Twenty-four-hour coverage is standard practice for all successful hospitalist groups. At Lehigh Valley Hospital in Allentown, Pa., the hospitalist group features 17 FTEs that split time in a traditional seven-on/seven-off schedule. Five doctors per week round on units seeing patients; one works triage/admitting in the morning and sees some follow-ups in the afternoon; and one works a middle shift for admissions, consults, and ICU transfers.

The foundation of this coverage comes at night. We employ an overnight doctor—a nocturnist—every day of the year. This doctor’s sole responsibility is to cover night admissions, rapid responses, floor calls, and transfers.

Change Is Necessary, Difficult

Lehigh Valley’s change to a nocturnist model came about when members of the group asked for it. We needed to put a model in place that could help the group, improve morale, and improve our care at night. Of all of our shifts, nobody wanted to work overnight. Each clinician was working about four weeks of nights per year, and we started to notice that our new hires from residency were the only ones truly capable of handling the sleep challenges—or, more truthfully, our veteran hospitalists were having difficulty with the nights.

For such a large group, having a nocturnist makes sense. However, there are a few issues to contend with in hiring a nocturnist. Most notably, nocturnists are hard to come by. It takes a special type of person to come in and work the opposite schedule from everyone else. Nocturnists are typically alone in the hospital and don’t always have the support of other hospitalists when times get tough. They usually are at the mercy of other stakeholders. Namely, they are at the mercy of the ED. If the ED is busy, then so is the nocturnist. That special type of person knows the balance and becomes a specialist in ED dynamics, as well as in ED night staffing.

Nocturnists are expensive; we looked at MGMA and SHM data and realized that we would have to pay a 20% to 50% premium if we wanted to employ a true seven-on nocturnist. And if we wanted all nights covered, we would have to hire two of these doctors.

Another point of contention is the buy-in from administration. CEOs and CMOs often don’t understand the need to pay for a nocturnist, and more often than not, they fail to see the need to have a nocturnist employed in the first place.

Finally, in the event of sick time, holidays, or vacation time, the hospitalist team is at the mercy of the nocturnist in terms of necessitating coverage.

Internal Solution=Perfect Remedy

In addition to the aforementioned concerns, I recently experienced a “what’s most important to me?” moment at work with the expectation of my first child. I planned on returning to work after my maternity leave, but I was reassessing just exactly how much I wanted to come back to work. It was in this setting that I began to brainstorm ways to help the group with our concerns regarding working nights, as well as my own feelings of being torn with such a grueling schedule while having a new baby at home.

Then the solution hit me: a new nocturnist model.

After long discussions with the group and group leadership, we found, not surprisingly, there were a good number of people who valued time more than money. I fell into the category of desiring more time away over a premium salary. We also found two others like me who fit this same category. None of us were considered “nocturnists” up to this point, and none of us would have gone for the idea of being seven-on/seven-off nocturnists, either. So we needed a new plan.

And with a little brainstorming and schedule-wrenching, the new nocturnist was born at Lehigh Valley. We are a group of 17. By taking the three willing participants out of the pool of 17 hospitalists and asking them to exclusively work nights, rotating in a one-week-on, two-weeks-off rotation, we were able to still leave 14 doctors to run the day shifts. The daytime hospitalists would no longer have to work nights, drastically improving their quality of work life.

This was a huge step forward for our group. It was a morale boost for the daytime doctors and actually allowed the group to save money. We were looking for doctors 18 and 19, and instead found internal solutions to our night problems. The schedule fit together like a patchwork quilt.

In exchange for two weeks off, the three nocturnists agreed to no additional vacation time. Our salaries stayed the same, too. So from a budgetary standpoint, nothing changed. From a quality-of-life standpoint, everyone was happy. My nocturnist colleagues and I were happy to exchange working nights every third week for the same salary in exchange for more days off.

The new schedule even allowed the group to eliminate the middle shift, creating an additional hospitalist available for daytime rounding. And having three nocturnists creates a pool of night doctors who are readily available to cover each other’s sick or personal time.

In all fairness, this new model was not an easy sell to administration. But as the group became more stable and morale increased, we, as members of the group, relied on this stability. We also noticed an increase in recruitment. Veterans and rookies wanted to start in a practice that had its nights covered. Ultimately, increasing our daytime capacity increased our inpatient encounters, and by increasing recruitment and retaining our current staff, our administration saw the benefits.

Employing a team of nocturnists maintains group stability, is cost-effective, helps with retention, boosts morale, and is attractive new recruits. Hospitalist programs that are struggling with staffing should consider a similar approach—and remember that they might be able to change everyday life without changing the ever-important bottom line.

Dr. Verdetti-Healy is a nocturnist at Lehigh Valley Hospital in Allentown, Pa.

Daniel Bitetto, MD, SFHM, chief of the section of hospital medicine at Lehigh Valley Hospital in Allentown, Pa., contributed to this report.

Twenty-four-hour coverage is standard practice for all successful hospitalist groups. At Lehigh Valley Hospital in Allentown, Pa., the hospitalist group features 17 FTEs that split time in a traditional seven-on/seven-off schedule. Five doctors per week round on units seeing patients; one works triage/admitting in the morning and sees some follow-ups in the afternoon; and one works a middle shift for admissions, consults, and ICU transfers.

The foundation of this coverage comes at night. We employ an overnight doctor—a nocturnist—every day of the year. This doctor’s sole responsibility is to cover night admissions, rapid responses, floor calls, and transfers.

Change Is Necessary, Difficult

Lehigh Valley’s change to a nocturnist model came about when members of the group asked for it. We needed to put a model in place that could help the group, improve morale, and improve our care at night. Of all of our shifts, nobody wanted to work overnight. Each clinician was working about four weeks of nights per year, and we started to notice that our new hires from residency were the only ones truly capable of handling the sleep challenges—or, more truthfully, our veteran hospitalists were having difficulty with the nights.

For such a large group, having a nocturnist makes sense. However, there are a few issues to contend with in hiring a nocturnist. Most notably, nocturnists are hard to come by. It takes a special type of person to come in and work the opposite schedule from everyone else. Nocturnists are typically alone in the hospital and don’t always have the support of other hospitalists when times get tough. They usually are at the mercy of other stakeholders. Namely, they are at the mercy of the ED. If the ED is busy, then so is the nocturnist. That special type of person knows the balance and becomes a specialist in ED dynamics, as well as in ED night staffing.

Nocturnists are expensive; we looked at MGMA and SHM data and realized that we would have to pay a 20% to 50% premium if we wanted to employ a true seven-on nocturnist. And if we wanted all nights covered, we would have to hire two of these doctors.

Another point of contention is the buy-in from administration. CEOs and CMOs often don’t understand the need to pay for a nocturnist, and more often than not, they fail to see the need to have a nocturnist employed in the first place.

Finally, in the event of sick time, holidays, or vacation time, the hospitalist team is at the mercy of the nocturnist in terms of necessitating coverage.

Internal Solution=Perfect Remedy

In addition to the aforementioned concerns, I recently experienced a “what’s most important to me?” moment at work with the expectation of my first child. I planned on returning to work after my maternity leave, but I was reassessing just exactly how much I wanted to come back to work. It was in this setting that I began to brainstorm ways to help the group with our concerns regarding working nights, as well as my own feelings of being torn with such a grueling schedule while having a new baby at home.

Then the solution hit me: a new nocturnist model.

After long discussions with the group and group leadership, we found, not surprisingly, there were a good number of people who valued time more than money. I fell into the category of desiring more time away over a premium salary. We also found two others like me who fit this same category. None of us were considered “nocturnists” up to this point, and none of us would have gone for the idea of being seven-on/seven-off nocturnists, either. So we needed a new plan.

And with a little brainstorming and schedule-wrenching, the new nocturnist was born at Lehigh Valley. We are a group of 17. By taking the three willing participants out of the pool of 17 hospitalists and asking them to exclusively work nights, rotating in a one-week-on, two-weeks-off rotation, we were able to still leave 14 doctors to run the day shifts. The daytime hospitalists would no longer have to work nights, drastically improving their quality of work life.

This was a huge step forward for our group. It was a morale boost for the daytime doctors and actually allowed the group to save money. We were looking for doctors 18 and 19, and instead found internal solutions to our night problems. The schedule fit together like a patchwork quilt.

In exchange for two weeks off, the three nocturnists agreed to no additional vacation time. Our salaries stayed the same, too. So from a budgetary standpoint, nothing changed. From a quality-of-life standpoint, everyone was happy. My nocturnist colleagues and I were happy to exchange working nights every third week for the same salary in exchange for more days off.

The new schedule even allowed the group to eliminate the middle shift, creating an additional hospitalist available for daytime rounding. And having three nocturnists creates a pool of night doctors who are readily available to cover each other’s sick or personal time.

In all fairness, this new model was not an easy sell to administration. But as the group became more stable and morale increased, we, as members of the group, relied on this stability. We also noticed an increase in recruitment. Veterans and rookies wanted to start in a practice that had its nights covered. Ultimately, increasing our daytime capacity increased our inpatient encounters, and by increasing recruitment and retaining our current staff, our administration saw the benefits.

Employing a team of nocturnists maintains group stability, is cost-effective, helps with retention, boosts morale, and is attractive new recruits. Hospitalist programs that are struggling with staffing should consider a similar approach—and remember that they might be able to change everyday life without changing the ever-important bottom line.

Dr. Verdetti-Healy is a nocturnist at Lehigh Valley Hospital in Allentown, Pa.

Daniel Bitetto, MD, SFHM, chief of the section of hospital medicine at Lehigh Valley Hospital in Allentown, Pa., contributed to this report.

Twenty-four-hour coverage is standard practice for all successful hospitalist groups. At Lehigh Valley Hospital in Allentown, Pa., the hospitalist group features 17 FTEs that split time in a traditional seven-on/seven-off schedule. Five doctors per week round on units seeing patients; one works triage/admitting in the morning and sees some follow-ups in the afternoon; and one works a middle shift for admissions, consults, and ICU transfers.

The foundation of this coverage comes at night. We employ an overnight doctor—a nocturnist—every day of the year. This doctor’s sole responsibility is to cover night admissions, rapid responses, floor calls, and transfers.

Change Is Necessary, Difficult

Lehigh Valley’s change to a nocturnist model came about when members of the group asked for it. We needed to put a model in place that could help the group, improve morale, and improve our care at night. Of all of our shifts, nobody wanted to work overnight. Each clinician was working about four weeks of nights per year, and we started to notice that our new hires from residency were the only ones truly capable of handling the sleep challenges—or, more truthfully, our veteran hospitalists were having difficulty with the nights.

For such a large group, having a nocturnist makes sense. However, there are a few issues to contend with in hiring a nocturnist. Most notably, nocturnists are hard to come by. It takes a special type of person to come in and work the opposite schedule from everyone else. Nocturnists are typically alone in the hospital and don’t always have the support of other hospitalists when times get tough. They usually are at the mercy of other stakeholders. Namely, they are at the mercy of the ED. If the ED is busy, then so is the nocturnist. That special type of person knows the balance and becomes a specialist in ED dynamics, as well as in ED night staffing.

Nocturnists are expensive; we looked at MGMA and SHM data and realized that we would have to pay a 20% to 50% premium if we wanted to employ a true seven-on nocturnist. And if we wanted all nights covered, we would have to hire two of these doctors.

Another point of contention is the buy-in from administration. CEOs and CMOs often don’t understand the need to pay for a nocturnist, and more often than not, they fail to see the need to have a nocturnist employed in the first place.

Finally, in the event of sick time, holidays, or vacation time, the hospitalist team is at the mercy of the nocturnist in terms of necessitating coverage.

Internal Solution=Perfect Remedy

In addition to the aforementioned concerns, I recently experienced a “what’s most important to me?” moment at work with the expectation of my first child. I planned on returning to work after my maternity leave, but I was reassessing just exactly how much I wanted to come back to work. It was in this setting that I began to brainstorm ways to help the group with our concerns regarding working nights, as well as my own feelings of being torn with such a grueling schedule while having a new baby at home.

Then the solution hit me: a new nocturnist model.

After long discussions with the group and group leadership, we found, not surprisingly, there were a good number of people who valued time more than money. I fell into the category of desiring more time away over a premium salary. We also found two others like me who fit this same category. None of us were considered “nocturnists” up to this point, and none of us would have gone for the idea of being seven-on/seven-off nocturnists, either. So we needed a new plan.

And with a little brainstorming and schedule-wrenching, the new nocturnist was born at Lehigh Valley. We are a group of 17. By taking the three willing participants out of the pool of 17 hospitalists and asking them to exclusively work nights, rotating in a one-week-on, two-weeks-off rotation, we were able to still leave 14 doctors to run the day shifts. The daytime hospitalists would no longer have to work nights, drastically improving their quality of work life.

This was a huge step forward for our group. It was a morale boost for the daytime doctors and actually allowed the group to save money. We were looking for doctors 18 and 19, and instead found internal solutions to our night problems. The schedule fit together like a patchwork quilt.

In exchange for two weeks off, the three nocturnists agreed to no additional vacation time. Our salaries stayed the same, too. So from a budgetary standpoint, nothing changed. From a quality-of-life standpoint, everyone was happy. My nocturnist colleagues and I were happy to exchange working nights every third week for the same salary in exchange for more days off.

The new schedule even allowed the group to eliminate the middle shift, creating an additional hospitalist available for daytime rounding. And having three nocturnists creates a pool of night doctors who are readily available to cover each other’s sick or personal time.

In all fairness, this new model was not an easy sell to administration. But as the group became more stable and morale increased, we, as members of the group, relied on this stability. We also noticed an increase in recruitment. Veterans and rookies wanted to start in a practice that had its nights covered. Ultimately, increasing our daytime capacity increased our inpatient encounters, and by increasing recruitment and retaining our current staff, our administration saw the benefits.

Employing a team of nocturnists maintains group stability, is cost-effective, helps with retention, boosts morale, and is attractive new recruits. Hospitalist programs that are struggling with staffing should consider a similar approach—and remember that they might be able to change everyday life without changing the ever-important bottom line.

Dr. Verdetti-Healy is a nocturnist at Lehigh Valley Hospital in Allentown, Pa.

Daniel Bitetto, MD, SFHM, chief of the section of hospital medicine at Lehigh Valley Hospital in Allentown, Pa., contributed to this report.

Everything has a price, and we all have become accustomed to knowing how much something is going to cost before we buy it. Generally, we start with thinking about how much we are willing to pay, then finding what we need within the range of what we expect to pay. Whether it is shopping on Amazon.com, negotiating the price with a landscaper, or going out to eat, we get to weigh the options in advance of acquiring the goods or services. And, generally ahead of the purchase of big-ticket items, we get an itemized list of what is available.

I recently had to buy a car. Some of the many decisions that went into the purchase were whether to include some of the offered amenities, including:

• “Surround sound”;
• Seat heaters;
• Blind-spot indicator system;
• Premium floor mat package; and
• Built-in GPS.

My husband and I thought about the price of each of these line items relative to what we were going to “get out of it”—e.g., the value. Seat heaters in South Carolina? No, thanks. Surround sound? We had to flip a coin on that one. Safety features? Absolutely. Premium floor mat package? Only if they were guaranteed to be Fruit Roll-Ups-resistant.

Over the course of several negotiations, we picked and chose options that were highly likely to add value (safety, comfort, convenience) and omitted the rest. Then we settled on a total price, paid the negotiated price, and drove away fairly content.

Now, this doesn’t mean that we actually knew the cost of adding each of those amenities into our new car; would anyone actually be able to tell us exactly how much each of those features cost to innovate, create, and install? Probably not, but they might be able to give us a pretty good estimate, as well as an estimate of how much had been added in to ship it to the dealer, to pay the overhead for the dealership, and to pay the dealership staff (from the front desk to the CEO). And we could feel pretty certain that most buyers would be presented with similar prices, regardless of their personal characteristics.

So all in all, there was a reasonable amount of transparency around the cost and the price of the car and all of its amenities, as there would be in most industries. Except in health care.

A Ton of Money, for What?

There was a fascinating article in the March 4 edition of Time titled “Bitter Pill” that discussed the cost and the price of health-care services.¹ It certainly is a worthy topic, as the U.S. spends about 20% of our gross domestic product on health care, whereas most other developed countries spend half of that. In fact, according to the article, the U.S. spends more on health care annually ($2.8 trillion) than the top 10 countries combined—Japan, Germany, France, China, United Kingdom, Italy, Canada, Brazil, Spain, and Australia.

About $800 billion of our health care is paid out annually by the Centers for Medicare & Medicaid Services (CMS). CMS is an ongoing and substantial driver to the depth of the federal deficit. When Medicare was enacted in 1965, they expected the cost in 1990 to be about $12 billion per year, which was miscalculated by more than a factor of 10.

And the federal deficit, while insurmountably important, pales in comparison to the sobering statistic that 60% of personal bankruptcies are filed due to health-care bills.

Equally disappointing, the U.S. does not appear to get great value out of this exorbitant price tag, as our health-care outcomes certainly are not any better, and are sometimes worse, than other industrialized countries.

Elephants in the Room

The Time article talks extensively about the lack of transparency and drivers for cost in the industry. But there are two major, unreconciled questions the article fails to answer that are at the core of the issue:

1. Is health care in the U.S. a right or a luxury?
2. Can the U.S. health-care system be compassionate and restrictive at the same time?

You really don’t encounter the first question with any other industry. If I am hungry and do not have any money, I would not march into a restaurant and say, “I am hungry; therefore, you must feed me.” But we all feel like we can—and should—march into an emergency room and say, “I am sick; therefore, you must treat me,” no matter our financial situation. For all other industries, we rely on community resources, nonprofit agencies, and some state/federal funding to bridge gaps in basic necessities (food, housing, clothing, and transportation). And when those run short, people do without.

Car dealerships and Jiffy Lube do not have to follow any Emergency Medicine Treatment and Active Labor Act rules. If health care is a right, then we should not make individuals figure out how to get it, and we should not accept huge disparities in the provision of care based on personal characteristics.

My hospital, like most others in the U.S., is trying to figure out how to cut costs and do more with less. In a series of town-hall-style meetings, our leadership has been telling all of our hospital staff about planned cost-cutting and revenue-generating strategies. One of the tactics is to be more proactive and consistent with collecting copays in outpatient settings (before the delivery of any visit, test, or procedure) and to have parity with our local market on setting the price of those copays. But several employees were wrestling with the thought of collecting copays before the delivery of service. Some voiced a particular concern: “But what if they don’t have the money?” Again, not a conversation heard too often at car dealerships or Jiffy Lube.

The U.S. has a long way to go in reconciling these questions. Addressing them might be easier if there were more transparency in pricing. When you walk into Jiffy Lube, you are presented with all the things you might need for your car, based on make, model, and mileage; you get a listing of the cost of all the items, then you make decisions about what you do and do not need as you factor in what you are willing to spend. But when you go for your annual primary-care check-up, you are not presented a list of all the things you need (based on age, comorbidities, family history, etc.); you are not given a listing of the cost of those available services (check-up, eye exam, colonoscopy, pneumococcal vaccination); and rarely is there ever a discussion of what you are willing to spend. You just assume you need what is recommended, then get a bill later. There is almost no incentive for providers to discuss or present those prices to patients in advance. There is even less incentive to reduce the utilization of those offered services. And the price on the bill variably reflects the actual cost of the products/services provided.

In the hospital setting, the price of most products/services are based on the “chargemaster,” which is a fictional line listing of prices, which, according to the Time article, “gives them a big number to put in front of rich, uninsured patients” to make up for the losses in revenue from all other patients.

For the most part, health-care reform efforts have done little to address the two unanswered questions. And although reform efforts have triggered plenty of discussions about changing the rules on who pays for what and when, these efforts have done little to change the price or the cost of care, or make them more transparent.

The author of “Bitter Pill” makes an attempt to call out the “bad actors” in the industry, those who drive up the cost of health care—health-care leaders with generous salaries, pharmaceutical companies, device/product companies, trial lawyers, and profitable laboratory and radiology departments. But the article does not come close to capturing the other elephants in the room. Without confronting those issues, we will continue to fail to distinguish between the cost and the price, and any value within.

Reference

1. Brill S. Bitter pill: why medical bills are killing us. Time website. Available at: http://www.time.com/time/magazine/article/0,9171,2136864,00.html. Accessed March 26, 2013.

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].

Everything has a price, and we all have become accustomed to knowing how much something is going to cost before we buy it. Generally, we start with thinking about how much we are willing to pay, then finding what we need within the range of what we expect to pay. Whether it is shopping on Amazon.com, negotiating the price with a landscaper, or going out to eat, we get to weigh the options in advance of acquiring the goods or services. And, generally ahead of the purchase of big-ticket items, we get an itemized list of what is available.

I recently had to buy a car. Some of the many decisions that went into the purchase were whether to include some of the offered amenities, including:

• “Surround sound”;
• Seat heaters;
• Blind-spot indicator system;
• Premium floor mat package; and
• Built-in GPS.

My husband and I thought about the price of each of these line items relative to what we were going to “get out of it”—e.g., the value. Seat heaters in South Carolina? No, thanks. Surround sound? We had to flip a coin on that one. Safety features? Absolutely. Premium floor mat package? Only if they were guaranteed to be Fruit Roll-Ups-resistant.

Over the course of several negotiations, we picked and chose options that were highly likely to add value (safety, comfort, convenience) and omitted the rest. Then we settled on a total price, paid the negotiated price, and drove away fairly content.

Now, this doesn’t mean that we actually knew the cost of adding each of those amenities into our new car; would anyone actually be able to tell us exactly how much each of those features cost to innovate, create, and install? Probably not, but they might be able to give us a pretty good estimate, as well as an estimate of how much had been added in to ship it to the dealer, to pay the overhead for the dealership, and to pay the dealership staff (from the front desk to the CEO). And we could feel pretty certain that most buyers would be presented with similar prices, regardless of their personal characteristics.

So all in all, there was a reasonable amount of transparency around the cost and the price of the car and all of its amenities, as there would be in most industries. Except in health care.

A Ton of Money, for What?

There was a fascinating article in the March 4 edition of Time titled “Bitter Pill” that discussed the cost and the price of health-care services.¹ It certainly is a worthy topic, as the U.S. spends about 20% of our gross domestic product on health care, whereas most other developed countries spend half of that. In fact, according to the article, the U.S. spends more on health care annually ($2.8 trillion) than the top 10 countries combined—Japan, Germany, France, China, United Kingdom, Italy, Canada, Brazil, Spain, and Australia.

About $800 billion of our health care is paid out annually by the Centers for Medicare & Medicaid Services (CMS). CMS is an ongoing and substantial driver to the depth of the federal deficit. When Medicare was enacted in 1965, they expected the cost in 1990 to be about $12 billion per year, which was miscalculated by more than a factor of 10.

And the federal deficit, while insurmountably important, pales in comparison to the sobering statistic that 60% of personal bankruptcies are filed due to health-care bills.

Equally disappointing, the U.S. does not appear to get great value out of this exorbitant price tag, as our health-care outcomes certainly are not any better, and are sometimes worse, than other industrialized countries.

Elephants in the Room

The Time article talks extensively about the lack of transparency and drivers for cost in the industry. But there are two major, unreconciled questions the article fails to answer that are at the core of the issue:

1. Is health care in the U.S. a right or a luxury?
2. Can the U.S. health-care system be compassionate and restrictive at the same time?

You really don’t encounter the first question with any other industry. If I am hungry and do not have any money, I would not march into a restaurant and say, “I am hungry; therefore, you must feed me.” But we all feel like we can—and should—march into an emergency room and say, “I am sick; therefore, you must treat me,” no matter our financial situation. For all other industries, we rely on community resources, nonprofit agencies, and some state/federal funding to bridge gaps in basic necessities (food, housing, clothing, and transportation). And when those run short, people do without.

Car dealerships and Jiffy Lube do not have to follow any Emergency Medicine Treatment and Active Labor Act rules. If health care is a right, then we should not make individuals figure out how to get it, and we should not accept huge disparities in the provision of care based on personal characteristics.

My hospital, like most others in the U.S., is trying to figure out how to cut costs and do more with less. In a series of town-hall-style meetings, our leadership has been telling all of our hospital staff about planned cost-cutting and revenue-generating strategies. One of the tactics is to be more proactive and consistent with collecting copays in outpatient settings (before the delivery of any visit, test, or procedure) and to have parity with our local market on setting the price of those copays. But several employees were wrestling with the thought of collecting copays before the delivery of service. Some voiced a particular concern: “But what if they don’t have the money?” Again, not a conversation heard too often at car dealerships or Jiffy Lube.

The U.S. has a long way to go in reconciling these questions. Addressing them might be easier if there were more transparency in pricing. When you walk into Jiffy Lube, you are presented with all the things you might need for your car, based on make, model, and mileage; you get a listing of the cost of all the items, then you make decisions about what you do and do not need as you factor in what you are willing to spend. But when you go for your annual primary-care check-up, you are not presented a list of all the things you need (based on age, comorbidities, family history, etc.); you are not given a listing of the cost of those available services (check-up, eye exam, colonoscopy, pneumococcal vaccination); and rarely is there ever a discussion of what you are willing to spend. You just assume you need what is recommended, then get a bill later. There is almost no incentive for providers to discuss or present those prices to patients in advance. There is even less incentive to reduce the utilization of those offered services. And the price on the bill variably reflects the actual cost of the products/services provided.

In the hospital setting, the price of most products/services are based on the “chargemaster,” which is a fictional line listing of prices, which, according to the Time article, “gives them a big number to put in front of rich, uninsured patients” to make up for the losses in revenue from all other patients.

For the most part, health-care reform efforts have done little to address the two unanswered questions. And although reform efforts have triggered plenty of discussions about changing the rules on who pays for what and when, these efforts have done little to change the price or the cost of care, or make them more transparent.

The author of “Bitter Pill” makes an attempt to call out the “bad actors” in the industry, those who drive up the cost of health care—health-care leaders with generous salaries, pharmaceutical companies, device/product companies, trial lawyers, and profitable laboratory and radiology departments. But the article does not come close to capturing the other elephants in the room. Without confronting those issues, we will continue to fail to distinguish between the cost and the price, and any value within.

Reference

1. Brill S. Bitter pill: why medical bills are killing us. Time website. Available at: http://www.time.com/time/magazine/article/0,9171,2136864,00.html. Accessed March 26, 2013.

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].

Everything has a price, and we all have become accustomed to knowing how much something is going to cost before we buy it. Generally, we start with thinking about how much we are willing to pay, then finding what we need within the range of what we expect to pay. Whether it is shopping on Amazon.com, negotiating the price with a landscaper, or going out to eat, we get to weigh the options in advance of acquiring the goods or services. And, generally ahead of the purchase of big-ticket items, we get an itemized list of what is available.

I recently had to buy a car. Some of the many decisions that went into the purchase were whether to include some of the offered amenities, including:

• “Surround sound”;
• Seat heaters;
• Blind-spot indicator system;
• Premium floor mat package; and
• Built-in GPS.

My husband and I thought about the price of each of these line items relative to what we were going to “get out of it”—e.g., the value. Seat heaters in South Carolina? No, thanks. Surround sound? We had to flip a coin on that one. Safety features? Absolutely. Premium floor mat package? Only if they were guaranteed to be Fruit Roll-Ups-resistant.

Over the course of several negotiations, we picked and chose options that were highly likely to add value (safety, comfort, convenience) and omitted the rest. Then we settled on a total price, paid the negotiated price, and drove away fairly content.

Now, this doesn’t mean that we actually knew the cost of adding each of those amenities into our new car; would anyone actually be able to tell us exactly how much each of those features cost to innovate, create, and install? Probably not, but they might be able to give us a pretty good estimate, as well as an estimate of how much had been added in to ship it to the dealer, to pay the overhead for the dealership, and to pay the dealership staff (from the front desk to the CEO). And we could feel pretty certain that most buyers would be presented with similar prices, regardless of their personal characteristics.

So all in all, there was a reasonable amount of transparency around the cost and the price of the car and all of its amenities, as there would be in most industries. Except in health care.

A Ton of Money, for What?

There was a fascinating article in the March 4 edition of Time titled “Bitter Pill” that discussed the cost and the price of health-care services.¹ It certainly is a worthy topic, as the U.S. spends about 20% of our gross domestic product on health care, whereas most other developed countries spend half of that. In fact, according to the article, the U.S. spends more on health care annually ($2.8 trillion) than the top 10 countries combined—Japan, Germany, France, China, United Kingdom, Italy, Canada, Brazil, Spain, and Australia.

About $800 billion of our health care is paid out annually by the Centers for Medicare & Medicaid Services (CMS). CMS is an ongoing and substantial driver to the depth of the federal deficit. When Medicare was enacted in 1965, they expected the cost in 1990 to be about $12 billion per year, which was miscalculated by more than a factor of 10.

And the federal deficit, while insurmountably important, pales in comparison to the sobering statistic that 60% of personal bankruptcies are filed due to health-care bills.

Equally disappointing, the U.S. does not appear to get great value out of this exorbitant price tag, as our health-care outcomes certainly are not any better, and are sometimes worse, than other industrialized countries.

Elephants in the Room

The Time article talks extensively about the lack of transparency and drivers for cost in the industry. But there are two major, unreconciled questions the article fails to answer that are at the core of the issue:

1. Is health care in the U.S. a right or a luxury?
2. Can the U.S. health-care system be compassionate and restrictive at the same time?

You really don’t encounter the first question with any other industry. If I am hungry and do not have any money, I would not march into a restaurant and say, “I am hungry; therefore, you must feed me.” But we all feel like we can—and should—march into an emergency room and say, “I am sick; therefore, you must treat me,” no matter our financial situation. For all other industries, we rely on community resources, nonprofit agencies, and some state/federal funding to bridge gaps in basic necessities (food, housing, clothing, and transportation). And when those run short, people do without.

Car dealerships and Jiffy Lube do not have to follow any Emergency Medicine Treatment and Active Labor Act rules. If health care is a right, then we should not make individuals figure out how to get it, and we should not accept huge disparities in the provision of care based on personal characteristics.

My hospital, like most others in the U.S., is trying to figure out how to cut costs and do more with less. In a series of town-hall-style meetings, our leadership has been telling all of our hospital staff about planned cost-cutting and revenue-generating strategies. One of the tactics is to be more proactive and consistent with collecting copays in outpatient settings (before the delivery of any visit, test, or procedure) and to have parity with our local market on setting the price of those copays. But several employees were wrestling with the thought of collecting copays before the delivery of service. Some voiced a particular concern: “But what if they don’t have the money?” Again, not a conversation heard too often at car dealerships or Jiffy Lube.

The U.S. has a long way to go in reconciling these questions. Addressing them might be easier if there were more transparency in pricing. When you walk into Jiffy Lube, you are presented with all the things you might need for your car, based on make, model, and mileage; you get a listing of the cost of all the items, then you make decisions about what you do and do not need as you factor in what you are willing to spend. But when you go for your annual primary-care check-up, you are not presented a list of all the things you need (based on age, comorbidities, family history, etc.); you are not given a listing of the cost of those available services (check-up, eye exam, colonoscopy, pneumococcal vaccination); and rarely is there ever a discussion of what you are willing to spend. You just assume you need what is recommended, then get a bill later. There is almost no incentive for providers to discuss or present those prices to patients in advance. There is even less incentive to reduce the utilization of those offered services. And the price on the bill variably reflects the actual cost of the products/services provided.

In the hospital setting, the price of most products/services are based on the “chargemaster,” which is a fictional line listing of prices, which, according to the Time article, “gives them a big number to put in front of rich, uninsured patients” to make up for the losses in revenue from all other patients.

For the most part, health-care reform efforts have done little to address the two unanswered questions. And although reform efforts have triggered plenty of discussions about changing the rules on who pays for what and when, these efforts have done little to change the price or the cost of care, or make them more transparent.

The author of “Bitter Pill” makes an attempt to call out the “bad actors” in the industry, those who drive up the cost of health care—health-care leaders with generous salaries, pharmaceutical companies, device/product companies, trial lawyers, and profitable laboratory and radiology departments. But the article does not come close to capturing the other elephants in the room. Without confronting those issues, we will continue to fail to distinguish between the cost and the price, and any value within.

Reference

1. Brill S. Bitter pill: why medical bills are killing us. Time website. Available at: http://www.time.com/time/magazine/article/0,9171,2136864,00.html. Accessed March 26, 2013.

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].

Judy Shumway, DO

Judy Shumway, DO, practice group leader and regional medical director of IPC: The Hospitalist Company’s San Antonio region, received IPC’s Hospitalist of the Year award for acute-care practice. Dr. Shumway helped pioneer the hospitalist program at Methodist Stone Oak Hospital in San Antonio. She has been a hospitalist with IPC since 2007.

Rafael Rondon, MD

Rafael Rondon, MD, practice group leader in IPC: The Hospitalist Company’s Tampa, Fla., region, received IPC’s Hospitalist of the Year award for post-acute care. Dr. Rondon has been with IPC since 2008. He is actively pursuing the IPC-UCSF Fellowship Program for Hospitalist Leaders.

Ty Montgomery, FN-C

Ty Montgomery, FN-C, a nurse practitioner and practice group representative in IPC: The Hospitalist Company’s Phoenix region, has been awarded IPC’s Hospitalist of the Year award for non-physician providers. Montgomery was recognized for helping to bring the hospitalist care model to northern Arizona’s rural communities.

Gary G. Gammon, MD

Gary G. Gammon, MD, has been named the new medical director of hospitalist services at Moore Regional Hospital (MRH) in Pinehurst, N.C. Dr. Gammon previously worked for the hospitalist program at Gaston Memorial Hospital in Gastonia, N.C. In his new role, Dr. Gammon will oversee 36 hospitalists and 15 nonphysician providers in the hospitalist service.

Kerry Weiner, MD

Kerry Weiner, MD, is the new chief medical officer at North Hollywood, Calif.-based IPC: The Hospitalist Company. Prior to his new position, Dr. Weiner served as IPC’s chief clinical officer. Before joining IPC in 2011, he served as CMO for Lakeside Medical Organization, a multispecialty community health-care provider based in Northridge, Calif.

Business Moves

Sound Physicians, based in Tacoma, Wash., has announced plans to begin managing hospitalist services at Sentara Obici Hospital in Suffolk, Va. The 168-bed facility is one of 10 Sentara Medical Group acute-care hospitals throughout Virginia. Sound Physicians manages more than 650 hospitalists at more than 70 facilities across the U.S.

Hillsdale Community Health Center in Hillsdale, Mich., has announced plans to launch a new hospitalist program later this year. The 78-bed community hospital will begin staffing six hospitalists to serve its patients.

The South Bend, Ind.-based OB/GYN Associates of Northern Indiana is offering OB hospitalist services at Saint Joseph Regional Medical Center in Mishawaka. OBNI will provide round-the-clock services at the 286-bed acute-care facility.

Henry County Health Center in Mount Pleasant, Iowa, in partnership with nearby Family Medicine of Mt. Pleasant, has launched a new hospitalist program at the 74-bed community hospital. The program will begin with two hospitalists, and Family Medicine of Mt. Pleasant will provide supplementary coverage as needed.

Reference

1. Dr. Robert Stoelting (President, Anesthesia Patient Safety Foundation) slides presented January 13, 2013 at The Patient Safety, Science & Technology Summit (http://www.patientsafetysummit.org).

Judy Shumway, DO

Judy Shumway, DO, practice group leader and regional medical director of IPC: The Hospitalist Company’s San Antonio region, received IPC’s Hospitalist of the Year award for acute-care practice. Dr. Shumway helped pioneer the hospitalist program at Methodist Stone Oak Hospital in San Antonio. She has been a hospitalist with IPC since 2007.

Rafael Rondon, MD

Rafael Rondon, MD, practice group leader in IPC: The Hospitalist Company’s Tampa, Fla., region, received IPC’s Hospitalist of the Year award for post-acute care. Dr. Rondon has been with IPC since 2008. He is actively pursuing the IPC-UCSF Fellowship Program for Hospitalist Leaders.

Ty Montgomery, FN-C

Ty Montgomery, FN-C, a nurse practitioner and practice group representative in IPC: The Hospitalist Company’s Phoenix region, has been awarded IPC’s Hospitalist of the Year award for non-physician providers. Montgomery was recognized for helping to bring the hospitalist care model to northern Arizona’s rural communities.

Gary G. Gammon, MD

Gary G. Gammon, MD, has been named the new medical director of hospitalist services at Moore Regional Hospital (MRH) in Pinehurst, N.C. Dr. Gammon previously worked for the hospitalist program at Gaston Memorial Hospital in Gastonia, N.C. In his new role, Dr. Gammon will oversee 36 hospitalists and 15 nonphysician providers in the hospitalist service.

Kerry Weiner, MD

Kerry Weiner, MD, is the new chief medical officer at North Hollywood, Calif.-based IPC: The Hospitalist Company. Prior to his new position, Dr. Weiner served as IPC’s chief clinical officer. Before joining IPC in 2011, he served as CMO for Lakeside Medical Organization, a multispecialty community health-care provider based in Northridge, Calif.

Business Moves

Sound Physicians, based in Tacoma, Wash., has announced plans to begin managing hospitalist services at Sentara Obici Hospital in Suffolk, Va. The 168-bed facility is one of 10 Sentara Medical Group acute-care hospitals throughout Virginia. Sound Physicians manages more than 650 hospitalists at more than 70 facilities across the U.S.

Hillsdale Community Health Center in Hillsdale, Mich., has announced plans to launch a new hospitalist program later this year. The 78-bed community hospital will begin staffing six hospitalists to serve its patients.

The South Bend, Ind.-based OB/GYN Associates of Northern Indiana is offering OB hospitalist services at Saint Joseph Regional Medical Center in Mishawaka. OBNI will provide round-the-clock services at the 286-bed acute-care facility.

Henry County Health Center in Mount Pleasant, Iowa, in partnership with nearby Family Medicine of Mt. Pleasant, has launched a new hospitalist program at the 74-bed community hospital. The program will begin with two hospitalists, and Family Medicine of Mt. Pleasant will provide supplementary coverage as needed.

Reference

1. Dr. Robert Stoelting (President, Anesthesia Patient Safety Foundation) slides presented January 13, 2013 at The Patient Safety, Science & Technology Summit (http://www.patientsafetysummit.org).

Judy Shumway, DO

Judy Shumway, DO, practice group leader and regional medical director of IPC: The Hospitalist Company’s San Antonio region, received IPC’s Hospitalist of the Year award for acute-care practice. Dr. Shumway helped pioneer the hospitalist program at Methodist Stone Oak Hospital in San Antonio. She has been a hospitalist with IPC since 2007.

Rafael Rondon, MD

Rafael Rondon, MD, practice group leader in IPC: The Hospitalist Company’s Tampa, Fla., region, received IPC’s Hospitalist of the Year award for post-acute care. Dr. Rondon has been with IPC since 2008. He is actively pursuing the IPC-UCSF Fellowship Program for Hospitalist Leaders.

Ty Montgomery, FN-C

Ty Montgomery, FN-C, a nurse practitioner and practice group representative in IPC: The Hospitalist Company’s Phoenix region, has been awarded IPC’s Hospitalist of the Year award for non-physician providers. Montgomery was recognized for helping to bring the hospitalist care model to northern Arizona’s rural communities.

Gary G. Gammon, MD

Gary G. Gammon, MD, has been named the new medical director of hospitalist services at Moore Regional Hospital (MRH) in Pinehurst, N.C. Dr. Gammon previously worked for the hospitalist program at Gaston Memorial Hospital in Gastonia, N.C. In his new role, Dr. Gammon will oversee 36 hospitalists and 15 nonphysician providers in the hospitalist service.

Kerry Weiner, MD

Kerry Weiner, MD, is the new chief medical officer at North Hollywood, Calif.-based IPC: The Hospitalist Company. Prior to his new position, Dr. Weiner served as IPC’s chief clinical officer. Before joining IPC in 2011, he served as CMO for Lakeside Medical Organization, a multispecialty community health-care provider based in Northridge, Calif.

Business Moves

Sound Physicians, based in Tacoma, Wash., has announced plans to begin managing hospitalist services at Sentara Obici Hospital in Suffolk, Va. The 168-bed facility is one of 10 Sentara Medical Group acute-care hospitals throughout Virginia. Sound Physicians manages more than 650 hospitalists at more than 70 facilities across the U.S.

Hillsdale Community Health Center in Hillsdale, Mich., has announced plans to launch a new hospitalist program later this year. The 78-bed community hospital will begin staffing six hospitalists to serve its patients.

The South Bend, Ind.-based OB/GYN Associates of Northern Indiana is offering OB hospitalist services at Saint Joseph Regional Medical Center in Mishawaka. OBNI will provide round-the-clock services at the 286-bed acute-care facility.

Henry County Health Center in Mount Pleasant, Iowa, in partnership with nearby Family Medicine of Mt. Pleasant, has launched a new hospitalist program at the 74-bed community hospital. The program will begin with two hospitalists, and Family Medicine of Mt. Pleasant will provide supplementary coverage as needed.

Reference

1. Dr. Robert Stoelting (President, Anesthesia Patient Safety Foundation) slides presented January 13, 2013 at The Patient Safety, Science & Technology Summit (http://www.patientsafetysummit.org).

Dr. Hospitalist

Hospitalists Should Not Hesitate to Join Hospital Committees

What’s the story with hospital committee work? Is this part of my job?

–Timothy P. Young, Fort Worth, Texas

Dr. Hospitalist responds:

Yes. Allow me to explain. It’s 2013, and hospitalists are the physician workforce in the hospital. Yes, radiologists, anesthesiologists, and ED physicians are hospital-based, but their work is location-focused, not longitudinal and cross-discipline, as it is for general hospitalists. A hospital has a rather cumbersome administrative apparatus, and, as in any large organization, committees are its lifeblood. Your hospital leadership also will appreciate your contribution in a role outside of day-to-day clinical work.

The standing rule in our group is that every hospitalist must serve on at least one hospital committee. Here are three committees that strike me as most vital to our job:

Peer review: Arguably, this is the committee with the most impact in the hospital when it is run correctly. Although its stated objective is to review physician-related clinical concerns, don’t be surprised if offending physicians interpret clinical complaints as political grievances. This requires a thick skin and the ability to park your allegiances at the door. Physicians generally have done a pretty poor job policing themselves over the years, and while this committee does not need to be Draconian in nature, it should review complaints seriously and objectively. That also means recusing yourself from discussions involving your partners.

Credentialing: Another essential committee. I can’t tell you the number of times over the years we have hired a new physician with a specific start date in mind, only to miss that date over a delay with hospital credentialing. Talk about a morale killer—when everyone is overworked and the promised extra help doesn’t arrive ... ouch. Having a representative on this committee is no guarantee of punctual credentialing; however, it can help your group stay on top of expected deadlines and potential hiccups.

Information technology: EMR? Meaningful use? CPOE? Physician champion for IT issues? At the rate we’re going, it looks like all of us are going to work for the IT department someday. Lovely as these people are, they often have imperfect insight into the day-to-day workload of a hospitalist. Little things—such as the fact that a computer workstation also needs a telephone so you can answer pages—will never make it onto their radar screen without physician input.

Other committees of note: internal medicine, pharmacy and therapeutics (P&T), infection control, quality control, patient safety, ethics, and executive council. One caveat: The importance of these committees will vary greatly from hospital to hospital, so if you are new, take the time to ask around and get the lay of the land. My list and the rankings are by no means definitive.

Go ahead and join a committee, even if it does not happen to be your first choice. It does not mean that you will be on that committee for life, but it will grant you good exposure across multiple disciplines in the hospital. Overall, for your practice health, your group should be well represented on hospital committees.

Dr. Hospitalist

Hospitalists Should Not Hesitate to Join Hospital Committees

What’s the story with hospital committee work? Is this part of my job?

–Timothy P. Young, Fort Worth, Texas

Dr. Hospitalist responds:

Yes. Allow me to explain. It’s 2013, and hospitalists are the physician workforce in the hospital. Yes, radiologists, anesthesiologists, and ED physicians are hospital-based, but their work is location-focused, not longitudinal and cross-discipline, as it is for general hospitalists. A hospital has a rather cumbersome administrative apparatus, and, as in any large organization, committees are its lifeblood. Your hospital leadership also will appreciate your contribution in a role outside of day-to-day clinical work.

The standing rule in our group is that every hospitalist must serve on at least one hospital committee. Here are three committees that strike me as most vital to our job:

Peer review: Arguably, this is the committee with the most impact in the hospital when it is run correctly. Although its stated objective is to review physician-related clinical concerns, don’t be surprised if offending physicians interpret clinical complaints as political grievances. This requires a thick skin and the ability to park your allegiances at the door. Physicians generally have done a pretty poor job policing themselves over the years, and while this committee does not need to be Draconian in nature, it should review complaints seriously and objectively. That also means recusing yourself from discussions involving your partners.

Credentialing: Another essential committee. I can’t tell you the number of times over the years we have hired a new physician with a specific start date in mind, only to miss that date over a delay with hospital credentialing. Talk about a morale killer—when everyone is overworked and the promised extra help doesn’t arrive ... ouch. Having a representative on this committee is no guarantee of punctual credentialing; however, it can help your group stay on top of expected deadlines and potential hiccups.

Information technology: EMR? Meaningful use? CPOE? Physician champion for IT issues? At the rate we’re going, it looks like all of us are going to work for the IT department someday. Lovely as these people are, they often have imperfect insight into the day-to-day workload of a hospitalist. Little things—such as the fact that a computer workstation also needs a telephone so you can answer pages—will never make it onto their radar screen without physician input.

Other committees of note: internal medicine, pharmacy and therapeutics (P&T), infection control, quality control, patient safety, ethics, and executive council. One caveat: The importance of these committees will vary greatly from hospital to hospital, so if you are new, take the time to ask around and get the lay of the land. My list and the rankings are by no means definitive.

Go ahead and join a committee, even if it does not happen to be your first choice. It does not mean that you will be on that committee for life, but it will grant you good exposure across multiple disciplines in the hospital. Overall, for your practice health, your group should be well represented on hospital committees.

Dr. Hospitalist

Hospitalists Should Not Hesitate to Join Hospital Committees

What’s the story with hospital committee work? Is this part of my job?

–Timothy P. Young, Fort Worth, Texas

Dr. Hospitalist responds:

Yes. Allow me to explain. It’s 2013, and hospitalists are the physician workforce in the hospital. Yes, radiologists, anesthesiologists, and ED physicians are hospital-based, but their work is location-focused, not longitudinal and cross-discipline, as it is for general hospitalists. A hospital has a rather cumbersome administrative apparatus, and, as in any large organization, committees are its lifeblood. Your hospital leadership also will appreciate your contribution in a role outside of day-to-day clinical work.

The standing rule in our group is that every hospitalist must serve on at least one hospital committee. Here are three committees that strike me as most vital to our job:

Peer review: Arguably, this is the committee with the most impact in the hospital when it is run correctly. Although its stated objective is to review physician-related clinical concerns, don’t be surprised if offending physicians interpret clinical complaints as political grievances. This requires a thick skin and the ability to park your allegiances at the door. Physicians generally have done a pretty poor job policing themselves over the years, and while this committee does not need to be Draconian in nature, it should review complaints seriously and objectively. That also means recusing yourself from discussions involving your partners.

Credentialing: Another essential committee. I can’t tell you the number of times over the years we have hired a new physician with a specific start date in mind, only to miss that date over a delay with hospital credentialing. Talk about a morale killer—when everyone is overworked and the promised extra help doesn’t arrive ... ouch. Having a representative on this committee is no guarantee of punctual credentialing; however, it can help your group stay on top of expected deadlines and potential hiccups.

Information technology: EMR? Meaningful use? CPOE? Physician champion for IT issues? At the rate we’re going, it looks like all of us are going to work for the IT department someday. Lovely as these people are, they often have imperfect insight into the day-to-day workload of a hospitalist. Little things—such as the fact that a computer workstation also needs a telephone so you can answer pages—will never make it onto their radar screen without physician input.

Other committees of note: internal medicine, pharmacy and therapeutics (P&T), infection control, quality control, patient safety, ethics, and executive council. One caveat: The importance of these committees will vary greatly from hospital to hospital, so if you are new, take the time to ask around and get the lay of the land. My list and the rankings are by no means definitive.

Go ahead and join a committee, even if it does not happen to be your first choice. It does not mean that you will be on that committee for life, but it will grant you good exposure across multiple disciplines in the hospital. Overall, for your practice health, your group should be well represented on hospital committees.

A study is underway to assess the impact of a dermatologist’s consultation for patients admitted to the hospital with cellulitis.

Started last October, the randomized controlled trial is comparing patients overseen by internal-medicine hospitalists alone to those who are also evaluated by a dermatologist soon after admission to Massachusetts General Hospital in Boston. Daniela Kroshinsky, MD, MPH, the principal investigator, hypothesizes that hospital admission for cellulitis involving consultation with a dermatologist might decrease length of stay, readmission rates, incidence of pseudocellulitis, cost, and/or antibiotic usage.

“We did a similar study in the outpatient setting that demonstrated over 80 percent reduction in antibiotic use,” says Dr. Kroshinsky, the hospital’s director of pediatric dermatology and director of inpatient dermatology, education, and research.

Patients in the control group are instructed to follow hospitalists’ recommendations solely. This includes the timing and type of post-discharge appointments. As part of the standard of care, these patients can consult with a dermatologist if necessary or requested.

Patients randomized to the treatment group receive a consultation with a dermatologist, along with treatment recommendations. They also have a follow-up visit in a dermatology clinic after discharge. Both groups will be assessed for readmission or complications.

A study is underway to assess the impact of a dermatologist’s consultation for patients admitted to the hospital with cellulitis.

Started last October, the randomized controlled trial is comparing patients overseen by internal-medicine hospitalists alone to those who are also evaluated by a dermatologist soon after admission to Massachusetts General Hospital in Boston. Daniela Kroshinsky, MD, MPH, the principal investigator, hypothesizes that hospital admission for cellulitis involving consultation with a dermatologist might decrease length of stay, readmission rates, incidence of pseudocellulitis, cost, and/or antibiotic usage.

“We did a similar study in the outpatient setting that demonstrated over 80 percent reduction in antibiotic use,” says Dr. Kroshinsky, the hospital’s director of pediatric dermatology and director of inpatient dermatology, education, and research.

Patients in the control group are instructed to follow hospitalists’ recommendations solely. This includes the timing and type of post-discharge appointments. As part of the standard of care, these patients can consult with a dermatologist if necessary or requested.

Patients randomized to the treatment group receive a consultation with a dermatologist, along with treatment recommendations. They also have a follow-up visit in a dermatology clinic after discharge. Both groups will be assessed for readmission or complications.

A study is underway to assess the impact of a dermatologist’s consultation for patients admitted to the hospital with cellulitis.

Started last October, the randomized controlled trial is comparing patients overseen by internal-medicine hospitalists alone to those who are also evaluated by a dermatologist soon after admission to Massachusetts General Hospital in Boston. Daniela Kroshinsky, MD, MPH, the principal investigator, hypothesizes that hospital admission for cellulitis involving consultation with a dermatologist might decrease length of stay, readmission rates, incidence of pseudocellulitis, cost, and/or antibiotic usage.

“We did a similar study in the outpatient setting that demonstrated over 80 percent reduction in antibiotic use,” says Dr. Kroshinsky, the hospital’s director of pediatric dermatology and director of inpatient dermatology, education, and research.

Patients in the control group are instructed to follow hospitalists’ recommendations solely. This includes the timing and type of post-discharge appointments. As part of the standard of care, these patients can consult with a dermatologist if necessary or requested.

Patients randomized to the treatment group receive a consultation with a dermatologist, along with treatment recommendations. They also have a follow-up visit in a dermatology clinic after discharge. Both groups will be assessed for readmission or complications.

Experienced hospitalists and medical directors agree that the key to multiple hospitalist groups coexisting effectively under one roof—whether directly competing or not—is good communication. Effective communication can take time to build.

“Start by working together on something—anything, [such as] a hospital committee of some sort where there’s not likely to be much tension,” says hospitalist pioneer and practice consultant John Nelson, MD, MHM.

Dr. Nelson practices at Overlake Hospital in Bellevue, Wash., which has a hospitalist group employed by the hospital and another employed by Group Health Cooperative, a nonprofit health system in Washington state. It is important to put some trust in the trust bank, he says, “and that’s hard if you have no social connections at all. At my hospital, we enjoy each other’s company, we visit each other at lunch, and we even tried to have a journal club.” The two hospitalist groups work together on developing care protocols. Dr. Nelson says it also makes sense for the groups’ leaders to sit down together on a regular basis and have a venue for discussing important issues and solving problems that may arise.

Other suggestions for hospitalist groups working together under one roof include:

• Clearly define each group’s territory. The groups’ representatives can go out and try to persuade health plans or physician groups to shift their hospitalist allegiances, but there should be no “trolling” or “poaching” of patients going on inside the hospital’s walls. That will only confuse patients and disrupt the hospital’s larger service goals.
• Inform the ED and other key staff of your schedules. It’s important that everyone know exactly who is supposed to get which patients, and how these referrals get made. But recognize that mistakes happen and, hopefully, these will even out between the groups over time.
• Transparency, honesty, and even-handed treatment of all hospitalists can prevent resentment. Clearly defined guidelines and expectations are helpful. If the policy spells out transfers for an incorrectly referred patient, both sides should be accessible and cooperative with that process.
• Identify areas of common interest and agree to work together on these areas (i.e. competition-free zones). It might be possible, for example, for competing groups to take each others’ after-hours call on a rotating basis, with a firm commitment not to steal patients along the way.
• Spell out responsibilities in a way that everyone can agree is fair, such as alternating referrals or taking call on alternating days. For example, if subsidies are paid to more than one hospitalist group, is this done equitably, such as based on the number of hospitalist FTEs or shifts?
• Restrictive covenants and contractual noncompete clauses could become an issue in areas where multiple groups practice. Rather than using overly broad, blanket language, it could be clarified that such pacts apply only to the hospital where the physician currently works, and within a reasonable time frame. But everyone involved should be aware of what these covenants contain and, if they appear unreasonable, don’t sign them.

—Larry Beresford

Experienced hospitalists and medical directors agree that the key to multiple hospitalist groups coexisting effectively under one roof—whether directly competing or not—is good communication. Effective communication can take time to build.

“Start by working together on something—anything, [such as] a hospital committee of some sort where there’s not likely to be much tension,” says hospitalist pioneer and practice consultant John Nelson, MD, MHM.

Dr. Nelson practices at Overlake Hospital in Bellevue, Wash., which has a hospitalist group employed by the hospital and another employed by Group Health Cooperative, a nonprofit health system in Washington state. It is important to put some trust in the trust bank, he says, “and that’s hard if you have no social connections at all. At my hospital, we enjoy each other’s company, we visit each other at lunch, and we even tried to have a journal club.” The two hospitalist groups work together on developing care protocols. Dr. Nelson says it also makes sense for the groups’ leaders to sit down together on a regular basis and have a venue for discussing important issues and solving problems that may arise.

Other suggestions for hospitalist groups working together under one roof include:

• Clearly define each group’s territory. The groups’ representatives can go out and try to persuade health plans or physician groups to shift their hospitalist allegiances, but there should be no “trolling” or “poaching” of patients going on inside the hospital’s walls. That will only confuse patients and disrupt the hospital’s larger service goals.
• Inform the ED and other key staff of your schedules. It’s important that everyone know exactly who is supposed to get which patients, and how these referrals get made. But recognize that mistakes happen and, hopefully, these will even out between the groups over time.
• Transparency, honesty, and even-handed treatment of all hospitalists can prevent resentment. Clearly defined guidelines and expectations are helpful. If the policy spells out transfers for an incorrectly referred patient, both sides should be accessible and cooperative with that process.
• Identify areas of common interest and agree to work together on these areas (i.e. competition-free zones). It might be possible, for example, for competing groups to take each others’ after-hours call on a rotating basis, with a firm commitment not to steal patients along the way.
• Spell out responsibilities in a way that everyone can agree is fair, such as alternating referrals or taking call on alternating days. For example, if subsidies are paid to more than one hospitalist group, is this done equitably, such as based on the number of hospitalist FTEs or shifts?
• Restrictive covenants and contractual noncompete clauses could become an issue in areas where multiple groups practice. Rather than using overly broad, blanket language, it could be clarified that such pacts apply only to the hospital where the physician currently works, and within a reasonable time frame. But everyone involved should be aware of what these covenants contain and, if they appear unreasonable, don’t sign them.

—Larry Beresford

Experienced hospitalists and medical directors agree that the key to multiple hospitalist groups coexisting effectively under one roof—whether directly competing or not—is good communication. Effective communication can take time to build.

“Start by working together on something—anything, [such as] a hospital committee of some sort where there’s not likely to be much tension,” says hospitalist pioneer and practice consultant John Nelson, MD, MHM.

Dr. Nelson practices at Overlake Hospital in Bellevue, Wash., which has a hospitalist group employed by the hospital and another employed by Group Health Cooperative, a nonprofit health system in Washington state. It is important to put some trust in the trust bank, he says, “and that’s hard if you have no social connections at all. At my hospital, we enjoy each other’s company, we visit each other at lunch, and we even tried to have a journal club.” The two hospitalist groups work together on developing care protocols. Dr. Nelson says it also makes sense for the groups’ leaders to sit down together on a regular basis and have a venue for discussing important issues and solving problems that may arise.

Other suggestions for hospitalist groups working together under one roof include:

• Clearly define each group’s territory. The groups’ representatives can go out and try to persuade health plans or physician groups to shift their hospitalist allegiances, but there should be no “trolling” or “poaching” of patients going on inside the hospital’s walls. That will only confuse patients and disrupt the hospital’s larger service goals.
• Inform the ED and other key staff of your schedules. It’s important that everyone know exactly who is supposed to get which patients, and how these referrals get made. But recognize that mistakes happen and, hopefully, these will even out between the groups over time.
• Transparency, honesty, and even-handed treatment of all hospitalists can prevent resentment. Clearly defined guidelines and expectations are helpful. If the policy spells out transfers for an incorrectly referred patient, both sides should be accessible and cooperative with that process.
• Identify areas of common interest and agree to work together on these areas (i.e. competition-free zones). It might be possible, for example, for competing groups to take each others’ after-hours call on a rotating basis, with a firm commitment not to steal patients along the way.
• Spell out responsibilities in a way that everyone can agree is fair, such as alternating referrals or taking call on alternating days. For example, if subsidies are paid to more than one hospitalist group, is this done equitably, such as based on the number of hospitalist FTEs or shifts?
• Restrictive covenants and contractual noncompete clauses could become an issue in areas where multiple groups practice. Rather than using overly broad, blanket language, it could be clarified that such pacts apply only to the hospital where the physician currently works, and within a reasonable time frame. But everyone involved should be aware of what these covenants contain and, if they appear unreasonable, don’t sign them.

—Larry Beresford

When hospitalists work in academic centers, medical and surgical services are furnished, in part, by a resident within the scope of the hospitalists’ training program. A resident is “an individual who participates in an approved graduate medical education (GME) program or a physician who is not in an approved GME program but who is authorized to practice only in a hospital setting.”¹ Resident services are covered by Centers for Medicare & Medicaid Services (CMS) and paid by the Fiscal Intermediary through direct GME and Indirect Medical Education (IME) payments. These services are not billed or paid using the Medicare Physician Fee Schedule. The teaching physician is responsible for supervising the resident’s health-care delivery but is not paid for the resident’s work. The teaching physician is paid for their personal and medically necessary service in providing patient care. The teaching physician has the option to perform the entire service, or perform the self-determined critical or key portion(s) of the service.

Comprehensive Service

Teaching physicians independently see the patient and perform all required elements to support the visit level (e.g. 99233: subsequent hospital care, per day, which requires at least two of the following three key components: a detailed interval history, a detailed examination, or high-complexity medical decision-making).² The teaching physician writes a note independent of a resident encounter with the patient or documentation. The teaching physician note “stands alone” and does not rely on the resident’s documentation. If the resident saw the patient and documented the encounter, the teaching physician might choose to “link to” the resident note in lieu of personally documenting the entire service. The linking statement must demonstrate teaching physician involvement in the patient encounter and participation in patient management. Use of CMS-approved statements is best to meet these requirements. Statement examples include:³

• “I performed a history and physical examination of the patient and discussed his management with the resident. I reviewed the resident’s note and agree with the documented findings and plan of care.”
• “I saw and evaluated the patient. I agree with the findings and the plan of care as documented in the resident’s note.”
• “I saw and examined the patient. I agree with the resident’s note, except the heart murmur is louder, so I will obtain an echo to evaluate.”

Each of these statements meets the minimum requirements for billing. However, teaching physicians should offer more information in support of other clinical, quality, and regulatory initiatives and mandates, better exemplified in the last example. The reported visit level will be supported by the combined documentation (teaching physician and resident).

The teaching physician submits a claim in their name and, if it is a Medicare claim, appends modifier GC to the selected visit level (e.g. 99223-GC). This alerts the Medicare contractor that services were provided under teaching physician rules. Requests for documentation should include a response with medical record entries from the teaching physician and resident.

Critical/Key Portion

“Supervised” service: The resident and teaching physician can round together; they can see the patient at the same time. The teaching physician observes the resident’s performance during the patient encounter, or personally performs self-determined elements of patient care. The resident documents their patient care. The attending must still note their presence in the medical record, performance of the critical or key portions of the service, and involvement in patient management. CMS-accepted statements include:³

• “I was present with the resident during the history and exam. I discussed the case with the resident and agree with the findings and plan as documented in the resident’s note.”
• “I saw the patient with the resident and agree with the resident’s findings and plan.”

Although these statements demonstrate acceptable billing language, they lack patient-specific details that support the teaching physician’s personal contribution to patient care and the quality of their expertise. The teaching physician selects the visit level that represents the combined documentation and, if it is a Medicare claim, appends modifier GC to the selected visit level (e.g. 99232-GC).

“Shared” service: The resident sees the patient unaccompanied and documents the corresponding care provided. The teaching physician sees the patient at a different time but performs only the critical or key portions of the service. The case is subsequently discussed with the resident. The teaching physician must document their presence and performance of the critical or key portions of the service, along with any patient management. Using CMS-quoted statements ensures regulatory compliance:³

• “I saw and evaluated the patient. I reviewed the resident’s note and agree, except that the picture is more consistent with pericarditis than myocardial ischemia. Will begin NSAIDs.”
• “I saw and evaluated the patient. Discussed with resident and agree with resident’s findings and plan as documented in the resident’s note.”
• “See resident’s note for details. I saw and evaluated the patient and agree with the resident’s finding and plans as written.”
• “I saw and evaluated the patient. Agree with resident’s note, but lower extremities are weaker, now 3/5; MRI of L/S spine today.”

Once again, the teaching physician selects the visit level that represents the combined documentation and, if it is a Medicare claim, appends modifier GC to the selected visit level (e.g. 99233-GC).

EHR Considerations

When seeing patients independent of one another, the timing of the teaching physician and resident encounters does not impact billing. However, the time that the resident encounter is documented in the medical record can significantly impact the payment when reviewed by external auditors. When the resident note is dated and timed later than the teaching physician’s entry, the teaching physician cannot consider the resident’s note for visit-level selection. The teaching physician should not “link to” a resident note that is viewed as “not having been written” prior to the teaching physician note. This would not fulfill the requirements represented in the CMS-approved language “I reviewed the resident’s note and agree.”

Electronic health record (EHR) systems sometimes hinder compliance. If the resident completes the note but does not “finalize” or “close” the encounter until after the teaching physician documents their own note, it can falsely appear that the resident note did not exist at the time the teaching physician created their entry. Because an auditor can only view the finalized entries, the timing of each entry might be erroneously represented. Proper training and closing of encounters can diminish these issues.

Additionally, scribing the attestation is not permitted. Residents cannot document the teaching physician attestation on behalf of the physician under any circumstance. CMS rules require the teaching physician to document their presence, participation, and management of the patient. In an EHR, the teaching physician must document this entry under his/her own log-in and password, which is not to be shared with anyone.

Students

CMS defines student as “an individual who participates in an accredited educational program [e.g. a medical school] that is not an approved GME program.”1 A student is not regarded as a “physician in training,” and the service is not eligible for reimbursement consideration under the teaching physician rules.

Per CMS guidelines, students can document services in the medical record, but the teaching physician may only refer to the student’s systems review and past/family/social history entries. The teaching physician must verify and redocument the history of present illness. A student’s physical exam findings or medical decision-making are not suitable for tethering, and the teaching physician must personally perform and redocument the physical exam and medical decision-making. The visit level reflects only the teaching physician’s personally performed and documented service.

Carol Pohlig is a billing and coding expert with the University of Pennsylvania Medical Center, Philadelphia. She is also on the faculty of SHM’s inpatient coding course.

References

1. Centers for Medicare and Medicaid Services. Guidelines for Teaching Physicians, Interns, Residents. CMS website. Available at: http://www.cms.gov/MLNProducts/downloads/gdelinesteachgresfctsht.pdf. Accessed Jan. 8, 2013.
2. Abraham M, Ahlman J, Anderson C, Boudreau A, Connelly J. Current Procedural Terminology 2012 Professional Edition. Chicago: American Medical Association Press; 2011.
3. Centers for Medicare and Medicaid Services. Medicare Claims Processing Manual: Chapter 12, Section 100. CMS website. Available at: http://www.cms.hhs.gov/manuals/downloads/clm104c12.pdf. Accessed Jan. 8, 2013.
4. Centers for Medicare and Medicaid Services. Medicare Benefit Policy Manual: Chapter 15, Section 30.2. CMS website. Available at: http://www.cms.hhs.gov/manuals/Downloads/bp102c15.pdf. Accessed Jan. 8, 2013.

When hospitalists work in academic centers, medical and surgical services are furnished, in part, by a resident within the scope of the hospitalists’ training program. A resident is “an individual who participates in an approved graduate medical education (GME) program or a physician who is not in an approved GME program but who is authorized to practice only in a hospital setting.”¹ Resident services are covered by Centers for Medicare & Medicaid Services (CMS) and paid by the Fiscal Intermediary through direct GME and Indirect Medical Education (IME) payments. These services are not billed or paid using the Medicare Physician Fee Schedule. The teaching physician is responsible for supervising the resident’s health-care delivery but is not paid for the resident’s work. The teaching physician is paid for their personal and medically necessary service in providing patient care. The teaching physician has the option to perform the entire service, or perform the self-determined critical or key portion(s) of the service.

Comprehensive Service

Teaching physicians independently see the patient and perform all required elements to support the visit level (e.g. 99233: subsequent hospital care, per day, which requires at least two of the following three key components: a detailed interval history, a detailed examination, or high-complexity medical decision-making).² The teaching physician writes a note independent of a resident encounter with the patient or documentation. The teaching physician note “stands alone” and does not rely on the resident’s documentation. If the resident saw the patient and documented the encounter, the teaching physician might choose to “link to” the resident note in lieu of personally documenting the entire service. The linking statement must demonstrate teaching physician involvement in the patient encounter and participation in patient management. Use of CMS-approved statements is best to meet these requirements. Statement examples include:³

• “I performed a history and physical examination of the patient and discussed his management with the resident. I reviewed the resident’s note and agree with the documented findings and plan of care.”
• “I saw and evaluated the patient. I agree with the findings and the plan of care as documented in the resident’s note.”
• “I saw and examined the patient. I agree with the resident’s note, except the heart murmur is louder, so I will obtain an echo to evaluate.”

Each of these statements meets the minimum requirements for billing. However, teaching physicians should offer more information in support of other clinical, quality, and regulatory initiatives and mandates, better exemplified in the last example. The reported visit level will be supported by the combined documentation (teaching physician and resident).

The teaching physician submits a claim in their name and, if it is a Medicare claim, appends modifier GC to the selected visit level (e.g. 99223-GC). This alerts the Medicare contractor that services were provided under teaching physician rules. Requests for documentation should include a response with medical record entries from the teaching physician and resident.

Critical/Key Portion

“Supervised” service: The resident and teaching physician can round together; they can see the patient at the same time. The teaching physician observes the resident’s performance during the patient encounter, or personally performs self-determined elements of patient care. The resident documents their patient care. The attending must still note their presence in the medical record, performance of the critical or key portions of the service, and involvement in patient management. CMS-accepted statements include:³

• “I was present with the resident during the history and exam. I discussed the case with the resident and agree with the findings and plan as documented in the resident’s note.”
• “I saw the patient with the resident and agree with the resident’s findings and plan.”

Although these statements demonstrate acceptable billing language, they lack patient-specific details that support the teaching physician’s personal contribution to patient care and the quality of their expertise. The teaching physician selects the visit level that represents the combined documentation and, if it is a Medicare claim, appends modifier GC to the selected visit level (e.g. 99232-GC).

“Shared” service: The resident sees the patient unaccompanied and documents the corresponding care provided. The teaching physician sees the patient at a different time but performs only the critical or key portions of the service. The case is subsequently discussed with the resident. The teaching physician must document their presence and performance of the critical or key portions of the service, along with any patient management. Using CMS-quoted statements ensures regulatory compliance:³

• “I saw and evaluated the patient. I reviewed the resident’s note and agree, except that the picture is more consistent with pericarditis than myocardial ischemia. Will begin NSAIDs.”
• “I saw and evaluated the patient. Discussed with resident and agree with resident’s findings and plan as documented in the resident’s note.”
• “See resident’s note for details. I saw and evaluated the patient and agree with the resident’s finding and plans as written.”
• “I saw and evaluated the patient. Agree with resident’s note, but lower extremities are weaker, now 3/5; MRI of L/S spine today.”

Once again, the teaching physician selects the visit level that represents the combined documentation and, if it is a Medicare claim, appends modifier GC to the selected visit level (e.g. 99233-GC).

EHR Considerations

When seeing patients independent of one another, the timing of the teaching physician and resident encounters does not impact billing. However, the time that the resident encounter is documented in the medical record can significantly impact the payment when reviewed by external auditors. When the resident note is dated and timed later than the teaching physician’s entry, the teaching physician cannot consider the resident’s note for visit-level selection. The teaching physician should not “link to” a resident note that is viewed as “not having been written” prior to the teaching physician note. This would not fulfill the requirements represented in the CMS-approved language “I reviewed the resident’s note and agree.”

Electronic health record (EHR) systems sometimes hinder compliance. If the resident completes the note but does not “finalize” or “close” the encounter until after the teaching physician documents their own note, it can falsely appear that the resident note did not exist at the time the teaching physician created their entry. Because an auditor can only view the finalized entries, the timing of each entry might be erroneously represented. Proper training and closing of encounters can diminish these issues.

Additionally, scribing the attestation is not permitted. Residents cannot document the teaching physician attestation on behalf of the physician under any circumstance. CMS rules require the teaching physician to document their presence, participation, and management of the patient. In an EHR, the teaching physician must document this entry under his/her own log-in and password, which is not to be shared with anyone.

Students

CMS defines student as “an individual who participates in an accredited educational program [e.g. a medical school] that is not an approved GME program.”1 A student is not regarded as a “physician in training,” and the service is not eligible for reimbursement consideration under the teaching physician rules.

Per CMS guidelines, students can document services in the medical record, but the teaching physician may only refer to the student’s systems review and past/family/social history entries. The teaching physician must verify and redocument the history of present illness. A student’s physical exam findings or medical decision-making are not suitable for tethering, and the teaching physician must personally perform and redocument the physical exam and medical decision-making. The visit level reflects only the teaching physician’s personally performed and documented service.

Carol Pohlig is a billing and coding expert with the University of Pennsylvania Medical Center, Philadelphia. She is also on the faculty of SHM’s inpatient coding course.

References

1. Centers for Medicare and Medicaid Services. Guidelines for Teaching Physicians, Interns, Residents. CMS website. Available at: http://www.cms.gov/MLNProducts/downloads/gdelinesteachgresfctsht.pdf. Accessed Jan. 8, 2013.
2. Abraham M, Ahlman J, Anderson C, Boudreau A, Connelly J. Current Procedural Terminology 2012 Professional Edition. Chicago: American Medical Association Press; 2011.
3. Centers for Medicare and Medicaid Services. Medicare Claims Processing Manual: Chapter 12, Section 100. CMS website. Available at: http://www.cms.hhs.gov/manuals/downloads/clm104c12.pdf. Accessed Jan. 8, 2013.
4. Centers for Medicare and Medicaid Services. Medicare Benefit Policy Manual: Chapter 15, Section 30.2. CMS website. Available at: http://www.cms.hhs.gov/manuals/Downloads/bp102c15.pdf. Accessed Jan. 8, 2013.

When hospitalists work in academic centers, medical and surgical services are furnished, in part, by a resident within the scope of the hospitalists’ training program. A resident is “an individual who participates in an approved graduate medical education (GME) program or a physician who is not in an approved GME program but who is authorized to practice only in a hospital setting.”¹ Resident services are covered by Centers for Medicare & Medicaid Services (CMS) and paid by the Fiscal Intermediary through direct GME and Indirect Medical Education (IME) payments. These services are not billed or paid using the Medicare Physician Fee Schedule. The teaching physician is responsible for supervising the resident’s health-care delivery but is not paid for the resident’s work. The teaching physician is paid for their personal and medically necessary service in providing patient care. The teaching physician has the option to perform the entire service, or perform the self-determined critical or key portion(s) of the service.

Comprehensive Service

Teaching physicians independently see the patient and perform all required elements to support the visit level (e.g. 99233: subsequent hospital care, per day, which requires at least two of the following three key components: a detailed interval history, a detailed examination, or high-complexity medical decision-making).² The teaching physician writes a note independent of a resident encounter with the patient or documentation. The teaching physician note “stands alone” and does not rely on the resident’s documentation. If the resident saw the patient and documented the encounter, the teaching physician might choose to “link to” the resident note in lieu of personally documenting the entire service. The linking statement must demonstrate teaching physician involvement in the patient encounter and participation in patient management. Use of CMS-approved statements is best to meet these requirements. Statement examples include:³

• “I performed a history and physical examination of the patient and discussed his management with the resident. I reviewed the resident’s note and agree with the documented findings and plan of care.”
• “I saw and evaluated the patient. I agree with the findings and the plan of care as documented in the resident’s note.”
• “I saw and examined the patient. I agree with the resident’s note, except the heart murmur is louder, so I will obtain an echo to evaluate.”

Each of these statements meets the minimum requirements for billing. However, teaching physicians should offer more information in support of other clinical, quality, and regulatory initiatives and mandates, better exemplified in the last example. The reported visit level will be supported by the combined documentation (teaching physician and resident).

The teaching physician submits a claim in their name and, if it is a Medicare claim, appends modifier GC to the selected visit level (e.g. 99223-GC). This alerts the Medicare contractor that services were provided under teaching physician rules. Requests for documentation should include a response with medical record entries from the teaching physician and resident.

Critical/Key Portion

“Supervised” service: The resident and teaching physician can round together; they can see the patient at the same time. The teaching physician observes the resident’s performance during the patient encounter, or personally performs self-determined elements of patient care. The resident documents their patient care. The attending must still note their presence in the medical record, performance of the critical or key portions of the service, and involvement in patient management. CMS-accepted statements include:³

• “I was present with the resident during the history and exam. I discussed the case with the resident and agree with the findings and plan as documented in the resident’s note.”
• “I saw the patient with the resident and agree with the resident’s findings and plan.”

Although these statements demonstrate acceptable billing language, they lack patient-specific details that support the teaching physician’s personal contribution to patient care and the quality of their expertise. The teaching physician selects the visit level that represents the combined documentation and, if it is a Medicare claim, appends modifier GC to the selected visit level (e.g. 99232-GC).

“Shared” service: The resident sees the patient unaccompanied and documents the corresponding care provided. The teaching physician sees the patient at a different time but performs only the critical or key portions of the service. The case is subsequently discussed with the resident. The teaching physician must document their presence and performance of the critical or key portions of the service, along with any patient management. Using CMS-quoted statements ensures regulatory compliance:³

• “I saw and evaluated the patient. I reviewed the resident’s note and agree, except that the picture is more consistent with pericarditis than myocardial ischemia. Will begin NSAIDs.”
• “I saw and evaluated the patient. Discussed with resident and agree with resident’s findings and plan as documented in the resident’s note.”
• “See resident’s note for details. I saw and evaluated the patient and agree with the resident’s finding and plans as written.”
• “I saw and evaluated the patient. Agree with resident’s note, but lower extremities are weaker, now 3/5; MRI of L/S spine today.”

Once again, the teaching physician selects the visit level that represents the combined documentation and, if it is a Medicare claim, appends modifier GC to the selected visit level (e.g. 99233-GC).

EHR Considerations

When seeing patients independent of one another, the timing of the teaching physician and resident encounters does not impact billing. However, the time that the resident encounter is documented in the medical record can significantly impact the payment when reviewed by external auditors. When the resident note is dated and timed later than the teaching physician’s entry, the teaching physician cannot consider the resident’s note for visit-level selection. The teaching physician should not “link to” a resident note that is viewed as “not having been written” prior to the teaching physician note. This would not fulfill the requirements represented in the CMS-approved language “I reviewed the resident’s note and agree.”

Electronic health record (EHR) systems sometimes hinder compliance. If the resident completes the note but does not “finalize” or “close” the encounter until after the teaching physician documents their own note, it can falsely appear that the resident note did not exist at the time the teaching physician created their entry. Because an auditor can only view the finalized entries, the timing of each entry might be erroneously represented. Proper training and closing of encounters can diminish these issues.

Additionally, scribing the attestation is not permitted. Residents cannot document the teaching physician attestation on behalf of the physician under any circumstance. CMS rules require the teaching physician to document their presence, participation, and management of the patient. In an EHR, the teaching physician must document this entry under his/her own log-in and password, which is not to be shared with anyone.

Students

CMS defines student as “an individual who participates in an accredited educational program [e.g. a medical school] that is not an approved GME program.”1 A student is not regarded as a “physician in training,” and the service is not eligible for reimbursement consideration under the teaching physician rules.

Per CMS guidelines, students can document services in the medical record, but the teaching physician may only refer to the student’s systems review and past/family/social history entries. The teaching physician must verify and redocument the history of present illness. A student’s physical exam findings or medical decision-making are not suitable for tethering, and the teaching physician must personally perform and redocument the physical exam and medical decision-making. The visit level reflects only the teaching physician’s personally performed and documented service.

Carol Pohlig is a billing and coding expert with the University of Pennsylvania Medical Center, Philadelphia. She is also on the faculty of SHM’s inpatient coding course.

References

1. Centers for Medicare and Medicaid Services. Guidelines for Teaching Physicians, Interns, Residents. CMS website. Available at: http://www.cms.gov/MLNProducts/downloads/gdelinesteachgresfctsht.pdf. Accessed Jan. 8, 2013.
2. Abraham M, Ahlman J, Anderson C, Boudreau A, Connelly J. Current Procedural Terminology 2012 Professional Edition. Chicago: American Medical Association Press; 2011.
3. Centers for Medicare and Medicaid Services. Medicare Claims Processing Manual: Chapter 12, Section 100. CMS website. Available at: http://www.cms.hhs.gov/manuals/downloads/clm104c12.pdf. Accessed Jan. 8, 2013.
4. Centers for Medicare and Medicaid Services. Medicare Benefit Policy Manual: Chapter 15, Section 30.2. CMS website. Available at: http://www.cms.hhs.gov/manuals/Downloads/bp102c15.pdf. Accessed Jan. 8, 2013.

Dr. Vinik

1. Maintain a broader range of differential diagnoses before ruling in or out something more concrete.
2. Attend dermatology lectures as part of primary care’s continuing medical education courses.
3. Review a good basic dermatology atlas from time to time.
4. Learn to correctly describe lesions to a dermatologist by phone.
5. Don’t assume that groin rashes are all fungal.
6. Don’t mistakenly associate a drug-related reaction with a medication given one to two days before the onset of a rash.
7. Consider involving a dermatologist to help manage open skin lesions, particularly if you’re unsure of the cause.
8. Prescribe an adequate quantity of topical corticosteroids for the duration of treatment.
9. Beware of painful or blistering rashes, especially if they involve the mucosa of the mouth, eyes, or genitals.
10. Watch out for zoster, widespread herpes, pemphigus, and pemphigoid.
11. Pay attention to itching in the wrists, genital region, and web spaces of fingers and toes.
12. Be mindful of the rapid onset of purpuric lesions on the skin.
13. Avoid consults for improving rashes and seborrheic keratosis, as well as nonurgent outpatient issues, such as psoriasis, rosacea, or a history of skin cancer.
14. Don’t prescribe combined betamethasone/clotrimazole, also known as Lotrisone, for chronic scaly hands, feet, or groin.
15. Encourage patients to follow up with a dermatologist on an outpatient basis.

Dermatologic diseases tend to receive little attention at most U.S. medical schools—typically only several days of lectures or a few weeks of clinical exposure.

“Not surprisingly, many general practitioners may feel unprepared to address hospitalized patients with challenging dermatologic findings,” says R. Samuel Hopkins, MD, assistant professor of dermatology and assistant residency program director at Oregon Health & Science University in Portland.

Few studies have examined the quality of inpatient dermatologic care. One study, a retrospective chart review at a Midwestern university hospital, found that the primary ward team submitted an accurate dermatologic diagnosis in only 23.9% of cases. Meanwhile, consultation with a dermatologist led to a change or addition to treatment in 77% of patients (Dermatol Online J. 2010;16(2):12).

“Given that medical schools may not be able to dedicate more time to managing dermatologic conditions, the burden of education may fall on post-graduate programs and continuing medical education to fill this gap,” Dr. Hopkins says. To further complicate matters, “it is difficult in many hospitals to obtain a dermatology consult on an inpatient, reflecting the limited access hospitalists often have to dermatologists.”

Dr. Vinik

The most frequently encountered dermatologic conditions in the hospital setting are drug eruptions and skin infections. Dermatitis is the most misdiagnosed condition by nondermatologists in hospitals, says Russell Vinik, MD, co-director of the hospitalist group at the University of Utah Health Care in Salt Lake City.

The majority of skin issues don’t require a dermatologist’s input, but some do. “Clearly, there’s also the rash that we just don’t know what it is,” Dr. Vinik says. When in doubt, it’s best to err on the safe side and call the specialist.

Here’s how to assess whether to manage a dermatologic case yourself, or how to involve a dermatologist for appropriate diagnosis and treatment. In general, Dr. Hopkins says, “Whether one can handle a case on their own or not is a case-by-case decision by the hospitalist based on their comfort with their diagnosis and management.”

Maintain a broader range of differential diagnoses before ruling in or out something more concrete.

“Very often, patients with skin diseases are given a specific diagnosis without consideration of mimickers,” says Daniela Kroshinsky, MD, MPH, assistant professor of dermatology at Harvard Medical School in Boston.

“Cellulitis is a great example. People will come in with hot, red skin and be diagnosed with and treated for cellulitis but really have stasis dermatitis, Lyme [disease], gout, et cetera,” says Dr. Kroshinsky, who also is director of pediatric dermatology and director of inpatient dermatology, education, and research at Massachusetts General Hospital.

“The clinical picture of warm, red, tender skin can fit many conditions but is most often called cellulitis by nondermatologists,” she explains. “It’s not clear why, but I would suspect this is because cellulitis is one of the few dermatologic conditions taught in medical school, while the mimickers get less attention.”

Attend dermatology lectures as part of primary care’s continuing medical education courses.

This would increase your knowledge of skin conditions affecting hospitalized patients, Dr. Kroshinsky says. If there is a dermatologic consultant for your hospital, work closely with this specialist until you feel comfortable making diagnoses and incorporating treatment plans.

Similarly, if you are a resident who is interested in a career in hospital medicine, consider doing a rotation in dermatology.

Review a good basic dermatology atlas from time to time.

This keeps your mind open to differential diagnoses for a given situation that you may encounter in the hospital setting. A more comprehensive book or online reference can be helpful to peruse after seeing a patient with a particular rash, Dr. Kroshinsky says.

Learn to correctly describe lesions to a dermatologist by phone.

When a specialist isn’t available on site, the phone communication is vital to the specialist. This includes familiarizing yourself with some of the more life-threatening dermatologic problems, such as drug-induced hypersensitivity reactions. It will be easier to recognize when an urgent dermatologic consultation is required. Sometimes this is necessary when a patient doesn’t respond to treatment for a reasonable and presumed diagnosis—when one condition seems to mimic the symptoms of another, says Lindy Fox, MD, associate professor of clinical dermatology at the University of California at San Francisco and director of its hospital dermatology consultation service.

Don’t assume that groin rashes are all fungal.

In fact, there is a very large differential diagnosis for intertriginous eruptions, Dr. Fox says. Perform a KOH test (potassium hydroxide) and fungal cultures on intertriginous eruptions. If no fungus is identified or the patient is not responding appropriately to therapy, call for a dermatologic consultation.

Don’t mistakenly associate a drug-related reaction with a medication given one to two days before the onset of a rash.

It is typically seven to 10 days post-exposure that a drug eruption develops, Dr. Fox says. He suggests making a drug chart to highlight dates of medication administration. This helps pinpoint the most likely culprit based on timing and the probability that a certain drug may induce cutaneous eruptions. Correct identification of the type of drug eruption (e.g. simple drug eruption vs. hypersensitivity vs. potentially deadly Stevens-Johnson syndrome) is important.

Consider involving a dermatologist to help manage open skin lesions, particularly if you’re unsure of the cause.

There are many different causes of skin ulcers. Trauma, infections, and even malignancies can present as open wounds. Leg ulcers may be due to venous stasis, but they also can be caused by arterial insufficiency, vasculitis, and other conditions. A dermatologist might opt to perform a skin biopsy to help diagnose the lesion.

Dr. Schwarzenberger

“Wound-care nurses can be very helpful in managing skin lesions, but they do not always have the experience needed to correctly diagnose the underlying problem,” says Kathryn Schwarzenberger, MD, professor of medicine at the University of Vermont College of Medicine in Burlington. “If you’re thinking of calling the wound-care nurse, think of calling the dermatologist first.”

Prescribe an adequate quantity of topical corticosteroids for the duration of treatment.

“It’s really important to provide enough medicine,” Dr. Schwarzenberger says. Typically, a patient will receive a small tube, apply the contents, and find that “it’s enough medicine to cover their body once. This doesn’t work if you intended to have the patient apply it all over for two weeks.”

It takes, on average, 30 g of a topical medication to cover the body once. With topical steroids, prescribing an insufficient quantity “dooms your therapy to failure.”

Allergic reactions from these medications are rare, and some insurance companies charge the same regardless of the size. Prescribing a small amount initially might incur an additional expense for the patient.

Beware of painful or blistering rashes, especially if they involve the mucosa of the mouth, eyes, or genitals.

“These symptoms can be associated with potentially deadly toxic epidermal necrolysis,” says Daniel Aires, MD, JD, director of the division of dermatology at the University of Kansas School of Medicine in Kansas City, Kan. “Consult dermatology immediately. The sooner treatment is begun, the better the odds of survival.”

If a rash involves the eye, call an ophthalmologist and a dermatologist. “Eyes are more likely than skin to develop chronic complications after resolution of an acute condition,” he says.

For a rash involving primarily the mouth, call an otolaryngologist, a dentist, or both, as well as a dermatologist. These specialists are more skilled in visualizing and treating oral conditions.

Watch out for zoster, widespread herpes, pemphigus, and pemphigoid.

These blistering conditions require urgent diagnosis and treatment, so a dermatologist’s expertise is needed quickly, Dr. Aires says. Even without the presence of blisters, a single region of the skin or “dermatome” gives pause for concern.

Dr. Aires

“This could be a sign of zoster, which is especially dangerous in immunosuppressed or otherwise debilitated patients,” he cautions. “Either perform a culture and begin treatment, or consult dermatology, or do both.”

Pay attention to itching in the wrists, genital region, and web spaces of fingers and toes.

This may be due to scabies infestation. “Scabies can spread rapidly throughout a hospital ward,” Dr. Aires says. What to do: Scrape for scabies, consider a trial of topical treatment, and consult a dermatologist if you’re unsure.

Be mindful of the rapid onset of purpuric lesionscon the skin.

They warrant suspicion of such conditions as vasculitis, hypercoaguable states, and disseminated angiotropic infections, says Dr. Hopkins of Oregon Health & Science University. “The shape and size of purpuric skin lesions help determine the etiology. A few characteristic examples include papular purpura and retiform purpura. Papular purpura [raised purpuric papules] may suggest vasculitis. Purpura that forms net-like patches is called retiform purpura and suggests a vaso-occlusive process, such as from a hypercoaguable state, embolic phenomena, or calciphylaxis.”

13 Avoid consults for improving rashes and seborrheic keratosis, as well as nonurgent outpatient issues, such as psoriasis, rosacea, or a history of skin cancer. These conditions “are more easily addressed in a clinic, as opposed to in a hospital, where the patient is lying in a bed feeling ill with IV tubes in place,” Dr. Aires says. “It also reflects respect for the dermatologist’s time. Inpatient dermatology can be pretty busy, so it’s preferable to consult primarily for urgent skin issues.” Consultations can be costly, too, and most patients would rather avoid additional medical bills.

Don’t prescribe combined betamethasone/clotrimazole, also known as Lotrisone, for chronic scaly hands, feet, or groin.

Although it is not harmful, “it is not usually a great choice for typical ‘dermatophyte’ fungal infections, such as athlete’s foot and ‘jock itch,’” Dr. Aires says. “Over-the-counter Lamisil is better, particularly following daily use of 10-minute soaks in 50-50 vinegar-water. Even for yeast infections, miconazole is better than clotrimazole.”

As for betamethasone, this “component is way too strong for the groin area and can cause atrophy or worse,” he says.

“The clinical picture of warm, red, tender skin can fit many conditions but is most often called cellulitis by nondermatologists. It’s not clear why, but I would suspect this is because cellulitis is one of the few dermatologic conditions taught in medical school, while the mimickers get less attention.”

—Daniela Kroshinsky, MD, MPH, director of inpatient dermatology, education, and research, Massachusetts General Hospital, Boston

Encourage patients to follow up with a dermatologist on an outpatient basis.

By heeding this advice, patients are less likely to return to the ED for skin conditions that can be managed in an office, says Kirsten Flynn, MD, a dermatologist at Banner Health Center in Sun City West, Ariz. Inpatient admissions by dermatologists have been decreasing over the years. Most patients with skin diseases or cutaneous manifestations of systemic illnesses are admitted to hospitals by other physicians.

“Many dermatologists are happy to fit in urgent consults in their clinics. Drug eruptions are by far the most common consultation request,” says Dr. Flynn, who notes that high-dose IV steroids can cause complications, such as gastrointestinal bleeding, bowel perforation, opportunistic infections, and exacerbation of underlying diseases. “In most cases, removing the offending agent and providing supportive care is the best option.”

Susan Kreimer is a freelance writer in New York.

Dr. Vinik

1. Maintain a broader range of differential diagnoses before ruling in or out something more concrete.
2. Attend dermatology lectures as part of primary care’s continuing medical education courses.
3. Review a good basic dermatology atlas from time to time.
4. Learn to correctly describe lesions to a dermatologist by phone.
5. Don’t assume that groin rashes are all fungal.
6. Don’t mistakenly associate a drug-related reaction with a medication given one to two days before the onset of a rash.
7. Consider involving a dermatologist to help manage open skin lesions, particularly if you’re unsure of the cause.
8. Prescribe an adequate quantity of topical corticosteroids for the duration of treatment.
9. Beware of painful or blistering rashes, especially if they involve the mucosa of the mouth, eyes, or genitals.
10. Watch out for zoster, widespread herpes, pemphigus, and pemphigoid.
11. Pay attention to itching in the wrists, genital region, and web spaces of fingers and toes.
12. Be mindful of the rapid onset of purpuric lesions on the skin.
13. Avoid consults for improving rashes and seborrheic keratosis, as well as nonurgent outpatient issues, such as psoriasis, rosacea, or a history of skin cancer.
14. Don’t prescribe combined betamethasone/clotrimazole, also known as Lotrisone, for chronic scaly hands, feet, or groin.
15. Encourage patients to follow up with a dermatologist on an outpatient basis.

Dermatologic diseases tend to receive little attention at most U.S. medical schools—typically only several days of lectures or a few weeks of clinical exposure.

“Not surprisingly, many general practitioners may feel unprepared to address hospitalized patients with challenging dermatologic findings,” says R. Samuel Hopkins, MD, assistant professor of dermatology and assistant residency program director at Oregon Health & Science University in Portland.

Few studies have examined the quality of inpatient dermatologic care. One study, a retrospective chart review at a Midwestern university hospital, found that the primary ward team submitted an accurate dermatologic diagnosis in only 23.9% of cases. Meanwhile, consultation with a dermatologist led to a change or addition to treatment in 77% of patients (Dermatol Online J. 2010;16(2):12).

“Given that medical schools may not be able to dedicate more time to managing dermatologic conditions, the burden of education may fall on post-graduate programs and continuing medical education to fill this gap,” Dr. Hopkins says. To further complicate matters, “it is difficult in many hospitals to obtain a dermatology consult on an inpatient, reflecting the limited access hospitalists often have to dermatologists.”

Dr. Vinik

The most frequently encountered dermatologic conditions in the hospital setting are drug eruptions and skin infections. Dermatitis is the most misdiagnosed condition by nondermatologists in hospitals, says Russell Vinik, MD, co-director of the hospitalist group at the University of Utah Health Care in Salt Lake City.

The majority of skin issues don’t require a dermatologist’s input, but some do. “Clearly, there’s also the rash that we just don’t know what it is,” Dr. Vinik says. When in doubt, it’s best to err on the safe side and call the specialist.

Here’s how to assess whether to manage a dermatologic case yourself, or how to involve a dermatologist for appropriate diagnosis and treatment. In general, Dr. Hopkins says, “Whether one can handle a case on their own or not is a case-by-case decision by the hospitalist based on their comfort with their diagnosis and management.”

Maintain a broader range of differential diagnoses before ruling in or out something more concrete.

“Very often, patients with skin diseases are given a specific diagnosis without consideration of mimickers,” says Daniela Kroshinsky, MD, MPH, assistant professor of dermatology at Harvard Medical School in Boston.

“Cellulitis is a great example. People will come in with hot, red skin and be diagnosed with and treated for cellulitis but really have stasis dermatitis, Lyme [disease], gout, et cetera,” says Dr. Kroshinsky, who also is director of pediatric dermatology and director of inpatient dermatology, education, and research at Massachusetts General Hospital.

“The clinical picture of warm, red, tender skin can fit many conditions but is most often called cellulitis by nondermatologists,” she explains. “It’s not clear why, but I would suspect this is because cellulitis is one of the few dermatologic conditions taught in medical school, while the mimickers get less attention.”

Attend dermatology lectures as part of primary care’s continuing medical education courses.

This would increase your knowledge of skin conditions affecting hospitalized patients, Dr. Kroshinsky says. If there is a dermatologic consultant for your hospital, work closely with this specialist until you feel comfortable making diagnoses and incorporating treatment plans.

Similarly, if you are a resident who is interested in a career in hospital medicine, consider doing a rotation in dermatology.

Review a good basic dermatology atlas from time to time.

This keeps your mind open to differential diagnoses for a given situation that you may encounter in the hospital setting. A more comprehensive book or online reference can be helpful to peruse after seeing a patient with a particular rash, Dr. Kroshinsky says.

Learn to correctly describe lesions to a dermatologist by phone.

When a specialist isn’t available on site, the phone communication is vital to the specialist. This includes familiarizing yourself with some of the more life-threatening dermatologic problems, such as drug-induced hypersensitivity reactions. It will be easier to recognize when an urgent dermatologic consultation is required. Sometimes this is necessary when a patient doesn’t respond to treatment for a reasonable and presumed diagnosis—when one condition seems to mimic the symptoms of another, says Lindy Fox, MD, associate professor of clinical dermatology at the University of California at San Francisco and director of its hospital dermatology consultation service.

Don’t assume that groin rashes are all fungal.

In fact, there is a very large differential diagnosis for intertriginous eruptions, Dr. Fox says. Perform a KOH test (potassium hydroxide) and fungal cultures on intertriginous eruptions. If no fungus is identified or the patient is not responding appropriately to therapy, call for a dermatologic consultation.

Don’t mistakenly associate a drug-related reaction with a medication given one to two days before the onset of a rash.

It is typically seven to 10 days post-exposure that a drug eruption develops, Dr. Fox says. He suggests making a drug chart to highlight dates of medication administration. This helps pinpoint the most likely culprit based on timing and the probability that a certain drug may induce cutaneous eruptions. Correct identification of the type of drug eruption (e.g. simple drug eruption vs. hypersensitivity vs. potentially deadly Stevens-Johnson syndrome) is important.

Consider involving a dermatologist to help manage open skin lesions, particularly if you’re unsure of the cause.

There are many different causes of skin ulcers. Trauma, infections, and even malignancies can present as open wounds. Leg ulcers may be due to venous stasis, but they also can be caused by arterial insufficiency, vasculitis, and other conditions. A dermatologist might opt to perform a skin biopsy to help diagnose the lesion.

Dr. Schwarzenberger

“Wound-care nurses can be very helpful in managing skin lesions, but they do not always have the experience needed to correctly diagnose the underlying problem,” says Kathryn Schwarzenberger, MD, professor of medicine at the University of Vermont College of Medicine in Burlington. “If you’re thinking of calling the wound-care nurse, think of calling the dermatologist first.”

Prescribe an adequate quantity of topical corticosteroids for the duration of treatment.

“It’s really important to provide enough medicine,” Dr. Schwarzenberger says. Typically, a patient will receive a small tube, apply the contents, and find that “it’s enough medicine to cover their body once. This doesn’t work if you intended to have the patient apply it all over for two weeks.”

It takes, on average, 30 g of a topical medication to cover the body once. With topical steroids, prescribing an insufficient quantity “dooms your therapy to failure.”

Allergic reactions from these medications are rare, and some insurance companies charge the same regardless of the size. Prescribing a small amount initially might incur an additional expense for the patient.

Beware of painful or blistering rashes, especially if they involve the mucosa of the mouth, eyes, or genitals.

“These symptoms can be associated with potentially deadly toxic epidermal necrolysis,” says Daniel Aires, MD, JD, director of the division of dermatology at the University of Kansas School of Medicine in Kansas City, Kan. “Consult dermatology immediately. The sooner treatment is begun, the better the odds of survival.”

If a rash involves the eye, call an ophthalmologist and a dermatologist. “Eyes are more likely than skin to develop chronic complications after resolution of an acute condition,” he says.

For a rash involving primarily the mouth, call an otolaryngologist, a dentist, or both, as well as a dermatologist. These specialists are more skilled in visualizing and treating oral conditions.

Watch out for zoster, widespread herpes, pemphigus, and pemphigoid.

These blistering conditions require urgent diagnosis and treatment, so a dermatologist’s expertise is needed quickly, Dr. Aires says. Even without the presence of blisters, a single region of the skin or “dermatome” gives pause for concern.

Dr. Aires

“This could be a sign of zoster, which is especially dangerous in immunosuppressed or otherwise debilitated patients,” he cautions. “Either perform a culture and begin treatment, or consult dermatology, or do both.”

Pay attention to itching in the wrists, genital region, and web spaces of fingers and toes.

This may be due to scabies infestation. “Scabies can spread rapidly throughout a hospital ward,” Dr. Aires says. What to do: Scrape for scabies, consider a trial of topical treatment, and consult a dermatologist if you’re unsure.

Be mindful of the rapid onset of purpuric lesionscon the skin.

They warrant suspicion of such conditions as vasculitis, hypercoaguable states, and disseminated angiotropic infections, says Dr. Hopkins of Oregon Health & Science University. “The shape and size of purpuric skin lesions help determine the etiology. A few characteristic examples include papular purpura and retiform purpura. Papular purpura [raised purpuric papules] may suggest vasculitis. Purpura that forms net-like patches is called retiform purpura and suggests a vaso-occlusive process, such as from a hypercoaguable state, embolic phenomena, or calciphylaxis.”

13 Avoid consults for improving rashes and seborrheic keratosis, as well as nonurgent outpatient issues, such as psoriasis, rosacea, or a history of skin cancer. These conditions “are more easily addressed in a clinic, as opposed to in a hospital, where the patient is lying in a bed feeling ill with IV tubes in place,” Dr. Aires says. “It also reflects respect for the dermatologist’s time. Inpatient dermatology can be pretty busy, so it’s preferable to consult primarily for urgent skin issues.” Consultations can be costly, too, and most patients would rather avoid additional medical bills.

Don’t prescribe combined betamethasone/clotrimazole, also known as Lotrisone, for chronic scaly hands, feet, or groin.

Although it is not harmful, “it is not usually a great choice for typical ‘dermatophyte’ fungal infections, such as athlete’s foot and ‘jock itch,’” Dr. Aires says. “Over-the-counter Lamisil is better, particularly following daily use of 10-minute soaks in 50-50 vinegar-water. Even for yeast infections, miconazole is better than clotrimazole.”

As for betamethasone, this “component is way too strong for the groin area and can cause atrophy or worse,” he says.

“The clinical picture of warm, red, tender skin can fit many conditions but is most often called cellulitis by nondermatologists. It’s not clear why, but I would suspect this is because cellulitis is one of the few dermatologic conditions taught in medical school, while the mimickers get less attention.”

—Daniela Kroshinsky, MD, MPH, director of inpatient dermatology, education, and research, Massachusetts General Hospital, Boston

Encourage patients to follow up with a dermatologist on an outpatient basis.

By heeding this advice, patients are less likely to return to the ED for skin conditions that can be managed in an office, says Kirsten Flynn, MD, a dermatologist at Banner Health Center in Sun City West, Ariz. Inpatient admissions by dermatologists have been decreasing over the years. Most patients with skin diseases or cutaneous manifestations of systemic illnesses are admitted to hospitals by other physicians.

“Many dermatologists are happy to fit in urgent consults in their clinics. Drug eruptions are by far the most common consultation request,” says Dr. Flynn, who notes that high-dose IV steroids can cause complications, such as gastrointestinal bleeding, bowel perforation, opportunistic infections, and exacerbation of underlying diseases. “In most cases, removing the offending agent and providing supportive care is the best option.”

Susan Kreimer is a freelance writer in New York.

Dr. Vinik

1. Maintain a broader range of differential diagnoses before ruling in or out something more concrete.
2. Attend dermatology lectures as part of primary care’s continuing medical education courses.
3. Review a good basic dermatology atlas from time to time.
4. Learn to correctly describe lesions to a dermatologist by phone.
5. Don’t assume that groin rashes are all fungal.
6. Don’t mistakenly associate a drug-related reaction with a medication given one to two days before the onset of a rash.
7. Consider involving a dermatologist to help manage open skin lesions, particularly if you’re unsure of the cause.
8. Prescribe an adequate quantity of topical corticosteroids for the duration of treatment.
9. Beware of painful or blistering rashes, especially if they involve the mucosa of the mouth, eyes, or genitals.
10. Watch out for zoster, widespread herpes, pemphigus, and pemphigoid.
11. Pay attention to itching in the wrists, genital region, and web spaces of fingers and toes.
12. Be mindful of the rapid onset of purpuric lesions on the skin.
13. Avoid consults for improving rashes and seborrheic keratosis, as well as nonurgent outpatient issues, such as psoriasis, rosacea, or a history of skin cancer.
14. Don’t prescribe combined betamethasone/clotrimazole, also known as Lotrisone, for chronic scaly hands, feet, or groin.
15. Encourage patients to follow up with a dermatologist on an outpatient basis.

Dermatologic diseases tend to receive little attention at most U.S. medical schools—typically only several days of lectures or a few weeks of clinical exposure.

“Not surprisingly, many general practitioners may feel unprepared to address hospitalized patients with challenging dermatologic findings,” says R. Samuel Hopkins, MD, assistant professor of dermatology and assistant residency program director at Oregon Health & Science University in Portland.

Few studies have examined the quality of inpatient dermatologic care. One study, a retrospective chart review at a Midwestern university hospital, found that the primary ward team submitted an accurate dermatologic diagnosis in only 23.9% of cases. Meanwhile, consultation with a dermatologist led to a change or addition to treatment in 77% of patients (Dermatol Online J. 2010;16(2):12).

“Given that medical schools may not be able to dedicate more time to managing dermatologic conditions, the burden of education may fall on post-graduate programs and continuing medical education to fill this gap,” Dr. Hopkins says. To further complicate matters, “it is difficult in many hospitals to obtain a dermatology consult on an inpatient, reflecting the limited access hospitalists often have to dermatologists.”

Dr. Vinik

The most frequently encountered dermatologic conditions in the hospital setting are drug eruptions and skin infections. Dermatitis is the most misdiagnosed condition by nondermatologists in hospitals, says Russell Vinik, MD, co-director of the hospitalist group at the University of Utah Health Care in Salt Lake City.

The majority of skin issues don’t require a dermatologist’s input, but some do. “Clearly, there’s also the rash that we just don’t know what it is,” Dr. Vinik says. When in doubt, it’s best to err on the safe side and call the specialist.

Here’s how to assess whether to manage a dermatologic case yourself, or how to involve a dermatologist for appropriate diagnosis and treatment. In general, Dr. Hopkins says, “Whether one can handle a case on their own or not is a case-by-case decision by the hospitalist based on their comfort with their diagnosis and management.”

Maintain a broader range of differential diagnoses before ruling in or out something more concrete.

“Very often, patients with skin diseases are given a specific diagnosis without consideration of mimickers,” says Daniela Kroshinsky, MD, MPH, assistant professor of dermatology at Harvard Medical School in Boston.

“Cellulitis is a great example. People will come in with hot, red skin and be diagnosed with and treated for cellulitis but really have stasis dermatitis, Lyme [disease], gout, et cetera,” says Dr. Kroshinsky, who also is director of pediatric dermatology and director of inpatient dermatology, education, and research at Massachusetts General Hospital.

“The clinical picture of warm, red, tender skin can fit many conditions but is most often called cellulitis by nondermatologists,” she explains. “It’s not clear why, but I would suspect this is because cellulitis is one of the few dermatologic conditions taught in medical school, while the mimickers get less attention.”

Attend dermatology lectures as part of primary care’s continuing medical education courses.

This would increase your knowledge of skin conditions affecting hospitalized patients, Dr. Kroshinsky says. If there is a dermatologic consultant for your hospital, work closely with this specialist until you feel comfortable making diagnoses and incorporating treatment plans.

Similarly, if you are a resident who is interested in a career in hospital medicine, consider doing a rotation in dermatology.

Review a good basic dermatology atlas from time to time.

This keeps your mind open to differential diagnoses for a given situation that you may encounter in the hospital setting. A more comprehensive book or online reference can be helpful to peruse after seeing a patient with a particular rash, Dr. Kroshinsky says.

Learn to correctly describe lesions to a dermatologist by phone.

When a specialist isn’t available on site, the phone communication is vital to the specialist. This includes familiarizing yourself with some of the more life-threatening dermatologic problems, such as drug-induced hypersensitivity reactions. It will be easier to recognize when an urgent dermatologic consultation is required. Sometimes this is necessary when a patient doesn’t respond to treatment for a reasonable and presumed diagnosis—when one condition seems to mimic the symptoms of another, says Lindy Fox, MD, associate professor of clinical dermatology at the University of California at San Francisco and director of its hospital dermatology consultation service.

Don’t assume that groin rashes are all fungal.

In fact, there is a very large differential diagnosis for intertriginous eruptions, Dr. Fox says. Perform a KOH test (potassium hydroxide) and fungal cultures on intertriginous eruptions. If no fungus is identified or the patient is not responding appropriately to therapy, call for a dermatologic consultation.

Don’t mistakenly associate a drug-related reaction with a medication given one to two days before the onset of a rash.

It is typically seven to 10 days post-exposure that a drug eruption develops, Dr. Fox says. He suggests making a drug chart to highlight dates of medication administration. This helps pinpoint the most likely culprit based on timing and the probability that a certain drug may induce cutaneous eruptions. Correct identification of the type of drug eruption (e.g. simple drug eruption vs. hypersensitivity vs. potentially deadly Stevens-Johnson syndrome) is important.

Consider involving a dermatologist to help manage open skin lesions, particularly if you’re unsure of the cause.

There are many different causes of skin ulcers. Trauma, infections, and even malignancies can present as open wounds. Leg ulcers may be due to venous stasis, but they also can be caused by arterial insufficiency, vasculitis, and other conditions. A dermatologist might opt to perform a skin biopsy to help diagnose the lesion.

Dr. Schwarzenberger

“Wound-care nurses can be very helpful in managing skin lesions, but they do not always have the experience needed to correctly diagnose the underlying problem,” says Kathryn Schwarzenberger, MD, professor of medicine at the University of Vermont College of Medicine in Burlington. “If you’re thinking of calling the wound-care nurse, think of calling the dermatologist first.”

Prescribe an adequate quantity of topical corticosteroids for the duration of treatment.

“It’s really important to provide enough medicine,” Dr. Schwarzenberger says. Typically, a patient will receive a small tube, apply the contents, and find that “it’s enough medicine to cover their body once. This doesn’t work if you intended to have the patient apply it all over for two weeks.”

It takes, on average, 30 g of a topical medication to cover the body once. With topical steroids, prescribing an insufficient quantity “dooms your therapy to failure.”

Allergic reactions from these medications are rare, and some insurance companies charge the same regardless of the size. Prescribing a small amount initially might incur an additional expense for the patient.

Beware of painful or blistering rashes, especially if they involve the mucosa of the mouth, eyes, or genitals.

“These symptoms can be associated with potentially deadly toxic epidermal necrolysis,” says Daniel Aires, MD, JD, director of the division of dermatology at the University of Kansas School of Medicine in Kansas City, Kan. “Consult dermatology immediately. The sooner treatment is begun, the better the odds of survival.”

If a rash involves the eye, call an ophthalmologist and a dermatologist. “Eyes are more likely than skin to develop chronic complications after resolution of an acute condition,” he says.

For a rash involving primarily the mouth, call an otolaryngologist, a dentist, or both, as well as a dermatologist. These specialists are more skilled in visualizing and treating oral conditions.

Watch out for zoster, widespread herpes, pemphigus, and pemphigoid.

These blistering conditions require urgent diagnosis and treatment, so a dermatologist’s expertise is needed quickly, Dr. Aires says. Even without the presence of blisters, a single region of the skin or “dermatome” gives pause for concern.

Dr. Aires

“This could be a sign of zoster, which is especially dangerous in immunosuppressed or otherwise debilitated patients,” he cautions. “Either perform a culture and begin treatment, or consult dermatology, or do both.”

Pay attention to itching in the wrists, genital region, and web spaces of fingers and toes.

This may be due to scabies infestation. “Scabies can spread rapidly throughout a hospital ward,” Dr. Aires says. What to do: Scrape for scabies, consider a trial of topical treatment, and consult a dermatologist if you’re unsure.

Be mindful of the rapid onset of purpuric lesionscon the skin.

They warrant suspicion of such conditions as vasculitis, hypercoaguable states, and disseminated angiotropic infections, says Dr. Hopkins of Oregon Health & Science University. “The shape and size of purpuric skin lesions help determine the etiology. A few characteristic examples include papular purpura and retiform purpura. Papular purpura [raised purpuric papules] may suggest vasculitis. Purpura that forms net-like patches is called retiform purpura and suggests a vaso-occlusive process, such as from a hypercoaguable state, embolic phenomena, or calciphylaxis.”

13 Avoid consults for improving rashes and seborrheic keratosis, as well as nonurgent outpatient issues, such as psoriasis, rosacea, or a history of skin cancer. These conditions “are more easily addressed in a clinic, as opposed to in a hospital, where the patient is lying in a bed feeling ill with IV tubes in place,” Dr. Aires says. “It also reflects respect for the dermatologist’s time. Inpatient dermatology can be pretty busy, so it’s preferable to consult primarily for urgent skin issues.” Consultations can be costly, too, and most patients would rather avoid additional medical bills.

Don’t prescribe combined betamethasone/clotrimazole, also known as Lotrisone, for chronic scaly hands, feet, or groin.

Although it is not harmful, “it is not usually a great choice for typical ‘dermatophyte’ fungal infections, such as athlete’s foot and ‘jock itch,’” Dr. Aires says. “Over-the-counter Lamisil is better, particularly following daily use of 10-minute soaks in 50-50 vinegar-water. Even for yeast infections, miconazole is better than clotrimazole.”

As for betamethasone, this “component is way too strong for the groin area and can cause atrophy or worse,” he says.

“The clinical picture of warm, red, tender skin can fit many conditions but is most often called cellulitis by nondermatologists. It’s not clear why, but I would suspect this is because cellulitis is one of the few dermatologic conditions taught in medical school, while the mimickers get less attention.”

—Daniela Kroshinsky, MD, MPH, director of inpatient dermatology, education, and research, Massachusetts General Hospital, Boston

Encourage patients to follow up with a dermatologist on an outpatient basis.

By heeding this advice, patients are less likely to return to the ED for skin conditions that can be managed in an office, says Kirsten Flynn, MD, a dermatologist at Banner Health Center in Sun City West, Ariz. Inpatient admissions by dermatologists have been decreasing over the years. Most patients with skin diseases or cutaneous manifestations of systemic illnesses are admitted to hospitals by other physicians.

“Many dermatologists are happy to fit in urgent consults in their clinics. Drug eruptions are by far the most common consultation request,” says Dr. Flynn, who notes that high-dose IV steroids can cause complications, such as gastrointestinal bleeding, bowel perforation, opportunistic infections, and exacerbation of underlying diseases. “In most cases, removing the offending agent and providing supportive care is the best option.”

Susan Kreimer is a freelance writer in New York.

A quote in the March 2013 story “Lucky No. 7?” did not accurately represent comments expressed by Bradley Eshbaugh, MBA, FACMPE, chief administrator of Hospitalists of Northern Michigan (HNM) in Traverse City, Mich. His quote should have read: “I really believe that [seven-on/seven-off] scheduling is probably more desirable to Generation Y, which tends to have a lot more life quality and life balance as part of their mentality.”

A quote in the March 2013 story “Lucky No. 7?” did not accurately represent comments expressed by Bradley Eshbaugh, MBA, FACMPE, chief administrator of Hospitalists of Northern Michigan (HNM) in Traverse City, Mich. His quote should have read: “I really believe that [seven-on/seven-off] scheduling is probably more desirable to Generation Y, which tends to have a lot more life quality and life balance as part of their mentality.”

A quote in the March 2013 story “Lucky No. 7?” did not accurately represent comments expressed by Bradley Eshbaugh, MBA, FACMPE, chief administrator of Hospitalists of Northern Michigan (HNM) in Traverse City, Mich. His quote should have read: “I really believe that [seven-on/seven-off] scheduling is probably more desirable to Generation Y, which tends to have a lot more life quality and life balance as part of their mentality.”

Rate of 30-day, all-cause hospital readmissions for the fourth quarter of 2012, per the Centers for Medicare & Medicaid Services (CMS). The figure had fluctuated between 18.5% and 19.5% the prior five years. The drop corresponds with the implementation of Medicare penalties for higher-than-expected readmission rates. Previous studies of readmissions, including the recent Dartmouth Atlas of Health Care report described in last month’s “Innovations” found little or no progress on reducing hospital readmissions.

Larry Beresford is a freelance writer in Oakland, Calif.

References

1. Quinn K, Neeman N, Mourad M, Sliwka D. Communication coaching: A multifaceted intervention to improve physician-patient communication [abstract]. J Hosp Med. 2012;7 Suppl 2:S108.
2. Sokol PE, Wynia MK. There and Home Again, Safely: Five Responsibilities of Ambulatory Practices in High Quality Care Transitions. American Medical Association website. http://www.ama-assn.org/resources/doc/patient-safety/ambulatory-practices.pdf. Accessed February 12, 2013.
3. Dharmarajan K, Hsieh AF, Lin Z, et al. Diagnoses and timing of 30-day readmissions after hospitalization for heart failure, acute myocardial infarction, or pneumonia. JAMA. 2013;309(4):355-363.
4. JAMA Internal Medicine. Nearly one-third of physicians report missing electronic notification of test results. JAMA Internal Medicine website. Available at: http://media.jamanetwork.com/news-item/nearly-one-third-of-physicians-report-missing-electronic-notification-of-test-results/.Accessed April 8, 2013.
5. Miliard M. VA enlists telehealth for disasters. Healthcare IT News website. http://www.healthcareitnews.com/news/va-enlists-telehealth-disasters. Published February 27, 2013. Accessed April 1, 2013.

Rate of 30-day, all-cause hospital readmissions for the fourth quarter of 2012, per the Centers for Medicare & Medicaid Services (CMS). The figure had fluctuated between 18.5% and 19.5% the prior five years. The drop corresponds with the implementation of Medicare penalties for higher-than-expected readmission rates. Previous studies of readmissions, including the recent Dartmouth Atlas of Health Care report described in last month’s “Innovations” found little or no progress on reducing hospital readmissions.

Larry Beresford is a freelance writer in Oakland, Calif.

References

1. Quinn K, Neeman N, Mourad M, Sliwka D. Communication coaching: A multifaceted intervention to improve physician-patient communication [abstract]. J Hosp Med. 2012;7 Suppl 2:S108.
2. Sokol PE, Wynia MK. There and Home Again, Safely: Five Responsibilities of Ambulatory Practices in High Quality Care Transitions. American Medical Association website. http://www.ama-assn.org/resources/doc/patient-safety/ambulatory-practices.pdf. Accessed February 12, 2013.
3. Dharmarajan K, Hsieh AF, Lin Z, et al. Diagnoses and timing of 30-day readmissions after hospitalization for heart failure, acute myocardial infarction, or pneumonia. JAMA. 2013;309(4):355-363.
4. JAMA Internal Medicine. Nearly one-third of physicians report missing electronic notification of test results. JAMA Internal Medicine website. Available at: http://media.jamanetwork.com/news-item/nearly-one-third-of-physicians-report-missing-electronic-notification-of-test-results/.Accessed April 8, 2013.
5. Miliard M. VA enlists telehealth for disasters. Healthcare IT News website. http://www.healthcareitnews.com/news/va-enlists-telehealth-disasters. Published February 27, 2013. Accessed April 1, 2013.

Rate of 30-day, all-cause hospital readmissions for the fourth quarter of 2012, per the Centers for Medicare & Medicaid Services (CMS). The figure had fluctuated between 18.5% and 19.5% the prior five years. The drop corresponds with the implementation of Medicare penalties for higher-than-expected readmission rates. Previous studies of readmissions, including the recent Dartmouth Atlas of Health Care report described in last month’s “Innovations” found little or no progress on reducing hospital readmissions.

Larry Beresford is a freelance writer in Oakland, Calif.

References

1. Quinn K, Neeman N, Mourad M, Sliwka D. Communication coaching: A multifaceted intervention to improve physician-patient communication [abstract]. J Hosp Med. 2012;7 Suppl 2:S108.
2. Sokol PE, Wynia MK. There and Home Again, Safely: Five Responsibilities of Ambulatory Practices in High Quality Care Transitions. American Medical Association website. http://www.ama-assn.org/resources/doc/patient-safety/ambulatory-practices.pdf. Accessed February 12, 2013.
3. Dharmarajan K, Hsieh AF, Lin Z, et al. Diagnoses and timing of 30-day readmissions after hospitalization for heart failure, acute myocardial infarction, or pneumonia. JAMA. 2013;309(4):355-363.
4. JAMA Internal Medicine. Nearly one-third of physicians report missing electronic notification of test results. JAMA Internal Medicine website. Available at: http://media.jamanetwork.com/news-item/nearly-one-third-of-physicians-report-missing-electronic-notification-of-test-results/.Accessed April 8, 2013.
5. Miliard M. VA enlists telehealth for disasters. Healthcare IT News website. http://www.healthcareitnews.com/news/va-enlists-telehealth-disasters. Published February 27, 2013. Accessed April 1, 2013.