The most recent report on hospital quality issued by independent healthcare rating company HealthGrades estimates that 254,000 safety incidents that occurred in U.S. hospitals from 2008 to 2010 could have been prevented, and that 56,367 hospitalized patients who died experienced one or more of those preventable events.¹

Drawing upon consumer-reported quality data in CMS’ Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey, HealthGrades concluded that 15% more patient safety incidents occurred at hospitals who ranked lowest (the bottom 10%) on the quality of their physician communication.

Reference

1. CPM Healthgrades. Patient safety and satisfaction: the state of American hospitals. CPM Healthgrades website. Available at: https://www.cpm.com/CPM/assets/File/HealthGradesPatientSafetySatisfactionReport2012.pdf. Accessed July 8, 2012.

The most recent report on hospital quality issued by independent healthcare rating company HealthGrades estimates that 254,000 safety incidents that occurred in U.S. hospitals from 2008 to 2010 could have been prevented, and that 56,367 hospitalized patients who died experienced one or more of those preventable events.¹

Drawing upon consumer-reported quality data in CMS’ Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey, HealthGrades concluded that 15% more patient safety incidents occurred at hospitals who ranked lowest (the bottom 10%) on the quality of their physician communication.

Reference

1. CPM Healthgrades. Patient safety and satisfaction: the state of American hospitals. CPM Healthgrades website. Available at: https://www.cpm.com/CPM/assets/File/HealthGradesPatientSafetySatisfactionReport2012.pdf. Accessed July 8, 2012.

The most recent report on hospital quality issued by independent healthcare rating company HealthGrades estimates that 254,000 safety incidents that occurred in U.S. hospitals from 2008 to 2010 could have been prevented, and that 56,367 hospitalized patients who died experienced one or more of those preventable events.¹

Drawing upon consumer-reported quality data in CMS’ Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey, HealthGrades concluded that 15% more patient safety incidents occurred at hospitals who ranked lowest (the bottom 10%) on the quality of their physician communication.

Reference

1. CPM Healthgrades. Patient safety and satisfaction: the state of American hospitals. CPM Healthgrades website. Available at: https://www.cpm.com/CPM/assets/File/HealthGradesPatientSafetySatisfactionReport2012.pdf. Accessed July 8, 2012.

EDITOR’S NOTE: An incorrect version of Win Whitcomb’s “On the Horizon” column was published in the July issue of The Hospitalist. We deeply regret the error. The correct version of Dr. Whitcomb’s column appears this month, with proper attribution given to hospitalist Brad Flansbaum, DO, SFHM, who contributed to the column.

Assigning the appropriate status to patients (“inpatient” or “observation”) has emerged as a front-and-center issue for hospitalists. Also known as “medical necessity,” many HM groups have been called upon to help solve the “status” problem for their institutions. With nearly 1 in 5 hospitalized patients on observation status in U.S. hospitals, appropriately assigning status is now a dominant, system-level challenge for hospitalists.

This month, we asked two experts to shed light on the nature of this beast, with a focus on the impact on the patient. Brad Flansbaum, DO, SFHM, hospitalist at Lenox Hill Hospital in New York City, and Patrick Conway, MD, FAAP, MSC, SFHM, chief medical officer at the Centers for Medicare & Medicaid Services (CMS), were kind enough to participate in the interview. We start with Dr. Flansbaum.

Dr. Whitcomb: It appears that patients are caught in the middle of the observation status challenge, at least as it relates to footing the bill. Explain the patient perspective of being unwittingly placed on observation status.

Dr. Flansbaum: Recall your last credit card statement. On it is the hotel charge from your last out-of-town CME excursion. Below the total charge, which you were expecting, is a separate line item for a $75 “recreational fee.” You call the hotel, and they inform you that, because you used the hotel gym and pool—accessed with your room key, they levied the fee. No signs, alerts, or postings denoted the policy, so you expected inclusive use of the facilities as a price of your visit. Capture the emotion of the moment, when you see that bill, feel your heart race, and think to yourself, “Get me the manager!”

WW: Why has assigning appropriate status captured the attention of hospitals?

BF: Out of vigilance for penalties and fraud from recovery audit contractor (RAC) investigations, as well attentiveness to unnecessary readmissions, hospitals increasingly are categorizing patients under observation, rather than inpatient, status to avoid conflict with regulators. Beneficiaries are in the crosshairs because of this designation change, and much in the same way of our hotel charge, our patients experience sticker shock when they receive their bill. It is leading to confusion among providers and consternation within the Medicare recipient community.

WW: Why is there so much confusion around appropriate patient status?

BF: The dilemma stems from Medicare payment, and the key distinction between inpatient coverage (Part A) and outpatient coverage, including pharmaceuticals (Parts B and D). When a patient receives their discharge notification—without an “official” inpatient designation, sometimes staying greater than 24 to 48 hours in the ED or in a specially defined observation unit, beneficiary charges are different. This could result in discrete—and sometimes jolting—enrollee copayments and deductibles for drugs and services.

WW: I’ve heard observation status is having a big, adverse impact on patients who go to skilled nursing facilities. Why?

BF: If a patient requires a skilled nursing facility stay (the “three-day stay” inpatient requirement), Medicare will not pay because the patient never registered “official” hospital time. Patients and caregivers are not prepared for the unexpected bills, and consequently, tempers are rising. The rules for Medicare Advantage enrollees (Part C—commercial payers receive a fixed sum from CMS, and oversee parts A, B, and D for an individual beneficiary), which comprise 25% of the program, differ from conventional Medicare. However, commercial plans often shadow traditional, fee-for-service in their policies and, consequently, no exemplar of success in this realm exits.

WW: Why is the number of patients on observation status growing?

BF: Hospitals have significantly increased both the number of their observation stays, as well as their hourly lengths (>48 hours). Because the definition of “observation status” is vague, and even the one- to two-day window is inflating, hospitals and hospitalists often are navigating without a compass. Again, fear of fraud and penalty places hospitals and, indirectly, hospitalists—who often make judgments on admission grade—in a precarious position.

The responsibility of hospitals to notify beneficiaries of their status hinges on this murky determination milieu, which may change in real time during the stay, and makes for an unsatisfactory standard. Understandably, CMS is attempting to rectify this quandary, taking into account a hospital’s need to clarify its billing and designation practices, as well as the beneficiaries’ desire to obtain clear guidance on their responsibilities both during and after the stay. Hospitalists, of course, want direction on coding, along with an understanding of the impact their decisions will have on patients and subspecialty colleagues.

Let’s now bring in Dr. Conway, a pediatric hospitalist. I thank Dr. Flansbaum, who formulated the following questions.

BF/WW: Is it tenable to keep the current system in place? Would it help to require payors and providers to inform beneficiaries of inpatient versus observation status at time zero in a more rigorous, yet to-be-determined manner?

Dr. Conway: Current regulations only require CMS to inform beneficiaries when they are admitted as an inpatient and not when they are an outpatient receiving observation services. There are important implications for beneficiary coverage post-hospital stay, coverage of self-administered drugs, and beneficiary coinsurance from this distinction. As a hospitalist, I think it is best to inform the patient of their status, especially if it has the potential to impact beneficiary liability, including coverage of post-acute care. CMS prepared a pamphlet in 2009, “Are You a Hospital Inpatient or Outpatient? If You Have Medicare, Ask,” to educate beneficiaries on this issue. (Download a PDF of the pamphlet at www.medicare.gov/Publications/Pubs/pdf/11435.pdf.)

BF/WW: Due to the nature of how hospital care is changing, are admission decisions potentially becoming too conflicted an endeavor for inpatient caregivers?  

PC: We want admission decisions to be based on clinical considerations. The decision to admit a patient should be based on the clinical judgment of the primary-care, emergency medicine, and/or HM clinician.

BF/WW: Before the U.S. healthcare system matures to a more full-out, integrated model with internalized risk, can you envision any near-term code changes that might simplify the difficulties all parties are facing, in a budget-neutral fashion?

PC: CMS is currently investigating options to clarify when it is appropriate to admit the patient as an inpatient versus keeping the patient as an outpatient receiving observation services. We understand that this issue is of concern to hospitals, hospitalists, and patients, and we are considering carefully how to simplify the rules in a way that best meets the needs of patients and providers without increasing costs to the system.

With growing attention to observation status coming from patients and provider groups (the AMA is requesting that CMS revise its coverage rules), we will no doubt be hearing more about this going forward.

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].

EDITOR’S NOTE: An incorrect version of Win Whitcomb’s “On the Horizon” column was published in the July issue of The Hospitalist. We deeply regret the error. The correct version of Dr. Whitcomb’s column appears this month, with proper attribution given to hospitalist Brad Flansbaum, DO, SFHM, who contributed to the column.

Assigning the appropriate status to patients (“inpatient” or “observation”) has emerged as a front-and-center issue for hospitalists. Also known as “medical necessity,” many HM groups have been called upon to help solve the “status” problem for their institutions. With nearly 1 in 5 hospitalized patients on observation status in U.S. hospitals, appropriately assigning status is now a dominant, system-level challenge for hospitalists.

This month, we asked two experts to shed light on the nature of this beast, with a focus on the impact on the patient. Brad Flansbaum, DO, SFHM, hospitalist at Lenox Hill Hospital in New York City, and Patrick Conway, MD, FAAP, MSC, SFHM, chief medical officer at the Centers for Medicare & Medicaid Services (CMS), were kind enough to participate in the interview. We start with Dr. Flansbaum.

Dr. Whitcomb: It appears that patients are caught in the middle of the observation status challenge, at least as it relates to footing the bill. Explain the patient perspective of being unwittingly placed on observation status.

Dr. Flansbaum: Recall your last credit card statement. On it is the hotel charge from your last out-of-town CME excursion. Below the total charge, which you were expecting, is a separate line item for a $75 “recreational fee.” You call the hotel, and they inform you that, because you used the hotel gym and pool—accessed with your room key, they levied the fee. No signs, alerts, or postings denoted the policy, so you expected inclusive use of the facilities as a price of your visit. Capture the emotion of the moment, when you see that bill, feel your heart race, and think to yourself, “Get me the manager!”

WW: Why has assigning appropriate status captured the attention of hospitals?

BF: Out of vigilance for penalties and fraud from recovery audit contractor (RAC) investigations, as well attentiveness to unnecessary readmissions, hospitals increasingly are categorizing patients under observation, rather than inpatient, status to avoid conflict with regulators. Beneficiaries are in the crosshairs because of this designation change, and much in the same way of our hotel charge, our patients experience sticker shock when they receive their bill. It is leading to confusion among providers and consternation within the Medicare recipient community.

WW: Why is there so much confusion around appropriate patient status?

BF: The dilemma stems from Medicare payment, and the key distinction between inpatient coverage (Part A) and outpatient coverage, including pharmaceuticals (Parts B and D). When a patient receives their discharge notification—without an “official” inpatient designation, sometimes staying greater than 24 to 48 hours in the ED or in a specially defined observation unit, beneficiary charges are different. This could result in discrete—and sometimes jolting—enrollee copayments and deductibles for drugs and services.

WW: I’ve heard observation status is having a big, adverse impact on patients who go to skilled nursing facilities. Why?

BF: If a patient requires a skilled nursing facility stay (the “three-day stay” inpatient requirement), Medicare will not pay because the patient never registered “official” hospital time. Patients and caregivers are not prepared for the unexpected bills, and consequently, tempers are rising. The rules for Medicare Advantage enrollees (Part C—commercial payers receive a fixed sum from CMS, and oversee parts A, B, and D for an individual beneficiary), which comprise 25% of the program, differ from conventional Medicare. However, commercial plans often shadow traditional, fee-for-service in their policies and, consequently, no exemplar of success in this realm exits.

WW: Why is the number of patients on observation status growing?

BF: Hospitals have significantly increased both the number of their observation stays, as well as their hourly lengths (>48 hours). Because the definition of “observation status” is vague, and even the one- to two-day window is inflating, hospitals and hospitalists often are navigating without a compass. Again, fear of fraud and penalty places hospitals and, indirectly, hospitalists—who often make judgments on admission grade—in a precarious position.

The responsibility of hospitals to notify beneficiaries of their status hinges on this murky determination milieu, which may change in real time during the stay, and makes for an unsatisfactory standard. Understandably, CMS is attempting to rectify this quandary, taking into account a hospital’s need to clarify its billing and designation practices, as well as the beneficiaries’ desire to obtain clear guidance on their responsibilities both during and after the stay. Hospitalists, of course, want direction on coding, along with an understanding of the impact their decisions will have on patients and subspecialty colleagues.

Let’s now bring in Dr. Conway, a pediatric hospitalist. I thank Dr. Flansbaum, who formulated the following questions.

BF/WW: Is it tenable to keep the current system in place? Would it help to require payors and providers to inform beneficiaries of inpatient versus observation status at time zero in a more rigorous, yet to-be-determined manner?

Dr. Conway: Current regulations only require CMS to inform beneficiaries when they are admitted as an inpatient and not when they are an outpatient receiving observation services. There are important implications for beneficiary coverage post-hospital stay, coverage of self-administered drugs, and beneficiary coinsurance from this distinction. As a hospitalist, I think it is best to inform the patient of their status, especially if it has the potential to impact beneficiary liability, including coverage of post-acute care. CMS prepared a pamphlet in 2009, “Are You a Hospital Inpatient or Outpatient? If You Have Medicare, Ask,” to educate beneficiaries on this issue. (Download a PDF of the pamphlet at www.medicare.gov/Publications/Pubs/pdf/11435.pdf.)

BF/WW: Due to the nature of how hospital care is changing, are admission decisions potentially becoming too conflicted an endeavor for inpatient caregivers?  

PC: We want admission decisions to be based on clinical considerations. The decision to admit a patient should be based on the clinical judgment of the primary-care, emergency medicine, and/or HM clinician.

BF/WW: Before the U.S. healthcare system matures to a more full-out, integrated model with internalized risk, can you envision any near-term code changes that might simplify the difficulties all parties are facing, in a budget-neutral fashion?

PC: CMS is currently investigating options to clarify when it is appropriate to admit the patient as an inpatient versus keeping the patient as an outpatient receiving observation services. We understand that this issue is of concern to hospitals, hospitalists, and patients, and we are considering carefully how to simplify the rules in a way that best meets the needs of patients and providers without increasing costs to the system.

With growing attention to observation status coming from patients and provider groups (the AMA is requesting that CMS revise its coverage rules), we will no doubt be hearing more about this going forward.

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].

EDITOR’S NOTE: An incorrect version of Win Whitcomb’s “On the Horizon” column was published in the July issue of The Hospitalist. We deeply regret the error. The correct version of Dr. Whitcomb’s column appears this month, with proper attribution given to hospitalist Brad Flansbaum, DO, SFHM, who contributed to the column.

Assigning the appropriate status to patients (“inpatient” or “observation”) has emerged as a front-and-center issue for hospitalists. Also known as “medical necessity,” many HM groups have been called upon to help solve the “status” problem for their institutions. With nearly 1 in 5 hospitalized patients on observation status in U.S. hospitals, appropriately assigning status is now a dominant, system-level challenge for hospitalists.

This month, we asked two experts to shed light on the nature of this beast, with a focus on the impact on the patient. Brad Flansbaum, DO, SFHM, hospitalist at Lenox Hill Hospital in New York City, and Patrick Conway, MD, FAAP, MSC, SFHM, chief medical officer at the Centers for Medicare & Medicaid Services (CMS), were kind enough to participate in the interview. We start with Dr. Flansbaum.

Dr. Whitcomb: It appears that patients are caught in the middle of the observation status challenge, at least as it relates to footing the bill. Explain the patient perspective of being unwittingly placed on observation status.

Dr. Flansbaum: Recall your last credit card statement. On it is the hotel charge from your last out-of-town CME excursion. Below the total charge, which you were expecting, is a separate line item for a $75 “recreational fee.” You call the hotel, and they inform you that, because you used the hotel gym and pool—accessed with your room key, they levied the fee. No signs, alerts, or postings denoted the policy, so you expected inclusive use of the facilities as a price of your visit. Capture the emotion of the moment, when you see that bill, feel your heart race, and think to yourself, “Get me the manager!”

WW: Why has assigning appropriate status captured the attention of hospitals?

BF: Out of vigilance for penalties and fraud from recovery audit contractor (RAC) investigations, as well attentiveness to unnecessary readmissions, hospitals increasingly are categorizing patients under observation, rather than inpatient, status to avoid conflict with regulators. Beneficiaries are in the crosshairs because of this designation change, and much in the same way of our hotel charge, our patients experience sticker shock when they receive their bill. It is leading to confusion among providers and consternation within the Medicare recipient community.

WW: Why is there so much confusion around appropriate patient status?

BF: The dilemma stems from Medicare payment, and the key distinction between inpatient coverage (Part A) and outpatient coverage, including pharmaceuticals (Parts B and D). When a patient receives their discharge notification—without an “official” inpatient designation, sometimes staying greater than 24 to 48 hours in the ED or in a specially defined observation unit, beneficiary charges are different. This could result in discrete—and sometimes jolting—enrollee copayments and deductibles for drugs and services.

WW: I’ve heard observation status is having a big, adverse impact on patients who go to skilled nursing facilities. Why?

BF: If a patient requires a skilled nursing facility stay (the “three-day stay” inpatient requirement), Medicare will not pay because the patient never registered “official” hospital time. Patients and caregivers are not prepared for the unexpected bills, and consequently, tempers are rising. The rules for Medicare Advantage enrollees (Part C—commercial payers receive a fixed sum from CMS, and oversee parts A, B, and D for an individual beneficiary), which comprise 25% of the program, differ from conventional Medicare. However, commercial plans often shadow traditional, fee-for-service in their policies and, consequently, no exemplar of success in this realm exits.

WW: Why is the number of patients on observation status growing?

BF: Hospitals have significantly increased both the number of their observation stays, as well as their hourly lengths (>48 hours). Because the definition of “observation status” is vague, and even the one- to two-day window is inflating, hospitals and hospitalists often are navigating without a compass. Again, fear of fraud and penalty places hospitals and, indirectly, hospitalists—who often make judgments on admission grade—in a precarious position.

The responsibility of hospitals to notify beneficiaries of their status hinges on this murky determination milieu, which may change in real time during the stay, and makes for an unsatisfactory standard. Understandably, CMS is attempting to rectify this quandary, taking into account a hospital’s need to clarify its billing and designation practices, as well as the beneficiaries’ desire to obtain clear guidance on their responsibilities both during and after the stay. Hospitalists, of course, want direction on coding, along with an understanding of the impact their decisions will have on patients and subspecialty colleagues.

Let’s now bring in Dr. Conway, a pediatric hospitalist. I thank Dr. Flansbaum, who formulated the following questions.

BF/WW: Is it tenable to keep the current system in place? Would it help to require payors and providers to inform beneficiaries of inpatient versus observation status at time zero in a more rigorous, yet to-be-determined manner?

Dr. Conway: Current regulations only require CMS to inform beneficiaries when they are admitted as an inpatient and not when they are an outpatient receiving observation services. There are important implications for beneficiary coverage post-hospital stay, coverage of self-administered drugs, and beneficiary coinsurance from this distinction. As a hospitalist, I think it is best to inform the patient of their status, especially if it has the potential to impact beneficiary liability, including coverage of post-acute care. CMS prepared a pamphlet in 2009, “Are You a Hospital Inpatient or Outpatient? If You Have Medicare, Ask,” to educate beneficiaries on this issue. (Download a PDF of the pamphlet at www.medicare.gov/Publications/Pubs/pdf/11435.pdf.)

BF/WW: Due to the nature of how hospital care is changing, are admission decisions potentially becoming too conflicted an endeavor for inpatient caregivers?  

PC: We want admission decisions to be based on clinical considerations. The decision to admit a patient should be based on the clinical judgment of the primary-care, emergency medicine, and/or HM clinician.

BF/WW: Before the U.S. healthcare system matures to a more full-out, integrated model with internalized risk, can you envision any near-term code changes that might simplify the difficulties all parties are facing, in a budget-neutral fashion?

PC: CMS is currently investigating options to clarify when it is appropriate to admit the patient as an inpatient versus keeping the patient as an outpatient receiving observation services. We understand that this issue is of concern to hospitals, hospitalists, and patients, and we are considering carefully how to simplify the rules in a way that best meets the needs of patients and providers without increasing costs to the system.

With growing attention to observation status coming from patients and provider groups (the AMA is requesting that CMS revise its coverage rules), we will no doubt be hearing more about this going forward.

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].

When Harbor UCLA Medical Center, a teaching hospital in Torrance, Calif., and a major safety-net facility for Los Angeles County, looked at its 30-day readmissions data, it found that readmissions for heart failure patients had increased by about 25% in just one year.

“We parsed the data and said we’re going have to sort this out,” explains Charles McKay, MD, a cardiologist at the hospital. “Then the opportunity to join Project BOOST came along. It’s been helpful to have their tools, mentors, and the whole collaborative experience.”

Harbor UCLA is one of seven Southern California hospitals participating in the yearlong Readmissions Reduction Collaborative, co-sponsored by SHM and the Hospital Association of Southern California (HASC). The hospitals convened in early June in Montebello, Calif., to report results from their quality initiatives. Four of the hospitals reported reductions in readmissions ranging from 24% to 55%. The other three were slower in implementing their quality processes and are just now starting to see results, executives said.

Project BOOST is a national quality initiative created by SHM to improve hospital discharges and care transitions while reducing readmissions—a growing focus for hospitals and health policy makers. About 100 participating sites across the country have benefited from BOOST’s expert mentoring and collaboration, as well as access to such tools as the “teachback” communication techniques and the “8Ps” comprehensive patient risk assessment.

Harbor UCLA’s multidisciplinary readmissions team, with Dr. McKay as its physician champion, zeroed in on heart failure and developed a Cardiovascular Open Access Rapid Evaluation (CORE) service, which he describes as a sort of observation or clinical decisions unit aimed at relieving pressure on the ED. Open 7 a.m. to 7 p.m., the CORE service coordinates medical interventions—stress tests and trips to the cardiac catheter lab, for example—for patients who have not been admitted to the hospital.

The team also focuses on discharged patients who return to the hospital within 72 hours, before the hospital could place post-discharge follow-up phone calls. Many of these patients could not be reached after they left the hospital.

“These are the patients where the system has failed,” Dr. McKay says. “But you could flip it over and say they are our biggest opportunity. That’s where BOOST comes in, to talk about interventions during hospitalization, implementing teachback, streamlining the coordination of care.”

BOOST aims to accelerate the quality-improvement (QI) process, identifying readmission risks and making them a higher priority for nurses and doctors to mobilize resources in the discharge process. “That’s where BOOST shone at our institution,” Dr. McKay says, “and where we still have a lot to learn.”

Harbor UCLA also brought a home healthcare representative onto the team, engaged a discharge advocate, and referred appropriate patients to a heart failure disease management registry. Over the year of the collaborative, it posted a 5.5% decrease in readmissions of heart failure patients.

Hospitalists do not have prominent roles at most HASC readmissions sites; traditional hospitalist services are less common in Southern California hospitals, in part due to the prevalence of independent practice associations (IPAs), which act as intermediaries between physicians and health plans in the region, explains Z. Joseph Wanski, MD, FACE, medical director of the public L.A. Care Health Plan, which co-sponsored the readmissions collaborative. “The IPA is in charge of its members’ hospital and post-hospital care,” he says.

Dr. Wanski, a practicing endocrinologist and a hospitalist at California Hospital Medical Center in Los Angeles, says L.A. Care is now testing the use of hospitalists at some of its contracted acute-care facilities.

In many cases, readmissions involve avoidable costs, as well as reduce patient satisfaction. “If they do not get rehospitalized, patients are happier, their caretakers are happier, and I feel the quality of their care is better,” Dr. Wanski says. “If you can keep the person well at home, make sure they take their medications, hopefully not go back to the ER, and get on with their lives—all those things together are why we’re supporting this collaborative.”

But hospitalists, especially in larger groups, potentially have the leverage to negotiate access to services and the care coordination needed to reduce hospital costs and preventable readmissions, Dr. McKay notes. “In 2012, hospitalists are key, and we need to find a way to make readmission reduction part of their job description, so that they can direct that,” he says.

At Valley Presbyterian Hospital in Van Nuys, which employs three part-time hospitalists who also maintain busy office practices, “the hospitalists have been very cooperative with our project,” reports Adriana Quintero, MSW, the hospital’s full-time Project BOOST facilitator. “They see a lot of our patients in their offices.” The physicians have agreed to carve out time to see, within seven days, discharge patients going home without scheduled appointments with their primary-care physicians (PCPs).

“We find that many of our discharged patients do not call their primary-care physicians for post-discharge appointments” and decline the hospital team’s offers for help—which makes it important for the discharge coordinator to follow up as soon as possible after the patient goes home, Quintero says.

At the collaborative congress in early June, team member Alice Gunderson reported results for Saint Francis Hospital in Lynwood. Gunderson, who sits on the hospital’s quality and safety board, has been a volunteer patient family advocate (PFA) for the past year and a half; she was inspired by her own experience as a family caregiver for her husband and mother, both of whom were Saint Francis patients. Gunderson challenged those in the audience to bring a PFA from their own hospital to the next BOOST meeting.

“From my point of view, wherever healthcare goes, the patient is becoming more educated, with all of the communication technology that is out there, and claiming that empowerment,” Gunderson says. “We must all work together, not in separate silos, for the best outcomes, and we can all learn from one another.”

Larry Beresford is a freelance writer in Oakland, Calif.

When Harbor UCLA Medical Center, a teaching hospital in Torrance, Calif., and a major safety-net facility for Los Angeles County, looked at its 30-day readmissions data, it found that readmissions for heart failure patients had increased by about 25% in just one year.

“We parsed the data and said we’re going have to sort this out,” explains Charles McKay, MD, a cardiologist at the hospital. “Then the opportunity to join Project BOOST came along. It’s been helpful to have their tools, mentors, and the whole collaborative experience.”

Harbor UCLA is one of seven Southern California hospitals participating in the yearlong Readmissions Reduction Collaborative, co-sponsored by SHM and the Hospital Association of Southern California (HASC). The hospitals convened in early June in Montebello, Calif., to report results from their quality initiatives. Four of the hospitals reported reductions in readmissions ranging from 24% to 55%. The other three were slower in implementing their quality processes and are just now starting to see results, executives said.

Project BOOST is a national quality initiative created by SHM to improve hospital discharges and care transitions while reducing readmissions—a growing focus for hospitals and health policy makers. About 100 participating sites across the country have benefited from BOOST’s expert mentoring and collaboration, as well as access to such tools as the “teachback” communication techniques and the “8Ps” comprehensive patient risk assessment.

Harbor UCLA’s multidisciplinary readmissions team, with Dr. McKay as its physician champion, zeroed in on heart failure and developed a Cardiovascular Open Access Rapid Evaluation (CORE) service, which he describes as a sort of observation or clinical decisions unit aimed at relieving pressure on the ED. Open 7 a.m. to 7 p.m., the CORE service coordinates medical interventions—stress tests and trips to the cardiac catheter lab, for example—for patients who have not been admitted to the hospital.

The team also focuses on discharged patients who return to the hospital within 72 hours, before the hospital could place post-discharge follow-up phone calls. Many of these patients could not be reached after they left the hospital.

“These are the patients where the system has failed,” Dr. McKay says. “But you could flip it over and say they are our biggest opportunity. That’s where BOOST comes in, to talk about interventions during hospitalization, implementing teachback, streamlining the coordination of care.”

BOOST aims to accelerate the quality-improvement (QI) process, identifying readmission risks and making them a higher priority for nurses and doctors to mobilize resources in the discharge process. “That’s where BOOST shone at our institution,” Dr. McKay says, “and where we still have a lot to learn.”

Harbor UCLA also brought a home healthcare representative onto the team, engaged a discharge advocate, and referred appropriate patients to a heart failure disease management registry. Over the year of the collaborative, it posted a 5.5% decrease in readmissions of heart failure patients.

Hospitalists do not have prominent roles at most HASC readmissions sites; traditional hospitalist services are less common in Southern California hospitals, in part due to the prevalence of independent practice associations (IPAs), which act as intermediaries between physicians and health plans in the region, explains Z. Joseph Wanski, MD, FACE, medical director of the public L.A. Care Health Plan, which co-sponsored the readmissions collaborative. “The IPA is in charge of its members’ hospital and post-hospital care,” he says.

Dr. Wanski, a practicing endocrinologist and a hospitalist at California Hospital Medical Center in Los Angeles, says L.A. Care is now testing the use of hospitalists at some of its contracted acute-care facilities.

In many cases, readmissions involve avoidable costs, as well as reduce patient satisfaction. “If they do not get rehospitalized, patients are happier, their caretakers are happier, and I feel the quality of their care is better,” Dr. Wanski says. “If you can keep the person well at home, make sure they take their medications, hopefully not go back to the ER, and get on with their lives—all those things together are why we’re supporting this collaborative.”

But hospitalists, especially in larger groups, potentially have the leverage to negotiate access to services and the care coordination needed to reduce hospital costs and preventable readmissions, Dr. McKay notes. “In 2012, hospitalists are key, and we need to find a way to make readmission reduction part of their job description, so that they can direct that,” he says.

At Valley Presbyterian Hospital in Van Nuys, which employs three part-time hospitalists who also maintain busy office practices, “the hospitalists have been very cooperative with our project,” reports Adriana Quintero, MSW, the hospital’s full-time Project BOOST facilitator. “They see a lot of our patients in their offices.” The physicians have agreed to carve out time to see, within seven days, discharge patients going home without scheduled appointments with their primary-care physicians (PCPs).

“We find that many of our discharged patients do not call their primary-care physicians for post-discharge appointments” and decline the hospital team’s offers for help—which makes it important for the discharge coordinator to follow up as soon as possible after the patient goes home, Quintero says.

At the collaborative congress in early June, team member Alice Gunderson reported results for Saint Francis Hospital in Lynwood. Gunderson, who sits on the hospital’s quality and safety board, has been a volunteer patient family advocate (PFA) for the past year and a half; she was inspired by her own experience as a family caregiver for her husband and mother, both of whom were Saint Francis patients. Gunderson challenged those in the audience to bring a PFA from their own hospital to the next BOOST meeting.

“From my point of view, wherever healthcare goes, the patient is becoming more educated, with all of the communication technology that is out there, and claiming that empowerment,” Gunderson says. “We must all work together, not in separate silos, for the best outcomes, and we can all learn from one another.”

Larry Beresford is a freelance writer in Oakland, Calif.

When Harbor UCLA Medical Center, a teaching hospital in Torrance, Calif., and a major safety-net facility for Los Angeles County, looked at its 30-day readmissions data, it found that readmissions for heart failure patients had increased by about 25% in just one year.

“We parsed the data and said we’re going have to sort this out,” explains Charles McKay, MD, a cardiologist at the hospital. “Then the opportunity to join Project BOOST came along. It’s been helpful to have their tools, mentors, and the whole collaborative experience.”

Harbor UCLA is one of seven Southern California hospitals participating in the yearlong Readmissions Reduction Collaborative, co-sponsored by SHM and the Hospital Association of Southern California (HASC). The hospitals convened in early June in Montebello, Calif., to report results from their quality initiatives. Four of the hospitals reported reductions in readmissions ranging from 24% to 55%. The other three were slower in implementing their quality processes and are just now starting to see results, executives said.

Project BOOST is a national quality initiative created by SHM to improve hospital discharges and care transitions while reducing readmissions—a growing focus for hospitals and health policy makers. About 100 participating sites across the country have benefited from BOOST’s expert mentoring and collaboration, as well as access to such tools as the “teachback” communication techniques and the “8Ps” comprehensive patient risk assessment.

Harbor UCLA’s multidisciplinary readmissions team, with Dr. McKay as its physician champion, zeroed in on heart failure and developed a Cardiovascular Open Access Rapid Evaluation (CORE) service, which he describes as a sort of observation or clinical decisions unit aimed at relieving pressure on the ED. Open 7 a.m. to 7 p.m., the CORE service coordinates medical interventions—stress tests and trips to the cardiac catheter lab, for example—for patients who have not been admitted to the hospital.

The team also focuses on discharged patients who return to the hospital within 72 hours, before the hospital could place post-discharge follow-up phone calls. Many of these patients could not be reached after they left the hospital.

“These are the patients where the system has failed,” Dr. McKay says. “But you could flip it over and say they are our biggest opportunity. That’s where BOOST comes in, to talk about interventions during hospitalization, implementing teachback, streamlining the coordination of care.”

BOOST aims to accelerate the quality-improvement (QI) process, identifying readmission risks and making them a higher priority for nurses and doctors to mobilize resources in the discharge process. “That’s where BOOST shone at our institution,” Dr. McKay says, “and where we still have a lot to learn.”

Harbor UCLA also brought a home healthcare representative onto the team, engaged a discharge advocate, and referred appropriate patients to a heart failure disease management registry. Over the year of the collaborative, it posted a 5.5% decrease in readmissions of heart failure patients.

Hospitalists do not have prominent roles at most HASC readmissions sites; traditional hospitalist services are less common in Southern California hospitals, in part due to the prevalence of independent practice associations (IPAs), which act as intermediaries between physicians and health plans in the region, explains Z. Joseph Wanski, MD, FACE, medical director of the public L.A. Care Health Plan, which co-sponsored the readmissions collaborative. “The IPA is in charge of its members’ hospital and post-hospital care,” he says.

Dr. Wanski, a practicing endocrinologist and a hospitalist at California Hospital Medical Center in Los Angeles, says L.A. Care is now testing the use of hospitalists at some of its contracted acute-care facilities.

In many cases, readmissions involve avoidable costs, as well as reduce patient satisfaction. “If they do not get rehospitalized, patients are happier, their caretakers are happier, and I feel the quality of their care is better,” Dr. Wanski says. “If you can keep the person well at home, make sure they take their medications, hopefully not go back to the ER, and get on with their lives—all those things together are why we’re supporting this collaborative.”

But hospitalists, especially in larger groups, potentially have the leverage to negotiate access to services and the care coordination needed to reduce hospital costs and preventable readmissions, Dr. McKay notes. “In 2012, hospitalists are key, and we need to find a way to make readmission reduction part of their job description, so that they can direct that,” he says.

At Valley Presbyterian Hospital in Van Nuys, which employs three part-time hospitalists who also maintain busy office practices, “the hospitalists have been very cooperative with our project,” reports Adriana Quintero, MSW, the hospital’s full-time Project BOOST facilitator. “They see a lot of our patients in their offices.” The physicians have agreed to carve out time to see, within seven days, discharge patients going home without scheduled appointments with their primary-care physicians (PCPs).

“We find that many of our discharged patients do not call their primary-care physicians for post-discharge appointments” and decline the hospital team’s offers for help—which makes it important for the discharge coordinator to follow up as soon as possible after the patient goes home, Quintero says.

At the collaborative congress in early June, team member Alice Gunderson reported results for Saint Francis Hospital in Lynwood. Gunderson, who sits on the hospital’s quality and safety board, has been a volunteer patient family advocate (PFA) for the past year and a half; she was inspired by her own experience as a family caregiver for her husband and mother, both of whom were Saint Francis patients. Gunderson challenged those in the audience to bring a PFA from their own hospital to the next BOOST meeting.

“From my point of view, wherever healthcare goes, the patient is becoming more educated, with all of the communication technology that is out there, and claiming that empowerment,” Gunderson says. “We must all work together, not in separate silos, for the best outcomes, and we can all learn from one another.”

Larry Beresford is a freelance writer in Oakland, Calif.

Quotes from the Field

We cannot rely solely on a tool to make decisions. The tool is a decision aid.

Alvin H. Moss, MD, FAAHPM

Professor of medicine in the nephrology section and director of the Center for Health Ethics and Law at West Virginia University School of Medicine in Morgantown

 

Predictions really apply to groups of people, not individuals.

J. Randall Curtis, MD, MPH

Professor and section head in the division of pulmonary and critical care medicine at the University of Washington’s Harborview Medical Center in Seattle

 

if you ask a physician to provide you with his or her impression of a patient progression, we generally tend to overestimate how well they’re doing.

JoAnn Wood, MD, MSEd, MHA

Hospitalist and division director of general internal medicine at the University of Arkansas for Medical Sciences in Little Rock

 

Patients feel that you’re almost abandoning them, that there’s something you’re withholding.

Ann Sheehy

Director of the hospitalist service at University of Wisconsin Medical Center in Madison

 

Telling patients there is a 20% chance that they might die in the next year isn’t usually enough to change their thinking.

David Casarett, MD, MA

Associate professor of medicine at the University of Pennsylvania and chief medical officer of Penn-Wissahickon Hospice in Philadelphia

End-of-life conversations are common in hospital medicine, and Caitlin Foxley, MD, FHM, is no stranger to their nuance. She offers patients and loved ones as much factual information as she can. And regardless of their preference—aggressive treatment, comfort care, something in between—it’s ultimately their choice, not hers. But no matter what, she will ensure the patient’s pain remains under control.

“The way I practice is to allow my patients to make the end-of-life decision that is in accordance with their wishes, and not simply push the least expensive one on them,” says Dr. Foxley, medical director of IMI Hospitalists and hospital service chief of internal medicine at Nebraska Medical Center in Omaha. However, she adds, “most people, given accurate information in a compassionate manner, would choose to die at home, and not in an ICU on a ventilator, with chemo and pressers going through a central line.”

Although hospitalists differ in their approaches to end-of-life discussions, most agree that the majority of critically ill patients want to know their prognosis. Tested end-of-life prediction tools can help physicians provide realistic ranges for patients and families (see “Helpful End-of-Life Prediction Tools,” p. 39). Armed with this insight, they can hope to deliver better and more cost-effective end-of-life care.

Nonetheless, “we cannot rely solely on a tool to make decisions,” says Alvin H. Moss, MD, FAAHPM, professor of medicine in the nephrology section and director of the Center for Health Ethics and Law at West Virginia University School of Medicine in Morgantown. “The tool is a decision aid.”

Clinicians still need to help patients and families identify their treatment goals while determining which life-sustaining options they would or wouldn’t want to pursue, Dr. Moss says. That conversation would include an estimated prognosis of survival.

“If you try to prognosticate a specific length of time, you will be wrong,” says Steven Z. Pantilat, MD, FACP, SFHM, professor of clinical medicine and director of the palliative care program at the University of California San Francisco Medical Center. “You can give patients a lot of useful information by speaking in ranges.”

But it’s important to also convey the inherent uncertainty of any prognosis, considering that a very sick patient might suffer a sudden decline. For this reason, even the best prognostic indicators aren’t exact, Dr. Pantilat cautions. A prediction tool could forecast a 20% chance of six-month survival on the day before a patient’s death in the ICU.

“Predictions really apply to groups of people, not individuals,” says J. Randall Curtis, MD, MPH, professor and section head in the division of pulmonary and critical care medicine at the University of Washington’s Harborview Medical Center in Seattle. Physicians can’t possibly know whether someone will fall into the 95% of patients who die or the 5% of patients who beat the odds.

“It’s never certain that a patient is not going to survive,” says Dr. Curtis, who is director of the Harborview/University of Washington End-of-Life Care Research Program. While patients are less likely to request aggressive care in light of a poor prognosis, some will elect intensive treatment in hopes of defying even the grimmest statistics.

More Medical Tests and Procedures

In the U.S., it’s much more common for patients to receive life-saving treatments than in other countries. The expectation is that expensive medical technology can always prolong life.¹

“A lot of patients have that mentality,” says Ann Sheehy, MD, MS, director of the hospitalist service at University of Wisconsin Medical Center in Madison. “That makes it harder to have the discussion with patients that there isn’t something else we can do.” Patients feel “that you’re almost abandoning them, that there’s something you’re withholding.”

The widespread assumption that more medical tests and procedures lead to better outcomes goes hand in hand with the misperception that sufficiently controlling pain and other symptoms draws death closer. As a result, many patients end up dying with distressing symptoms in the hospital instead of peacefully at home.¹

As physicians, Dr. Sheehy points out, “We don’t do a good job of saying, ‘This care probably is not going to help you or that it will leave you with a very bad quality of life in the end.’” But projections are far from perfect.

“Telling patients there is a 20% chance that they might die in the next year isn’t usually enough to change their thinking. Nor is it enough to justify withholding treatment,” says David Casarett, MD, MA, associate professor of medicine at the University of Pennsylvania and chief medical officer of Penn-Wissahickon Hospice in Philadelphia.

What prognostic information can do is play an important part in guiding appropriate screening and preventive health measures. For example, if a male patient has a 50% chance of dying within four years, it doesn’t make sense to screen for prostate cancer, a slow-growing malignancy that often takes years to develop. This protocol may also apply to cancer screenings, as well as treatments for diabetes, high blood pressure, or high cholesterol, Dr. Casarett says. 

End-of-Life Conversations

By not taking a patient’s prognosis into account, many clinical decisions are not fully informed. In physicians’ clinical practice and training, there tends to be less emphasis on estimating prognosis than on diagnosing and treating illness. This is particularly significant in older adults with competing chronic conditions and diminished life expectancy.²

“Many physicians have not been trained in how to have these conversations, which is something we’re trying to change,” says Dr. Curtis, the pulmonary and critical care specialist at the University of Washington. “This is very emotionally difficult for patients and families, and therefore, it can also be emotionally difficult for physicians.”

Starting this summer, medical residents at Cooper University Hospital in Camden, N.J., will have mandated exposure to palliative care. The rotation, lasting from two to four weeks, will occur in their second year of training, says Mark Angelo, MD, FACP, director of palliative medicine.

Residents will accompany the palliative-care team for an intensive period of time to learn about different techniques for symptom control and to observe end-of-life conversations, which often elicit patients’ angst, depression, and physiologic and spiritual unrest.

“We already have residents rotating with us now in the palliative-care program, and everybody is very struck by how honest patients want you to be,” Dr. Angelo says. “It certainly is devastating, and we understand that. But it does give patients the opportunity to reorganize their lives and to prioritize a number of issues, including medical treatment.”

Some patients opt to spend more time with their grandchildren rather than stay in the hospital. Others prefer to eat and drink whatever they want. Many terminally ill Hispanic patients in the Camden area travel to Latin America, where they were born, or they invite relatives to visit them here, Dr. Angelo says.

While it’s difficult to accept finality, “there’s a certain amount of freedom that comes with that,” he says. “If someone has a prognosis of two months, they may make very different decisions than someone who has a prognosis of two years.”

Physicians tend to be overly optimistic, notes JoAnn Wood, MD, MSEd, MHA, a hospitalist and division director of general internal medicine at the University of Arkansas for Medical Sciences in Little Rock. “The data suggest that, if you ask a physician to provide you with his or her impression of a patient progression, we generally tend to overestimate how well they’re doing,” particularly with cancer patients, Dr. Wood says. “Physicians don’t choose this line of work to facilitate people’s dying.”

When Doing Less Is More

End-of-life prediction tools enable clinicians to keep their expectations of a patient’s survival grounded in reality. And in many hospitals, palliative-care providers are available to lend their expertise. “The field of palliative medicine has taken a lot of strides,” Dr. Wood says, “in helping us to seeing that dying is something that can be done well, just like living can be done well.”

In fact, growing evidence indicates that treating a patient’s discomfort is linked to improvement in physical status and might even increase survival.³ What this means is that, at the end of life, sometimes doing less is actually more. And if patients request less medical care, physicians should honor those desires.^4,5

Dr. Pantilat, the UCSF palliative-care expert, suggests asking open-ended questions to get at the heart of a patient’s wishes. For instance: “‘When you look to the future, what do you hope will happen?’ Or ‘When you think of life ahead, what worries you the most?’” The responses guide physicians in devising a plan of care that is consistent with a patient’s values. Having these discussions sooner rather than later is best for everyone involved, Dr. Pantilat says. Unfortunately, that’s not what usually happens.

About half of the more than 40% of Americans who die annually under hospice care do so within two weeks after being admitted. In such a short timeframe, even the most skilled experts are limited in what they can do, according to the National Hospice and Palliative Care Organization. To reverse this trend, Dr. Pantilat recommends that physicians consider making referrals to palliative care much earlier, whenever they sense that a patient may have a year or less to live.

Providing palliative care can be done in conjunction with life-prolonging therapies or as the central focus. The goal is to prevent and relieve suffering and to ensure the best possible quality of life for patients and their families, regardless of disease stage or the need for other treatments. Such care is suitable for patients with cancer, heart conditions, liver or renal failure, Alzheimer’s disease, spinal cord injuries, and a number of other illnesses, according to the National Consensus Project for Quality Palliative Care.

We have a lot of work to do to educate the public about the dying process. We are all going to die someday, and we all need to think about how and where we want to be when it happens, if we have any choice in it.

—Caitlin Foxley, MD, FHM, medical director, IMI Hospitalists, hospital service chief of internal medicine, Nebraska Medical Center, Omaha

Planning Ahead

In Arkansas, Dr. Wood typically turns to the hospital’s palliative-care team in end-of-life situations, asking its members to join in a conference with the patient and family. The team typically consists of a nurse, social worker and chaplain who can address various concerns. An employee from the medical billing department participates if necessary.

“Physicians should never assume that they understand the healthcare system, because it’s incredibly complicated,” Dr. Wood says, adding that she doesn’t pretend to be an expert in Medicare, Medicaid, or private insurance reimbursement issues.

Helping patients with advanced care planning can minimize difficulties later. Most patients who die in hospitals are admitted with end-stage disease, and most spend time in the ICU with mechanical ventilation. Physicians often are unaware of patients’ preferences, and this could lead to misunderstandings, especially in the ICU setting, where prognoses can shift quickly. One study showed that, in order for some of these patients to die, clinicians and families generally had to decide explicitly to strive toward less-than-completely-aggressive care.¹

“We’re trying to make sure that patients and families have an opportunity to do advanced-care planning,” Dr. Curtis says. Talking with them about their values and goals is essential for clinicians to understand their preferences.

Part of this involves crafting advanced-care directives. One such directive would be a power of attorney for healthcare, in which a patient states who is authorized to make decisions if he or she becomes unable to do so. This is particularly important for patients who select someone other than whom their state’s law would normally designate.

Another document—the living will—allows patients to specify their own preferences for end-of-life care. Yet “it’s often very difficult to know exactly what decisions will need to be made,” Dr. Curtis says. “Those documents are rarely determinative.” Even when a patient stipulates his or her wishes against “extraordinary life-sustaining measures, it still leaves a lot for interpretation.”

Some patients may spell out more clearly whether they wouldn’t want tube-feeding, CPR, or ventilation. This can be prescribed in written and signed Physician Orders for Life-Sustaining Treatment (POLST).

If you try to prognosticate a specific length of time, you will be wrong. You can give patients a lot of useful information by speaking in ranges.

—Steven Z. Pantilat, MD, FACP, professor of clinical medicine, director of the palliative-care program, University of California San Francisco Medical Center

Educating the Public

End-of-life discussions also pose a threat of litigation. “It takes a significant amount of time, often during a very busy day, to sit down with a patient and family members to bring up an issue that will undoubtedly raise many questions, some of which are impossible to answer,” says Dr. Foxley, the hospitalist service chief in Omaha. “I’m sure many physicians are uncomfortable with the tears that are shed.”

When Dr. Foxley recently advised a patient’s family that aggressive care would be futile, they directed their anger toward her. Their loved one died, despite the intensive treatment. It’s just one example of many in which Dr. Foxley has witnessed how high-tech medical treatments can incur astronomical hospital bills after just a few days while doing little—if anything—helpful for the patient.

“We have a lot of work to do to educate the public about the dying process,” she says, adding that the entire burden shouldn’t fall on physicians, and that patients should inform family members of their end-of-life wishes. “We are all going to die someday, and we all need to think about how and where we want to be when it happens, if we have any choice in it.”

Susan Kreimer is a freelance medical writer based in New York.

Helpful End-of-Life Prediction Tools

APACHE II (Acute Physiology and Chronic Health Evaluation II)

A severity-of-disease classification system and one of several ICU scoring systems, it is applied within 24 hours of patient admission. An integer score from 0 to 71 is computed based on several measurements; higher scores correspond to more severe disease and a higher risk of death. http://clincalc.com/IcuMortality/APACHEII.aspx

SOFA (Sequential Organ Failure Assessment)

SOFA tracks a patient’s status during an ICU stay. This scoring system determines the extent of a person’s organ function or rate of failure. The overall score is based on scores of the respiratory, cardiovascular, hepatic, coagulation, renal, and neurological systems. http://www.sfar.org/scores2/sofa2.html

The Karnofsky Performance Scale Index

This tool allows patients to be classified by functional impairment. It compares effectiveness of different therapies and assesses the prognosis in individual patients. The lower the Karnofsky score, the worse the survival outlook for most serious illnesses. http://www.hospicepatients.org/karnofsky.html

PPS (Palliative Performance Scale) 

First introduced in 1996 as a tool for performance status in palliative care, the PPS uses five observer-rated domains correlated to the Karnofsky index (100-0). PPS is used in many countries and is translated into many languages. http://supportforhome.wordpress.com/2011/06/15/palliative-performance-scale/

The BODE Index

BODE helps predict mortality from chronic obstructive pulmonary disease (COPD) after diagnosis. Presumably, a higher BODE score correlates with an increased risk of death. http://copd.about.com/od/copdbasics/a/BODEIndex.htm

The Charlson Comorbidity Index

This index predicts the 10-year mortality for a patient who might have a range of comorbid conditions, such as heart disease, AIDS, or cancer (a total of 22 conditions). Each condition is assigned a score, depending on the risk of dying associated with the condition. http://www.medal.org/OnlineCalculators/ch1/ch1.13/ch1.13.01.php

Hemodialysis Mortality Predictor

This online calculator estimates prognosis in end-stage renal disease patients using an integrated model that incorporates the patient age, serum albumin, comorbidities, and clinician assessment of the patient’s likelihood of being dead within a year. http://touchcalc.com/calculators/sq

—Susan Kreimer

References

1. Walling AM, Asch SM, Lorenz KA, et al. The quality of care provided to hospitalized patients at the end of life. Arch Intern Med. 2010;170(12):1057-1063.
2. Yourman LC, Lee SJ, Schonberg MA, Widera EW, Smith AK. Prognostic indices for older adults: a systematic review. JAMA. 2012;307(2):182-192.
3. Grudzen C, Grady D. Improving care at the end of life. Arch Intern Med. 2011;171(13):1202.
4. Grudzen C. At the end of life, sometimes less is more. Arch Intern Med. 2011;171(13):1201.
5. Bale PW. Honoring patients’ wishes for less health care. Arch Intern Med. 2011;171(13):1200.

Quotes from the Field

We cannot rely solely on a tool to make decisions. The tool is a decision aid.

Alvin H. Moss, MD, FAAHPM

Professor of medicine in the nephrology section and director of the Center for Health Ethics and Law at West Virginia University School of Medicine in Morgantown

 

Predictions really apply to groups of people, not individuals.

J. Randall Curtis, MD, MPH

Professor and section head in the division of pulmonary and critical care medicine at the University of Washington’s Harborview Medical Center in Seattle

 

if you ask a physician to provide you with his or her impression of a patient progression, we generally tend to overestimate how well they’re doing.

JoAnn Wood, MD, MSEd, MHA

Hospitalist and division director of general internal medicine at the University of Arkansas for Medical Sciences in Little Rock

 

Patients feel that you’re almost abandoning them, that there’s something you’re withholding.

Ann Sheehy

Director of the hospitalist service at University of Wisconsin Medical Center in Madison

 

Telling patients there is a 20% chance that they might die in the next year isn’t usually enough to change their thinking.

David Casarett, MD, MA

Associate professor of medicine at the University of Pennsylvania and chief medical officer of Penn-Wissahickon Hospice in Philadelphia

End-of-life conversations are common in hospital medicine, and Caitlin Foxley, MD, FHM, is no stranger to their nuance. She offers patients and loved ones as much factual information as she can. And regardless of their preference—aggressive treatment, comfort care, something in between—it’s ultimately their choice, not hers. But no matter what, she will ensure the patient’s pain remains under control.

“The way I practice is to allow my patients to make the end-of-life decision that is in accordance with their wishes, and not simply push the least expensive one on them,” says Dr. Foxley, medical director of IMI Hospitalists and hospital service chief of internal medicine at Nebraska Medical Center in Omaha. However, she adds, “most people, given accurate information in a compassionate manner, would choose to die at home, and not in an ICU on a ventilator, with chemo and pressers going through a central line.”

Although hospitalists differ in their approaches to end-of-life discussions, most agree that the majority of critically ill patients want to know their prognosis. Tested end-of-life prediction tools can help physicians provide realistic ranges for patients and families (see “Helpful End-of-Life Prediction Tools,” p. 39). Armed with this insight, they can hope to deliver better and more cost-effective end-of-life care.

Nonetheless, “we cannot rely solely on a tool to make decisions,” says Alvin H. Moss, MD, FAAHPM, professor of medicine in the nephrology section and director of the Center for Health Ethics and Law at West Virginia University School of Medicine in Morgantown. “The tool is a decision aid.”

Clinicians still need to help patients and families identify their treatment goals while determining which life-sustaining options they would or wouldn’t want to pursue, Dr. Moss says. That conversation would include an estimated prognosis of survival.

“If you try to prognosticate a specific length of time, you will be wrong,” says Steven Z. Pantilat, MD, FACP, SFHM, professor of clinical medicine and director of the palliative care program at the University of California San Francisco Medical Center. “You can give patients a lot of useful information by speaking in ranges.”

But it’s important to also convey the inherent uncertainty of any prognosis, considering that a very sick patient might suffer a sudden decline. For this reason, even the best prognostic indicators aren’t exact, Dr. Pantilat cautions. A prediction tool could forecast a 20% chance of six-month survival on the day before a patient’s death in the ICU.

“Predictions really apply to groups of people, not individuals,” says J. Randall Curtis, MD, MPH, professor and section head in the division of pulmonary and critical care medicine at the University of Washington’s Harborview Medical Center in Seattle. Physicians can’t possibly know whether someone will fall into the 95% of patients who die or the 5% of patients who beat the odds.

“It’s never certain that a patient is not going to survive,” says Dr. Curtis, who is director of the Harborview/University of Washington End-of-Life Care Research Program. While patients are less likely to request aggressive care in light of a poor prognosis, some will elect intensive treatment in hopes of defying even the grimmest statistics.

More Medical Tests and Procedures

In the U.S., it’s much more common for patients to receive life-saving treatments than in other countries. The expectation is that expensive medical technology can always prolong life.¹

“A lot of patients have that mentality,” says Ann Sheehy, MD, MS, director of the hospitalist service at University of Wisconsin Medical Center in Madison. “That makes it harder to have the discussion with patients that there isn’t something else we can do.” Patients feel “that you’re almost abandoning them, that there’s something you’re withholding.”

The widespread assumption that more medical tests and procedures lead to better outcomes goes hand in hand with the misperception that sufficiently controlling pain and other symptoms draws death closer. As a result, many patients end up dying with distressing symptoms in the hospital instead of peacefully at home.¹

As physicians, Dr. Sheehy points out, “We don’t do a good job of saying, ‘This care probably is not going to help you or that it will leave you with a very bad quality of life in the end.’” But projections are far from perfect.

“Telling patients there is a 20% chance that they might die in the next year isn’t usually enough to change their thinking. Nor is it enough to justify withholding treatment,” says David Casarett, MD, MA, associate professor of medicine at the University of Pennsylvania and chief medical officer of Penn-Wissahickon Hospice in Philadelphia.

What prognostic information can do is play an important part in guiding appropriate screening and preventive health measures. For example, if a male patient has a 50% chance of dying within four years, it doesn’t make sense to screen for prostate cancer, a slow-growing malignancy that often takes years to develop. This protocol may also apply to cancer screenings, as well as treatments for diabetes, high blood pressure, or high cholesterol, Dr. Casarett says. 

End-of-Life Conversations

By not taking a patient’s prognosis into account, many clinical decisions are not fully informed. In physicians’ clinical practice and training, there tends to be less emphasis on estimating prognosis than on diagnosing and treating illness. This is particularly significant in older adults with competing chronic conditions and diminished life expectancy.²

“Many physicians have not been trained in how to have these conversations, which is something we’re trying to change,” says Dr. Curtis, the pulmonary and critical care specialist at the University of Washington. “This is very emotionally difficult for patients and families, and therefore, it can also be emotionally difficult for physicians.”

Starting this summer, medical residents at Cooper University Hospital in Camden, N.J., will have mandated exposure to palliative care. The rotation, lasting from two to four weeks, will occur in their second year of training, says Mark Angelo, MD, FACP, director of palliative medicine.

Residents will accompany the palliative-care team for an intensive period of time to learn about different techniques for symptom control and to observe end-of-life conversations, which often elicit patients’ angst, depression, and physiologic and spiritual unrest.

“We already have residents rotating with us now in the palliative-care program, and everybody is very struck by how honest patients want you to be,” Dr. Angelo says. “It certainly is devastating, and we understand that. But it does give patients the opportunity to reorganize their lives and to prioritize a number of issues, including medical treatment.”

Some patients opt to spend more time with their grandchildren rather than stay in the hospital. Others prefer to eat and drink whatever they want. Many terminally ill Hispanic patients in the Camden area travel to Latin America, where they were born, or they invite relatives to visit them here, Dr. Angelo says.

While it’s difficult to accept finality, “there’s a certain amount of freedom that comes with that,” he says. “If someone has a prognosis of two months, they may make very different decisions than someone who has a prognosis of two years.”

Physicians tend to be overly optimistic, notes JoAnn Wood, MD, MSEd, MHA, a hospitalist and division director of general internal medicine at the University of Arkansas for Medical Sciences in Little Rock. “The data suggest that, if you ask a physician to provide you with his or her impression of a patient progression, we generally tend to overestimate how well they’re doing,” particularly with cancer patients, Dr. Wood says. “Physicians don’t choose this line of work to facilitate people’s dying.”

When Doing Less Is More

End-of-life prediction tools enable clinicians to keep their expectations of a patient’s survival grounded in reality. And in many hospitals, palliative-care providers are available to lend their expertise. “The field of palliative medicine has taken a lot of strides,” Dr. Wood says, “in helping us to seeing that dying is something that can be done well, just like living can be done well.”

In fact, growing evidence indicates that treating a patient’s discomfort is linked to improvement in physical status and might even increase survival.³ What this means is that, at the end of life, sometimes doing less is actually more. And if patients request less medical care, physicians should honor those desires.^4,5

Dr. Pantilat, the UCSF palliative-care expert, suggests asking open-ended questions to get at the heart of a patient’s wishes. For instance: “‘When you look to the future, what do you hope will happen?’ Or ‘When you think of life ahead, what worries you the most?’” The responses guide physicians in devising a plan of care that is consistent with a patient’s values. Having these discussions sooner rather than later is best for everyone involved, Dr. Pantilat says. Unfortunately, that’s not what usually happens.

About half of the more than 40% of Americans who die annually under hospice care do so within two weeks after being admitted. In such a short timeframe, even the most skilled experts are limited in what they can do, according to the National Hospice and Palliative Care Organization. To reverse this trend, Dr. Pantilat recommends that physicians consider making referrals to palliative care much earlier, whenever they sense that a patient may have a year or less to live.

Providing palliative care can be done in conjunction with life-prolonging therapies or as the central focus. The goal is to prevent and relieve suffering and to ensure the best possible quality of life for patients and their families, regardless of disease stage or the need for other treatments. Such care is suitable for patients with cancer, heart conditions, liver or renal failure, Alzheimer’s disease, spinal cord injuries, and a number of other illnesses, according to the National Consensus Project for Quality Palliative Care.

We have a lot of work to do to educate the public about the dying process. We are all going to die someday, and we all need to think about how and where we want to be when it happens, if we have any choice in it.

—Caitlin Foxley, MD, FHM, medical director, IMI Hospitalists, hospital service chief of internal medicine, Nebraska Medical Center, Omaha

Planning Ahead

In Arkansas, Dr. Wood typically turns to the hospital’s palliative-care team in end-of-life situations, asking its members to join in a conference with the patient and family. The team typically consists of a nurse, social worker and chaplain who can address various concerns. An employee from the medical billing department participates if necessary.

“Physicians should never assume that they understand the healthcare system, because it’s incredibly complicated,” Dr. Wood says, adding that she doesn’t pretend to be an expert in Medicare, Medicaid, or private insurance reimbursement issues.

Helping patients with advanced care planning can minimize difficulties later. Most patients who die in hospitals are admitted with end-stage disease, and most spend time in the ICU with mechanical ventilation. Physicians often are unaware of patients’ preferences, and this could lead to misunderstandings, especially in the ICU setting, where prognoses can shift quickly. One study showed that, in order for some of these patients to die, clinicians and families generally had to decide explicitly to strive toward less-than-completely-aggressive care.¹

“We’re trying to make sure that patients and families have an opportunity to do advanced-care planning,” Dr. Curtis says. Talking with them about their values and goals is essential for clinicians to understand their preferences.

Part of this involves crafting advanced-care directives. One such directive would be a power of attorney for healthcare, in which a patient states who is authorized to make decisions if he or she becomes unable to do so. This is particularly important for patients who select someone other than whom their state’s law would normally designate.

Another document—the living will—allows patients to specify their own preferences for end-of-life care. Yet “it’s often very difficult to know exactly what decisions will need to be made,” Dr. Curtis says. “Those documents are rarely determinative.” Even when a patient stipulates his or her wishes against “extraordinary life-sustaining measures, it still leaves a lot for interpretation.”

Some patients may spell out more clearly whether they wouldn’t want tube-feeding, CPR, or ventilation. This can be prescribed in written and signed Physician Orders for Life-Sustaining Treatment (POLST).

If you try to prognosticate a specific length of time, you will be wrong. You can give patients a lot of useful information by speaking in ranges.

—Steven Z. Pantilat, MD, FACP, professor of clinical medicine, director of the palliative-care program, University of California San Francisco Medical Center

Educating the Public

End-of-life discussions also pose a threat of litigation. “It takes a significant amount of time, often during a very busy day, to sit down with a patient and family members to bring up an issue that will undoubtedly raise many questions, some of which are impossible to answer,” says Dr. Foxley, the hospitalist service chief in Omaha. “I’m sure many physicians are uncomfortable with the tears that are shed.”

When Dr. Foxley recently advised a patient’s family that aggressive care would be futile, they directed their anger toward her. Their loved one died, despite the intensive treatment. It’s just one example of many in which Dr. Foxley has witnessed how high-tech medical treatments can incur astronomical hospital bills after just a few days while doing little—if anything—helpful for the patient.

“We have a lot of work to do to educate the public about the dying process,” she says, adding that the entire burden shouldn’t fall on physicians, and that patients should inform family members of their end-of-life wishes. “We are all going to die someday, and we all need to think about how and where we want to be when it happens, if we have any choice in it.”

Susan Kreimer is a freelance medical writer based in New York.

Helpful End-of-Life Prediction Tools

APACHE II (Acute Physiology and Chronic Health Evaluation II)

A severity-of-disease classification system and one of several ICU scoring systems, it is applied within 24 hours of patient admission. An integer score from 0 to 71 is computed based on several measurements; higher scores correspond to more severe disease and a higher risk of death. http://clincalc.com/IcuMortality/APACHEII.aspx

SOFA (Sequential Organ Failure Assessment)

SOFA tracks a patient’s status during an ICU stay. This scoring system determines the extent of a person’s organ function or rate of failure. The overall score is based on scores of the respiratory, cardiovascular, hepatic, coagulation, renal, and neurological systems. http://www.sfar.org/scores2/sofa2.html

The Karnofsky Performance Scale Index

This tool allows patients to be classified by functional impairment. It compares effectiveness of different therapies and assesses the prognosis in individual patients. The lower the Karnofsky score, the worse the survival outlook for most serious illnesses. http://www.hospicepatients.org/karnofsky.html

PPS (Palliative Performance Scale) 

First introduced in 1996 as a tool for performance status in palliative care, the PPS uses five observer-rated domains correlated to the Karnofsky index (100-0). PPS is used in many countries and is translated into many languages. http://supportforhome.wordpress.com/2011/06/15/palliative-performance-scale/

The BODE Index

BODE helps predict mortality from chronic obstructive pulmonary disease (COPD) after diagnosis. Presumably, a higher BODE score correlates with an increased risk of death. http://copd.about.com/od/copdbasics/a/BODEIndex.htm

The Charlson Comorbidity Index

This index predicts the 10-year mortality for a patient who might have a range of comorbid conditions, such as heart disease, AIDS, or cancer (a total of 22 conditions). Each condition is assigned a score, depending on the risk of dying associated with the condition. http://www.medal.org/OnlineCalculators/ch1/ch1.13/ch1.13.01.php

Hemodialysis Mortality Predictor

This online calculator estimates prognosis in end-stage renal disease patients using an integrated model that incorporates the patient age, serum albumin, comorbidities, and clinician assessment of the patient’s likelihood of being dead within a year. http://touchcalc.com/calculators/sq

—Susan Kreimer

References

1. Walling AM, Asch SM, Lorenz KA, et al. The quality of care provided to hospitalized patients at the end of life. Arch Intern Med. 2010;170(12):1057-1063.
2. Yourman LC, Lee SJ, Schonberg MA, Widera EW, Smith AK. Prognostic indices for older adults: a systematic review. JAMA. 2012;307(2):182-192.
3. Grudzen C, Grady D. Improving care at the end of life. Arch Intern Med. 2011;171(13):1202.
4. Grudzen C. At the end of life, sometimes less is more. Arch Intern Med. 2011;171(13):1201.
5. Bale PW. Honoring patients’ wishes for less health care. Arch Intern Med. 2011;171(13):1200.

Quotes from the Field

We cannot rely solely on a tool to make decisions. The tool is a decision aid.

Alvin H. Moss, MD, FAAHPM

Professor of medicine in the nephrology section and director of the Center for Health Ethics and Law at West Virginia University School of Medicine in Morgantown

 

Predictions really apply to groups of people, not individuals.

J. Randall Curtis, MD, MPH

Professor and section head in the division of pulmonary and critical care medicine at the University of Washington’s Harborview Medical Center in Seattle

 

if you ask a physician to provide you with his or her impression of a patient progression, we generally tend to overestimate how well they’re doing.

JoAnn Wood, MD, MSEd, MHA

Hospitalist and division director of general internal medicine at the University of Arkansas for Medical Sciences in Little Rock

 

Patients feel that you’re almost abandoning them, that there’s something you’re withholding.

Ann Sheehy

Director of the hospitalist service at University of Wisconsin Medical Center in Madison

 

Telling patients there is a 20% chance that they might die in the next year isn’t usually enough to change their thinking.

David Casarett, MD, MA

Associate professor of medicine at the University of Pennsylvania and chief medical officer of Penn-Wissahickon Hospice in Philadelphia

End-of-life conversations are common in hospital medicine, and Caitlin Foxley, MD, FHM, is no stranger to their nuance. She offers patients and loved ones as much factual information as she can. And regardless of their preference—aggressive treatment, comfort care, something in between—it’s ultimately their choice, not hers. But no matter what, she will ensure the patient’s pain remains under control.

“The way I practice is to allow my patients to make the end-of-life decision that is in accordance with their wishes, and not simply push the least expensive one on them,” says Dr. Foxley, medical director of IMI Hospitalists and hospital service chief of internal medicine at Nebraska Medical Center in Omaha. However, she adds, “most people, given accurate information in a compassionate manner, would choose to die at home, and not in an ICU on a ventilator, with chemo and pressers going through a central line.”

Although hospitalists differ in their approaches to end-of-life discussions, most agree that the majority of critically ill patients want to know their prognosis. Tested end-of-life prediction tools can help physicians provide realistic ranges for patients and families (see “Helpful End-of-Life Prediction Tools,” p. 39). Armed with this insight, they can hope to deliver better and more cost-effective end-of-life care.

Nonetheless, “we cannot rely solely on a tool to make decisions,” says Alvin H. Moss, MD, FAAHPM, professor of medicine in the nephrology section and director of the Center for Health Ethics and Law at West Virginia University School of Medicine in Morgantown. “The tool is a decision aid.”

Clinicians still need to help patients and families identify their treatment goals while determining which life-sustaining options they would or wouldn’t want to pursue, Dr. Moss says. That conversation would include an estimated prognosis of survival.

“If you try to prognosticate a specific length of time, you will be wrong,” says Steven Z. Pantilat, MD, FACP, SFHM, professor of clinical medicine and director of the palliative care program at the University of California San Francisco Medical Center. “You can give patients a lot of useful information by speaking in ranges.”

But it’s important to also convey the inherent uncertainty of any prognosis, considering that a very sick patient might suffer a sudden decline. For this reason, even the best prognostic indicators aren’t exact, Dr. Pantilat cautions. A prediction tool could forecast a 20% chance of six-month survival on the day before a patient’s death in the ICU.

“Predictions really apply to groups of people, not individuals,” says J. Randall Curtis, MD, MPH, professor and section head in the division of pulmonary and critical care medicine at the University of Washington’s Harborview Medical Center in Seattle. Physicians can’t possibly know whether someone will fall into the 95% of patients who die or the 5% of patients who beat the odds.

“It’s never certain that a patient is not going to survive,” says Dr. Curtis, who is director of the Harborview/University of Washington End-of-Life Care Research Program. While patients are less likely to request aggressive care in light of a poor prognosis, some will elect intensive treatment in hopes of defying even the grimmest statistics.

More Medical Tests and Procedures

In the U.S., it’s much more common for patients to receive life-saving treatments than in other countries. The expectation is that expensive medical technology can always prolong life.¹

“A lot of patients have that mentality,” says Ann Sheehy, MD, MS, director of the hospitalist service at University of Wisconsin Medical Center in Madison. “That makes it harder to have the discussion with patients that there isn’t something else we can do.” Patients feel “that you’re almost abandoning them, that there’s something you’re withholding.”

The widespread assumption that more medical tests and procedures lead to better outcomes goes hand in hand with the misperception that sufficiently controlling pain and other symptoms draws death closer. As a result, many patients end up dying with distressing symptoms in the hospital instead of peacefully at home.¹

As physicians, Dr. Sheehy points out, “We don’t do a good job of saying, ‘This care probably is not going to help you or that it will leave you with a very bad quality of life in the end.’” But projections are far from perfect.

“Telling patients there is a 20% chance that they might die in the next year isn’t usually enough to change their thinking. Nor is it enough to justify withholding treatment,” says David Casarett, MD, MA, associate professor of medicine at the University of Pennsylvania and chief medical officer of Penn-Wissahickon Hospice in Philadelphia.

What prognostic information can do is play an important part in guiding appropriate screening and preventive health measures. For example, if a male patient has a 50% chance of dying within four years, it doesn’t make sense to screen for prostate cancer, a slow-growing malignancy that often takes years to develop. This protocol may also apply to cancer screenings, as well as treatments for diabetes, high blood pressure, or high cholesterol, Dr. Casarett says. 

End-of-Life Conversations

By not taking a patient’s prognosis into account, many clinical decisions are not fully informed. In physicians’ clinical practice and training, there tends to be less emphasis on estimating prognosis than on diagnosing and treating illness. This is particularly significant in older adults with competing chronic conditions and diminished life expectancy.²

“Many physicians have not been trained in how to have these conversations, which is something we’re trying to change,” says Dr. Curtis, the pulmonary and critical care specialist at the University of Washington. “This is very emotionally difficult for patients and families, and therefore, it can also be emotionally difficult for physicians.”

Starting this summer, medical residents at Cooper University Hospital in Camden, N.J., will have mandated exposure to palliative care. The rotation, lasting from two to four weeks, will occur in their second year of training, says Mark Angelo, MD, FACP, director of palliative medicine.

Residents will accompany the palliative-care team for an intensive period of time to learn about different techniques for symptom control and to observe end-of-life conversations, which often elicit patients’ angst, depression, and physiologic and spiritual unrest.

“We already have residents rotating with us now in the palliative-care program, and everybody is very struck by how honest patients want you to be,” Dr. Angelo says. “It certainly is devastating, and we understand that. But it does give patients the opportunity to reorganize their lives and to prioritize a number of issues, including medical treatment.”

Some patients opt to spend more time with their grandchildren rather than stay in the hospital. Others prefer to eat and drink whatever they want. Many terminally ill Hispanic patients in the Camden area travel to Latin America, where they were born, or they invite relatives to visit them here, Dr. Angelo says.

While it’s difficult to accept finality, “there’s a certain amount of freedom that comes with that,” he says. “If someone has a prognosis of two months, they may make very different decisions than someone who has a prognosis of two years.”

Physicians tend to be overly optimistic, notes JoAnn Wood, MD, MSEd, MHA, a hospitalist and division director of general internal medicine at the University of Arkansas for Medical Sciences in Little Rock. “The data suggest that, if you ask a physician to provide you with his or her impression of a patient progression, we generally tend to overestimate how well they’re doing,” particularly with cancer patients, Dr. Wood says. “Physicians don’t choose this line of work to facilitate people’s dying.”

When Doing Less Is More

End-of-life prediction tools enable clinicians to keep their expectations of a patient’s survival grounded in reality. And in many hospitals, palliative-care providers are available to lend their expertise. “The field of palliative medicine has taken a lot of strides,” Dr. Wood says, “in helping us to seeing that dying is something that can be done well, just like living can be done well.”

In fact, growing evidence indicates that treating a patient’s discomfort is linked to improvement in physical status and might even increase survival.³ What this means is that, at the end of life, sometimes doing less is actually more. And if patients request less medical care, physicians should honor those desires.^4,5

Dr. Pantilat, the UCSF palliative-care expert, suggests asking open-ended questions to get at the heart of a patient’s wishes. For instance: “‘When you look to the future, what do you hope will happen?’ Or ‘When you think of life ahead, what worries you the most?’” The responses guide physicians in devising a plan of care that is consistent with a patient’s values. Having these discussions sooner rather than later is best for everyone involved, Dr. Pantilat says. Unfortunately, that’s not what usually happens.

About half of the more than 40% of Americans who die annually under hospice care do so within two weeks after being admitted. In such a short timeframe, even the most skilled experts are limited in what they can do, according to the National Hospice and Palliative Care Organization. To reverse this trend, Dr. Pantilat recommends that physicians consider making referrals to palliative care much earlier, whenever they sense that a patient may have a year or less to live.

Providing palliative care can be done in conjunction with life-prolonging therapies or as the central focus. The goal is to prevent and relieve suffering and to ensure the best possible quality of life for patients and their families, regardless of disease stage or the need for other treatments. Such care is suitable for patients with cancer, heart conditions, liver or renal failure, Alzheimer’s disease, spinal cord injuries, and a number of other illnesses, according to the National Consensus Project for Quality Palliative Care.

We have a lot of work to do to educate the public about the dying process. We are all going to die someday, and we all need to think about how and where we want to be when it happens, if we have any choice in it.

—Caitlin Foxley, MD, FHM, medical director, IMI Hospitalists, hospital service chief of internal medicine, Nebraska Medical Center, Omaha

Planning Ahead

In Arkansas, Dr. Wood typically turns to the hospital’s palliative-care team in end-of-life situations, asking its members to join in a conference with the patient and family. The team typically consists of a nurse, social worker and chaplain who can address various concerns. An employee from the medical billing department participates if necessary.

“Physicians should never assume that they understand the healthcare system, because it’s incredibly complicated,” Dr. Wood says, adding that she doesn’t pretend to be an expert in Medicare, Medicaid, or private insurance reimbursement issues.

Helping patients with advanced care planning can minimize difficulties later. Most patients who die in hospitals are admitted with end-stage disease, and most spend time in the ICU with mechanical ventilation. Physicians often are unaware of patients’ preferences, and this could lead to misunderstandings, especially in the ICU setting, where prognoses can shift quickly. One study showed that, in order for some of these patients to die, clinicians and families generally had to decide explicitly to strive toward less-than-completely-aggressive care.¹

“We’re trying to make sure that patients and families have an opportunity to do advanced-care planning,” Dr. Curtis says. Talking with them about their values and goals is essential for clinicians to understand their preferences.

Part of this involves crafting advanced-care directives. One such directive would be a power of attorney for healthcare, in which a patient states who is authorized to make decisions if he or she becomes unable to do so. This is particularly important for patients who select someone other than whom their state’s law would normally designate.

Another document—the living will—allows patients to specify their own preferences for end-of-life care. Yet “it’s often very difficult to know exactly what decisions will need to be made,” Dr. Curtis says. “Those documents are rarely determinative.” Even when a patient stipulates his or her wishes against “extraordinary life-sustaining measures, it still leaves a lot for interpretation.”

Some patients may spell out more clearly whether they wouldn’t want tube-feeding, CPR, or ventilation. This can be prescribed in written and signed Physician Orders for Life-Sustaining Treatment (POLST).

If you try to prognosticate a specific length of time, you will be wrong. You can give patients a lot of useful information by speaking in ranges.

—Steven Z. Pantilat, MD, FACP, professor of clinical medicine, director of the palliative-care program, University of California San Francisco Medical Center

Educating the Public

End-of-life discussions also pose a threat of litigation. “It takes a significant amount of time, often during a very busy day, to sit down with a patient and family members to bring up an issue that will undoubtedly raise many questions, some of which are impossible to answer,” says Dr. Foxley, the hospitalist service chief in Omaha. “I’m sure many physicians are uncomfortable with the tears that are shed.”

When Dr. Foxley recently advised a patient’s family that aggressive care would be futile, they directed their anger toward her. Their loved one died, despite the intensive treatment. It’s just one example of many in which Dr. Foxley has witnessed how high-tech medical treatments can incur astronomical hospital bills after just a few days while doing little—if anything—helpful for the patient.

“We have a lot of work to do to educate the public about the dying process,” she says, adding that the entire burden shouldn’t fall on physicians, and that patients should inform family members of their end-of-life wishes. “We are all going to die someday, and we all need to think about how and where we want to be when it happens, if we have any choice in it.”

Susan Kreimer is a freelance medical writer based in New York.

Helpful End-of-Life Prediction Tools

APACHE II (Acute Physiology and Chronic Health Evaluation II)

A severity-of-disease classification system and one of several ICU scoring systems, it is applied within 24 hours of patient admission. An integer score from 0 to 71 is computed based on several measurements; higher scores correspond to more severe disease and a higher risk of death. http://clincalc.com/IcuMortality/APACHEII.aspx

SOFA (Sequential Organ Failure Assessment)

SOFA tracks a patient’s status during an ICU stay. This scoring system determines the extent of a person’s organ function or rate of failure. The overall score is based on scores of the respiratory, cardiovascular, hepatic, coagulation, renal, and neurological systems. http://www.sfar.org/scores2/sofa2.html

The Karnofsky Performance Scale Index

This tool allows patients to be classified by functional impairment. It compares effectiveness of different therapies and assesses the prognosis in individual patients. The lower the Karnofsky score, the worse the survival outlook for most serious illnesses. http://www.hospicepatients.org/karnofsky.html

PPS (Palliative Performance Scale) 

First introduced in 1996 as a tool for performance status in palliative care, the PPS uses five observer-rated domains correlated to the Karnofsky index (100-0). PPS is used in many countries and is translated into many languages. http://supportforhome.wordpress.com/2011/06/15/palliative-performance-scale/

The BODE Index

BODE helps predict mortality from chronic obstructive pulmonary disease (COPD) after diagnosis. Presumably, a higher BODE score correlates with an increased risk of death. http://copd.about.com/od/copdbasics/a/BODEIndex.htm

The Charlson Comorbidity Index

This index predicts the 10-year mortality for a patient who might have a range of comorbid conditions, such as heart disease, AIDS, or cancer (a total of 22 conditions). Each condition is assigned a score, depending on the risk of dying associated with the condition. http://www.medal.org/OnlineCalculators/ch1/ch1.13/ch1.13.01.php

Hemodialysis Mortality Predictor

This online calculator estimates prognosis in end-stage renal disease patients using an integrated model that incorporates the patient age, serum albumin, comorbidities, and clinician assessment of the patient’s likelihood of being dead within a year. http://touchcalc.com/calculators/sq

—Susan Kreimer

References

1. Walling AM, Asch SM, Lorenz KA, et al. The quality of care provided to hospitalized patients at the end of life. Arch Intern Med. 2010;170(12):1057-1063.
2. Yourman LC, Lee SJ, Schonberg MA, Widera EW, Smith AK. Prognostic indices for older adults: a systematic review. JAMA. 2012;307(2):182-192.
3. Grudzen C, Grady D. Improving care at the end of life. Arch Intern Med. 2011;171(13):1202.
4. Grudzen C. At the end of life, sometimes less is more. Arch Intern Med. 2011;171(13):1201.
5. Bale PW. Honoring patients’ wishes for less health care. Arch Intern Med. 2011;171(13):1200.

Picture this likely scenario: You’re a hospitalist in a remote setting, and a patient with stroke symptoms is rushed in by ambulance. Numbness has overcome one side of his body. Dizziness disrupts his balance, his speech becomes slurred, and his vision is blurred. Treatment must be started swiftly to halt irreversible brain damage. The nearest neurologist is located hours away, but thanks to advanced video technology, you’re able to instantly consult face to face with that specialist to help ensure optimal recovery for the patient.

Such applications of telemedicine are becoming more mainstream and affordable, facilitating discussions and decisions between healthcare providers while improving patient access to specialty care in emergencies and other situations.

Remote hospitalist services include videoconferencing for patient monitoring and assessment of various clinical services, says Jonathan D. Linkous, CEO of the American Telemedicine Association in Washington, D.C. About 60 specialities and subspecialties—from mental health to wound care—rely on telemedicine.

Advantages and Challenges

Remote patient monitoring in intensive-care units is on the upswing, filling gaps in the shortage of physicians specializing in critical care. Some unit administrators have established off-site command centers for these specialists to follow multiple facilities with the assistance of video technology and to intervene at urgent times.¹

In a neonatal ICU, this type of live-feed technology allows for a face-to-face interaction with a pediatric pulmonologist, for example, when a premature infant is exhibiting symptoms of respiratory distress in the middle of the night, says David Cattell-Gordon, MSW, director of the Office of Telemedicine at the University of Virginia in Charlottesville.

Similarly, in rural areas where women don’t have immediate access to high-risk obstetricians, telemedicine makes it possible to consult with maternal-fetal medicine specialists from a distance, boosting the chances for pregnant mothers with complex conditions to carry healthy babies to term, says Cattell-Gordon. “Our approach has been to bring telemedicine to hospitals and clinics in communities where that resource [specialists] otherwise is unavailable,” he adds.

Compared with telephone conversations, the advantages of video consultations are multifold: They display a patient’s facial expressions, gestures, and other body language, which might assist with the diagnosis and prescribed treatment, says Kerry Weiner, MD, chief clinical officer for IPC: The Hospitalist Company in North Hollywood, Calif., which has a presence in about 900 facilities in 25 states.

When the strength of that assessment depends on visual inspection, the technology can be particularly helpful. “The weak part of it is when you need to touch” to guide that assessment, Dr. Weiner says. That’s when the technology isn’t as useful. Still, he adds, “We use teleconferencing all over the place in a Skype-like manner, only more sophisticated. It’s more encrypted.”

Interacting within a secure network is crucial to protect privacy, says Peter Kragel, MD, clinical director of the Telemedicine Center at East Carolina University’s Brody School of Medicine in Greenville, N.C. As with any form of communication that transmits identifiable patient information, healthcare providers must comply with HIPAA guidelines when employing videoconferencing services similar to Skype.

“Because of concerns about compliance with encryption and confidentiality regulations, we do not use [videoconferencing] here,” Dr. Kragel says.

Additionally, “telemedicine isn’t always appropriate for patient care,” Linkous says. “All of this depends on the circumstances and needs of the patient. Obviously, surgery requires a direct physician-patient interaction, except for robotic surgery.” For hospitals that don’t have any neurology coverage, telemedicine robots can assist with outside consults for time-sensitive stroke care.

Videoconferencing isn’t necessary for all telemedicine encounters, Linkous says. Teledermatology and retinal screening use “store and forward” communication of images, which allows for the electronic transmission of images and documents in non-emergent situations in which immediate video isn’t necessary.

“As a society, we’ve become more comfortable with the technology,” says Matthew Harbison, MD, medical director of Sound Physicians hospitalist services at Memorial Hermann-Texas Medical Center in Houston. “And as the technology continues to develop, ultimately there will be [more of] a role, but how large that will be is difficult to predict.” He adds that “the advantages are obviously in low-staffed places or staffing-challenged sites.”

Moving Ahead

As experts continue to iron out the kinks and as communities obtain greater access to broadband signals, telemedicine equipment is moving to advanced high-definition platforms. Meanwhile, the expense has come down considerably since its inception in the mid-1990s. A high-definition setup that once cost upward of $130,000 is now available for less than $10,000, Cattell-Gordon says.

The digital transmission also can assist in patient follow-up after discharge from the hospital and in monitoring various chronic diseases from home. It’s an effective tool for medical staff meetings and training purposes as well.

IPC’s hospitalists have been using the technology to communicate with each other, brainstorming across regions of the country. “Because we’re a national company,” Dr. Weiner says, “this has changed the game in terms of being able to collaborate.”

Susan Kreimer is a freelance medical writer based in New York.

References

1. Thomas EJ, Lucke JF, Wueste L, Weavind L, Patel B. Association of telemedicine for remote monitoring of intensive care patients with mortality, complications, and length of stay. JAMA. 2009;302:2671-2678.

Picture this likely scenario: You’re a hospitalist in a remote setting, and a patient with stroke symptoms is rushed in by ambulance. Numbness has overcome one side of his body. Dizziness disrupts his balance, his speech becomes slurred, and his vision is blurred. Treatment must be started swiftly to halt irreversible brain damage. The nearest neurologist is located hours away, but thanks to advanced video technology, you’re able to instantly consult face to face with that specialist to help ensure optimal recovery for the patient.

Such applications of telemedicine are becoming more mainstream and affordable, facilitating discussions and decisions between healthcare providers while improving patient access to specialty care in emergencies and other situations.

Remote hospitalist services include videoconferencing for patient monitoring and assessment of various clinical services, says Jonathan D. Linkous, CEO of the American Telemedicine Association in Washington, D.C. About 60 specialities and subspecialties—from mental health to wound care—rely on telemedicine.

Advantages and Challenges

Remote patient monitoring in intensive-care units is on the upswing, filling gaps in the shortage of physicians specializing in critical care. Some unit administrators have established off-site command centers for these specialists to follow multiple facilities with the assistance of video technology and to intervene at urgent times.¹

In a neonatal ICU, this type of live-feed technology allows for a face-to-face interaction with a pediatric pulmonologist, for example, when a premature infant is exhibiting symptoms of respiratory distress in the middle of the night, says David Cattell-Gordon, MSW, director of the Office of Telemedicine at the University of Virginia in Charlottesville.

Similarly, in rural areas where women don’t have immediate access to high-risk obstetricians, telemedicine makes it possible to consult with maternal-fetal medicine specialists from a distance, boosting the chances for pregnant mothers with complex conditions to carry healthy babies to term, says Cattell-Gordon. “Our approach has been to bring telemedicine to hospitals and clinics in communities where that resource [specialists] otherwise is unavailable,” he adds.

Compared with telephone conversations, the advantages of video consultations are multifold: They display a patient’s facial expressions, gestures, and other body language, which might assist with the diagnosis and prescribed treatment, says Kerry Weiner, MD, chief clinical officer for IPC: The Hospitalist Company in North Hollywood, Calif., which has a presence in about 900 facilities in 25 states.

When the strength of that assessment depends on visual inspection, the technology can be particularly helpful. “The weak part of it is when you need to touch” to guide that assessment, Dr. Weiner says. That’s when the technology isn’t as useful. Still, he adds, “We use teleconferencing all over the place in a Skype-like manner, only more sophisticated. It’s more encrypted.”

Interacting within a secure network is crucial to protect privacy, says Peter Kragel, MD, clinical director of the Telemedicine Center at East Carolina University’s Brody School of Medicine in Greenville, N.C. As with any form of communication that transmits identifiable patient information, healthcare providers must comply with HIPAA guidelines when employing videoconferencing services similar to Skype.

“Because of concerns about compliance with encryption and confidentiality regulations, we do not use [videoconferencing] here,” Dr. Kragel says.

Additionally, “telemedicine isn’t always appropriate for patient care,” Linkous says. “All of this depends on the circumstances and needs of the patient. Obviously, surgery requires a direct physician-patient interaction, except for robotic surgery.” For hospitals that don’t have any neurology coverage, telemedicine robots can assist with outside consults for time-sensitive stroke care.

Videoconferencing isn’t necessary for all telemedicine encounters, Linkous says. Teledermatology and retinal screening use “store and forward” communication of images, which allows for the electronic transmission of images and documents in non-emergent situations in which immediate video isn’t necessary.

“As a society, we’ve become more comfortable with the technology,” says Matthew Harbison, MD, medical director of Sound Physicians hospitalist services at Memorial Hermann-Texas Medical Center in Houston. “And as the technology continues to develop, ultimately there will be [more of] a role, but how large that will be is difficult to predict.” He adds that “the advantages are obviously in low-staffed places or staffing-challenged sites.”

Moving Ahead

As experts continue to iron out the kinks and as communities obtain greater access to broadband signals, telemedicine equipment is moving to advanced high-definition platforms. Meanwhile, the expense has come down considerably since its inception in the mid-1990s. A high-definition setup that once cost upward of $130,000 is now available for less than $10,000, Cattell-Gordon says.

The digital transmission also can assist in patient follow-up after discharge from the hospital and in monitoring various chronic diseases from home. It’s an effective tool for medical staff meetings and training purposes as well.

IPC’s hospitalists have been using the technology to communicate with each other, brainstorming across regions of the country. “Because we’re a national company,” Dr. Weiner says, “this has changed the game in terms of being able to collaborate.”

Susan Kreimer is a freelance medical writer based in New York.

References

1. Thomas EJ, Lucke JF, Wueste L, Weavind L, Patel B. Association of telemedicine for remote monitoring of intensive care patients with mortality, complications, and length of stay. JAMA. 2009;302:2671-2678.

Picture this likely scenario: You’re a hospitalist in a remote setting, and a patient with stroke symptoms is rushed in by ambulance. Numbness has overcome one side of his body. Dizziness disrupts his balance, his speech becomes slurred, and his vision is blurred. Treatment must be started swiftly to halt irreversible brain damage. The nearest neurologist is located hours away, but thanks to advanced video technology, you’re able to instantly consult face to face with that specialist to help ensure optimal recovery for the patient.

Such applications of telemedicine are becoming more mainstream and affordable, facilitating discussions and decisions between healthcare providers while improving patient access to specialty care in emergencies and other situations.

Remote hospitalist services include videoconferencing for patient monitoring and assessment of various clinical services, says Jonathan D. Linkous, CEO of the American Telemedicine Association in Washington, D.C. About 60 specialities and subspecialties—from mental health to wound care—rely on telemedicine.

Advantages and Challenges

Remote patient monitoring in intensive-care units is on the upswing, filling gaps in the shortage of physicians specializing in critical care. Some unit administrators have established off-site command centers for these specialists to follow multiple facilities with the assistance of video technology and to intervene at urgent times.¹

In a neonatal ICU, this type of live-feed technology allows for a face-to-face interaction with a pediatric pulmonologist, for example, when a premature infant is exhibiting symptoms of respiratory distress in the middle of the night, says David Cattell-Gordon, MSW, director of the Office of Telemedicine at the University of Virginia in Charlottesville.

Similarly, in rural areas where women don’t have immediate access to high-risk obstetricians, telemedicine makes it possible to consult with maternal-fetal medicine specialists from a distance, boosting the chances for pregnant mothers with complex conditions to carry healthy babies to term, says Cattell-Gordon. “Our approach has been to bring telemedicine to hospitals and clinics in communities where that resource [specialists] otherwise is unavailable,” he adds.

Compared with telephone conversations, the advantages of video consultations are multifold: They display a patient’s facial expressions, gestures, and other body language, which might assist with the diagnosis and prescribed treatment, says Kerry Weiner, MD, chief clinical officer for IPC: The Hospitalist Company in North Hollywood, Calif., which has a presence in about 900 facilities in 25 states.

When the strength of that assessment depends on visual inspection, the technology can be particularly helpful. “The weak part of it is when you need to touch” to guide that assessment, Dr. Weiner says. That’s when the technology isn’t as useful. Still, he adds, “We use teleconferencing all over the place in a Skype-like manner, only more sophisticated. It’s more encrypted.”

Interacting within a secure network is crucial to protect privacy, says Peter Kragel, MD, clinical director of the Telemedicine Center at East Carolina University’s Brody School of Medicine in Greenville, N.C. As with any form of communication that transmits identifiable patient information, healthcare providers must comply with HIPAA guidelines when employing videoconferencing services similar to Skype.

“Because of concerns about compliance with encryption and confidentiality regulations, we do not use [videoconferencing] here,” Dr. Kragel says.

Additionally, “telemedicine isn’t always appropriate for patient care,” Linkous says. “All of this depends on the circumstances and needs of the patient. Obviously, surgery requires a direct physician-patient interaction, except for robotic surgery.” For hospitals that don’t have any neurology coverage, telemedicine robots can assist with outside consults for time-sensitive stroke care.

Videoconferencing isn’t necessary for all telemedicine encounters, Linkous says. Teledermatology and retinal screening use “store and forward” communication of images, which allows for the electronic transmission of images and documents in non-emergent situations in which immediate video isn’t necessary.

“As a society, we’ve become more comfortable with the technology,” says Matthew Harbison, MD, medical director of Sound Physicians hospitalist services at Memorial Hermann-Texas Medical Center in Houston. “And as the technology continues to develop, ultimately there will be [more of] a role, but how large that will be is difficult to predict.” He adds that “the advantages are obviously in low-staffed places or staffing-challenged sites.”

Moving Ahead

As experts continue to iron out the kinks and as communities obtain greater access to broadband signals, telemedicine equipment is moving to advanced high-definition platforms. Meanwhile, the expense has come down considerably since its inception in the mid-1990s. A high-definition setup that once cost upward of $130,000 is now available for less than $10,000, Cattell-Gordon says.

The digital transmission also can assist in patient follow-up after discharge from the hospital and in monitoring various chronic diseases from home. It’s an effective tool for medical staff meetings and training purposes as well.

IPC’s hospitalists have been using the technology to communicate with each other, brainstorming across regions of the country. “Because we’re a national company,” Dr. Weiner says, “this has changed the game in terms of being able to collaborate.”

Susan Kreimer is a freelance medical writer based in New York.

References

1. Thomas EJ, Lucke JF, Wueste L, Weavind L, Patel B. Association of telemedicine for remote monitoring of intensive care patients with mortality, complications, and length of stay. JAMA. 2009;302:2671-2678.

Larry Wellikson, MD, SFHM

In the June edition of The Hospitalist, I wrote about the “Future of Hospital Medicine.” I wanted to concentrate this column on how SHM is evolving to support this vision of the future.

I previously referenced the variability of maturity and competence of the thousands of HM groups (HMGs) spread across the nation. SHM is considering creating standards that are validated by the stakeholders in hospital medicine. We hope that each HMG might use these standards to assess its own stage of development. For those HMGs that are already performing at a high level, SHM might recognize this status with an award. For those not quite at the highest level of function, SHM hopes to work with other organizations in HM to create programs and projects to raise your level of function. Our goal is for this process to be aspirational and, hopefully, support HMGs by having a platform to request more resources and to develop additional capabilities so that more and more HMGs over time can reach the highest level of function.

Attracting the Future of Hospital Medicine

SHM also recognizes that as we strive to have hospitalists continue to be key partners in creating the hospital of the future, we need to attract the best medical students and residents into hospital medicine. With this in mind, SHM is developing a detailed plan to communicate with medical students and residents about the best aspects of a career in HM. While this strategy has a long lead time, we do expect that over the next five to 10 years, more and more students will select HM as their career—and give us a deeper bench strength to meet the needs of future HMGs.

In order to keep hospitalists at the top of their game, SHM is looking for innovative ways to provide key educational content. Currently, the SHM annual meeting (www.hospitalmedicine2013.org) is the largest gathering of hospitalists, but even this huge meeting only attracts 25% of our members. Plans are under way to expand the reach of the annual meeting, allowing remote learning and participation through streaming and Web-based technology. For those 3,000 hospitalists who travel to the SHM annual meeting, SHM is looking to expand networking opportunities and create content for the bedside that is taught at the meeting, but that can be easily transported (e.g. via smartphone or tablet) with the attendee back to the bedside.

Certification, MOC, and Leadership

Hospitalists now and in the future will need to have tools that help them maintain their board certification and licensure. SHM has developed hospitalist-specific medical knowledge modules (MKMs) and self-assessment products, and has started to develop Performance Improvement Modules (PIMs) for hospitalists (www.hospitalmedicine.org/moc). SHM plans to partner with ACP, ABIM, and other organizations to allow our members access to additional important resources during the maintenance of certification (MOC) process. SHM’s commitment is to work with the boards to create the best interface and support for hospitalists during their lifelong learning and their certification efforts.

For those of you who already are HMG leaders, or are aspiring to become leaders, SHM has its nationally recognized Leadership Academies (www.hospitalmedicine.org/leadership), which have educated more than 2,000 hospitalist leaders. This year, we launch the Certification in Hospital Medicine Leadership program to provide recognition of those trained and committed to providing future leadership of the HMG and their hospitals. This unique certification will be an important credential for organizations and institutions recruiting new leaders, as well as for hospitalists looking for career advancement to become the leaders of the future.

Leadership in Performance Improvement

SHM continues to obtain funding from the government, foundations, and industry to provide tools and support to help hospitalists make real improvements at their hospitals. To date, SHM has been active in improving transitions of care in more than 500 hospitals with Project BOOST, preventing DVTs, and improving glycemic control (www.hospitalmedicine.org/thecenter). SHM now spends more than $3 million annually in these quality-improvement (QI) efforts, which are directed primarily at helping hospitalists improve their hospitals. Recently named the winner of the prestigious Eisenberg Award, given by the National Quality Forum and the Joint Commission, SHM expects that its QI efforts will expand to $5 million to $10 million annually in the coming years and provide opportunities for many of our members to be change agents. All of the changes on the horizon only increase the need for SHM to provide support to our hospitalists as they are called upon to lead and manage change.

SHM is no longer a small fringe medical society. With more than 11,000 members in all 50 states and Canada, SHM truly is a big tent. And the family keeps expanding as we now include internists, pediatricians, family physicians, medical students, residents, nurse practitioners, physician assistants, administrators, pharmacists, and nurses. In addition, HM now includes those practicing outside the hospital in extended-care facilities, long-term care and rehab facilities, LTACs, and other post-acute-care venues. And the ranks of hospitalists are increasing with the addition of hospitalists in such specialties as obstetrics, acute-care surgery, neurology, and orthopedics.

To continue to be the big tent for all hospitalists but still create a society with opportunities for networking and affinity groups, SHM has embarked on several strategies. SHM plans to create virtual communities (i.e. social networking) using Higher Logic. We plan to start with cohorts in Project BOOST and alumni from our Quality and Safety Educators Academy (QSEA) and our Leadership Academies, where contacts already have been made face to face over time. We see this as applicable for any subset of SHM that has the need and desire to create virtual communities and connections.

SHM also has created sections for our members trained in med-peds and international members from around the globe. In the future, SHM could expand to have 10 to 20 sections, including those for family physicians or pediatricians or nurse practitioners or administrators. We hope these organizations within an organization will give our members a platform to be in contact with other hospitalists just like themselves and create an opportunity for SHM to continually understand our members’ needs, and to design those projects and programs to meet those needs.

Just as our nation’s hospitalists are challenged to be innovative and creative as they play an active role in developing the hospital of the future, it is important for SHM to continue to evolve and develop new technologies and approaches to ensure our members have the support they need for the difficult tasks ahead.

Dr. Wellikson is CEO of SHM.

Larry Wellikson, MD, SFHM

In the June edition of The Hospitalist, I wrote about the “Future of Hospital Medicine.” I wanted to concentrate this column on how SHM is evolving to support this vision of the future.

I previously referenced the variability of maturity and competence of the thousands of HM groups (HMGs) spread across the nation. SHM is considering creating standards that are validated by the stakeholders in hospital medicine. We hope that each HMG might use these standards to assess its own stage of development. For those HMGs that are already performing at a high level, SHM might recognize this status with an award. For those not quite at the highest level of function, SHM hopes to work with other organizations in HM to create programs and projects to raise your level of function. Our goal is for this process to be aspirational and, hopefully, support HMGs by having a platform to request more resources and to develop additional capabilities so that more and more HMGs over time can reach the highest level of function.

Attracting the Future of Hospital Medicine

SHM also recognizes that as we strive to have hospitalists continue to be key partners in creating the hospital of the future, we need to attract the best medical students and residents into hospital medicine. With this in mind, SHM is developing a detailed plan to communicate with medical students and residents about the best aspects of a career in HM. While this strategy has a long lead time, we do expect that over the next five to 10 years, more and more students will select HM as their career—and give us a deeper bench strength to meet the needs of future HMGs.

In order to keep hospitalists at the top of their game, SHM is looking for innovative ways to provide key educational content. Currently, the SHM annual meeting (www.hospitalmedicine2013.org) is the largest gathering of hospitalists, but even this huge meeting only attracts 25% of our members. Plans are under way to expand the reach of the annual meeting, allowing remote learning and participation through streaming and Web-based technology. For those 3,000 hospitalists who travel to the SHM annual meeting, SHM is looking to expand networking opportunities and create content for the bedside that is taught at the meeting, but that can be easily transported (e.g. via smartphone or tablet) with the attendee back to the bedside.

Certification, MOC, and Leadership

Hospitalists now and in the future will need to have tools that help them maintain their board certification and licensure. SHM has developed hospitalist-specific medical knowledge modules (MKMs) and self-assessment products, and has started to develop Performance Improvement Modules (PIMs) for hospitalists (www.hospitalmedicine.org/moc). SHM plans to partner with ACP, ABIM, and other organizations to allow our members access to additional important resources during the maintenance of certification (MOC) process. SHM’s commitment is to work with the boards to create the best interface and support for hospitalists during their lifelong learning and their certification efforts.

For those of you who already are HMG leaders, or are aspiring to become leaders, SHM has its nationally recognized Leadership Academies (www.hospitalmedicine.org/leadership), which have educated more than 2,000 hospitalist leaders. This year, we launch the Certification in Hospital Medicine Leadership program to provide recognition of those trained and committed to providing future leadership of the HMG and their hospitals. This unique certification will be an important credential for organizations and institutions recruiting new leaders, as well as for hospitalists looking for career advancement to become the leaders of the future.

Leadership in Performance Improvement

SHM continues to obtain funding from the government, foundations, and industry to provide tools and support to help hospitalists make real improvements at their hospitals. To date, SHM has been active in improving transitions of care in more than 500 hospitals with Project BOOST, preventing DVTs, and improving glycemic control (www.hospitalmedicine.org/thecenter). SHM now spends more than $3 million annually in these quality-improvement (QI) efforts, which are directed primarily at helping hospitalists improve their hospitals. Recently named the winner of the prestigious Eisenberg Award, given by the National Quality Forum and the Joint Commission, SHM expects that its QI efforts will expand to $5 million to $10 million annually in the coming years and provide opportunities for many of our members to be change agents. All of the changes on the horizon only increase the need for SHM to provide support to our hospitalists as they are called upon to lead and manage change.

SHM is no longer a small fringe medical society. With more than 11,000 members in all 50 states and Canada, SHM truly is a big tent. And the family keeps expanding as we now include internists, pediatricians, family physicians, medical students, residents, nurse practitioners, physician assistants, administrators, pharmacists, and nurses. In addition, HM now includes those practicing outside the hospital in extended-care facilities, long-term care and rehab facilities, LTACs, and other post-acute-care venues. And the ranks of hospitalists are increasing with the addition of hospitalists in such specialties as obstetrics, acute-care surgery, neurology, and orthopedics.

To continue to be the big tent for all hospitalists but still create a society with opportunities for networking and affinity groups, SHM has embarked on several strategies. SHM plans to create virtual communities (i.e. social networking) using Higher Logic. We plan to start with cohorts in Project BOOST and alumni from our Quality and Safety Educators Academy (QSEA) and our Leadership Academies, where contacts already have been made face to face over time. We see this as applicable for any subset of SHM that has the need and desire to create virtual communities and connections.

SHM also has created sections for our members trained in med-peds and international members from around the globe. In the future, SHM could expand to have 10 to 20 sections, including those for family physicians or pediatricians or nurse practitioners or administrators. We hope these organizations within an organization will give our members a platform to be in contact with other hospitalists just like themselves and create an opportunity for SHM to continually understand our members’ needs, and to design those projects and programs to meet those needs.

Just as our nation’s hospitalists are challenged to be innovative and creative as they play an active role in developing the hospital of the future, it is important for SHM to continue to evolve and develop new technologies and approaches to ensure our members have the support they need for the difficult tasks ahead.

Dr. Wellikson is CEO of SHM.

Larry Wellikson, MD, SFHM

In the June edition of The Hospitalist, I wrote about the “Future of Hospital Medicine.” I wanted to concentrate this column on how SHM is evolving to support this vision of the future.

I previously referenced the variability of maturity and competence of the thousands of HM groups (HMGs) spread across the nation. SHM is considering creating standards that are validated by the stakeholders in hospital medicine. We hope that each HMG might use these standards to assess its own stage of development. For those HMGs that are already performing at a high level, SHM might recognize this status with an award. For those not quite at the highest level of function, SHM hopes to work with other organizations in HM to create programs and projects to raise your level of function. Our goal is for this process to be aspirational and, hopefully, support HMGs by having a platform to request more resources and to develop additional capabilities so that more and more HMGs over time can reach the highest level of function.

Attracting the Future of Hospital Medicine

SHM also recognizes that as we strive to have hospitalists continue to be key partners in creating the hospital of the future, we need to attract the best medical students and residents into hospital medicine. With this in mind, SHM is developing a detailed plan to communicate with medical students and residents about the best aspects of a career in HM. While this strategy has a long lead time, we do expect that over the next five to 10 years, more and more students will select HM as their career—and give us a deeper bench strength to meet the needs of future HMGs.

In order to keep hospitalists at the top of their game, SHM is looking for innovative ways to provide key educational content. Currently, the SHM annual meeting (www.hospitalmedicine2013.org) is the largest gathering of hospitalists, but even this huge meeting only attracts 25% of our members. Plans are under way to expand the reach of the annual meeting, allowing remote learning and participation through streaming and Web-based technology. For those 3,000 hospitalists who travel to the SHM annual meeting, SHM is looking to expand networking opportunities and create content for the bedside that is taught at the meeting, but that can be easily transported (e.g. via smartphone or tablet) with the attendee back to the bedside.

Certification, MOC, and Leadership

Hospitalists now and in the future will need to have tools that help them maintain their board certification and licensure. SHM has developed hospitalist-specific medical knowledge modules (MKMs) and self-assessment products, and has started to develop Performance Improvement Modules (PIMs) for hospitalists (www.hospitalmedicine.org/moc). SHM plans to partner with ACP, ABIM, and other organizations to allow our members access to additional important resources during the maintenance of certification (MOC) process. SHM’s commitment is to work with the boards to create the best interface and support for hospitalists during their lifelong learning and their certification efforts.

For those of you who already are HMG leaders, or are aspiring to become leaders, SHM has its nationally recognized Leadership Academies (www.hospitalmedicine.org/leadership), which have educated more than 2,000 hospitalist leaders. This year, we launch the Certification in Hospital Medicine Leadership program to provide recognition of those trained and committed to providing future leadership of the HMG and their hospitals. This unique certification will be an important credential for organizations and institutions recruiting new leaders, as well as for hospitalists looking for career advancement to become the leaders of the future.

Leadership in Performance Improvement

SHM continues to obtain funding from the government, foundations, and industry to provide tools and support to help hospitalists make real improvements at their hospitals. To date, SHM has been active in improving transitions of care in more than 500 hospitals with Project BOOST, preventing DVTs, and improving glycemic control (www.hospitalmedicine.org/thecenter). SHM now spends more than $3 million annually in these quality-improvement (QI) efforts, which are directed primarily at helping hospitalists improve their hospitals. Recently named the winner of the prestigious Eisenberg Award, given by the National Quality Forum and the Joint Commission, SHM expects that its QI efforts will expand to $5 million to $10 million annually in the coming years and provide opportunities for many of our members to be change agents. All of the changes on the horizon only increase the need for SHM to provide support to our hospitalists as they are called upon to lead and manage change.

SHM is no longer a small fringe medical society. With more than 11,000 members in all 50 states and Canada, SHM truly is a big tent. And the family keeps expanding as we now include internists, pediatricians, family physicians, medical students, residents, nurse practitioners, physician assistants, administrators, pharmacists, and nurses. In addition, HM now includes those practicing outside the hospital in extended-care facilities, long-term care and rehab facilities, LTACs, and other post-acute-care venues. And the ranks of hospitalists are increasing with the addition of hospitalists in such specialties as obstetrics, acute-care surgery, neurology, and orthopedics.

To continue to be the big tent for all hospitalists but still create a society with opportunities for networking and affinity groups, SHM has embarked on several strategies. SHM plans to create virtual communities (i.e. social networking) using Higher Logic. We plan to start with cohorts in Project BOOST and alumni from our Quality and Safety Educators Academy (QSEA) and our Leadership Academies, where contacts already have been made face to face over time. We see this as applicable for any subset of SHM that has the need and desire to create virtual communities and connections.

SHM also has created sections for our members trained in med-peds and international members from around the globe. In the future, SHM could expand to have 10 to 20 sections, including those for family physicians or pediatricians or nurse practitioners or administrators. We hope these organizations within an organization will give our members a platform to be in contact with other hospitalists just like themselves and create an opportunity for SHM to continually understand our members’ needs, and to design those projects and programs to meet those needs.

Just as our nation’s hospitalists are challenged to be innovative and creative as they play an active role in developing the hospital of the future, it is important for SHM to continue to evolve and develop new technologies and approaches to ensure our members have the support they need for the difficult tasks ahead.

Dr. Wellikson is CEO of SHM.

Danielle Scheurer, MD, MSCR, SFHM

As we all know, the HM revolution has evolved at a breakneck pace. While our specialty’s growth has outpaced that of any other in the history of modern medicine, hospitalists have a narrow bell curve of age, with a relatively rare “old” hospitalist. Having been a specialty for less than 20 years, HM’s working hospitalists primarily encompass a single generation. However, we are on the brink of brining a new generations of hospitalists into the workforce: Generation Y.

Social scientists and peer-reviewed publications have spent countless hours and pages speculating and defining generational spans. The typicality of each generation is both completely fascinating and grotesquely overgeneralized.

Baby boomers (born 1946-1961) are characterized by expansive individual freedoms; they are associated with civil rights, gay rights, and the feminist movement. They are notoriously hard-working, disciplined, independent, and relied little on their parents.

Generation X (born 1962-1981) is characterized as being media-savvy and highly educated, but more materialistic and less hard-working than baby boomers. Most hospitalists fall into Generation X, currently ages 31 to 50.

And now enter Generation Y, born beginning in 1982. This generation has more nicknames than Snoop Dogg. They also are known as Millennials, Generation Next, the Net Generation (referring to a reliance and comfort with the Internet), the Trophy Generation (referring to their need for rewards based solely on participation), the Boomerang/Peter Pan Generation (referring to their delay of typical adult transitions and a longer reliance on their parents), and “echo boomers” (as children of the baby boomers).

David McCullough brilliantly summarized Generation Y in a recent commencement speech. If his name does not sound familiar, it is likely because you have never lived in Wellesley, Mass. Known as “Swellesley” to local residents, it is a charming town about 15 miles west of Boston. Wellesley has a “Lake Wobegon” mentality, where “all the children are above average.” McCullough, a Wellesley High School English teacher, delivered the high school’s commencement speech this year to a packed room of high achievers. His message?

“Contrary to what your under-9 soccer trophy suggests, your glowing seventh-grade report card, despite every assurance of a certain corpulent purple dinosaur, that nice Mister Rogers, and your batty Aunt Sylvia, no matter how often your maternal caped crusader has swooped in to save you … you’re nothing special.

“Yes, you’ve been pampered, cosseted, doted upon, helmeted, bubble-wrapped. Yes, capable adults with other things to do have held you, kissed you, fed you, wiped your mouth, wiped your bottom, trained you, taught you, tutored you, coached you, listened to you, counseled you, encouraged you, consoled you, and encouraged you again. You’ve been nudged, cajoled, wheedled, and implored. You’ve been feted and fawned over, and called sweetie pie. Yes, you have. And, certainly, we’ve been to your games, your plays, your recitals, your science fairs. Absolutely, smiles ignite when you walk into a room, and hundreds gasp with delight at your every tweet. Why, maybe you’ve even had your picture in the [local newspaper]. And now you’ve conquered high school … and, indisputably, here we all have gathered for you, the pride and joy of this fine community, the first to emerge from that magnificent new building …

“But do not get the idea you’re anything special. Because you’re not.”¹

I imagine this blasphemy caused something on the order of an existential crisis in Wellesley, but it does capture the essence of what it has been like to grow up as a Generation Y’er.

Two longitudinal surveys also give a glimpse into the generational psyche separating baby boomers, Generation X, and Generation Y: the “Monitoring the Future” survey and the “American Freshman” survey, both conducted annually by the University of Michigan and UCLA, respectively. A few notable trends from these surveys comparing the last three generations include:²

• The proportion who responded that being wealthy is very important ranged from 45% of baby boomers to 70% of Generation X and 75% of Generation Y;
• Fifty percent of baby boomers, 39% of Generation X, and 35% of Generation Y said it is important to keep up to date with political affairs; and
• Seventy-three percent of baby boomers and 45% of Generation Y responded that it was important to develop a meaningful philosophy of life.

While these characteristics might not sound particularly appealing, social scientists have found highly laudable adjectives that accurately describe the psyche of Generation Y, which include confidence, tolerance, and affability. One writer describes them as “polite, pleasant, moderate, earnest, friendly … no anger, no edge, no ego.”³

So, as with every generation, Generation Y comes with its share of traits that are irresistible and those that are maddening. Eighty million strong, accounting for about one-quarter of all Americans, how can future HM groups adapt to the flood coming down the pipeline?

We can learn from other industries, as Generation Y has been in the workforce elsewhere for years. Companies like Goldman Sachs and IBM figured out how to keep them engaged in their workplaces in a meaningful way, knowing they have high expectations for workplace mentorship/coaching, salary, and advancement, and seek more feedback and decision-making involvement.

Recommendations

I offer a few tangible recommendations; many of these will be beneficial for any hospitalist group:

• Ensure a robust and ongoing mentoring program. Generation Y’ers are more likely to need and thrive from a functional mentor program, where they can seek and receive advice and guidance in regular intervals.
• Ensure that financial compensation, incentive programs, and pathways for advancement are clearly defined. As mentioned above, many Generation Y’ers consider wealth important, so avenues for advancement should be well defined for those willing to pursue it.
• Create non-financial reward systems, such as “Hospitalist of the Month” recognitions based on clinical or other criteria (teamwork, attitude, fortitude). This generation, more than most, has an expectation for recognition and rewards. These non-financial rewards can be easily, appropriately, and fairly built in.
• Utilize information technology to its fullest capacity, and engage them in creating ways of using technology to its advantage, including blogs, Twitter, etc. More than past generations, they are comfortable with and have an aptitude for information technology, and that should be harnessed at the point of care.
• Ensure hospitalists have a firm understanding of the appropriate use of social media at work, and outside it. They are as comfortable with social media as past generations have been with email, and helping define clear boundaries will be of benefit to everyone in the group.

And when you spend a few years getting all your Generation Y’ers settled in, along will come Generation Z.

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

References

1. Brown B. Wellesley High grads told: “You’re not special.” The Swellesley Report website. Available at: http://www.theswellesleyreport.com/2012/06/wellesley-high-grads-told-youre-not-special/. Accessed July 8, 2012.
2. Healy M. Millennials might not be so special after all, study finds. USA Today website. Available at: http://www.usatoday.com/news/health/wellness/story/2012-03-15/Millennials-might-not-be-so-special-after-all-study-finds/53552744/1. Accessed July 9, 2012.
3. Deresiewicz W. Generation Sell. The New York Times website. Available at: http://www.nytimes.com/2011/11/13/opinion/sunday/the-entrepreneurial-generation.html?pagewanted=1&_r=1. Accessed July 8, 2012.

Danielle Scheurer, MD, MSCR, SFHM

As we all know, the HM revolution has evolved at a breakneck pace. While our specialty’s growth has outpaced that of any other in the history of modern medicine, hospitalists have a narrow bell curve of age, with a relatively rare “old” hospitalist. Having been a specialty for less than 20 years, HM’s working hospitalists primarily encompass a single generation. However, we are on the brink of brining a new generations of hospitalists into the workforce: Generation Y.

Social scientists and peer-reviewed publications have spent countless hours and pages speculating and defining generational spans. The typicality of each generation is both completely fascinating and grotesquely overgeneralized.

Baby boomers (born 1946-1961) are characterized by expansive individual freedoms; they are associated with civil rights, gay rights, and the feminist movement. They are notoriously hard-working, disciplined, independent, and relied little on their parents.

Generation X (born 1962-1981) is characterized as being media-savvy and highly educated, but more materialistic and less hard-working than baby boomers. Most hospitalists fall into Generation X, currently ages 31 to 50.

And now enter Generation Y, born beginning in 1982. This generation has more nicknames than Snoop Dogg. They also are known as Millennials, Generation Next, the Net Generation (referring to a reliance and comfort with the Internet), the Trophy Generation (referring to their need for rewards based solely on participation), the Boomerang/Peter Pan Generation (referring to their delay of typical adult transitions and a longer reliance on their parents), and “echo boomers” (as children of the baby boomers).

David McCullough brilliantly summarized Generation Y in a recent commencement speech. If his name does not sound familiar, it is likely because you have never lived in Wellesley, Mass. Known as “Swellesley” to local residents, it is a charming town about 15 miles west of Boston. Wellesley has a “Lake Wobegon” mentality, where “all the children are above average.” McCullough, a Wellesley High School English teacher, delivered the high school’s commencement speech this year to a packed room of high achievers. His message?

“Contrary to what your under-9 soccer trophy suggests, your glowing seventh-grade report card, despite every assurance of a certain corpulent purple dinosaur, that nice Mister Rogers, and your batty Aunt Sylvia, no matter how often your maternal caped crusader has swooped in to save you … you’re nothing special.

“Yes, you’ve been pampered, cosseted, doted upon, helmeted, bubble-wrapped. Yes, capable adults with other things to do have held you, kissed you, fed you, wiped your mouth, wiped your bottom, trained you, taught you, tutored you, coached you, listened to you, counseled you, encouraged you, consoled you, and encouraged you again. You’ve been nudged, cajoled, wheedled, and implored. You’ve been feted and fawned over, and called sweetie pie. Yes, you have. And, certainly, we’ve been to your games, your plays, your recitals, your science fairs. Absolutely, smiles ignite when you walk into a room, and hundreds gasp with delight at your every tweet. Why, maybe you’ve even had your picture in the [local newspaper]. And now you’ve conquered high school … and, indisputably, here we all have gathered for you, the pride and joy of this fine community, the first to emerge from that magnificent new building …

“But do not get the idea you’re anything special. Because you’re not.”¹

I imagine this blasphemy caused something on the order of an existential crisis in Wellesley, but it does capture the essence of what it has been like to grow up as a Generation Y’er.

Two longitudinal surveys also give a glimpse into the generational psyche separating baby boomers, Generation X, and Generation Y: the “Monitoring the Future” survey and the “American Freshman” survey, both conducted annually by the University of Michigan and UCLA, respectively. A few notable trends from these surveys comparing the last three generations include:²

• The proportion who responded that being wealthy is very important ranged from 45% of baby boomers to 70% of Generation X and 75% of Generation Y;
• Fifty percent of baby boomers, 39% of Generation X, and 35% of Generation Y said it is important to keep up to date with political affairs; and
• Seventy-three percent of baby boomers and 45% of Generation Y responded that it was important to develop a meaningful philosophy of life.

While these characteristics might not sound particularly appealing, social scientists have found highly laudable adjectives that accurately describe the psyche of Generation Y, which include confidence, tolerance, and affability. One writer describes them as “polite, pleasant, moderate, earnest, friendly … no anger, no edge, no ego.”³

So, as with every generation, Generation Y comes with its share of traits that are irresistible and those that are maddening. Eighty million strong, accounting for about one-quarter of all Americans, how can future HM groups adapt to the flood coming down the pipeline?

We can learn from other industries, as Generation Y has been in the workforce elsewhere for years. Companies like Goldman Sachs and IBM figured out how to keep them engaged in their workplaces in a meaningful way, knowing they have high expectations for workplace mentorship/coaching, salary, and advancement, and seek more feedback and decision-making involvement.

Recommendations

I offer a few tangible recommendations; many of these will be beneficial for any hospitalist group:

• Ensure a robust and ongoing mentoring program. Generation Y’ers are more likely to need and thrive from a functional mentor program, where they can seek and receive advice and guidance in regular intervals.
• Ensure that financial compensation, incentive programs, and pathways for advancement are clearly defined. As mentioned above, many Generation Y’ers consider wealth important, so avenues for advancement should be well defined for those willing to pursue it.
• Create non-financial reward systems, such as “Hospitalist of the Month” recognitions based on clinical or other criteria (teamwork, attitude, fortitude). This generation, more than most, has an expectation for recognition and rewards. These non-financial rewards can be easily, appropriately, and fairly built in.
• Utilize information technology to its fullest capacity, and engage them in creating ways of using technology to its advantage, including blogs, Twitter, etc. More than past generations, they are comfortable with and have an aptitude for information technology, and that should be harnessed at the point of care.
• Ensure hospitalists have a firm understanding of the appropriate use of social media at work, and outside it. They are as comfortable with social media as past generations have been with email, and helping define clear boundaries will be of benefit to everyone in the group.

And when you spend a few years getting all your Generation Y’ers settled in, along will come Generation Z.

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

References

1. Brown B. Wellesley High grads told: “You’re not special.” The Swellesley Report website. Available at: http://www.theswellesleyreport.com/2012/06/wellesley-high-grads-told-youre-not-special/. Accessed July 8, 2012.
2. Healy M. Millennials might not be so special after all, study finds. USA Today website. Available at: http://www.usatoday.com/news/health/wellness/story/2012-03-15/Millennials-might-not-be-so-special-after-all-study-finds/53552744/1. Accessed July 9, 2012.
3. Deresiewicz W. Generation Sell. The New York Times website. Available at: http://www.nytimes.com/2011/11/13/opinion/sunday/the-entrepreneurial-generation.html?pagewanted=1&_r=1. Accessed July 8, 2012.

Danielle Scheurer, MD, MSCR, SFHM

As we all know, the HM revolution has evolved at a breakneck pace. While our specialty’s growth has outpaced that of any other in the history of modern medicine, hospitalists have a narrow bell curve of age, with a relatively rare “old” hospitalist. Having been a specialty for less than 20 years, HM’s working hospitalists primarily encompass a single generation. However, we are on the brink of brining a new generations of hospitalists into the workforce: Generation Y.

Social scientists and peer-reviewed publications have spent countless hours and pages speculating and defining generational spans. The typicality of each generation is both completely fascinating and grotesquely overgeneralized.

Baby boomers (born 1946-1961) are characterized by expansive individual freedoms; they are associated with civil rights, gay rights, and the feminist movement. They are notoriously hard-working, disciplined, independent, and relied little on their parents.

Generation X (born 1962-1981) is characterized as being media-savvy and highly educated, but more materialistic and less hard-working than baby boomers. Most hospitalists fall into Generation X, currently ages 31 to 50.

And now enter Generation Y, born beginning in 1982. This generation has more nicknames than Snoop Dogg. They also are known as Millennials, Generation Next, the Net Generation (referring to a reliance and comfort with the Internet), the Trophy Generation (referring to their need for rewards based solely on participation), the Boomerang/Peter Pan Generation (referring to their delay of typical adult transitions and a longer reliance on their parents), and “echo boomers” (as children of the baby boomers).

David McCullough brilliantly summarized Generation Y in a recent commencement speech. If his name does not sound familiar, it is likely because you have never lived in Wellesley, Mass. Known as “Swellesley” to local residents, it is a charming town about 15 miles west of Boston. Wellesley has a “Lake Wobegon” mentality, where “all the children are above average.” McCullough, a Wellesley High School English teacher, delivered the high school’s commencement speech this year to a packed room of high achievers. His message?

“Contrary to what your under-9 soccer trophy suggests, your glowing seventh-grade report card, despite every assurance of a certain corpulent purple dinosaur, that nice Mister Rogers, and your batty Aunt Sylvia, no matter how often your maternal caped crusader has swooped in to save you … you’re nothing special.

“Yes, you’ve been pampered, cosseted, doted upon, helmeted, bubble-wrapped. Yes, capable adults with other things to do have held you, kissed you, fed you, wiped your mouth, wiped your bottom, trained you, taught you, tutored you, coached you, listened to you, counseled you, encouraged you, consoled you, and encouraged you again. You’ve been nudged, cajoled, wheedled, and implored. You’ve been feted and fawned over, and called sweetie pie. Yes, you have. And, certainly, we’ve been to your games, your plays, your recitals, your science fairs. Absolutely, smiles ignite when you walk into a room, and hundreds gasp with delight at your every tweet. Why, maybe you’ve even had your picture in the [local newspaper]. And now you’ve conquered high school … and, indisputably, here we all have gathered for you, the pride and joy of this fine community, the first to emerge from that magnificent new building …

“But do not get the idea you’re anything special. Because you’re not.”¹

I imagine this blasphemy caused something on the order of an existential crisis in Wellesley, but it does capture the essence of what it has been like to grow up as a Generation Y’er.

Two longitudinal surveys also give a glimpse into the generational psyche separating baby boomers, Generation X, and Generation Y: the “Monitoring the Future” survey and the “American Freshman” survey, both conducted annually by the University of Michigan and UCLA, respectively. A few notable trends from these surveys comparing the last three generations include:²

• The proportion who responded that being wealthy is very important ranged from 45% of baby boomers to 70% of Generation X and 75% of Generation Y;
• Fifty percent of baby boomers, 39% of Generation X, and 35% of Generation Y said it is important to keep up to date with political affairs; and
• Seventy-three percent of baby boomers and 45% of Generation Y responded that it was important to develop a meaningful philosophy of life.

While these characteristics might not sound particularly appealing, social scientists have found highly laudable adjectives that accurately describe the psyche of Generation Y, which include confidence, tolerance, and affability. One writer describes them as “polite, pleasant, moderate, earnest, friendly … no anger, no edge, no ego.”³

So, as with every generation, Generation Y comes with its share of traits that are irresistible and those that are maddening. Eighty million strong, accounting for about one-quarter of all Americans, how can future HM groups adapt to the flood coming down the pipeline?

We can learn from other industries, as Generation Y has been in the workforce elsewhere for years. Companies like Goldman Sachs and IBM figured out how to keep them engaged in their workplaces in a meaningful way, knowing they have high expectations for workplace mentorship/coaching, salary, and advancement, and seek more feedback and decision-making involvement.

Recommendations

I offer a few tangible recommendations; many of these will be beneficial for any hospitalist group:

• Ensure a robust and ongoing mentoring program. Generation Y’ers are more likely to need and thrive from a functional mentor program, where they can seek and receive advice and guidance in regular intervals.
• Ensure that financial compensation, incentive programs, and pathways for advancement are clearly defined. As mentioned above, many Generation Y’ers consider wealth important, so avenues for advancement should be well defined for those willing to pursue it.
• Create non-financial reward systems, such as “Hospitalist of the Month” recognitions based on clinical or other criteria (teamwork, attitude, fortitude). This generation, more than most, has an expectation for recognition and rewards. These non-financial rewards can be easily, appropriately, and fairly built in.
• Utilize information technology to its fullest capacity, and engage them in creating ways of using technology to its advantage, including blogs, Twitter, etc. More than past generations, they are comfortable with and have an aptitude for information technology, and that should be harnessed at the point of care.
• Ensure hospitalists have a firm understanding of the appropriate use of social media at work, and outside it. They are as comfortable with social media as past generations have been with email, and helping define clear boundaries will be of benefit to everyone in the group.

And when you spend a few years getting all your Generation Y’ers settled in, along will come Generation Z.

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

References

1. Brown B. Wellesley High grads told: “You’re not special.” The Swellesley Report website. Available at: http://www.theswellesleyreport.com/2012/06/wellesley-high-grads-told-youre-not-special/. Accessed July 8, 2012.
2. Healy M. Millennials might not be so special after all, study finds. USA Today website. Available at: http://www.usatoday.com/news/health/wellness/story/2012-03-15/Millennials-might-not-be-so-special-after-all-study-finds/53552744/1. Accessed July 9, 2012.
3. Deresiewicz W. Generation Sell. The New York Times website. Available at: http://www.nytimes.com/2011/11/13/opinion/sunday/the-entrepreneurial-generation.html?pagewanted=1&_r=1. Accessed July 8, 2012.

John Nelson, MD, MHM

Editor’s note: Second in a two-part series.

I used last month’s column to frame the issue of disagreement between doctors over who should admit a particular patient, as well as discuss the value of good social connections to reduce the chance that divergent opinions lead to outright conflict. This month, I’ll review another worthwhile strategy—one that could be a definitive solution to these disagreements but often falls short of that goal in practice.

Service Agreements, or “Compacts,” between Physician Groups

If, at your hospital, there are reasonably frequent cases of divergent opinions regarding whether an ED admission or transfer from elsewhere should be admitted by a hospitalist or doctor in another specialty, why not meet in advance to decide this? Many hospitalist groups have held meetings with doctors in other specialties and now have a collection of agreements outlining scenarios, such as:

• ESRD patients: Hospitalist admits for non-dialysis issues (pneumonia, diabetic issues, etc.); nephrologist admits for urgent dialysis issues (K+>6.3, pH<7.3, etc.).
• Cardiology: Hospitalist admits CHF and non-ST elevation chest pain; cardiologist admits STEMI.
• General surgery: Hospitalist admits ileus, pseudo obstruction, and SBO due to adhesions; general surgery admits bowel obstruction in “virgin abdomen,” volvulus, and any obstruction thought to require urgent surgery.

To be clear, I’m not suggesting the above guidelines are evidence-based or are the right ones for your institution. I just made these up, so yours might differ significantly. I just want to provide a sense of the kinds of issues these agreements typically cover. The comanagement section of the SHM website has several documents regarding hospitalist-orthopedic service agreements.

The Negotiation Process

It’s tempting for the lead hospitalist to just have a hallway chat with a spokesperson from the other specialty, then email a draft agreement, exchange a few messages until both parties are satisfied, then email a copy of the final document to all the doctors in both groups. This might work for some simple service agreements, but for any area with significant ambiguity or disagreements (or potential for disagreements), one or more in-person meetings are usually necessary. Ideally, several doctors in both groups will attend these meetings.

Much work could be done in advance of the first meeting, including surveying other practices to see how they decide which group admits the same kinds of patents, gathering any relevant published research, and possibly drafting a “straw man” proposed agreement. When meeting in person, the doctors will have a chance to explain their points of view, needs, and concerns, and gain a greater appreciation of the way “the other guy” sees things. An important purpose of the in-person meeting is to “look the other guy in the eye” to know if he or she really is committed to following through.

Remember that written agreements like these might become an issue in malpractice suits, so you might want to have them reviewed first by risk managers. You might also write them as guidelines rather than rigid protocols that don’t allow variations.

Maximize Effectiveness

Ideally, every doctor involved in the agreement should document their approval with a signature and date. My experience is that this doesn’t happen at most places, but if there is concern about whether everyone will comply, signing the document will probably help at least a little.

The completed agreements should be provided to all doctors in both groups, the ED, affected hospital nursing units, and others. Any new doctor should get a copy of all such agreements that might be relevant. And, most important, it should be made available electronically so that it is easy to find at any time. Some agreements cover uncommon events, and the doctors on duty might not remember what the agreement said and will need ready access to it.

Most service agreements should be reviewed and updated every two or three years or as needed. If there is confusion or controversy around a particular agreement, or if disagreements about which doctor does the admission are common despite the agreement, then an in-person meeting between the physician groups should be scheduled to revise or update it.

Keep Your Fingers Crossed

If it sounds like a lot of work to develop and maintain these agreements, it is. But they’re worth every bit of that work if they reduce confusion or discord. Sadly, for several reasons, they rarely prove so effective.

One doctor might think the agreement applies, but the other doctor says this patient is an exception and the agreement doesn’t apply. It is impossible to write an agreement that addresses all possible scenarios, so a doctor can argue that any particular patient falls outside the agreement because of things like comorbidities, which service admitted the patient last time (many agreements will have defined “bounce back” intervals), which primary-care physician (PCP) the patient sees, etc.

Even if there is no dispute about whether the agreement covers a particular patient, many doctors simply don’t feel obligated to uphold the agreement. Such a doctor might tell the ED doctor: “Yep, I signed the agreement, but only as a way to get the meeting over with. I was never in favor of it and just can’t admit the patient. Call the other guy to admit.” So in spite of all the work done to create a reasonable agreement, some doctors might feel entitled to ignore it when it suits them.

Compliance Is Critical

Sadly, my take is that despite the tremendous hoped-for benefits that service agreements might provide, poor compliance means they rarely achieve their potential. Even so, they are usually worth the time and effort to create them if it leads doctors in the two specialties to schedule time away from patient care to listen to the other group’s point of view and discuss how best to handle particular types of patients. In some cases, it will be the first time the two groups of doctors have set aside time to talk about the work they do together; that alone can have significant value.

Tom Lorence, MD, a Kaiser hospitalist in Portland, Ore., who is chief of hospital medicine for Northwest Permanente, developed more than 20 service agreements with many different specialties at his institution. He has found that they are worth the effort, and that they helped allay hospitalists’ feeling of being “dumped on.”

He also told me a rule that probably applies to all such agreements in any setting: The tie goes to the hospitalist—that is, when there is reasonable uncertainty or disagreement about which group should admit a patient, it is nearly always the hospitalist who will do so.

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.

John Nelson, MD, MHM

Editor’s note: Second in a two-part series.

I used last month’s column to frame the issue of disagreement between doctors over who should admit a particular patient, as well as discuss the value of good social connections to reduce the chance that divergent opinions lead to outright conflict. This month, I’ll review another worthwhile strategy—one that could be a definitive solution to these disagreements but often falls short of that goal in practice.

Service Agreements, or “Compacts,” between Physician Groups

If, at your hospital, there are reasonably frequent cases of divergent opinions regarding whether an ED admission or transfer from elsewhere should be admitted by a hospitalist or doctor in another specialty, why not meet in advance to decide this? Many hospitalist groups have held meetings with doctors in other specialties and now have a collection of agreements outlining scenarios, such as:

• ESRD patients: Hospitalist admits for non-dialysis issues (pneumonia, diabetic issues, etc.); nephrologist admits for urgent dialysis issues (K+>6.3, pH<7.3, etc.).
• Cardiology: Hospitalist admits CHF and non-ST elevation chest pain; cardiologist admits STEMI.
• General surgery: Hospitalist admits ileus, pseudo obstruction, and SBO due to adhesions; general surgery admits bowel obstruction in “virgin abdomen,” volvulus, and any obstruction thought to require urgent surgery.

To be clear, I’m not suggesting the above guidelines are evidence-based or are the right ones for your institution. I just made these up, so yours might differ significantly. I just want to provide a sense of the kinds of issues these agreements typically cover. The comanagement section of the SHM website has several documents regarding hospitalist-orthopedic service agreements.

The Negotiation Process

It’s tempting for the lead hospitalist to just have a hallway chat with a spokesperson from the other specialty, then email a draft agreement, exchange a few messages until both parties are satisfied, then email a copy of the final document to all the doctors in both groups. This might work for some simple service agreements, but for any area with significant ambiguity or disagreements (or potential for disagreements), one or more in-person meetings are usually necessary. Ideally, several doctors in both groups will attend these meetings.

Much work could be done in advance of the first meeting, including surveying other practices to see how they decide which group admits the same kinds of patents, gathering any relevant published research, and possibly drafting a “straw man” proposed agreement. When meeting in person, the doctors will have a chance to explain their points of view, needs, and concerns, and gain a greater appreciation of the way “the other guy” sees things. An important purpose of the in-person meeting is to “look the other guy in the eye” to know if he or she really is committed to following through.

Remember that written agreements like these might become an issue in malpractice suits, so you might want to have them reviewed first by risk managers. You might also write them as guidelines rather than rigid protocols that don’t allow variations.

Maximize Effectiveness

Ideally, every doctor involved in the agreement should document their approval with a signature and date. My experience is that this doesn’t happen at most places, but if there is concern about whether everyone will comply, signing the document will probably help at least a little.

The completed agreements should be provided to all doctors in both groups, the ED, affected hospital nursing units, and others. Any new doctor should get a copy of all such agreements that might be relevant. And, most important, it should be made available electronically so that it is easy to find at any time. Some agreements cover uncommon events, and the doctors on duty might not remember what the agreement said and will need ready access to it.

Most service agreements should be reviewed and updated every two or three years or as needed. If there is confusion or controversy around a particular agreement, or if disagreements about which doctor does the admission are common despite the agreement, then an in-person meeting between the physician groups should be scheduled to revise or update it.

Keep Your Fingers Crossed

If it sounds like a lot of work to develop and maintain these agreements, it is. But they’re worth every bit of that work if they reduce confusion or discord. Sadly, for several reasons, they rarely prove so effective.

One doctor might think the agreement applies, but the other doctor says this patient is an exception and the agreement doesn’t apply. It is impossible to write an agreement that addresses all possible scenarios, so a doctor can argue that any particular patient falls outside the agreement because of things like comorbidities, which service admitted the patient last time (many agreements will have defined “bounce back” intervals), which primary-care physician (PCP) the patient sees, etc.

Even if there is no dispute about whether the agreement covers a particular patient, many doctors simply don’t feel obligated to uphold the agreement. Such a doctor might tell the ED doctor: “Yep, I signed the agreement, but only as a way to get the meeting over with. I was never in favor of it and just can’t admit the patient. Call the other guy to admit.” So in spite of all the work done to create a reasonable agreement, some doctors might feel entitled to ignore it when it suits them.

Compliance Is Critical

Sadly, my take is that despite the tremendous hoped-for benefits that service agreements might provide, poor compliance means they rarely achieve their potential. Even so, they are usually worth the time and effort to create them if it leads doctors in the two specialties to schedule time away from patient care to listen to the other group’s point of view and discuss how best to handle particular types of patients. In some cases, it will be the first time the two groups of doctors have set aside time to talk about the work they do together; that alone can have significant value.

Tom Lorence, MD, a Kaiser hospitalist in Portland, Ore., who is chief of hospital medicine for Northwest Permanente, developed more than 20 service agreements with many different specialties at his institution. He has found that they are worth the effort, and that they helped allay hospitalists’ feeling of being “dumped on.”

He also told me a rule that probably applies to all such agreements in any setting: The tie goes to the hospitalist—that is, when there is reasonable uncertainty or disagreement about which group should admit a patient, it is nearly always the hospitalist who will do so.

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.

John Nelson, MD, MHM

Editor’s note: Second in a two-part series.

I used last month’s column to frame the issue of disagreement between doctors over who should admit a particular patient, as well as discuss the value of good social connections to reduce the chance that divergent opinions lead to outright conflict. This month, I’ll review another worthwhile strategy—one that could be a definitive solution to these disagreements but often falls short of that goal in practice.

Service Agreements, or “Compacts,” between Physician Groups

If, at your hospital, there are reasonably frequent cases of divergent opinions regarding whether an ED admission or transfer from elsewhere should be admitted by a hospitalist or doctor in another specialty, why not meet in advance to decide this? Many hospitalist groups have held meetings with doctors in other specialties and now have a collection of agreements outlining scenarios, such as:

• ESRD patients: Hospitalist admits for non-dialysis issues (pneumonia, diabetic issues, etc.); nephrologist admits for urgent dialysis issues (K+>6.3, pH<7.3, etc.).
• Cardiology: Hospitalist admits CHF and non-ST elevation chest pain; cardiologist admits STEMI.
• General surgery: Hospitalist admits ileus, pseudo obstruction, and SBO due to adhesions; general surgery admits bowel obstruction in “virgin abdomen,” volvulus, and any obstruction thought to require urgent surgery.

To be clear, I’m not suggesting the above guidelines are evidence-based or are the right ones for your institution. I just made these up, so yours might differ significantly. I just want to provide a sense of the kinds of issues these agreements typically cover. The comanagement section of the SHM website has several documents regarding hospitalist-orthopedic service agreements.

The Negotiation Process

It’s tempting for the lead hospitalist to just have a hallway chat with a spokesperson from the other specialty, then email a draft agreement, exchange a few messages until both parties are satisfied, then email a copy of the final document to all the doctors in both groups. This might work for some simple service agreements, but for any area with significant ambiguity or disagreements (or potential for disagreements), one or more in-person meetings are usually necessary. Ideally, several doctors in both groups will attend these meetings.

Much work could be done in advance of the first meeting, including surveying other practices to see how they decide which group admits the same kinds of patents, gathering any relevant published research, and possibly drafting a “straw man” proposed agreement. When meeting in person, the doctors will have a chance to explain their points of view, needs, and concerns, and gain a greater appreciation of the way “the other guy” sees things. An important purpose of the in-person meeting is to “look the other guy in the eye” to know if he or she really is committed to following through.

Remember that written agreements like these might become an issue in malpractice suits, so you might want to have them reviewed first by risk managers. You might also write them as guidelines rather than rigid protocols that don’t allow variations.

Maximize Effectiveness

Ideally, every doctor involved in the agreement should document their approval with a signature and date. My experience is that this doesn’t happen at most places, but if there is concern about whether everyone will comply, signing the document will probably help at least a little.

The completed agreements should be provided to all doctors in both groups, the ED, affected hospital nursing units, and others. Any new doctor should get a copy of all such agreements that might be relevant. And, most important, it should be made available electronically so that it is easy to find at any time. Some agreements cover uncommon events, and the doctors on duty might not remember what the agreement said and will need ready access to it.

Most service agreements should be reviewed and updated every two or three years or as needed. If there is confusion or controversy around a particular agreement, or if disagreements about which doctor does the admission are common despite the agreement, then an in-person meeting between the physician groups should be scheduled to revise or update it.

Keep Your Fingers Crossed

If it sounds like a lot of work to develop and maintain these agreements, it is. But they’re worth every bit of that work if they reduce confusion or discord. Sadly, for several reasons, they rarely prove so effective.

One doctor might think the agreement applies, but the other doctor says this patient is an exception and the agreement doesn’t apply. It is impossible to write an agreement that addresses all possible scenarios, so a doctor can argue that any particular patient falls outside the agreement because of things like comorbidities, which service admitted the patient last time (many agreements will have defined “bounce back” intervals), which primary-care physician (PCP) the patient sees, etc.

Even if there is no dispute about whether the agreement covers a particular patient, many doctors simply don’t feel obligated to uphold the agreement. Such a doctor might tell the ED doctor: “Yep, I signed the agreement, but only as a way to get the meeting over with. I was never in favor of it and just can’t admit the patient. Call the other guy to admit.” So in spite of all the work done to create a reasonable agreement, some doctors might feel entitled to ignore it when it suits them.

Compliance Is Critical

Sadly, my take is that despite the tremendous hoped-for benefits that service agreements might provide, poor compliance means they rarely achieve their potential. Even so, they are usually worth the time and effort to create them if it leads doctors in the two specialties to schedule time away from patient care to listen to the other group’s point of view and discuss how best to handle particular types of patients. In some cases, it will be the first time the two groups of doctors have set aside time to talk about the work they do together; that alone can have significant value.

Tom Lorence, MD, a Kaiser hospitalist in Portland, Ore., who is chief of hospital medicine for Northwest Permanente, developed more than 20 service agreements with many different specialties at his institution. He has found that they are worth the effort, and that they helped allay hospitalists’ feeling of being “dumped on.”

He also told me a rule that probably applies to all such agreements in any setting: The tie goes to the hospitalist—that is, when there is reasonable uncertainty or disagreement about which group should admit a patient, it is nearly always the hospitalist who will do so.

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.

Dr. Hospitalist

I would like to know where payment for the service of hospitalists fits into the insurance/Medicare payment system. Are hospitalists considered employees of the hospital and, therefore, billed through the hospital system? Are they considered independent doctors and, therefore, do their own direct billing? Do they, in general, accept assignment of benefits from you for your insurance/Medicare? Do they sign contracts with insurance/Medicare to participate in their plans?

Carole L. Hughes

Dr. Hospitalist responds:

For the sake of argument, let’s say that Carole is on the outside looking in—meaning she’s not a healthcare practitioner, but a consumer. It might seem a bit strange to wonder where all these “hospitalists” come from, and who pays for them. Let’s walk through a few scenarios as outlined here.

Are hospitalists considered employees of the hospital? They certainly could be directly employed by the hospital, but it’s just as likely they could be contracted with the hospital for certain services, such as taking ED call for unassigned patients. It’s also entirely possible that the hospitalist has no direct financial relationship with the hospital at all. In this case, a hospitalist is taking cases that are referred from other physicians and for which there is a coverage agreement. The most common situation is a primary-care physician group that is looking for a hospitalist to care for their patients in the hospital. This is usually a handshake agreement, with no money involved.

Do hospitalists do their own direct billing to the insurers? As for this part of the question, it’s time to separate “hospital services” from “hospitalist services.” Hospital services are billed under Medicare Part A, while physician services are billed under Medicare Part B, meaning that even if a physician is employed directly by the hospital, that physician’s professional services are still billed and paid separate from any hospital charges (for things like the bed, supplies, and nursing). Because Medicare sets the ground rules, other insurances typically follow suit. Payment applies similarly to the contracted hospitalists and independent hospitalists.

Do hospitalists have to be credentialed with the insurers? Yes. Whether it is Medicare or Cigna or United, each individual physician must be credentialed with the payors to receive payment. Medicare credentialing for physicians is pretty universal, given that most of our patients have this as their primary insurance. Without it, there is no payment from Medicare to the physician. Many groups or hospitals won’t even let their physicians begin seeing patients until that paperwork is approved. Due to timely filing rules, you can’t just start to see patients and hope to get paid later. And there’s no negotiating with the government—whatever Medicare pays in a region for a specific service is the payment the physician receives.

For the private insurers, it’s generally easier to receive payment if you are credentialed, but I’ve seen a few physician groups negotiate payments without agreeing to a flat contracted rate. I don’t recommend this setup, as the patient can often get caught in the middle with a rather hefty bill. Still, there is some room for negotiation on the private insurer payment rates.

In summary, whether a hospitalist is employed by the hospital, contracted, or truly independent, they all bill Medicare and the insurers for their professional fees. Medicare payments won’t vary, but private insurance payments can. It’s certainly a challenging payment system to understand, from either the provider or the patient point of view.

Dr. Hospitalist

I would like to know where payment for the service of hospitalists fits into the insurance/Medicare payment system. Are hospitalists considered employees of the hospital and, therefore, billed through the hospital system? Are they considered independent doctors and, therefore, do their own direct billing? Do they, in general, accept assignment of benefits from you for your insurance/Medicare? Do they sign contracts with insurance/Medicare to participate in their plans?

Carole L. Hughes

Dr. Hospitalist responds:

For the sake of argument, let’s say that Carole is on the outside looking in—meaning she’s not a healthcare practitioner, but a consumer. It might seem a bit strange to wonder where all these “hospitalists” come from, and who pays for them. Let’s walk through a few scenarios as outlined here.

Are hospitalists considered employees of the hospital? They certainly could be directly employed by the hospital, but it’s just as likely they could be contracted with the hospital for certain services, such as taking ED call for unassigned patients. It’s also entirely possible that the hospitalist has no direct financial relationship with the hospital at all. In this case, a hospitalist is taking cases that are referred from other physicians and for which there is a coverage agreement. The most common situation is a primary-care physician group that is looking for a hospitalist to care for their patients in the hospital. This is usually a handshake agreement, with no money involved.

Do hospitalists do their own direct billing to the insurers? As for this part of the question, it’s time to separate “hospital services” from “hospitalist services.” Hospital services are billed under Medicare Part A, while physician services are billed under Medicare Part B, meaning that even if a physician is employed directly by the hospital, that physician’s professional services are still billed and paid separate from any hospital charges (for things like the bed, supplies, and nursing). Because Medicare sets the ground rules, other insurances typically follow suit. Payment applies similarly to the contracted hospitalists and independent hospitalists.

Do hospitalists have to be credentialed with the insurers? Yes. Whether it is Medicare or Cigna or United, each individual physician must be credentialed with the payors to receive payment. Medicare credentialing for physicians is pretty universal, given that most of our patients have this as their primary insurance. Without it, there is no payment from Medicare to the physician. Many groups or hospitals won’t even let their physicians begin seeing patients until that paperwork is approved. Due to timely filing rules, you can’t just start to see patients and hope to get paid later. And there’s no negotiating with the government—whatever Medicare pays in a region for a specific service is the payment the physician receives.

For the private insurers, it’s generally easier to receive payment if you are credentialed, but I’ve seen a few physician groups negotiate payments without agreeing to a flat contracted rate. I don’t recommend this setup, as the patient can often get caught in the middle with a rather hefty bill. Still, there is some room for negotiation on the private insurer payment rates.

In summary, whether a hospitalist is employed by the hospital, contracted, or truly independent, they all bill Medicare and the insurers for their professional fees. Medicare payments won’t vary, but private insurance payments can. It’s certainly a challenging payment system to understand, from either the provider or the patient point of view.

Dr. Hospitalist

I would like to know where payment for the service of hospitalists fits into the insurance/Medicare payment system. Are hospitalists considered employees of the hospital and, therefore, billed through the hospital system? Are they considered independent doctors and, therefore, do their own direct billing? Do they, in general, accept assignment of benefits from you for your insurance/Medicare? Do they sign contracts with insurance/Medicare to participate in their plans?

Carole L. Hughes

Dr. Hospitalist responds:

For the sake of argument, let’s say that Carole is on the outside looking in—meaning she’s not a healthcare practitioner, but a consumer. It might seem a bit strange to wonder where all these “hospitalists” come from, and who pays for them. Let’s walk through a few scenarios as outlined here.

Are hospitalists considered employees of the hospital? They certainly could be directly employed by the hospital, but it’s just as likely they could be contracted with the hospital for certain services, such as taking ED call for unassigned patients. It’s also entirely possible that the hospitalist has no direct financial relationship with the hospital at all. In this case, a hospitalist is taking cases that are referred from other physicians and for which there is a coverage agreement. The most common situation is a primary-care physician group that is looking for a hospitalist to care for their patients in the hospital. This is usually a handshake agreement, with no money involved.

Do hospitalists do their own direct billing to the insurers? As for this part of the question, it’s time to separate “hospital services” from “hospitalist services.” Hospital services are billed under Medicare Part A, while physician services are billed under Medicare Part B, meaning that even if a physician is employed directly by the hospital, that physician’s professional services are still billed and paid separate from any hospital charges (for things like the bed, supplies, and nursing). Because Medicare sets the ground rules, other insurances typically follow suit. Payment applies similarly to the contracted hospitalists and independent hospitalists.

Do hospitalists have to be credentialed with the insurers? Yes. Whether it is Medicare or Cigna or United, each individual physician must be credentialed with the payors to receive payment. Medicare credentialing for physicians is pretty universal, given that most of our patients have this as their primary insurance. Without it, there is no payment from Medicare to the physician. Many groups or hospitals won’t even let their physicians begin seeing patients until that paperwork is approved. Due to timely filing rules, you can’t just start to see patients and hope to get paid later. And there’s no negotiating with the government—whatever Medicare pays in a region for a specific service is the payment the physician receives.

For the private insurers, it’s generally easier to receive payment if you are credentialed, but I’ve seen a few physician groups negotiate payments without agreeing to a flat contracted rate. I don’t recommend this setup, as the patient can often get caught in the middle with a rather hefty bill. Still, there is some room for negotiation on the private insurer payment rates.

In summary, whether a hospitalist is employed by the hospital, contracted, or truly independent, they all bill Medicare and the insurers for their professional fees. Medicare payments won’t vary, but private insurance payments can. It’s certainly a challenging payment system to understand, from either the provider or the patient point of view.

In response to your April 25 eWire article “Study: Medicare Pay for Performance Might Not Work as Currently Designed,” we would like to point out that although the analyses you cite may be correct, the conclusion of the article is overly broad.

The Hospital Quality Incentive Demonstration (HQID) was designed to test whether incentives would improve care processes and a limited number of outcomes in hospitals beyond what was possible with public reporting alone. It accomplished that goal. HQID hospitals improved quality scores, achieving an 18.6% improvement, administering more than 960,000 additional evidence-based care measures.

Further, HQID was distinguished by the rapid nature of improvements. As HQID progressed, non-participant hospitals ultimately “caught up” in the second three-year measure period. Considering HQID hospital average composite quality scores were close to perfect, averaging between 95% and 98% across all clinical areas at the end of the project, this is a result that is certainly good for healthcare overall.

Too often, researchers, including the authors of the New England Journal of Medicine study, assume the 30-day measurement of mortality is the gold standard of effectiveness. That’s a highly flawed assumption. In many cases, 30-day mortality is a very blunt measure of quality because it is a relatively rare event, and it comprises an extremely narrow time frame. In fact, most studies evaluating interventions find it much more effective to look at long-term outcomes, not an arbitrary 30-day window.

Moreover, in the 10 years since HQID was designed, the science of medicine has advanced, as have measures to evaluate performance. What is important and unquestioned is that an HQID-type execution strategy is a good one for driving rapid and sustainable improvements. That is why we used the best of what we learned in HQID and combined it with new measures to drive a higher level of performance in the QUEST quality and cost-reduction collaborative.  QUEST has produced strong results in reducing mortality, harm rates, and readmissions, saving nearly 25,000 lives while reducing healthcare spending by nearly $4.5 billion in just three years. The Centers for Medicare & Medicaid Services (CMS) has followed a similar approach, combining what was successful in HQID with newer measures of performance in the national hospital value-based purchasing program.

To conclude that value-based purchasing will have a limited effect based on a narrow measure of outcomes, without an acknowledgement of how the program has evolved over the course of a decade, is a very big leap. We can all agree that today’s status quo is not producing the optimized results we’d like, but casting doubt on public policies before they have even been implemented is not the solution. The more helpful approach would be to foster a constructive dialogue on how we can take what has worked and improve upon it.

Richard Bankowitz, MD, MBA, FACP,

chief medical officer,

Premier Inc. healthcare alliance

In response to your April 25 eWire article “Study: Medicare Pay for Performance Might Not Work as Currently Designed,” we would like to point out that although the analyses you cite may be correct, the conclusion of the article is overly broad.

The Hospital Quality Incentive Demonstration (HQID) was designed to test whether incentives would improve care processes and a limited number of outcomes in hospitals beyond what was possible with public reporting alone. It accomplished that goal. HQID hospitals improved quality scores, achieving an 18.6% improvement, administering more than 960,000 additional evidence-based care measures.

Further, HQID was distinguished by the rapid nature of improvements. As HQID progressed, non-participant hospitals ultimately “caught up” in the second three-year measure period. Considering HQID hospital average composite quality scores were close to perfect, averaging between 95% and 98% across all clinical areas at the end of the project, this is a result that is certainly good for healthcare overall.

Too often, researchers, including the authors of the New England Journal of Medicine study, assume the 30-day measurement of mortality is the gold standard of effectiveness. That’s a highly flawed assumption. In many cases, 30-day mortality is a very blunt measure of quality because it is a relatively rare event, and it comprises an extremely narrow time frame. In fact, most studies evaluating interventions find it much more effective to look at long-term outcomes, not an arbitrary 30-day window.

Moreover, in the 10 years since HQID was designed, the science of medicine has advanced, as have measures to evaluate performance. What is important and unquestioned is that an HQID-type execution strategy is a good one for driving rapid and sustainable improvements. That is why we used the best of what we learned in HQID and combined it with new measures to drive a higher level of performance in the QUEST quality and cost-reduction collaborative.  QUEST has produced strong results in reducing mortality, harm rates, and readmissions, saving nearly 25,000 lives while reducing healthcare spending by nearly $4.5 billion in just three years. The Centers for Medicare & Medicaid Services (CMS) has followed a similar approach, combining what was successful in HQID with newer measures of performance in the national hospital value-based purchasing program.

To conclude that value-based purchasing will have a limited effect based on a narrow measure of outcomes, without an acknowledgement of how the program has evolved over the course of a decade, is a very big leap. We can all agree that today’s status quo is not producing the optimized results we’d like, but casting doubt on public policies before they have even been implemented is not the solution. The more helpful approach would be to foster a constructive dialogue on how we can take what has worked and improve upon it.

Richard Bankowitz, MD, MBA, FACP,

chief medical officer,

Premier Inc. healthcare alliance

In response to your April 25 eWire article “Study: Medicare Pay for Performance Might Not Work as Currently Designed,” we would like to point out that although the analyses you cite may be correct, the conclusion of the article is overly broad.

The Hospital Quality Incentive Demonstration (HQID) was designed to test whether incentives would improve care processes and a limited number of outcomes in hospitals beyond what was possible with public reporting alone. It accomplished that goal. HQID hospitals improved quality scores, achieving an 18.6% improvement, administering more than 960,000 additional evidence-based care measures.

Further, HQID was distinguished by the rapid nature of improvements. As HQID progressed, non-participant hospitals ultimately “caught up” in the second three-year measure period. Considering HQID hospital average composite quality scores were close to perfect, averaging between 95% and 98% across all clinical areas at the end of the project, this is a result that is certainly good for healthcare overall.

Too often, researchers, including the authors of the New England Journal of Medicine study, assume the 30-day measurement of mortality is the gold standard of effectiveness. That’s a highly flawed assumption. In many cases, 30-day mortality is a very blunt measure of quality because it is a relatively rare event, and it comprises an extremely narrow time frame. In fact, most studies evaluating interventions find it much more effective to look at long-term outcomes, not an arbitrary 30-day window.

Moreover, in the 10 years since HQID was designed, the science of medicine has advanced, as have measures to evaluate performance. What is important and unquestioned is that an HQID-type execution strategy is a good one for driving rapid and sustainable improvements. That is why we used the best of what we learned in HQID and combined it with new measures to drive a higher level of performance in the QUEST quality and cost-reduction collaborative.  QUEST has produced strong results in reducing mortality, harm rates, and readmissions, saving nearly 25,000 lives while reducing healthcare spending by nearly $4.5 billion in just three years. The Centers for Medicare & Medicaid Services (CMS) has followed a similar approach, combining what was successful in HQID with newer measures of performance in the national hospital value-based purchasing program.

To conclude that value-based purchasing will have a limited effect based on a narrow measure of outcomes, without an acknowledgement of how the program has evolved over the course of a decade, is a very big leap. We can all agree that today’s status quo is not producing the optimized results we’d like, but casting doubt on public policies before they have even been implemented is not the solution. The more helpful approach would be to foster a constructive dialogue on how we can take what has worked and improve upon it.

Richard Bankowitz, MD, MBA, FACP,

chief medical officer,

Premier Inc. healthcare alliance