Recently, I was invited to present surgical grand rounds on an ethics topic.  After the talk, a senior surgeon, now retired, who was in the audience confided to me that in all of his years of residency, he had never had a lecture on ethics.  This off-hand comment raised a question that demands consideration in the contemporary era of increasingly limited time available for teaching in surgical residencies.  Do we need ethics teaching in surgery residencies?

As someone who spent significant time in the last few years in ethics teaching activities, my reflex answer is “Yes.”  However, it is worthwhile to explore the reasons why, in the education of contemporary surgeons, it is important to focus dedicated attention on the ethical issues that arise in the practice of surgery.

Certainly, it is not true that ethics was previously unimportant in surgery.  In 1915 when the early organizers of the American College of Surgeons were first writing down the qualifications for membership, they emphasized the importance of ethics:  “The moral and ethical fitness of the candidates shall be determined by the reports of surgeons whose names are submitted by the candidate himself, and by such other reports and data as the Credentials Committee and the administration of the College may obtain.”[i]  Thus, the early founders of the College considered “ethical fitness” to be essential to their members.  Since there were clearly ethical and unethical ways to practice surgery, why has the focused emphasis on ethics teaching only occurred in recent decades?

I believe that there are three changes that have occurred in surgical care and surgical education that have led to the importance of this recent focus on ethics education in contemporary surgical training programs:  the limitations on work hours for surgical residents, the increasing shift to outpatient care, and the increasing number of options for surgical patients brought about by improvements in surgical technology. 

To begin with, surgical residents today spend significantly less time in the hospital every week than did surgical residents in years past.  Although one could debate the actual educational value the additional time that I and my surgical predecessors spent in the hospital, there is no question that the significant shortening of the amount of time that surgical residents spend with surgical faculty has resulted in fewer opportunities for learning through role modeling.  These many additional hours in the hospital for surgical residents in the past resulted in greater opportunities for residents to see how their faculty dealt with the challenges of managing ethically complex cases.  Although these interactions were not often thought of as “ethical role modeling” in prior years, there is no question that significant ethical teaching occurred in this informal curriculum.

Second, and closely related to the reduction in surgical resident work hours, has been the significant shift to outpatient surgical care.  This shift has meant that surgical residents whose time is focused on what happens in the hospital have even fewer opportunities to witness faculty engaging in many central aspects of the ethical care of surgical patients (e.g., obtaining informed consent for complex surgical procedures, communicating bad news to patients and families, or weighing risks and benefits of high risk elective surgical procedures).

Perhaps most importantly, today there are more options for surgical therapies than ever before.  The central question for a surgeon in 1913 when the American College of Surgeons was formed was, “What can be done for this patient?”  Today, in caring for the most complex and critically ill patients, the question that is foremost for surgeons is often “What should be done?”  This question is not a purely surgical question, but also an ethical question.  Consider a patient who has developed multisystem organ failure after complications from surgery.  Because of the advances in critical care, such a patient might be able to be kept alive with technologies such as mechanical ventilation, augmented cardiac output with a ventricular assist device, and hemodialysis.  These therapies cannot be judged to be appropriate or not without thoughtful consideration of an individual patient’s overall goals and values.   In such a case, weighing values and probabilities for success or failure relative to a particular patient’s goals moves beyond purely scientific surgical decision making into the realm of ethics.

For all of these reasons, I believe that although surgeons have practiced in an ethical fashion for countless generations, the contemporary education of surgeons should include focused attention on ethics and the ethical implications of the surgical interventions that we recommend for our patients.  Some might argue that the ultimate goal of surgical education should be to fully integrate the ethical considerations into the surgical care rendered to patients.  However, there is so much surgical science to be learned in residency, that in order for consideration of the ethical implications to not be lost, I believe that there must be dedicated attention to ethics teaching. 

Although it is an artificial separation to think about distinguishing the ethical considerations from the surgical decision making for a particular patient, the separation is valuable to emphasize the differences between surgical science and surgical ethics.  The former is dependent on anatomy, physiology, and surgical technique; whereas the latter is dependent on relationships, communication, and patient values.  Although we can train surgical residents to be excellent technicians with a focus purely on surgical science, we can only educate great doctors who are also surgeons by expanding the discussions of optimal surgical care to include the considerations central to surgical ethics.

 [1] This important historical background is courtesy of David Nahrwold, MD.

Dr. Angelos is an ACS Fellow, the Linda Kohler Anderson Professor of Surgery and Surgical Ethics, chief, endocrine surgery, and associate director of the MacLean Center for Clinical Medical Ethics at the University of Chicago.

Recently, I was invited to present surgical grand rounds on an ethics topic.  After the talk, a senior surgeon, now retired, who was in the audience confided to me that in all of his years of residency, he had never had a lecture on ethics.  This off-hand comment raised a question that demands consideration in the contemporary era of increasingly limited time available for teaching in surgical residencies.  Do we need ethics teaching in surgery residencies?

As someone who spent significant time in the last few years in ethics teaching activities, my reflex answer is “Yes.”  However, it is worthwhile to explore the reasons why, in the education of contemporary surgeons, it is important to focus dedicated attention on the ethical issues that arise in the practice of surgery.

Certainly, it is not true that ethics was previously unimportant in surgery.  In 1915 when the early organizers of the American College of Surgeons were first writing down the qualifications for membership, they emphasized the importance of ethics:  “The moral and ethical fitness of the candidates shall be determined by the reports of surgeons whose names are submitted by the candidate himself, and by such other reports and data as the Credentials Committee and the administration of the College may obtain.”[i]  Thus, the early founders of the College considered “ethical fitness” to be essential to their members.  Since there were clearly ethical and unethical ways to practice surgery, why has the focused emphasis on ethics teaching only occurred in recent decades?

I believe that there are three changes that have occurred in surgical care and surgical education that have led to the importance of this recent focus on ethics education in contemporary surgical training programs:  the limitations on work hours for surgical residents, the increasing shift to outpatient care, and the increasing number of options for surgical patients brought about by improvements in surgical technology. 

To begin with, surgical residents today spend significantly less time in the hospital every week than did surgical residents in years past.  Although one could debate the actual educational value the additional time that I and my surgical predecessors spent in the hospital, there is no question that the significant shortening of the amount of time that surgical residents spend with surgical faculty has resulted in fewer opportunities for learning through role modeling.  These many additional hours in the hospital for surgical residents in the past resulted in greater opportunities for residents to see how their faculty dealt with the challenges of managing ethically complex cases.  Although these interactions were not often thought of as “ethical role modeling” in prior years, there is no question that significant ethical teaching occurred in this informal curriculum.

Second, and closely related to the reduction in surgical resident work hours, has been the significant shift to outpatient surgical care.  This shift has meant that surgical residents whose time is focused on what happens in the hospital have even fewer opportunities to witness faculty engaging in many central aspects of the ethical care of surgical patients (e.g., obtaining informed consent for complex surgical procedures, communicating bad news to patients and families, or weighing risks and benefits of high risk elective surgical procedures).

Perhaps most importantly, today there are more options for surgical therapies than ever before.  The central question for a surgeon in 1913 when the American College of Surgeons was formed was, “What can be done for this patient?”  Today, in caring for the most complex and critically ill patients, the question that is foremost for surgeons is often “What should be done?”  This question is not a purely surgical question, but also an ethical question.  Consider a patient who has developed multisystem organ failure after complications from surgery.  Because of the advances in critical care, such a patient might be able to be kept alive with technologies such as mechanical ventilation, augmented cardiac output with a ventricular assist device, and hemodialysis.  These therapies cannot be judged to be appropriate or not without thoughtful consideration of an individual patient’s overall goals and values.   In such a case, weighing values and probabilities for success or failure relative to a particular patient’s goals moves beyond purely scientific surgical decision making into the realm of ethics.

For all of these reasons, I believe that although surgeons have practiced in an ethical fashion for countless generations, the contemporary education of surgeons should include focused attention on ethics and the ethical implications of the surgical interventions that we recommend for our patients.  Some might argue that the ultimate goal of surgical education should be to fully integrate the ethical considerations into the surgical care rendered to patients.  However, there is so much surgical science to be learned in residency, that in order for consideration of the ethical implications to not be lost, I believe that there must be dedicated attention to ethics teaching. 

Although it is an artificial separation to think about distinguishing the ethical considerations from the surgical decision making for a particular patient, the separation is valuable to emphasize the differences between surgical science and surgical ethics.  The former is dependent on anatomy, physiology, and surgical technique; whereas the latter is dependent on relationships, communication, and patient values.  Although we can train surgical residents to be excellent technicians with a focus purely on surgical science, we can only educate great doctors who are also surgeons by expanding the discussions of optimal surgical care to include the considerations central to surgical ethics.

 [1] This important historical background is courtesy of David Nahrwold, MD.

Dr. Angelos is an ACS Fellow, the Linda Kohler Anderson Professor of Surgery and Surgical Ethics, chief, endocrine surgery, and associate director of the MacLean Center for Clinical Medical Ethics at the University of Chicago.

Recently, I was invited to present surgical grand rounds on an ethics topic.  After the talk, a senior surgeon, now retired, who was in the audience confided to me that in all of his years of residency, he had never had a lecture on ethics.  This off-hand comment raised a question that demands consideration in the contemporary era of increasingly limited time available for teaching in surgical residencies.  Do we need ethics teaching in surgery residencies?

As someone who spent significant time in the last few years in ethics teaching activities, my reflex answer is “Yes.”  However, it is worthwhile to explore the reasons why, in the education of contemporary surgeons, it is important to focus dedicated attention on the ethical issues that arise in the practice of surgery.

Certainly, it is not true that ethics was previously unimportant in surgery.  In 1915 when the early organizers of the American College of Surgeons were first writing down the qualifications for membership, they emphasized the importance of ethics:  “The moral and ethical fitness of the candidates shall be determined by the reports of surgeons whose names are submitted by the candidate himself, and by such other reports and data as the Credentials Committee and the administration of the College may obtain.”[i]  Thus, the early founders of the College considered “ethical fitness” to be essential to their members.  Since there were clearly ethical and unethical ways to practice surgery, why has the focused emphasis on ethics teaching only occurred in recent decades?

I believe that there are three changes that have occurred in surgical care and surgical education that have led to the importance of this recent focus on ethics education in contemporary surgical training programs:  the limitations on work hours for surgical residents, the increasing shift to outpatient care, and the increasing number of options for surgical patients brought about by improvements in surgical technology. 

To begin with, surgical residents today spend significantly less time in the hospital every week than did surgical residents in years past.  Although one could debate the actual educational value the additional time that I and my surgical predecessors spent in the hospital, there is no question that the significant shortening of the amount of time that surgical residents spend with surgical faculty has resulted in fewer opportunities for learning through role modeling.  These many additional hours in the hospital for surgical residents in the past resulted in greater opportunities for residents to see how their faculty dealt with the challenges of managing ethically complex cases.  Although these interactions were not often thought of as “ethical role modeling” in prior years, there is no question that significant ethical teaching occurred in this informal curriculum.

Second, and closely related to the reduction in surgical resident work hours, has been the significant shift to outpatient surgical care.  This shift has meant that surgical residents whose time is focused on what happens in the hospital have even fewer opportunities to witness faculty engaging in many central aspects of the ethical care of surgical patients (e.g., obtaining informed consent for complex surgical procedures, communicating bad news to patients and families, or weighing risks and benefits of high risk elective surgical procedures).

Perhaps most importantly, today there are more options for surgical therapies than ever before.  The central question for a surgeon in 1913 when the American College of Surgeons was formed was, “What can be done for this patient?”  Today, in caring for the most complex and critically ill patients, the question that is foremost for surgeons is often “What should be done?”  This question is not a purely surgical question, but also an ethical question.  Consider a patient who has developed multisystem organ failure after complications from surgery.  Because of the advances in critical care, such a patient might be able to be kept alive with technologies such as mechanical ventilation, augmented cardiac output with a ventricular assist device, and hemodialysis.  These therapies cannot be judged to be appropriate or not without thoughtful consideration of an individual patient’s overall goals and values.   In such a case, weighing values and probabilities for success or failure relative to a particular patient’s goals moves beyond purely scientific surgical decision making into the realm of ethics.

For all of these reasons, I believe that although surgeons have practiced in an ethical fashion for countless generations, the contemporary education of surgeons should include focused attention on ethics and the ethical implications of the surgical interventions that we recommend for our patients.  Some might argue that the ultimate goal of surgical education should be to fully integrate the ethical considerations into the surgical care rendered to patients.  However, there is so much surgical science to be learned in residency, that in order for consideration of the ethical implications to not be lost, I believe that there must be dedicated attention to ethics teaching. 

Although it is an artificial separation to think about distinguishing the ethical considerations from the surgical decision making for a particular patient, the separation is valuable to emphasize the differences between surgical science and surgical ethics.  The former is dependent on anatomy, physiology, and surgical technique; whereas the latter is dependent on relationships, communication, and patient values.  Although we can train surgical residents to be excellent technicians with a focus purely on surgical science, we can only educate great doctors who are also surgeons by expanding the discussions of optimal surgical care to include the considerations central to surgical ethics.

 [1] This important historical background is courtesy of David Nahrwold, MD.

Dr. Angelos is an ACS Fellow, the Linda Kohler Anderson Professor of Surgery and Surgical Ethics, chief, endocrine surgery, and associate director of the MacLean Center for Clinical Medical Ethics at the University of Chicago.

Every year, hospitalists from across the country come together at SHM’s annual meeting. With this year’s convention located just a few miles south of Washington, D.C., HM13 will be the most convenient meeting for thousands of hospitalists who live and work on or near the East Coast.

In fact, many won’t even need to board a plane to meet up with thousands of fellow hospitalists. For those in Boston, Baltimore, New York, Philadelphia, and other cities in the northeast corridor, the only meeting designed specifically for hospitalists is just a short drive or train ride away.

And when they arrive at the Gaylord National Resort and Convention Center in National Harbor, Md., hospitalists will find a truly expansive experience dedicated to the specialty. In addition to featuring four days of educational content, the meeting gives hospitalists the chance to catch up with old friends and network with new colleagues. Plus, with an exhibit floor filled with the nation’s top recruiters, service providers, and pharmaceutical innovators, hospitalists can get up to speed on the best offerings in the industry in a matter of hours.

Check out our 6-minute feature video: "Five Reasons You Should Attend HM13"

With so many offerings and opportunities in one place, the challenge for most hospitalists isn’t finding something to do—it’s planning their meeting schedule to achieve all of their career and educational goals.

This year, hospitalists can plan their meeting experience with HM13 at Hand, SHM’s mobile application. Now, any hospitalist with a tablet or smartphone and an Internet connection can add educational sessions to their HM13 plan, view paperless abstracts, and connect with other HM13 attendees in advance of the meeting.

For more HM13 information, visit www.hospitalmedicine2013.org.

Brendon Shank is SHM’s associate vice president of communications.

Every year, hospitalists from across the country come together at SHM’s annual meeting. With this year’s convention located just a few miles south of Washington, D.C., HM13 will be the most convenient meeting for thousands of hospitalists who live and work on or near the East Coast.

In fact, many won’t even need to board a plane to meet up with thousands of fellow hospitalists. For those in Boston, Baltimore, New York, Philadelphia, and other cities in the northeast corridor, the only meeting designed specifically for hospitalists is just a short drive or train ride away.

And when they arrive at the Gaylord National Resort and Convention Center in National Harbor, Md., hospitalists will find a truly expansive experience dedicated to the specialty. In addition to featuring four days of educational content, the meeting gives hospitalists the chance to catch up with old friends and network with new colleagues. Plus, with an exhibit floor filled with the nation’s top recruiters, service providers, and pharmaceutical innovators, hospitalists can get up to speed on the best offerings in the industry in a matter of hours.

Check out our 6-minute feature video: "Five Reasons You Should Attend HM13"

With so many offerings and opportunities in one place, the challenge for most hospitalists isn’t finding something to do—it’s planning their meeting schedule to achieve all of their career and educational goals.

This year, hospitalists can plan their meeting experience with HM13 at Hand, SHM’s mobile application. Now, any hospitalist with a tablet or smartphone and an Internet connection can add educational sessions to their HM13 plan, view paperless abstracts, and connect with other HM13 attendees in advance of the meeting.

For more HM13 information, visit www.hospitalmedicine2013.org.

Brendon Shank is SHM’s associate vice president of communications.

Every year, hospitalists from across the country come together at SHM’s annual meeting. With this year’s convention located just a few miles south of Washington, D.C., HM13 will be the most convenient meeting for thousands of hospitalists who live and work on or near the East Coast.

In fact, many won’t even need to board a plane to meet up with thousands of fellow hospitalists. For those in Boston, Baltimore, New York, Philadelphia, and other cities in the northeast corridor, the only meeting designed specifically for hospitalists is just a short drive or train ride away.

And when they arrive at the Gaylord National Resort and Convention Center in National Harbor, Md., hospitalists will find a truly expansive experience dedicated to the specialty. In addition to featuring four days of educational content, the meeting gives hospitalists the chance to catch up with old friends and network with new colleagues. Plus, with an exhibit floor filled with the nation’s top recruiters, service providers, and pharmaceutical innovators, hospitalists can get up to speed on the best offerings in the industry in a matter of hours.

Check out our 6-minute feature video: "Five Reasons You Should Attend HM13"

With so many offerings and opportunities in one place, the challenge for most hospitalists isn’t finding something to do—it’s planning their meeting schedule to achieve all of their career and educational goals.

This year, hospitalists can plan their meeting experience with HM13 at Hand, SHM’s mobile application. Now, any hospitalist with a tablet or smartphone and an Internet connection can add educational sessions to their HM13 plan, view paperless abstracts, and connect with other HM13 attendees in advance of the meeting.

For more HM13 information, visit www.hospitalmedicine2013.org.

Brendon Shank is SHM’s associate vice president of communications.

Johnbuck Creamer, MD

SHM added a new item to its 2012 State of Hospital Medicine report: the ratio of respondents’ observation admissions to inpatient admission encounters. This metric was added because observation encounters have been increasing, with financial effects on hospitals and patients. SHM survey respondents reported a 20% observation rate for both adult and pediatric practice groups (see Figure 1).

Johnbuck Creamer, MD

Under observation status, services that used to be billed as inpatient status (e.g. chest pain evaluation, treatment of asthma exacerbation) must be billed by the hospital at much lower outpatient rates. Some hospitals have responded to this financial pressure by creating observation units or making other operational adjustments. One recent analysis suggested that nationwide adoption of such efforts could save billions of dollars.¹

Becoming lean enough to do short work in short time, though, does not address all of the observation-related issues facing hospitals. When the Centers for Medicare & Medicaid Services’ (CMS) Recovery Audit Contractors (RACs) determine retrospectively that an inpatient admission should have been an observation encounter, the hospital’s payment is not downgraded but forfeited.² This development has prompted hospitals to preemptively opt for observation status for certain patients. Case managers and providers increasingly are spending time reviewing inpatient versus observation status throughout a patient’s stay. Many hospitals have turned to third-party contractors to help review observation status.

Observation status has financial implications for patients as well. In the past year, USA Today, The Wall Street Journal, and CNN Money all have reported on patients hit with unexpected out-of-pocket expenses related to observation care.^3,4,5 A common theme: Medicare patient hospitalized with an acute fracture, managed nonoperatively but requiring rehabilitation prior to returning home. These patients found out too late that observation, a status they were often unaware of, did not qualify for CMS’ three-day inpatient requirement to cover rehabilitation costs. Some patients were charged exorbitant prices for noncovered “outpatient” services, such as providing their routine medications.

Advocacy groups have joined the fray on patients’ behalf, and legal challenges have ensued. AARP and others are educating patients about observation status—and their right to challenge it. The Center for Medicare Advocacy (www.kslaw.com/Library/publication/HH111411_Bagnall.pdf) has filed a lawsuit against the U.S. Department of Health and Human Services on behalf of patients hit with uncovered rehabilitation costs, and the American Hospital Association has teamed with several hospitals to sue over funds forfeited in RAC audits (www.aha.org/content/12/121101-aha-hhs-medicare-com.pdf). Both houses of Congress have legislation (H.R. 1543 and S. 818) seeking to count observation days toward the Medicare three-day rule. For its part, CMS has promised to review observation status and, hopefully, clarify the rules.

Hospitalists, meanwhile, are gearing up for more observation care. The 2012 State of Hospital Medicine report shows that 37% of adult groups and 28% of pediatric groups reported having primary responsibility for observation or short-stay units. My own hospital runs both a clinical decision unit in the ED and a short-stay unit staffed by our hospitalist group. As SHM tracks observation status in future surveys, HM groups will be able to follow this phenomenon among their colleagues and benchmark their own rates of observation encounters.

Dr. Creamer is medical director of the short-stay unit at MetroHealth Medical Center in Cleveland and a member of SHM’s Practice Analysis Committee.

References

1. Feng Z, Wright DB, Mor V. Sharp rise in Medicare enrollees being held in hospitals for observation raises concerns about causes and consequences. Health Aff (Millwood). 2012;31(6):1251-1259.
2. Baugh CW, Venkatesh AK, Hilton JA, Samuel PA, Schuur JD, Bohan JS. Making greater use of dedicated hospital observation units for many short-stay patients could save $3.1 billion a year. Health Aff (Millwood). 2012;31(10):2314-2323.
3. Gengler A. The painful new trend in Medicare. CNN Money website. Available at: http://money.cnn.com/2012/08/07/pf/medicare-rehab-costs.moneymag/index.htm. Accessed March 6, 2013.
4. Jaffe S. Patients held for observation can face steep drug bills. USA Today website. Available at: http://usatoday30.usatoday.com/money/industries/health/drugs/story/2012-04-30/drugs-can-be-expensive-in-observation-care/54646378/1. Accessed March 6, 2013.
5. Landro L. Filling a gap between ERs and inpatient rooms. The Wall Street Journal website. Available at: http://online.wsj.com/article/SB10001424052970204349404578101060863887052.html. Accessed March 6, 2013.

Johnbuck Creamer, MD

SHM added a new item to its 2012 State of Hospital Medicine report: the ratio of respondents’ observation admissions to inpatient admission encounters. This metric was added because observation encounters have been increasing, with financial effects on hospitals and patients. SHM survey respondents reported a 20% observation rate for both adult and pediatric practice groups (see Figure 1).

Johnbuck Creamer, MD

Under observation status, services that used to be billed as inpatient status (e.g. chest pain evaluation, treatment of asthma exacerbation) must be billed by the hospital at much lower outpatient rates. Some hospitals have responded to this financial pressure by creating observation units or making other operational adjustments. One recent analysis suggested that nationwide adoption of such efforts could save billions of dollars.¹

Becoming lean enough to do short work in short time, though, does not address all of the observation-related issues facing hospitals. When the Centers for Medicare & Medicaid Services’ (CMS) Recovery Audit Contractors (RACs) determine retrospectively that an inpatient admission should have been an observation encounter, the hospital’s payment is not downgraded but forfeited.² This development has prompted hospitals to preemptively opt for observation status for certain patients. Case managers and providers increasingly are spending time reviewing inpatient versus observation status throughout a patient’s stay. Many hospitals have turned to third-party contractors to help review observation status.

Observation status has financial implications for patients as well. In the past year, USA Today, The Wall Street Journal, and CNN Money all have reported on patients hit with unexpected out-of-pocket expenses related to observation care.^3,4,5 A common theme: Medicare patient hospitalized with an acute fracture, managed nonoperatively but requiring rehabilitation prior to returning home. These patients found out too late that observation, a status they were often unaware of, did not qualify for CMS’ three-day inpatient requirement to cover rehabilitation costs. Some patients were charged exorbitant prices for noncovered “outpatient” services, such as providing their routine medications.

Advocacy groups have joined the fray on patients’ behalf, and legal challenges have ensued. AARP and others are educating patients about observation status—and their right to challenge it. The Center for Medicare Advocacy (www.kslaw.com/Library/publication/HH111411_Bagnall.pdf) has filed a lawsuit against the U.S. Department of Health and Human Services on behalf of patients hit with uncovered rehabilitation costs, and the American Hospital Association has teamed with several hospitals to sue over funds forfeited in RAC audits (www.aha.org/content/12/121101-aha-hhs-medicare-com.pdf). Both houses of Congress have legislation (H.R. 1543 and S. 818) seeking to count observation days toward the Medicare three-day rule. For its part, CMS has promised to review observation status and, hopefully, clarify the rules.

Hospitalists, meanwhile, are gearing up for more observation care. The 2012 State of Hospital Medicine report shows that 37% of adult groups and 28% of pediatric groups reported having primary responsibility for observation or short-stay units. My own hospital runs both a clinical decision unit in the ED and a short-stay unit staffed by our hospitalist group. As SHM tracks observation status in future surveys, HM groups will be able to follow this phenomenon among their colleagues and benchmark their own rates of observation encounters.

Dr. Creamer is medical director of the short-stay unit at MetroHealth Medical Center in Cleveland and a member of SHM’s Practice Analysis Committee.

References

1. Feng Z, Wright DB, Mor V. Sharp rise in Medicare enrollees being held in hospitals for observation raises concerns about causes and consequences. Health Aff (Millwood). 2012;31(6):1251-1259.
2. Baugh CW, Venkatesh AK, Hilton JA, Samuel PA, Schuur JD, Bohan JS. Making greater use of dedicated hospital observation units for many short-stay patients could save $3.1 billion a year. Health Aff (Millwood). 2012;31(10):2314-2323.
3. Gengler A. The painful new trend in Medicare. CNN Money website. Available at: http://money.cnn.com/2012/08/07/pf/medicare-rehab-costs.moneymag/index.htm. Accessed March 6, 2013.
4. Jaffe S. Patients held for observation can face steep drug bills. USA Today website. Available at: http://usatoday30.usatoday.com/money/industries/health/drugs/story/2012-04-30/drugs-can-be-expensive-in-observation-care/54646378/1. Accessed March 6, 2013.
5. Landro L. Filling a gap between ERs and inpatient rooms. The Wall Street Journal website. Available at: http://online.wsj.com/article/SB10001424052970204349404578101060863887052.html. Accessed March 6, 2013.

Johnbuck Creamer, MD

SHM added a new item to its 2012 State of Hospital Medicine report: the ratio of respondents’ observation admissions to inpatient admission encounters. This metric was added because observation encounters have been increasing, with financial effects on hospitals and patients. SHM survey respondents reported a 20% observation rate for both adult and pediatric practice groups (see Figure 1).

Johnbuck Creamer, MD

Under observation status, services that used to be billed as inpatient status (e.g. chest pain evaluation, treatment of asthma exacerbation) must be billed by the hospital at much lower outpatient rates. Some hospitals have responded to this financial pressure by creating observation units or making other operational adjustments. One recent analysis suggested that nationwide adoption of such efforts could save billions of dollars.¹

Becoming lean enough to do short work in short time, though, does not address all of the observation-related issues facing hospitals. When the Centers for Medicare & Medicaid Services’ (CMS) Recovery Audit Contractors (RACs) determine retrospectively that an inpatient admission should have been an observation encounter, the hospital’s payment is not downgraded but forfeited.² This development has prompted hospitals to preemptively opt for observation status for certain patients. Case managers and providers increasingly are spending time reviewing inpatient versus observation status throughout a patient’s stay. Many hospitals have turned to third-party contractors to help review observation status.

Observation status has financial implications for patients as well. In the past year, USA Today, The Wall Street Journal, and CNN Money all have reported on patients hit with unexpected out-of-pocket expenses related to observation care.^3,4,5 A common theme: Medicare patient hospitalized with an acute fracture, managed nonoperatively but requiring rehabilitation prior to returning home. These patients found out too late that observation, a status they were often unaware of, did not qualify for CMS’ three-day inpatient requirement to cover rehabilitation costs. Some patients were charged exorbitant prices for noncovered “outpatient” services, such as providing their routine medications.

Advocacy groups have joined the fray on patients’ behalf, and legal challenges have ensued. AARP and others are educating patients about observation status—and their right to challenge it. The Center for Medicare Advocacy (www.kslaw.com/Library/publication/HH111411_Bagnall.pdf) has filed a lawsuit against the U.S. Department of Health and Human Services on behalf of patients hit with uncovered rehabilitation costs, and the American Hospital Association has teamed with several hospitals to sue over funds forfeited in RAC audits (www.aha.org/content/12/121101-aha-hhs-medicare-com.pdf). Both houses of Congress have legislation (H.R. 1543 and S. 818) seeking to count observation days toward the Medicare three-day rule. For its part, CMS has promised to review observation status and, hopefully, clarify the rules.

Hospitalists, meanwhile, are gearing up for more observation care. The 2012 State of Hospital Medicine report shows that 37% of adult groups and 28% of pediatric groups reported having primary responsibility for observation or short-stay units. My own hospital runs both a clinical decision unit in the ED and a short-stay unit staffed by our hospitalist group. As SHM tracks observation status in future surveys, HM groups will be able to follow this phenomenon among their colleagues and benchmark their own rates of observation encounters.

Dr. Creamer is medical director of the short-stay unit at MetroHealth Medical Center in Cleveland and a member of SHM’s Practice Analysis Committee.

References

1. Feng Z, Wright DB, Mor V. Sharp rise in Medicare enrollees being held in hospitals for observation raises concerns about causes and consequences. Health Aff (Millwood). 2012;31(6):1251-1259.
2. Baugh CW, Venkatesh AK, Hilton JA, Samuel PA, Schuur JD, Bohan JS. Making greater use of dedicated hospital observation units for many short-stay patients could save $3.1 billion a year. Health Aff (Millwood). 2012;31(10):2314-2323.
3. Gengler A. The painful new trend in Medicare. CNN Money website. Available at: http://money.cnn.com/2012/08/07/pf/medicare-rehab-costs.moneymag/index.htm. Accessed March 6, 2013.
4. Jaffe S. Patients held for observation can face steep drug bills. USA Today website. Available at: http://usatoday30.usatoday.com/money/industries/health/drugs/story/2012-04-30/drugs-can-be-expensive-in-observation-care/54646378/1. Accessed March 6, 2013.
5. Landro L. Filling a gap between ERs and inpatient rooms. The Wall Street Journal website. Available at: http://online.wsj.com/article/SB10001424052970204349404578101060863887052.html. Accessed March 6, 2013.

• E. Cornatzer, MD, Alabama
• P. Cornatzer, MD, Alabama
• S. Meadows, MD, Alabama
• F. Shaikh, MD, PhD, Alabama
• A. Zouhary, MACP, Alabama
• L. Balk, Arizona
• E. Harding, MD, Arizona
• G. Rao, MD, Arizona
• S. Shah, MD, Arizona
• R. Snedecor, Arizona
• M. Dirst-Roberts, MD, Arkansas
• R. Campbell, California
• J. Idury, MD, California
• H. Jackson, MD, California
• C. Johnson, MD, MS, California
• G. Kanwar, California
• B. Kong, MD, California
• P. Lee, MD, California
• S. Pendharkar, USA, California
• S. Perry, California
• T. Pham, MD, California
• M. Sarwar Sr., MD, California
• A. Tandon, California
• E. Wu, MD, California
• G. Clover, MD, Colorado
• J. Cunningham, MD, Colorado
• A. Del Pino-Jones, Colorado
• D. Hilty, Colorado
• K. Kanel, Colorado
• E. Batista, MD, Connecticut
• A. Montero, MD, District of Columbia
• D. Westervelt, NP, District of Columbia
• C. Dumois, MD, Florida
• L. Gatien, DO, Florida
• G. Del Rio, MD, Florida
• M. Khan, MD, Florida
• I. Kuizon, MD, Florida
• S. Menon, DO, MPH, Florida
• G. Newlands, Florida
• R. Patil, MD, MBBS, Florida
• R. Ribon, MD, Florida
• C. Shah, MD, Florida
• C. Brooks, FAAP, Georgia
• S. Clarke, M.H.A., Georgia
• S. Lofgren, MD, Georgia
• K. Nieh, MD, Georgia
• R. Wright, MD, Georgia
• T. Dibuono, RN, Illinois
• C. Kandaswamy, MD, Illinois
• K. Kaul, MD, Illinois
• M. Majid, MD, Illinois
• D. Mitra, MD, Illinois
• J. Peace, Illinois
• A. Rahman, Illinois
• J. Rogers, Illinois
• M. Bolden, MD, Indiana
• T. Callahan, DO, Indiana
• G. Dupre, MD, Indiana
• K. Hall, MD, Indiana
• K. Hunt, MD, Indiana
• E. Tripp, MD, Indiana
• J. Gehling, Iowa
• B. Halsch, Iowa
• H. Zook, Kansas
• R. McLendon Jr., MD, Louisiana
• J. Newsom, Louisiana
• A. Karikkineth, USA, Maryland
• M. Lee, Maryland
• A. Rahim, MD, Maryland
• J. Riley, PA, Maryland
• M. Short, MD, Maryland
• L. Balestrero, MD, Massachusetts
• S. Dhungel, Massachusetts
• A. Finn, Massachusetts
• W. Garcia-Beltran, Massachusetts
• A. Khan, Massachusetts
• N. Najjar, MD, Massachusetts
• A. Sharma, MD, Massachusetts
• J. Cimadevilla, MD, Massachusetts
• M. Byland, MD, Michigan
• D. Coffin, PA-C, Michigan
• K. Covell, DO, Michigan
• J. Hill, Michigan
• M. Howard, PA-C, Michigan
• M. Kabach, Michigan
• K. Karikari, MD, MS, Michigan
• M. Kelsey, PA-C, Michigan
• J. Knoke, PA-C, Michigan
• A. Lawrin, Michigan
• E. Li Fuentes, MD, Michigan
• C. Petrilli, MD, Michigan
• J. Peyton, DO, Michigan
• L. Reynolds, PA-C, Michigan
• O. Sinyavskiy, MD, Michigan
• N. Veerapaneni, MD, MS, Michigan
• D. Wells, PA-C, Michigan
• L. Worthington, PA, Michigan
• E. Canan, MHA, Minnesota
• J. Hsieh, MD, Minnesota
• S. Hsieh, MD, Minnesota
• M. Moore, MD, Minnesota
• S. Xie, MD, Minnesota
• R. Bardowell, MD, Missouri
• A. Chowdhury, MD, Missouri
• I. Elayyan, MD, Missouri
• S. Majcina, Missouri
• P. Martin, Missouri
• S. Budd, MD, Nebraska
• U. Indukuri, MBBS, Nebraska
• J. Stolp, DO, Nebraska
• M. Mahdavian, MD, Canada
• I. Ahmad, MBBS, New Jersey
• T. Kostrub, MS, New Jersey
• S. Ozawa, RN, New Jersey
• G. Smith, MD, New Mexico
• D. Yu, MBA, FACP, New Mexico
• S. Aruchamy, MD, New York
• S. Chikoti, MD, New York
• J. Cohen, MD, New York
• M. Nerkar, MD, New York
• A. Mednick, MD, New York
• E. Metzger, NP, New York
• C. Morrow, MD, New York
• A. Ragusa, MD, New York
• D. Silverstein, MD, New York
• L. Sinvani, MD, New York
• A. Subramony, FAAP, New York
• P. Tierney, MD, New York
• A. Vien, New York
• F. Volpicelli, MD, New York
• E. Bindewald, MD, New Zealand
• R. Brown, FACP, North Carolina
• T. Cook, North Carolina
• K. Gallagher, MD, North Carolina
• C. Jones, North Carolina
• C. McKay, MB, North Carolina
• R. Nagaraj, MBBS, MPH, North Carolina
• A. Purohit, MD, North Carolina
• J. Guntakandla, FHM, North Dakota
• E. Albert, MD, Ohio
• F. Kuo, MD, MBA, Ohio
• A. Suciu, Ohio
• H. Tiu, MN, Ohio
• K. Wright, Ohio
• C. Kaufman, Oklahoma
• R. McGuire, MD, Ontario, Canada
• M. Shafiee, MD, Ontario, Canada
• J. Hughson, MD, Oregon
• M. Moore, MD, Oregon
• J. Richards, Oregon
• K. Alcorn, Pennsylvania
• J. Bogart Jr., ACNP, MSN, RN, Pennsylvania
• M. Buisch, PA-C, Pennsylvania
• P. Dolan, RN, Pennsylvania
• M. Dunkle, PA-C, Pennsylvania
• E. Faulconbridge, PA-C, Pennsylvania
• J. Frommer Jr., DO, Pennsylvania
• G. Horn, Pennsylvania
• K. Killian, PA-C, Pennsylvania
• J. Klutz, MD, FACFM, Pennsylvania
• B. Nolt, MD, Pennsylvania
• B. Randleman, DO, Pennsylvania
• E. Reynolds, MHS, PA-C, Pennsylvania
• S. Schwalm, MA, Pennsylvania
• K. McNally, BSC, CCFP, MD, Prince
• Edward Island, Canada
• J. Germain, CCFP, Quebec, Canada
• J. Garzone, DO, South Carolina
• M. Chaney, MD, Tennessee
• C. Foxley, MD, Tennessee
• S. Geller, MD, FACP, MPH, Tennessee
• J. Mann, MD, Tennessee
• D. Sargent, MD, Tennessee
• O. Adeyinka, MBBS, Texas
• J. Asuaje, Texas
• A. Bhuriwala, MBBS, Texas
• B. Fishman, MD, FACP, Texas
• S. Gerineni, Texas
• G. Guzman, MD, Texas
• R. Ledesma, Texas
• R. Mckelvey, BC, Texas
• R. Mohme, MD, Texas
• J. Ramineni, MD, Texas
• N. Robinson, MD, Texas
• M. Seas, Texas
• E. Silva, MD, Texas
• S. Siripurapu, Texas
• E. Trevino, DMD, Texas
• J. Miller, MD, Utah
• S. Sadiq, MBBS, Utah
• C. Wells, MD, Utah
• C. Mitchell, MD, Vermont
• K. Free, PA-C, Virginia
• M. Gomez-Sanchez, MD, Virginia
• P. Lee, MD, Virginia
• M. Ayub, MD, Washington
• B. Dentler, MD, Washington
• S. Fogarty, MD, Washington
• J. James, MD, Washington
• M. Larrabee, MD, Washington
• M. Marton, PhD, Washington
• C. Meyers, MD, Washington
• M. Narayanan, MD, MPH, Washington
• B. Randhawa, MD, Washington
• T. Spector, MD, Washington
• A. Thomas, Washington
• J. Tieder, MD, Washington
• J. Yoon, MD, Washington
• L. Mousa, MD, West Virginia
• D. La Voie, MD, Wisconsin

• E. Cornatzer, MD, Alabama
• P. Cornatzer, MD, Alabama
• S. Meadows, MD, Alabama
• F. Shaikh, MD, PhD, Alabama
• A. Zouhary, MACP, Alabama
• L. Balk, Arizona
• E. Harding, MD, Arizona
• G. Rao, MD, Arizona
• S. Shah, MD, Arizona
• R. Snedecor, Arizona
• M. Dirst-Roberts, MD, Arkansas
• R. Campbell, California
• J. Idury, MD, California
• H. Jackson, MD, California
• C. Johnson, MD, MS, California
• G. Kanwar, California
• B. Kong, MD, California
• P. Lee, MD, California
• S. Pendharkar, USA, California
• S. Perry, California
• T. Pham, MD, California
• M. Sarwar Sr., MD, California
• A. Tandon, California
• E. Wu, MD, California
• G. Clover, MD, Colorado
• J. Cunningham, MD, Colorado
• A. Del Pino-Jones, Colorado
• D. Hilty, Colorado
• K. Kanel, Colorado
• E. Batista, MD, Connecticut
• A. Montero, MD, District of Columbia
• D. Westervelt, NP, District of Columbia
• C. Dumois, MD, Florida
• L. Gatien, DO, Florida
• G. Del Rio, MD, Florida
• M. Khan, MD, Florida
• I. Kuizon, MD, Florida
• S. Menon, DO, MPH, Florida
• G. Newlands, Florida
• R. Patil, MD, MBBS, Florida
• R. Ribon, MD, Florida
• C. Shah, MD, Florida
• C. Brooks, FAAP, Georgia
• S. Clarke, M.H.A., Georgia
• S. Lofgren, MD, Georgia
• K. Nieh, MD, Georgia
• R. Wright, MD, Georgia
• T. Dibuono, RN, Illinois
• C. Kandaswamy, MD, Illinois
• K. Kaul, MD, Illinois
• M. Majid, MD, Illinois
• D. Mitra, MD, Illinois
• J. Peace, Illinois
• A. Rahman, Illinois
• J. Rogers, Illinois
• M. Bolden, MD, Indiana
• T. Callahan, DO, Indiana
• G. Dupre, MD, Indiana
• K. Hall, MD, Indiana
• K. Hunt, MD, Indiana
• E. Tripp, MD, Indiana
• J. Gehling, Iowa
• B. Halsch, Iowa
• H. Zook, Kansas
• R. McLendon Jr., MD, Louisiana
• J. Newsom, Louisiana
• A. Karikkineth, USA, Maryland
• M. Lee, Maryland
• A. Rahim, MD, Maryland
• J. Riley, PA, Maryland
• M. Short, MD, Maryland
• L. Balestrero, MD, Massachusetts
• S. Dhungel, Massachusetts
• A. Finn, Massachusetts
• W. Garcia-Beltran, Massachusetts
• A. Khan, Massachusetts
• N. Najjar, MD, Massachusetts
• A. Sharma, MD, Massachusetts
• J. Cimadevilla, MD, Massachusetts
• M. Byland, MD, Michigan
• D. Coffin, PA-C, Michigan
• K. Covell, DO, Michigan
• J. Hill, Michigan
• M. Howard, PA-C, Michigan
• M. Kabach, Michigan
• K. Karikari, MD, MS, Michigan
• M. Kelsey, PA-C, Michigan
• J. Knoke, PA-C, Michigan
• A. Lawrin, Michigan
• E. Li Fuentes, MD, Michigan
• C. Petrilli, MD, Michigan
• J. Peyton, DO, Michigan
• L. Reynolds, PA-C, Michigan
• O. Sinyavskiy, MD, Michigan
• N. Veerapaneni, MD, MS, Michigan
• D. Wells, PA-C, Michigan
• L. Worthington, PA, Michigan
• E. Canan, MHA, Minnesota
• J. Hsieh, MD, Minnesota
• S. Hsieh, MD, Minnesota
• M. Moore, MD, Minnesota
• S. Xie, MD, Minnesota
• R. Bardowell, MD, Missouri
• A. Chowdhury, MD, Missouri
• I. Elayyan, MD, Missouri
• S. Majcina, Missouri
• P. Martin, Missouri
• S. Budd, MD, Nebraska
• U. Indukuri, MBBS, Nebraska
• J. Stolp, DO, Nebraska
• M. Mahdavian, MD, Canada
• I. Ahmad, MBBS, New Jersey
• T. Kostrub, MS, New Jersey
• S. Ozawa, RN, New Jersey
• G. Smith, MD, New Mexico
• D. Yu, MBA, FACP, New Mexico
• S. Aruchamy, MD, New York
• S. Chikoti, MD, New York
• J. Cohen, MD, New York
• M. Nerkar, MD, New York
• A. Mednick, MD, New York
• E. Metzger, NP, New York
• C. Morrow, MD, New York
• A. Ragusa, MD, New York
• D. Silverstein, MD, New York
• L. Sinvani, MD, New York
• A. Subramony, FAAP, New York
• P. Tierney, MD, New York
• A. Vien, New York
• F. Volpicelli, MD, New York
• E. Bindewald, MD, New Zealand
• R. Brown, FACP, North Carolina
• T. Cook, North Carolina
• K. Gallagher, MD, North Carolina
• C. Jones, North Carolina
• C. McKay, MB, North Carolina
• R. Nagaraj, MBBS, MPH, North Carolina
• A. Purohit, MD, North Carolina
• J. Guntakandla, FHM, North Dakota
• E. Albert, MD, Ohio
• F. Kuo, MD, MBA, Ohio
• A. Suciu, Ohio
• H. Tiu, MN, Ohio
• K. Wright, Ohio
• C. Kaufman, Oklahoma
• R. McGuire, MD, Ontario, Canada
• M. Shafiee, MD, Ontario, Canada
• J. Hughson, MD, Oregon
• M. Moore, MD, Oregon
• J. Richards, Oregon
• K. Alcorn, Pennsylvania
• J. Bogart Jr., ACNP, MSN, RN, Pennsylvania
• M. Buisch, PA-C, Pennsylvania
• P. Dolan, RN, Pennsylvania
• M. Dunkle, PA-C, Pennsylvania
• E. Faulconbridge, PA-C, Pennsylvania
• J. Frommer Jr., DO, Pennsylvania
• G. Horn, Pennsylvania
• K. Killian, PA-C, Pennsylvania
• J. Klutz, MD, FACFM, Pennsylvania
• B. Nolt, MD, Pennsylvania
• B. Randleman, DO, Pennsylvania
• E. Reynolds, MHS, PA-C, Pennsylvania
• S. Schwalm, MA, Pennsylvania
• K. McNally, BSC, CCFP, MD, Prince
• Edward Island, Canada
• J. Germain, CCFP, Quebec, Canada
• J. Garzone, DO, South Carolina
• M. Chaney, MD, Tennessee
• C. Foxley, MD, Tennessee
• S. Geller, MD, FACP, MPH, Tennessee
• J. Mann, MD, Tennessee
• D. Sargent, MD, Tennessee
• O. Adeyinka, MBBS, Texas
• J. Asuaje, Texas
• A. Bhuriwala, MBBS, Texas
• B. Fishman, MD, FACP, Texas
• S. Gerineni, Texas
• G. Guzman, MD, Texas
• R. Ledesma, Texas
• R. Mckelvey, BC, Texas
• R. Mohme, MD, Texas
• J. Ramineni, MD, Texas
• N. Robinson, MD, Texas
• M. Seas, Texas
• E. Silva, MD, Texas
• S. Siripurapu, Texas
• E. Trevino, DMD, Texas
• J. Miller, MD, Utah
• S. Sadiq, MBBS, Utah
• C. Wells, MD, Utah
• C. Mitchell, MD, Vermont
• K. Free, PA-C, Virginia
• M. Gomez-Sanchez, MD, Virginia
• P. Lee, MD, Virginia
• M. Ayub, MD, Washington
• B. Dentler, MD, Washington
• S. Fogarty, MD, Washington
• J. James, MD, Washington
• M. Larrabee, MD, Washington
• M. Marton, PhD, Washington
• C. Meyers, MD, Washington
• M. Narayanan, MD, MPH, Washington
• B. Randhawa, MD, Washington
• T. Spector, MD, Washington
• A. Thomas, Washington
• J. Tieder, MD, Washington
• J. Yoon, MD, Washington
• L. Mousa, MD, West Virginia
• D. La Voie, MD, Wisconsin

• E. Cornatzer, MD, Alabama
• P. Cornatzer, MD, Alabama
• S. Meadows, MD, Alabama
• F. Shaikh, MD, PhD, Alabama
• A. Zouhary, MACP, Alabama
• L. Balk, Arizona
• E. Harding, MD, Arizona
• G. Rao, MD, Arizona
• S. Shah, MD, Arizona
• R. Snedecor, Arizona
• M. Dirst-Roberts, MD, Arkansas
• R. Campbell, California
• J. Idury, MD, California
• H. Jackson, MD, California
• C. Johnson, MD, MS, California
• G. Kanwar, California
• B. Kong, MD, California
• P. Lee, MD, California
• S. Pendharkar, USA, California
• S. Perry, California
• T. Pham, MD, California
• M. Sarwar Sr., MD, California
• A. Tandon, California
• E. Wu, MD, California
• G. Clover, MD, Colorado
• J. Cunningham, MD, Colorado
• A. Del Pino-Jones, Colorado
• D. Hilty, Colorado
• K. Kanel, Colorado
• E. Batista, MD, Connecticut
• A. Montero, MD, District of Columbia
• D. Westervelt, NP, District of Columbia
• C. Dumois, MD, Florida
• L. Gatien, DO, Florida
• G. Del Rio, MD, Florida
• M. Khan, MD, Florida
• I. Kuizon, MD, Florida
• S. Menon, DO, MPH, Florida
• G. Newlands, Florida
• R. Patil, MD, MBBS, Florida
• R. Ribon, MD, Florida
• C. Shah, MD, Florida
• C. Brooks, FAAP, Georgia
• S. Clarke, M.H.A., Georgia
• S. Lofgren, MD, Georgia
• K. Nieh, MD, Georgia
• R. Wright, MD, Georgia
• T. Dibuono, RN, Illinois
• C. Kandaswamy, MD, Illinois
• K. Kaul, MD, Illinois
• M. Majid, MD, Illinois
• D. Mitra, MD, Illinois
• J. Peace, Illinois
• A. Rahman, Illinois
• J. Rogers, Illinois
• M. Bolden, MD, Indiana
• T. Callahan, DO, Indiana
• G. Dupre, MD, Indiana
• K. Hall, MD, Indiana
• K. Hunt, MD, Indiana
• E. Tripp, MD, Indiana
• J. Gehling, Iowa
• B. Halsch, Iowa
• H. Zook, Kansas
• R. McLendon Jr., MD, Louisiana
• J. Newsom, Louisiana
• A. Karikkineth, USA, Maryland
• M. Lee, Maryland
• A. Rahim, MD, Maryland
• J. Riley, PA, Maryland
• M. Short, MD, Maryland
• L. Balestrero, MD, Massachusetts
• S. Dhungel, Massachusetts
• A. Finn, Massachusetts
• W. Garcia-Beltran, Massachusetts
• A. Khan, Massachusetts
• N. Najjar, MD, Massachusetts
• A. Sharma, MD, Massachusetts
• J. Cimadevilla, MD, Massachusetts
• M. Byland, MD, Michigan
• D. Coffin, PA-C, Michigan
• K. Covell, DO, Michigan
• J. Hill, Michigan
• M. Howard, PA-C, Michigan
• M. Kabach, Michigan
• K. Karikari, MD, MS, Michigan
• M. Kelsey, PA-C, Michigan
• J. Knoke, PA-C, Michigan
• A. Lawrin, Michigan
• E. Li Fuentes, MD, Michigan
• C. Petrilli, MD, Michigan
• J. Peyton, DO, Michigan
• L. Reynolds, PA-C, Michigan
• O. Sinyavskiy, MD, Michigan
• N. Veerapaneni, MD, MS, Michigan
• D. Wells, PA-C, Michigan
• L. Worthington, PA, Michigan
• E. Canan, MHA, Minnesota
• J. Hsieh, MD, Minnesota
• S. Hsieh, MD, Minnesota
• M. Moore, MD, Minnesota
• S. Xie, MD, Minnesota
• R. Bardowell, MD, Missouri
• A. Chowdhury, MD, Missouri
• I. Elayyan, MD, Missouri
• S. Majcina, Missouri
• P. Martin, Missouri
• S. Budd, MD, Nebraska
• U. Indukuri, MBBS, Nebraska
• J. Stolp, DO, Nebraska
• M. Mahdavian, MD, Canada
• I. Ahmad, MBBS, New Jersey
• T. Kostrub, MS, New Jersey
• S. Ozawa, RN, New Jersey
• G. Smith, MD, New Mexico
• D. Yu, MBA, FACP, New Mexico
• S. Aruchamy, MD, New York
• S. Chikoti, MD, New York
• J. Cohen, MD, New York
• M. Nerkar, MD, New York
• A. Mednick, MD, New York
• E. Metzger, NP, New York
• C. Morrow, MD, New York
• A. Ragusa, MD, New York
• D. Silverstein, MD, New York
• L. Sinvani, MD, New York
• A. Subramony, FAAP, New York
• P. Tierney, MD, New York
• A. Vien, New York
• F. Volpicelli, MD, New York
• E. Bindewald, MD, New Zealand
• R. Brown, FACP, North Carolina
• T. Cook, North Carolina
• K. Gallagher, MD, North Carolina
• C. Jones, North Carolina
• C. McKay, MB, North Carolina
• R. Nagaraj, MBBS, MPH, North Carolina
• A. Purohit, MD, North Carolina
• J. Guntakandla, FHM, North Dakota
• E. Albert, MD, Ohio
• F. Kuo, MD, MBA, Ohio
• A. Suciu, Ohio
• H. Tiu, MN, Ohio
• K. Wright, Ohio
• C. Kaufman, Oklahoma
• R. McGuire, MD, Ontario, Canada
• M. Shafiee, MD, Ontario, Canada
• J. Hughson, MD, Oregon
• M. Moore, MD, Oregon
• J. Richards, Oregon
• K. Alcorn, Pennsylvania
• J. Bogart Jr., ACNP, MSN, RN, Pennsylvania
• M. Buisch, PA-C, Pennsylvania
• P. Dolan, RN, Pennsylvania
• M. Dunkle, PA-C, Pennsylvania
• E. Faulconbridge, PA-C, Pennsylvania
• J. Frommer Jr., DO, Pennsylvania
• G. Horn, Pennsylvania
• K. Killian, PA-C, Pennsylvania
• J. Klutz, MD, FACFM, Pennsylvania
• B. Nolt, MD, Pennsylvania
• B. Randleman, DO, Pennsylvania
• E. Reynolds, MHS, PA-C, Pennsylvania
• S. Schwalm, MA, Pennsylvania
• K. McNally, BSC, CCFP, MD, Prince
• Edward Island, Canada
• J. Germain, CCFP, Quebec, Canada
• J. Garzone, DO, South Carolina
• M. Chaney, MD, Tennessee
• C. Foxley, MD, Tennessee
• S. Geller, MD, FACP, MPH, Tennessee
• J. Mann, MD, Tennessee
• D. Sargent, MD, Tennessee
• O. Adeyinka, MBBS, Texas
• J. Asuaje, Texas
• A. Bhuriwala, MBBS, Texas
• B. Fishman, MD, FACP, Texas
• S. Gerineni, Texas
• G. Guzman, MD, Texas
• R. Ledesma, Texas
• R. Mckelvey, BC, Texas
• R. Mohme, MD, Texas
• J. Ramineni, MD, Texas
• N. Robinson, MD, Texas
• M. Seas, Texas
• E. Silva, MD, Texas
• S. Siripurapu, Texas
• E. Trevino, DMD, Texas
• J. Miller, MD, Utah
• S. Sadiq, MBBS, Utah
• C. Wells, MD, Utah
• C. Mitchell, MD, Vermont
• K. Free, PA-C, Virginia
• M. Gomez-Sanchez, MD, Virginia
• P. Lee, MD, Virginia
• M. Ayub, MD, Washington
• B. Dentler, MD, Washington
• S. Fogarty, MD, Washington
• J. James, MD, Washington
• M. Larrabee, MD, Washington
• M. Marton, PhD, Washington
• C. Meyers, MD, Washington
• M. Narayanan, MD, MPH, Washington
• B. Randhawa, MD, Washington
• T. Spector, MD, Washington
• A. Thomas, Washington
• J. Tieder, MD, Washington
• J. Yoon, MD, Washington
• L. Mousa, MD, West Virginia
• D. La Voie, MD, Wisconsin

For those who remain unaware, hospitalists who care for Medicaid patients will be getting a raise in 2013 and 2014. The reason is that the Affordable Care Act (ACA) requires Medicaid rates for specified primary-care services to be equal to those of Medicare rates during those two years, with the federal government paying the difference. Hospitalists generally meet the requirements and, therefore, will see this pay increase for their applicable Medicaid billing. For some context of the scope of this change, on average, Medicaid pays physicians at 66% of the national Medicare rates, although there is significant variation among the states.

To qualify, a physician must have a specialty designation of family medicine, internal medicine, or pediatrics, then further attest to board certification in one of those specialties or related subspecialties. Alternatively, the physician must have a 60% claims history for the specified evaluation and management (E&M) codes.

Multiple parties who have heard reports about state plans for Medicaid parity recently have contacted SHM; the plans, they report, intentionally would exclude hospitalists from the promised increase. There are variations on the explanation for the exclusion and where the idea is coming from, but the inquiries follow this general theme: “Since the definition of eligible physicians remains a grey area, states are developing alternative plans with a more narrow interpretation of the qualifying factors for the increase. These plans are only including physicians who practice in the community setting (i.e. not the hospital setting).”

This is demonstrably wrong. Even if states are having these discussions, such a plan is not going to come to fruition. The final rule for Medicaid parity, which essentially has the effect of law, is very clear: It does not allow for differing eligibility or alternate state plans.

The Centers for Medicare & Medicaid Services (CMS) specifically stated in the final rule that the increase is not limited to office-based primary-care services, but it will also include hospital observation and consultation for inpatient services provided by nonadmitting physicians, ED services, and critical-care services. In other words, a hospitalist who attests eligibility for their respective state Medicaid agency and bills 99231-3, 99221-3, 99238-9, etc., will receive the increased payment for these codes.

In response to an SHM inquiry for further clarification, CMS officials have stated, “The regulation requires that qualified physicians billing eligible codes receive higher payment. States do not have the latitude to exclude physicians simply because they practice in hospitals.”

It is possible that some confusion might be arising due to the recent controversies around the upcoming Medicaid expansion, which would extend Medicaid eligibility to individuals who earn up to 138% of the federal poverty line. Some states have chosen to opt out of this expansion and have publicly fought its implementation. The Medicaid parity provision is parallel to, but independent of, Medicaid expansion. Even if a state opts out of the expansion, the Medicaid payment increase for primary-care services should remain unaffected.

This isn’t to say that the Medicaid parity provision is a certainty. With the eyes of Congress turned toward budget cuts and austerity, the funds allocated for this temporary increase could easily be targeted. Regardless, any change in eligibility would require a rule change at the federal level, which is unlikely.

Many states have already devoted much time and effort on plans to implement the provision, and the plans were due to be submitted to CMS on March 31. It is pretty late in the game to consider changes. Barring an unlikely rule change or total elimination of funding, it is clear that hospitalists are eligible for the payment bump and should remain so.

Josh Boswell is SHM’s senior manager of government relations.

For those who remain unaware, hospitalists who care for Medicaid patients will be getting a raise in 2013 and 2014. The reason is that the Affordable Care Act (ACA) requires Medicaid rates for specified primary-care services to be equal to those of Medicare rates during those two years, with the federal government paying the difference. Hospitalists generally meet the requirements and, therefore, will see this pay increase for their applicable Medicaid billing. For some context of the scope of this change, on average, Medicaid pays physicians at 66% of the national Medicare rates, although there is significant variation among the states.

To qualify, a physician must have a specialty designation of family medicine, internal medicine, or pediatrics, then further attest to board certification in one of those specialties or related subspecialties. Alternatively, the physician must have a 60% claims history for the specified evaluation and management (E&M) codes.

Multiple parties who have heard reports about state plans for Medicaid parity recently have contacted SHM; the plans, they report, intentionally would exclude hospitalists from the promised increase. There are variations on the explanation for the exclusion and where the idea is coming from, but the inquiries follow this general theme: “Since the definition of eligible physicians remains a grey area, states are developing alternative plans with a more narrow interpretation of the qualifying factors for the increase. These plans are only including physicians who practice in the community setting (i.e. not the hospital setting).”

This is demonstrably wrong. Even if states are having these discussions, such a plan is not going to come to fruition. The final rule for Medicaid parity, which essentially has the effect of law, is very clear: It does not allow for differing eligibility or alternate state plans.

The Centers for Medicare & Medicaid Services (CMS) specifically stated in the final rule that the increase is not limited to office-based primary-care services, but it will also include hospital observation and consultation for inpatient services provided by nonadmitting physicians, ED services, and critical-care services. In other words, a hospitalist who attests eligibility for their respective state Medicaid agency and bills 99231-3, 99221-3, 99238-9, etc., will receive the increased payment for these codes.

In response to an SHM inquiry for further clarification, CMS officials have stated, “The regulation requires that qualified physicians billing eligible codes receive higher payment. States do not have the latitude to exclude physicians simply because they practice in hospitals.”

It is possible that some confusion might be arising due to the recent controversies around the upcoming Medicaid expansion, which would extend Medicaid eligibility to individuals who earn up to 138% of the federal poverty line. Some states have chosen to opt out of this expansion and have publicly fought its implementation. The Medicaid parity provision is parallel to, but independent of, Medicaid expansion. Even if a state opts out of the expansion, the Medicaid payment increase for primary-care services should remain unaffected.

This isn’t to say that the Medicaid parity provision is a certainty. With the eyes of Congress turned toward budget cuts and austerity, the funds allocated for this temporary increase could easily be targeted. Regardless, any change in eligibility would require a rule change at the federal level, which is unlikely.

Many states have already devoted much time and effort on plans to implement the provision, and the plans were due to be submitted to CMS on March 31. It is pretty late in the game to consider changes. Barring an unlikely rule change or total elimination of funding, it is clear that hospitalists are eligible for the payment bump and should remain so.

Josh Boswell is SHM’s senior manager of government relations.

For those who remain unaware, hospitalists who care for Medicaid patients will be getting a raise in 2013 and 2014. The reason is that the Affordable Care Act (ACA) requires Medicaid rates for specified primary-care services to be equal to those of Medicare rates during those two years, with the federal government paying the difference. Hospitalists generally meet the requirements and, therefore, will see this pay increase for their applicable Medicaid billing. For some context of the scope of this change, on average, Medicaid pays physicians at 66% of the national Medicare rates, although there is significant variation among the states.

To qualify, a physician must have a specialty designation of family medicine, internal medicine, or pediatrics, then further attest to board certification in one of those specialties or related subspecialties. Alternatively, the physician must have a 60% claims history for the specified evaluation and management (E&M) codes.

Multiple parties who have heard reports about state plans for Medicaid parity recently have contacted SHM; the plans, they report, intentionally would exclude hospitalists from the promised increase. There are variations on the explanation for the exclusion and where the idea is coming from, but the inquiries follow this general theme: “Since the definition of eligible physicians remains a grey area, states are developing alternative plans with a more narrow interpretation of the qualifying factors for the increase. These plans are only including physicians who practice in the community setting (i.e. not the hospital setting).”

This is demonstrably wrong. Even if states are having these discussions, such a plan is not going to come to fruition. The final rule for Medicaid parity, which essentially has the effect of law, is very clear: It does not allow for differing eligibility or alternate state plans.

The Centers for Medicare & Medicaid Services (CMS) specifically stated in the final rule that the increase is not limited to office-based primary-care services, but it will also include hospital observation and consultation for inpatient services provided by nonadmitting physicians, ED services, and critical-care services. In other words, a hospitalist who attests eligibility for their respective state Medicaid agency and bills 99231-3, 99221-3, 99238-9, etc., will receive the increased payment for these codes.

In response to an SHM inquiry for further clarification, CMS officials have stated, “The regulation requires that qualified physicians billing eligible codes receive higher payment. States do not have the latitude to exclude physicians simply because they practice in hospitals.”

It is possible that some confusion might be arising due to the recent controversies around the upcoming Medicaid expansion, which would extend Medicaid eligibility to individuals who earn up to 138% of the federal poverty line. Some states have chosen to opt out of this expansion and have publicly fought its implementation. The Medicaid parity provision is parallel to, but independent of, Medicaid expansion. Even if a state opts out of the expansion, the Medicaid payment increase for primary-care services should remain unaffected.

This isn’t to say that the Medicaid parity provision is a certainty. With the eyes of Congress turned toward budget cuts and austerity, the funds allocated for this temporary increase could easily be targeted. Regardless, any change in eligibility would require a rule change at the federal level, which is unlikely.

Many states have already devoted much time and effort on plans to implement the provision, and the plans were due to be submitted to CMS on March 31. It is pretty late in the game to consider changes. Barring an unlikely rule change or total elimination of funding, it is clear that hospitalists are eligible for the payment bump and should remain so.

Josh Boswell is SHM’s senior manager of government relations.

Arvind Gupta, MD, FACP, FHM

Dr. Gupta is a hospitalist at Wellspan York Hospital in York, Pa. He is the former medical director of the hospitalist program at Holy Spirit Hospital in Camp Hill, Pa., and the former director of the department of medicine research at Lehigh Valley Hospital in Allentown, Pa. He is president and founder of the South Central Pennsylvania chapter of SHM.

Undergraduate education: Punjab University, India

Medical school: Ross University School of Medicine, Dominica

Notable: After spending 10 years as a director of microbiology at Vencor Hospital in Arlington, Va., Dr. Gupta began attending medical school when he was 36. Although he started his hospitalist career much later than most, he has made up the time through active participation at the hospitals in which he worked. He has been a part of the medical executive committee, the quality council, and the performance improvement committee,. He also chaired the credential committee. As a research specialist, he has taken part in 34 clinical trials. As a hospitalist, he focuses on providing efficient, safe, and cost-effective care for his patients.

FYI: Dr. Gupta’s favorite pastime is golf. He loves watching sports and movies with his family. He says one of his greatest achievements is having sons who attend Duke University and Cornell University.

Quotable: “Becoming an SHM fellow is a great honor and recognition. It means a lot for the new designation of the hospitalist.”

Arvind Gupta, MD, FACP, FHM

Dr. Gupta is a hospitalist at Wellspan York Hospital in York, Pa. He is the former medical director of the hospitalist program at Holy Spirit Hospital in Camp Hill, Pa., and the former director of the department of medicine research at Lehigh Valley Hospital in Allentown, Pa. He is president and founder of the South Central Pennsylvania chapter of SHM.

Undergraduate education: Punjab University, India

Medical school: Ross University School of Medicine, Dominica

Notable: After spending 10 years as a director of microbiology at Vencor Hospital in Arlington, Va., Dr. Gupta began attending medical school when he was 36. Although he started his hospitalist career much later than most, he has made up the time through active participation at the hospitals in which he worked. He has been a part of the medical executive committee, the quality council, and the performance improvement committee,. He also chaired the credential committee. As a research specialist, he has taken part in 34 clinical trials. As a hospitalist, he focuses on providing efficient, safe, and cost-effective care for his patients.

FYI: Dr. Gupta’s favorite pastime is golf. He loves watching sports and movies with his family. He says one of his greatest achievements is having sons who attend Duke University and Cornell University.

Quotable: “Becoming an SHM fellow is a great honor and recognition. It means a lot for the new designation of the hospitalist.”

Arvind Gupta, MD, FACP, FHM

Dr. Gupta is a hospitalist at Wellspan York Hospital in York, Pa. He is the former medical director of the hospitalist program at Holy Spirit Hospital in Camp Hill, Pa., and the former director of the department of medicine research at Lehigh Valley Hospital in Allentown, Pa. He is president and founder of the South Central Pennsylvania chapter of SHM.

Undergraduate education: Punjab University, India

Medical school: Ross University School of Medicine, Dominica

Notable: After spending 10 years as a director of microbiology at Vencor Hospital in Arlington, Va., Dr. Gupta began attending medical school when he was 36. Although he started his hospitalist career much later than most, he has made up the time through active participation at the hospitals in which he worked. He has been a part of the medical executive committee, the quality council, and the performance improvement committee,. He also chaired the credential committee. As a research specialist, he has taken part in 34 clinical trials. As a hospitalist, he focuses on providing efficient, safe, and cost-effective care for his patients.

FYI: Dr. Gupta’s favorite pastime is golf. He loves watching sports and movies with his family. He says one of his greatest achievements is having sons who attend Duke University and Cornell University.

Quotable: “Becoming an SHM fellow is a great honor and recognition. It means a lot for the new designation of the hospitalist.”

Larry Wellikson, MD, SFHM

Exceptional hospitalists

Dr. Cawley

Dr. Gottlieb

Dr. Wachter

Dr. Gorman

Dr. Conway

Even though hospital medicine and SHM are still relatively young, we can be very proud of what our specialty already has brought to changing our nation’s health care for the better. Many of these accomplishments, from winning the prestigious Eisenberg Award to our change leadership by SHM’s Center for Healthcare Innovation and Improvement at more 300 hospitals to the extraordinary growth of our specialty, have been well chronicled in The Hospitalist and elsewhere the last few years.

I wanted to use this month’s column to highlight the unique career directions of a few SHM members to shine a bright light on the influence hospitalists are making nationwide. Certainly, there are many more hospitalists beyond this group of five that I have selected, but this small cadre should serve as an example of the talent and reach of our specialty—with only more and greater things ahead to come in the future.

Chief Medical Officer of CMS

Pat Conway, MD, SFHM, is a pediatric hospitalist and the former chair of SHM’s Public Policy Committee. He left his pediatric academic practice to become a White House fellow, then returned to Cincinnati Children’s Hospital to serve as chief medical officer (CMO). When Don Berwick was in charge of the Centers for Medicare & Medicaid Services (CMS), he reached out to Pat and asked him to come to Washington to be part of Medicare’s senior team as the CMO for CMS. In this role, Pat has been a nationally recognized leader in performance improvement and patient safety, and he has been instrumental in bringing about evolutionary changes to the largest healthcare program in the world. Pat will be sharing his perspectives as a keynote speaker at HM13 (check out our 10-page HM13 preview starting on p. 45).

Resident Fellow at the American Enterprise Institute

Scott Gottlieb, MD, is a practicing hospitalist in New York City, but he is better known as a leading expert in healthcare policy, most recently acting as an advisor to presidential candidate Mitt Romney. From 2005 to 2007, Scott was a deputy commissioner at the FDA. He has worked as a senior advisor to the administrator at CMS, where he played an instrumental role in the implementation of the Medicare Drug Benefit in 2004.

Scott is best known for his frequent contributions to The Wall Street Journal, The New York Times, USA Today, and Forbes. He has held editorial positions at the British Medical Journal and the Journal of the American Medical Association, regularly appears as a guest commentator on CNBC, and is a frequent contributor to Politico.

At SHM, Scott has brought his national viewpoint to the Public Policy Committee. He proudly touts his experience as a practicing hospitalist as bringing a front-line reality to his national recognition and much-sought-after critical thinking about healthcare policy.

Chairman of the American Board of Internal Medicine

Bob Wachter, MD, MHM, was a thought leader in HM before our specialty even had a name, writing the initial peer-reviewed articles and coining the term “hospitalist.” Bob has built a pre-eminent hospitalist program at the University of California at San Francisco and helped influence and populate much of academic HM. His Wachter’s World blog (www.wachtersworld.com) is one of the most widely read medical blogs, reaching an audience well beyond our specialty.

Bob was one of the first presidents of SHM—back when we were known as NAIP, or the National Association of Inpatient Physicians—and set SHM on its strong growth and innovative direction that has made us the envy of other medical specialty societies. Last year, Modern Healthcare hailed Bob as the 14th most influential physician executive in the entire country.

On the ABIM board, Bob has represented the best of HM and brought our innovative spirit and our commitment to improvement, safety, and change leadership, culminating this year in the ABIM chairmanship. Bob will offer his unique insights into HM and the national healthcare agenda at HM13 (www.hospitalmedicine 2013.org).

CEO: Telemedicine for the ICU

Mary Jo Gorman, MD, MHM, is a hospitalist and intensivist who made her mark on HM as the chief medical officer (CMO) of IPC: The Hospitalist Company. As she offered her talents to SHM, she became chairman of SHM’s Public Policy Committee and eventually SHM president.

For the last few years, Mary Jo has been the CEO of ICUMedicine. In this role, she has been active around the country, bringing ICU competencies to many community hospitals by offering a telemedicine solution for critically ill patients. This unconventional approach to meeting a glaring need fits into Mary Jo’s career history of looking for new and different ways to bring better healthcare solutions to the front lines of patient care. Last year, Modern Healthcare recognized Mary Jo as one of the most influential female physician executives in the country.

CEO, Medical University of South Carolina (MUSC) Hospitals

After leaving Duke University, Pat Cawley, MD, MBA, MHM, started his career as a community-based hospitalist leader. After a number of leadership roles at SHM, Pat served as SHM president and was elected a Master in Hospital Medicine in 2012.

Pat initially was recruited to MUSC to build and manage their HM group. Soon he was tapped to be the CMO at MUSC. Earlier this year, Pat became the first hospitalist to be chosen to run a major academic medical center when he was promoted to CEO at MUSC.

In recent years, Pat has been a leading voice as the American Hospital Association looks to involve physician leaders. He is a rising star at AHA, helping to merge the cultures of hospital administrators and physicians to create the hospital of the future.

Hospitalists Contribute at the Highest Level

Obviously, I could go on and on, adding other hospitalists who are making unique and important contributions at the local and national level. It is interesting that at a time when many are still trying to get their heads around just what HM is, we already can recognize the immense talent that resides in hospitalist groups across the country. At a time when the U.S. healthcare system is being reshaped, hospitalists, such as those mentioned above and oh-so-many more, are already making large and small steps forward. We are helping to create a new healthcare enterprise, based on value, efficiency, effectiveness, and putting the patient first.

SHM wants to continue to be the place where the innovators and thought leaders of today and tomorrow can come together to multiply their efforts. The challenges are daunting, but the results can be rewarding, and the members of SHM are ready to bring our talents, energies, and commitments to do our part in this great American journey.

Larry Wellikson, MD, SFHM

Exceptional hospitalists

Dr. Cawley

Dr. Gottlieb

Dr. Wachter

Dr. Gorman

Dr. Conway

Even though hospital medicine and SHM are still relatively young, we can be very proud of what our specialty already has brought to changing our nation’s health care for the better. Many of these accomplishments, from winning the prestigious Eisenberg Award to our change leadership by SHM’s Center for Healthcare Innovation and Improvement at more 300 hospitals to the extraordinary growth of our specialty, have been well chronicled in The Hospitalist and elsewhere the last few years.

I wanted to use this month’s column to highlight the unique career directions of a few SHM members to shine a bright light on the influence hospitalists are making nationwide. Certainly, there are many more hospitalists beyond this group of five that I have selected, but this small cadre should serve as an example of the talent and reach of our specialty—with only more and greater things ahead to come in the future.

Chief Medical Officer of CMS

Pat Conway, MD, SFHM, is a pediatric hospitalist and the former chair of SHM’s Public Policy Committee. He left his pediatric academic practice to become a White House fellow, then returned to Cincinnati Children’s Hospital to serve as chief medical officer (CMO). When Don Berwick was in charge of the Centers for Medicare & Medicaid Services (CMS), he reached out to Pat and asked him to come to Washington to be part of Medicare’s senior team as the CMO for CMS. In this role, Pat has been a nationally recognized leader in performance improvement and patient safety, and he has been instrumental in bringing about evolutionary changes to the largest healthcare program in the world. Pat will be sharing his perspectives as a keynote speaker at HM13 (check out our 10-page HM13 preview starting on p. 45).

Resident Fellow at the American Enterprise Institute

Scott Gottlieb, MD, is a practicing hospitalist in New York City, but he is better known as a leading expert in healthcare policy, most recently acting as an advisor to presidential candidate Mitt Romney. From 2005 to 2007, Scott was a deputy commissioner at the FDA. He has worked as a senior advisor to the administrator at CMS, where he played an instrumental role in the implementation of the Medicare Drug Benefit in 2004.

Scott is best known for his frequent contributions to The Wall Street Journal, The New York Times, USA Today, and Forbes. He has held editorial positions at the British Medical Journal and the Journal of the American Medical Association, regularly appears as a guest commentator on CNBC, and is a frequent contributor to Politico.

At SHM, Scott has brought his national viewpoint to the Public Policy Committee. He proudly touts his experience as a practicing hospitalist as bringing a front-line reality to his national recognition and much-sought-after critical thinking about healthcare policy.

Chairman of the American Board of Internal Medicine

Bob Wachter, MD, MHM, was a thought leader in HM before our specialty even had a name, writing the initial peer-reviewed articles and coining the term “hospitalist.” Bob has built a pre-eminent hospitalist program at the University of California at San Francisco and helped influence and populate much of academic HM. His Wachter’s World blog (www.wachtersworld.com) is one of the most widely read medical blogs, reaching an audience well beyond our specialty.

Bob was one of the first presidents of SHM—back when we were known as NAIP, or the National Association of Inpatient Physicians—and set SHM on its strong growth and innovative direction that has made us the envy of other medical specialty societies. Last year, Modern Healthcare hailed Bob as the 14th most influential physician executive in the entire country.

On the ABIM board, Bob has represented the best of HM and brought our innovative spirit and our commitment to improvement, safety, and change leadership, culminating this year in the ABIM chairmanship. Bob will offer his unique insights into HM and the national healthcare agenda at HM13 (www.hospitalmedicine 2013.org).

CEO: Telemedicine for the ICU

Mary Jo Gorman, MD, MHM, is a hospitalist and intensivist who made her mark on HM as the chief medical officer (CMO) of IPC: The Hospitalist Company. As she offered her talents to SHM, she became chairman of SHM’s Public Policy Committee and eventually SHM president.

For the last few years, Mary Jo has been the CEO of ICUMedicine. In this role, she has been active around the country, bringing ICU competencies to many community hospitals by offering a telemedicine solution for critically ill patients. This unconventional approach to meeting a glaring need fits into Mary Jo’s career history of looking for new and different ways to bring better healthcare solutions to the front lines of patient care. Last year, Modern Healthcare recognized Mary Jo as one of the most influential female physician executives in the country.

CEO, Medical University of South Carolina (MUSC) Hospitals

After leaving Duke University, Pat Cawley, MD, MBA, MHM, started his career as a community-based hospitalist leader. After a number of leadership roles at SHM, Pat served as SHM president and was elected a Master in Hospital Medicine in 2012.

Pat initially was recruited to MUSC to build and manage their HM group. Soon he was tapped to be the CMO at MUSC. Earlier this year, Pat became the first hospitalist to be chosen to run a major academic medical center when he was promoted to CEO at MUSC.

In recent years, Pat has been a leading voice as the American Hospital Association looks to involve physician leaders. He is a rising star at AHA, helping to merge the cultures of hospital administrators and physicians to create the hospital of the future.

Hospitalists Contribute at the Highest Level

Obviously, I could go on and on, adding other hospitalists who are making unique and important contributions at the local and national level. It is interesting that at a time when many are still trying to get their heads around just what HM is, we already can recognize the immense talent that resides in hospitalist groups across the country. At a time when the U.S. healthcare system is being reshaped, hospitalists, such as those mentioned above and oh-so-many more, are already making large and small steps forward. We are helping to create a new healthcare enterprise, based on value, efficiency, effectiveness, and putting the patient first.

SHM wants to continue to be the place where the innovators and thought leaders of today and tomorrow can come together to multiply their efforts. The challenges are daunting, but the results can be rewarding, and the members of SHM are ready to bring our talents, energies, and commitments to do our part in this great American journey.

Larry Wellikson, MD, SFHM

Exceptional hospitalists

Dr. Cawley

Dr. Gottlieb

Dr. Wachter

Dr. Gorman

Dr. Conway

Even though hospital medicine and SHM are still relatively young, we can be very proud of what our specialty already has brought to changing our nation’s health care for the better. Many of these accomplishments, from winning the prestigious Eisenberg Award to our change leadership by SHM’s Center for Healthcare Innovation and Improvement at more 300 hospitals to the extraordinary growth of our specialty, have been well chronicled in The Hospitalist and elsewhere the last few years.

I wanted to use this month’s column to highlight the unique career directions of a few SHM members to shine a bright light on the influence hospitalists are making nationwide. Certainly, there are many more hospitalists beyond this group of five that I have selected, but this small cadre should serve as an example of the talent and reach of our specialty—with only more and greater things ahead to come in the future.

Chief Medical Officer of CMS

Pat Conway, MD, SFHM, is a pediatric hospitalist and the former chair of SHM’s Public Policy Committee. He left his pediatric academic practice to become a White House fellow, then returned to Cincinnati Children’s Hospital to serve as chief medical officer (CMO). When Don Berwick was in charge of the Centers for Medicare & Medicaid Services (CMS), he reached out to Pat and asked him to come to Washington to be part of Medicare’s senior team as the CMO for CMS. In this role, Pat has been a nationally recognized leader in performance improvement and patient safety, and he has been instrumental in bringing about evolutionary changes to the largest healthcare program in the world. Pat will be sharing his perspectives as a keynote speaker at HM13 (check out our 10-page HM13 preview starting on p. 45).

Resident Fellow at the American Enterprise Institute

Scott Gottlieb, MD, is a practicing hospitalist in New York City, but he is better known as a leading expert in healthcare policy, most recently acting as an advisor to presidential candidate Mitt Romney. From 2005 to 2007, Scott was a deputy commissioner at the FDA. He has worked as a senior advisor to the administrator at CMS, where he played an instrumental role in the implementation of the Medicare Drug Benefit in 2004.

Scott is best known for his frequent contributions to The Wall Street Journal, The New York Times, USA Today, and Forbes. He has held editorial positions at the British Medical Journal and the Journal of the American Medical Association, regularly appears as a guest commentator on CNBC, and is a frequent contributor to Politico.

At SHM, Scott has brought his national viewpoint to the Public Policy Committee. He proudly touts his experience as a practicing hospitalist as bringing a front-line reality to his national recognition and much-sought-after critical thinking about healthcare policy.

Chairman of the American Board of Internal Medicine

Bob Wachter, MD, MHM, was a thought leader in HM before our specialty even had a name, writing the initial peer-reviewed articles and coining the term “hospitalist.” Bob has built a pre-eminent hospitalist program at the University of California at San Francisco and helped influence and populate much of academic HM. His Wachter’s World blog (www.wachtersworld.com) is one of the most widely read medical blogs, reaching an audience well beyond our specialty.

Bob was one of the first presidents of SHM—back when we were known as NAIP, or the National Association of Inpatient Physicians—and set SHM on its strong growth and innovative direction that has made us the envy of other medical specialty societies. Last year, Modern Healthcare hailed Bob as the 14th most influential physician executive in the entire country.

On the ABIM board, Bob has represented the best of HM and brought our innovative spirit and our commitment to improvement, safety, and change leadership, culminating this year in the ABIM chairmanship. Bob will offer his unique insights into HM and the national healthcare agenda at HM13 (www.hospitalmedicine 2013.org).

CEO: Telemedicine for the ICU

Mary Jo Gorman, MD, MHM, is a hospitalist and intensivist who made her mark on HM as the chief medical officer (CMO) of IPC: The Hospitalist Company. As she offered her talents to SHM, she became chairman of SHM’s Public Policy Committee and eventually SHM president.

For the last few years, Mary Jo has been the CEO of ICUMedicine. In this role, she has been active around the country, bringing ICU competencies to many community hospitals by offering a telemedicine solution for critically ill patients. This unconventional approach to meeting a glaring need fits into Mary Jo’s career history of looking for new and different ways to bring better healthcare solutions to the front lines of patient care. Last year, Modern Healthcare recognized Mary Jo as one of the most influential female physician executives in the country.

CEO, Medical University of South Carolina (MUSC) Hospitals

After leaving Duke University, Pat Cawley, MD, MBA, MHM, started his career as a community-based hospitalist leader. After a number of leadership roles at SHM, Pat served as SHM president and was elected a Master in Hospital Medicine in 2012.

Pat initially was recruited to MUSC to build and manage their HM group. Soon he was tapped to be the CMO at MUSC. Earlier this year, Pat became the first hospitalist to be chosen to run a major academic medical center when he was promoted to CEO at MUSC.

In recent years, Pat has been a leading voice as the American Hospital Association looks to involve physician leaders. He is a rising star at AHA, helping to merge the cultures of hospital administrators and physicians to create the hospital of the future.

Hospitalists Contribute at the Highest Level

Obviously, I could go on and on, adding other hospitalists who are making unique and important contributions at the local and national level. It is interesting that at a time when many are still trying to get their heads around just what HM is, we already can recognize the immense talent that resides in hospitalist groups across the country. At a time when the U.S. healthcare system is being reshaped, hospitalists, such as those mentioned above and oh-so-many more, are already making large and small steps forward. We are helping to create a new healthcare enterprise, based on value, efficiency, effectiveness, and putting the patient first.

SHM wants to continue to be the place where the innovators and thought leaders of today and tomorrow can come together to multiply their efforts. The challenges are daunting, but the results can be rewarding, and the members of SHM are ready to bring our talents, energies, and commitments to do our part in this great American journey.

2013 marks a turning point in the way hospitals are held accountable for the prevention of healthcare-associated infections (HAIs). It has been known for some time that HAIs are a serious cause of morbidity, with 1 in 20 hospital patients in the U.S. acquiring one. That represents 1.7 million Americans and accounts for about 100,000 lives lost each year. On a personal note, my father died of an HAI after surgery in 2000.

Now, with the Affordable Care Act coming into full swing, hospitals must get serious about preventing HAIs. This presents a major opportunity for hospitalists. There are three ways that hospitals will be affected:

• Since 2008, hospitals have not been reimbursed at a higher rate for vascular catheter-associated infections, catheter-associated urinary tract infections (UTIs), or surgical-site infections when acquired in the hospital.
• Over the next few years, Medicare’s Hospital Value-Based Purchasing (HVBP) program will begin to pay hospitals more or less, depending on how they perform, on six HAIs.
• Beginning in October 2014, in a roll-up measure for hospital-acquired conditions (which include infections), the worst-performing quartile of U.S. hospitals will be penalized 1% of their Medicare inpatient payments (see Table 1, below).

There are six HAIs that will be increasingly tied to hospital reimbursement. Each can be partially or completely prevented based on sets of practices, or care bundles, that require teamwork both in the planning stages and at the bedside. And, of course, the single most important way to reduce the spread of HAIs is to clean your hands before and after each patient encounter.

Clostridium-Difficile-Associated Disease (CDAD)

It is likely that your hospital has some type of CDAD prevention program. Here are a few things to keep in mind for CDAD prevention:

• Avoid alcohol-based hand rubs, because they do not kill C. diff spores. Vigorous hand washing with soap and water is the best approach.
• Use clindamycin, fluoroquinolones, and third-generation cephalosporins judiciously, as their restriction has been associated with reduced rates of CDAD.
• Place patients with suspected or proven C. diff infection on contact precautions, including gloves and gowns.

click for large version

Methicillin-Resistant Staphylococcus Aureus (MRSA)

This includes hospital-acquired MRSA bacteremia. This topic will be discussed in future columns. Approaches to prevention include hand hygiene, cohorting patients, effective environmental cleaning, and antibiotic stewardship.

Central-Line-Associated Bloodstream Infection (CLABSI)

Adherence to the central-line insertion bundle has been conclusively shown to prevent CLABSI. It will become a process measure for HVBP in the near future. Prevention measures include hand hygiene, maximal barrier precautions during insertion, skin antisepsis with chlorhexidine, avoidance of the femoral vein, and daily assessment for readiness to discontinue the central line (which should involve every hospitalist).

Catheter-Associated Urinary Tract Infection (CAUTI)

CAUTI has been mentioned frequently in this column, and for good reason: It is the most common HAI. Although the evidence supporting practices that prevent CAUTI is not as strong as for CLABSI, every institution should have a bundle of practices embedded in nurses’ and doctors’ workflow to prevent CAUTI (see “Quality Meets Finance,” January 2013, p. 31).

Surgical-Site Infection (SSI)

For the most part, SSI can be left to the surgeons and other operating room professionals. However, with increasing involvement of hospitalists in surgical cases, we must have an understanding of how SSIs are prevented. The World Health Organization surgical checklist (www.who.int/patientsafety/safesurgery) is a great starting point for any organization.

Ventilator-Associated Pneumonia (VAP)

For hospitalists who provide critical care, adherence to a VAP prevention bundle includes:

• Elevation of the head of the bed;
• Daily “sedation vacation” and readiness to extubate;
• Oral care with chlorhexidine; and
• Peptic ulcer disease and venous thromboembolism prophylaxis.

In 2009, the U.S. Department of Health and Human Services (HHS) launched an action plan to prevent HAIs. As part of this effort, the Agency for Health Research and Quality (AHRQ) created a comprehensive unit-based safety program (CUSP) aimed at preventing CLABSI and CAUTI. The effort also focuses on safety culture and teamwork. For those interested in participating, visit www.onthecuspstophai.org.

Another way to get involved is to work Partnership for Patients, a public-private partnership led by HHS (http://partnershipforpatients.cms.gov), if a team at your hospital is participating. The Partnership for Patients seeks to reduce harm, including HAIs, by 40% by the end of 2013 compared with a 2010 baseline.

Dr. Whitcomb is medical director of healthcare quality at Baystate Medical Center in Springfield, Mass. He is a co-founder and past president of SHM. Email him at [email protected].

The View from The Center

As many of you know, SHM recently submitted five recommendations to the American Board of Internal Medicine Foundation’s Choosing Wisely campaign. This campaign encourages physicians and patients to have crucial conversations about appropriate utilization of tests and treatments. Seventeen specialty societies released lists in the second phase of the campaign. Many of the lists, including SHM’s, include recommendations that can help reduce hospital-acquired infections.

For example, one of SHM’s recommendations suggests not placing, or leaving in place, urinary catheters for any reason other than those indicated by the guidelines (e.g. bladder outlet obstruction, acute urinary retention, patient requires prolonged immobilization, to improve comfort for end of life, selected perioperative conditions). As Dr. Whitcomb indicates above, CAUTIs are low-hanging fruit when it comes to improving this condition—the guidelines are clear-cut, and relatively simple protocols can be put into place to prevent CAUTI.

Among the American Academy of Family Physicians and other society recommendations is avoidance of routine prescriptions of antibiotics for acute sinusitis or upper respiratory infections. Good antimicrobial stewardship policies are another approach to reduce or eliminate harmful antibiotic-resistant infections.

SHM will be offering multiple opportunities in the coming months to support your institution in Choosing Wisely. A daylong pre-course and two breakout sessions will be offered at HM13 (www.hospitalmedicine2013.org) addressing how you can implement the various recommendations. Additionally, publications are in the works describing the evidence base for SHM’s “avoid lists.” For resources, more information about SHM’s recommendations, and the latest Choosing Wisely developments, visit www.hospitalmedicine.org/choosingwisely.

2013 marks a turning point in the way hospitals are held accountable for the prevention of healthcare-associated infections (HAIs). It has been known for some time that HAIs are a serious cause of morbidity, with 1 in 20 hospital patients in the U.S. acquiring one. That represents 1.7 million Americans and accounts for about 100,000 lives lost each year. On a personal note, my father died of an HAI after surgery in 2000.

Now, with the Affordable Care Act coming into full swing, hospitals must get serious about preventing HAIs. This presents a major opportunity for hospitalists. There are three ways that hospitals will be affected:

• Since 2008, hospitals have not been reimbursed at a higher rate for vascular catheter-associated infections, catheter-associated urinary tract infections (UTIs), or surgical-site infections when acquired in the hospital.
• Over the next few years, Medicare’s Hospital Value-Based Purchasing (HVBP) program will begin to pay hospitals more or less, depending on how they perform, on six HAIs.
• Beginning in October 2014, in a roll-up measure for hospital-acquired conditions (which include infections), the worst-performing quartile of U.S. hospitals will be penalized 1% of their Medicare inpatient payments (see Table 1, below).

There are six HAIs that will be increasingly tied to hospital reimbursement. Each can be partially or completely prevented based on sets of practices, or care bundles, that require teamwork both in the planning stages and at the bedside. And, of course, the single most important way to reduce the spread of HAIs is to clean your hands before and after each patient encounter.

Clostridium-Difficile-Associated Disease (CDAD)

It is likely that your hospital has some type of CDAD prevention program. Here are a few things to keep in mind for CDAD prevention:

• Avoid alcohol-based hand rubs, because they do not kill C. diff spores. Vigorous hand washing with soap and water is the best approach.
• Use clindamycin, fluoroquinolones, and third-generation cephalosporins judiciously, as their restriction has been associated with reduced rates of CDAD.
• Place patients with suspected or proven C. diff infection on contact precautions, including gloves and gowns.

click for large version

Methicillin-Resistant Staphylococcus Aureus (MRSA)

This includes hospital-acquired MRSA bacteremia. This topic will be discussed in future columns. Approaches to prevention include hand hygiene, cohorting patients, effective environmental cleaning, and antibiotic stewardship.

Central-Line-Associated Bloodstream Infection (CLABSI)

Adherence to the central-line insertion bundle has been conclusively shown to prevent CLABSI. It will become a process measure for HVBP in the near future. Prevention measures include hand hygiene, maximal barrier precautions during insertion, skin antisepsis with chlorhexidine, avoidance of the femoral vein, and daily assessment for readiness to discontinue the central line (which should involve every hospitalist).

Catheter-Associated Urinary Tract Infection (CAUTI)

CAUTI has been mentioned frequently in this column, and for good reason: It is the most common HAI. Although the evidence supporting practices that prevent CAUTI is not as strong as for CLABSI, every institution should have a bundle of practices embedded in nurses’ and doctors’ workflow to prevent CAUTI (see “Quality Meets Finance,” January 2013, p. 31).

Surgical-Site Infection (SSI)

For the most part, SSI can be left to the surgeons and other operating room professionals. However, with increasing involvement of hospitalists in surgical cases, we must have an understanding of how SSIs are prevented. The World Health Organization surgical checklist (www.who.int/patientsafety/safesurgery) is a great starting point for any organization.

Ventilator-Associated Pneumonia (VAP)

For hospitalists who provide critical care, adherence to a VAP prevention bundle includes:

• Elevation of the head of the bed;
• Daily “sedation vacation” and readiness to extubate;
• Oral care with chlorhexidine; and
• Peptic ulcer disease and venous thromboembolism prophylaxis.

In 2009, the U.S. Department of Health and Human Services (HHS) launched an action plan to prevent HAIs. As part of this effort, the Agency for Health Research and Quality (AHRQ) created a comprehensive unit-based safety program (CUSP) aimed at preventing CLABSI and CAUTI. The effort also focuses on safety culture and teamwork. For those interested in participating, visit www.onthecuspstophai.org.

Another way to get involved is to work Partnership for Patients, a public-private partnership led by HHS (http://partnershipforpatients.cms.gov), if a team at your hospital is participating. The Partnership for Patients seeks to reduce harm, including HAIs, by 40% by the end of 2013 compared with a 2010 baseline.

Dr. Whitcomb is medical director of healthcare quality at Baystate Medical Center in Springfield, Mass. He is a co-founder and past president of SHM. Email him at [email protected].

The View from The Center

As many of you know, SHM recently submitted five recommendations to the American Board of Internal Medicine Foundation’s Choosing Wisely campaign. This campaign encourages physicians and patients to have crucial conversations about appropriate utilization of tests and treatments. Seventeen specialty societies released lists in the second phase of the campaign. Many of the lists, including SHM’s, include recommendations that can help reduce hospital-acquired infections.

For example, one of SHM’s recommendations suggests not placing, or leaving in place, urinary catheters for any reason other than those indicated by the guidelines (e.g. bladder outlet obstruction, acute urinary retention, patient requires prolonged immobilization, to improve comfort for end of life, selected perioperative conditions). As Dr. Whitcomb indicates above, CAUTIs are low-hanging fruit when it comes to improving this condition—the guidelines are clear-cut, and relatively simple protocols can be put into place to prevent CAUTI.

Among the American Academy of Family Physicians and other society recommendations is avoidance of routine prescriptions of antibiotics for acute sinusitis or upper respiratory infections. Good antimicrobial stewardship policies are another approach to reduce or eliminate harmful antibiotic-resistant infections.

SHM will be offering multiple opportunities in the coming months to support your institution in Choosing Wisely. A daylong pre-course and two breakout sessions will be offered at HM13 (www.hospitalmedicine2013.org) addressing how you can implement the various recommendations. Additionally, publications are in the works describing the evidence base for SHM’s “avoid lists.” For resources, more information about SHM’s recommendations, and the latest Choosing Wisely developments, visit www.hospitalmedicine.org/choosingwisely.

2013 marks a turning point in the way hospitals are held accountable for the prevention of healthcare-associated infections (HAIs). It has been known for some time that HAIs are a serious cause of morbidity, with 1 in 20 hospital patients in the U.S. acquiring one. That represents 1.7 million Americans and accounts for about 100,000 lives lost each year. On a personal note, my father died of an HAI after surgery in 2000.

Now, with the Affordable Care Act coming into full swing, hospitals must get serious about preventing HAIs. This presents a major opportunity for hospitalists. There are three ways that hospitals will be affected:

• Since 2008, hospitals have not been reimbursed at a higher rate for vascular catheter-associated infections, catheter-associated urinary tract infections (UTIs), or surgical-site infections when acquired in the hospital.
• Over the next few years, Medicare’s Hospital Value-Based Purchasing (HVBP) program will begin to pay hospitals more or less, depending on how they perform, on six HAIs.
• Beginning in October 2014, in a roll-up measure for hospital-acquired conditions (which include infections), the worst-performing quartile of U.S. hospitals will be penalized 1% of their Medicare inpatient payments (see Table 1, below).

There are six HAIs that will be increasingly tied to hospital reimbursement. Each can be partially or completely prevented based on sets of practices, or care bundles, that require teamwork both in the planning stages and at the bedside. And, of course, the single most important way to reduce the spread of HAIs is to clean your hands before and after each patient encounter.

Clostridium-Difficile-Associated Disease (CDAD)

It is likely that your hospital has some type of CDAD prevention program. Here are a few things to keep in mind for CDAD prevention:

• Avoid alcohol-based hand rubs, because they do not kill C. diff spores. Vigorous hand washing with soap and water is the best approach.
• Use clindamycin, fluoroquinolones, and third-generation cephalosporins judiciously, as their restriction has been associated with reduced rates of CDAD.
• Place patients with suspected or proven C. diff infection on contact precautions, including gloves and gowns.

click for large version

Methicillin-Resistant Staphylococcus Aureus (MRSA)

This includes hospital-acquired MRSA bacteremia. This topic will be discussed in future columns. Approaches to prevention include hand hygiene, cohorting patients, effective environmental cleaning, and antibiotic stewardship.

Central-Line-Associated Bloodstream Infection (CLABSI)

Adherence to the central-line insertion bundle has been conclusively shown to prevent CLABSI. It will become a process measure for HVBP in the near future. Prevention measures include hand hygiene, maximal barrier precautions during insertion, skin antisepsis with chlorhexidine, avoidance of the femoral vein, and daily assessment for readiness to discontinue the central line (which should involve every hospitalist).

Catheter-Associated Urinary Tract Infection (CAUTI)

CAUTI has been mentioned frequently in this column, and for good reason: It is the most common HAI. Although the evidence supporting practices that prevent CAUTI is not as strong as for CLABSI, every institution should have a bundle of practices embedded in nurses’ and doctors’ workflow to prevent CAUTI (see “Quality Meets Finance,” January 2013, p. 31).

Surgical-Site Infection (SSI)

For the most part, SSI can be left to the surgeons and other operating room professionals. However, with increasing involvement of hospitalists in surgical cases, we must have an understanding of how SSIs are prevented. The World Health Organization surgical checklist (www.who.int/patientsafety/safesurgery) is a great starting point for any organization.

Ventilator-Associated Pneumonia (VAP)

For hospitalists who provide critical care, adherence to a VAP prevention bundle includes:

• Elevation of the head of the bed;
• Daily “sedation vacation” and readiness to extubate;
• Oral care with chlorhexidine; and
• Peptic ulcer disease and venous thromboembolism prophylaxis.

In 2009, the U.S. Department of Health and Human Services (HHS) launched an action plan to prevent HAIs. As part of this effort, the Agency for Health Research and Quality (AHRQ) created a comprehensive unit-based safety program (CUSP) aimed at preventing CLABSI and CAUTI. The effort also focuses on safety culture and teamwork. For those interested in participating, visit www.onthecuspstophai.org.

Another way to get involved is to work Partnership for Patients, a public-private partnership led by HHS (http://partnershipforpatients.cms.gov), if a team at your hospital is participating. The Partnership for Patients seeks to reduce harm, including HAIs, by 40% by the end of 2013 compared with a 2010 baseline.

Dr. Whitcomb is medical director of healthcare quality at Baystate Medical Center in Springfield, Mass. He is a co-founder and past president of SHM. Email him at [email protected].

The View from The Center

As many of you know, SHM recently submitted five recommendations to the American Board of Internal Medicine Foundation’s Choosing Wisely campaign. This campaign encourages physicians and patients to have crucial conversations about appropriate utilization of tests and treatments. Seventeen specialty societies released lists in the second phase of the campaign. Many of the lists, including SHM’s, include recommendations that can help reduce hospital-acquired infections.

For example, one of SHM’s recommendations suggests not placing, or leaving in place, urinary catheters for any reason other than those indicated by the guidelines (e.g. bladder outlet obstruction, acute urinary retention, patient requires prolonged immobilization, to improve comfort for end of life, selected perioperative conditions). As Dr. Whitcomb indicates above, CAUTIs are low-hanging fruit when it comes to improving this condition—the guidelines are clear-cut, and relatively simple protocols can be put into place to prevent CAUTI.

Among the American Academy of Family Physicians and other society recommendations is avoidance of routine prescriptions of antibiotics for acute sinusitis or upper respiratory infections. Good antimicrobial stewardship policies are another approach to reduce or eliminate harmful antibiotic-resistant infections.

SHM will be offering multiple opportunities in the coming months to support your institution in Choosing Wisely. A daylong pre-course and two breakout sessions will be offered at HM13 (www.hospitalmedicine2013.org) addressing how you can implement the various recommendations. Additionally, publications are in the works describing the evidence base for SHM’s “avoid lists.” For resources, more information about SHM’s recommendations, and the latest Choosing Wisely developments, visit www.hospitalmedicine.org/choosingwisely.

“Forty percent of physicians reported that their typical inpatient census exceeded safe levels at least monthly.”¹

This quote is taken from an article by Henry Michtalik and colleagues that appeared at the end of January this year in JAMA Internal Medicine. In 2010 the authors conducted an on-line survey asking hospitalists their perceptions of their workload. Respondents indicated that with concerning frequency a high workload prevented them from adequately discussing with patients treatment options or answering questions, delay admitting or discharging patients until the next day or shift, or in some other way risk patient safety or the overall quality of their work.

This alarming finding matches my anecdotal experience working with many different hospitalist groups around the country. I think few hospitalists were surprised by the survey’s findings. Excess hospitalist workloads are indeed a problem in some settings, and those who bear them are typically not shy about speaking out.

The demand for hospitalists has exceeded the supply of doctors available to do the work throughout the history of the field. Under the weight of stunningly rapid growth in referral volume, from about 1995 to 2002, it was reasonably common for the original doctors in a hospitalist practice to become overwhelmed and leave for other work after a year or two, sometimes resulting in the collapse of the practice. Most practices are no longer in such a rapid-growth phase, but for many of them, staffing has not yet caught up with workload. The result can be chronic excess work, and even if daily patient volume is not seen as being unsafe, the number of days or shifts worked might be excessive and lead to fatigue and poor performance.

Other Workload Data

The respondents to the Michtalik survey reported that regardless of any assistance, “they could safely see 15 patients per shift, if their effort was 100% clinical.” What we don’t know is how long their shifts were, whether they included things like ICU coverage, and how many shifts they work consecutively or in a year.

SHM’s 2012 State of Hospital Medicine report, which is based on 2011 data, provides additional context. It shows that hospitalists serving adult patients report a median 2,092 billed encounters annually (mean 2,245, standard deviation 1,161). They spread this work over a median 185 shifts (“work periods”) annually (mean 192). While there are lots of methodological problems in manipulating those numbers further, 2,092 encounters divided by 185 shifts yields 11.3 encounters per shift. These numbers exclude academicians who typically spend significant time in activities other than direct patient care, and I’m intentionally ignoring such issues as the night-shift doctor, who typically has low productivity, bringing down the average per full-time doctor in a practice.

The numbers from both surveys are sort of fuzzy because they aren’t audited or verified, but the 2012 State of Hospital Medicine data suggest that typical workloads aren’t too high in most practices, yet 40% of respondents in the Michtalik survey said they were high enough—unreasonably high—to risk quality and safety at least once a month.

One way to reconcile these findings is to take into account the standard deviation in daily volume in a single practice of about 30% to 40% on above or below the mean. If a hospitalist averages 14 encounters each day shift, then he should expect that the daily number might vary between about eight and 20. The Michtalik survey responses were likely reflecting the shifts on the high end.

Perspective

I wonder what a survey of physician workload opinions in other specialties would show, or what a survey of workers across all segments of the U.S. workforce in and out of healthcare would show. Of course, many or most jobs outside of healthcare don’t risk another’s health or well-being as significantly as ours do, but it would still be instructive to know how people in general think about the work they do.

I suspect a significant number of people across many different jobs feel like too much work is expected of them, and they can point to the ways their performance suffers as a result. It is difficult to know what portion of those who report too much work is just complaining versus a thoughtful self-reflection of the determinants of their performance. Lots of hospitalists do face worrisome high workloads, but some would probably still complain even with a much lower workload.

What Can Be Done?

For those practices facing remarkably high patient volumes, the solution is to make sure you’re recruiting additional doctors, and/or NPs/PAs, as fast as you can. But a portion of these practices must first convince their employers that more staff is needed. Some practices face a real uphill battle in getting the required additional funding, and the place to start is with a careful analysis of your current workload—based on hard numbers from your practice, not just anecdotes and estimates.

Don’t forget that some hospitalists put themselves in the position of having to manage high daily patient volumes by choosing a schedule of relatively few worked days annually. For example, a group working a seven-on/seven-off schedule that also has 14 shifts of time off means that each doctor will work only 168.5 shifts annually. Compressing a year’s worth of work into only 168 shifts means that each shift will be busy, and many will involve patient volumes that exceed what is seen as safe.

It could make more sense to titrate that same work volume over more annual shifts so that the average shift is less busy. I would love to see the Michtalik data segregated by those who work many shifts annually versus those who work few shifts. It is possible that those working more shifts have reported excessive workloads less often.

SHM has a role in influencing hospitalist workloads and promotes dissemination of data and opinions about it. At HM13 next month in Washington, D.C., I am leading a session titled “Hospitalist Workload: Is 15 the Right Number?” Although it won’t provide the “right” workload for all hospitalists, it will offer worthwhile data and food for thought.

It is much more difficult to do studies of how workload influences performance than something like effects of sleep deprivation on performance, so we may never get clear answers. You could take some consolation in the fact that successive surveys have shown little change or even modest decreases in annual patient encounters. But then again, maybe that hasn’t helped with excess work since providing hospital care gets harder and more complex every year.

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

Reference

1. Michtalik HJ, Yeh HC, Pronovost PJ, Brotman DJ. Impact of attending physician workload on patient care: a survey of hospitalists. JAMA Intern Med. 2013;28:1-2.

“Forty percent of physicians reported that their typical inpatient census exceeded safe levels at least monthly.”¹

This quote is taken from an article by Henry Michtalik and colleagues that appeared at the end of January this year in JAMA Internal Medicine. In 2010 the authors conducted an on-line survey asking hospitalists their perceptions of their workload. Respondents indicated that with concerning frequency a high workload prevented them from adequately discussing with patients treatment options or answering questions, delay admitting or discharging patients until the next day or shift, or in some other way risk patient safety or the overall quality of their work.

This alarming finding matches my anecdotal experience working with many different hospitalist groups around the country. I think few hospitalists were surprised by the survey’s findings. Excess hospitalist workloads are indeed a problem in some settings, and those who bear them are typically not shy about speaking out.

The demand for hospitalists has exceeded the supply of doctors available to do the work throughout the history of the field. Under the weight of stunningly rapid growth in referral volume, from about 1995 to 2002, it was reasonably common for the original doctors in a hospitalist practice to become overwhelmed and leave for other work after a year or two, sometimes resulting in the collapse of the practice. Most practices are no longer in such a rapid-growth phase, but for many of them, staffing has not yet caught up with workload. The result can be chronic excess work, and even if daily patient volume is not seen as being unsafe, the number of days or shifts worked might be excessive and lead to fatigue and poor performance.

Other Workload Data

The respondents to the Michtalik survey reported that regardless of any assistance, “they could safely see 15 patients per shift, if their effort was 100% clinical.” What we don’t know is how long their shifts were, whether they included things like ICU coverage, and how many shifts they work consecutively or in a year.

SHM’s 2012 State of Hospital Medicine report, which is based on 2011 data, provides additional context. It shows that hospitalists serving adult patients report a median 2,092 billed encounters annually (mean 2,245, standard deviation 1,161). They spread this work over a median 185 shifts (“work periods”) annually (mean 192). While there are lots of methodological problems in manipulating those numbers further, 2,092 encounters divided by 185 shifts yields 11.3 encounters per shift. These numbers exclude academicians who typically spend significant time in activities other than direct patient care, and I’m intentionally ignoring such issues as the night-shift doctor, who typically has low productivity, bringing down the average per full-time doctor in a practice.

The numbers from both surveys are sort of fuzzy because they aren’t audited or verified, but the 2012 State of Hospital Medicine data suggest that typical workloads aren’t too high in most practices, yet 40% of respondents in the Michtalik survey said they were high enough—unreasonably high—to risk quality and safety at least once a month.

One way to reconcile these findings is to take into account the standard deviation in daily volume in a single practice of about 30% to 40% on above or below the mean. If a hospitalist averages 14 encounters each day shift, then he should expect that the daily number might vary between about eight and 20. The Michtalik survey responses were likely reflecting the shifts on the high end.

Perspective

I wonder what a survey of physician workload opinions in other specialties would show, or what a survey of workers across all segments of the U.S. workforce in and out of healthcare would show. Of course, many or most jobs outside of healthcare don’t risk another’s health or well-being as significantly as ours do, but it would still be instructive to know how people in general think about the work they do.

I suspect a significant number of people across many different jobs feel like too much work is expected of them, and they can point to the ways their performance suffers as a result. It is difficult to know what portion of those who report too much work is just complaining versus a thoughtful self-reflection of the determinants of their performance. Lots of hospitalists do face worrisome high workloads, but some would probably still complain even with a much lower workload.

What Can Be Done?

For those practices facing remarkably high patient volumes, the solution is to make sure you’re recruiting additional doctors, and/or NPs/PAs, as fast as you can. But a portion of these practices must first convince their employers that more staff is needed. Some practices face a real uphill battle in getting the required additional funding, and the place to start is with a careful analysis of your current workload—based on hard numbers from your practice, not just anecdotes and estimates.

Don’t forget that some hospitalists put themselves in the position of having to manage high daily patient volumes by choosing a schedule of relatively few worked days annually. For example, a group working a seven-on/seven-off schedule that also has 14 shifts of time off means that each doctor will work only 168.5 shifts annually. Compressing a year’s worth of work into only 168 shifts means that each shift will be busy, and many will involve patient volumes that exceed what is seen as safe.

It could make more sense to titrate that same work volume over more annual shifts so that the average shift is less busy. I would love to see the Michtalik data segregated by those who work many shifts annually versus those who work few shifts. It is possible that those working more shifts have reported excessive workloads less often.

SHM has a role in influencing hospitalist workloads and promotes dissemination of data and opinions about it. At HM13 next month in Washington, D.C., I am leading a session titled “Hospitalist Workload: Is 15 the Right Number?” Although it won’t provide the “right” workload for all hospitalists, it will offer worthwhile data and food for thought.

It is much more difficult to do studies of how workload influences performance than something like effects of sleep deprivation on performance, so we may never get clear answers. You could take some consolation in the fact that successive surveys have shown little change or even modest decreases in annual patient encounters. But then again, maybe that hasn’t helped with excess work since providing hospital care gets harder and more complex every year.

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

Reference

1. Michtalik HJ, Yeh HC, Pronovost PJ, Brotman DJ. Impact of attending physician workload on patient care: a survey of hospitalists. JAMA Intern Med. 2013;28:1-2.

“Forty percent of physicians reported that their typical inpatient census exceeded safe levels at least monthly.”¹

This quote is taken from an article by Henry Michtalik and colleagues that appeared at the end of January this year in JAMA Internal Medicine. In 2010 the authors conducted an on-line survey asking hospitalists their perceptions of their workload. Respondents indicated that with concerning frequency a high workload prevented them from adequately discussing with patients treatment options or answering questions, delay admitting or discharging patients until the next day or shift, or in some other way risk patient safety or the overall quality of their work.

This alarming finding matches my anecdotal experience working with many different hospitalist groups around the country. I think few hospitalists were surprised by the survey’s findings. Excess hospitalist workloads are indeed a problem in some settings, and those who bear them are typically not shy about speaking out.

The demand for hospitalists has exceeded the supply of doctors available to do the work throughout the history of the field. Under the weight of stunningly rapid growth in referral volume, from about 1995 to 2002, it was reasonably common for the original doctors in a hospitalist practice to become overwhelmed and leave for other work after a year or two, sometimes resulting in the collapse of the practice. Most practices are no longer in such a rapid-growth phase, but for many of them, staffing has not yet caught up with workload. The result can be chronic excess work, and even if daily patient volume is not seen as being unsafe, the number of days or shifts worked might be excessive and lead to fatigue and poor performance.

Other Workload Data

The respondents to the Michtalik survey reported that regardless of any assistance, “they could safely see 15 patients per shift, if their effort was 100% clinical.” What we don’t know is how long their shifts were, whether they included things like ICU coverage, and how many shifts they work consecutively or in a year.

SHM’s 2012 State of Hospital Medicine report, which is based on 2011 data, provides additional context. It shows that hospitalists serving adult patients report a median 2,092 billed encounters annually (mean 2,245, standard deviation 1,161). They spread this work over a median 185 shifts (“work periods”) annually (mean 192). While there are lots of methodological problems in manipulating those numbers further, 2,092 encounters divided by 185 shifts yields 11.3 encounters per shift. These numbers exclude academicians who typically spend significant time in activities other than direct patient care, and I’m intentionally ignoring such issues as the night-shift doctor, who typically has low productivity, bringing down the average per full-time doctor in a practice.

The numbers from both surveys are sort of fuzzy because they aren’t audited or verified, but the 2012 State of Hospital Medicine data suggest that typical workloads aren’t too high in most practices, yet 40% of respondents in the Michtalik survey said they were high enough—unreasonably high—to risk quality and safety at least once a month.

One way to reconcile these findings is to take into account the standard deviation in daily volume in a single practice of about 30% to 40% on above or below the mean. If a hospitalist averages 14 encounters each day shift, then he should expect that the daily number might vary between about eight and 20. The Michtalik survey responses were likely reflecting the shifts on the high end.

Perspective

I wonder what a survey of physician workload opinions in other specialties would show, or what a survey of workers across all segments of the U.S. workforce in and out of healthcare would show. Of course, many or most jobs outside of healthcare don’t risk another’s health or well-being as significantly as ours do, but it would still be instructive to know how people in general think about the work they do.

I suspect a significant number of people across many different jobs feel like too much work is expected of them, and they can point to the ways their performance suffers as a result. It is difficult to know what portion of those who report too much work is just complaining versus a thoughtful self-reflection of the determinants of their performance. Lots of hospitalists do face worrisome high workloads, but some would probably still complain even with a much lower workload.

What Can Be Done?

For those practices facing remarkably high patient volumes, the solution is to make sure you’re recruiting additional doctors, and/or NPs/PAs, as fast as you can. But a portion of these practices must first convince their employers that more staff is needed. Some practices face a real uphill battle in getting the required additional funding, and the place to start is with a careful analysis of your current workload—based on hard numbers from your practice, not just anecdotes and estimates.

Don’t forget that some hospitalists put themselves in the position of having to manage high daily patient volumes by choosing a schedule of relatively few worked days annually. For example, a group working a seven-on/seven-off schedule that also has 14 shifts of time off means that each doctor will work only 168.5 shifts annually. Compressing a year’s worth of work into only 168 shifts means that each shift will be busy, and many will involve patient volumes that exceed what is seen as safe.

It could make more sense to titrate that same work volume over more annual shifts so that the average shift is less busy. I would love to see the Michtalik data segregated by those who work many shifts annually versus those who work few shifts. It is possible that those working more shifts have reported excessive workloads less often.

SHM has a role in influencing hospitalist workloads and promotes dissemination of data and opinions about it. At HM13 next month in Washington, D.C., I am leading a session titled “Hospitalist Workload: Is 15 the Right Number?” Although it won’t provide the “right” workload for all hospitalists, it will offer worthwhile data and food for thought.

It is much more difficult to do studies of how workload influences performance than something like effects of sleep deprivation on performance, so we may never get clear answers. You could take some consolation in the fact that successive surveys have shown little change or even modest decreases in annual patient encounters. But then again, maybe that hasn’t helped with excess work since providing hospital care gets harder and more complex every year.

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

Reference

1. Michtalik HJ, Yeh HC, Pronovost PJ, Brotman DJ. Impact of attending physician workload on patient care: a survey of hospitalists. JAMA Intern Med. 2013;28:1-2.

Dr. Wachter

Most hospitalists have heard the adage “If you’ve seen one hospitalist group, you’ve seen one hospitalist group.” Another HM truism is “If you’ve seen one SHM annual meeting, then you’ve seen Bob Wachter, MD, MHM.”

Dr. Wachter, professor, chief of the division of hospital medicine, and chief of the medical service at the University of California at San Francisco Medical Center, is to HM conventions as warfarin is to anticoagulation. His keynote address is the finale to the yearly confab, and HM13’s version is scheduled for noon May 19 at the Gaylord National Harbor Resort & Convention Center in National Harbor, Md.

This year’s address is titled “Quality, Safety, and IT: A Decade of Successes, Failures, Surprises, and Epiphanies.” Dr. Wachter spoke recently with The Hospitalist about his annual tradition.

Question: With your interest in the intersection between healthcare and politics, to be back in D.C. has to be something enjoyable for you to write and talk about.

Answer: It’s a very interesting time in the life of healthcare, in that now that everybody knows that the [Affordable Care Act] is real and not going away, and we’re actually beginning to implement parts of it, you can kind of see what the future is going to look like, and everybody’s responding. And there are parts of that that are very exciting, because they’re forcing us to think about value in new ways. [And] there are parts of it that are somewhat frustrating.

Q: Does that give the hospitalist community the chance to ride herd on more global issues?

A: I think that’s the most optimistic interpretation—that we stick to our knitting, that we continue to be the leaders in improvement, and eventually all of the deals will be done, lawyers will be dismissed, and people will turn back to focusing on performance and say to us, “Thank goodness you’ve been doing this work, because now we realize that it’s not just about contracts; it’s about how we deliver care, and you’re the ones that have been leading the way.”

Q: What’s the most realistic interpretation?

A: This work gets less attention and less support than it needs. … I think we’re going to go through three to five years where we’re continuing to do the work. It’s really important—in many ways, it’s as important as growing—but as its importance is growing, the importance of other things that require more tending-to by the senior leadership is growing even faster. The risk is that there will be a disconnect.

Q: When you see the literature that suggests just how difficult the nuts and bolts implementation of reform is, what message do you want to get across to the people who are going to be listening, in terms of actually implementing all of this?

A: The message I don’t want to get across is “frustration, burnout, and it’s not worth it.” The endgame is worth it. The endgame is not even elective. We have to get to a place where we’re delivering higher-quality, safer, more satisfying care to patients at a lower cost. We’re in a unique position to deliver on that promise. … This is really tough stuff, and it takes time and it takes learning.

Check out our 6-minute feature video: "Five Reasons You Should Attend HM13"

Richard Quinn is a freelance writer in New Jersey.

Dr. Wachter

Most hospitalists have heard the adage “If you’ve seen one hospitalist group, you’ve seen one hospitalist group.” Another HM truism is “If you’ve seen one SHM annual meeting, then you’ve seen Bob Wachter, MD, MHM.”

Dr. Wachter, professor, chief of the division of hospital medicine, and chief of the medical service at the University of California at San Francisco Medical Center, is to HM conventions as warfarin is to anticoagulation. His keynote address is the finale to the yearly confab, and HM13’s version is scheduled for noon May 19 at the Gaylord National Harbor Resort & Convention Center in National Harbor, Md.

This year’s address is titled “Quality, Safety, and IT: A Decade of Successes, Failures, Surprises, and Epiphanies.” Dr. Wachter spoke recently with The Hospitalist about his annual tradition.

Question: With your interest in the intersection between healthcare and politics, to be back in D.C. has to be something enjoyable for you to write and talk about.

Answer: It’s a very interesting time in the life of healthcare, in that now that everybody knows that the [Affordable Care Act] is real and not going away, and we’re actually beginning to implement parts of it, you can kind of see what the future is going to look like, and everybody’s responding. And there are parts of that that are very exciting, because they’re forcing us to think about value in new ways. [And] there are parts of it that are somewhat frustrating.

Q: Does that give the hospitalist community the chance to ride herd on more global issues?

A: I think that’s the most optimistic interpretation—that we stick to our knitting, that we continue to be the leaders in improvement, and eventually all of the deals will be done, lawyers will be dismissed, and people will turn back to focusing on performance and say to us, “Thank goodness you’ve been doing this work, because now we realize that it’s not just about contracts; it’s about how we deliver care, and you’re the ones that have been leading the way.”

Q: What’s the most realistic interpretation?

A: This work gets less attention and less support than it needs. … I think we’re going to go through three to five years where we’re continuing to do the work. It’s really important—in many ways, it’s as important as growing—but as its importance is growing, the importance of other things that require more tending-to by the senior leadership is growing even faster. The risk is that there will be a disconnect.

Q: When you see the literature that suggests just how difficult the nuts and bolts implementation of reform is, what message do you want to get across to the people who are going to be listening, in terms of actually implementing all of this?

A: The message I don’t want to get across is “frustration, burnout, and it’s not worth it.” The endgame is worth it. The endgame is not even elective. We have to get to a place where we’re delivering higher-quality, safer, more satisfying care to patients at a lower cost. We’re in a unique position to deliver on that promise. … This is really tough stuff, and it takes time and it takes learning.

Check out our 6-minute feature video: "Five Reasons You Should Attend HM13"

Richard Quinn is a freelance writer in New Jersey.

Dr. Wachter

Most hospitalists have heard the adage “If you’ve seen one hospitalist group, you’ve seen one hospitalist group.” Another HM truism is “If you’ve seen one SHM annual meeting, then you’ve seen Bob Wachter, MD, MHM.”

Dr. Wachter, professor, chief of the division of hospital medicine, and chief of the medical service at the University of California at San Francisco Medical Center, is to HM conventions as warfarin is to anticoagulation. His keynote address is the finale to the yearly confab, and HM13’s version is scheduled for noon May 19 at the Gaylord National Harbor Resort & Convention Center in National Harbor, Md.

This year’s address is titled “Quality, Safety, and IT: A Decade of Successes, Failures, Surprises, and Epiphanies.” Dr. Wachter spoke recently with The Hospitalist about his annual tradition.

Question: With your interest in the intersection between healthcare and politics, to be back in D.C. has to be something enjoyable for you to write and talk about.

Answer: It’s a very interesting time in the life of healthcare, in that now that everybody knows that the [Affordable Care Act] is real and not going away, and we’re actually beginning to implement parts of it, you can kind of see what the future is going to look like, and everybody’s responding. And there are parts of that that are very exciting, because they’re forcing us to think about value in new ways. [And] there are parts of it that are somewhat frustrating.

Q: Does that give the hospitalist community the chance to ride herd on more global issues?

A: I think that’s the most optimistic interpretation—that we stick to our knitting, that we continue to be the leaders in improvement, and eventually all of the deals will be done, lawyers will be dismissed, and people will turn back to focusing on performance and say to us, “Thank goodness you’ve been doing this work, because now we realize that it’s not just about contracts; it’s about how we deliver care, and you’re the ones that have been leading the way.”

Q: What’s the most realistic interpretation?

A: This work gets less attention and less support than it needs. … I think we’re going to go through three to five years where we’re continuing to do the work. It’s really important—in many ways, it’s as important as growing—but as its importance is growing, the importance of other things that require more tending-to by the senior leadership is growing even faster. The risk is that there will be a disconnect.

Q: When you see the literature that suggests just how difficult the nuts and bolts implementation of reform is, what message do you want to get across to the people who are going to be listening, in terms of actually implementing all of this?

A: The message I don’t want to get across is “frustration, burnout, and it’s not worth it.” The endgame is worth it. The endgame is not even elective. We have to get to a place where we’re delivering higher-quality, safer, more satisfying care to patients at a lower cost. We’re in a unique position to deliver on that promise. … This is really tough stuff, and it takes time and it takes learning.

Check out our 6-minute feature video: "Five Reasons You Should Attend HM13"

Richard Quinn is a freelance writer in New Jersey.