections: fiscal years 2013 to 2023. Congressional Budget Office website. Available at: http://www.cbo.gov/publication/ 44172. Accessed June 15, 2013.

The Congressional Budget Office in May sharply lowered its projections for the next decade’s outlays on Medicare, Medicaid, and the extension of coverage for 25 million uninsured Americans under the Affordable Care Act.¹

“During the past several years, health-care spending has grown much more slowly, both nationally and for federal programs, than it did historically and more slowly than CBO had projected,” according to the CBO report.

Health-care spending in 2012 was 5% below the amount the nonpartisan budgetary analysts had estimated in a 2010 projection for 2012. If these trends continue, commentators note, that could lessen budgetary pressures and perhaps strengthen the economy, as well as reduce the urgency for Congress to achieve a “grand bargain” confronting national debt issues.

However, CBO notes, budgetary shortfalls are expected to increase later this decade under the pressures of an aging population, expanded federal subsidies for health insurance, and the resumption of health-care cost inflation.

Larry Beresford is a freelance writer in San Francisco.

Reference

1. Congressional Budget Office. Updated budget projections: fiscal years 2013 to 2023. Congressional Budget Office website. Available at: http://www.cbo.gov/publication/ 44172. Accessed June 15, 2013.

The Congressional Budget Office in May sharply lowered its projections for the next decade’s outlays on Medicare, Medicaid, and the extension of coverage for 25 million uninsured Americans under the Affordable Care Act.¹

“During the past several years, health-care spending has grown much more slowly, both nationally and for federal programs, than it did historically and more slowly than CBO had projected,” according to the CBO report.

Health-care spending in 2012 was 5% below the amount the nonpartisan budgetary analysts had estimated in a 2010 projection for 2012. If these trends continue, commentators note, that could lessen budgetary pressures and perhaps strengthen the economy, as well as reduce the urgency for Congress to achieve a “grand bargain” confronting national debt issues.

However, CBO notes, budgetary shortfalls are expected to increase later this decade under the pressures of an aging population, expanded federal subsidies for health insurance, and the resumption of health-care cost inflation.

Larry Beresford is a freelance writer in San Francisco.

Reference

1. Congressional Budget Office. Updated budget projections: fiscal years 2013 to 2023. Congressional Budget Office website. Available at: http://www.cbo.gov/publication/ 44172. Accessed June 15, 2013.

In June, the Robert Wood Johnson Foundation announced a national competition for technology developers to help consumers understand and utilize data for comparing the prices of hospital procedures. Winners of the foundation’s Hospital Price Transparency Challenge, to be announced later this year, will share $120,000 in prizes for intuitive, actionable tools leading to more transparent hospital pricing in two categories.

One category involves the creation of visual aids that would help consumers and others better understand the Centers for Medicare & Medicaid Services’ (CMS) hospital-cost data, which was released in May and compares widely variable hospital prices for 100 common inpatient procedures. The other category involves developing applications and tools that could help consumers price-shop.

The foundation is offering support and opportunities for submitters to interact with experts and technical innovators. The deadline for applications is Aug. 25.

In June, the Robert Wood Johnson Foundation announced a national competition for technology developers to help consumers understand and utilize data for comparing the prices of hospital procedures. Winners of the foundation’s Hospital Price Transparency Challenge, to be announced later this year, will share $120,000 in prizes for intuitive, actionable tools leading to more transparent hospital pricing in two categories.

One category involves the creation of visual aids that would help consumers and others better understand the Centers for Medicare & Medicaid Services’ (CMS) hospital-cost data, which was released in May and compares widely variable hospital prices for 100 common inpatient procedures. The other category involves developing applications and tools that could help consumers price-shop.

The foundation is offering support and opportunities for submitters to interact with experts and technical innovators. The deadline for applications is Aug. 25.

In June, the Robert Wood Johnson Foundation announced a national competition for technology developers to help consumers understand and utilize data for comparing the prices of hospital procedures. Winners of the foundation’s Hospital Price Transparency Challenge, to be announced later this year, will share $120,000 in prizes for intuitive, actionable tools leading to more transparent hospital pricing in two categories.

One category involves the creation of visual aids that would help consumers and others better understand the Centers for Medicare & Medicaid Services’ (CMS) hospital-cost data, which was released in May and compares widely variable hospital prices for 100 common inpatient procedures. The other category involves developing applications and tools that could help consumers price-shop.

The foundation is offering support and opportunities for submitters to interact with experts and technical innovators. The deadline for applications is Aug. 25.

A Joint Commission Sentinel Event Alert released this spring tackles “alarm fatigue” resulting from the constant beeping of medical-device alarms and information being broadcast from these devices. If not properly managed, the proliferation of alarms can put hospitalized patients at serious risk because the barrage of warning noises can desensitize professional caregivers or distract them from truly critical alarms. U.S. Food and Drug Administration data show that 566 hospital deaths from 2005 to 2008 were alarm-related, while the Joint Commission’s own sentinel-events database lists 80 alarm-related deaths in the same period.

The commission urges hospital leaders to look at this serious patient-safety issue. “By making alarm safety a priority, lives can be saved,” said Ana McKee, MD, the commission’s executive vice president and chief medical officer.

Among its recommendations:

• Ensure that there is a process for safe alarm management and response in high-risk areas;
• Prepare an inventory of alarm-equipped medical devices in these high-risk areas;
• Regularly inspect, check, and maintain the devices; and
• Establish guidelines for alarm settings, including situations in which alarm signals are not clinically necessary.

The commission, which participated in a 2011 summit of national safety and medical-technology organizations seeking solutions to the problem, is considering the possible promulgation of a national patient-safety goal on alarm fatigue, a draft of which was field-tested in February and released for public comment.

Larry Beresford is a freelance writer in San Francisco.

A Joint Commission Sentinel Event Alert released this spring tackles “alarm fatigue” resulting from the constant beeping of medical-device alarms and information being broadcast from these devices. If not properly managed, the proliferation of alarms can put hospitalized patients at serious risk because the barrage of warning noises can desensitize professional caregivers or distract them from truly critical alarms. U.S. Food and Drug Administration data show that 566 hospital deaths from 2005 to 2008 were alarm-related, while the Joint Commission’s own sentinel-events database lists 80 alarm-related deaths in the same period.

The commission urges hospital leaders to look at this serious patient-safety issue. “By making alarm safety a priority, lives can be saved,” said Ana McKee, MD, the commission’s executive vice president and chief medical officer.

Among its recommendations:

• Ensure that there is a process for safe alarm management and response in high-risk areas;
• Prepare an inventory of alarm-equipped medical devices in these high-risk areas;
• Regularly inspect, check, and maintain the devices; and
• Establish guidelines for alarm settings, including situations in which alarm signals are not clinically necessary.

The commission, which participated in a 2011 summit of national safety and medical-technology organizations seeking solutions to the problem, is considering the possible promulgation of a national patient-safety goal on alarm fatigue, a draft of which was field-tested in February and released for public comment.

Larry Beresford is a freelance writer in San Francisco.

A Joint Commission Sentinel Event Alert released this spring tackles “alarm fatigue” resulting from the constant beeping of medical-device alarms and information being broadcast from these devices. If not properly managed, the proliferation of alarms can put hospitalized patients at serious risk because the barrage of warning noises can desensitize professional caregivers or distract them from truly critical alarms. U.S. Food and Drug Administration data show that 566 hospital deaths from 2005 to 2008 were alarm-related, while the Joint Commission’s own sentinel-events database lists 80 alarm-related deaths in the same period.

The commission urges hospital leaders to look at this serious patient-safety issue. “By making alarm safety a priority, lives can be saved,” said Ana McKee, MD, the commission’s executive vice president and chief medical officer.

Among its recommendations:

• Ensure that there is a process for safe alarm management and response in high-risk areas;
• Prepare an inventory of alarm-equipped medical devices in these high-risk areas;
• Regularly inspect, check, and maintain the devices; and
• Establish guidelines for alarm settings, including situations in which alarm signals are not clinically necessary.

The commission, which participated in a 2011 summit of national safety and medical-technology organizations seeking solutions to the problem, is considering the possible promulgation of a national patient-safety goal on alarm fatigue, a draft of which was field-tested in February and released for public comment.

Larry Beresford is a freelance writer in San Francisco.

A common theme among abstracts presented at HM13 was the need for more leadership training, as current and future hospitalists take on bigger roles in their hospitalist groups and institutions.

In an oral abstract presentation at the annual meeting in May in National Harbor, Md., lead author Darlene Tad-y, MD, assistant professor of medicine at the University of Colorado School of Medicine in Aurora, described the Hospitalist Training Program Leaders Track (HTP-LT), which launched in 2012 for hospitalist residents interested in program-level leadership.¹ Dr. Tad-y notes that a generation ago, one-third of hospitals were led by physician CEOs; today, that figure is only 4%, even though quality metrics suggest that clinical outcomes might be better at physician-led facilities.

Faculty at the University of Colorado were inspired to create the program after learning that graduates of its nine-year-old hospitalist residency program were being thrust into clinical, operational, and quality-improvement (QI) leadership positions. Most were forced to learn how to be a leader on the fly.

“That got us thinking: We should be more deliberate about leadership training and the gap around the development of hospitalist leaders,” says co-author Read Pierce, MD, HTP-LT director. “We started asking those in medical leadership positions: How did you learn leadership and what would you teach to residents in the pipeline?”

HTP-LT guides residents through an intensive curriculum offering mentorship and opportunities to observe, practice, and reflect upon clinical leadership in real-world settings. It emphasizes hospital operations, finance, and change management within large, complex organizations. All HTP-LT residents complete a leadership project.

The same faculty also developed the Young Hospitalist Academy, a summer program for medical students from across the country; the goal of the academy is to spur interest in hospital medicine at an earlier stage of medical training.

“We thought it’s never too early for medical students to start thinking about what it means to be a hospitalist and to be a medical leader,” Dr. Tad-y says.

Larry Beresford is a freelance writer in San Francisco.

Reference

1. Tad-y D, Pierce R, Guthrie M, Glasheen J. Developing hospitalist leaders: the Hospitalist Training Program Leaders Track [abstract]. J Hosp Med. 2013;8(Suppl 1):540.

A common theme among abstracts presented at HM13 was the need for more leadership training, as current and future hospitalists take on bigger roles in their hospitalist groups and institutions.

In an oral abstract presentation at the annual meeting in May in National Harbor, Md., lead author Darlene Tad-y, MD, assistant professor of medicine at the University of Colorado School of Medicine in Aurora, described the Hospitalist Training Program Leaders Track (HTP-LT), which launched in 2012 for hospitalist residents interested in program-level leadership.¹ Dr. Tad-y notes that a generation ago, one-third of hospitals were led by physician CEOs; today, that figure is only 4%, even though quality metrics suggest that clinical outcomes might be better at physician-led facilities.

Faculty at the University of Colorado were inspired to create the program after learning that graduates of its nine-year-old hospitalist residency program were being thrust into clinical, operational, and quality-improvement (QI) leadership positions. Most were forced to learn how to be a leader on the fly.

“That got us thinking: We should be more deliberate about leadership training and the gap around the development of hospitalist leaders,” says co-author Read Pierce, MD, HTP-LT director. “We started asking those in medical leadership positions: How did you learn leadership and what would you teach to residents in the pipeline?”

HTP-LT guides residents through an intensive curriculum offering mentorship and opportunities to observe, practice, and reflect upon clinical leadership in real-world settings. It emphasizes hospital operations, finance, and change management within large, complex organizations. All HTP-LT residents complete a leadership project.

The same faculty also developed the Young Hospitalist Academy, a summer program for medical students from across the country; the goal of the academy is to spur interest in hospital medicine at an earlier stage of medical training.

“We thought it’s never too early for medical students to start thinking about what it means to be a hospitalist and to be a medical leader,” Dr. Tad-y says.

Larry Beresford is a freelance writer in San Francisco.

Reference

1. Tad-y D, Pierce R, Guthrie M, Glasheen J. Developing hospitalist leaders: the Hospitalist Training Program Leaders Track [abstract]. J Hosp Med. 2013;8(Suppl 1):540.

A common theme among abstracts presented at HM13 was the need for more leadership training, as current and future hospitalists take on bigger roles in their hospitalist groups and institutions.

In an oral abstract presentation at the annual meeting in May in National Harbor, Md., lead author Darlene Tad-y, MD, assistant professor of medicine at the University of Colorado School of Medicine in Aurora, described the Hospitalist Training Program Leaders Track (HTP-LT), which launched in 2012 for hospitalist residents interested in program-level leadership.¹ Dr. Tad-y notes that a generation ago, one-third of hospitals were led by physician CEOs; today, that figure is only 4%, even though quality metrics suggest that clinical outcomes might be better at physician-led facilities.

Faculty at the University of Colorado were inspired to create the program after learning that graduates of its nine-year-old hospitalist residency program were being thrust into clinical, operational, and quality-improvement (QI) leadership positions. Most were forced to learn how to be a leader on the fly.

“That got us thinking: We should be more deliberate about leadership training and the gap around the development of hospitalist leaders,” says co-author Read Pierce, MD, HTP-LT director. “We started asking those in medical leadership positions: How did you learn leadership and what would you teach to residents in the pipeline?”

HTP-LT guides residents through an intensive curriculum offering mentorship and opportunities to observe, practice, and reflect upon clinical leadership in real-world settings. It emphasizes hospital operations, finance, and change management within large, complex organizations. All HTP-LT residents complete a leadership project.

The same faculty also developed the Young Hospitalist Academy, a summer program for medical students from across the country; the goal of the academy is to spur interest in hospital medicine at an earlier stage of medical training.

“We thought it’s never too early for medical students to start thinking about what it means to be a hospitalist and to be a medical leader,” Dr. Tad-y says.

Larry Beresford is a freelance writer in San Francisco.

Reference

1. Tad-y D, Pierce R, Guthrie M, Glasheen J. Developing hospitalist leaders: the Hospitalist Training Program Leaders Track [abstract]. J Hosp Med. 2013;8(Suppl 1):540.

Bryan Weiss, MBA, likes to say he’s “passionate” about HM. The twist? He isn’t even a practicing physician. Nevertheless, he’s been involved in medicine for 25 years, having worked with hospitals, health plans, and multispecialty groups before joining IPC: The Hospitalist Company in 2003. During his first few years working in the field, he realized the specialty had a bright future.

“I enjoy working with the hospitalists and assisting them to become the cornerstone of the hospitals they work in,” says Weiss, managing director of the consulting services practice at Irving, Texas-based MedSynergies. “Creating the open communications among the hospital administration, emergency room, nursing, case management, consultants, and PCPs—as well as moving the specialty forward with actionable, balanced scorecards—is the most satisfying component.”

Weiss previously was president of the hospitalist division at Hospital Physician Partners of Hollywood, Fla., and COO of inpatient services at Dallas-based EmCare. He graduated with a bachelor’s degree in business administration from California State University and earned his master’s degree from California Lutheran University.

He is one of nine new Team Hospitalist members, The Hospitalist’s volunteer group of editorial advisors. He sees challenges ahead for hospitalists, administrators, and the health-care system, but he also has faith the specialty will be up to the task.

“I think the incredibly rapid growth of the specialty is huge,” he says. “The acceptance of the specialty has gone from needing to explain what a hospitalist is to insurance companies and hospitals and other physicians to [knowing] the value of a hospitalist program and how disadvantaged a hospital is without a program.”

I want to make sure the hospitalist team truly operates as a team and not a bunch of physicians who happen to work in the same hospital. The bottom line is it is about the patient experience and how hospitalists will be pivotal as health care moves to more risk-based and population health.

Question: As a nonphysician, explain your role in the health-care system and HM.

Answer: I want to make sure the hospitalist team truly operates as a team and not a bunch of physicians who happen to work in the same hospital. The bottom line is it is about the patient experience and how hospitalists will be pivotal as health care moves to more risk-based and population health.

Q: What is your biggest professional challenge?

A: Ensuring the alignment of the goals of the hospital and the hospitalists are translated to measurable outcomes is probably the biggest challenge in the current state of health care.

Q: What is your biggest professional reward?

A: The number of hospital administrators who value my contribution and commitment to making the hospitalist program at their facilities the best they can become.

Q: When you aren’t working, what is important to you?

A: My family time and the balance of work and life have become the most important as I have matured professionally.

Q: What’s next professionally?

A: I am doing my ideal professional position.

Q: If you had to do it all over again, what career would you be doing right now?

A: If I wasn’t an executive in healthcare, I would have probably been a lawyer since I contemplated law school over my MBA.

Q: What’s the best book you’ve read recently?

A: New Orleans Saints quarterback Drew Brees’ book, “Coming Back Stronger.” As an avid sports fan, I appreciate what this athlete experienced personally and professionally, and still was able to pick himself back up from situations that many of us would have struggled to overcome. He is one of the biggest class acts in sports and the book just solidified that opinion. We can apply what he says to our own lives and make ourselves better in what we do as leaders.

Q: How many Apple products (phones, iPods, tablets, iTunes, etc.) do you interface with in a given week?

A: I am constantly on my iPad and use iTunes regularly during my weekly travels. My cellphone is an Android, so only two Apple products, but I use Apple countless times a week.

Richard Quinn is a freelance author in New Jersey.

Bryan Weiss, MBA, likes to say he’s “passionate” about HM. The twist? He isn’t even a practicing physician. Nevertheless, he’s been involved in medicine for 25 years, having worked with hospitals, health plans, and multispecialty groups before joining IPC: The Hospitalist Company in 2003. During his first few years working in the field, he realized the specialty had a bright future.

“I enjoy working with the hospitalists and assisting them to become the cornerstone of the hospitals they work in,” says Weiss, managing director of the consulting services practice at Irving, Texas-based MedSynergies. “Creating the open communications among the hospital administration, emergency room, nursing, case management, consultants, and PCPs—as well as moving the specialty forward with actionable, balanced scorecards—is the most satisfying component.”

Weiss previously was president of the hospitalist division at Hospital Physician Partners of Hollywood, Fla., and COO of inpatient services at Dallas-based EmCare. He graduated with a bachelor’s degree in business administration from California State University and earned his master’s degree from California Lutheran University.

He is one of nine new Team Hospitalist members, The Hospitalist’s volunteer group of editorial advisors. He sees challenges ahead for hospitalists, administrators, and the health-care system, but he also has faith the specialty will be up to the task.

“I think the incredibly rapid growth of the specialty is huge,” he says. “The acceptance of the specialty has gone from needing to explain what a hospitalist is to insurance companies and hospitals and other physicians to [knowing] the value of a hospitalist program and how disadvantaged a hospital is without a program.”

I want to make sure the hospitalist team truly operates as a team and not a bunch of physicians who happen to work in the same hospital. The bottom line is it is about the patient experience and how hospitalists will be pivotal as health care moves to more risk-based and population health.

Question: As a nonphysician, explain your role in the health-care system and HM.

Answer: I want to make sure the hospitalist team truly operates as a team and not a bunch of physicians who happen to work in the same hospital. The bottom line is it is about the patient experience and how hospitalists will be pivotal as health care moves to more risk-based and population health.

Q: What is your biggest professional challenge?

A: Ensuring the alignment of the goals of the hospital and the hospitalists are translated to measurable outcomes is probably the biggest challenge in the current state of health care.

Q: What is your biggest professional reward?

A: The number of hospital administrators who value my contribution and commitment to making the hospitalist program at their facilities the best they can become.

Q: When you aren’t working, what is important to you?

A: My family time and the balance of work and life have become the most important as I have matured professionally.

Q: What’s next professionally?

A: I am doing my ideal professional position.

Q: If you had to do it all over again, what career would you be doing right now?

A: If I wasn’t an executive in healthcare, I would have probably been a lawyer since I contemplated law school over my MBA.

Q: What’s the best book you’ve read recently?

A: New Orleans Saints quarterback Drew Brees’ book, “Coming Back Stronger.” As an avid sports fan, I appreciate what this athlete experienced personally and professionally, and still was able to pick himself back up from situations that many of us would have struggled to overcome. He is one of the biggest class acts in sports and the book just solidified that opinion. We can apply what he says to our own lives and make ourselves better in what we do as leaders.

Q: How many Apple products (phones, iPods, tablets, iTunes, etc.) do you interface with in a given week?

A: I am constantly on my iPad and use iTunes regularly during my weekly travels. My cellphone is an Android, so only two Apple products, but I use Apple countless times a week.

Richard Quinn is a freelance author in New Jersey.

Bryan Weiss, MBA, likes to say he’s “passionate” about HM. The twist? He isn’t even a practicing physician. Nevertheless, he’s been involved in medicine for 25 years, having worked with hospitals, health plans, and multispecialty groups before joining IPC: The Hospitalist Company in 2003. During his first few years working in the field, he realized the specialty had a bright future.

“I enjoy working with the hospitalists and assisting them to become the cornerstone of the hospitals they work in,” says Weiss, managing director of the consulting services practice at Irving, Texas-based MedSynergies. “Creating the open communications among the hospital administration, emergency room, nursing, case management, consultants, and PCPs—as well as moving the specialty forward with actionable, balanced scorecards—is the most satisfying component.”

Weiss previously was president of the hospitalist division at Hospital Physician Partners of Hollywood, Fla., and COO of inpatient services at Dallas-based EmCare. He graduated with a bachelor’s degree in business administration from California State University and earned his master’s degree from California Lutheran University.

He is one of nine new Team Hospitalist members, The Hospitalist’s volunteer group of editorial advisors. He sees challenges ahead for hospitalists, administrators, and the health-care system, but he also has faith the specialty will be up to the task.

“I think the incredibly rapid growth of the specialty is huge,” he says. “The acceptance of the specialty has gone from needing to explain what a hospitalist is to insurance companies and hospitals and other physicians to [knowing] the value of a hospitalist program and how disadvantaged a hospital is without a program.”

I want to make sure the hospitalist team truly operates as a team and not a bunch of physicians who happen to work in the same hospital. The bottom line is it is about the patient experience and how hospitalists will be pivotal as health care moves to more risk-based and population health.

Question: As a nonphysician, explain your role in the health-care system and HM.

Answer: I want to make sure the hospitalist team truly operates as a team and not a bunch of physicians who happen to work in the same hospital. The bottom line is it is about the patient experience and how hospitalists will be pivotal as health care moves to more risk-based and population health.

Q: What is your biggest professional challenge?

A: Ensuring the alignment of the goals of the hospital and the hospitalists are translated to measurable outcomes is probably the biggest challenge in the current state of health care.

Q: What is your biggest professional reward?

A: The number of hospital administrators who value my contribution and commitment to making the hospitalist program at their facilities the best they can become.

Q: When you aren’t working, what is important to you?

A: My family time and the balance of work and life have become the most important as I have matured professionally.

Q: What’s next professionally?

A: I am doing my ideal professional position.

Q: If you had to do it all over again, what career would you be doing right now?

A: If I wasn’t an executive in healthcare, I would have probably been a lawyer since I contemplated law school over my MBA.

Q: What’s the best book you’ve read recently?

A: New Orleans Saints quarterback Drew Brees’ book, “Coming Back Stronger.” As an avid sports fan, I appreciate what this athlete experienced personally and professionally, and still was able to pick himself back up from situations that many of us would have struggled to overcome. He is one of the biggest class acts in sports and the book just solidified that opinion. We can apply what he says to our own lives and make ourselves better in what we do as leaders.

Q: How many Apple products (phones, iPods, tablets, iTunes, etc.) do you interface with in a given week?

A: I am constantly on my iPad and use iTunes regularly during my weekly travels. My cellphone is an Android, so only two Apple products, but I use Apple countless times a week.

Richard Quinn is a freelance author in New Jersey.

The government has made extensive efforts to combat fraud in the Medicare and Medicaid programs, recovering a record $4.2 billion in fiscal 2012 from individuals and companies trying to cheat the system. One of the largest sources of recovered monies is the Recovery Audit Contractor (RAC) program.

The RAC program was created through the Medicare Modernization Act of 2003 (MMA) to identify and recover improper Medicare payments to health-care providers under fee-for-service (FFS) Medicare plans. The goal of the RAC program is to identify improper payments made on claims of health-care services provided to Medicare beneficiaries. Improper payments could be overpayments or underpayments. Hospitals have been hit by the audits, with recoveries reaching $3.6 billion since the national program launched in 2010, according to Centers for Medicare & Medicaid Services (CMS) data.¹ About $895 million was reclaimed from just six states during the RAC Demonstration Project between 2005 and 2008.^1,2

CMS is more alert on the medical necessity of one-day length of stay (LOS) for inpatient admissions and is trying to detect and reduce Medicare waste, fraud, and abuse. Hospital charges represent about a third of the $718 billion spent on U.S. health care annually. Medicare reimbursement is a major source of revenue for hospitals, but some hospitals claim Medicare pays them only 93% to 97% of what it costs to provide patient care, whereas private insurers pay between 115% and 125% of those costs.^3,4 These data suggest that private insurers are paying hospitals far more than they need to make up for Medicare’s “underpayment.”

So the first question is: Do hospitals overcharge for care? The next question is: What can be done? Or, in today’s economy, what is being done?

How It All Works

When an RAC determines that a provider was paid for inpatient hospital services but that the patient in question should have been treated as an outpatient, CMS takes back the entire Part A payment. Moreover, CMS takes the position that once an inpatient claim paid under Medicare Part A is later denied (usually years later), the hospital cannot receive Medicare Part B payment except for a few ancillary services. As a result, when an RAC concludes that a hospital should have provided items and services on an outpatient basis rather than an inpatient basis, the hospital ends up receiving little, if any, reimbursement for reasonable and medically necessary items and services provided.^5,6

RACs function through a different model. They keep a contingency percentage—9% to 12.5%—of the entire Part A payment.⁵

Imagine a situation in which a physician decides that a patient needs to be admitted to the hospital for a surgical procedure, and the cost of care provided to the patient—surgery, drugs, and the like—amounts to $20,000. CMS reimburses the hospital under Part A. Two years later, an RAC employee reviewing hospital records overrules the physician’s judgment and decides the patient should have received basically the same care but on an outpatient basis. That decision, taken together with CMS’ Payment Denial Policy, means the hospital will end up receiving essentially no payment for the surgery and other care it provided. The RAC, by contrast, will receive approximately $2,000 for that one case alone.

To Admit or Not to Admit

Medicare expects attending physicians and physician reviewers to make the appropriate bedding status based on severity of signs and symptoms, comorbid and complicating conditions, and the practicality of outpatient management.

Let’s take two examples of patients presenting with acute asthma exacerbation (AAE) to differentiate observation and inpatient status. Asthma affects 20 million Americans, and 450,000 patients present to the ED annually with AAE. One third of these patients are hospitalized, which translates to more than $1 billion in costs annually.

Case 1: A 62-year-old female presents with two weeks of progressive shortness of breath and cough productive of white sputum. She has a history of asthma and hypertension. She presented to the ED with blood pressure of 140/90, heart rate of 101, respiratory rate of 20, temperature of 99.6°F, and pulse oximetry of 93% on room air, which increased to 99% on 2L of oxygen. She was given two breathing treatments with albuterol in the ED, IV methylprednisolone, and IV magnesium sulphate. Over the course of two hours, her wheezes improved, her heart rate decreased to 90 BPM, and her oxygen requirements were weaned to 1L of oxygen. Her WBC count was 9,800, with a potassium level of 4.0 and a creatinine level of 1.0. Her EKG showed sinus tachycardia, and her chest X-ray was negative for any infiltrates. The ED physician called the hospitalist for admission. What status should she be in?

Case 2: A 62-year-old female presents with a three-day history of shortness of breath and wheezing associated with vomiting. She was sent from her PCP’s office for asthma exacerbation and failure of resolution of symptoms despite one week of oral antibiotics and prednisone. Her past medical history includes asthma, diastolic congestive heart failure, hypertension, diabetes, and end-stage renal disease on hemodialysis. She presented to the ED with blood pressure of 90/63, pulse of 120, temperature of 97.7°F, respiratory rate of 24, and pulse oximetry of 89% on room air. She had bilateral wheezes on respiratory examination, and her WBC was 16,500, with a creatinine level of 3.5 and BNP level of 190. Her chest X-ray showed peribronchial thickening, and an EKG showed sinus tachycardia. She was given IV Solu-Medrol and two breathing treatments with albuterol, and the hospitalist was called for admission. What status should she be in?

Case 1 answer: Observation. The medical predictability of adverse clinical outcome from AAE is low due to hemodynamic stability, absence of fever, improvement in hypoxia, and negative chest X-ray for acute bronchopulmonary process in the setting of normal blood counts. She improved dramatically in the ED with no history of previous intubation or hospitalization or use of previous steroids. Her oxygen requirements decreased within 12 hours of first treatment. Even though FEV1 was not monitored, there is documented improvement in her vital signs as well as respiratory examination.

Case 2 answer: Inpatient. The medical predictability of adverse clinical outcome is significant due to hemodynamic instability evidenced by hypotension, tachycardia, and hypoxia; wheezes on respiratory examination with leukocytosis; and abnormal chest X-ray in the setting of comorbid diseases, such as end-stage renal disease and congestive heart failure.

The treatments given to both patients were similar; however, Case 2 had a higher predictability of adverse clinical outcome and would require medical evaluation and management that would exceed 24 hours. An inpatient level of care is justified based on her clinical presentation, comorbidities, and the risk for adverse clinical outcomes.

It is important that the patient be described appropriately in the medical record to support the status. Documentation should include clinical decision-making and rationale of the attending, objective findings, and the treatment given in the ED as well as the treatment planned during the hospitalization. It is expected that the physician will document the possibility and probability of adverse clinical outcome as well as follow evidence-based guidelines for treatment.

Financial Facts

The AHA collects data and anecdotal evidence from member hospitals regarding the RAC program and its effects. Those data show the following:

• More than 95% of the general medical-surgical hospitals that provided information to the AHA have been targeted by RACs;
• RACs have demanded more than a half-million medical records to audit;
• Many audits result in RAC determinations of “overpayment”; and
• Of those overpayment determinations, more than 60% relate to one- or two-day inpatient admissions that RACs deem medically unnecessary.

Hospitals thus have been required to give back hundreds of millions of dollars per year due to RAC determinations that services should have been provided in an outpatient, rather than inpatient, setting. In the first quarter of 2012 alone, information provided to the AHA by hospitals shows that they were forced to repay $236 million for medically necessary items and services that RACs deemed should have been provided on an outpatient, rather than inpatient, basis. And this amount does not include the millions of dollars recovered from hospitals that did not report data to the AHA.

The RAC program has been a continued financial success for CMS and the auditors: RACs collected $1.86 billion in overpayments from October 2009 through March 2012. Over that same time period, RACs identified only $245.2 million in underpayments.⁷

The government, no doubt, is on a mission to rein in health-care costs. All stakeholders in the system, including hospitalists and administrations, need extensive education to document appropriate patient status to ensure accurate reimbursement and prevent the fallout of future repayments.

Dr. Pahuja is founder and CEO of Aerolib Healthcare Solutions (aerolib.com). He is pursuing his MBA in health-care administration from the Isenberg School of Management at the University of Massachusetts in Amherst.

References

1. PR Web. Medicare anti-fraud recovered $19 billion, how much for private self-insured plans? Fiduciary overpayment recovery programs announced from ERISAclaim.com. PR Web website. Available at: http://www.prweb.com/releases/2013/3/prweb10501376.htm. Accessed April 4, 2013.
2. Viebeck E. GAO reports billions in overpayments to private Medicare plans. The Hill website. Available at: http://thehill.com/blogs/healthwatch/medicare/286041-gao-reports-billions-in-overpayments-to-private-medicare-plans#ixzz2NASaVVIK. Accessed April 4, 2013.
3. Centers for Medicare & Medicare Services. Cost reports. Centers for Medicare & Medicare Services website. Available at: http://www.cms.gov/Research-Statistics-Data-and-Systems/Files-for-Order/CostReports/index.html. Accessed April 4, 2013.
4. Whelan D. America’s most profitable hospitals. Forbes website. Available at: http://www.forbes.com/2010/08/30/profitable-hospitals-hca-healthcare-business-mayo-clinic.html. Accessed April 4, 2013.
5. American Medical Association. Recovery Audit Contractors. American Medical Association website. Available at: http://www.ama-assn.org/ama/pub/physician-resources/solutions-managing-your-practice/coding-billing-insurance/medicare/recovery-audit-contractors.page. Accessed April 4, 2013.
6. American Hospital Association, Missouri Baptist Sullivan Hospital, Munson Medical Center, Lancaster General Hospital, and Trinity Health Corporation v. Kathleen Sebelius. American Hospital Association website. Available at: http://www.aha.org/content/12/121101-aha-hhs-medicare-com.pdf. Accessed March 12, 2013.
7. Centers for Medicare & Medicare Services. Medicare fee-for-service Recovery Audit Program, May 2012. Centers for Medicare & Medicare Services website. Available at: http://www.cms.gov/Research-Statistics-Data-and-Systems/Monitoring-Programs/Recovery-Audit-Program/Downloads/National-Program-Corrections-FY-2012-2nd-Qtr.pdf. Accessed April 4, 2013.
8. Centers for Medicare & Medicaid Services. FY 2014 IPPS proposed rule home page items. Centers for Medicare & Medicaid Services website. Available at: http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/AcuteInpatientPPS/FY-2014-IPPS-Proposed-Rule-Home-Page-Items/FY-2014-IPPS-Proposed-Rule-CMS-1599-P-Regulations.html. Accessed June 10, 2013.

The government has made extensive efforts to combat fraud in the Medicare and Medicaid programs, recovering a record $4.2 billion in fiscal 2012 from individuals and companies trying to cheat the system. One of the largest sources of recovered monies is the Recovery Audit Contractor (RAC) program.

The RAC program was created through the Medicare Modernization Act of 2003 (MMA) to identify and recover improper Medicare payments to health-care providers under fee-for-service (FFS) Medicare plans. The goal of the RAC program is to identify improper payments made on claims of health-care services provided to Medicare beneficiaries. Improper payments could be overpayments or underpayments. Hospitals have been hit by the audits, with recoveries reaching $3.6 billion since the national program launched in 2010, according to Centers for Medicare & Medicaid Services (CMS) data.¹ About $895 million was reclaimed from just six states during the RAC Demonstration Project between 2005 and 2008.^1,2

CMS is more alert on the medical necessity of one-day length of stay (LOS) for inpatient admissions and is trying to detect and reduce Medicare waste, fraud, and abuse. Hospital charges represent about a third of the $718 billion spent on U.S. health care annually. Medicare reimbursement is a major source of revenue for hospitals, but some hospitals claim Medicare pays them only 93% to 97% of what it costs to provide patient care, whereas private insurers pay between 115% and 125% of those costs.^3,4 These data suggest that private insurers are paying hospitals far more than they need to make up for Medicare’s “underpayment.”

So the first question is: Do hospitals overcharge for care? The next question is: What can be done? Or, in today’s economy, what is being done?

How It All Works

When an RAC determines that a provider was paid for inpatient hospital services but that the patient in question should have been treated as an outpatient, CMS takes back the entire Part A payment. Moreover, CMS takes the position that once an inpatient claim paid under Medicare Part A is later denied (usually years later), the hospital cannot receive Medicare Part B payment except for a few ancillary services. As a result, when an RAC concludes that a hospital should have provided items and services on an outpatient basis rather than an inpatient basis, the hospital ends up receiving little, if any, reimbursement for reasonable and medically necessary items and services provided.^5,6

RACs function through a different model. They keep a contingency percentage—9% to 12.5%—of the entire Part A payment.⁵

Imagine a situation in which a physician decides that a patient needs to be admitted to the hospital for a surgical procedure, and the cost of care provided to the patient—surgery, drugs, and the like—amounts to $20,000. CMS reimburses the hospital under Part A. Two years later, an RAC employee reviewing hospital records overrules the physician’s judgment and decides the patient should have received basically the same care but on an outpatient basis. That decision, taken together with CMS’ Payment Denial Policy, means the hospital will end up receiving essentially no payment for the surgery and other care it provided. The RAC, by contrast, will receive approximately $2,000 for that one case alone.

To Admit or Not to Admit

Medicare expects attending physicians and physician reviewers to make the appropriate bedding status based on severity of signs and symptoms, comorbid and complicating conditions, and the practicality of outpatient management.

Let’s take two examples of patients presenting with acute asthma exacerbation (AAE) to differentiate observation and inpatient status. Asthma affects 20 million Americans, and 450,000 patients present to the ED annually with AAE. One third of these patients are hospitalized, which translates to more than $1 billion in costs annually.

Case 1: A 62-year-old female presents with two weeks of progressive shortness of breath and cough productive of white sputum. She has a history of asthma and hypertension. She presented to the ED with blood pressure of 140/90, heart rate of 101, respiratory rate of 20, temperature of 99.6°F, and pulse oximetry of 93% on room air, which increased to 99% on 2L of oxygen. She was given two breathing treatments with albuterol in the ED, IV methylprednisolone, and IV magnesium sulphate. Over the course of two hours, her wheezes improved, her heart rate decreased to 90 BPM, and her oxygen requirements were weaned to 1L of oxygen. Her WBC count was 9,800, with a potassium level of 4.0 and a creatinine level of 1.0. Her EKG showed sinus tachycardia, and her chest X-ray was negative for any infiltrates. The ED physician called the hospitalist for admission. What status should she be in?

Case 2: A 62-year-old female presents with a three-day history of shortness of breath and wheezing associated with vomiting. She was sent from her PCP’s office for asthma exacerbation and failure of resolution of symptoms despite one week of oral antibiotics and prednisone. Her past medical history includes asthma, diastolic congestive heart failure, hypertension, diabetes, and end-stage renal disease on hemodialysis. She presented to the ED with blood pressure of 90/63, pulse of 120, temperature of 97.7°F, respiratory rate of 24, and pulse oximetry of 89% on room air. She had bilateral wheezes on respiratory examination, and her WBC was 16,500, with a creatinine level of 3.5 and BNP level of 190. Her chest X-ray showed peribronchial thickening, and an EKG showed sinus tachycardia. She was given IV Solu-Medrol and two breathing treatments with albuterol, and the hospitalist was called for admission. What status should she be in?

Case 1 answer: Observation. The medical predictability of adverse clinical outcome from AAE is low due to hemodynamic stability, absence of fever, improvement in hypoxia, and negative chest X-ray for acute bronchopulmonary process in the setting of normal blood counts. She improved dramatically in the ED with no history of previous intubation or hospitalization or use of previous steroids. Her oxygen requirements decreased within 12 hours of first treatment. Even though FEV1 was not monitored, there is documented improvement in her vital signs as well as respiratory examination.

Case 2 answer: Inpatient. The medical predictability of adverse clinical outcome is significant due to hemodynamic instability evidenced by hypotension, tachycardia, and hypoxia; wheezes on respiratory examination with leukocytosis; and abnormal chest X-ray in the setting of comorbid diseases, such as end-stage renal disease and congestive heart failure.

The treatments given to both patients were similar; however, Case 2 had a higher predictability of adverse clinical outcome and would require medical evaluation and management that would exceed 24 hours. An inpatient level of care is justified based on her clinical presentation, comorbidities, and the risk for adverse clinical outcomes.

It is important that the patient be described appropriately in the medical record to support the status. Documentation should include clinical decision-making and rationale of the attending, objective findings, and the treatment given in the ED as well as the treatment planned during the hospitalization. It is expected that the physician will document the possibility and probability of adverse clinical outcome as well as follow evidence-based guidelines for treatment.

Financial Facts

The AHA collects data and anecdotal evidence from member hospitals regarding the RAC program and its effects. Those data show the following:

• More than 95% of the general medical-surgical hospitals that provided information to the AHA have been targeted by RACs;
• RACs have demanded more than a half-million medical records to audit;
• Many audits result in RAC determinations of “overpayment”; and
• Of those overpayment determinations, more than 60% relate to one- or two-day inpatient admissions that RACs deem medically unnecessary.

Hospitals thus have been required to give back hundreds of millions of dollars per year due to RAC determinations that services should have been provided in an outpatient, rather than inpatient, setting. In the first quarter of 2012 alone, information provided to the AHA by hospitals shows that they were forced to repay $236 million for medically necessary items and services that RACs deemed should have been provided on an outpatient, rather than inpatient, basis. And this amount does not include the millions of dollars recovered from hospitals that did not report data to the AHA.

The RAC program has been a continued financial success for CMS and the auditors: RACs collected $1.86 billion in overpayments from October 2009 through March 2012. Over that same time period, RACs identified only $245.2 million in underpayments.⁷

The government, no doubt, is on a mission to rein in health-care costs. All stakeholders in the system, including hospitalists and administrations, need extensive education to document appropriate patient status to ensure accurate reimbursement and prevent the fallout of future repayments.

Dr. Pahuja is founder and CEO of Aerolib Healthcare Solutions (aerolib.com). He is pursuing his MBA in health-care administration from the Isenberg School of Management at the University of Massachusetts in Amherst.

References

1. PR Web. Medicare anti-fraud recovered $19 billion, how much for private self-insured plans? Fiduciary overpayment recovery programs announced from ERISAclaim.com. PR Web website. Available at: http://www.prweb.com/releases/2013/3/prweb10501376.htm. Accessed April 4, 2013.
2. Viebeck E. GAO reports billions in overpayments to private Medicare plans. The Hill website. Available at: http://thehill.com/blogs/healthwatch/medicare/286041-gao-reports-billions-in-overpayments-to-private-medicare-plans#ixzz2NASaVVIK. Accessed April 4, 2013.
3. Centers for Medicare & Medicare Services. Cost reports. Centers for Medicare & Medicare Services website. Available at: http://www.cms.gov/Research-Statistics-Data-and-Systems/Files-for-Order/CostReports/index.html. Accessed April 4, 2013.
4. Whelan D. America’s most profitable hospitals. Forbes website. Available at: http://www.forbes.com/2010/08/30/profitable-hospitals-hca-healthcare-business-mayo-clinic.html. Accessed April 4, 2013.
5. American Medical Association. Recovery Audit Contractors. American Medical Association website. Available at: http://www.ama-assn.org/ama/pub/physician-resources/solutions-managing-your-practice/coding-billing-insurance/medicare/recovery-audit-contractors.page. Accessed April 4, 2013.
6. American Hospital Association, Missouri Baptist Sullivan Hospital, Munson Medical Center, Lancaster General Hospital, and Trinity Health Corporation v. Kathleen Sebelius. American Hospital Association website. Available at: http://www.aha.org/content/12/121101-aha-hhs-medicare-com.pdf. Accessed March 12, 2013.
7. Centers for Medicare & Medicare Services. Medicare fee-for-service Recovery Audit Program, May 2012. Centers for Medicare & Medicare Services website. Available at: http://www.cms.gov/Research-Statistics-Data-and-Systems/Monitoring-Programs/Recovery-Audit-Program/Downloads/National-Program-Corrections-FY-2012-2nd-Qtr.pdf. Accessed April 4, 2013.
8. Centers for Medicare & Medicaid Services. FY 2014 IPPS proposed rule home page items. Centers for Medicare & Medicaid Services website. Available at: http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/AcuteInpatientPPS/FY-2014-IPPS-Proposed-Rule-Home-Page-Items/FY-2014-IPPS-Proposed-Rule-CMS-1599-P-Regulations.html. Accessed June 10, 2013.

The government has made extensive efforts to combat fraud in the Medicare and Medicaid programs, recovering a record $4.2 billion in fiscal 2012 from individuals and companies trying to cheat the system. One of the largest sources of recovered monies is the Recovery Audit Contractor (RAC) program.

The RAC program was created through the Medicare Modernization Act of 2003 (MMA) to identify and recover improper Medicare payments to health-care providers under fee-for-service (FFS) Medicare plans. The goal of the RAC program is to identify improper payments made on claims of health-care services provided to Medicare beneficiaries. Improper payments could be overpayments or underpayments. Hospitals have been hit by the audits, with recoveries reaching $3.6 billion since the national program launched in 2010, according to Centers for Medicare & Medicaid Services (CMS) data.¹ About $895 million was reclaimed from just six states during the RAC Demonstration Project between 2005 and 2008.^1,2

CMS is more alert on the medical necessity of one-day length of stay (LOS) for inpatient admissions and is trying to detect and reduce Medicare waste, fraud, and abuse. Hospital charges represent about a third of the $718 billion spent on U.S. health care annually. Medicare reimbursement is a major source of revenue for hospitals, but some hospitals claim Medicare pays them only 93% to 97% of what it costs to provide patient care, whereas private insurers pay between 115% and 125% of those costs.^3,4 These data suggest that private insurers are paying hospitals far more than they need to make up for Medicare’s “underpayment.”

So the first question is: Do hospitals overcharge for care? The next question is: What can be done? Or, in today’s economy, what is being done?

How It All Works

When an RAC determines that a provider was paid for inpatient hospital services but that the patient in question should have been treated as an outpatient, CMS takes back the entire Part A payment. Moreover, CMS takes the position that once an inpatient claim paid under Medicare Part A is later denied (usually years later), the hospital cannot receive Medicare Part B payment except for a few ancillary services. As a result, when an RAC concludes that a hospital should have provided items and services on an outpatient basis rather than an inpatient basis, the hospital ends up receiving little, if any, reimbursement for reasonable and medically necessary items and services provided.^5,6

RACs function through a different model. They keep a contingency percentage—9% to 12.5%—of the entire Part A payment.⁵

Imagine a situation in which a physician decides that a patient needs to be admitted to the hospital for a surgical procedure, and the cost of care provided to the patient—surgery, drugs, and the like—amounts to $20,000. CMS reimburses the hospital under Part A. Two years later, an RAC employee reviewing hospital records overrules the physician’s judgment and decides the patient should have received basically the same care but on an outpatient basis. That decision, taken together with CMS’ Payment Denial Policy, means the hospital will end up receiving essentially no payment for the surgery and other care it provided. The RAC, by contrast, will receive approximately $2,000 for that one case alone.

To Admit or Not to Admit

Medicare expects attending physicians and physician reviewers to make the appropriate bedding status based on severity of signs and symptoms, comorbid and complicating conditions, and the practicality of outpatient management.

Let’s take two examples of patients presenting with acute asthma exacerbation (AAE) to differentiate observation and inpatient status. Asthma affects 20 million Americans, and 450,000 patients present to the ED annually with AAE. One third of these patients are hospitalized, which translates to more than $1 billion in costs annually.

Case 1: A 62-year-old female presents with two weeks of progressive shortness of breath and cough productive of white sputum. She has a history of asthma and hypertension. She presented to the ED with blood pressure of 140/90, heart rate of 101, respiratory rate of 20, temperature of 99.6°F, and pulse oximetry of 93% on room air, which increased to 99% on 2L of oxygen. She was given two breathing treatments with albuterol in the ED, IV methylprednisolone, and IV magnesium sulphate. Over the course of two hours, her wheezes improved, her heart rate decreased to 90 BPM, and her oxygen requirements were weaned to 1L of oxygen. Her WBC count was 9,800, with a potassium level of 4.0 and a creatinine level of 1.0. Her EKG showed sinus tachycardia, and her chest X-ray was negative for any infiltrates. The ED physician called the hospitalist for admission. What status should she be in?

Case 2: A 62-year-old female presents with a three-day history of shortness of breath and wheezing associated with vomiting. She was sent from her PCP’s office for asthma exacerbation and failure of resolution of symptoms despite one week of oral antibiotics and prednisone. Her past medical history includes asthma, diastolic congestive heart failure, hypertension, diabetes, and end-stage renal disease on hemodialysis. She presented to the ED with blood pressure of 90/63, pulse of 120, temperature of 97.7°F, respiratory rate of 24, and pulse oximetry of 89% on room air. She had bilateral wheezes on respiratory examination, and her WBC was 16,500, with a creatinine level of 3.5 and BNP level of 190. Her chest X-ray showed peribronchial thickening, and an EKG showed sinus tachycardia. She was given IV Solu-Medrol and two breathing treatments with albuterol, and the hospitalist was called for admission. What status should she be in?

Case 1 answer: Observation. The medical predictability of adverse clinical outcome from AAE is low due to hemodynamic stability, absence of fever, improvement in hypoxia, and negative chest X-ray for acute bronchopulmonary process in the setting of normal blood counts. She improved dramatically in the ED with no history of previous intubation or hospitalization or use of previous steroids. Her oxygen requirements decreased within 12 hours of first treatment. Even though FEV1 was not monitored, there is documented improvement in her vital signs as well as respiratory examination.

Case 2 answer: Inpatient. The medical predictability of adverse clinical outcome is significant due to hemodynamic instability evidenced by hypotension, tachycardia, and hypoxia; wheezes on respiratory examination with leukocytosis; and abnormal chest X-ray in the setting of comorbid diseases, such as end-stage renal disease and congestive heart failure.

The treatments given to both patients were similar; however, Case 2 had a higher predictability of adverse clinical outcome and would require medical evaluation and management that would exceed 24 hours. An inpatient level of care is justified based on her clinical presentation, comorbidities, and the risk for adverse clinical outcomes.

It is important that the patient be described appropriately in the medical record to support the status. Documentation should include clinical decision-making and rationale of the attending, objective findings, and the treatment given in the ED as well as the treatment planned during the hospitalization. It is expected that the physician will document the possibility and probability of adverse clinical outcome as well as follow evidence-based guidelines for treatment.

Financial Facts

The AHA collects data and anecdotal evidence from member hospitals regarding the RAC program and its effects. Those data show the following:

• More than 95% of the general medical-surgical hospitals that provided information to the AHA have been targeted by RACs;
• RACs have demanded more than a half-million medical records to audit;
• Many audits result in RAC determinations of “overpayment”; and
• Of those overpayment determinations, more than 60% relate to one- or two-day inpatient admissions that RACs deem medically unnecessary.

Hospitals thus have been required to give back hundreds of millions of dollars per year due to RAC determinations that services should have been provided in an outpatient, rather than inpatient, setting. In the first quarter of 2012 alone, information provided to the AHA by hospitals shows that they were forced to repay $236 million for medically necessary items and services that RACs deemed should have been provided on an outpatient, rather than inpatient, basis. And this amount does not include the millions of dollars recovered from hospitals that did not report data to the AHA.

The RAC program has been a continued financial success for CMS and the auditors: RACs collected $1.86 billion in overpayments from October 2009 through March 2012. Over that same time period, RACs identified only $245.2 million in underpayments.⁷

The government, no doubt, is on a mission to rein in health-care costs. All stakeholders in the system, including hospitalists and administrations, need extensive education to document appropriate patient status to ensure accurate reimbursement and prevent the fallout of future repayments.

Dr. Pahuja is founder and CEO of Aerolib Healthcare Solutions (aerolib.com). He is pursuing his MBA in health-care administration from the Isenberg School of Management at the University of Massachusetts in Amherst.

References

1. PR Web. Medicare anti-fraud recovered $19 billion, how much for private self-insured plans? Fiduciary overpayment recovery programs announced from ERISAclaim.com. PR Web website. Available at: http://www.prweb.com/releases/2013/3/prweb10501376.htm. Accessed April 4, 2013.
2. Viebeck E. GAO reports billions in overpayments to private Medicare plans. The Hill website. Available at: http://thehill.com/blogs/healthwatch/medicare/286041-gao-reports-billions-in-overpayments-to-private-medicare-plans#ixzz2NASaVVIK. Accessed April 4, 2013.
3. Centers for Medicare & Medicare Services. Cost reports. Centers for Medicare & Medicare Services website. Available at: http://www.cms.gov/Research-Statistics-Data-and-Systems/Files-for-Order/CostReports/index.html. Accessed April 4, 2013.
4. Whelan D. America’s most profitable hospitals. Forbes website. Available at: http://www.forbes.com/2010/08/30/profitable-hospitals-hca-healthcare-business-mayo-clinic.html. Accessed April 4, 2013.
5. American Medical Association. Recovery Audit Contractors. American Medical Association website. Available at: http://www.ama-assn.org/ama/pub/physician-resources/solutions-managing-your-practice/coding-billing-insurance/medicare/recovery-audit-contractors.page. Accessed April 4, 2013.
6. American Hospital Association, Missouri Baptist Sullivan Hospital, Munson Medical Center, Lancaster General Hospital, and Trinity Health Corporation v. Kathleen Sebelius. American Hospital Association website. Available at: http://www.aha.org/content/12/121101-aha-hhs-medicare-com.pdf. Accessed March 12, 2013.
7. Centers for Medicare & Medicare Services. Medicare fee-for-service Recovery Audit Program, May 2012. Centers for Medicare & Medicare Services website. Available at: http://www.cms.gov/Research-Statistics-Data-and-Systems/Monitoring-Programs/Recovery-Audit-Program/Downloads/National-Program-Corrections-FY-2012-2nd-Qtr.pdf. Accessed April 4, 2013.
8. Centers for Medicare & Medicaid Services. FY 2014 IPPS proposed rule home page items. Centers for Medicare & Medicaid Services website. Available at: http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/AcuteInpatientPPS/FY-2014-IPPS-Proposed-Rule-Home-Page-Items/FY-2014-IPPS-Proposed-Rule-CMS-1599-P-Regulations.html. Accessed June 10, 2013.

Although it was more than a decade ago (the last century, in fact), I remember it like it was yesterday. It was my first month as chief resident at Johns Hopkins Bayview Medical Center in Baltimore, our 335-bed hospital, with the ED chair and my chair of medicine in a heated argument. Very heated. There was no yelling; it was the kind of discussion where, even as a kid, you knew the severely stern voices meant that this was beyond the yelling stage.

“Medicine patients clog up my ED. Your docs take hours to arrive and then hours more on the workup,” the ED chair said. “They block and delay. Patients are suffering.”

“If your ED knew who to admit to which service, we wouldn’t have to spend hours figuring out where to admit them. We have a lot of work upstairs; we’re not sitting around waiting for the ED to call,” my chair replied.

They both were right, of course.

The ED chair had internal data that showed medicine did, in fact, cause delays, hours and hours of delays, every day. The department of medicine had concrete examples of less-than-ideal disposition decisions that, in hindsight, could have been done better (and sometimes a lot better).

This was the late 1990s, and all of us were just beginning to understand the adverse impact that ED boarding (admissions stuck in the ED) has on patients and our institution. Over the last decade, a number of studies have proved the fears we had in the 1990s right: From increased pain to higher mortality, admitted patients suffer when they need to be “upstairs” but are stuck in the ED.^1-4

Prior to this meeting of chairmen, we tried multiple “ED fixes” over the years. Like so many other institutions, we mandated medicine physician response times to the ED, drew policies, sent memos, and even gave the ED admitting privileges to medicine. None of them worked. Culture and cultural divide trumped policy every time, and the more than 100 house staff and attendings, both in the ED and in medicine, never made a change that positively impacted ED boarding during my entire three-year residency.

In hindsight, that’s not surprising. There has been a lot of study on ED flow and quality improvement (QI) more broadly.^5-8 To expect individuals to “do better” in a broken system is asking for failure. Asking hundreds of physicians to change behavior is an exercise in futility, especially when resources are limited and systems force “silo” behavior. Even drastic measures, such as expanding total ED capacity, don’t impact ED flow favorably. Institutions must find ways to open the “admission door.”

To the Rescue

Mirroring the rest of the country, in the late 1990s, a new group of doctors were being hired at my hospital. Ex-chief residents were staying on a year or two to run a new inpatient service. Although hospitalists were still new at the time, the idea to give them the “admission problem” took about a nanosecond.

Hospitalists across the country have become adept at tackling many institutional challenges, from readmissions (think Project BOOST) to teaching attendings from comanagement to neuromanagement. If it happens inside the walls of the hospital (and sometimes outside), hospitalists likely have played an important role in making it better somewhere.

Our hospitalists became a vital partner with the ED and within our own department of medicine, of course. We did the usual: seeing inpatients. But we also began experimenting with new and radical ways to get admitted patients out of the ED and upstairs as quickly as possible. We tried a number of admission systems, and many failed initially. We learned important lessons from the failures and continued to innovate.

Soon, hospitalists were successfully triaging admitted patients to all of general medicine using a combination of telephone and in-person triage based on the needs of the patient. This process had the triage hospitalist doing a limited ED assessment and then assigning the admission duties, often done after transfer upstairs to the best available medicine team, including the four house staff inpatient teams and hospitalist group. Later, this hospitalist admission process was expanded to all of medicine, using hospitalists to triage to the ICUs as well as specialty units in addition to general medicine. The hospital dedicated large amounts of money to allow a dedicated triage shift 24-7, staffed exclusively by hospitalists. A few years later, the hospitalists developed an in-house Web-based triage program, allowing accurate tracking of the more than 14,000 admissions annually.

The results have been better than anyone could have imagined 15 years ago. ED length of stay for admitted patients has continued to decrease dramatically—by hours, not minutes. Certain types of ambulance diversion (red alert in the state of Maryland) that were commonplace a decade ago, to the tune of 2,000-plus hours a year, virtually have been eliminated. Since ambulance diversion is known to harm patients and drive away business, this was a true win for patients as well as our hospital.⁹ Our ED volumes continued to grow, and patient-care indicators show the care provided by the current admissions process is at least as safe as before.

Hospitalists partnering with EDs to improve the admissions process are not isolated to Johns Hopkins Bayview. Many hospitalist leaders recognize that there are a variety of options for improving the care our patients get during the admissions process:

• Virginia Commonwealth University’s hospitalist group, led by Dr. Heather Masters, has worked tirelessly for years on a triage program.
• Dr. Melinda Kantsiper has done something similar at Howard County General Hospital in Maryland.
• Dr. MaryEllen Pfeiffer of Wellspan in York, Pa., is launching a triage program for admissions in the fall, and Dr. Christine Soong has focused on educating her house staff on the triage process at Mount Sinai in Toronto.

The Institute of Medicine reports that 91% of EDs are crowded routinely, an issue unlikely to go away on its own. I believe that hospitalists hold the key to unlocking the “admission door.” Hospitalists are critical partners in quality improvement, including ED flow, and can positively impact our patients, our institutions, and our specialty.

If that’s not enough to convince you, then let me tell you the true story of how the Hopkins Bayview ED physicians and hospitalists became close colleagues and the time I had Thanksgiving dinner at the ED chairman’s house. It was a lovely dinner, really.

Dr. Howell is president of SHM, chief of the division of hospital medicine at Johns Hopkins Bayview in Baltimore, and spends a significant part of his time and research on hospital operations. Email questions or comments to [email protected].

References

1. Chaflin DB, Trzeciak S, Likourezos A, Baumann BM, Dellinger RP. Impact of delayed transfer of critically ill patients from the ED to the ICU. Crit Care Med. 2007;35(6):1477-1483.
2. Duke G, Green J, Briedis J. Survival of critically ill patients is time-critical. Crit Care Resusc. 2004;6(4):261-267.
3. Scheulen JJ, Li G, Kelen GD. Impact of ambulance diversion policies in urban, suburban and rural areas of central Maryland. Acad Emerg Med. 2001;8(1):36-40.
4. Sikka R, Metha S, Kaucky C, Kulstad EB. ED crowding is associated with increased time to pneumonia treatment. Am J of Emerg Med. 2010; 28(7):809-812.
5. Holroyd BR, Bullard MJ, Latoszek K. Impact of a triage physician on emergency department overcrowding and throughput: a randomized trial. Acad Emerg Med. 2007;14(8)702-708.
6. Han JH, Zhou C, France DJ. The effect of emergency department expansion on emergency department overcrowding. Acad Emerg Med. 2007;14(4)338-343.
7. Howell E, Bessman E, Kravet S, Kolodner K, Marshall R, Wright S. Active bed management by hospitalists and emergency department throughput. Ann Intern Med. 2008;149(11):804-811.
8. Briones A, Markoff B, Kathuria N. A model of a hospitalist role in the care of admitted patients in the emergency department. J Hosp Med. 2010;5(6):360-364.
9. Nicholl J, West J, Goodacre S, Turner J. The relationship between distance to hospital and patient mortality in emergencies: an observational study. Emerg Med J. 2007; 24(9):665-668.

Although it was more than a decade ago (the last century, in fact), I remember it like it was yesterday. It was my first month as chief resident at Johns Hopkins Bayview Medical Center in Baltimore, our 335-bed hospital, with the ED chair and my chair of medicine in a heated argument. Very heated. There was no yelling; it was the kind of discussion where, even as a kid, you knew the severely stern voices meant that this was beyond the yelling stage.

“Medicine patients clog up my ED. Your docs take hours to arrive and then hours more on the workup,” the ED chair said. “They block and delay. Patients are suffering.”

“If your ED knew who to admit to which service, we wouldn’t have to spend hours figuring out where to admit them. We have a lot of work upstairs; we’re not sitting around waiting for the ED to call,” my chair replied.

They both were right, of course.

The ED chair had internal data that showed medicine did, in fact, cause delays, hours and hours of delays, every day. The department of medicine had concrete examples of less-than-ideal disposition decisions that, in hindsight, could have been done better (and sometimes a lot better).

This was the late 1990s, and all of us were just beginning to understand the adverse impact that ED boarding (admissions stuck in the ED) has on patients and our institution. Over the last decade, a number of studies have proved the fears we had in the 1990s right: From increased pain to higher mortality, admitted patients suffer when they need to be “upstairs” but are stuck in the ED.^1-4

Prior to this meeting of chairmen, we tried multiple “ED fixes” over the years. Like so many other institutions, we mandated medicine physician response times to the ED, drew policies, sent memos, and even gave the ED admitting privileges to medicine. None of them worked. Culture and cultural divide trumped policy every time, and the more than 100 house staff and attendings, both in the ED and in medicine, never made a change that positively impacted ED boarding during my entire three-year residency.

In hindsight, that’s not surprising. There has been a lot of study on ED flow and quality improvement (QI) more broadly.^5-8 To expect individuals to “do better” in a broken system is asking for failure. Asking hundreds of physicians to change behavior is an exercise in futility, especially when resources are limited and systems force “silo” behavior. Even drastic measures, such as expanding total ED capacity, don’t impact ED flow favorably. Institutions must find ways to open the “admission door.”

To the Rescue

Mirroring the rest of the country, in the late 1990s, a new group of doctors were being hired at my hospital. Ex-chief residents were staying on a year or two to run a new inpatient service. Although hospitalists were still new at the time, the idea to give them the “admission problem” took about a nanosecond.

Hospitalists across the country have become adept at tackling many institutional challenges, from readmissions (think Project BOOST) to teaching attendings from comanagement to neuromanagement. If it happens inside the walls of the hospital (and sometimes outside), hospitalists likely have played an important role in making it better somewhere.

Our hospitalists became a vital partner with the ED and within our own department of medicine, of course. We did the usual: seeing inpatients. But we also began experimenting with new and radical ways to get admitted patients out of the ED and upstairs as quickly as possible. We tried a number of admission systems, and many failed initially. We learned important lessons from the failures and continued to innovate.

Soon, hospitalists were successfully triaging admitted patients to all of general medicine using a combination of telephone and in-person triage based on the needs of the patient. This process had the triage hospitalist doing a limited ED assessment and then assigning the admission duties, often done after transfer upstairs to the best available medicine team, including the four house staff inpatient teams and hospitalist group. Later, this hospitalist admission process was expanded to all of medicine, using hospitalists to triage to the ICUs as well as specialty units in addition to general medicine. The hospital dedicated large amounts of money to allow a dedicated triage shift 24-7, staffed exclusively by hospitalists. A few years later, the hospitalists developed an in-house Web-based triage program, allowing accurate tracking of the more than 14,000 admissions annually.

The results have been better than anyone could have imagined 15 years ago. ED length of stay for admitted patients has continued to decrease dramatically—by hours, not minutes. Certain types of ambulance diversion (red alert in the state of Maryland) that were commonplace a decade ago, to the tune of 2,000-plus hours a year, virtually have been eliminated. Since ambulance diversion is known to harm patients and drive away business, this was a true win for patients as well as our hospital.⁹ Our ED volumes continued to grow, and patient-care indicators show the care provided by the current admissions process is at least as safe as before.

Hospitalists partnering with EDs to improve the admissions process are not isolated to Johns Hopkins Bayview. Many hospitalist leaders recognize that there are a variety of options for improving the care our patients get during the admissions process:

• Virginia Commonwealth University’s hospitalist group, led by Dr. Heather Masters, has worked tirelessly for years on a triage program.
• Dr. Melinda Kantsiper has done something similar at Howard County General Hospital in Maryland.
• Dr. MaryEllen Pfeiffer of Wellspan in York, Pa., is launching a triage program for admissions in the fall, and Dr. Christine Soong has focused on educating her house staff on the triage process at Mount Sinai in Toronto.

The Institute of Medicine reports that 91% of EDs are crowded routinely, an issue unlikely to go away on its own. I believe that hospitalists hold the key to unlocking the “admission door.” Hospitalists are critical partners in quality improvement, including ED flow, and can positively impact our patients, our institutions, and our specialty.

If that’s not enough to convince you, then let me tell you the true story of how the Hopkins Bayview ED physicians and hospitalists became close colleagues and the time I had Thanksgiving dinner at the ED chairman’s house. It was a lovely dinner, really.

Dr. Howell is president of SHM, chief of the division of hospital medicine at Johns Hopkins Bayview in Baltimore, and spends a significant part of his time and research on hospital operations. Email questions or comments to [email protected].

References

1. Chaflin DB, Trzeciak S, Likourezos A, Baumann BM, Dellinger RP. Impact of delayed transfer of critically ill patients from the ED to the ICU. Crit Care Med. 2007;35(6):1477-1483.
2. Duke G, Green J, Briedis J. Survival of critically ill patients is time-critical. Crit Care Resusc. 2004;6(4):261-267.
3. Scheulen JJ, Li G, Kelen GD. Impact of ambulance diversion policies in urban, suburban and rural areas of central Maryland. Acad Emerg Med. 2001;8(1):36-40.
4. Sikka R, Metha S, Kaucky C, Kulstad EB. ED crowding is associated with increased time to pneumonia treatment. Am J of Emerg Med. 2010; 28(7):809-812.
5. Holroyd BR, Bullard MJ, Latoszek K. Impact of a triage physician on emergency department overcrowding and throughput: a randomized trial. Acad Emerg Med. 2007;14(8)702-708.
6. Han JH, Zhou C, France DJ. The effect of emergency department expansion on emergency department overcrowding. Acad Emerg Med. 2007;14(4)338-343.
7. Howell E, Bessman E, Kravet S, Kolodner K, Marshall R, Wright S. Active bed management by hospitalists and emergency department throughput. Ann Intern Med. 2008;149(11):804-811.
8. Briones A, Markoff B, Kathuria N. A model of a hospitalist role in the care of admitted patients in the emergency department. J Hosp Med. 2010;5(6):360-364.
9. Nicholl J, West J, Goodacre S, Turner J. The relationship between distance to hospital and patient mortality in emergencies: an observational study. Emerg Med J. 2007; 24(9):665-668.

Although it was more than a decade ago (the last century, in fact), I remember it like it was yesterday. It was my first month as chief resident at Johns Hopkins Bayview Medical Center in Baltimore, our 335-bed hospital, with the ED chair and my chair of medicine in a heated argument. Very heated. There was no yelling; it was the kind of discussion where, even as a kid, you knew the severely stern voices meant that this was beyond the yelling stage.

“Medicine patients clog up my ED. Your docs take hours to arrive and then hours more on the workup,” the ED chair said. “They block and delay. Patients are suffering.”

“If your ED knew who to admit to which service, we wouldn’t have to spend hours figuring out where to admit them. We have a lot of work upstairs; we’re not sitting around waiting for the ED to call,” my chair replied.

They both were right, of course.

The ED chair had internal data that showed medicine did, in fact, cause delays, hours and hours of delays, every day. The department of medicine had concrete examples of less-than-ideal disposition decisions that, in hindsight, could have been done better (and sometimes a lot better).

This was the late 1990s, and all of us were just beginning to understand the adverse impact that ED boarding (admissions stuck in the ED) has on patients and our institution. Over the last decade, a number of studies have proved the fears we had in the 1990s right: From increased pain to higher mortality, admitted patients suffer when they need to be “upstairs” but are stuck in the ED.^1-4

Prior to this meeting of chairmen, we tried multiple “ED fixes” over the years. Like so many other institutions, we mandated medicine physician response times to the ED, drew policies, sent memos, and even gave the ED admitting privileges to medicine. None of them worked. Culture and cultural divide trumped policy every time, and the more than 100 house staff and attendings, both in the ED and in medicine, never made a change that positively impacted ED boarding during my entire three-year residency.

In hindsight, that’s not surprising. There has been a lot of study on ED flow and quality improvement (QI) more broadly.^5-8 To expect individuals to “do better” in a broken system is asking for failure. Asking hundreds of physicians to change behavior is an exercise in futility, especially when resources are limited and systems force “silo” behavior. Even drastic measures, such as expanding total ED capacity, don’t impact ED flow favorably. Institutions must find ways to open the “admission door.”

To the Rescue

Mirroring the rest of the country, in the late 1990s, a new group of doctors were being hired at my hospital. Ex-chief residents were staying on a year or two to run a new inpatient service. Although hospitalists were still new at the time, the idea to give them the “admission problem” took about a nanosecond.

Hospitalists across the country have become adept at tackling many institutional challenges, from readmissions (think Project BOOST) to teaching attendings from comanagement to neuromanagement. If it happens inside the walls of the hospital (and sometimes outside), hospitalists likely have played an important role in making it better somewhere.

Our hospitalists became a vital partner with the ED and within our own department of medicine, of course. We did the usual: seeing inpatients. But we also began experimenting with new and radical ways to get admitted patients out of the ED and upstairs as quickly as possible. We tried a number of admission systems, and many failed initially. We learned important lessons from the failures and continued to innovate.

Soon, hospitalists were successfully triaging admitted patients to all of general medicine using a combination of telephone and in-person triage based on the needs of the patient. This process had the triage hospitalist doing a limited ED assessment and then assigning the admission duties, often done after transfer upstairs to the best available medicine team, including the four house staff inpatient teams and hospitalist group. Later, this hospitalist admission process was expanded to all of medicine, using hospitalists to triage to the ICUs as well as specialty units in addition to general medicine. The hospital dedicated large amounts of money to allow a dedicated triage shift 24-7, staffed exclusively by hospitalists. A few years later, the hospitalists developed an in-house Web-based triage program, allowing accurate tracking of the more than 14,000 admissions annually.

The results have been better than anyone could have imagined 15 years ago. ED length of stay for admitted patients has continued to decrease dramatically—by hours, not minutes. Certain types of ambulance diversion (red alert in the state of Maryland) that were commonplace a decade ago, to the tune of 2,000-plus hours a year, virtually have been eliminated. Since ambulance diversion is known to harm patients and drive away business, this was a true win for patients as well as our hospital.⁹ Our ED volumes continued to grow, and patient-care indicators show the care provided by the current admissions process is at least as safe as before.

Hospitalists partnering with EDs to improve the admissions process are not isolated to Johns Hopkins Bayview. Many hospitalist leaders recognize that there are a variety of options for improving the care our patients get during the admissions process:

• Virginia Commonwealth University’s hospitalist group, led by Dr. Heather Masters, has worked tirelessly for years on a triage program.
• Dr. Melinda Kantsiper has done something similar at Howard County General Hospital in Maryland.
• Dr. MaryEllen Pfeiffer of Wellspan in York, Pa., is launching a triage program for admissions in the fall, and Dr. Christine Soong has focused on educating her house staff on the triage process at Mount Sinai in Toronto.

The Institute of Medicine reports that 91% of EDs are crowded routinely, an issue unlikely to go away on its own. I believe that hospitalists hold the key to unlocking the “admission door.” Hospitalists are critical partners in quality improvement, including ED flow, and can positively impact our patients, our institutions, and our specialty.

If that’s not enough to convince you, then let me tell you the true story of how the Hopkins Bayview ED physicians and hospitalists became close colleagues and the time I had Thanksgiving dinner at the ED chairman’s house. It was a lovely dinner, really.

Dr. Howell is president of SHM, chief of the division of hospital medicine at Johns Hopkins Bayview in Baltimore, and spends a significant part of his time and research on hospital operations. Email questions or comments to [email protected].

References

1. Chaflin DB, Trzeciak S, Likourezos A, Baumann BM, Dellinger RP. Impact of delayed transfer of critically ill patients from the ED to the ICU. Crit Care Med. 2007;35(6):1477-1483.
2. Duke G, Green J, Briedis J. Survival of critically ill patients is time-critical. Crit Care Resusc. 2004;6(4):261-267.
3. Scheulen JJ, Li G, Kelen GD. Impact of ambulance diversion policies in urban, suburban and rural areas of central Maryland. Acad Emerg Med. 2001;8(1):36-40.
4. Sikka R, Metha S, Kaucky C, Kulstad EB. ED crowding is associated with increased time to pneumonia treatment. Am J of Emerg Med. 2010; 28(7):809-812.
5. Holroyd BR, Bullard MJ, Latoszek K. Impact of a triage physician on emergency department overcrowding and throughput: a randomized trial. Acad Emerg Med. 2007;14(8)702-708.
6. Han JH, Zhou C, France DJ. The effect of emergency department expansion on emergency department overcrowding. Acad Emerg Med. 2007;14(4)338-343.
7. Howell E, Bessman E, Kravet S, Kolodner K, Marshall R, Wright S. Active bed management by hospitalists and emergency department throughput. Ann Intern Med. 2008;149(11):804-811.
8. Briones A, Markoff B, Kathuria N. A model of a hospitalist role in the care of admitted patients in the emergency department. J Hosp Med. 2010;5(6):360-364.
9. Nicholl J, West J, Goodacre S, Turner J. The relationship between distance to hospital and patient mortality in emergencies: an observational study. Emerg Med J. 2007; 24(9):665-668.

Who doesn’t know and love Consumer Reports? I personally have used this product to help me make a wide range of purchases, from child-care products to a new automobile. Consumer Reports has enjoyed a relatively unblemished reputation since its inception as an unbiased repository of invaluable information for consumers. This nonprofit advocacy organization advises consumers looking to purchase anything from small, menial items (e.g. blenders and toasters) to large, expensive ones (e.g. computers, lawn mowers, cars). It has been categorizing and publishing large-scale consumer feedback and in-house testing since 1936. According to Wikipedia, Consumer Reports has more than 7 million subscribers and runs a budget in excess of $21 million annually.

One of the reasons for its longstanding success is that it does not appear to have any hidden agenda. It does not have any partiality to a specific company or service, and therefore has maintained its impartial stance during testing and evaluation of any good or service. Its Consumer Reports magazine houses no advertisements in order to maintain its objectivity. Its only agenda is to reflect the interests and opinions of the consumers themselves, and its mission is to provide a “fair, just, and safe marketplace for all consumers and to empower consumers to protect themselves.”¹ A perfect agent from which to seek advice.

And as a company, it has grown with the times, as it now hosts a variety of platforms from which consumers can seek advice. It has long hosted a website (ConsumerReports.org). Now it has Consumer Reports Television and The Consumerist blog, the latter of which accepts “tips” from anyone on what stories to cover, helpful tips for consumers, or interesting pictures. For a few years, there was also Consumer Reports WebWatch, which was aimed at improving the credibility of websites through rigorous investigative reporting.

So it seems that Consumer Reports could be a good avenue to seek advice on where to “consume” health care. And, in fact, it is now in the business of rating the health-care industry. Recent blog posts from Consumer Reports have entailed topics as wide-ranging as the number of uninsured in the U.S. to the number and types of recalls of food products.

The health part of the website covers beauty and personal care (sunscreens and anti-wrinkle serums), exercise and fitness (bikes and diet plans), foods (coffee to frozen meals), home medical supplies (heart rate and blood pressure monitors), vitamins, supplements, and, last but not least, health services. This last section rates health insurance, heart surgeons, heart screening tests, and hospitals.

It even goes so far as to “rate” medications; its Best Buy Drugs compares the cost and effectiveness of a variety of prescription drugs ranging from anti-hypertensives to diabetic agents.

In Focus: Hospitals

Consumer Reports’ latest foray into the health-care industry now includes reporting on the quality of hospitals. The current ratings evaluated more than 2,000 acute-care hospitals in the U.S. and came up with several rankings.

The first rating includes “patient outcomes,” which is a conglomerate of hospital-acquired central-line-associated bloodstream infection (CLABSI) rates, select surgical-site-infection [SSI] rates, 30-day readmission rates (for acute MI [AMI], congestive heart failure [CHF], and pneumonia), and eight “Patient Safety Indicators” (derived from definitions from the Agency for Healthcare Research & Quality [AHRQ], and includes pressure ulcers, pneumothorax, CLABSI, accidental puncture injury during surgery, and four postoperative complications, including VTE, sepsis, hip fracture, and wound dehiscence).

It also includes ratings of the patient experience (from a subset of HCAHPS questions) and two measures of hospital practices, including the use of electronic health records (from the American Hospital Association) and the use of “double scans” (simultaneous thoracic and abdominal CT scans).

From all of these ratings, Consumer Reports combined some of the metrics to arrive at a “Safety Score,” which ranges from 0 to 100 (100 being the safest), based on five categories, including infections (CLABSI and SSI), readmission rates (for AMI, CHF, and pneumonia), patient ratings of communication about their medications and about their discharge process, rate of double scans, and avoidance of the aforementioned AHRQ Patient Safety Indicators.

As to how potential patients are supposed to use this information, Consumer Reports gives the following advice to those wanting to know how the ratings can help a patient get better care: “They can help you compare hospitals in your area so you can choose the one that’s best for you. Even if you don’t have a choice of hospitals, our ratings can alert you to particular concerns so you can take steps to prevent problems no matter which hospital you go to. For example, if a hospital scores low in communicating with patients about what to do when they’re discharged, you should ask about discharge planning at the hospital you choose and make sure you know what to do when you leave.”

Overall, the average Safety Score for included hospitals was a 49, with a range from 14 to 74 across the U.S. Teaching hospitals were among the lowest scorers, with two-thirds of them rated below average.

At first blush, the numbers seem humbling, even startling, but it is not clear if they reflect bad care or bad metrics. Consumer Reports, similar to many other rating scales, has glued together a hodge-podge of different metrics and converted them into a summary score that may or may not line up with other organizational ratings (e.g. U.S. News and World Report, Leapfrog Group, Healthgrades, etc). Consumer Reports does acknowledge that none of the information for their rankings is actually collected from Consumer Reports but from other sources, such as the Centers for Medicare & Medicaid Services (CMS) and the American Hospital Association (AHA).

The Bottom Line

Despite all this attention from Consumer Reports and others, online ratings are only used by about 14% of consumers to review hospitals or health-care facilities and by about 17% of consumers to review physicians or other health-care providers.² Although the uptick is relatively low for use of online ratings to seek health care, that likely will change as the measurements get better and are more reflective of true care quality.

The bottom line for consumers is: Where do I want to be hospitalized when I get sick, and can I tell at the front end in which aspects a hospital is going to do well?

I think the answer for consumers should be to stay informed, always have an advocate at your side, and never stop asking questions.And for now, relegate Consumer Reports to purchases, not health care.

Dr. Scheurer is a hospitalist and chief quality officer at the Medical University of South Carolina in Charleston. She is physician editor of The Hospitalist. Email her at [email protected].

References

1. Consumer Reports. How we rate hospitals. Consumer Reports website. Available at: http://www.consumerreports.org/cro/2012/10/how-we-rate-hospitals/index.htm. Accessed May 12, 2013.
2. Pew Internet & American Life Project. Peer-to-peer health care. Pew Internet website. Available at: http://www.pewinternet.org/Reports/2013/Health-online/Part-Two/Section-2.aspx. Accessed May 12, 2013.

Who doesn’t know and love Consumer Reports? I personally have used this product to help me make a wide range of purchases, from child-care products to a new automobile. Consumer Reports has enjoyed a relatively unblemished reputation since its inception as an unbiased repository of invaluable information for consumers. This nonprofit advocacy organization advises consumers looking to purchase anything from small, menial items (e.g. blenders and toasters) to large, expensive ones (e.g. computers, lawn mowers, cars). It has been categorizing and publishing large-scale consumer feedback and in-house testing since 1936. According to Wikipedia, Consumer Reports has more than 7 million subscribers and runs a budget in excess of $21 million annually.

One of the reasons for its longstanding success is that it does not appear to have any hidden agenda. It does not have any partiality to a specific company or service, and therefore has maintained its impartial stance during testing and evaluation of any good or service. Its Consumer Reports magazine houses no advertisements in order to maintain its objectivity. Its only agenda is to reflect the interests and opinions of the consumers themselves, and its mission is to provide a “fair, just, and safe marketplace for all consumers and to empower consumers to protect themselves.”¹ A perfect agent from which to seek advice.

And as a company, it has grown with the times, as it now hosts a variety of platforms from which consumers can seek advice. It has long hosted a website (ConsumerReports.org). Now it has Consumer Reports Television and The Consumerist blog, the latter of which accepts “tips” from anyone on what stories to cover, helpful tips for consumers, or interesting pictures. For a few years, there was also Consumer Reports WebWatch, which was aimed at improving the credibility of websites through rigorous investigative reporting.

So it seems that Consumer Reports could be a good avenue to seek advice on where to “consume” health care. And, in fact, it is now in the business of rating the health-care industry. Recent blog posts from Consumer Reports have entailed topics as wide-ranging as the number of uninsured in the U.S. to the number and types of recalls of food products.

The health part of the website covers beauty and personal care (sunscreens and anti-wrinkle serums), exercise and fitness (bikes and diet plans), foods (coffee to frozen meals), home medical supplies (heart rate and blood pressure monitors), vitamins, supplements, and, last but not least, health services. This last section rates health insurance, heart surgeons, heart screening tests, and hospitals.

It even goes so far as to “rate” medications; its Best Buy Drugs compares the cost and effectiveness of a variety of prescription drugs ranging from anti-hypertensives to diabetic agents.

In Focus: Hospitals

Consumer Reports’ latest foray into the health-care industry now includes reporting on the quality of hospitals. The current ratings evaluated more than 2,000 acute-care hospitals in the U.S. and came up with several rankings.

The first rating includes “patient outcomes,” which is a conglomerate of hospital-acquired central-line-associated bloodstream infection (CLABSI) rates, select surgical-site-infection [SSI] rates, 30-day readmission rates (for acute MI [AMI], congestive heart failure [CHF], and pneumonia), and eight “Patient Safety Indicators” (derived from definitions from the Agency for Healthcare Research & Quality [AHRQ], and includes pressure ulcers, pneumothorax, CLABSI, accidental puncture injury during surgery, and four postoperative complications, including VTE, sepsis, hip fracture, and wound dehiscence).

It also includes ratings of the patient experience (from a subset of HCAHPS questions) and two measures of hospital practices, including the use of electronic health records (from the American Hospital Association) and the use of “double scans” (simultaneous thoracic and abdominal CT scans).

From all of these ratings, Consumer Reports combined some of the metrics to arrive at a “Safety Score,” which ranges from 0 to 100 (100 being the safest), based on five categories, including infections (CLABSI and SSI), readmission rates (for AMI, CHF, and pneumonia), patient ratings of communication about their medications and about their discharge process, rate of double scans, and avoidance of the aforementioned AHRQ Patient Safety Indicators.

As to how potential patients are supposed to use this information, Consumer Reports gives the following advice to those wanting to know how the ratings can help a patient get better care: “They can help you compare hospitals in your area so you can choose the one that’s best for you. Even if you don’t have a choice of hospitals, our ratings can alert you to particular concerns so you can take steps to prevent problems no matter which hospital you go to. For example, if a hospital scores low in communicating with patients about what to do when they’re discharged, you should ask about discharge planning at the hospital you choose and make sure you know what to do when you leave.”

Overall, the average Safety Score for included hospitals was a 49, with a range from 14 to 74 across the U.S. Teaching hospitals were among the lowest scorers, with two-thirds of them rated below average.

At first blush, the numbers seem humbling, even startling, but it is not clear if they reflect bad care or bad metrics. Consumer Reports, similar to many other rating scales, has glued together a hodge-podge of different metrics and converted them into a summary score that may or may not line up with other organizational ratings (e.g. U.S. News and World Report, Leapfrog Group, Healthgrades, etc). Consumer Reports does acknowledge that none of the information for their rankings is actually collected from Consumer Reports but from other sources, such as the Centers for Medicare & Medicaid Services (CMS) and the American Hospital Association (AHA).

The Bottom Line

Despite all this attention from Consumer Reports and others, online ratings are only used by about 14% of consumers to review hospitals or health-care facilities and by about 17% of consumers to review physicians or other health-care providers.² Although the uptick is relatively low for use of online ratings to seek health care, that likely will change as the measurements get better and are more reflective of true care quality.

The bottom line for consumers is: Where do I want to be hospitalized when I get sick, and can I tell at the front end in which aspects a hospital is going to do well?

I think the answer for consumers should be to stay informed, always have an advocate at your side, and never stop asking questions.And for now, relegate Consumer Reports to purchases, not health care.

Dr. Scheurer is a hospitalist and chief quality officer at the Medical University of South Carolina in Charleston. She is physician editor of The Hospitalist. Email her at [email protected].

References

1. Consumer Reports. How we rate hospitals. Consumer Reports website. Available at: http://www.consumerreports.org/cro/2012/10/how-we-rate-hospitals/index.htm. Accessed May 12, 2013.
2. Pew Internet & American Life Project. Peer-to-peer health care. Pew Internet website. Available at: http://www.pewinternet.org/Reports/2013/Health-online/Part-Two/Section-2.aspx. Accessed May 12, 2013.

Who doesn’t know and love Consumer Reports? I personally have used this product to help me make a wide range of purchases, from child-care products to a new automobile. Consumer Reports has enjoyed a relatively unblemished reputation since its inception as an unbiased repository of invaluable information for consumers. This nonprofit advocacy organization advises consumers looking to purchase anything from small, menial items (e.g. blenders and toasters) to large, expensive ones (e.g. computers, lawn mowers, cars). It has been categorizing and publishing large-scale consumer feedback and in-house testing since 1936. According to Wikipedia, Consumer Reports has more than 7 million subscribers and runs a budget in excess of $21 million annually.

One of the reasons for its longstanding success is that it does not appear to have any hidden agenda. It does not have any partiality to a specific company or service, and therefore has maintained its impartial stance during testing and evaluation of any good or service. Its Consumer Reports magazine houses no advertisements in order to maintain its objectivity. Its only agenda is to reflect the interests and opinions of the consumers themselves, and its mission is to provide a “fair, just, and safe marketplace for all consumers and to empower consumers to protect themselves.”¹ A perfect agent from which to seek advice.

And as a company, it has grown with the times, as it now hosts a variety of platforms from which consumers can seek advice. It has long hosted a website (ConsumerReports.org). Now it has Consumer Reports Television and The Consumerist blog, the latter of which accepts “tips” from anyone on what stories to cover, helpful tips for consumers, or interesting pictures. For a few years, there was also Consumer Reports WebWatch, which was aimed at improving the credibility of websites through rigorous investigative reporting.

So it seems that Consumer Reports could be a good avenue to seek advice on where to “consume” health care. And, in fact, it is now in the business of rating the health-care industry. Recent blog posts from Consumer Reports have entailed topics as wide-ranging as the number of uninsured in the U.S. to the number and types of recalls of food products.

The health part of the website covers beauty and personal care (sunscreens and anti-wrinkle serums), exercise and fitness (bikes and diet plans), foods (coffee to frozen meals), home medical supplies (heart rate and blood pressure monitors), vitamins, supplements, and, last but not least, health services. This last section rates health insurance, heart surgeons, heart screening tests, and hospitals.

It even goes so far as to “rate” medications; its Best Buy Drugs compares the cost and effectiveness of a variety of prescription drugs ranging from anti-hypertensives to diabetic agents.

In Focus: Hospitals

Consumer Reports’ latest foray into the health-care industry now includes reporting on the quality of hospitals. The current ratings evaluated more than 2,000 acute-care hospitals in the U.S. and came up with several rankings.

The first rating includes “patient outcomes,” which is a conglomerate of hospital-acquired central-line-associated bloodstream infection (CLABSI) rates, select surgical-site-infection [SSI] rates, 30-day readmission rates (for acute MI [AMI], congestive heart failure [CHF], and pneumonia), and eight “Patient Safety Indicators” (derived from definitions from the Agency for Healthcare Research & Quality [AHRQ], and includes pressure ulcers, pneumothorax, CLABSI, accidental puncture injury during surgery, and four postoperative complications, including VTE, sepsis, hip fracture, and wound dehiscence).

It also includes ratings of the patient experience (from a subset of HCAHPS questions) and two measures of hospital practices, including the use of electronic health records (from the American Hospital Association) and the use of “double scans” (simultaneous thoracic and abdominal CT scans).

From all of these ratings, Consumer Reports combined some of the metrics to arrive at a “Safety Score,” which ranges from 0 to 100 (100 being the safest), based on five categories, including infections (CLABSI and SSI), readmission rates (for AMI, CHF, and pneumonia), patient ratings of communication about their medications and about their discharge process, rate of double scans, and avoidance of the aforementioned AHRQ Patient Safety Indicators.

As to how potential patients are supposed to use this information, Consumer Reports gives the following advice to those wanting to know how the ratings can help a patient get better care: “They can help you compare hospitals in your area so you can choose the one that’s best for you. Even if you don’t have a choice of hospitals, our ratings can alert you to particular concerns so you can take steps to prevent problems no matter which hospital you go to. For example, if a hospital scores low in communicating with patients about what to do when they’re discharged, you should ask about discharge planning at the hospital you choose and make sure you know what to do when you leave.”

Overall, the average Safety Score for included hospitals was a 49, with a range from 14 to 74 across the U.S. Teaching hospitals were among the lowest scorers, with two-thirds of them rated below average.

At first blush, the numbers seem humbling, even startling, but it is not clear if they reflect bad care or bad metrics. Consumer Reports, similar to many other rating scales, has glued together a hodge-podge of different metrics and converted them into a summary score that may or may not line up with other organizational ratings (e.g. U.S. News and World Report, Leapfrog Group, Healthgrades, etc). Consumer Reports does acknowledge that none of the information for their rankings is actually collected from Consumer Reports but from other sources, such as the Centers for Medicare & Medicaid Services (CMS) and the American Hospital Association (AHA).

The Bottom Line

Despite all this attention from Consumer Reports and others, online ratings are only used by about 14% of consumers to review hospitals or health-care facilities and by about 17% of consumers to review physicians or other health-care providers.² Although the uptick is relatively low for use of online ratings to seek health care, that likely will change as the measurements get better and are more reflective of true care quality.

The bottom line for consumers is: Where do I want to be hospitalized when I get sick, and can I tell at the front end in which aspects a hospital is going to do well?

I think the answer for consumers should be to stay informed, always have an advocate at your side, and never stop asking questions.And for now, relegate Consumer Reports to purchases, not health care.

Dr. Scheurer is a hospitalist and chief quality officer at the Medical University of South Carolina in Charleston. She is physician editor of The Hospitalist. Email her at [email protected].

References

1. Consumer Reports. How we rate hospitals. Consumer Reports website. Available at: http://www.consumerreports.org/cro/2012/10/how-we-rate-hospitals/index.htm. Accessed May 12, 2013.
2. Pew Internet & American Life Project. Peer-to-peer health care. Pew Internet website. Available at: http://www.pewinternet.org/Reports/2013/Health-online/Part-Two/Section-2.aspx. Accessed May 12, 2013.

I continue to believe that hospitalists should routinely provide patients a copy of their discharge summary. I made the case for this in a 2006 column (“Keeping Patients in the Loop,” October 2006, p. 74), but I don’t see the idea catching on. I bet this simple act would have all kinds of benefits, including at least modest reductions in overall health-care expenditures and readmissions.

The whole dynamic of this issue seems to be changing as a result of “patient portals” allowing direct access to review test results and, in some cases, physician documentation. Typically, these are integrated with or at least connected to an electronic health record (EHR) and allow a patient, and those provided access (e.g. the password) by the patient, to review records. My own PCP provides access to a portal that I’ve found very useful, but I think, like most others, it doesn’t provide access to physician notes.

So there still is a case to be made for hospitalists (and all specialties) to provide copies of the discharge summary directly to patients and perhaps other forms of documentation as well.

Timeliness

I think all discharge summaries should be completed before the patient leaves the hospital and amended as needed to capture any last-minute changes and details. The act of generating the summary often leads the discharging doctor to notice, and have a chance to address, important details that may have dropped off the daily problem list. Things like the need to recheck a lab test to ensure normalization prior to discharge, or make arrangements for outpatient colonoscopy to pursue the heme-positive stool found on admission, have sometimes slipped off the radar during the hospital stay and can be caught when preparing discharge summary.

Preparing a discharge summary the night before anticipated discharge can have many advantages, including improving early discharge times the next morning. And it means the doctor can prepare the summary late in the day after routine rounding is finished and interruptions are less likely. Although I think quality of care is enhanced by generating the summary the night before (and amending it as needed), I worked with a hospital that was cited by the Centers for Medicare & Medicaid Services (CMS) for doing this and was told they can’t be done prior to the calendar day of discharge.

Creation of the discharge summary isn’t the only relevant step. It should be transcribed on a stat basis (e.g. within two to four hours) and pushed to the PCP and other treating physicians. It isn’t enough that the document is available to the PCP via an EHR; these doctors need some sort of notice, such as an email.

To take advantage of the new “transitional-care management” codes (99495 and 99496), PCPs must make telephone contact with patients within two days of discharge and must have a face-to-face visit within one or two weeks of discharge (depending on whether the patient is high- or moderate-risk). Making the summary available to the PCP quickly can be crucial in ensuring these phone calls and visits are meaningful. (For an excellent review of the TCM codes, see Dr. Lauren Doctoroff’s article “New Codes Bridge Hospitals’ Post-Discharge Billing Gap” in the February 2013 issue of The Hospitalist.)

So I think both patients and other treating physicians should get the discharge summary on the day of discharge or no more than a day or two after. I bet this improves quality of care and readmissions, but one study found no association, and another found a trend toward reduced readmissions that did not reach statistical significance.^1,2

Content

Just what information should go in a discharge summary? There are lots of opinions here, but it is worth starting with the components required by The Joint Commission. (You were aware of these, right?) The commission requires:

• Reason for hospitalization;
• Significant findings;
• Procedures and treatment provided;
• Patient’s discharge condition;
• Patient and family instructions; and
• Attending physician’s signature

To this list, I would add enumeration of tests pending at discharge.

The May/June 2005 issue of The Hospitalist has a terrific article by three thoughtful hospitalists titled “Advancing Toward the Ideal Hospital Discharge for the Elderly Patient.” It summarizes a 2005 workshop at the SHM annual meeting that produced a checklist of elements to consider including in every summary.

Brevity is a worthwhile goal but not at the expense of conveying the thought processes behind decisions. Things like how a decision was made to pursue watchful waiting versus aggressive workup now should be spelled out. Was it simply patient preference? It is common to start a trial of a medical therapy during a hospital stay, and it should be made clear that its effect should be assessed and a deliberate decision regarding continuing or stopping the therapy will be needed after discharge.

Lots of things need context and explanation for subsequent caregivers.

Format

The hospital in which I practice recently switched to a new EHR, and our hospitalist group has talked some about all of us using the same basic template for our notes. This should be valuable to all other caregivers who read a reasonable number of our notes and might improve our communication with one another around handoffs, etc. Although we haven’t reached a final decision about this, I’m an advocate for a shared template rather than each doctor using his or her own. This would be a worthwhile thing for all groups to consider.

Dr. Nelson has been a practicing hospitalist since 1988. He is co-founder and past president of SHM, and principal in Nelson Flores Hospital Medicine Consultants. He is co-director for SHM’s “Best Practices in Managing a Hospital Medicine Program” course. Write to him at [email protected].

References

1. Hanson LO. Hospital discharge documentation and risk of rehospitalization. BMJ Qual Saf. 2011;20(9):773-778.
2. Van Walraven C, Seth R, Austin PC, Laupacis A. Effect of discharge summary availability during post-discharge visits on hospital readmission. J Gen Intern Med. 2002;17(3):186-192.

I continue to believe that hospitalists should routinely provide patients a copy of their discharge summary. I made the case for this in a 2006 column (“Keeping Patients in the Loop,” October 2006, p. 74), but I don’t see the idea catching on. I bet this simple act would have all kinds of benefits, including at least modest reductions in overall health-care expenditures and readmissions.

The whole dynamic of this issue seems to be changing as a result of “patient portals” allowing direct access to review test results and, in some cases, physician documentation. Typically, these are integrated with or at least connected to an electronic health record (EHR) and allow a patient, and those provided access (e.g. the password) by the patient, to review records. My own PCP provides access to a portal that I’ve found very useful, but I think, like most others, it doesn’t provide access to physician notes.

So there still is a case to be made for hospitalists (and all specialties) to provide copies of the discharge summary directly to patients and perhaps other forms of documentation as well.

Timeliness

I think all discharge summaries should be completed before the patient leaves the hospital and amended as needed to capture any last-minute changes and details. The act of generating the summary often leads the discharging doctor to notice, and have a chance to address, important details that may have dropped off the daily problem list. Things like the need to recheck a lab test to ensure normalization prior to discharge, or make arrangements for outpatient colonoscopy to pursue the heme-positive stool found on admission, have sometimes slipped off the radar during the hospital stay and can be caught when preparing discharge summary.

Preparing a discharge summary the night before anticipated discharge can have many advantages, including improving early discharge times the next morning. And it means the doctor can prepare the summary late in the day after routine rounding is finished and interruptions are less likely. Although I think quality of care is enhanced by generating the summary the night before (and amending it as needed), I worked with a hospital that was cited by the Centers for Medicare & Medicaid Services (CMS) for doing this and was told they can’t be done prior to the calendar day of discharge.

Creation of the discharge summary isn’t the only relevant step. It should be transcribed on a stat basis (e.g. within two to four hours) and pushed to the PCP and other treating physicians. It isn’t enough that the document is available to the PCP via an EHR; these doctors need some sort of notice, such as an email.

To take advantage of the new “transitional-care management” codes (99495 and 99496), PCPs must make telephone contact with patients within two days of discharge and must have a face-to-face visit within one or two weeks of discharge (depending on whether the patient is high- or moderate-risk). Making the summary available to the PCP quickly can be crucial in ensuring these phone calls and visits are meaningful. (For an excellent review of the TCM codes, see Dr. Lauren Doctoroff’s article “New Codes Bridge Hospitals’ Post-Discharge Billing Gap” in the February 2013 issue of The Hospitalist.)

So I think both patients and other treating physicians should get the discharge summary on the day of discharge or no more than a day or two after. I bet this improves quality of care and readmissions, but one study found no association, and another found a trend toward reduced readmissions that did not reach statistical significance.^1,2

Content

Just what information should go in a discharge summary? There are lots of opinions here, but it is worth starting with the components required by The Joint Commission. (You were aware of these, right?) The commission requires:

• Reason for hospitalization;
• Significant findings;
• Procedures and treatment provided;
• Patient’s discharge condition;
• Patient and family instructions; and
• Attending physician’s signature

To this list, I would add enumeration of tests pending at discharge.

The May/June 2005 issue of The Hospitalist has a terrific article by three thoughtful hospitalists titled “Advancing Toward the Ideal Hospital Discharge for the Elderly Patient.” It summarizes a 2005 workshop at the SHM annual meeting that produced a checklist of elements to consider including in every summary.

Brevity is a worthwhile goal but not at the expense of conveying the thought processes behind decisions. Things like how a decision was made to pursue watchful waiting versus aggressive workup now should be spelled out. Was it simply patient preference? It is common to start a trial of a medical therapy during a hospital stay, and it should be made clear that its effect should be assessed and a deliberate decision regarding continuing or stopping the therapy will be needed after discharge.

Lots of things need context and explanation for subsequent caregivers.

Format

The hospital in which I practice recently switched to a new EHR, and our hospitalist group has talked some about all of us using the same basic template for our notes. This should be valuable to all other caregivers who read a reasonable number of our notes and might improve our communication with one another around handoffs, etc. Although we haven’t reached a final decision about this, I’m an advocate for a shared template rather than each doctor using his or her own. This would be a worthwhile thing for all groups to consider.

Dr. Nelson has been a practicing hospitalist since 1988. He is co-founder and past president of SHM, and principal in Nelson Flores Hospital Medicine Consultants. He is co-director for SHM’s “Best Practices in Managing a Hospital Medicine Program” course. Write to him at [email protected].

References

1. Hanson LO. Hospital discharge documentation and risk of rehospitalization. BMJ Qual Saf. 2011;20(9):773-778.
2. Van Walraven C, Seth R, Austin PC, Laupacis A. Effect of discharge summary availability during post-discharge visits on hospital readmission. J Gen Intern Med. 2002;17(3):186-192.

I continue to believe that hospitalists should routinely provide patients a copy of their discharge summary. I made the case for this in a 2006 column (“Keeping Patients in the Loop,” October 2006, p. 74), but I don’t see the idea catching on. I bet this simple act would have all kinds of benefits, including at least modest reductions in overall health-care expenditures and readmissions.

The whole dynamic of this issue seems to be changing as a result of “patient portals” allowing direct access to review test results and, in some cases, physician documentation. Typically, these are integrated with or at least connected to an electronic health record (EHR) and allow a patient, and those provided access (e.g. the password) by the patient, to review records. My own PCP provides access to a portal that I’ve found very useful, but I think, like most others, it doesn’t provide access to physician notes.

So there still is a case to be made for hospitalists (and all specialties) to provide copies of the discharge summary directly to patients and perhaps other forms of documentation as well.

Timeliness

I think all discharge summaries should be completed before the patient leaves the hospital and amended as needed to capture any last-minute changes and details. The act of generating the summary often leads the discharging doctor to notice, and have a chance to address, important details that may have dropped off the daily problem list. Things like the need to recheck a lab test to ensure normalization prior to discharge, or make arrangements for outpatient colonoscopy to pursue the heme-positive stool found on admission, have sometimes slipped off the radar during the hospital stay and can be caught when preparing discharge summary.

Preparing a discharge summary the night before anticipated discharge can have many advantages, including improving early discharge times the next morning. And it means the doctor can prepare the summary late in the day after routine rounding is finished and interruptions are less likely. Although I think quality of care is enhanced by generating the summary the night before (and amending it as needed), I worked with a hospital that was cited by the Centers for Medicare & Medicaid Services (CMS) for doing this and was told they can’t be done prior to the calendar day of discharge.

Creation of the discharge summary isn’t the only relevant step. It should be transcribed on a stat basis (e.g. within two to four hours) and pushed to the PCP and other treating physicians. It isn’t enough that the document is available to the PCP via an EHR; these doctors need some sort of notice, such as an email.

To take advantage of the new “transitional-care management” codes (99495 and 99496), PCPs must make telephone contact with patients within two days of discharge and must have a face-to-face visit within one or two weeks of discharge (depending on whether the patient is high- or moderate-risk). Making the summary available to the PCP quickly can be crucial in ensuring these phone calls and visits are meaningful. (For an excellent review of the TCM codes, see Dr. Lauren Doctoroff’s article “New Codes Bridge Hospitals’ Post-Discharge Billing Gap” in the February 2013 issue of The Hospitalist.)

So I think both patients and other treating physicians should get the discharge summary on the day of discharge or no more than a day or two after. I bet this improves quality of care and readmissions, but one study found no association, and another found a trend toward reduced readmissions that did not reach statistical significance.^1,2

Content

Just what information should go in a discharge summary? There are lots of opinions here, but it is worth starting with the components required by The Joint Commission. (You were aware of these, right?) The commission requires:

• Reason for hospitalization;
• Significant findings;
• Procedures and treatment provided;
• Patient’s discharge condition;
• Patient and family instructions; and
• Attending physician’s signature

To this list, I would add enumeration of tests pending at discharge.

The May/June 2005 issue of The Hospitalist has a terrific article by three thoughtful hospitalists titled “Advancing Toward the Ideal Hospital Discharge for the Elderly Patient.” It summarizes a 2005 workshop at the SHM annual meeting that produced a checklist of elements to consider including in every summary.

Brevity is a worthwhile goal but not at the expense of conveying the thought processes behind decisions. Things like how a decision was made to pursue watchful waiting versus aggressive workup now should be spelled out. Was it simply patient preference? It is common to start a trial of a medical therapy during a hospital stay, and it should be made clear that its effect should be assessed and a deliberate decision regarding continuing or stopping the therapy will be needed after discharge.

Lots of things need context and explanation for subsequent caregivers.

Format

The hospital in which I practice recently switched to a new EHR, and our hospitalist group has talked some about all of us using the same basic template for our notes. This should be valuable to all other caregivers who read a reasonable number of our notes and might improve our communication with one another around handoffs, etc. Although we haven’t reached a final decision about this, I’m an advocate for a shared template rather than each doctor using his or her own. This would be a worthwhile thing for all groups to consider.

Dr. Nelson has been a practicing hospitalist since 1988. He is co-founder and past president of SHM, and principal in Nelson Flores Hospital Medicine Consultants. He is co-director for SHM’s “Best Practices in Managing a Hospital Medicine Program” course. Write to him at [email protected].

References

1. Hanson LO. Hospital discharge documentation and risk of rehospitalization. BMJ Qual Saf. 2011;20(9):773-778.
2. Van Walraven C, Seth R, Austin PC, Laupacis A. Effect of discharge summary availability during post-discharge visits on hospital readmission. J Gen Intern Med. 2002;17(3):186-192.

Legend has it that Alexander the Great once was confronted with an intricate knot tying up a sacred ox cart in the palace of the Phrygians, whom he was trying to conquer. When his attempts to untie the knot proved unsuccessful, he drew his sword and sliced it in half, thus providing a rapid if inelegant solution.

Pediatric hospital medicine (PHM) now finds itself facing a similar dilemma in its attempts to define its “kingdom.” The question: Who will become citizens of this kingdom—and who will be left outside the gates? And will this intricate knot be unraveled or simply cut?

In some ways, the mere posing of this question signifies the success PHM has forged for itself over the past decade. At its core, the question of how to define the identity, and thus the training, of a pediatric hospitalist is rooted in noble ideals: excellence in the management of hospitalized children, robust training in quality improvement, patient safety, and cost-effective care.¹ Yet this question also stirs up more base feelings frequently articulated in many a physician lounge: territoriality, inadequacy, feeling excluded.

Nevertheless, the question must be answered.

In many ways, the situation in which PHM finds itself mirrors the dilemma facing pediatrics itself in its infancy. As Borden Veeder, the first president of the American Board of Pediatrics (ABP), wrote in the 1930s, “There were no legal or medical requirements relating to the training and education of specialists—all a man licensed to practice medicine had to do was to announce himself as a surgeon, internist, pediatrician, etc., as he preferred.”² In 1933, the ABP was incorporated, with representatives from the American Academy of Pediatrics (AAP), the American Medical Association (AMA) section on pediatrics, and the American Pediatric Society.

Facing a similar state of confusion, hospitalist leaders of the PHM community in 2010 formed the Strategic Planning Committee (STP) to evaluate training and certification options for PHM as a distinct discipline.³ Co-chairs of the STP Committee were chosen by consensus from a group composed of one representative each from the AAP Section on Hospital Medicine (AAP SOHM), the Academic Pediatric Association (APA), and SHM. The STP identified various training and/or certification options that could define PHM as a subspecialty. A survey with these options was distributed to the PHM community via the listservs of the APA, the AAP SOHM, and the AAP. The results:³

• 33% of respondents preferred Recognition of Focused Practice through the American Board of Internal Medicine’s (ABIM) Maintenance of Certification (MOC);
• 30% preferred a two-year fellowship; and
• 17% suggested an HM track within pediatric residency.

Yet at the PHM Leaders Conference in Chapel Hill, N.C., in April, “there was overwhelming consensus that an MOC program could not provide the rigor to insure [sic] that all pediatric hospitalists would meet a standard.”⁴ Further, “there was overwhelming consensus that a standardized training program resulting in certification was the best option to assure adequate training in the PHM Core Competencies and provide the public with a meaningful definition of a pediatric hospitalist” and “that the duration of such training should be two years.” Why, one might ask, would those present feel so strongly that the MOC model would be inadequate?

Many concerns regarding MOC were voiced, including whether MOC addresses a knowledge gap after residency (which it does to some extent through ongoing recertification requirements), whether it ensures public trust (but it had “positive potential”), and whether it addressed core competencies (to which the leadership present answered “yes, if rigorous”).⁴

The perception that the Focused Practice in Hospital Medicine (FPHM) MOC was “not a successful model so far in adult hospital medicine” seemed to weigh heavily on the minds of those in attendance. This perception may have arisen from data showing a somewhat low number of adult hospitalists (363 completed, 527 in process) having successfully completed the FPHM MOC to date. Of note, the possibility of a FPHM MOC for PHM was considered a “non-starter” by the ABP representatives, who in turn attributed this determination to the American Board of Medical Specialties (ABMS).⁵

There are, of course, many reasons for the low turnout for adult FPHM MOC. Candidates must have been previously certified in internal medicine of family medicine, and thus entry into the FPHM MOC would only arise at recertification or if one decided to seek FPHM certification “early”—that is, prior to the need for recertification. Being not only a Procrastination Club president but also a client, I was not among the 67 virtuous hospitalists who were among the first class of FPHM diplomates in 2011.⁶ The FPHM MOC also initially was more rigorous than the traditional IM recertification, in that it required completion of a practice-improvement module (PIM) every three years versus every 10 years (in 2014, both the traditional IM and FPHM MOC programs will require PIM completion every 5 years). Without a clearly mandated requirement from most HM groups, at the inception of the FPHM MOC one would be entering a more rigorous recertification process without a clear benefit.

This lack of a requirement from adult HM groups for completion or entry into the FPHM MOC, in turn, arises from a straightforward issue: workforce. Requiring all hospitalists in your HM group to have completed or entered FPHM MOC is a bar most directors and chiefs are not prepared to raise given its potential to shrink their applicant pool. With only 32 to 35 graduates of pediatric HM fellowship programs yearly, workforce issues should clearly be of concern to the PHM community given the current estimates that pediatric hospitalists number anywhere from 1,500 to 3,000.^6,7

Is the adult FPHM MOC process perfect? Nothing created by so many committees and professional societies could ever be, but as a first iteration, it certainly created a relatively sturdy straw man. Could the PHM community create a FPHM MOC upon this model that was refined and tailored to their needs? Creating and requiring completion of a robust PHM-specific curriculum via required self-evaluation modules, requiring not only patient encounter thresholds but also evidence of quality care, and developing PIMs specific to PHM would all go a long way to making a FPHM MOC an acceptable alternative for pediatric hospitalist “designation.”

In any case, the gauntlet seems to have been thrown down already in Chapel Hill in favor of a two-year fellowship leading to certification. I admire those present for advocating a training and certification that provides the least compromise in defining the path of future pediatric hospitalists. But I suspect that the answer to the problem of PHM’s future may not be so simple as a single sharp-edged solution and might lie in a more complex array of options for future pediatric hospitalists.

Dr. Chang is pediatric editor of The Hospitalist. He is associate clinical professor of medicine and pediatrics at the University of California at San Diego (UCSD) School of Medicine, and a hospitalist at both UCSD Medical Center and Rady Children’s Hospital. Send comments and questions to [email protected].

References

1. Maniscalco J, Fisher ES. Pediatric hospital medicine and education: why we can’t stand still. JAMA Pediatr. 2013;167:412-413.
2. Brownlee RC. The American Board of Pediatrics: its origin and early history. Pediatrics. 1994;94:732-735.
3. Maloney CG, Mendez SS, Quinonez RA, et al. The Strategic Planning Committee report: the first step in a journey to recognize pediatric hospital medicine as a distinct discipline. Hospital Pediatrics. 2012;2:187-190.
4. Strategic Planning Committee. Strategic planning for the future of pediatric hospital medicine. Strategic Planning Committee website. Available at: http://stpcommittee.blogspot.com/2013/04/phm-leadership-conference-april-4-5.htmlfiles/97/phm-leadership-conference-april-4-5.html. Accessed July 4, 2013.
5. Fisher ES. (2013) Email sent to Chang WW. 25 June.
6. Carris J. Defining moment: focused practice in HM. The Hospitalist website. Available at: http://www.the-hospitalist.org/details/article/1018793/Defining_Moment_Focused_Practice_in_HM.html. Accessed June 15, 2013.
7. American Academy of Pediatrics. PHM fellowship info. American Academy of Pediatrics website. Available at: http://www.aap.org/en-us/about-the-aap/Committees-Councils-Sections/Section-on-Hospital-Medicine.html. Accessed June 15, 2013.
8. Rauch DA, Lye PS, Carlson D, et al. Pediatric hospital medicine: a strategic planning roundtable to chart the future. J Hosp Med. 2012;7:329-334.

Legend has it that Alexander the Great once was confronted with an intricate knot tying up a sacred ox cart in the palace of the Phrygians, whom he was trying to conquer. When his attempts to untie the knot proved unsuccessful, he drew his sword and sliced it in half, thus providing a rapid if inelegant solution.

Pediatric hospital medicine (PHM) now finds itself facing a similar dilemma in its attempts to define its “kingdom.” The question: Who will become citizens of this kingdom—and who will be left outside the gates? And will this intricate knot be unraveled or simply cut?

In some ways, the mere posing of this question signifies the success PHM has forged for itself over the past decade. At its core, the question of how to define the identity, and thus the training, of a pediatric hospitalist is rooted in noble ideals: excellence in the management of hospitalized children, robust training in quality improvement, patient safety, and cost-effective care.¹ Yet this question also stirs up more base feelings frequently articulated in many a physician lounge: territoriality, inadequacy, feeling excluded.

Nevertheless, the question must be answered.

In many ways, the situation in which PHM finds itself mirrors the dilemma facing pediatrics itself in its infancy. As Borden Veeder, the first president of the American Board of Pediatrics (ABP), wrote in the 1930s, “There were no legal or medical requirements relating to the training and education of specialists—all a man licensed to practice medicine had to do was to announce himself as a surgeon, internist, pediatrician, etc., as he preferred.”² In 1933, the ABP was incorporated, with representatives from the American Academy of Pediatrics (AAP), the American Medical Association (AMA) section on pediatrics, and the American Pediatric Society.

Facing a similar state of confusion, hospitalist leaders of the PHM community in 2010 formed the Strategic Planning Committee (STP) to evaluate training and certification options for PHM as a distinct discipline.³ Co-chairs of the STP Committee were chosen by consensus from a group composed of one representative each from the AAP Section on Hospital Medicine (AAP SOHM), the Academic Pediatric Association (APA), and SHM. The STP identified various training and/or certification options that could define PHM as a subspecialty. A survey with these options was distributed to the PHM community via the listservs of the APA, the AAP SOHM, and the AAP. The results:³

• 33% of respondents preferred Recognition of Focused Practice through the American Board of Internal Medicine’s (ABIM) Maintenance of Certification (MOC);
• 30% preferred a two-year fellowship; and
• 17% suggested an HM track within pediatric residency.

Yet at the PHM Leaders Conference in Chapel Hill, N.C., in April, “there was overwhelming consensus that an MOC program could not provide the rigor to insure [sic] that all pediatric hospitalists would meet a standard.”⁴ Further, “there was overwhelming consensus that a standardized training program resulting in certification was the best option to assure adequate training in the PHM Core Competencies and provide the public with a meaningful definition of a pediatric hospitalist” and “that the duration of such training should be two years.” Why, one might ask, would those present feel so strongly that the MOC model would be inadequate?

Many concerns regarding MOC were voiced, including whether MOC addresses a knowledge gap after residency (which it does to some extent through ongoing recertification requirements), whether it ensures public trust (but it had “positive potential”), and whether it addressed core competencies (to which the leadership present answered “yes, if rigorous”).⁴

The perception that the Focused Practice in Hospital Medicine (FPHM) MOC was “not a successful model so far in adult hospital medicine” seemed to weigh heavily on the minds of those in attendance. This perception may have arisen from data showing a somewhat low number of adult hospitalists (363 completed, 527 in process) having successfully completed the FPHM MOC to date. Of note, the possibility of a FPHM MOC for PHM was considered a “non-starter” by the ABP representatives, who in turn attributed this determination to the American Board of Medical Specialties (ABMS).⁵

There are, of course, many reasons for the low turnout for adult FPHM MOC. Candidates must have been previously certified in internal medicine of family medicine, and thus entry into the FPHM MOC would only arise at recertification or if one decided to seek FPHM certification “early”—that is, prior to the need for recertification. Being not only a Procrastination Club president but also a client, I was not among the 67 virtuous hospitalists who were among the first class of FPHM diplomates in 2011.⁶ The FPHM MOC also initially was more rigorous than the traditional IM recertification, in that it required completion of a practice-improvement module (PIM) every three years versus every 10 years (in 2014, both the traditional IM and FPHM MOC programs will require PIM completion every 5 years). Without a clearly mandated requirement from most HM groups, at the inception of the FPHM MOC one would be entering a more rigorous recertification process without a clear benefit.

This lack of a requirement from adult HM groups for completion or entry into the FPHM MOC, in turn, arises from a straightforward issue: workforce. Requiring all hospitalists in your HM group to have completed or entered FPHM MOC is a bar most directors and chiefs are not prepared to raise given its potential to shrink their applicant pool. With only 32 to 35 graduates of pediatric HM fellowship programs yearly, workforce issues should clearly be of concern to the PHM community given the current estimates that pediatric hospitalists number anywhere from 1,500 to 3,000.^6,7

Is the adult FPHM MOC process perfect? Nothing created by so many committees and professional societies could ever be, but as a first iteration, it certainly created a relatively sturdy straw man. Could the PHM community create a FPHM MOC upon this model that was refined and tailored to their needs? Creating and requiring completion of a robust PHM-specific curriculum via required self-evaluation modules, requiring not only patient encounter thresholds but also evidence of quality care, and developing PIMs specific to PHM would all go a long way to making a FPHM MOC an acceptable alternative for pediatric hospitalist “designation.”

In any case, the gauntlet seems to have been thrown down already in Chapel Hill in favor of a two-year fellowship leading to certification. I admire those present for advocating a training and certification that provides the least compromise in defining the path of future pediatric hospitalists. But I suspect that the answer to the problem of PHM’s future may not be so simple as a single sharp-edged solution and might lie in a more complex array of options for future pediatric hospitalists.

Dr. Chang is pediatric editor of The Hospitalist. He is associate clinical professor of medicine and pediatrics at the University of California at San Diego (UCSD) School of Medicine, and a hospitalist at both UCSD Medical Center and Rady Children’s Hospital. Send comments and questions to [email protected].

References

1. Maniscalco J, Fisher ES. Pediatric hospital medicine and education: why we can’t stand still. JAMA Pediatr. 2013;167:412-413.
2. Brownlee RC. The American Board of Pediatrics: its origin and early history. Pediatrics. 1994;94:732-735.
3. Maloney CG, Mendez SS, Quinonez RA, et al. The Strategic Planning Committee report: the first step in a journey to recognize pediatric hospital medicine as a distinct discipline. Hospital Pediatrics. 2012;2:187-190.
4. Strategic Planning Committee. Strategic planning for the future of pediatric hospital medicine. Strategic Planning Committee website. Available at: http://stpcommittee.blogspot.com/2013/04/phm-leadership-conference-april-4-5.htmlfiles/97/phm-leadership-conference-april-4-5.html. Accessed July 4, 2013.
5. Fisher ES. (2013) Email sent to Chang WW. 25 June.
6. Carris J. Defining moment: focused practice in HM. The Hospitalist website. Available at: http://www.the-hospitalist.org/details/article/1018793/Defining_Moment_Focused_Practice_in_HM.html. Accessed June 15, 2013.
7. American Academy of Pediatrics. PHM fellowship info. American Academy of Pediatrics website. Available at: http://www.aap.org/en-us/about-the-aap/Committees-Councils-Sections/Section-on-Hospital-Medicine.html. Accessed June 15, 2013.
8. Rauch DA, Lye PS, Carlson D, et al. Pediatric hospital medicine: a strategic planning roundtable to chart the future. J Hosp Med. 2012;7:329-334.

Legend has it that Alexander the Great once was confronted with an intricate knot tying up a sacred ox cart in the palace of the Phrygians, whom he was trying to conquer. When his attempts to untie the knot proved unsuccessful, he drew his sword and sliced it in half, thus providing a rapid if inelegant solution.

Pediatric hospital medicine (PHM) now finds itself facing a similar dilemma in its attempts to define its “kingdom.” The question: Who will become citizens of this kingdom—and who will be left outside the gates? And will this intricate knot be unraveled or simply cut?

In some ways, the mere posing of this question signifies the success PHM has forged for itself over the past decade. At its core, the question of how to define the identity, and thus the training, of a pediatric hospitalist is rooted in noble ideals: excellence in the management of hospitalized children, robust training in quality improvement, patient safety, and cost-effective care.¹ Yet this question also stirs up more base feelings frequently articulated in many a physician lounge: territoriality, inadequacy, feeling excluded.

Nevertheless, the question must be answered.

In many ways, the situation in which PHM finds itself mirrors the dilemma facing pediatrics itself in its infancy. As Borden Veeder, the first president of the American Board of Pediatrics (ABP), wrote in the 1930s, “There were no legal or medical requirements relating to the training and education of specialists—all a man licensed to practice medicine had to do was to announce himself as a surgeon, internist, pediatrician, etc., as he preferred.”² In 1933, the ABP was incorporated, with representatives from the American Academy of Pediatrics (AAP), the American Medical Association (AMA) section on pediatrics, and the American Pediatric Society.

Facing a similar state of confusion, hospitalist leaders of the PHM community in 2010 formed the Strategic Planning Committee (STP) to evaluate training and certification options for PHM as a distinct discipline.³ Co-chairs of the STP Committee were chosen by consensus from a group composed of one representative each from the AAP Section on Hospital Medicine (AAP SOHM), the Academic Pediatric Association (APA), and SHM. The STP identified various training and/or certification options that could define PHM as a subspecialty. A survey with these options was distributed to the PHM community via the listservs of the APA, the AAP SOHM, and the AAP. The results:³

• 33% of respondents preferred Recognition of Focused Practice through the American Board of Internal Medicine’s (ABIM) Maintenance of Certification (MOC);
• 30% preferred a two-year fellowship; and
• 17% suggested an HM track within pediatric residency.

Yet at the PHM Leaders Conference in Chapel Hill, N.C., in April, “there was overwhelming consensus that an MOC program could not provide the rigor to insure [sic] that all pediatric hospitalists would meet a standard.”⁴ Further, “there was overwhelming consensus that a standardized training program resulting in certification was the best option to assure adequate training in the PHM Core Competencies and provide the public with a meaningful definition of a pediatric hospitalist” and “that the duration of such training should be two years.” Why, one might ask, would those present feel so strongly that the MOC model would be inadequate?

Many concerns regarding MOC were voiced, including whether MOC addresses a knowledge gap after residency (which it does to some extent through ongoing recertification requirements), whether it ensures public trust (but it had “positive potential”), and whether it addressed core competencies (to which the leadership present answered “yes, if rigorous”).⁴

The perception that the Focused Practice in Hospital Medicine (FPHM) MOC was “not a successful model so far in adult hospital medicine” seemed to weigh heavily on the minds of those in attendance. This perception may have arisen from data showing a somewhat low number of adult hospitalists (363 completed, 527 in process) having successfully completed the FPHM MOC to date. Of note, the possibility of a FPHM MOC for PHM was considered a “non-starter” by the ABP representatives, who in turn attributed this determination to the American Board of Medical Specialties (ABMS).⁵

There are, of course, many reasons for the low turnout for adult FPHM MOC. Candidates must have been previously certified in internal medicine of family medicine, and thus entry into the FPHM MOC would only arise at recertification or if one decided to seek FPHM certification “early”—that is, prior to the need for recertification. Being not only a Procrastination Club president but also a client, I was not among the 67 virtuous hospitalists who were among the first class of FPHM diplomates in 2011.⁶ The FPHM MOC also initially was more rigorous than the traditional IM recertification, in that it required completion of a practice-improvement module (PIM) every three years versus every 10 years (in 2014, both the traditional IM and FPHM MOC programs will require PIM completion every 5 years). Without a clearly mandated requirement from most HM groups, at the inception of the FPHM MOC one would be entering a more rigorous recertification process without a clear benefit.

This lack of a requirement from adult HM groups for completion or entry into the FPHM MOC, in turn, arises from a straightforward issue: workforce. Requiring all hospitalists in your HM group to have completed or entered FPHM MOC is a bar most directors and chiefs are not prepared to raise given its potential to shrink their applicant pool. With only 32 to 35 graduates of pediatric HM fellowship programs yearly, workforce issues should clearly be of concern to the PHM community given the current estimates that pediatric hospitalists number anywhere from 1,500 to 3,000.^6,7

Is the adult FPHM MOC process perfect? Nothing created by so many committees and professional societies could ever be, but as a first iteration, it certainly created a relatively sturdy straw man. Could the PHM community create a FPHM MOC upon this model that was refined and tailored to their needs? Creating and requiring completion of a robust PHM-specific curriculum via required self-evaluation modules, requiring not only patient encounter thresholds but also evidence of quality care, and developing PIMs specific to PHM would all go a long way to making a FPHM MOC an acceptable alternative for pediatric hospitalist “designation.”

In any case, the gauntlet seems to have been thrown down already in Chapel Hill in favor of a two-year fellowship leading to certification. I admire those present for advocating a training and certification that provides the least compromise in defining the path of future pediatric hospitalists. But I suspect that the answer to the problem of PHM’s future may not be so simple as a single sharp-edged solution and might lie in a more complex array of options for future pediatric hospitalists.

Dr. Chang is pediatric editor of The Hospitalist. He is associate clinical professor of medicine and pediatrics at the University of California at San Diego (UCSD) School of Medicine, and a hospitalist at both UCSD Medical Center and Rady Children’s Hospital. Send comments and questions to [email protected].

References

1. Maniscalco J, Fisher ES. Pediatric hospital medicine and education: why we can’t stand still. JAMA Pediatr. 2013;167:412-413.
2. Brownlee RC. The American Board of Pediatrics: its origin and early history. Pediatrics. 1994;94:732-735.
3. Maloney CG, Mendez SS, Quinonez RA, et al. The Strategic Planning Committee report: the first step in a journey to recognize pediatric hospital medicine as a distinct discipline. Hospital Pediatrics. 2012;2:187-190.
4. Strategic Planning Committee. Strategic planning for the future of pediatric hospital medicine. Strategic Planning Committee website. Available at: http://stpcommittee.blogspot.com/2013/04/phm-leadership-conference-april-4-5.htmlfiles/97/phm-leadership-conference-april-4-5.html. Accessed July 4, 2013.
5. Fisher ES. (2013) Email sent to Chang WW. 25 June.
6. Carris J. Defining moment: focused practice in HM. The Hospitalist website. Available at: http://www.the-hospitalist.org/details/article/1018793/Defining_Moment_Focused_Practice_in_HM.html. Accessed June 15, 2013.
7. American Academy of Pediatrics. PHM fellowship info. American Academy of Pediatrics website. Available at: http://www.aap.org/en-us/about-the-aap/Committees-Councils-Sections/Section-on-Hospital-Medicine.html. Accessed June 15, 2013.
8. Rauch DA, Lye PS, Carlson D, et al. Pediatric hospital medicine: a strategic planning roundtable to chart the future. J Hosp Med. 2012;7:329-334.